RU2645243C1 - Correction method for cognitive impairment after traumatic brain injury - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurology, and can be used to restore cognitive functions in patients with craniocerebral trauma (CCT). Provide the patient with image of the object on the screen of the monitor to recognize the patient provided image. At the same time, a number of images of objects are simultaneously provided. Patient performs by recognizing choice of subject from given options, and correction classes are conducted for at least 10 days, 1 time per day. In doing so, they apply a comprehensive program of neurorehabilitation, consisting of task blocks, each of which promotes the preferential recovery of one of the aphasia species: motor, in which two main types are distinguished: afferent and efferent; amnestic; acoustic-gnostic and semantic. In this case, each task has no time limits.

EFFECT: method allows to increase the efficiency of rehabilitation of cognitive impairments in patients due to the use of a complex of computer programs that increase the patient's motivation for studies.

1 cl, 5 dwg, 3 tbl, 1 ex

Description

The invention relates to medicine, namely to neurology, and can be used to restore cognitive function in patients after traumatic brain injury (TBI).

A number of methods are known for the treatment and rehabilitation of cognitive functions in people with cerebrovascular diseases and with traumatic brain damage.

A known method of treating cognitive disorders in individuals also with cerebrovascular diseases (RU 2268723 C1 A61K 31/4015; A61K 31/522; A61M 21/00; A61P 25/28; 01/27/2006), including the introduction of microcirculatory and nootropic drugs, in the form of intravenous infusions for 10 days, then tablet forms of the same drugs are administered for 1 month and neuropsychological training is conducted to improve the patient’s everyday skills related to remembering names, important dates, medications and home locations subjects with a complication of 2 tasks as patients achieve success; training lasting 30 minutes is carried out 3 times a week; The course of treatment includes 12 lessons.

The known method of treatment involves the supervision and participation of highly qualified specialists and cannot be carried out by the patient on his own, it is also used in patients with cerebrovascular pathology.

A known method that is used in the process of treatment and rehabilitation measures for patients with the consequences of focal brain injuries, in particular with stroke and / or head injury (patent No. 2581707 C1 IPC A61B 5/16, op. 04.20.2016), including neuropsychological testing, which is carried out in dynamics, before and after treatment and rehabilitation measures. Testing involves evaluating dominant non-verbal and verbal functions. The results of each test are evaluated on a 10-point scale and determine the dynamics of the state of higher mental functions of the patient in the process of treatment and rehabilitation measures.

The disadvantages of this method include its complexity, the need for a large amount of stimulus material and special improvised tools for conducting training sessions, time consuming, high requirements for the qualification of a neurologist or neuropsychologist. This method is inaccessible for widespread use due to the fact that it requires the participation of a specialist neuropsychologist, it is mainly a diagnostic technique, and not a way to correct cognitive functions.

A known rehabilitation method is “A Game System for Cognitive Rehabilitation” (Hindawi Publishing Corporation BioMed Research International Volume 2015, Article ID 493562, 7 pages http://dx.doi.org/10.1155/2015/493562).

http://www.hindawi.com/journals/bmri/2015/493562/.

This method is similar in method of cognitive rehabilitation to the one we proposed, but it does not affect the zones of speech domains, does not have a Russian version, it is also quite expensive and requires the participation of a highly qualified specialist with experience working with a PC and Adobe Flash Player.

A method of specific neuropsychological rehabilitation is known (L. Tsvetkova. Neuropsychological rehabilitation of patients. Speech and intellectual activity. Moscow University Press, 1985, 326 pages (pp. 16-18, 21-24, 120-135), which consists in targeted training of impaired For example, in case of violation of the count, training is reduced to solving problems, if reading is impaired, it is training in reading ability.In addition to special speech therapy methods of training speech, reading, writing and counting in the rehabilitation of these patients, the use of special physical therapy techniques with exercises for speech muscles, special speech therapy massage, disinhibition of speech using non-verbal communication tools, electrical stimulation of oral muscles, development of the correct sequence of motor acts during apraxia, restoration of cognitive functions - attention, memory. refers to speech functions Special methods of neuropsychological rehabilitation are addressed to damaged or blocked sections of the cerebral cortex about the brain located in the dominant hemisphere.

