RU2260370C1 - Method for diagnosing posture disorders in patients having organic brain disturbances - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves applying Romberg test modification repeated twice. Statokinesiogram length (L), movement speed (V) and statokinesiogram area (S) is measured. Psychopathological component association index (PPCOI) is additionally calculated as PPCOI=meanLFS x meanV, where meanLFS is the mean path length per unit of area calculated as (LFS 1 + LFS 2)/2, meanV is the pressure center displacement speeds difference calculated as V2 - V1. When varying L, V, S values not more than by 35% from reference normal value, initial stage of posture disorders are to be diagnosed. The value being from 35% to 70% of the norm, moderately marked posture disorders are to be diagnosed. The changes exceeding the value of 70% of the norm, marked posture disorders are to be diagnosed. PPCOI being less than 1.6, insignificant psychopathological component association is to be diagnosed. The value being between 1.7 and 4.9, moderately marked association is to be diagnosed. When >5, marked association is to be diagnosed.

EFFECT: high accuracy of diagnosis.

2 cl

Description

The invention relates to medicine, namely to neurology, and can be used for diagnostics and dynamic monitoring in order to optimize therapeutic measures in patients with organic pathology of the brain of various origins, accompanied by postural disorders and various, in severity, intellectual-mnestic disorders.

To date, patients' complaints of instability are evaluated visually by the doctor, i.e. determination of violations of statics and coordination of movements (hereinafter referred to as postural disorders) in clinical practice is subjective in nature, which makes it impossible to identify the initial manifestations of these changes, give them a quantitative assessment and assess the severity of clinical manifestations. The closest in technical essence of the invention and the achieved result is a method for the diagnosis of postural disorders - a functional test for assessing balance in the elderly, proposed by M.E. Tinnetti et al. in 1986 (M.E. Tinnetti. Fall risk index for elderly patients based on number of chronic disabilities / Tinetti ME, Williams TF, Mayewski R. // Am. J. Med. - 1986 Mar - 80 (3): P.429-434; METinneui Performance-oriented assessment of mobility problems in elderly patients / Tinnetti ME // J. Am. Geriatr. Soc. - 1986 - Vol. 34. - P.119-126).

The effectiveness of the Tinetti scale for the quantitative state of the postural control system was confirmed by the research results of M. Lichlenstein et al. (Lichtenstein M. Deriving criteria for hearing impairment in the elderly: a functional approach. / M. Lichtenstein, F. Bess, S. Logan et al. // J. Amer. Acad. Audiol. - 1990. - Vol. 1. - P.11-22), HGWilliams et al. (Williams HG Spectral characteristics of postural control in elderly individuals / HGWilliams, BA Mc Clenaghan, J. Dickerson // Arch. Phys. Med. Rehabil. - 1997. - Vol. 7, No. 78. - P.737-744. ), who noted the coincidence of the results of this scale with the data of stabilometry and video footage of walking. However, the use of this scale is possible only in neuroheartic practice, and the data obtained are evaluated subjectively.

The technical result to which the present invention is directed is to increase the accuracy of diagnosis of postural disorders with the derivation of the stagedness of these changes, as well as to determine the degree of influence of the psychopathological component (disorders of the intellectual-mnestic sphere of organic or functional genesis) on static disorders (by calculating the proposed Index of accession psychopathological component). The specified technical result is achieved by the fact that in the method for diagnosing postural disorders in patients with organic brain pathology, including neurological and MR imaging of the brain, according to the invention, stabilization is performed using a modification of the "Romberg Test" for 51 s with open eyes and for 51 s with closed eyes, the resulting statokinesiogram is processed, and additionally, the index of accession of the psychopathological component is calculated - Psychopathological Compone nt Overlay Index (PPCOI) according to the formula: PPCOI = cp.LFS × cp.V (where cp.LFS = (LFS1 + LFS2) / 2, the average length per unit area in two consecutive stabilometric passes, cp.V = | V2- V1 |, the modulus of the difference in the velocity of the center of pressure between the second and first successive stabilometric passes, while with index values of up to 1.6, a slight, from 1.7 to 4.9 - moderately expressed, over 5.0 - the pronounced effect of cognitive disorders spheres on manifestations of statokinetic dysfunction. With changes in two or more parameters of the statokinesiogram (L - length, S - area and V - speed) not more than 35% of the norm (Normes-85, 1985), the initial stage of postural disorders is diagnosed, from 35 to 70% - the stage is moderate expressed postural disorders, more than 70% - diagnose the stage of pronounced postural disorders.

