RU2743222C1 - Method of correction of human locomotor functions after cerebral blood flow disorder of ischemic genesis - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to restorative medicine, and can be used for human locomotor abilities correction after cerebral blood circulation disorder of ischemic genesis. It involves high-frequency transcranial magnetic stimulation (TMS) and percutaneous electric spinal cord stimulation (PESCS). Therapeutic course consisting of 18 sessions is performed 6 times a week, 2 times a day. Using electroneuromyography for each patient, a threshold irritant of the induced motor response (IMR) of lower extremity muscles is individually selected in posterior roots PESCS between Th11-Th12 and primary motor vessel TMS in projection of lower limb muscles representation. Each session consists of 3 parts. First part of the session involves magnetic stimulation of the primary motor cortex in the innervation zone of the lower extremity on the side of the source of stroke with frequency of 10 Hz and intensity of the magnetic stimulus of 90 % of the threshold of the induced motor response in the TMS of the distal muscles of the injured extremity. Exposure time of magnetic pulses to the cerebral cortex is 3 minutes. Parts 2 and 3 of the lesson include percutaneous electric stimulation of the spinal cord in a Th11-Th12 projection of the vertebrae to affect a lumbar thickening of the spinal cord, in which neuron networks of human locomotor function are localized (Generator of walking movements). Current intensity in PESCS makes 90 % of IMR threshold of distal muscles of involved limb, which was detected by electroneuromyographic examination. Duration 2 of session is 25 minutes, stimulation is performed at frequency 5 Hz. 3 part including PESCS with application of electrodes similar to part 2, and stimulus value 90 % of threshold. In contrast to the second part, the frequency of electrical stimuli is 30 Hz. Duration of the third part of session is 25 minutes.EFFECT: method enables selective action on primary cerebral motor cortex and neural network of spinal cord responsible for initiation of locomotion act due to combined application of TMS and PESCS in several stages.1 cl, 2 ex

Description

The invention relates to medicine, namely to methods of rehabilitation of patients with ischemic stroke in the acute period of rehabilitation treatment and can be used in neurology, for the correction of locomotor function in patients with plegia and paresis of the lower extremities.

Violation of the locomotor function of patients after a stroke leads to a significant limitation of life, since in most cases the degree of dependence of patients on outside help determines their ability to move independently, therefore, the urgent problem of restorative medicine is the search for new methods for correcting locomotor function that do not expose patients to the risk of undesirable effects.

Correction of motor functions after a stroke is carried out due to the mechanisms of neuroplasticity of the central nervous system and remodeling of cerebral and spinal assemblies. The launch of these processes can be activated by direct stimulation of the affected centers of the primary motor cortex, and neural ensembles of the spinal cord, which has received its expert confirmation [Clinical significance of the phenomenon of neuroplasticity in ischemic stroke / I.V. Damulin, E.V. Ekusheva 2016. T. 10. No. 1. S. 57-64.].

There are a number of techniques for restoring motor functions in stroke patients. In particular, a method for the treatment of paralysis and paresis [Tyshkevich TG, Nikitina V.V. Application RU No. 94017115. IPC A1, publ. 09/10/1997]. The authors propose a method of using low-frequency electromagnetic stimulation of the brain zones and spinal cord segments that innervate the paretic muscles, in combination with their electromyostimulation.

The disadvantage of this method is the use of low-frequency electromagnetic pulses, which have a braking effect on the affected parts of the motor system [Rossi S., Hallett M., Rossini P. M., Pascual-Leone A. Safety, ethicalconsiderations, andapplicationguidelinesfortheuseoftranscranialmagneticstimulationinclinicalpracticeandresearch. Clin. Neurophysiol. 2009; 120 (12): 2008-2039.].

There is a method of treating patients with ischemic stroke in the acute period [Kulishova TV, Shinkorenko OV, Timoshnikova A.V. Copyright certificate RU No. 2500441. IPC A1, publ. Bul. N 34 date: 12/10/2013], which involves magnetic stimulation with several configurations of magnetic impulses of different parts of the cerebral cortex during one session.

The disadvantages of the proposed method include isolated stimulation of brain neurons, which significantly limits the degree of restoration of voluntary movements in the affected limbs, since one of the main factors in triggering neuroplasticity processes is afferent stimulation from the periphery.

The closest way to the one proposed by us is a method of treating ischemic cerebral strokes [Mikhailov VP, Vizilo TL, Kuzmichev AA, Petushenko KV. Patent RU No. 2157265. IPC C1, publ. Bul. N 28 date: 10.10.2000]. The rehabilitation course consists of 14 daily sessions. The lesson consists of magnetic stimulation of the primary motor cortex at 4 points: in the projection of the right and left hand for 5 minutes; in the projection of the right and left legs for 5 minutes, after which magnetic stimulation of the spinal cord roots is sequentially carried out at the level of the cervical thickening C7 and the lumbar thickening L5.

