RU2767932C1 - Method for identifying patients who need to continue cognitive training courses against the background of drug support after an acute ischemic stroke - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to medical rehabilitation, psychological rehabilitation, diagnostics and screening methods for evaluating the results of therapeutic effects in patients after acute ischemic stroke (AIS). To do this, patients are identified who need to continue courses of cognitive training against the background of drug support after suffering an acute ischemic stroke (AIS). Training and testing of cognitive functions is carried out before and after a course of cognitive rehabilitation. Moreover, initially before and after the course of cognitive rehabilitation, with the help of testing, a complex of the following cognitive functions of the patient is studied: a study of the amount of RAM; study of the function of active attention by determining the average response time to the stimulus for the test and the magnitude of the scatter of reaction time values. Conducted cognitive rehabilitation is considered effective and drug therapy with vasoactive, neutrotrophic and cholinergic agents aimed at stimulating cognitive functions is not further indicated, if at the end of the course of cognitive rehabilitation, compared with what took place before it began, a decrease in impaired indicators of the average reaction time is diagnosed at least than by 25% in combination with a decrease by at least 15% of the spread of reaction time values ​​in cases of their initial deviation from the norm and in combination with an increase in the amount of RAM - an expansion of the block range by at least 1 unit. If these parameters are not achieved after a course of cognitive rehabilitation, then the patient continues drug therapy with vasoactive, neutrotrophic and cholinergic agents aimed at stimulating cognitive functions, against which a second course of cognitive training is carried out no later than 3 months after the end of the previous one. To assess the amount of RAM - the block range, a block tapping test is carried out using a computer diagnostic system, and to assess active attention with the determination of the average reaction time and the magnitude of the spread in reaction time values ​​- the WAFA test using the same diagnostic system.

EFFECT: method allows to accurately assess the level of existing cognitive impairment (CI) and the effectiveness of cognitive rehabilitation in patients after ischemic stroke, as well as help in resolving the issue of the need for drug support aimed at preventing/slowing the progression of cognitive impairment, with a small time investment.

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Description

The invention relates to medicine, medical and psychological rehabilitation, diagnostics and screening methods for evaluating the effectiveness of cognitive training in patients after acute ischemic stroke (AIS) with an assessment of the need for further courses of cognitive rehabilitation. The method can be used in profile and day hospitals, sanatorium conditions, as well as outpatients.

In recent years, the number of cases of cerebral stroke has been growing, and therefore the rehabilitation of post-stroke patients, aimed at restoring impaired functions, social contacts, and returning them to feasible work, is relevant. Motor and sensory disorders after a stroke are often accompanied by cognitive (CI) and emotional disorders (EN), which greatly complicates the development of a positive attitude of the patient to treatment and the continuation of social activities (Kuzyukova A.A., Odarushchenko O.I., Rachin A.P. , 2019). Clinical and psychological correction in the rehabilitation of patients with the consequences of a stroke contributes to the creation of an active orientation of the individual to overcome a cognitive, emotional and physical defect, the creation of an optimistic perspective (Odarushchenko O.I., Vygovskaya S.N., Rachin A.P., 2019). 6 months after a stroke, CI is detected in approximately 45-80% of patients, dementia - in 10-15%; after 5 years, dementia develops in 20-25% of patients (V.V. Zakharov, 2011). The risk of developing dementia in the first three months after a stroke in patients over 60 years of age is 9 times higher than in the elderly without a stroke.

CI in stroke can be: focal, associated with focal brain damage, capturing only one cognitive function (for example, agraphia, acalculia, digital agnosia), or have a generalized character, reaching a degree of mild cognitive decline or various stages of dementia.

In neurological and psychiatric practice, tests are usually used to diagnose CI: the MMSE short mental status scale, the Montreal MoCa scale, and the mini-Cog test. They are quite easy to use and allow you to quickly evaluate various cognitive functions (memory, gnosis, praxis, intelligence, speech). To improve cognitive abilities, in addition to drug therapy (vascular, cholinergic, neurotrophic, etc.), it is recommended to use cognitive training aimed at training memory and intelligence (memorizing and retelling texts, solving crossword puzzles, mathematical problems, logical exercises, etc.) . However, they are usually offered for patients to go through on their own, while patients are often not motivated.

In general, cognitive functions are understood as the perception, processing, memorization and storage of information significant for a person, language activity, expression and application of knowledge in situations suitable for this. With stroke and TBI, prospective memory most often suffers: the patient forgets to take the medicine, water the flowers, and call the phone. Less commonly, an amnestic syndrome develops, in which the patient cannot retain new information (fixation amnesia), forgets what happened to him before acute brain damage (retrograde amnesia) or after damage (anterograde amnesia).

Attention disturbances after AIS or TBI are manifested in increased distractibility and difficulty in distinguishing between problems that require and do not require concentration. It is difficult for a person to concentrate on the interlocutor when communicating with him or to distract himself from extraneous noise when reading or mental work, to switch attention from the previous task to the new one. Disorders of visual perception can manifest themselves in impaired recognition of familiar objects, faces; difficulty in recognizing surrounding objects when they are seen from a new angle; deterioration of orientation in space; violation of the estimation of distance or depth; inattention to one half of the surrounding space or one's own body. Praxis disorders are manifested in the fact that a person cannot set the table, spread butter on bread, make the bed, get dressed. With disorders of the programming and control function in patients with lesions of the frontal lobes, any form of daily, professional and social activity suffers, since these functions serve as the basis for successful voluntary regulation of human activity; often such patients have reduced criticism of their violations. All these and other cognitive impairments (CI) significantly limit the daily activity of patients, reducing the quality of life.

The recovery of mental functions after a stroke or brain injury can partially occur spontaneously, however, cognitive rehabilitation (CR) speeds up recovery and helps a person adapt to new living conditions even with persistent cognitive deficits.

The main strategies of the Kyrgyz Republic are: 1) promoting the natural restoration of mental functions; 2) recovery training of individual cognitive functions and "retraining" of the former everyday skills; 3) teaching the patient internal strategies to compensate for impairments to individual cognitive functions with the formation of new stereotypes of cognitive and behavioral activity; 4) the use of external compensatory devices and outside assistance; 5) reorganization and structuring of the external environment.

The essence of computer training in restoring the patient's perception, memory and attention lies in the dosed presentation of the simplest, one-component tasks to him. They are designed to predominantly activate and restore various elements of mental activity, which are used to implement more complex forms of purposeful voluntary behavior. Involving the patient in simple but interesting exercises contributes to the gradual improvement of cognitive functions, due to the integrative effect - a change in the functioning of some brain structures leads to a change in the functioning of others. Their implementation allows the patient to more easily notice and realize his violations (for example, instability or difficulty switching voluntary attention). A necessary condition for training is the gradual complication of tasks, an increase in their volume as functional capabilities improve, positive biofeedback and encouragement of even small successes.

If the restoration of the lost mental function in the previous volume is impossible, the patient is taught internal or external strategies for compensating functions. Compensatory strategies are understood as a self-initiated procedure for the patient to achieve the desired goal, the implementation of which is otherwise difficult due to his functional disorders. Internal methods of compensation include simple behavior modifications (for example, asking the interlocutor to speak more slowly), mental self-instructions (for example, “be careful!”, “Take your time!”), or more complex cognitive-behavioral strategies that facilitate the processing of information when it is needed. memorization. The neurophysiological basis of internal strategies for compensating higher mental functions is the reorganization of the neuronal systems of intact brain regions with their activation and involvement in the implementation of previously uncharacteristic functions. Such an intersystem reorganization of the morphological and functional systems of the brain allows a person to achieve the same goals of his activity as before the illness, when all brain structures were preserved.

Patients need intensive practice to move to the automated use of compensatory strategies, so it is important for the specialist to encourage them to acquire and consolidate new skills. An example of an internal compensatory strategy, which is often specifically taught to patients with memory impairment, is the strategy of "enhanced memory" - conscious concentration of attention on the information to be remembered, isolation from external interference, repetition of the information to be remembered, mental repetition of actions or the path traveled ("stop - think - remember the action”) and the real repetition of actions (working out the skill to automatism). Similar to how it is done during simple rehabilitation training of individual mental functions, when teaching a patient internal compensatory strategies, it is important to gradually increase the duration, complexity and intensity of cognitive loads and their repetition.