The disadvantage of this method: with this method, insufficient attention is paid to the participation of the subdominant hemisphere, as well as the "non-speech" zones of the dominant hemisphere of the brain in restoring impaired functions, and improving the interaction and exchange of information between the two hemispheres. In addition, a specific training requires the availability of specialists who are familiar with the methods of neuropsychological diagnosis and rehabilitation; therefore, in most hospitals, patients do not receive this qualified help in the required amount.

The closest in technical essence and purpose to the proposed method is a method for the correction of cognitive impairment in cerebrovascular pathology using the Schulte table and noisy images (RF patent No. 2506963, IPC A61M 21/00, op. 20.02.2014), including providing the patient with an image of the subject “Noisy picture” with the possibility of dosing the density of “noisiness”, recognition of the provided image by the patient, characterized in that the image on the “noisy picture” is provided to the patient on e the wound of the monitor, while simultaneously additionally providing a series of images of objects made in clear lines, on one of which an object is shown with a “noisy picture”, the patient recognizes the object shown in the “noisy picture” by recognizing and selecting the object from the options provided, assignment of time is allotted, the maximum interval of which is determined by the doctor and after which the task is evaluated with a demonstration to the patient of the assessment on the monitor screen, while we demonstrate the patient’s score in points is directly proportional to the density of the “noise” of the picture, in which the patient gives the correct answer, and which is calculated according to the formula, the output of the score is accompanied by visual and / or sound means, correction exercises are carried out for at least 10 days, 1 time per day, with a duration of one lesson no more than 40 minutes.

A disadvantage of the known technical solution is:

- one-sided focus of the invention on the restoration of functions related to visual recognition and visual attention, the absence of tasks training other higher brain functions;

- lack of tasks of varying difficulty;

- the impossibility of emotional reinforcement of a positive result in the form of feedback from the patient;

- limited amount of stimulus material.

The objective of the invention is to create a rehabilitation method aimed at improving cognitive impairment in patients after head injury, through the development and use of computer programs.

The technical result from the application of the proposed method is to increase the efficiency of rehabilitation of cognitive impairment in patients through the use of a new set of computer programs that increase the patient's motivation for classes.

This is achieved due to the fact that the method of correction of cognitive impairment after traumatic brain injury, which includes providing the patient with an image of an object on a monitor screen, recognizing the image provided to the patient, while simultaneously providing a series of images of objects, the patient implements by recognizing and selecting an object from the options provided , correction classes are carried out for at least 10 days, 1 time per day, with a duration of one lesson of not more than 40 minutes, according to the invention in It includes the use of a comprehensive program of neurorehabilitation, consisting of 8 blocks of tasks, each of which contributes to the preferential restoration of one of the types of aphasia:

- motor, in which there are two main types of it - afferent and efferent; For the rehabilitation of these violations, several versions of the games were created: 1 - the image of the object is presented on the screen, the patient must choose the correct words from the following correctly composed words; 2 - the item is displayed on the screen, the name of this item in various variations is presented below, only one of which is correct (cloud-utcha-utach), the patient needs to choose the correct written version; 3 - the patient must compose the word to the image on the screen from the letters below; 4 - the patient is required to insert the missing letter into the word, while in more complex cases, words with similar phonemes are used (daughter-dot; cat-code, etc.). The number of reduced words to the image, the number of letters in the word varies in proportion to the severity of the violations.

- Amnestic (acoustic and optical-mnestic) to restore this type of aphasia, games have been developed in which the patient needs to select the right word for the picture, while depending on the complexity of the task, the number of words increases;

- acoustic-gnostic (sensory); for the rehabilitation of this type of speech disorders, games have been developed in which the patient is invited to select a picture for the voiced text; at the same time, the similarity of pictures among themselves varies depending on the level of tasks; in this case, in one of the blocks, which is divided into several levels of difficulty, the patient needs to select only a phrase (phrase) to the picture; at the same time, in the second level, the picture is selected for the whole story; at the same time, to facilitate tasks, the patient can use the prompt and / or listen to the text again and / or display by pressing a specially defined button on the screen in the form of a printed version;

- semantic; in this type of aphasia, the next block consists of several types of levels (games), in which the patient is asked to compare the beginning and end of the sentence, choose the desired ending in meaning, etc .;

in addition, each block is divided into several levels of the task in accordance with the severity of the degree of disorders; in addition, each task has no time limits.