Disadvantages of the method:

1. Prolonged high-intensity magnetic stimulation of the cerebral cortex can provoke the appearance of epileptic brain activity;

2. Short-term magnetic stimulation of the spinal cord;

3. At the level of the 5th lumbar vertebra, the lumbar thickening ends and it is ineffective to stimulate it for the purpose of targeted training of the neural networks of the spinal cord and the neuromuscular apparatus;

The technical result of the claimed invention is to improve the efficiency of rehabilitation of patients after ischemic stroke in the acute period of rehabilitation treatment.

The technical result is achieved by the fact that the patient 6 days a week, 2 times a day sequentially conducts classes, including transcranial magnetic stimulation (TMS) and percutaneous electrical stimulation of the spinal cord (TESSC). TMS is performed using the Neuro-MS apparatus: the coil IDU-02-100-O is placed in the projection of the primary motor cortex in the innervation zone of the lower extremity, by contact, the duration of stimulation is 3 min, the intertrain interval is 5 sec, the duration of the train is 5 sec , stimulation frequency - 10 Hz, magnetic field intensity - 90% of the threshold of the evoked motor response (EMR) of the distal muscles of the lower extremities. Immediately after the end of TMS, transcutaneous electrical stimulation of the spinal cord is performed using the "TESSM-3" apparatus, which initiates rectangular impulses filled with a high-frequency component. The active electrode is located skin between the spinous processes in the Th11-Th12 projection, the indifferent electrodes are placed skin in the projection of the iliac crests. The duration of the second part of the lesson reaches 25 minutes, the strength of the electrical stimulus is 90% of the threshold of the BMO of the distal muscles of the lower extremities, the stimulation frequency is 5 Hz. Immediately after the 2nd part of the lesson, the 3rd part of the lesson is carried out, including TSCS, increasing the frequency of stimulation to 30 Hz The duration of the third part of the lesson reaches 25 minutes. 18 lessons are assigned to the course.

The method is carried out as follows.

Transcranial magnetic stimulation is performed using the extended therapeutic magnetic stimulator Neuro-MS / D, which is entered in the register of medical equipment and approved by the Ministry of Health of Russia for use in medical practice "Magnetic stimulator Neuro-MS / D" according to TU 9442-009-12318158-2015 manufactured by OOO Neurosoft, Russia (registration certificate No. RZN 2017/6130 dated 23.08.2017).

For percutaneous electrical stimulation of the spinal cord, a 3-channel electrical stimulator is used, which is entered in the register of medical equipment and approved by the Ministry of Health of Russia for use in medical practice "Three-channel electrical stimulator for stimulating the spinal cord with electrodes" according to TU 9444-001-65248032-2013 manufactured "Kosima", Russia (registration certificate No. RZN 2014/1523 dated 4.03.2019)

The proposed method for the correction of human locomotor abilities after ischemic stroke, namely the use of non-invasive magnetic stimulation of the cerebral cortex and dorsal roots of the lumbar thickening of the spinal cord, makes it possible to influence the correction of motor functions, regulation of muscle tone, increase in muscle strength and excitability of the neural structures of the spinal cord, improvement of mobility and patient self-care.

The study involved patients after ischemic stroke, in whose neurological status there was left-sided or right-sided hemiparesis. The course of locomotor function correction includes 18 lessons. Classes are held 2 times a day, 6 times a week. Each lesson consists of three consecutive parts. During the entire session, patients are located lying on a couch with a raised head end.

Preliminary testing includes an assessment of the amplitude and threshold characteristics of evoked motor responses (EMR) of the muscles of the lower extremities in TESC in the Th11-Th12 projection and in TMS in the projection of the primary motor cortex: Biceps femoris brevis (BF); Gastrocnemius, Tibialis (GT); Rectus femoris, (RF); Tibialis anterior (TA). For registration of WMO, the electroneuromyograph Neuro-MEP-8 was used, which was entered in the register of medical equipment and approved by the Ministry of Health of Russia for use in medical practice "Multifunctional computer complex for the study of EMG, EP, ERG and UAE Neuro-MEP-8" according to TU 9441- 006-13218158-2005 produced by Neurosoft LLC, Russia (registration certificate No. FSR 2010/09381 of 13.12.2010). Neurosoft Russia. We used cup surface bipolar electrodes, with an interelectrode distance of 3 cm, which are applied to the abdomen of the muscles under study.