In recent years, it has been customary to start CR already in the acute period of a stroke or brain injury. CR, in addition to medication support aimed at stimulating cognitive functions, involves conducting special sessions with the patient to restore his individual mental functions and everyday skills, but in recent years, elements of CR are increasingly being purposefully implemented in the process of patient care, kinesitherapy and occupational therapy.

The current stage of the Kyrgyz Republic is characterized by the widespread introduction of new technologies. For rehabilitation training of individual mental functions in the acute period of a disease or brain injury abroad, in recent years, computer programs have been used with sets of structured, standardized and well-designed tasks, a choice of exercises of a given level of complexity and duration, providing the patient with instant biofeedback based on the results of the task, accessibility at home, patients with severe physical defects. The disadvantages of computer training, however, include the impossibility of a fine differentiation of exercises depending on the individual characteristics of the disorders, as well as the lack of dissemination of the achievements observed in the process of training to everyday life.

In general, there are no similar standard programs for the restoration of cognitive functions and everyday skills, even for patients with the same form of brain damage. Rehabilitation programs are compiled individually based on the results of patient monitoring, neuropsychological examination data and important goals for the patient.

Along with this, an important problem in cognitive rehabilitation (CR) is the assessment of its effectiveness. These difficulties are associated with the lack of generally accepted criteria for such an assessment, the heterogeneity of the contingent of patients admitted for treatment in terms of their age, nature of injuries, as well as the complexity of conducting randomized clinical trials. Some authors determine the results of CR by the progress of those skills of daily life of patients that were impaired due to cognitive deficits. Others are focused on the completeness of achieving the rehabilitation goals. Still others take into account the satisfaction of the patients themselves with the results of CI.

Depending on the choice of criteria for evaluating the results of rehabilitation, conclusions about its effectiveness and, accordingly, the need for repeated rehabilitation courses and their frequency can vary greatly. Thus, the improvement in the state of individual neuropsychological functions after treatment in patients is by no means always accompanied by an increase in self-esteem of their quality of life and an increase in daily activity. However, various methods for assessing cognitive functions are used, including in dynamics, which could be applicable to assess the results of CR and conclude on the continuation of rehabilitation courses.

It is known to predict cognitive impairment (CI) based on a complex of neuropsychological, clinical and laboratory parameters of a post-stroke patient in the early recovery period (RU 2721465 C1, 05/19/2020, VMedA, RU), including the assessment of mental status, frontal dysfunction, test results drawing a clock, CT data of the brain, the level of serum concentration of matrix metalloproteinase-9, with the calculation of linear discriminant functions. The prognostic model enables a simple, highly sensitive and specific prognosis of the development of CI in the early recovery period of AIS due to a comprehensive assessment of neuropsychological, laboratory and neuroimaging data, and, in accordance with the prognosis, it is possible to judge the performed CI and plan a repeated CI.

An attempt was also made to assess cognitive functions, including attention, using EEG (RU 2749408 C1, 06/09/2021, FSCC RR, RU), however, the results were not sufficiently objective.

Known system for computerized diagnosis of the psychological state of the Vienna Test System (VTS, Vienna, Vienna) (https://physiomed.upacom.ru/sistemy/vienna), which is a kit for neuroscreening (assessment of intelligence, concentration, RAM, test for multistimulus response).

This system of psychological testing and training allows you to objectively, accurately and in a standardized form evaluate the psychological characteristics of the individual, as well as cognitive functions from the point of view of clinical psychology and neuropsychology (http://psychologischtesten.nl/wp-content/uploads/Catalogus-Vienna-Test -System-Neuropsychologie-SCHUHFRIED_Psychologischtesten.nl_.pdf).

Neuropsychological assessment is used to accurately diagnose changes in performance or personality traits in diseases that affect the CNS. The tests include an almost complete set of tools for measuring basic mental functions: attention, memory, motor skills, executive functions, providing reliable results. Tests are used for an objective description of functional disorders, including for screening workers in certain professions (drivers, pilots, railway workers, etc.). Based on their results, an appropriate treatment method can be selected, including biofeedback (BFB).

At the same time, the Vienna testing system supports the administration of both individual tests and their sets. There are different versions (modalities) of the same test (visual, auditory, crossmodal). After selecting a test, its versions or a set of tests, entering the respondent's data, the testing program is launched. After passing the test or their set, the results are calculated. The computer summarizes the initial results obtained in the tests and compares them with normative (reference) indicators. At the same time, the results of the respondent are compared with a healthy sample, taking into account the age, gender or educational level of the respondents.

The results are displayed in the form of help on the screen and can be printed in summary form. The examiner can set the data area to be printed and print only the data that is required. Thanks to the data management function, it is possible to prepare an overview of the respondents and the tests performed, which allows you to select, copy and delete the recorded data with a search by certain criteria (https://www.psyfactorplus.com/schuhfried), in dynamics.

Computerized presentation of data and process guidance allow you to create a training program tailored specifically to a particular patient, for example, for research:

- attention,

- development of visual-spatial working memory,

- separation of attention

- focusing attention

- long-term memory,

- selective attention

- hand-eye coordination.

In general, the Vienna system (Schuhfried) consists of separate hardware and software modules, in particular:

- Vienna Test System - a program with tests in various areas of psychology;

- CogniPlus - a package of developmental training programs.

The Vienna system is used in various fields (clinical psychology, neuropsychology, transport and aviation, sports and educational psychology, etc.). For example, this scoring system was used to determine the behavioral inattention of drivers after a cerebral infarction (Mervi Jehkonen et al. Driving ability in stroke patients with residual visual inattention: a case study. // Case Reports Neurocase. 2012;18(2):160 -6 doi: 10.1080/13554794.2011.568504 Epub 2011 Jul 26. PMID: 21787245).

It is also known to use the Vienna system in patients after stroke, in particular, to study the relationship of cognitive impairment in patients with impaired emotion recognition (Hugo P. Aben et al. High occurrence of impaired emotion recognition after ischemic stroke. // European Stroke Journal. 2020. Vol.5(3), pp. 262-270).

In our earlier studies, the Vienna system was used to assess cognitive impairment in patients in the late recovery period of AIS (Kuzyukova A.A., Rachin A.P., Odarushchenko O.I., Nuvakhova M.B., Romanenko D.N. , Evloeva Z.M. The function of active attention in patients in the late recovery period of ischemic stroke // Issues of balneology, physiotherapy and exercise therapy. 2021. V.98, No. 3-2, p. . At the same time, clinical-anamnestic and psychopathological methods were also used; the severity of CI was assessed using the MMSE scale. At the same time, the computerized psychological diagnostic system Vienna Test system investigated the functions of active attention using the WAFA test, which measures the reaction time to a simple visual irritant material. The stimulus was offered without a warning signal and with an audible and visual warning (internal and phasic attention). Two parameters were studied: the average reaction time and the scatter of the reaction time (difference in reaction speed over the entire time interval of the task), the test time did not exceed 10-12 minutes.

As a result, it was found that according to the MMSE scale, cognitive impairment (CI) occurs in 61% of the examined, of which 46% have mild (pre-dementia) disorders and 15% have dementia. At the same time, it is noteworthy that the indicators of impaired attention, determined during testing using the Vienna system, did not always correlate with the severity of CI, measured on the MMSE scale: in some cases, patients showed low indicators for this parameter, while their attention function was quite intact. . And vice versa, often normal indicators of the MMSE scale and clinical and anamnestic data corresponded to reduced indicators of reaction time and the magnitude of the reaction time scatter. The data obtained demonstrate violations of active attention in the vast majority of patients (95%) in the late recovery period of AIS, regardless of the presence of a recorded cognitive deficit according to the MMSE test. These disturbances of attention negatively affect the general functioning of patients.

In another publication of the co-authors of the proposed invention (Kuzyukova A.A., Rachin A.P., Odarushchenko O.I., Nuvakhova M.B., Romanenko D.N., Evloeva Z.M. The volume of short-term memory in patients in late recovery period of ischemic stroke // Issues of balneology, physiotherapy and physical therapy 2021. V.98, No. 3-2, pp.104-105. DOI: 10.17116/kurort20219803221) shows the results of studying the memory capacity in patients in the late recovery period of AIS (the period from the moment of transferring acute cerebrovascular accident (ACC) from 6 to 24 months). Patients were asked to perform a block tapping test to measure the actual block (block) range - the amount of working memory (CORSI block tapping test in the Vienna Test System computerized psychological diagnostics system). In this case, it was about working memory (WP), with the help of which a person is able to keep in mind the information with which he works. RP or, in other words, working memory allows you to combine information received from the organs of perception with long-term and short-term memory. The term "working memory" was introduced by D. Miller, E. Galanter and K. Pribram. Initially, the concept of working memory was not specified, so Atkinson and Shiffrin used it in their model of short-term memory. However, they did not focus on its functional part, so the model was later redesigned. The main difference of the new view of RP was that short-term memory can be divided into subcomponents, and such a system is capable of complex cognitive actions. At the moment, many scientists use the concept of RP as a replacement or extension of the concept of short-term memory, focusing on the manipulation of information, and not on the duration of its simple storage.

