WO2021118382A1 - Method for increasing the effectiveness of arm motor rehabilitation after stroke - Google Patents

Abstract

The invention relates to the field of medicine, and more particularly to methods for the rehabilitation of stroke patients. The technical result of the claimed solution is more effective normalization of the motor kinematic portrait in a paretic arm by means of targeted modulation of motor cortex excitability using TES of the brain and modification of the protocols used during FES that is synchronized to voluntary movements by means of EMG, in accordance with the severity of the patient's paresis and their functional capacities. The claimed technical result is achieved by means of a method for arm motor rehabilitation in stroke patients which includes steps in which the brain is subjected to TES, after which a target muscle is subjected to functional electrical stimulation using a pulsed current while the patient executes a cyclical movement with the aid of the muscle in question; at the same time, electromyography of the muscle in question is carried out, wherein a muscle that acts as a synergist in the execution of the cyclical movement is used as an EMG trigger for the FES, the EMG trigger electrode being attached outside of the region of activity of the muscle being stimulated.

Description

METHOD FOR INCREASING THE EFFICIENCY OF REHABILITATION OF MOTOR DISORDERS IN THE HAND AFTER STROKE

The invention relates to medicine, namely to methods of rehabilitation of patients who have suffered a stroke.

PRIOR ART

Stroke is the most important medical and social problem around the world [1]. Stroke is characterized, on the one hand, by high mortality, and on the other, by the persistence of residual neurological deficit in the majority of surviving patients, which is the cause of disability after the end of the acute period [2]. Stroke occurs in about 16.9 million people worldwide every year [3]. According to the official statistics of the Ministry of Health, 428,053 cases of stroke were registered in the Russian Federation in 2017, the incidence was 291.55 per 100,000 population [4]. Hand dysfunctions in patients with stroke are detected with a frequency of up to 80% and are one of the most significant factors in the decline in the quality of life, disturbances in everyday and social adaptation [5]. Improving rehabilitation methods for patients with post-stroke movement disorders is the most important direction in reducing the social and economic burden of stroke [6,

7] ·

In recent years, there has been an intensive development of neurorehabilitation methods, which is largely associated with an improved understanding of the fundamental aspects of neuroplasticity - the basis for the restoration of functions impaired as a result of the disease [8-10]. Methods of non-invasive brain stimulation - rhythmic transcranial magnetic stimulation (rTMS) and transcranial electrical stimulation (TES) - are one of the most promising approaches to non-invasive modulation of neuroplastic processes in patients with movement disorders after stroke [11]. Clinical studies conducted to date and several meta-analyzes have shown that rTMS statistically significantly improves hand motor function in the recovery period of stroke [12-15]. Interest in the use of TES, another method of non-invasive brain stimulation in post-stroke rehabilitation, is associated with several factors: a more favorable safety profile, portability of devices, their lower cost, the ability to use at home under the supervision of a doctor (including the use of telemedicine technologies), as well as ease of use and combination with other methods of neurorehabilitation [16]. Combining the use of direct current TES and functional electrical stimulation (FES) is a promising direction for increasing the effectiveness of rehabilitation of patients with movement disorders in the arm after a stroke.

Below is an analysis of the data on the effectiveness of the use of various protocols of transcranial electrical stimulation in patients with movement disorders in the arm after a stroke.

The main and most common method of EFT is transcranial direct current stimulation (tDCS). The device for TPP includes a generator and two electrodes. Typically, a current strength of 0.5 to 2 mA and a stimulation duration of 10 to 30 minutes are used [17].

With tDCS, one of the electrodes is the anode and the other is the cathode. Experimental studies have shown that tDCS causes a subthreshold change in the membrane potential, which, in turn, leads to a change in the excitability of neurons, depending on the polarity of the stimulating electrode [17-20]. When the anode is located on the surface of the skull, an incoming (towards the electrode) current is generated in the nerve tissue, which causes a displacement of the membrane potential in the positive direction - depolarization of the membrane, which facilitates (makes more likely) the formation of adhesions. The location of the cathode, on the contrary, causes an outgoing (in the direction from the cathode) current, which displaces the resting potential in the negative direction, causing hyperpolarization of the membrane and reducing the likelihood of spike formation [21]. At the systemic level in humans, these effects can be directly assessed by measuring the excitability of the motor cortex using transcranial magnetic stimulation (TMS). When the anode is located above the primary motor cortex and stimulated for 5–20 minutes with a current of 1 mA, an increase in the excitability of the motor cortex (an increase in the amplitude of evoked motor responses) is observed, while when the cathode is located, on the contrary, a decrease in excitability is observed [18, 19]. Thus, conducting tDCS allows directionally modulating the excitability of the cerebral cortex when using an electrode of the appropriate polarity.