The threshold of transcranial magnetic stimulation was detected in the presence of IOM at a frequency of 1 Hz in the distal muscles of the affected lower limb, while the primary motor cortex was stimulated in the projection of the innervation of the lower limb on the side of the stroke focus. The threshold intensity of the magnetic pulse, depending on the individual characteristics of the patients, varied from 1T to 1.3T. The threshold stimulus tESC is selected individually for each patient at a stimulation frequency of 1 Hz, and the criterion was the presence of evoked motor responses of the distal muscles of the lower extremities on the electromyogram during tESC. Stimulation was carried out at the Th11-Th12 level, the strength of the threshold electrical stimulus in accordance with the individual characteristics of the patients and varied from 90 mA to 115 mA.

Preliminary testing is carried out during which neurological deficit is assessed using scales and indices: Barthel; Revermid; NIHSS and 15-meter walking test, and threshold values for the intensity of magnetic transcranial stimulation and the strength of electrical stimulation of the spinal cord for a rehabilitation course are selected based on a preliminary electromyographic examination.

Each lesson of the course of rehabilitation treatment consisted of three parts:

1. The first part: transcranial magnetic stimulation in the projection of the primary motor cortex in the area of innervation of the lower limb on the side of the stroke focus. The duration was 3 minutes, the intertrain interval was 5 seconds, the duration of the train was 5 seconds, the stimulation frequency was 10 Hz, the intensity of the magnetic pulse was 90% of the threshold of the evoked motor response in TMS of the distal muscles of the paretic lower extremity;

2. The second part: percutaneous electrical stimulation of the spinal cord. The active electrode is applied to the skin along the midline of the spine between the spinous processes Th11-Th 12. Indifferent electrodes in the projection of the iliac crests. The strength of the electrical stimulus is 90% of the BMO threshold of the distal muscles of the lower affected limb. The stimulation frequency is 5 Hz. Depending on the state of health of the patients and their tolerance to electrical stimulation, the time of the second part of the lesson reaches 25 minutes;

3. The third part: percutaneous electrical stimulation of the spinal cord. The location of the active and indifferent electrodes is similar to the 2nd part of the lesson. The stimulation frequency is 30 Hz, the duration reaches 25 minutes.

During the study, the method was tested on 8 patients after ischemic stroke. No adverse effects were noted during rehabilitation. All patients tolerated the exercise well according to the proposed method.

Examination of patients during the course included:

1. Electroneuromyography of the muscles of the lower extremities (BF; GT; RF; TA);

2. Assessment of mobility (Rivermead index);

3. Self-service assessment (Bartel index);

4. NIHSS;

5. 15-meter walking test.

In the course of electromyographic examination, objectively in all patients, a decrease in the threshold and an increase in the amplitude of the BMO of the studied muscles of the paretic limb during transcutaneous electrical stimulation of the spinal cord were observed, which indicates an increase in the excitability of the neural networks of the spinal cord and an improvement in neuromuscular interactions.

Changes in the neurological status of patients after a course of rehabilitation treatment indicate a positive effect of TMS and TSCS on an increase in the ability of patients to move independently in the ward, department, hospital, there is an increase in muscle strength in the paretic limb, an increase in movement speed and an improvement in walking pattern, refusal of 5 patients out of 8 from mobility aids, 1 patient changed from a wheelchair to a rolling walker, and 2 patients changed from a wheelchair to a cane with a wide base.

Clinical example 1.

Patient V., male, 63 years old. Was admitted to the primary vascular department of the "GUZ Central Committee of the Medical Center named after V.A. Egorova, Ulyanovsk "with complaints of weakness and decreased motor activity in the limbs of the left side of the body.

The main diagnosis: ischemic stroke in the basin of the right middle cerebral artery.

Concomitant diseases: hypertension 3 tbsp .; arterial hypertension 3 tbsp.; atherosclerosis of the vessels of the brain, heart.

Neurological status: Left-sided hemiparesis.

On the background of complex treatment, the patient underwent a course of magnetic stimulation of the primary motor cortex of the brain and percutaneous electrical stimulation of the lumbar thickening of the spinal cord.

For TMS, a Neuro-MS / D magnetic stimulator was used. Magnetic stimulation parameters: a figure-eight coil (IDU-02-100-O) was imposed on the skin in the projection of the primary motor cortex on the side of the stroke focus, in the area of innervation of the lower extremity. The intensity of magnetic stimulation was 90% of the BMO threshold, the stimulation frequency was 10 Hz. The stimulator TESSM-3 was used for tESCS. Electrical stimulation parameters: the active electrode was applied cutaneous along the midline of the spine between the spinous processes Th11-Th12, indifferent electrodes were applied in the projection of the iliac crests. The strength of electrical stimulation was 90% of the BMO threshold, with a frequency of 5 Hz during 2 parts and 30 Hz during 3 parts.

The patient tolerated the exercises well, throughout the course during the lessons did not notice discomfort, headaches, dizziness, and after the exercise, the patient did not notice these phenomena.