Normal indicators of the block range vary from 5 to 9 blocks (7+2 units) in people under 54 years old and from 4 to 8 blocks (6+2) in people over 55 years old. According to the data obtained by us earlier, in 37% of patients, the values of the block range were below the norm, in 41% - at the lower limit of the norm, and only in 22% of cases - were slightly above the lower limit of the norm. There were practically no patients with high rates of short-term memory (7 blocks or more). At the same time, low values of the block range (memory size) also did not always correlate with the degree of recorded CI according to the MMSE test: often, with a fairly successful passing of the MMSE test, the patient, however, showed low values in terms of the amount of RAM in the CORSI test and vice versa.

Thus, previous studies and developments concerned, as such, the study of the results of using cognitive tests, including as part of the work of the Vienna system, for diagnosing and assessing the condition of patients with CI after strokes. However, it seems relevant to develop directly the parameters of such an assessment, in particular, to identify patients for continuation, repetition in the future courses of CR and addressing the issue of the need to continue long-term drug support in the form of vascular, neurotrophic and cholinergic drugs.

The severity of CI, manifested by a decrease in praxis, intellectual abilities, regulatory functions, significantly depends on age, the presence of concomitant diseases, repeated strokes (Nuvakhova M.B., Kuzyukova A.A. Aspects of post-stroke rehabilitation of patients with cognitive impairment. // Questions of balneology, Physiotherapy and Therapeutic Physical Culture, 2021, V.98, No. 3-2, pp.141-142, DOI: 10.17116/kurort20219803221). In the first 3 months after AIS, a significant memory impairment is observed, although its severity depends on the location and degree of brain damage. The most pronounced CI are recorded in patients who have had a repeated stroke in the same hemisphere.

The speed and volume of assimilation of information, the ability to quickly solve problems, switch from one action to another depend on the state of attention. Schuhfried (the manufacturer of the Vienna system, VTS) notes that in case of impaired attention, CR should begin with the training of this particular function, since in this case the training of other more complex components, such as memory, intelligence, may be ineffective and even worsen the patient's condition.

The VTS has a range of tests for assessing different forms of attention: focused, divided, selective, spatial attention, mindfulness and vigilance (these are different versions of the Vienna WAF tests). Visual, auditory and crossmodal (i.e. simultaneously auditory and visual) forms of perception are evaluated - the average speed of reaction to a stimulus and the magnitude of the scatter in reaction time over the time the task is completed. A large variation in the reaction time (from minimum to maximum) indicates the instability of the patient's attention, the inability to hold it for a long time, i.e. about increased fatigue, exhaustion of mental processes. Each test for perception and attention of the Vienna system in Cogniplus has its own program aimed at training the corresponding form of attention and assessing its function. Training programs are designed in a playful way and flexibly adapt to the abilities of patients: if the task is completed quickly and correctly, the transition to more complex levels of the same test automatically occurs. In case of deterioration in dynamics or difficulties, the program transfers the patient to an easier level of training. For effective rehabilitation, daily training is recommended for 45 minutes daily with breaks for 2 days every 5 days.

Attention is the concentration of the subject's activity at a given moment of time on a real or ideal object (object, event, image, reasoning, etc.). It can influence the formation or implementation of other cognitive processes (memory, thinking, perception).

The distribution of attention is understood as the subjectively experienced ability to keep a certain number of heterogeneous objects in the center of attention at the same time (Leclercq M., Zimmermann P., 2000). It is this ability that allows you to perform several actions at once, keeping them in the field of attention (Berkhin N. B., Spichak S. F., 1972). This property is based on two different mechanisms: simultaneous processing of several input sources, simultaneous execution of many different tasks (Leclercq M., Zimmermann P., 2014).

Identifying and evaluating indicators of attention distribution can help with assessing the level of cognitive functions. At the same time, a person's ability to distribute attention to different subtasks presented in research depends on a number of factors: the relationship between tasks (similarity), task complexity and individual experience (Eysenck M., Keane M., 1995). To study the distribution of attention, a standard paradigm with two tasks is usually used, where the subject is asked to quickly respond to two different objects displayed among different stimuli (often multimodal: visual and auditory). Productivity is measured by two variables: reaction time and the number of correct answers (Giguere G., Lacroix G. L., 2010). Alport (Allport D. A., 1993) notes the amalgamation of multiple resources for each sensory modality that allows multiple tasks to be performed simultaneously when using different modalities. Productivity is reduced when two tasks involve the participation of resources emanating from the same modality, since then attention will need to be constantly switched between competing tasks (Tombu M, Jolicoeur P., 2005).

In practice, to assess attention, neuropsychological tools are used in the form of cognitive tests (paper and computer) and scales. However, the evaluation of the results of CR by long-term studies of all the numerous components of the attention function does not always seem justified, especially in rapidly exhausted patients who have had a stroke.

As shown earlier, the assessment of the function of active attention and the amount of RAM, with the low cost of these tests and ease of implementation, reveals more subtle impairments of cognitive functions that cannot be accurately diagnosed using well-known, routinely used scales, such as MMSE, MoCA. While timely diagnosis contributes to an earlier start of treatment, which is very important for patients with CI, the earlier cognitive impairment is detected in such patients and treatment and rehabilitation are started, the more opportunities they have to preserve their intelligence.

With regular training, patients improve to some extent indicators - the average reaction time to stimuli decreases, the magnitude of the variation in reaction time decreases; if it is impossible to initially perform a workout for more than 10-20 minutes due to the patient's fatigue, later an increase in endurance is noted - the ability to train for a longer time (which leads to a decrease in the magnitude of the variation in reaction time).

At the end of the training course (usually 5-10 sessions), the results of repeated diagnostic testing show a change in the reaction rate and the magnitude of the reaction time spread (WAF battery of tests for attention), as well as the volume of spatial working memory (CORSI test).

In this regard, we came up with the assumption that the results of tests for attention and working (operational) memory in post-stroke patients can be considered as screening results of CR for various CIs in general in post-stroke patients, which would make it possible to plan the need for further courses. rehabilitation and assess the need for long-term continuation of vascular, neutrotrophic, cholinergic drug therapy.

It is important to note the versatility of this possibility. For example, along with the Vienna tests, which are acceptable both for patients with mild and severe CI, as well as for patients with upper limb dysfunction and speech disorders, it is possible to use other tests for active attention and working memory capacity (for example, , the usual Schulte tables, the Caesar test, the Cogni-fit system (https://www.cognifit.com/ru/science/cognitive-skills/working-memory) and others, see, for example: Psychological workshop on the study of attention Method Instructions for Teachers, Nizhny Novgorod, NNGASU, 2014, 53 p.). What is important here is the very set of necessary indicators for testing: active attention, the spread of response time to a stimulus, and the block range (the amount of RAM).

The study of visual-spatial working memory can be carried out using a prototype computer version of the CORSI test - the Corsi block test: the experimenter touches the blocks in a certain sequence, and the patient must repeat it (Alloway et al., 2009). Another diagnostic method is the Self-Ordered Pointing task (Petrides, 1995) - the patient is offered from 3 to 12 objects (lines, abstract drawings or boxes with a reward inside), they are asked to touch one object, another, and then touch all objects in any order . It is considered a mistake if the patient points to an object that he has previously chosen. The Corsi test, as well as the Spatial Working Memory test, where the patient must memorize the location of squares of the same color and size, are presented, for example, in the computer battery of neuropsychological tests CANTAB (Cambridge Neuropsychological Test Automated Battery) (CANTABeclipseTM, 2006).

To assess working memory, the well-known memory scale (Wexler) can also be used, which is a test battery from a series of tasks for studying individual mnestic functions, in particular, the subtest is the reproduction of rows of numbers in forward and reverse order. Developed by D. Veksler in 1946.

