RU2014850C1 - Method of treating myotonic spasms - Google Patents

Abstract

FIELD: medicine, neurology. SUBSTANCE: method involves subjecting the regions of cervical and lumbar sympathetic ganglia to the action of lodocain-amplipulsephoresis in magnetic field so as to provide the action upon cyliospinal centers regulating sympathetic innervation of face muscles and outer muscles of eyes to reduce excitability of spinal cord, cumulation of endorfines, myotonic symptoms, to improve blood supply, muscle trophicity. Lidocain- amplipulsephoresis in magnetic field is carried out in a rectified mode with I and III kinds of works at modulation depth of 100%, at a frequency within the range of 50-100 Hz, half-period duration of 2-3 sec, with current magnitude of 20-30 mA, with duration of each kind of works of 8 min. The method is characterized in that magnetotherapy is simultaneously carried out for 20 min by pulsed magnetic field with rectangular pulses in continuous mode with alternation of frequencies of 10 Hz and 100 Hz and half-period durations of 3-1 sec, respectively, and with magnetic induction of 35-40 mT. Treatment course includes 15-20 procedures carried out daily. EFFECT: enhanced efficiency. 1 tbl

Description

 The invention relates to medicine, namely to the field of neurology, and can be used to treat myotonic spasms.

A method of treating patients myotonia using common coniferous baths, bath temperature 37 ^C and duration of exposure to 10-15 min (L. Nikolov and Sv.Boykikeva. Special physiotherapy. Sofia, 1972, s.311). The disadvantage of this method is its insignificant therapeutic effectiveness. The method is pathogenetically unreasonable, does not significantly affect the content of acetylcholine, potassium and the activity of cholinesterase, frequent manifestations of individual intolerance.

 Of the physical factors in myotonia, infrared rays are assigned to the distal regions, infrared rays to the distal limbs. A low thermal dose with a duration of exposure of 15-20 minutes is used (A.M. Gurlenya and G.E.Bagel. Physiotherapy and balneology of nervous diseases. Minsk, 1989, pp. 361-362). However, the method does not significantly affect the correction of myotonic spasms, and therefore this method is used as an additional for drug therapy of myotonia.

 The prototype of the invention is the complex treatment of dystrophic myotonia, including the use of drug therapy and the appointment of magnesium electrophoresis (EG Krutikova. Clinical features of dystrophic myotonia. V. Sb. Essays on Clinical Neurology. Leningrad, 1964, p. 78-85).

 The disadvantage of this method is the short duration of the clinical effect, the insignificant effect of direct current on the neuromuscular apparatus, a small intake of the drug introduced by the current, and the traditional use of quinine has been left to date.

 The aim of the invention is to reduce the severity of myotonic spasms, increase the duration of remission.

 This goal is achieved by the combined effect of lidocaine amplipulse phoresis and a magnetic field on the cervical and lumbar sympathetic ganglia, which makes it possible to effect on the ciliospinal centers that regulate the sympathetic innervation of the facial muscles and external muscles of the eyes, leads to a decrease in the excitability of the spinal cord, cumulation of endorphins, and improvement of blood circulation and trophic muscles.

 The need for the combined use of physical factors and pharmacological effects in the described method is due to the fact that each of the components of the physicopharmacological complex constituting it, acting on different pathogenetic links of the myotonic syndrome, at the same time has a pronounced potentiating effect on other components. The final high therapeutic effect of the combined method of lidocaine amplipulse phoresis in a magnetic field is explained precisely by the mechanism of mutual potentiation of well-chosen components, and is not reduced to the sum of the effects of each of the components of the effect.

 Lidocaine, administered at the indicated SMT parameters at therapeutic concentrations in reflexogenic zones corresponding to the location of the cervical and lumbar sympathetic ganglia, has a typical pharmacological effect. As a result of the inhibition of the slow transmembrane current of sodium ions in the fourth phase of depolarization caused by the drug, the threshold of excitation of efferent sympathetic neurons increases, decreasing the pathological impulse along the postganglionic fibers, and the pathological hypertonicity of the affected muscles is reduced.

 The indicated effect of lidocaine is repeatedly enhanced by the direct therapeutic effect of SMT, which normalizes the electrical activity of ganglionic efferent neurons that improve blood circulation and tissue trophism, both directly in the affected area and in the entire segment controlled by them, including in the affected muscle area, which is a factor additional potentiation of the total effect. The technique is enhanced by the location of the bifurcated second SMT electrode on the forearms and (or) lower legs, in the area of the affected muscles.