Stabilometry is carried out in the modification \ Romberg test \ - for 51 seconds with eyes open and for 51 seconds with eyes closed (stabilometric passage). It is proposed to conduct two successive (with a break between studies of 40 s according to Winter D.A., 1995) stabilometric passes with the calculation of the average value for the parameters considered below. The stabilometric data obtained in each pass is processed using the software package developed by the MBN company (Moscow) specifically for the medical-diagnostic complex MBN-Stabilo, and additionally (manually) they calculate the developed Index of accession of the psychopathological component - Psychopathological Component Overlay Index (PPCOI) - according to international terminology, according to the proposed formula: PPCOI = cp.LFS × cp.V (where cp.LFS = (LFS1 + LFS2) / 2, average length per unit area in two consecutive stabilometric passes, cp.V = | V2-V1 |, the module . NOSTA pressure center displacement speed between first and second successive passes stabilometric In calculating the parameters of the proposed index recorded LFS and V, obtained from a patient eyes open - in order to eliminate the influence of disturbances on proprioception calculation results). At the same time, with index values of 1.1-1.6, a slight, from 1.7 to 4.9 - moderately expressed, over 5.0 - the pronounced effect of cognitive disorders on the manifestations of statokinetic dysfunction is diagnosed. Note: Index values up to 1.09 are considered normal. The psychopathological component can be both psycho-functional and psycho-organic properties (further specification takes place on the basis of pathopsychological research).

In the subsequent analysis of the report of the stabilometric study, the obtained values of L (length), S (area) and V (speed) of the deviation of the patient’s center of mass from the absolute value are considered. It was determined that the L and V indicators characterize the tension of the compensatory links of the statokinetic system to maintain the vertical posture by the patient and vary within the same limits (up to 35%, from 35 to 70%, over 70% of normative data). It is proposed to consider the staging of postural disorders, quantified, by means of a stabilometric study: with a combined change in the average values of the parameters L-length and V-speed of the statokinesiogram with open eyes, by no more than 35% of normal values (Normes-85

/ Assoc. Française de Posturologie, France: Paris, 1985) diagnose stage I of postural disorders, 35-70% - stage II, over 70% - stage III (severe statokinetic dysfunction). Moreover, the combined change in these parameters also indirectly indicates an organic tenesus of static disturbances in the patient. Parameter S corresponds to the clinical manifestations of static disturbances, and the predominant change in this parameter (with normal and slightly changed values of the parameters L and V) or in combination with an increase in only the rate of deviation of the body CD (V) indirectly indicates the leading role of functional disorders in maintaining the vertical posture. At the same time, by changing the parameter S one can judge the clinical and stabilometric severity of static violations: for example, when the area index changes by 50% of the normative data, it is advisable to talk about insignificant (staggering when standing and walking, deviation in the complicated Romberg test), from 50 to 200% - moderate (side deviation when standing and walking, falling in the complicated Romberg test), more than 200% - of a clinically pronounced degree of astasia (side deviation, falling when standing and walking; falling in the Romberg test).

Sharing the assumption Fiez J. 1997, Grafman J. 1992, Zueva Yu.V. (Zueva Yu.V. Violation of cognitive processes in isolated cerebellar infarcts: Author. Diss. ... candidate of psychologist, sciences / Yu.V. Zueva. - M., 2003. - 20 p.) And other authors that there is a single functional system for both movement and cognitive processes and, taking into account the physiological features of motor function control and clinical observations, we hypothesized that organic brain diseases with diffuse and / or focal atrophy of the brain substance always lead to postural disorders and put their goal in identification of stabilometric parameters that contribute to the objectification of these violations, as well as determining the influence of disorders of the intellectual-mnestic sphere on the degree of their severity.