Electromyographic examination revealed an increase in the excitability of the neural networks of the lumbar thickening of the spinal cord: upon stimulation of the lumbar thickening of the spinal cord at the Th11 - Th12 level, an increase in the amplitude characteristics of the BMO of the muscles of the paretic lower limb was noted, which indicates an increase in the number of muscle fibers involved in contraction.

After a course of rehabilitation treatment, the ability to self-care according to the Barthel index improved by 20 points. When assessing the level of mobility, it was found that the patient after the course is able to move around the hospital and the hospital area, the Rivermead index increased by 7 points, there was an increase in muscle strength in the lower extremities, which was assessed using the NIHSS scale, the change on the NIHSS scale was 12 points. The patient's walking time by 15 meters decreased by 10 seconds, the ability to complete independent movement was restored.

Clinical example 2.

Patient A., male, 67 years old. Was admitted to the primary vascular department of the "GUZ Central Committee of the Medical Center named after V.A. Egorova, Ulyanovsk "with complaints of high blood pressure and decreased motor activity of the extremities of the left side of the body.

The main diagnosis: ischemic stroke in the basin of the right middle cerebral artery.

Concomitant diseases: hypertension 3 tbsp .; arterial hypertension 3 tbsp.; atherosclerosis of the vessels of the brain, heart.

Neurological status: Left-sided hemiparesis.

On the background of classical physical rehabilitation and drug treatment, the patient underwent a course of magnetic stimulation of the primary motor cortex of the brain and percutaneous electrical stimulation of the lumbar enlargement of the spinal cord.

For TMS, a Neuro-MS / D magnetic stimulator was used. Magnetic stimulation parameters: a figure-eight coil (IDU-02-100-O) was imposed on the skin in the projection of the primary motor cortex on the side of the stroke focus, in the area of innervation of the lower extremity. The intensity of magnetic stimulation was 90% of the BMO threshold, the stimulation frequency was 10 Hz. The stimulator TESSM-3 was used for tESCS. Electrical stimulation parameters: the active electrode was applied cutaneous along the midline of the spine between the spinous processes Th 11-Th 12, indifferent electrodes were applied in the projection of the iliac crests. The strength of electrical stimulation was 90% of the BMO threshold, with a frequency of 5 Hz during 2 parts and 30 Hz during 3 parts.

The patient tolerated the exercise well. Throughout the course, the patient did not notice the appearance of headaches, dizziness and discomfort during and after classes.

The results of the final electromyographic examination indicate an increase in the amplitude of evoked motor responses in the paretic lower limb against the background of a decrease in the threshold stimulus, which indicates an increase in the excitability of the neural networks of the lumbar thickening of the spinal cord and an improvement in neuromuscular interactions.

The results of the study indicate a positive change in the indicators of neurological deficit. Before the course of rehabilitation treatment, the ability to self-care according to the Barthel index was 65 points, after the course the indicators on the index improved by 35 points. When assessing the level of mobility of the patient, it was found that the patient after the course is able to move without aids and the help of third parties in the hospital and in the hospital area, the Rivermead index increased from 6 to 14 points. Changes in muscle strength in the lower extremities and coordination, which were assessed using the NIHSS scale, underwent positive dynamics; changes on the NIHSS scale were 11 points. During the 15-meter walk test, the patient improved his time from 19 to 15 seconds and stopped using a rolling walker when walking.

Claims (1)

A method for correcting a person's locomotor abilities after a violation of cerebral circulation of ischemic genesis, which consists in the fact that patients undergo transcranial magnetic stimulation, a coil is applied to the skin in the projection of the primary motor cortex on the side of the stroke focus, then the posterior roots of the spinal cord are stimulated in order to influence the neuromuscular device, characterized in that the patient is given transcranial magnetic stimulation 6 days a week on the Neuro-MS device: the IDU-02-100-O coil is placed over the primary motor cortex in the innervation zone of the lower extremity, contact, duration - 3 min, intertrain interval - 5 sec, train duration - 5 sec, stimulation frequency - 10 Hz, magnetic field intensity - 90% of the threshold of the evoked motor response of the muscles of the lower extremities, then immediately transcutaneous electrical stimulation of the spinal cord is performed using the TESSM-3 apparatus: active the electrode is placed on the skin between the spinous and processes in the Th11-Th12 projection, indifferent electrodes are placed on the skin in the projection of the iliac crests, duration - 25 min, the strength of the electrical stimulus is 90% of the threshold of the evoked motor response of the muscles of the lower extremities, the frequency of stimulation is 5 Hz, the final part of the lesson is a transcutaneous electrical stimulation of the spinal cord when using the "TESSM-3" apparatus: the active electrode is placed on the skin between the spinous processes in the Th11-Th12 projection, the indifferent electrodes are placed on the skin in the projection of the iliac crests, duration - 25 min, the strength of the electrical stimulus - 90% of the muscle IOM threshold lower extremities, the frequency of stimulation is 30 Hz, 18 sessions are prescribed for the course.