 The magnetic field is a factor of particular importance in the described technique. Firstly, under the influence of a magnetic field, the efficiency of CMT drug electrophoresis increases many times, and the capacity of the lidocaine skin depot increases. The magnetic field has a pronounced potentizing effect on the effects of lidocaine and SMT at the level of the membranes of nerve and muscle cells, modifying the transmembrane transport of electrolytes and, in particular, potassium and sodium, the magnetic field itself increases the threshold of excitation and spontaneous depolarization of the efferent neurons of the sympathetic ganglia and reduces tonicity the affected muscles they serve. This effect is greatly enhanced by combined exposure. A magnetic field normalizes trophism and improves blood circulation both in the region of the sympathetic ganglia and in the area of affected muscles, where, by its direct action, it also reduces the excitability of myofibrils and sensitivity to acetylcholine, and increases the activity of acetylcholinesterase. It is shown that to the greatest extent these effects occur with a pulsed field shape and an infrasound frequency of 10 Hz, and its alternation with a frequency of 100 Hz prevents adaptation and serves to further enhance the therapeutic effect.

The treatment method is carried out using the apparatus "ADMT Magnipulse" and "Amplipulse 4". On the first day, the following effect is carried out: a rectangular electrode with an area of 400 cm ² with a pad moistened with a 0.5% solution of lidocaine is installed in the region of spinal segments C ₅ -D ₃ and attached to the anode of the Amplipulse 4 apparatus. The second bifurcated electrode with an area of 200 cm ^{2 was} fixed on the outer surfaces of the forearms and attached to the cathode. At the same time, magnetotherapy from the ADMT Magnipuls apparatus was carried out. An inductor electromagnet was placed contactly through 2 layers of an insulating oilcloth on a cervical chest electrode. The patient's forearms are placed in a solenoid inductor. The next day: an electrode area of 400 cm ² with a pad moistened with a 0.5% solution of lidocaine, fixed in the lumbar region and attached to the anode of the apparatus "Aplipuls 4". The second (bifurcated) electrode with an area of 200 cm ^{2 is} fixed on the lower lateral surfaces of the legs and attached to the cathode. The inductor electromagnet from the ADMT Magnipuls apparatus is contacted through 2 layers of an insulating oilcloth on the lumbar electrode. The shins of the patient are introduced into the inductor-solenoid.

 Amplipulse therapy parameters: straightened mode. Childbirth I (PM), then III (PN). The modulation frequency is 30-50 Hz for severe lesions, 70-100 Hz for mild lesions. The modulation depth is 100%. Parcel duration 2-3 s. The current strength is 20-30 mA. The duration of exposure by each kind of work is 8 minutes.

 Magnetotherapy parameters: a pulsed magnetic field with a rectangular pulse shape with alternating frequencies of 10 and 100 Hz. The half-periods are 3 s and 1 s, respectively. Magnetic induction 35-40 MT. Duration of exposure 20 minutes At the beginning of the procedure, the ADMT Magnipulse apparatus is turned on, then Amplipulse 4. At the end of the procedure, the apparatus for amplitpool therapy is turned off, then the magnetotherapy apparatus. The course of treatment consists of 15-20 procedures conducted daily.

 The combined effect of lidocaine by amplipulsophoresis and a magnetic field produced on the cervical and lumbar sympathetic ganglia leads to an improvement in peripheral blood circulation as a result of the effect of temporary vascular dissympatization due to physical exposure. This leads to a decrease in the severity of myotonic spasms and improves trophic tissue.

 Lidocaine was injected in the cervicothoracic and lumbar region with the aim of telling the stabilizing effect on the transmembrane resting potential of the effector neurons located in the paravertebral ganglia of the cervical and lumbar sympathetic chains. The stabilizing effect of lidocaine is based on blocking the slow current of sodium ions in the fourth phase of depolarization, which leads to accelerated repolarization of cells, shortens the duration of the exposure potential, and increases the threshold for spontaneous depolarization of ganglionic sympathetic neurons. The result is a decrease in the excitability of nerve cells that support muscle hypertonicity in the innervation zone.

 During amplipulse therapy, a rectified regimen was used to administer the drug substance (the drug substance is not administered by the variable regime). The choice of the first and third kinds of work is connected with the fact that they introduce the greatest amount of the drug substance. The selection of modulation frequencies is made taking into account the degree of damage to the neuromuscular apparatus, which was determined by clinical indicators and using electrophysiological studies. With a severe degree of damage to the neuromuscular device, a frequency of 30-50 Hz was used, and with a mild degree of damage - 70-100 Hz. The choice of a modulation depth of 100% is dictated by the need for an intense effect of amplitude pulsations on the neuromuscular apparatus, the current strength of 20-30 mA is well tolerated by the patient and has a pronounced effect on the neuromuscular apparatus. The exposure time of 16 minutes is sufficient for the introduction of therapeutic doses of a medicinal substance.