It is proposed to use the Romberg test technique, performed on the MBN-Stabilo hardware and software complex manufactured by the MBN scientific and medical firm (Moscow). The method of studying the balance of the vertical rack is stabilometry (computer stabilization), which allows you to record the position, deviation and a number of other characteristics of the projection of the general center of gravity of the human body on the support plane (Skvortsov D.V. Human stabilization - history, methodology, standardization / D.V. Skvortsov . - Taganrog: Medical Information Systems, 1995. - P.132-135), successfully used in the last decade in various fields of medicine. Static stabilometry is most widely used in orthopedic practice; in neurology, studies are limited to the study of the postural balance of post-stroke patients with the goal of rehabilitating them by biofeedback (Chernikova L.A., 1999, Batysheva T.T., Rusina L.R., 2003), patients with cerebral palsy (Sologubov E.G. ., Kobrin V.I., Beznosova A.A., Yavorsky A.B. 2000) and Parkinson's disease (Karpova E.A., 2002, W. Ondo et al., 2000 J. Jankovic et al., 2000) . It is proposed to conduct a stabilometric study at the age of at least 4 years (Osipenko T.N., 1997). Necessary parameters entered into the patient database:

- height and weight of the patient;

- clinical base: the distance between the anteroposterior awns of the pelvis in the frontal plane;

- foot length;

- distance ankle-toe (from the outer ankle to the I phalanx of the big toe).

The patient is mounted on a stabilometric platform in the position of the main rack (both feet are placed flush with the centimeter marking line, as a result of which the feet are turned around the inner edge by 30 degrees with a 2 cm distance between the heels). During the study, the patient stands as straight and straight as possible, but in a position convenient for himself. Any means of support are excluded. During the registration process with open eyes (for 51 s), the patient focuses his eyes on a special marker (circle with a diameter of 5 cm at a distance of 3 m directly in front of the patient's eyes), the second half of the registration (51 s), the patient stands with his eyes closed. The study is repeated twice with a break between passes of 20-40 s.

In order to identify postural disorders, the parameters of the statokinesiogram are studied - the image of the trajectory of the center of pressure during the stabilometric study in the coordinate system, including the position of the feet of the subject. All parameters recorded during the study are transferred to the serial port of the computer, where they undergo software processing (Skvortsov D.V. / Clinical analysis of movements. Stabilometry. // M .: AOZT Antidor 2000). The indicators of the length (L) of the statokinesiogram characterizing the linear value of the path traveled by the center of pressure (CP) of the patient’s body during the study (measured in mm) are taken into account; the deviation area of the CD (S) is the part of the plane bounded by the curve of the statokinesiogram (mm ² ); the velocity of the center of pressure, determined by the ratio of the length of the CD pathway during the study to the time of the study (V, mm / s) and the LFS coefficient (ratio of the length to the area of deviation of the center of pressure of the patient’s body), proposed by the French Post-Urology Society and also included in the automatic processing by software developers package. In the modification of the Romberg test, the named parameters are calculated with open and with closed eyes.

Until now, there were no boundaries of the stabilometric staging of postural disorders in organic brain pathology. Table 1 shows the average normative values for a stabilometric study presented by the French Posturological Society (Normes-85, 1985).

Table 1. Stabilometric indicators of the norm (Normes-85, 1985) Average L mm S, mm ² Lfs V, mm / c Open eyes 435.3 182.2 1.0 9.6 Closed eyes 613.1 258.40 1.0 11.5

In organic pathology of the substance of the brain in a patient, as a rule, not only motor, but also intellectual-mnestic disorders develop, aggravating an existing motor defect.

To determine the degree of influence of the psychopathological component (disorders of higher mental functions) on the severity of postural disorders, we propose a formula for calculating the Psychopathological Component Overlay Index (PPCOI) using the formula: PPCOI = cp.LFS × cp.V (where cp.LFS = ( LFS1 + LFS2) / 2, the average length per unit area in two consecutive passes, cp.V = | V2-V1 |, the absolute value of the difference in the velocity of the center of pressure between the second and first consecutive stabilometric passes.LFS and V parameters obtained with the patient's eyes open, in order to exclude the influence of proprioreception disorders on the calculation results). At the same time, with index values of 1.1-1.6, a slight, from 1.7 to 4.9 - moderately expressed, over 5.0 - the pronounced effect of cognitive disorders on the manifestations of statokinetic dysfunction is diagnosed. Note: Index values up to 1.09 are considered normal. The psychopathological component can be both psycho-functional and psycho-organic properties (further specification takes place on the basis of pathopsychological research).