The advantage of this scale is the possibility of quantitative measurement of short-term and long-term memory, verbal-logical, visual and associative reproduction. Along with the measurement of many indicators, this compact and easy-to-use technique provides coverage of a wide age range of subjects (see also Rzhanova I.E., Alekseeva O.S., Fominykh A.Ya., Parshikova O.V. Index of working memory as one of the main indicators of the Wexler test for preschoolers // Psychological research, 2018, 11(57), p. 8. http://psystudy.ru Article address: http://psystudy.ru/index.php/num /2018v11n57/1529-rzhanova57.html). In our method, we can use the subtest of the Wechsler scale, designed to assess working memory. At the same time, for evaluation, it is sufficient to compare the scores obtained before and after the rehabilitation, i.e. what is significant is the relative increase in the volume of visual (spatial) working memory in the process of rehabilitation, and not compliance with the norms as such.

To study the function of active attention, in addition to automated systems of the Vienna type, ordinary Schulte tables with randomly located objects, usually numbers or letters, can be used. Initially, these tables were developed to study the properties of attention by the German psychiatrist and psychotherapist Walter Schulte. The simplest table is a square sheet of paper the width of a book page, conditionally divided into 25 identical square cells (5 rows by 5 columns), in which numbers from 1 to 25 are randomly entered in a normal book size font.

The Schulte tables were a set of numbers (from 1 to 25) arranged in random order in the cells. The patient had to show and name in a given sequence (usually increasing from 1 to 25) all the numbers. Five non-identical Schulte tables were proposed in a row, in which the numbers were arranged in a different order. The psychologist recorded the time spent by the patient on showing and naming the whole series of numbers in each table separately. The following indicators were noted:

1) exceeding the standard (40-50 seconds) time spent on showing and naming a number of numbers in the tables;

2) the dynamics of temporal indicators during the survey for all five tables.

According to the results of this test, the following characteristics of the patient's attention were possible. Attention with sufficient concentration - if the patient spends the standard time on each of the five Schulte tables (the average time for passing the test by healthy subjects). Attention is not concentrated enough if the patient spends more than the standard time on each of the tables. The patient's attention is stable if there are no pronounced time differences when counting the numbers in each of the tables. Attention is unstable if there is a pronounced fluctuation in the results obtained across all tables without increasing the time spent on each subsequent table. Attention is depleted if the time to pass the test increases compared to the standard. In this case, the standards for adult subjects can be considered:

25-35 sec - high rates of attention;

35-45 sec - medium;

45-55 sec - low;

more than 55 seconds - violations of attention.

Test indicators in the study of attention according to Schulte tables are also:

1. Selection reaction speed (SRV) - the time it takes to search for one number in the table. The search time for each number is given in the test protocol. Statistical indicators: average (arithmetic mean of RTS); standard deviation (average deviation from RTS towards lower and higher values); coefficient of variation (the degree of variability of the SRV, expressed as a percentage); errors (the number of incorrectly specified numbers).

2. Total time according to the tables. Statistical indicators: total time for completing tasks for each table and for all tables together (sec.); average total time for one table; standard deviation of the total execution time for one table; standard error of the mean (degree of measurement accuracy).

3. Integral assessment of test indicators. Statistical indicators: workability coefficient - the ratio of the total time to complete the task according to the first table to the average total time for all tables; fatigue coefficient - the ratio of the total time for completing the task according to the last table to the average total time for all tables; selectivity coefficient - average search time for one number (total time for all tables divided by the total number of all numbers for all tables); coefficient of instability - the ratio of the standard deviation to the average time according to the table.

When analyzing statistical indicators, it should be taken into account that chronometric indicators of human reaction time are characterized by the presence of significant positive asymmetry - in the system of factors that determine the value of the measured indicator, factors acting in one direction - upwards of the indicator predominate. The subject cannot complete the task faster than a certain minimum required period, but may be delayed significantly for a long time.

To evaluate the results, the time spent by the patient on each table is compared, or within the same table, the patient's performance indicators are compared for certain periods of time. It is important to establish a uniform pace of the task. Usually healthy people search for numbers in tables evenly, sometimes there is even an acceleration in the rate of reactions in the following tables. With an uneven search, it is worth clarifying the nature of this - whether this indicates increased exhaustion or delayed workability. The so-called "exhaustion curve", which objectively characterizes the type of asthenia, is of great importance.

With mental disabilities, the time spent searching for numbers is greatly increased compared to the standard. When looking for a number, usually at a normally fast pace, the patient suddenly "loses" the next number in sequence, i.e. “Looks at it, but does not see it,” sometimes asserting that this number is not there at all. That is, the slow rate of test execution in reality is a consequence of the extreme unevenness of the pace of individual operations performed by the patient.

Schulte tables have an equal degree of difficulty, they are almost not remembered, and therefore, in the process of research, they can be used repeatedly, repeatedly. The approximate time of one test is 5-15 minutes. The results are analyzed by a psychologist.

An option is the Schulte-Platonov table, where, depending on the methodology and detected deviations, the calculation of separately Arabic and Roman numerals is carried out in direct or reverse order, or their combinations (1, XXIV, 2, XXIII, ... 24, I, 25).

A two-color Schulte-Gorbov table (numbers, background of cells and their combination) is also used to examine distraction, switching, distribution, concentration of the patient's attention. These tests also allow you to determine the performance (workability and exhaustion), the presence or absence of attention disorders, while developing attention and will.

In particular, in the study of working capacity (work efficiency, degree of workability, mental stability) according to the method of Kozyreva A. Yu., the test is carried out on 5 Schulte tables 5 × 5 cells with different arrangements of numbers from 1 to 25 on each. The number of errors made (missing a number) and the time spent on finding each subsequent number in the table, as well as the time spent on passing each table, the dynamics of errors made and the time of the entire examination are estimated.

When testing, the distance from the table to the eyes should be the same as when reading a book (30-35 cm). Before starting work, the gaze is fixed in the center of the table and not shifted. You need to find numbers in ascending order from 1 to 25, without gaps, as quickly as possible, without saying the numbers to yourself or out loud. It is important to avoid moving your eyes, but look for numbers only with peripheral vision.

Evaluation of attention disorders can also be carried out using the EEG method with cognitive evoked potentials P300, however, it requires additional equipment, specially trained personnel and is more time consuming and costly.

Whatever the test for memory and attention, for the proposed method, only the principle of quantitative assessment in the dynamics of the average values of the reaction time and the magnitude of its spread, as well as the amount of operational (working) spatial memory, and on the basis of a relative improvement or absence changes in these indicators in their combination, it is possible to draw a fairly accurate and objective conclusion about the effectiveness of the CT in a particular patient, including the need to continue appropriate medication to prevent / slow down the progression of cognitive impairment and the frequency of subsequent courses of CT.

EFFECT: method allows to accurately assess the level of existing cognitive impairments (CI) and the effectiveness of cognitive rehabilitation in patients after ischemic stroke, including helping to resolve the issue of the need for additional medication for a particular patient, aimed at preventing/slowing down the progression of cognitive impairments, with little time investment. Moreover, such an assessment is universal, since relative changes in two cognitive functions are taken into account - the volume of working memory and active attention, regardless of the characteristics of the tests themselves: both computer versions of the tests and testing of the corresponding function of attention and memory in a paper version can be used.

To achieve this technical result, we have proposed a method for identifying patients who need to continue courses of cognitive training against the background of drug support after acute ischemic stroke (AIS). The method includes conducting cognitive training and testing cognitive functions before and after the course of cognitive rehabilitation (including the cognitive training itself and drug therapy with vasoactive, neutrotrophic and cholinergic agents aimed at stimulating cognitive functions). At the same time, initially, before the start and after the end of the course of cognitive rehabilitation, a study of the complex of the following cognitive functions of the patient is carried out using testing:

- study of the amount of RAM;

- study of the function of active attention by determining the average response time to the stimulus for the test and the magnitude of the spread in the values of the reaction time.

Conducted cognitive rehabilitation is considered effective and drug therapy with vasoactive, neutrotrophic and cholinergic agents aimed at stimulating cognitive functions is not further indicated, if at the end of the course of cognitive rehabilitation, compared with what took place before it began, a decrease in impaired indicators of the average reaction time is diagnosed at least than by 25% in combination with a decrease by at least 15% of the spread of reaction time values in cases of their initial deviation from the norm and in combination with an increase in the amount of RAM - an expansion of the block range by at least 1 unit.