The use of a magnetic field in myotonia is due to the ability of this factor to actively influence the transport of electrolytes (K ⁺ , Ca ²⁺ , sodium, magnesium) through the membranes of nerve and muscle cells. This is due to the induction of weak electric currents at the level of the membranes of nerve and muscle cells, the occurrence of a membrane effect. As a result, acts of de- and repolarization normalize, the excitability of nerve and muscle cells decreases, the transmembrane resting potential increases, and the ability to spontaneous depolarization decreases.

 The choice of the pulsed form of a magnetic field with rectangular pulses is due to the fact that a constant pulsed field causes the most pronounced magnetoelectric and magnetomechanical effects in tissues, with the greatest shifts being observed with a rectangular shape of pulses. The most intense effect is exerted by the magnetic fields of infrasound frequencies, close to or a multiple of the intrinsic resonance frequencies of most nerve and muscle cells. This determines the choice of frequency of 10 Hz. To prevent adaptation to a monotonous low-frequency effect, a contrast high frequency of 100 Hz is used, which has a sympatholytic and ganglioblocking effect. The half-cycle ratio of 3 s: 1 s is associated with the need for a longer exposure to a low-frequency magnetic field. The duration of the procedure is 20 minutes due to the gradual development of therapeutic effects inherent in this physical factor.

 PRI me R 1. Patient S., 33 years old, was hospitalized in the clinic of nervous diseases. Diagnosis: myotonia Erbsle.

 Upon receipt of a complaint about the difficulty of the initial movements in the masticatory muscles, opening of the eyes after squeezing.

 The disease began at the age of twenty-eight, when the first spasm in the masticatory muscles appeared during the first movement. Gradually, difficulty in opening the eyes after squinting, as well as in the muscles of the mouth, joined.

 In neurological status: the face is hypomimic. Mildly pronounced bilateral ptosis. Speech is dysarthria. Active myotonic reaction in the circular muscles of the eyes and mouth for up to 3 s. When a hammer hits the tongue, a ditch is formed. The reflex background is evenly reduced. Weakness of facial and chewing muscles. Coordination and sensitivity are not affected.

Additional research methods have shown that with QED (classical electrodiagnostics) myotonic reaction in the masticatory muscles. EEG data testify to the irritation and interest of the medio-basal formations of the temporal alone. ECHOEG: there is no displacement of the middle structures. The width of the 3rd ventricle is 4 mm. Blood biochemical parameters: sugar 5.0 mmol / L, urea 5.0, ALT 0.65, AST 0.13, cholesterol 4.7, β-lipoproteins 360, K plasma 4.15 mmol / L, K + red blood cells 96 mmol / L, plasma sodium 144 mmol / L, erythrocyte sodium 16 mmol / L, plasma Ca ²⁺ 2.28, bilirubin 12.0, CPK 15.0, alkaline phosphatase 1.4, sialic acids 120, prothrombin 78%, CRP (+++), total protein 78.0, albumin 48.0, globulins 52.0, α ₁ - 10.8, α ₂ - 12.4 β - 12.4, γ - 13.1, and / g coefficient of 0.9 creatine - creatinine index in daily urine of 1.0.

After 15 procedures of lidocaine amplipulphoresis in a magnetic field to the region of the cervical sympathetic nodes, a decrease in the active myotonic reaction in the facial and chewing muscles, a slight increase in strength in these muscles was noted. After the treatment, the following biochemical parameters were obtained: sugar 4.6 mmol / L, urea 5.5, ALT 0.53, AST 0.13, cholesterol 4.2, β-lipoproteins 360, K ⁺ plasma 4.4 mmol / l, K ⁺ erythrocytes 94 mmol / l, plasma sodium 125 mmol / l, erythrocyte sodium 18 mmol / l, Ca ²⁺ plasma 2.28, bilirubin 12.0, CPK 3.0, alkaline phosphatase 0.8, sialic acids 120, prothrombin 72%, CRP (-), total protein 80.0, albumin 57.1, globulins 42.9, α ₁ - 5.6, α ₂ - 9.6, β - 12.2, γ - 15.3, a / g coefficient 1.0, creatine-creatinine index 1.0.

 PRI me R 2. Patient C, 38 years old, was hospitalized in the clinic of nervous diseases. Diagnosis: dystrophic myotonia.

 Upon receipt of a complaint about weakness and weight loss of the muscles of the distal arms and legs, about the difficulty of the initial movements in the arms and legs, chewing muscles.

