RU2682873C1 - Method of treating patients with vascular cognitive impairment due to ischemic damage of brain in early recovery period of disease - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to the field of medicine, namely, neurology and medical rehabilitation, and can be used to treat patients with vascular cognitive impairment due to ischemic brain damage in the early recovery period of the disease. In the setting of basic nootropic therapy and correction of cognitive impairment with the help of coursework on stimulus techniques of A. R. Lourie, a photochromotherapy is performed. Applying green narrow-band optical LED radiation with a wavelength of 530 nm, the radiation power of 90 mW is carried out. Initially, transorbital action is applied to each orbit for 1.5–2.5 minutes with the patient's eyes closed, and then the same radiation with the same wavelength is applied to the neck-collar zone labile for 8–10 minutes with a radiation power of 120 mW. Course of treatment consists of 10–12 procedures, carried out on 1 procedure every other day on the SHATL-Combi IR+ apparatus, VEGA modification.EFFECT: method provides improvement of cognitive functions in patients, reduction in the number of cases in patients with benign headache due to a combination of nootropic therapy, correction of cognitive impairments according to the methods of Lourie and photochromotherapy.1 cl, 2 ex, 1 tbl

Description

The invention relates to medicine, namely neurology and medical rehabilitation, and can be used for medical rehabilitation of patients with vascular cognitive impairment due to ischemic brain damage in the early recovery period of the disease.

In order to correct cognitive impairment in patients after ischemic stroke, two main strategies are currently used: drug therapy and physiotherapeutic methods of treatment.

Among drug methods for the correction of cognitive impairment in cerebrovascular diseases, several groups of drugs are widely used [1]. Among them: neuroprotectors (antioxidants - mexidol, a complex neuroprotective drug based on the extract of ginkgo biloba - tanakan); vasoactive drugs (nimodipine, vinpocetine); metabolic drugs (nootropil, ceraxon); neurotrophic drugs (cerebrolysin, actovegin, semax); drugs with dopaminergic action (pronoran); drugs with cholinergic action (gliatilin, rivastigmine, galantamine, donepezil); antiglutamatergic drug (akatinol).

Despite the wide variety of groups of drugs used to correct vascular cognitive impairment, the effectiveness of none of the drugs used is sufficient, therefore, drugs are most often used in combination. In addition, a long course intake of these drugs is necessary for the development of a visible effect, and the presence of side effects in some cases limits their use. The latter is most relevant for a group of drugs with cholinergic action [1].

The second direction of the correction of vascular cognitive impairment is physiotherapeutic methods of treatment. For this purpose, stroke patients use electrophoresis of nootropic drugs, laser therapy, hyperbaric oxygenation and transcranial magnetotherapy with a constant or alternating magnetic field [2].

However, the application of these techniques also has its drawbacks. So, when using electrophoresis of nootropic drugs, as a rule, an endonasal technique is used, and this, in turn, is often accompanied by damage and drying of the nasal mucosa, leading to nosebleeds, which prevents the full course of treatment.

The use of laser therapy and transcranial magnetotherapy has low efficiency when used alone compared to standard drug nootropic therapy.

The use of hyperbaric oxygenation is associated with the use of expensive equipment, namely, a pressure chamber. In addition, significant restrictions on its use are imposed by the frequent presence in patients of claustrophobia and impaired barofunction of the middle ear and paranasal sinuses.

As a prototype for the closest technical

In essence, we have chosen a method for treating patients with vascular cognitive impairment due to ischemic brain damage in the early recovery period of the disease, by means of a physiotherapeutic effect consisting of transcranial magnetic stimulation with a traveling magnetic field (TMS-BIMP) on the AMO-ATOS-E device. The irradiation was carried out in a sitting position of the patient according to the bitemporal technique using the attachment "Headband". We used an alternating reverse traveling magnetic field with a magnetic field induction of 45 mT, a base frequency of 50 Hz, and a modulation frequency of 10 Hz, which is a “frequency window” for the alpha rhythm of the cerebral cortex [3]. The course of procedures consisted of 10 procedures carried out every other day.