If these parameters are not achieved after a course of cognitive rehabilitation, then the patient continues drug therapy with vasoactive (vascular), neutrotrophic and cholinergic agents aimed at stimulating cognitive functions, against which a second course of cognitive training is carried out no later than 3 months after the end of the previous one.

To assess the amount of RAM - the block range, a block tapping test is carried out using a computer diagnostic system, and to assess active attention with the determination of the average reaction time and the magnitude of the spread in reaction time values - the WAFA test using the same diagnostic system.

When visual and auditory modalities are used (i.e., more than one test modality is used), the WAFA test uses the average of the resulting reaction times and the amount of variation in reaction times for calculation.

In the method proposed by us, as means of CR in patients, the mentioned groups of medications and cognitive training were used both on the Vienna system, and classes using didactic materials: Schulte tables, the Corsi block test, variants of tests for reproducing rows digits (Weskler subtest for working memory), Self-Ordered Pointing task, incl. computer, online test options, the choice of which depends on the patient's condition, since if it is impossible for him to use a computer mouse, he has to offer other testing options.

Training using the computer system for cognitive rehabilitation CogniPlus usually included 10 sessions - training aimed at improving the functions of active attention, general endurance, reaction speed, the amount of operative spatial memory, with a gradual complication of the training program and a possible increase in session time (in cases of initial increased fatigue of the patient ) - from 15-20 min initially, up to 45 min.

Additionally, patients received, in accordance with the clinical protocol, a basic course of physical rehabilitation after a stroke (according to current clinical guidelines), in accordance with the patient's physical disorders (exercise therapy, robotic mechanotherapy, preformed physical factors, including magnetotherapy, balneotherapy and etc.).

The assessment of active attention on the Vienna system was carried out using the WAFA test - aimed at assessing vigilance (https://asystems.as/wp-content/uploads/2018/05/Katalog_Vienna-Test-System_en.pdfе. C.115-117). Vigilance (active attention), the assessment of which is proposed as a criterion in the claimed method, is the ability to consistently focus attention for long periods of time on one or more sources of information, as well as to monitor, recognize and respond to minor changes in incoming information. In this case, relevant stimuli are presented only at irregular intervals, and also with a very low frequency of relatively irrelevant stimuli. The test can measure both visual alertness and auditory alertness. Thus, vigilance reflects a constant readiness to respond to sudden situations or danger (active attention), and is measured using the WAFA test (in the Vienna system). The respondent is monotonously presented with visual and auditory stimuli, which randomly sometimes slightly reduce their intensity. The task of the respondent is to correctly respond to these random changes, the total number of which is approximately 5% of the total number of stimuli. WAFA measures reaction time (and its mean values) in response to simple visual or auditory stimulus material, and also shows the amount of reaction time spread, which gives an idea of the patient's fatigue during the testing process. That is, the standardization process embedded in the testing program allows you to additionally measure the patient's fatigue parameters. In this case, the stimulus is presented either with a warning signal or without it in the same stimulus modality, or in the opposite one (internal and phasic (phasic) vigilance). In the test, it is possible to use a short form of a cross-modal subtest (phasic) with the presentation of visual and auditory stimuli and others.

All tests of attention (WAF) can take into account the average reaction time and various types of errors. For most variables, norms are also compared, resulting in percentile ranks and T-scores. Given the short testing time, the reliability (Cronbach's alpha), as well as the validity obtained for all WAF tests, is considered to be quite high.

The total duration of the WAFA battery of tests for attention is usually short, at the same time, the passage of all blocks of the test for some patients after strokes is very burdensome. A little time may be required if the patient is tested on the standard Schulte tables (in paper form), which in some cases we used in the framework of this invention as an alternative to the WAFA tests: we used 5 black and white square-shaped tables on which numbers are randomly placed from 1 to 25. The subject is at such a distance from the table to see it in its entirety. They give instructions to look for numbers in order, pointing and naming them aloud. At the same time, the time spent on each table is recorded (using a stopwatch, or a computer program, respectively), and the mistakes made. The average time to complete a task on one table is normally 40-50 seconds. In patients after a stroke, it is noticeably greater.

The rate of task completion by healthy people is usually uniform; therefore, the analysis of the speed characteristics of task completion is essential. A decrease in pace towards the end of the study indicates the exhaustion of the patient's mental performance. Skipping numbers, showing another instead of one digit indicates insufficient concentration of attention, and an increase in the number of errors in the last three tables indicates a decrease, exhaustion of mental performance. It is also evidenced by an increase in the scatter of the patient's response time to presented stimuli in the WAFA test.

Based on the results of each table, an “exhaustion (fatigue) curve” can be additionally constructed, reflecting the stability of attention and working capacity in dynamics. It allows you to determine the nature of the asthenic condition. In the hypersthenic variant, the exhaustion curve has a fairly high initial level, followed by a sharp decline, in the hyposthenic variant, a low initial level with a gradual decrease.

The main indicators are the execution time and the number of errors separately for each table. However, it is also possible to calculate the patient's average response time to stimuli by calculating the magnitude of the spread in the values of the response time to each stimulus (the number in the table), the nature of which indicates the respondent's performance. In the case of using several test options, the average values of the results obtained are used for calculations. The main thing is that before and after rehabilitation, the same types of tests are used to assess the same function or modality, so that the comparison of their results is correct. The absolute values depend on the nature of the specific test itself and, accordingly, on the various parameters of a particular patient (age, education, degree of existing disorders, etc.).

Thus, a dynamic and relative comparison of the results of these selective tests (aimed at assessing active attention and working memory capacity) before and after CT seems to be appropriate for assessing its effectiveness in patients after AIS and identifying patients who require subsequent courses of cognitive training. against the background of medical support.

The terms of inpatient rehabilitation of patients were 10-14 days, an outpatient appointment with a control examination was carried out after 3-6 months.

As additional - comparative with those proposed in the method - parameters for evaluating the results of CR and prescribing its subsequent courses, the following were considered: improvement in indicators on a scale of quality of life in stroke, a number of indicators of the cognitive and motor spheres, a decrease in the severity of chronic fatigue and the severity of anxiety-depressive emotions (hospital anxiety and depression scale HADS, scale of the degree of chronic fatigue by A.B. Leonov and I.V. Shishkin), decrease in the level of reactive and personal anxiety according to the Spielberger-Khanin test, normalization of cognitive functions (memory, attention) according to the Mini Mental State Examination test ( MMSE).

The study was conducted on the basis of the National Research Center for Rehabilitation and Balneology of the Russian Ministry of Health in 2018-2021. A total of 60 patients participated in the study (average age - 60.0 ± 1.25 years, including women - 36, men - 24) .2±0.12 years from the onset of ischemic stroke).

The criteria for inclusion of patients in the study were: the age of patients 45-70 years, voluntary informed consent after AIS in terms of 6 months to 2 years.

The exclusion criteria were:

- neuroimaging signs of a brain tumor, arteriovenous malformation, brain abscess, vascular aneurysm,

- severe general somatic pathology,

- acute infectious diseases,

- mental illness with symptoms of acute mental disorder, schizophrenia, schizotypal and delusional disorders, Alzheimer's disease, severe dementia, severe behavioral and social adaptation disorders,

- epilepsy or signs of convulsive readiness on the EEG.

At the screening stage, all patients underwent a comprehensive general clinical, neurological and additional study, including methods for assessing the severity of post-stroke changes (Rivermead mobility index, NIHSS stroke scale, assessment of quality of life in stroke, functional assessment of walking using the scale (Dynamic Gait Index), functional assessment of the condition balance using the Berg Balance Scale (Berg Balance Scale)), assessment of emotional state (Hospital Anxiety and Depression Scales), assessment of cognitive functions: mini-study questionnaire of cognitive state (Volstein scale), assessment of active attention (WAFA test taking into account the average reaction time and the magnitude of the variation in reaction time) and the amount of working memory (block range according to the Corsi block tapping test) using the Vienna system, some patients were tested using the Schulte tables and the working memory subtest of the Wechsler scale (digit repetition test in forward and reverse order) .

The patients were divided into two groups:

- control (without specific psychological, cognitive effects), n=30,

- group of cognitive trainings (CT), n=30.