 The disease began at the age of thirty, when there was weakness in the distal legs ("the feet began to clap when walking"). After some time, I noticed difficulty in the initial movements in the hands. Then myotonic spasms appeared in the masticatory muscles, emaciation of the distal parts of the arms and legs. Family history is not burdened.

 In neurological status: hypomimia. Low standing eyelids. Hypotrophy of the temporal, chewing, sternocleidomastoid muscles. Speech is dysarthria. Active myotonic reaction in masticatory muscles up to 2-3 s. When you hit the tongue with a hammer, a ditch is revealed. Weakness of facial, nodding, small muscles of the hands, extensors of the feet and hands, large pectoral muscles, muscles of the anterior surface of the thighs. The reflex background is low, Achilles reflexes are absent. Active myotonic reaction in the masticatory muscles, in the hands: 8-10 s on the right and 6-8 s on the left. Mechanical myotonic reaction when a hammer strikes the elevation of the thumb, in the deltoid muscles, in the extensors of the hands.

 Additional research methods: when conducting classical electrodiagnostics (QED), quantitative changes were found with a decrease in the electroexcitability of the peroneal muscle group. In m.opponeuspollicis myotonic reaction. On EMG, a decrease in the frequency and amplitude of oscillations of the extensors of the forearms and the peroneal muscle group with characteristic myotonic discharges was revealed. In an electroneuromyographic study (ENMG), the efferent and afferent impulse conduction velocities (SPIs) along the ulnar nerve are 58 m / s and 64 m / s, along the peroneal nerve - 44 m / s and 48 m / s. On the tomograms, a decrease in the total thermal fund of the extremities with a break in the glow at the level of the fingers is determined. Face - increased radiation from the forehead, left temporal, orbital and nasolabial folds. Resvasograficheskoe study of the hands and feet: the volumetric blood flow in the vessels of the upper and lower extremities saved. Curves of the main type, there is an increase in vascular tone on the legs, the rest is within normal limits. An oscillographic study revealed a decrease in the amplitude of oscillations in the legs and feet.

Biochemical blood tests: sugar 3.7 mmol / l, cholesterol 5.3, β-lipoproteins 540, alkaline phosphatase 1.2 mmol /, bilirubin 14.0, K ⁺ plasma 4.8 mmol / l, K ⁺ red blood cells 85 mmol / l, plasma sodium 167 mmol / l, erythrocyte sodium 200 mmol / l, Ca ²⁺ 2.26 mmol / l, CRP (+), total protein 80, albumin 48.8, globulins 51.2, α ₁ - 9 , 3, α ₂ - 11.6, β - 13.8, γ - 16.2, and / g coefficient 0.9, ALT 0.16, AST 0.34, creatine-creatinine index in daily urine 0.9 .

The patient underwent 15 procedures of lidocaine amplipulse phoresis in a magnetic field on the cervical and lumbar sympathetic ganglia. As a result of the treatment, a decrease in myotonic phenomena was noted, as well as an increase in muscle strength by 1-1.5 points. On ENMG, the pulse conduction velocity (SPI) is efferent and afferent along the ulnar nerve of 60 m / s and 65 m / s, along the fibular - 46 m / s and 49 m / s. Thermograms show an increase in infrared radiation of the extremities, an increase in the relative pulse volume by rheovasograms. Biochemical studies: sugar 4.0 mmol / l, cholesterol 5.1, β-lipoproteins 540, bilirubin 14.0, alkaline phosphatase 1.0, K ⁺ plasma 4.6 mmol / l, K ⁺ red blood cells 85 mmol / l , plasma sodium 169 mmol / L, erythrocyte sodium 21 mmol / L, Ca ²⁺ 2.27 mmol / L, CPK 2.0 units, creatine-creatinine index in daily urine 0.97.

 PRI me R 3. Patient B., 46 years old, was hospitalized in the clinic of nervous diseases. Diagnosis: Thomsen myotonia.

 Upon receipt of a complaint about the difficulty of the initial movements in the hands, as well as in the legs, especially when climbing stairs.

 She became ill at the age of twenty-five, when she noticed difficulty in unclenching her hands; gradually, the difficulty of the initial movements in the legs, at the beginning of walking and when climbing stairs, joined. I was not examined anywhere, I did not receive treatment. Family history is not burdened.

 In neurological status: of proper physique. Hypersthenic constitution, increased nutrition. The reflex background is symmetrical, of medium liveliness. There are no paresis. Coordination, sensitivity normal. Active myotonic reaction in the hands: on the right - 5-6 s, on the left - 3-4 s. A mechanical myotonic reaction when a hammer strikes the elevation of the thumb, and when a hammer strikes the tongue, a ditch.