The disadvantage of the method that we selected as a prototype, according to our own data, should be attributed to its insufficiently high efficiency, which is reflected in a low increase in scores on scales for evaluating cognitive functions, as well as the fact that the use of the prototype method in 10-15% of cases is accompanied by development benign headache, which limits the application of the method. The method we have chosen as a prototype also has a number of limitations for use in the form of contraindications: retinal detachment; acute inflammatory eye diseases; myopia above 5D; arachnoiditis; frequent attacks of epilepsy; tendency to bleeding; the presence of metal implants in the skull; bone defects of the skull; acute myocardial infarction; systemic blood diseases; severe hypotension; acute infectious diseases; purulent-inflammatory processes; intracranial hemorrhages of traumatic origin in the acute period [4].

Considering that the effectiveness of this technique is comparable to drug therapy, it is a large list of contraindications that limits its use in clinical practice.

The technical result of the invention is:

- improvement of cognitive functions in patients with vascular cognitive impairment caused by ischemic damage to the brain in the early recovery period of the disease due to the improvement of indicators of attention, verbal thinking and speech function;

- reduction in the number of cases of development of benign headache in patients;

- expansion of the patient population due to patients with myopia above 5D, arachnoiditis, a tendency to bleeding, the presence of metal implants in the skull, bone defects of the skull, acute myocardial infarction, systemic blood diseases, severe hypotension, acute infectious diseases, purulent-inflammatory processes, intracranial hemorrhages traumatic genesis in the acute period.

The technical result of the invention is achieved by the fact that against the background of basic nootropic therapy and the correction of cognitive impairment with the help of a course consisting of 10 classes by A.R. Lurie [5] conduct photochromotherapy (PCT) by exposure to green narrow-band optical LED radiation with a wavelength of 530 nm, a radiation power of 90 mW, initially transorbitally for 1.5-2.5 minutes per eye socket with the patient's eyes closed, and then the same radiation with a similar wavelength affect the cervical-collar zone labile for 8-10 minutes with a radiation power of 120 mW. The course of treatment consists of 10-12 procedures, carried out according to 1 procedure every other day on the device SHATL-Combi IK +, VEGA modification.

The method is as follows:

Patients with verified by a neuropsychologist cognitive impairment due to ischemic brain damage in the early recovery period of the disease against the background of basic medicinal neuroprotective therapy, as well as a standardized course of 10 lessons using stimulus techniques A.R. Lurie is exposed to green narrow-band optical LED radiation with a wavelength of 530 nm on a SHATL-Combi IR + device (VEGA modification), manufactured by Medlaz-Neva, St. Petersburg, Russia.

Before starting the procedure, the patient, naked to the waist, is seated on a chair in a room with room temperature and a muffled diffused upper light. Irradiation is carried out transorbitally for 1.5-2.5 minutes for each eye socket with the patient’s eyes closed at a radiation power of 90 mW, and then with the same radiation with a similar wavelength they affect the cervical-collar zone labile for 8-10 minutes with radiation power 120 mW. After the procedure, the patient is offered rest in a sitting position with his eyes closed for 5-7 minutes.

The course of treatment consists of 10-12 procedures every other day. Contraindications: frequent epipressures, retinal diseases, individual intolerance to the procedure.

The salient features of the proposed method and the causal relationship between them and the achieved technical result:

- As a physiotherapeutic effect, photochromotherapy is carried out by exposure to green narrow-band optical LED radiation with a wavelength of 530 nm transorbitally for 1.5-2.5 minutes per eye socket with the patient's eyes closed with a radiation power of 90 mW, and then with the same radiation with a similar length the waves act on the cervical-collar zone labile for 8-10 minutes with a radiation power of 120 mW, the treatment course consists of 10-12 procedures, carried out according to 1 procedure every other day on the device SHATL-Combi IK +, modification VEGA.

The invention is based on the theory of neurotrophic effects of photochromotherapy with monochrome incoherent radiation of electromagnetic waves of the optical range of green color with a wavelength of 530-540 nm both on peripheral neurons damaged as a result of trauma or compression due to restoration of nerve conduction [6], and on brain neurons, damaged due to ischemia [7, 8].