The main therapeutic effect of the proposed method relative to other cognitive functions is due to the fact that it is created on the basis of the principle of biological feedback, which significantly increases the patient's motivation for classes and increases the effectiveness of the rehabilitation process in acute and chronic cerebral pathology.

The novelty of the invention lies in the selection and sequence of exercises involving various "speech" parts of the brain, restoring other cognitive functions for the second time. It also allows you to increase the "game" motivation of patients, which makes the rehabilitation process more attractive, and eliminates the need for numerous cards and other didactic material.

The set of essential features of the invention allows to obtain a new technical result.

1. Using exercises, the effect is on higher cortical functions and higher mental processes, and not just on speech.

2. A holistic approach to the activity of the brain is used, taking into account the dynamic localization of functions, training is conducted for both the affected and unaffected sides.

3. Hemispheric connections are activated, which improves the interaction and information exchange between the two hemispheres in patients who have had a head injury.

4. It can be used on an outpatient basis and at home without the help of specially trained personnel, which greatly simplifies the rehabilitation process and also reduces the cost of patient recovery.

The essence of the invention.

In FIG. 1 - input interface, blocks of games for the restoration of cognitive functions, general view.

In FIG. 2a - a program for the restoration of cognitive functions in patients with motor aphasia, the choice is either a correctly written word, or the insertion of a missing letter in the word.

In FIG. 2b - the same, composing a word from letters.

In FIG. 3 - a program for the restoration of cognitive functions in patients with amnestic aphasia (acoustic and optical-mnestic), the selection of the desired word in the picture.

In FIG. 4 - the same, the selection of the desired word in the picture, a complicated version.

In FIG. 5a - a program for the restoration of cognitive functions in patients with sensory (acoustic-gnostic) aphasia, the selection of phrases to the picture.

Description of the method.

The method is implemented by applying the developed program. The program consists of 8 blocks of tasks (Fig. 1), each of which contributes to the primary restoration of one of the types of aphasia:

- motor (Fig. 2a, 2b). There are two main types of it - afferent and efferent. This type of aphasia develops with damage to the posterior sections of the lower frontal gyrus. In this type of speech disorder, literal (rearrangement of syllables and letters) and verbal (replacement, rearrangement of words) paraphases are often noted, in addition, articulation of sounds similar in place of formation is often severely disturbed, reading and writing are also affected. Based on the above symptoms of speech disorders, the patient is required, depending on the degree of aphasia, to choose either the correctly spelled word (Fig. 2a), or insert the missing letter in the word, and in mild cases, independently compose the word from the letters (Fig. 2b).

- amnestic (acoustic and optical-mnestic) (Fig. 3 and 4). This type of aphasia occurs when the lower and posterior parts of the parietal and temporal regions (acoustic-mnestic) or the parietal-occipital parts of the brain (optic-mnestic) are affected. It is characterized by forgetting the names of objects, names. The patient cannot name the subject, although it well defines its purpose. With this understanding of speech, reading is not disturbed. To restore this type of aphasia, games have been developed in which the patient needs to choose the right word for the picture. At the same time, depending on the degree of difficulty of the task, the number of words increases (Fig. 3 and 4).

- acoustic-gnostic (sensory) (Fig. 5a). This speech disorder occurs with damage to the middle and posterior parts of the dominant hemisphere. Sensory aphasia is characterized by impaired understanding of speech, both surrounding people and their own. Phonemic perception of speech is disturbed: voiced voices and deafness of consonants, stressedness and unstressed syllables, hardness and softness of endings (in milder cases). In more severe cases, extraneous speech is perceived as noise or conversation in a foreign language.