Additional research methods: when conducting classical electrodiagnostics (QED) on m.opponeus pollicis, a myotonic reaction in the form of a “myotonic tail” was revealed. With ENMG, the velocity along the ulnar nerve is 58 m / s, along the peroneal nerve 56 m / s. On thermograms of the hands - moderate hyperthermia of the hands, hypothermia of the forearms and shoulders. Thermography of the legs - hypothermia of the feet and legs (more pronounced on the right). On the oscillograms - the amplitude of the oscillations in the shoulders, forearms, lower third of the legs and feet - within normal limits, in the region of the upper third of the legs - reduced. A rheovasographic study of the arms and legs showed a slight increase in the vascular tone of the arteries of the forearms, venous outflow is not difficult. Biochemical blood tests before treatment: sugar 4.1 mmol / l, bilirubin 12.0, ALT 0.65, AST 0.18, alkaline phosphatase 1.1, cholesterol 6.7, β-lipoproteins 620, Ca ²⁺ 2, 29 mmol / L, K ⁺ plasma 4.95 mmol / L, K ⁺ red blood cells 91 mmol / L, plasma sodium 133 mmol / L, erythrocyte sodium 19 mmol / L, prothrombin 78%, CPK 2.0, creatine-creatinine index in daily urine 0.98.

The patient underwent 15 procedures of lidocaine amplipulse phoresis in a magnetic field on the cervical and lumbar sympathetic ganglia according to the developed technique. As a result of treatment, myotonic phenomena in the hands decreased to 1 s, the patient noted relief when climbing the stairs. On ENMG, the velocity along the ulnar nerve is 59 m / s, along the peroneal nerve - 58 m / s. An increase in IR glow in the forearms and shoulders was noted, as well as an increase in the relative volume pulse according to rheovasography. Biochemical blood tests: sugar 4.5 mmol / l, bilirubin 8.0, alkaline phosphatase 1.4, cholesterol 6.3, β-lipoproteins 540, Ca ²⁺ 2.26 mmol / l, K ⁺ plasma 4.4 mmol / l, K ⁺ erythrocytes 83 mmol / l, plasma sodium 148 mmol / l, erythrocyte sodium 19 mmol / l, prothrombin 86%, creatine-creatinine index in daily urine 1.0.

 The proposed method for the treatment of myotonic spasms was tested in the clinic of nervous diseases of LenGIDUV for 24 patients, of which 8 were women and 16 men aged 17 to 56 years with a disease duration of 1.5 to 23 years.

 As a result of the course treatment of patients with myotonic spasms of lidocaine amplipulsophoresis in a magnetic field, positive dynamics of clinical indicators was detected in 20 (83.3%) of 24 patients. Radiation of long-term results established that the stage of remission in the treated patients lasted 6-8 months. Comparison of the treatment results of the proposed and known methods, as well as persons of the II control group are presented in the table.

 Thus, the proposed method for the treatment of patients with myotonic spasms causes a positive effect, confirmed by the dynamics of clinical laboratory data. The novelty of the method is represented by the combined effect of the amplification of the drug substance in a magnetic field with the impact on the cervical and lumbar sympathetic ganglia, ciliospinal centers that regulate the sympathetic innervation of the facial muscles and external muscles of the eyes. This leads to a decrease in the excitability of the spinal cord, cumulation of endorphins. Conducted therapeutic effects help to reduce the severity of myotonic spasms, a longer remission. The most pronounced therapeutic effect was found in patients with Erbsle myotonia, a slightly lesser effect was observed in the treatment of Thomsen's myotonia and dystrophic myotonia. The proposed method is simple and available for use in outpatient and inpatient settings.

Claims (1)

 METHOD FOR TREATING MYOTONIC SPASMS, including electrophoresis of medicinal substances, characterized in that they carry out a combined effect on the cervical and lumbar nodes of lidocaine amplipulsophoresis in a magnetic field, while the phoresis is performed in the rectified mode, I and III labor for 8 min, the modulation depth is 100 min. %, a frequency of 50 to 100 Hz, a half-cycle duration of 2 to 3 seconds, a current of 20 to 30 mA, and magnetic therapy with a pulsed magnetic field with a rectangular shape of pulses in a continuous mode with alternating frequencies of 10 and 100 Hz, duration spans of half-periods, respectively, 3 sec - 1 sec, magnetic induction of 35 - 40 mT, duration of 20 minutes, treatment course of 15 - 20 procedures is carried out daily.