A method for diagnosing postural disorders in patients with organic brain pathology is illustrated by examples:

EXAMPLES TO THE METHOD FOR DIAGNOSTIC OF POSTURAL DISORDERS.

Observation 1

Patient P., 56 years old (medical history No. 87/02). Clinical diagnosis: stage 2 hypertension.

Upon admission, she complained of headaches, instability at rest and when walking, pain in the cervical spine.

Anamnesis of the disease: for several years he suffers from hypertension with rises in blood pressure up to 160/90 mm Hg, about which he periodically took hypotensive and vascular drugs.

Objectively: the condition is satisfactory. Proper physique, satisfactory nutrition. HELL 110/75 mm Hg, pulse 80 beats per 1 minute, rhythmic. Neurological status: without focal symptoms. In the Romberg test, it is stable.

Pathopsychological research: intellectual-mnestic disorders are absent.

TCD - vascular patency preserved. The vascular tone of the microvasculature is reduced. Signs of hemodynamically insignificant atherosclerotic lesion of arteries in the vertebral-basilar pool.

Radiography of the cervical spine - straightening physiological lordosis. Osteoporosis. Right-sided scoliosis. Degenerative-dystrophic changes in the form of arthrosis of the unco-vertebral joints C4-5.

MRI No. 10072/02 - no foci of altered MR signal were detected. The lateral ventricles are not dilated, the median structures are not displaced. Slots of the subarachnoid space are not expanded.

In Fig.1, 2 presents a report of a stabilometric study of patient P.

Figure 1. A fragment of the report of the Romberg test patient P., 56 years. Walkway 1

Note: hereinafter, on the left, the figure shows the position of the projection of the center of gravity in the norm of this patient; on the right is a statokinesiogram (the trajectory of the projection of the center of gravity).

Figure 2. A fragment of the report of the Romberg test patient P., 56 years.

Stabilometric indicators of patient P. are given in table.2.

Table 2. Stabilometric study of patient P., 56 years old Walkways L mm S, mm ² Lfs V, mm / c ABOUT 3 ABOUT 3 ABOUT 3 ABOUT 3 1 492.0 686.6 201.1 525.6 2,4 1.3 9.6 13,4 2 471.5 600.9 268.4 377.6 1.7 1,6 9.2 12.1 Norm 435.3 613.1 182.2 258.4 1,0 1,0 10.6 11.5

Conclusion of the media (Romberg test): the common center of mass is somewhat shifted to the left and back, there is a lack of body balance along the sagittal axis. The vertical balance of the body is stable - indicators of length, area, and speed of the statokinesiogram with open eyes do not exceed the average standard values. With eyes closed, there is a slight (less than 50%) increase in the parameters of the area and the rate of deviation of the CD (less than 35%) in the first pass, which is supposedly of an installation nature.

PPCOI = 0.8 (no attachment of a pathopsychological component).

Thus, in patient P., a relatively stable body balance was observed with a tendency to the development of postural insufficiency in the sagittal component. Deviations of the common center of mass are caused by right-sided scoliotic deformity of the spinal column.

Observation 2. Patient S., 64 years old (medical history No. 1104/02). Clinical diagnosis: hypertension 2-3 stages. Atherosclerosis of cerebral arteries. Transient cerebrovascular accident in WBB from 05.27.02. Discirculatory encephalopathy 2 stages.

Complaints upon admission (05.28.02) of general weakness, instability when walking, periodic increase in blood pressure.

Anamnesis of the disease: the patient suffered from hypertension for 10 years with rises in blood pressure to 220/140 mm Hg, antihypertensive drugs were taken irregularly. 05/27/02 in the morning, when trying to get into the vehicle, I felt a lack of coordination in my hands. Upon exiting the metro to the street, a “pre-fainting” state was observed twice; after a few hours, I felt insecure when standing and walking.