In addition, the patient is disturbed and expressive speech, the so-called phenomenon of "verbal okroshka" occurs. For the rehabilitation of this type of speech impairment, games have been developed in which the patient is invited to select a picture for the voiced text. The similarity between the pictures varies depending on the level of tasks. In one of the blocks, which is divided into several levels of difficulty, a person needs to pick up only a phrase (phrase) to a picture (Fig. 5a); in the second - the picture is selected for the whole story (not shown). To facilitate tasks, the patient can use the prompt - either listen to the text again, or display by pressing a specially defined button on the screen in the form of a printed version. To develop these blocks of games, paintings by famous artists such as G. Reburn, V.V. Pukirev, D. Zolan, I.I. Shishkin, V.G. Perov, A.K. Savrasov and others, which also increases the intellectual level of the patient.

- semantic (not shown). When the parietal-temporal-occipital region of the dominant hemisphere is damaged, so-called semantic aphasia occurs, in which the understanding of the meaning of sentences expressed with the help of complex logical-grammatical, comparative, recurrent and attributive constructions is violated. Based on the main defect in this type of aphasia, the next block consists of several types of levels (games), in which the patient is asked to compare the beginning and end of the sentence, choose the right ending in meaning, etc.

In this case, most often, given the volume of the lesion of the brain as a result of moderate traumatic brain injury, any type of aphasia does not occur in isolation, but is combined with others, leading to multiple complex speech disorder.

Each block is divided into several levels of the task in accordance with the severity of the degree of disorder. Each task has no time limits, however, it is recommended that classes be held according to the scheme once a day for an average of 20-30 minutes for 10 days.

An example implementation of the method.

In order to verify the effectiveness of the method, 20 patients were examined in the intermediate and residual period of moderate TBI, with cognitive impairment of varying severity from moderate cognitive impairment to mild dementia. Of these, 10 people were the study group, in which the correction of cognitive impairment was carried out in accordance with the claimed method, and 10 people were the control group, in which classes on correction were not carried out. In this case, all patients received standard drug therapy, taking into account existing concomitant diseases. The age of patients ranged from 18 to 59 years. Prior to the correction according to the claimed method, patients of the control and study groups had no differences in the severity of cognitive impairment and the degree of head injury. The diagnosis of trauma to the examined patients was confirmed by CT or MRI of the brain. The exclusion criteria were: severe somatic pathology in Art. decompensation, repeated TBI, the presence of visual and hearing pathologies that impede classes, education level of 7 years or less, severe dysarthria, severe aphasia, the presence of active epilepsy and active epileptic changes on the EEG, the presence of severe cerebrospinal fluid disturbances, patients with cognitive impairment history of injury. Before and after the correction, a neurological examination was carried out using methods of neurological examination and neuropsychological testing according to generally accepted neurological scales. Assessment of cognitive functions in patients of the studied and control groups was carried out in the intermediate and residual periods of moderate TBI (30-365 days from the moment of injury), a second assessment of cognitive impairment was carried out at the end of the course of correction of cognitive impairment by the proposed method in the studied group. The following methods were used to evaluate the correction of cognitive functions: literal association test, categorical association test, Mini-Mental State Examination, Mental Status Examination Scale, Frontal Assessment Battery, clock drawing test, 10-word test , memorization and graphic reproduction of six abstract figures, recognition of unreformed objects.

At the same time, emotional-volitional disorders were evaluated on a hospital scale of anxiety and depression (HADS).

All patients did not have clinically significant speech disorders in order to increase the purity of the assessment of recovery of post-traumatic cognitive impairment.

The results of the correction of cognitive impairment of the study group are shown in table 1.

The results of the correction of cognitive impairment in the control group are shown in table 2.

As can be seen from tables 1 and 2, against the background of correctional exercises using the proposed method, a significant regression of the severity of cognitive and motor impairments in the study group was noted. A significant improvement in cognitive functions against the background of the classes was indicated by the positive dynamics of the results of most neuropsychological tests that were used in the study. The functions of spatial gnosis improved due to increased regulatory influence, concentration and switching of attention, emotional-volitional disorders decreased. Compared with the control group, a statistically more pronounced positive effect of correction of cognitive impairment was noted. The proposed method is created on the basis of the principle of biological feedback, which significantly increases the patient's motivation for classes, rehabilitation accessibility and increases the efficiency of the rehabilitation process in persons who have had a head injury.