During the study, the results of testing by the Vienna system were displayed on the screen in a user-friendly form, stored in the respondent's database card index and could be processed in the most common programs for performing statistical calculations (Excel, SPSS, etc.) and printed. For clarity, the figures show examples of part of the reports on the study of the results of WAFA tests in patients of this group:

Fig.1. An example of a part of the report on the WAFA test using several of its modalities in the Vienna system - the reaction time and reaction time spread values are in the normal range or in the border zone close to it.

Fig.2. An example of a part of the report on the WAFA test using several of its modalities in the Vienna system - a graphical representation of indicators of active attention - the same patient as in figure 1: dots - reactions to the recorded stimulus approach a flat line, which indicates a fairly good retention of attention and low distractibility.

Fig.3. An example of a part of the report on the WAFA test using several modalities in the Vienna system - pronounced impairment of the attention function, there is increased fatigue, due to which the third block of tasks remained unfulfilled.

Fig.4. An example of a part of a WAFA test report using multiple modalities in the Vienna system - the same patient as in Fig. 3: graphical representation of a marked increase in reaction time and the magnitude of the reaction time spread, the patient is very tiring, does not hold attention, refused to perform the third block assignments.

During the WAFA test, the function of active attention was evaluated, in particular, such indicators as the speed of response to a stimulus (the average reaction time, taking into account all variants of the WAFA tests performed in a particular patient), where the stimulus was presented to the subject with a certain frequency for 5 minutes, and the value of the scatter of the reaction time (the difference in the response time to the presented stimuli - the maximum and minimum response time to the stimuli).

Taking into account these two indicators allows us to identify violations of the function of active attention - a slowdown in the speed of response and the difficulty of maintaining active attention associated with increased fatigue and exhaustion of the patient (which is determined by the value of the spread of the response time to the stimulus).

The CORSI test in the Vienna Test System assessed the ability of the subject to retain a certain amount of visually presented operational information. For this purpose, a block range was used in various sequences that must be memorized. The range gradually increased as the tasks were completed correctly, until the subject began to make mistakes. The higher the block range, the better the working memory functions.

Like other methods from the above (to assess the state of various functions of the patient, including motor, quality of life, emotional state), the WAFA and CORSI tests were presented to the subjects twice: before the start of rehabilitation measures and after their completion. Accordingly, the mentioned paper versions of tests for attention and memory were used in a similar way - for 6 patients who, due to limited physical capabilities, could not undergo diagnostic testing on the Vienna system.

Below we provide detailed data on the two study groups of patients during the course of rehabilitation.

For the purposes of the proposed method, 60 patients were studied, which were divided into two groups by simple randomization, depending on the rehabilitation complex used. Assessment of cognitive functions before and after the rehabilitation was carried out in patients of both groups - control group K (group 1, n=30), cognitive rehabilitation group CR (group 2, n=30).

group 1 - patients (control group, n=30, including 12 men, 18 women, average age - 61.1±1.07 years), who underwent a rehabilitation complex taking into account impaired functions (basic rehabilitation program): stretching exercises (stretching), mobilization, sensory stimulation to improve the functioning of the upper limbs, the use of orthoses or static adjustable splints, an anti-spastic complex for positioning the paretic limbs, electrical stimulation of the muscles of the wrist, forearm and shoulder in order to improve the functional activity of the upper limb, providing the need for technical means of rehabilitation, such as a cane, crutches or a wheelchair, a comprehensive program for the correction of post-stroke spastic muscle hypertonicity, which includes several technologies (kinesiotherapy, massage, orthotics, physiotherapy techniques). Also, in patients of this group, repeated, progressively adapted, targeted and purposeful training of the upper limbs and trunk was used to enhance motor control and restore the sensorimotor function of the paretic limbs of the hand; aerobic low-intensity cyclic exercises to increase exercise tolerance, improve the functions of the cardiovascular system and reduce the risk of recurrent cerebral stroke; the use of targeted training and training with a large number of movement repetitions, strength training with the ability to perform arbitrary movements; carrying out trainings to improve personal skills of daily activity, aimed at training balance (exercises "sit-stand"). The duration of the course of such rehabilitation was 12-14 days. At the same time, directed cognitive training was not carried out in patients of this group, however, they took vasoactive, neurotrophic drugs according to indications.

In the next group of patients with ischemic stroke, the therapeutic effect of the cognitive training (CT) program was studied against the background of the basic rehabilitation program, which was also used in the control group, including the appropriate drug therapy.

2nd group - patients (group of cognitive rehabilitation, n=30, including 12 men, 18 women, average age - 58.6±1.51 years), who underwent a complex that included the basic program mentioned above rehabilitation in combination with a cognitive training program performed by a computer-based cognitive rehabilitation system (Schuhfried Gmbh, Austria) - 24 people from the total number of this group were tested for active attention and working memory using the Vienna Test System computer diagnostic system, and 6 people with the help of variants of paper tests (Schulte tables, Wechsler test for working memory).

In patients of the 2nd (main) group, during the course of rehabilitation, CogniPlus cognitive training was performed lasting from 15 to 45 minutes at each lesson, 5 days a week in the "5 days - 2 days break - 5 days" mode. The course consisted of 10 sessions of cognitive rehabilitation (CR).

Statistical analysis and assessment of the reliability of the obtained results were carried out using the methods of variation statistics. The data were processed in MS Excel® 2007-2013, IBM SPSS Statistics for Windows v.26.0, using one-way ANOVA and discriminative analysis. Previously, each sample was checked for compliance with the normal distribution law using the Kolmogorov-Smirnov or Shapiro-Wilk test. Mean and standard deviation (M±SD) were used to represent data having a normal distribution. When describing abnormally distributed indicators, the median and interquantile range Me (25th and 75th percentiles) were used. Using Student's t test (t), the significance of differences in the mean values of two independent groups with normally distributed data was assessed. To assess the significance of differences between the percentages of two samples in which the trait of interest was registered, the method of Fisher's ϕ-angular transformation was used. When comparing two groups of qualitative traits, the Mann-Whitney test was used, the null hypothesis was rejected when significant differences were obtained. When comparing more than two sets of qualitative features, the Kruskal-Wallis H-test was calculated.

Of the 60 patients examined on the MMSE scale, 19 had normal values (32%), while the remaining 41 (68%) had cognitive impairment (34 (46%) had mild cognitive impairment (LCD) and 7 (12%) had moderate (UKR)).

Regardless of group affiliation, the study showed that in half of the patients with normal values on the MMSE scale, when examined using the proposed method, there is an increase in reaction time that exceeds the norm, in the vast majority of patients (7/8) the magnitude of the reaction time spread exceeded normal indicators, which testified in favor of a violation of the function of attention - the difficulty to maintain attention for a long time at one level) and only 1/8 of these patients recorded normal values for the magnitude of the variation in reaction time.

As the results of our studies showed, in patients of the control group (group 1) who received only the basic rehabilitation program, we did not notice statistically significant differences in assessing the severity of post-stroke changes. This applies to the assessment of the dynamics of the Rivermead index, the NIHSS stroke scale, the assessment of the quality of life in stroke, the functional assessment of walking using the Dynamic Gait Index scale, and the functional assessment of the balance state using the Berg Balance Scale, although there was a positive dynamics of the presented indicators (Table 1). one). However, there was a significant improvement in cognitive functions according to the mini-study of cognitive status questionnaire (Folstein scale). So, before the course of the basic rehabilitation program, the total score on this scale was 27.0 ± 0.40 points, and by the end of the course there was a statistically significant improvement in this indicator (respectively - 28.2 ± 0.42, with Р≤0.05) .

Table 1. Assessment of the severity of post-stroke changes.

Criteria (visit 1)
Before treatment (visit 2)
At the end of the course Rivermead mobility index (points) 12.0±0.48 12.6±0.39 NIHSS Stroke Scale 4.8±0.54 4.4±0.52 Assessment of quality of life in stroke 196.8±7.28 208.5±9.18 Cognitive State Mini-Study Questionnaire (Folstein Scale) 27.0±0.40 28.2±0.42* Functional assessment of walking using a scale (Dynamic Gait Index) 13.0±1.38 14.2±1.66 Functional assessment of the state of equilibrium using the Berg Balance Scale 37.9±2.05 38.2±2.34

Note: * - statistically significant difference between groups, p≤0.05.

When analyzing the emotional state of patients undergoing a basic rehabilitation program (Group 1), there was a positive trend in improving the general background of mood, the results indicated a statistically significant decrease in the severity of anxiety during the course of rehabilitation (5.1 ± 0.68 and 3, respectively, 1±1.48 points - before and after treatment (Table 2).