The impact on the cervical-collar zone with green narrow-band optical LED radiation with a wavelength of 530 nm is due to the fact that a large number of reflexogenic zones are located in this zone directly and indirectly involved in stimulating the reticular formation and thereby providing increased energy supply for voluntary mental activity.

The transorbital effect on each eye socket with the patient's eyes closed provides a direct stimulating effect on the cerebral cortex, mediated by the olfactory tract, which, ultimately, leads to stimulation of neuroplasticity and correction of cognitive deficit.

The exposure to the above green narrow-band optical LED radiation is carried out against the background of basic nootropic therapy and correction of cognitive impairment with the help of coursework using stimulus techniques A.R. Lurie.

Conducting a physiotherapeutic effect against the background of standard measures for the correction of cognitive impairment, such as course psychological exercises using stimulus methods A.R. Lurie and basic nootropic therapy (akatinola memantine or ceraxon or semax) enhances the effects of the latter in terms of improving memory, attention, abstract thinking and speech.

Examples from clinical practice:

Example 1. Patient A., 66 years old, a pensioner, was admitted to the rehabilitation department of the Nikolaev hospital in St. Petersburg on 08.28.15 with a diagnosis of Cerebrovascular disease. The early recovery period of ischemic stroke in the left cerebral artery basin from 07/21/15, with right-sided hemiparesis. Coronary heart disease, atherosclerosis of the aorta and coronary arteries. Hypertension 3 stages, the risk of cardiovascular complications 4. Chronic heart failure 2a degree (2 functional class according to NYHA classification). Type 2 diabetes.

Neurological status: mixed aphasia of mild degree, the pupils are the same, the reaction to light is lively. There is no diplopia. The movement of the eyeballs in full, nasal hemianopsia on the left. Central right-side prozoparesis. Tongue in the midline. Tendon reflexes are enlivened on the right. There are no symptoms of oral automatism; Rossolimo-Venderovich’s positive reflex is on the right. The positive Babinsky reflex on the right. Muscle tone increased in pyramidal type on the left. Muscle strength: right-sided hemiparesis - 4 points. In the Romberg position, staggering without clear lateralization. Sensitivity is not impaired. Cognitive impairment of mild dementia.

After neuropsychological testing, the patient revealed the presence of vascular cognitive impairment at the level of mild dementia. Indicators of cognitive functions at admission: total MMSE score - 23, total FAB score - 9, total score on the Roschina scale - 26, Schulte test result - 150 sec.

The patient underwent a standard course of rehabilitation measures for the correction of vascular cognitive impairment due to ischemic brain damage, provided for by the standards of medical care for this nosology: drug therapy (akatinola memantine, a blocker of glutamate NMDA receptors with nootropic activity, 20 mg per day); 10 lessons with a neuropsychologist using stimulus techniques A.R. Lurie; and also 10 sessions were conducted every other day after physiotherapeutic exposure to green narrow-band optical LED radiation with a wavelength of 530 nm on a SHATL-Combi IR + device (VEGA modification). Irradiation was carried out transorbitally with the patient's eyes closed for 1.5 minutes per eye socket with a radiation power of 90 mW, and then the cervical-collar zone was labile for 8 minutes with a radiation power of 120 mW.

As a result of the treatment, 25 days after admission, an improvement in the cognitive profile to the level of population norm was achieved: total MMSE score - 28, total FAB score - 17, total score on the Roschina scale - 18, Schulte test result - 65 sec.

Thus, the claimed method allowed to completely restore the cognitive deficit that developed after ischemic brain damage in patient A. in the left cerebral artery basin.

Example 2. Patient M., 68 years old, a pensioner, was admitted to the rehabilitation department of the Nikolaev hospital of St. Petersburg 01/23/15, with a diagnosis of Cerebrovascular disease. The early recovery period of ischemic stroke in the pool of the right midbrain artery dated January 4, 2015 against the background of cerebral arteriosclerosis, stage 3 hypertension. Risk of cardiovascular complications 4. Coronary heart disease. Atherosclerotic cardiosclerosis. Chronic heart failure 2a degree (2 functional class according to NYHA classification). A persistent form of atrial fibrillation of unknown duration. Chronic pyelonephritis, without exacerbation. Autoimmune thyroiditis.