The following is an example of the use of a method for the correction of cognitive impairment in cerebrovascular pathology.

The following is an example of the use of a method for the correction of cognitive impairment in cerebrovascular pathology.

Example: Patient S., 24 years old, male. Diagnosis: Intermediate period of brain injury from 05/17/2014: severe brain contusion with parenchymal-subarachnoid-ventricular hemorrhage in the form of extrapyramidal dysarthria of mild degree, imbalance in the type of moderate mixed ataxia (frontal, left-sided cerebellar hemiatraxis, tetra left, reflex on the right, auditory and oculomotor disorders, with impaired walking function as frontal dysbasia.

From the anamnesis: May 17, 2014, an accident, as a result of which, in a serious condition, he was taken to the central hospital, where he was diagnosed with: CCI. A severe brain contusion with parenchymal-subarachnoid-ventricular hemorrhage. Open fracture of the lower jaw. Fracture of the medial ankle of the left lower leg. 05/18 was transferred to KKB№1. Within 1 month I was in the OAiR, mechanical ventilation was performed. When stabilizing the condition, the following operations were performed: open reduction, osteosynthesis of the medial ankle; open reposition, MOS of the chin area of the lower jaw. Then he repeatedly took courses in motor rehabilitation. Chr. diseases: SVD mixed type. Syndrome of early repolarization of the ventricles. Chronic prostatitis.

According to the results of the additional examination: MSCT of the brain dated 05/17/2014 - data are not available. MSCT of the brain in dynamics from 05/20/2014: in the dynamics, contusion foci are preserved in the frontal lobe on the right. The blood volume in the bypass tank on the right, right lateral and posterior horn of the left lateral ventricle significantly decreased. In the right temporal region, congestion of liquor by convex up to 5 mm. Middle structures are not displaced. MSCT of the brain in dynamics from 05.29.2014: in comparison from 05.20 there is a positive dynamics of the concussion focus in the right frontal lobe and blood in the basal cisterns and the ventricular system. Middle structures are not displaced. Laboratory examination: accelerated ESR syndrome (35 mm / h), the rest - without pathological changes.

In the acute period, examined by a neuropsychologist: violation of the regulatory and neurodynamic components of HMF in the form of impulsivity and disinhibition, decreased general and directed attention, field behavior, and persistence in sensitized samples. Fatigue is expressed. The relative safety of visual gnosis, a secondary decrease in optical-spatial gnosis and praxis. Preservation of tactile gnosis on both sides. The relative safety of all types of praxis. Oral praxis preserved. Violation of mnestic activity against the background of violations of regulation of activity. Spontaneous and repeated speech is relatively preserved, difficulties due to tracheostomy. Nominal function saved. The relative safety of writing and reading. The primary safety of the account. The relative safety of the functions of generalization and abstraction. Thus, according to neuropsychological testing, a focal lesion of the prefrontal regions on the right with leading moderate frontal syndrome with behavioral disorders is determined.

In neurological status during examination: Clear consciousness, speech with elements of extrapyramidal dysarthria of mild degree. FMN: normosmia, vision is reduced in both eyes, palpebral fissures and pupils are symmetrical, diplopia when looking down, asymmetry of the NSA on the left, hearing is reduced, more on the right ear, swallowing is not difficult, pseudobulbar syndrome (increased pharyngeal reflex on both sides, elements of dysarthria) . The range of movements is not limited, muscle tone kinesiogenically increases in the left extremities, muscle strength is reduced in the left extremities to 4b, left-sided anisoreflexia with expansion of reflex zones on both sides, walking with elements of fronto-subcortical dysbasia. Sensitivity is not impaired. In the settlement of Romberg, the shakiness, which significantly increases under vestibular loads, the coordinator tests on the right correctly displays, on the left - with intention and dysmetria. Pelvic function controls. There are no meningeal signs.