Table 2. Assessment of the emotional state.

Criteria (visit 1)
Before treatment (visit 2)
At the end of the course Hospital anxiety scale 5.1±0.68 3.1±1.48* Hospital Depression Scale 5.3±0.95 4.3±1.07

Note: * - statistically significant difference between groups, p≤0.05

It is important to emphasize that in patients who received a course of only basic rehabilitation (Group 1), there was a significant improvement in the indicators of cognitive functions according to the Folstein scale (Table 1). However, according to the results of evaluation by more informative methods of the Vienna Diagnostic System (Vienna), we did not obtain significant differences between the groups before and after treatment in terms of reaction time, the magnitude of the spread in reaction time values, and the block range (according to the Corsi test) (Table 3).

Table 3. Assessment of cognitive functions according to the Vienna Diagnostic System.

Criteria (visit 1)
Before treatment (visit 2)
At the end of the course Reaction time 292.9±13.9 278.6±12.6 Response time spread 95.8±14.8 103.3±13.0 Block range (Corsi test) 4.1±0.19 4.2±0.17

At the same time, in 9 patients of the control group (who did not receive targeted cognitive training), who had impaired active attention function and operative memory during examination by the proposed method, but with normal indicators of the MMSE scale, later, during the control examination, a deterioration in cognitive functions was recorded already and according to the MMSE scale, despite improved or normal indicators detected at the end of rehabilitation, established by other scales.

In patients who underwent AIS and received a basic rehabilitation program without cognitive training (1st, control group), 14 days later, there was some improvement in cognitive function indicators on the MMSE scale, and the severity of the anxiety state significantly decreased. At the same time, we did not find a statistically significant decrease in the severity of post-stroke changes (according to the results of assessing the dynamics of the Rivermead index, the NIHSS stroke scale, assessing the quality of life in stroke, functional assessment of walking using the Dynamic Gait Index scale, and functional assessment of the state of balance using the Berg scale ( Berg Balance Scale.

In addition, the absence of statistically significant results of improvement in assessing cognitive functions according to the Vienna Diagnostic System (Vienna) in terms of reaction time, the magnitude of the scatter of reaction time values and the block range - working memory (Corsi test), with a significant improvement on the Folstein scale, shows that the questionnaire mini-studies of cognitive state do not always reliably reflect the state of cognitive functions. Adding to this study tests for reaction time, reaction time spread and block range, carried out, in particular, using the Vienna system, allows a more reliable assessment of the state of cognitive functions and is a more subtle tool for monitoring the state and evaluating the effectiveness of rehabilitation in relation to cognitive functions, planning its subsequent courses, resolving the issue of continuing drug support.

In patients of the 2nd group (experimental group), who received a basic rehabilitation program in combination with cognitive training on the Cogniplus (Shuhfrid) system, we did not notice statistically significant differences in assessing the severity of post-stroke changes. This included the assessment of the dynamics of the Rivermead index, the NIHSS stroke scale, the functional assessment of walking using the Dynamic Gait Index scale, and the functional assessment of the state of balance using the Berg Balance Scale. Although there was a positive dynamics of the presented indicators (Table 4). At the same time, at the end of the course of medical rehabilitation, we reliably established an improvement in cognitive functions according to the questionnaire of a mini-study of the cognitive state (Volstein scale) and an improvement in the quality of life of patients. So, before the course of the basic rehabilitation program, the total scores on these scales were 25.0 ± 0.32 and 176.8 ± 6.64 points, and by the end of the course there was a statistically significant improvement in short-term memory, concentration, as well as indicators of daily activity ( respectively, 28.9±0.30 and 200.0±5.90 points, at p≤0.05).

Table 4. Assessment of the severity of post-stroke changes.

Criteria (visit 1)
Before treatment (visit 2)
At the end of the course Rivermead mobility index (points) 11.2±0.55 11.7±0.49 NIHSS Stroke Scale 5.4±0.60 4.9±0.53 Assessment of quality of life in stroke 176.8±6.64 200.0±5.90* Cognitive State Mini-Study Questionnaire (Folstein Scale) 25.0±0.32 28.9±0.30* Functional assessment of walking using a scale (Dynamic Gait Index) 12.0±1.15 14.0±1.17 Functional assessment of the state of equilibrium using the Berg Balance Scale 33.1±2.36 35.9±2.54

Note: * - statistically significant difference between groups, p≤0.05

When analyzing the emotional state of patients in this group who underwent a course of a basic rehabilitation program in combination with a cognitive training program, we obtained significant differences in the dynamics of depression and anxiety. During the course of medical rehabilitation, it was also possible to achieve an improvement in mood on a scale of depression (from 6.5±0.89 to 3.6±0.43 points) and a decrease in the level of anxiety (from 6.8±0.84 to 3.6± 0.43 points). (Table 5).

Table 5. Assessment of the emotional state.

Criteria (visit 1)
Before treatment (visit 2)
At the end of the course Hospital anxiety scale 6.8±0.84 4.0±0.47* Hospital Depression Scale 6.5±0.89 3.6±0.43*

Note: * - statistically significant difference between groups, p≤0.05.

In 19 patients who received a course of basic rehabilitation in combination with a program of cognitive training, an improvement in the indicators of cognitive functions according to the Vollstein scale was significantly noted (Table 4), which was also confirmed by the presence of significant differences between groups before and after treatment in terms of the average response time to a stimulus and the value scatter in reaction time, block range (Vienna system: WAFA tests, Corsi) (Table 6), while in the other patients of this group such changes were not observed.

Table 6. Assessment of cognitive functions according to the Vienna Diagnostic System.

Criteria (visit 1)
Before treatment (visit 2)
At the end of the course Reaction time 286.8±15.61 234.0±8.73* Response time spread 159.8±9.03 105.5±9.49* Block range (Corsi test) 4.3±0.32 4.7±0.25*

Note: * - statistically significant difference between groups, p≤0.05

Thus, in patients of the 2nd (main) group, who underwent AIS and received a basic rehabilitation program in combination with a cognitive training program, after 14 days from the start of treatment, there was an improvement in spatial working memory and concentration of attention, and the severity of anxiety-depressive symptoms significantly decreased. condition and improve the quality of life. We did not find a statistically significant decrease in the severity of post-stroke changes using this program of medical rehabilitation according to the results of the Rivermead index dynamics, NIHSS stroke scale, functional assessment of walking using the Dynamic Gait Index scale, and functional assessment of the state of equilibrium using the Berg Balance Scale. It is important to note that in this group (2nd, i.e. experimental group), after cognitive training in stroke patients, the average response time to the stimulus and the magnitude of the scatter of reaction time decreased significantly (p<0.05), the block range increased when both the Vienna system and paper tests for active attention and spatial working memory were used for testing (in 6 patients).

In 5 patients (~16%) from this group, a statistically significant quantitative improvement in test results after a course of rehabilitation did not allow us to consider CR effective (an increase in the block range by at least 1, an increase in the average reaction time by at least 25%, a scatter in the reaction time by at least 15% compared with the results before the start of rehabilitation). Four of these five patients were monitored for signs of cognitive deterioration within 6 months of rehabilitation. This allows us to consider the results of CR in these patients as ineffective, despite the fact that according to a number of other cognitive tests listed above (in particular, the Volstein scale - MMSE), the results of the CR led to an improvement in cognitive functions (Table 4).

At the same time, in 25 patients of this experimental group (~80.3%, p<0.05), there were no signs of deterioration in cognitive functions during the next six months of follow-up. The results of their CR were found to be effective, despite the fact that according to the results of a number of other cognitive tests used in the study from those listed above (but not offered in the framework of the proposed method), a significant improvement in cognitive functions was not always confirmed.

Meanwhile, according to the proposed group of tests for active attention with the determination of the average reaction time to stimuli and the magnitude of the scatter of the reaction time, the block range, it was in these patients that, in accordance with the proposed method, a statistically significant improvement in the quantitative test results was found compared to their initial results up to rehabilitation. Cognitive improvements were maintained significantly over the next 6 months of monitoring in these patients. These results demonstrate the possibility of using a screening assessment of the effectiveness of CR on tests of active attention - the average reaction time to a stimulus and the magnitude of the spread of reaction time values, in combination with the block range (spatial working memory test) as quantitative criteria for such an assessment, identifying patients who need more intensive cognitive rehabilitation (cognitive training and medication) in the future, to reduce the risk of transition to dementia.