Objectively: the condition is satisfactory. HELL 150/90 mm Hg, pulse 76 beats per 1 minute, rhythmic. Neurological status: pupils D = S. Weakened convergence. Horizontal fine nystagmus. The right nasolabial fold is smoothed, the deviation of the tongue to the right of the midline. Dysarthria Reflexes of oral automatism (+). Tendon reflexes are increased, more on the left, a decrease in muscle strength in the left leg to 4 points. Intention and mimicking on the left when performing a finger-nasal test, in the Romberg position - falling back. Increased footprint when walking.

Pathopsychological examination: intellectual-mnestic disorders are moderate.

TKDG - atherosclerosis of the arteries of the vertebral-basilar and carotid pools, more pronounced on the left.

X-ray of the cervical spine - pronounced degenerative-dystrophic changes.

MRI No. 14482/02 - no pathological foci in the substance of the brain were detected. Internal and external replacement hydrocephalus of a pronounced degree. Curvature of the vertebral arteries in the spinal canals on both sides.

Figure 3, 4 shows the report of the stabilometric study of patient C.

Figure 3. Report of the Romberg test of patient S., 64 years old. Pass 1.

Figure 4. Report of the Romberg test of patient S., 64 years old. Pass 2.

Table 3 shows the stabilometric indicators of patient C.

Table 3. Stabilometric indicators of patient C. Walkways L mm S, mm ² Lfs V, mm / c ABOUT 3 ABOUT 3 ABOUT 3 ABOUT 3 1 732.6 1576.6 472.9 1799.3 1,5 0.9 14.3 30.9 2 824.7 1246.5 598.2 648.4 1.4 0.9 16,2 24.4 Norm 435.3 613.1 182.2 258.4 1,0 1,0 10.6 11.5

Conclusion of the stabilometric study (Romberg test): the common center of mass is shifted anteriorly and to the left. Frontal deficit; fluctuations are observed mainly along the sagittal axis. The length and speed, area of the statokinesiogram with open eyes significantly exceeds the normative indicators (> 70%;> 200%), which indicates the III stage of postural disorders and their pronounced degree. With eyes closed, there is an increase in the length, area and speed of deviation of the CD in the first pass, which indicates the leading role of the visual analyzer in maintaining the vertical posture and the development of disorders of proprioreception of presumably central genesis. In the second pass, against the background of an increase in the indicators of tension in the work of the links of the statokinetic system (length and velocity of the SCG) with open eyes, their moderate decrease and a significant decrease in the area of the oscillations of the central nervous system with closed eyes occur, which indicates the patient’s compensatory capabilities.

PPCOI = 2.8 (moderate attachment of the pathopsychological component).

Thus, in patient C. significant static disturbances were recorded. Based on the MRI data, it can be assumed that the postural dysfunction in this patient developed as a result of diffuse atrophic changes in the brain involving deep white matter in the pathological process. However, the results of the second pass indicate satisfactory compensatory abilities of patient S., and therefore it was recommended to include training on the basis of biological feedback in the treatment plan. The revealed imbalance of the body in the sagittal component may indicate a more significant manifestation of cerebrovascular insufficiency in the vertebral-basilar vascular pool.

Observation 3

Patient L., 79 years old (medical history No. 1683/02). Clinical diagnosis: hypertension 3 stages. Atherosclerosis of cerebral arteries. The consequences of ischemic stroke in the pool of the right middle cerebral artery from 04/11/2002. Dyscirculatory encephalopathy 3 stages.

Complaints upon admission (10.16.2002) on shakiness and insecurity when walking, poor sleep, impaired memory and attention.

Anamnesis of the disease: the patient suffered from hypertension for a long time. Against the background of an increase in blood pressure (up to 240/140 mm Hg), several cases of weakness and numbness in the right extremities were noted.

Objectively: the condition is satisfactory. HELL 180/100 mm Hg, pulse 70 beats per 1 minute, rhythmic. Neurological status: pupils D = S. Weakened convergence. Vertical nystagmus. The nasolabial fold on the right is smoothed. Swallowing, phonation - not broken. Deep reflexes are lively, more to the left. Symptom of Babinsky on the left. Reflexes of oral automatism (+). Has hemigipesthesia on the left. In the Romberg position is unstable (fall to the left). Coordination tests are performed uncertainly.

Pathopsychological research: expressed intellectual-mnestic disorders.

TCD - signs of severe atherosclerotic lesions of the arteries of the vertebral-basilar and carotid pools.