Neurological status: speech unchanged, the pupils are the same, the reaction to light is sluggish. Weakness of convergence of eyeballs on both sides. Central left-side prozoparesis. Tongue deviation to the left. Vestibuloataxia. Tendon reflexes are enlivened on the left. There are no pathological carpal and foot reflexes. Muscle tone increased in pyramidal type on the left. Muscle strength: in the distal part of the left hand 2 points, in the proximal - 3 points, in the left leg - up to 3.5 points. In the Romberg position, staggering with lateralization to the left. Muscle tone increased in pyramidal type on the left. Heel-heel test performs uncertainly. Sensitivity: left-sided hemihypesthesia, hemihypalgesia. Pronounced cognitive impairment.

After neuropsychological testing, the patient revealed the presence of vascular cognitive impairment at the level of moderate dementia. Indicators of cognitive functions at admission: total MMSE score - 19, total FAB score - 12, total score on the Roschina scale - 25, Schulte test result - 125 seconds.

The patient underwent a standard course of rehabilitation measures for the correction of vascular cognitive impairment due to ischemic brain damage, provided for by the standards of medical care for this nosology: drug therapy (0.1% solution of semax, a nootropic drug belonging to the group of analogues of neuropeptides, 2 drops each nasal passage 4 times a day for 14 days); 10 lessons with a neuropsychologist using stimulus techniques A.R. Lurie; and also 10 sessions were conducted every other day after physiotherapeutic exposure to green narrow-band optical LED radiation with a wavelength of 530 nm on a SHATL-Combi IR + device (VEGA modification). Irradiation was performed transorbitally with eyes closed for 2.5 minutes for each eye socket with a radiation power of 90 mW, and then to the cervical-collar zone labile for 10 minutes with a radiation power of 120 mW.

As a result of the treatment, 30 days after admission, an improvement in the cognitive profile to the level of mild cognitive impairment was achieved: total MMSE score - 27, total FAB score - 14, total score on the Roschina scale - 14, Schulte test result - 70 seconds.

This suggests that the inventive method significantly corrected the cognitive deficit that developed after ischemic brain damage in patient M. in the pool of the right midbrain artery.

In order to prove the higher efficiency of exposure to green narrow-band optical LED radiation according to the claimed method in the treatment of patients with vascular cognitive impairment due to ischemic brain damage in the early recovery period of the disease compared to transcranial magnetic stimulation by a traveling magnetic field, we decided to compare the two indicated methods physiotherapeutic effects in combination with basic nootropic therapy and correction to of cognitive impairment with the help of coursework by stimulus methods A.R. Lurie in both cases.

We conducted a comparison of the proposed method (23 patients — the experimental group) and the prototype method (35 patients — the control group). In the experimental group, patients received 10 sessions every other day with a physiotherapeutic exposure to green narrow-band optical LED radiation with a wavelength of 530 nm on the SHATL-Combi IR + device (VEGA modification) on the collar zone and transorbitally during studies with a neuropsychologist and basic nootropic therapy. In the control group, patients received 10 sessions every other day with physiotherapeutic effects against the background of basic nootropic therapy and correction of cognitive impairment with the help of coursework using stimulative techniques A.R. Lurie of transcranial magnetic stimulation by a running magnetic field (TMS-BIMP) on the AMO-ATOS-E apparatus using a bitemporal technique with a magnetic field induction of 45 mT, a base frequency of 50 Hz, a modulation frequency of 10 Hz, also against the background of basic nootropic therapy and correction of cognitive impairment with using coursework on stimulus techniques A.R. Lurie.

Groups were comparable by gender and age. A total of 26 women and 32 men were examined. The average age in the experimental group was 61.5 ± 9.4 years (min - 33 years, max - 74 years), in the control group - 61.2 ± 8.3 (min - 40 years, max - 78 years), respectively.