Note that 6 patients of this group (experimental group 2) underwent a study of the proposed functions of attention and working memory not on the Vienna system (Shuhfrid), but according to the Schulte tables (attention assessment) and the corresponding subtest of the Wechsler scale (digit repetition test), to determine the amount of short-term memory.

Example 1

Patient S.N.V., 50 years old, late recovery period (6.5 months) after AIS in the vertebrobasilar basin. The dynamics of criteria indicators of cognitive rehabilitation (CR) is presented in Table 7.

Table 7. Values of criteria indicators for evaluating the effectiveness of CI before and after it.

Test scores Before KR After KR The value of the block range - the amount of working memory (Corsi block tapping test (CORSI), Vienna system), points (blocks) 4 1 (upgrade by 1) WAFA test (Vienna), mean stimulus response time (visual, auditory, crossmodal tests), msec 316 235 (25.6% improvement) WAFA test (Vienne), stimulus response time spread (visual, auditory, crossmodal tests), units 61.6 42.6 (more than 16% improvement)

In this patient from the 2nd (main) group, when calculating according to the proposed method, cognitive rehabilitation was assessed as effective (a significant improvement was observed in all three indicators), while according to other tests (Volstein - MMSE) significant improvements in cognitive functions as a result of rehabilitation has not been established. In dynamics, 6 months after the CR, the patient retains the achieved level of basic cognitive functions, additional drug therapy to stimulate cognitive functions was used only during the first 4 months after the stroke, but was practically absent during the rehabilitation course and after it.

Example 2

Patient Ch.T.V., 57 years old, late recovery period (7 months) after AIS in the territory of the right internal carotid artery. Dynamics of criteria indicators of cognitive rehabilitation (CR) is presented in Table 8.

Table 8. Values of criteria indicators for evaluating the effectiveness of CI before and after it.

Test scores Before KR After KR The value of the block range - the amount of working memory (Corsi block tapping test (CORSI), Vienna system), points (blocks) <3 3 (upgrade by 1) WAFA test (Vienna), mean stimulus response time (visual, auditory, crossmodal tests), msec 613.3 507.3 (17.3% improvement) WAFA test (Vienne), stimulus response time spread (visual, auditory, crossmodal tests), units 61.6 73 (deterioration)

In this patient from the 2nd (main) group of the study, when calculating according to the proposed method, cognitive rehabilitation was assessed as ineffective (a significant improvement was found only for the magnitude of the variation in reaction time - more than 15% compared with the initial value). At the same time, according to other tests used (MMSE), improvements in active attention and block memory range were established as a result of rehabilitation. However, in dynamics, despite the CR, as well as the use of background drug therapy aimed at improving cognitive functions (a complex of neurotrophic, vasoactive drugs), by the end of the first year after AIS, the patient's cognitive functions correspond to the initial signs of dementia. There was an increase in drug therapy with the appointment of acetylcholinesterase inhibitors and repeated courses of cognitive training, against which a stabilization of the condition is observed, without further deterioration.

Example 3

Patient F.T.O., 55 years old, late recovery period (8 months) after AIS in the basin of the middle cerebral artery. The dynamics of criteria indicators of cognitive rehabilitation (CR) is represented by the following results:

- the value of the block range - the amount of working memory (Wechsler's subtest for memorizing numbers) - improvement by 1 unit,

- test for active attention, Schulte tables 5x5, average response time to a stimulus - improvement by 36.2%,

-test for active attention, Schulte tables 5x5, the magnitude of the scatter in response time to a stimulus - an improvement of 14.4%.

Thus, in this patient from the 2nd (main) group of the study, when calculating according to the proposed method, the CR was assessed as ineffective, since there was no significant improvement in the entire complex (combination) of criterion performance indicators. Thus, the magnitude of the spread in response time to stimuli (less than 15%) did not improve significantly for the assessment, although there is an improvement in the average reaction time (more than 25%). The lack of effectiveness of CR in the future is demonstrated by the fact that in dynamics, despite the CR, after 5 months the patient's cognitive functions correspond to the initial signs of dementia (the patient did not take neuroprotective and vasoactive drugs prescribed in accordance with the proposed method after the course of rehabilitation).

In general, a comparative analysis of the results of rehabilitation measures showed that when assessing cognitive functions on the MMSE scale, there was a higher frequency of improvement in cognitive functions in the form of a transition from LCR to normal (8 out of 30 patients) in the CT group, compared with 5 out of 30 in the group K (in which 1 case of deterioration was also recorded - a transition from the norm to LCR) (p> 0.05).

At the same time, the additional use of methods for determining active attention and the amount of RAM according to our method revealed the following features.

Only in the group of cognitive training (2nd group, experience) in 1/3 of patients (10 people) there was an improvement in the CORSI test by at least one point, while in the control group an improvement was observed only in 1 patient - these data indicate in the effectiveness of cognitive training.

The CR group (2nd) initially had the worst performance in terms of active attention function and RAM capacity. In this group, against the background of ongoing cognitive training, more than half of the patients (16 patients) showed significant improvements (by 20%) or more in reaction time and the magnitude of the reaction time spread, in the control group, clear improvements were observed only in 2 cases. Thus, significant improvements in active attention under the influence of cognitive rehabilitation are observed in more than half of the patients.

In the CT group (experimental group 2), in 8 patients with test scores corresponding to LCR according to MMSE, after CR, the indicators returned to normal, however, in 6 of them, the reaction time indicators remained below the norm, despite the improvement compared to baseline . These data indicate the persistence of the impaired function of active attention in patients and the need for further measures to restore it, including active drug correction. In 2 out of 3 cases of worsening of MMSE indicators in CR (Group 2) by -1 point (within LCR, without transition to the CR level), it was initially about extremely low CORSI test scores (3 points or less) along with reduced reaction time.

In the control group (Group 1, where CT was not performed), in 3 out of 4 cases of transition from LCR to normal and in 1 case of transition from LCR to LCR, there were initially normal and even high rates of reaction time and CORSI test, and only in one case they were below normal. In the other 6 patients of the same group, in whom the MMSE scores remained reduced before and after rehabilitation without positive dynamics, initially and at the end of rehabilitation, pronounced impairments in the function of active attention and/or operative memory capacity remained.

Thus, in cases of clear positive dynamics in patients from the control group, the improvement in cognitive functions was not so much due to rehabilitation measures, but due to initially high body reserves (good indicators of active attention and RAM capacity). In the only case of a transition from the norm to LCR, the patient initially had extremely low values of the block range and reaction time (i.e., low reserve capabilities that did not allow him to steadfastly compensate for the function).

Summarizing the above, we note that the use of indicators of working memory and active attention, with their low cost in time and ease of reproduction due to the universality of the available tests, can significantly expand information about the patient in terms of initial prediction of therapy tactics and assessment of rehabilitation results, timeliness of further assistance, aimed at improving cognitive functions.

Claims (8)

1. A method for identifying patients who need to continue cognitive training courses against the background of drug support after acute ischemic stroke (AIS), including training and testing of cognitive functions before and after a course of cognitive rehabilitation, characterized in that Initially, before and after a course of cognitive rehabilitation, with the help of testing, a complex of the following cognitive functions of the patient is studied: - study of the amount of RAM; - study of the function of active attention by determining the average response time to the stimulus for the test and the magnitude of the spread in the values of the reaction time, and consider the cognitive rehabilitation to be effective and drug therapy with vasoactive, neutrotrophic and cholinergic agents aimed at stimulating cognitive functions, which is not further indicated if, at the end of the course of cognitive rehabilitation, compared with what happened before it, a decrease in impaired indicators of the average reaction time is diagnosed by less than 25% in combination with a decrease by at least 15% of the spread of reaction time values in cases of their initial deviation from the norm and in combination with an increase in the amount of RAM - an expansion of the block range by at least 1 unit, and if these parameters are not achieved after a course of cognitive rehabilitation, then the patient continues drug therapy with vasoactive, neutrotrophic and cholinergic agents aimed at stimulating cognitive functions, against which a second course of cognitive training is carried out no later than 3 months after the end of the previous one. 2. The method according to claim 1, characterized in that to assess the amount of RAM - block range, a block tapping test is carried out using a computer diagnostic system, and to assess active attention with the determination of the average reaction time and the magnitude of the scatter of reaction time values - the WAFA test using the same diagnostic system.

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