Prior to the correction according to the claimed method, the patient underwent neuropsychological testing using the above-described scales, the examination was carried out 5 months after the injury (an intermediate period of severe brain injury of the brain injury). For 5 months, the patient was given standard medication taking into account concomitant diseases and a course of motor rehabilitation.

The following methods were used to assess cognitive impairment: a literal association test, a categorical association test, a brief Mental Status Assessment Scale - Mini-Mental State Examination, a Frontal Assessment Battery, a clock drawing test, a 10-word test, memorization and graphic reproduction of six abstract figures, recognition of under-detailed objects, emotional-volitional disorders on the hospital scale of anxiety and depression (HADS).

Rehabilitation using the proposed correction method was carried out for 10 days with a frequency of 1 time per day, the duration of classes was 20-25 minutes (given the severity of the condition, the presence of emotional-volitional disorders and a reduced level of motivation). The patient was in front of a computer screen on which options for the above program were presented. In one lesson, 2-3 blocks of tasks were carried out, in each of which it was necessary to accurately fulfill all the proposed levels of difficulty. After completion of the correction course, repeated neuropsychological testing was carried out using the same methods.

As a result of the rehabilitation, an improvement in cognitive functions was reliably observed, as evidenced by the positive dynamics of most of the neuropsychological tests used in the study, in addition, the level of motivation to study and further restore both cognitive and motor deficits increased due to a decrease in emotional-volitional disorders. The results of the correction of cognitive impairment in patient C. using the proposed method are shown in table 3.

As follows from the presented data, the patient's regulatory and neurodynamic component improved, which, in turn, contributed to the improvement of mnemonic activity, increased the level of motivation and voluntary attention, decreased the degree of impairment of executive functions.

Thus, based on the above information, the proposed method allows you to:

- use it to correct not only speech disorders, but also to restore concomitant cognitive impairment;

- increase the “game” motivation of patients (the design of the task in the form of a game with a demonstration of the results of the assessment and assessment of its support by visual and / or sound means), which makes the rehabilitation process more attractive, increasing the effectiveness of rehabilitation treatment;

- conduct classes for a general practitioner, exercise instructor or patient’s relatives at all stages of successive rehabilitation;

- adjust the degree of load;

- reduce the cost of restoration of HMF;

- eliminate the need for registration of numerous cards and other didactic material.

Claims (5)

A method for correcting cognitive impairment after a traumatic brain injury, including providing the patient with an image of an object on a monitor screen, recognizing the image provided by the patient, while simultaneously providing a series of images of objects, while the patient performs recognition and selection of the object from the options provided, correction exercises are carried out for at least 10 days, 1 time per day, characterized in that it includes the use of a comprehensive program of neurorehabilitation in the form of ig s consisting of eight blocks of tasks, each of which contributes to the advantageous recovery of one of the types of aphasia: - motor; for the rehabilitation of these violations offer game options: 1 - the image of the object is presented on the screen, the patient must choose the correct words from the following correctly composed words; 2 - the item is displayed on the screen, the name of this item in various variations is presented below, only one of which is correct, the patient is required to choose the correctly written version; 3 - the patient must compose the word to the image on the screen from the letters below; 4 - the patient is required to insert the missing letter into the word, while in more complex cases, words with similar phonemes are used, the number of reduced words to the image, the number of letters in the word changing in proportion to the severity of the violations; - amnestic; for the rehabilitation of these disorders, they offer games in which the patient needs to choose the right word for the picture shown on the monitor screen; - acoustic-gnostic; for the rehabilitation of this type of speech impairment, games are offered in which the patient must select the picture shown on the monitor screen to the voiced text; while the patient selects the phrase to the picture shown on the monitor screen; while the patient selects the picture for the story shown on the monitor screen; - semantic aphasia, for the rehabilitation of these disorders, they offer games in which the patient must compare the beginning and end of the sentence shown on the monitor screen, select the ending that is necessary in meaning; in addition, each task has no time limits.

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