MRI No. 12330/02 - a multifocal vascular lesion of the brain in the form of lacunar foci in the right half of the bridge, the right visual tubercle, the left frontal lobe. The expansion of perivascular spaces in the white matter of the hemispheres. Periventricular - zone of leukoaraiosis. Internal and external replacement hydrocephalus.

Figure 5, 6 shows the report of the stabilometric study of patient L.

Figure 5. Romberg test report patient L., 79 years old. Pass 1.

6. Romberg test report patient L., 79 years old. Pass 2.

Stabilometric indicators of patient L. are shown in table 4.

Table 4. Stabilometric indicators of patient L., 79 years old Walkways L mm S, mm ² Lfs V, mm / c ABOUT 3 ABOUT 3 ABOUT 3 ABOUT 3 1 1,100.9 1484.7 871.9 2036.1 1.3 1.4 21.6 29.1 2 1517.7 2194.4 925.7 2406.7 1,6 1,6 29.8 43.0 Norm 435.3 613.1 182.2 258.4 1,0 1,0 10.6 11.5

Conclusion of the stabilometric study (Romberg test): the patient's posture is unstable. The common center of mass is shifted somewhat to the left and back. The lack of balance of the body in the frontal and sagittal components. The indicators of length and speed, the area of the statokinesiogram significantly exceed the standard indicators for both open and closed eyes (> 70%;> 200%), which corresponds to stage III and a pronounced degree of postural disorders. Moreover, in the second pass, both with open and closed eyes, there was an increase in both indicators L, V, and S, i.e. decompensation was observed in the work of mechanisms to maintain a vertical posture.

PPCOI = 11.9 (pronounced accession of the psychopathological component).

Thus, statics disturbances in patient L. were of a pronounced nature and morphofunctional changes in the frontal and parietal lobes, deep sections of the white matter of the brain, and the right half of the bridge were observed at the basis of their manifestations. Cognitive impairment exacerbated the existing postural imbalance.

Thus, on the basis of a comprehensive examination of patients with organic pathology of the brain of various genesis, stabilometric parameters are determined that are able to diagnose significantly not only qualitatively, but also quantitatively determine the existing postural disorders; the parameters of the severity of postural disorders in relation to the data of a pathopsychological study were developed, developing the previously known influence of the emotional-cognitive sphere on maintaining the balance of the body in space. The proposed technique allows us to detect subclinical forms of static disorders that form against the background of pathological changes in the substance of the brain; the revealed parameters can be an indirect confirmation of the presence of an organic pathology of the brain in the patient and serve to determine the tactics of diagnostic and treatment measures in the patient’s individual medical plan (priority of neuroimaging and other instrumental research methods, expert advice); determination of the staging of postural disorders allows dynamic monitoring and evaluation of the effectiveness of ongoing rehabilitation treatment. The present invention will improve the accuracy of diagnosis of postural disorders and optimize the treatment process in patients with organic brain pathology, and also contributes to an expert assessment in patients with complaints of imbalance.

Our proposed method was tested in NIPNI them. V.M. Bekhterev in the departments of rehabilitation of neurological patients, treatment of neuropsychiatric patients with epilepsy, neurosis and psychotherapy.

Claims (1)

A method for diagnosing postural disorders in patients with organic brain pathology, including a stabilometric study, characterized in that the study is carried out in a modification of the Romberg test and repeated twice, measure the length of the statokinesiogram (L), the speed of movement (V) and the area of the statokinesiogram (S), additionally calculate the index of accession of the psychopathological component (PPCOI) according to the formula PPCOI = cp.LFScp.V, where cp.LFS is the average path length per unit area, calculated as (LFS 1 + LFS 2) / 2; cp.V is the module of the difference in the velocity of the center of pressure calculated as V2-V1, and when the value of L, V, S is changed by no more than 35% of the norm, the initial stage of postural disorders is diagnosed, when the value is changed from 35 to 70% of the norm, the stage of moderate disorders is diagnosed, and when the value changes by more than 70% from the norm - the stage of pronounced postural disorders, while with PPCOI values of up to 1.6, an insignificant connection of the psychopathological component is diagnosed, with values from 1.7 to 4.9 - moderately expressed, and with values of more than 5 - a pronounced connection of the psychopathological component nta.

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