In order to assess the level of cognitive functions, neuropsychological testing was performed before and after treatment. The following tests were evaluated: a brief assessment scale of mental functions MMSE (used to assess the level of cognitive functions), a 5-point clock drawing test (visual-spatial orientation assessment), a Schulte test (attention assessment), a FAB frontal test battery (overall rating control functions). Roshchina score was also used. The total score on this scale quantitatively characterizes the overall level of cognitive functions, while the subscales of this scale evaluate the following cognitive functions: 1, 4, 8, 10 - assessment of auditory-speech memory; 5 - assessment of visual spatial memory; 2, 6 - assessment of visuospatial orientation; 9, 11 - an assessment of the actualization of past knowledge; 3, 7, 12 - assessment of verbal thinking.

In addition, the speech therapist evaluated the general state of speech in points according to the following algorithm: 0 points - normal, 1 - mild dysphase (mild speech impairment), 2 - moderate dysphase (mild speech impairment), 3 - severe dysphasia (severe speech impairment), 4 - total aphasia (complete absence of speech function).

According to the results of the calculation, it was found that both methods provided a significant improvement in the cognitive profile on all evaluated scales by the end of the course (p <0.05).

The next stage of the study was a comparison of the effectiveness of the proposed method and the prototype method among themselves.

The comparison results are shown in table 1.

From table 1 it follows that in the experimental group, the increase in the speed of working with Schulte tables was 34.4 seconds (29% of the initial level), while in the control the increase was only 16.3 seconds (16% of the initial level). Also in the experimental group there was a greater increase in points on the subscale 7 of the Roschina scale - 1.36 points (78% of the initial level), and in the control group the increase in points for this subscale was only 0.35 points (25% of the initial level). In addition, in the experimental group there was a large decrease in the level of speech impairment - by 0.74 points (74% of the initial), while in the control there was a decrease of only 0.31 points (37% of the initial). All these differences had a significant level of significance of differences (p <0.05).

Thus, the claimed method, compared with the prototype method, significantly improved indicators:

- attention (Schulte test score);

- verbal thinking (assessment according to the subscale of the scale by Roschina No. 7);

- speech function (assessment by a point of speech and speech therapy assessment).

In addition, when applying the prototype method in 15% of cases, there was a development of benign headache, requiring the use of non-steroidal analgesics and interruption of the course of treatment for 2-3 days. Moreover, in none of the 23 patients who tested the proposed method, there were no cases of benign headache.

Thus, the claimed method allows, in comparison with the prototype:

- improve indicators of attention, verbal thinking and speech function;

- reduce by 100%, compared with the prototype, the incidence of benign headache;

- to expand the patient population by patients with myopia above 5D, arachnoiditis, bleeding tendency, presence of metal implants in the skull, bone defects of the skull, acute myocardial infarction, systemic blood diseases, severe hypotension, acute infectious diseases, purulent-inflammatory processes, intracranial hemorrhages traumatic genesis in the acute period.

Bibliography:

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3. Verkhlyutov, V.М. EEG overflows and moving waves of the alpha rhythm of the human cerebral cortex: dis ... cand. honey. Sciences: 14.03.17: protected 1999 / Verhlyutov Vitaliy Mihaylovich. - M., 1999 .-- 113 p.

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Claims (1)

A method for the treatment of patients with vascular cognitive impairment due to ischemic brain damage in the early recovery period of the disease, which consists in physiotherapeutic effect, characterized in that against the background of basic nootropic therapy and correction of cognitive impairment with the help of coursework using stimulation techniques A.R. Lurie, as a physiotherapeutic effect, conduct photochromotherapy by exposure to green narrow-band optical LED radiation with a wavelength of 530 nm, a radiation power of 90 mW, initially transorbitally for 1.5-2.5 minutes per eye socket with the patient’s eyes closed, and then with the same radiation with with a similar wavelength affect the cervical-collar zone labile for 8-10 minutes with a radiation power of 120 mW, the treatment course consists of 10-12 procedures, carried out according to 1 procedure every other day on the SHATL-Ko apparatus MBI IR +, VEGA modification.