The most important prerequisite for the use of EFT for the treatment of diseases of the nervous system is the presence of not only an online, but also an offline effect - a long-term modulation of the activity of the stimulated area, which persists for several minutes, hours or days, depending on the current strength, installation of electrodes and the duration of stimulation. The long-term effects of thermal power plants are probably based on processes similar with long-term potentiation (LTP) and depression (long-term depression, LTD), although the participation of other mechanisms has also been shown [20, 21].

The use of non-invasive brain stimulation to improve hand function in stroke is based on modern concepts of the structural and functional reorganization of the motor system caused by its unilateral damage. In the acute period of a stroke, restoration of impaired functions occurs primarily due to a decrease in cerebral edema and regression of inflammatory changes. In the chronic stage, neuroplasticity processes are of the greatest importance, providing functional reorganization of cortical motor areas with recruitment to perform the function of preserved neurons in the perifocal region of the affected hemisphere and / or homologous pathways and areas of the unaffected hemisphere [22-24]. These processes lead to complex and insufficiently unexplored changes in interhemispheric interactions. It is the modulation of interhemispheric interactions with the induction of neuroplastic changes that is the main point of application for a number of modern methods of neurorehabilitation, including EFT [22].

Currently, the most common model is interhemispheric competition. It is assumed that the basis for the development of interhemispheric imbalance in stroke is a violation of physiological inhibition by the affected hemisphere of the unaffected one. This leads to hyperexcitability of the unaffected hemisphere and increased inhibition by it of the affected hemisphere, which is, figuratively speaking, “twice affected” - due to focal damage caused by stroke and inhibition by the unaffected hemisphere [25]. Evidence of the maladaptive nature of the increase in the activity of the unaffected hemisphere was obtained in a series of longitudinal studies using modern methods of functional neuroimaging. For example, it has been shown that an increase in activation of the unaffected hemisphere during movement with the paretic arm is associated with poor recovery, and a more pronounced recovery of motor function is associated with the transition from bilateral activation of motor cortex zones to predominantly unilateral activation of the affected hemisphere [26]. An increase in the excitability of the unaffected hemisphere, according to studies using TMS, is also associated with poor recovery of function [27].

To date, clinical studies using EFT to improve hand function have been based on a model of interhemispheric competition, in accordance with which electrode mounting is used to inhibit the motor cortex of the unaffected hemisphere and / or activate the affected hemisphere. Analysis The results of the conducted studies indicate a high variability of the effect of TES on motor function and, in general, demonstrates that this method has only a slight effect in improving the function of the hand or is not at all effective. A Cochrane review of 15 studies and 455 patients found very low and low-level evidence for the efficacy of tDCS in improving arm function according to the Fugle-Meier scale and increasing daily activity according to the Barthel index [28]. A meta-analysis of 9 studies with a total enrollment of 371 patients showed no statistically significant effect of different tDCS protocols on hand function [29]. These findings were confirmed by a Cochrane review published in 2016, which analyzed 12 studies involving 431 patients to assess the effect of tDCS on arm function [30]. At the same time, the meta-analysis showed that the use of tDCS can improve the performance of fine movements in the hand (effect size - 0.31 (95% confidence interval (CI), 0.08-0.55; p = 0.010, effect size rTMS - 0.46 (95% CI 0.00-0.92; p = 0.05) [31] In all these studies, studies were analyzed with the inclusion of patients at different stages of the disease (acute / subacute / chronic) and with the use of different stimulation protocols within the framework of the model of interhemispheric competition (anodic stimulation of the affected hemisphere, cathodic stimulation of the unaffected hemisphere, and bilateral stimulation) .The heterogeneity of the analyzed studies also concerns other components of the protocols (current strength, electrode size, duration of one session, etc.), as well as methods for assessing the function of hands At the same time, there is still insufficient data on direct comparison of the effectiveness of various protocols (anodic tDCS of the affected hemisphere, cathodic tDCS of the unaffected hemisphere, bilateral stimulation) [32]. but studied their effectiveness depending on the severity of damage to the motor cortex and corticospinal tracts, the severity of motor deficit, as well as the period after stroke.

One of the ways to increase the effectiveness of tDCS for restoring motor function of the arm is to combine it with motor rehabilitation methods. The theoretical substantiation of this approach is the commonality of the mechanisms underlying the action of tDCS and motor learning. In addition, tDCS does not directly lead to depolarization of neuronal membranes, but only modulates the membrane potential and affects the likelihood of an action potential. A meta-analysis has shown that tDCS may be more effective when combined with other rehabilitation methods [31]. Currently, the prospects of the combined use of tDCS with robotic mechanotherapy, ergotherapy, and therapy with limitation of mobility of a healthy limb (constraint-induced movement therapy, CI-therapy), imagination of movements [33].

When tDCS is used in combination with motor rehabilitation methods, it is extremely important to have a definite optimal temporal pattern of such a combination. tDCS can be used before motor training (as a priming, to prepare for training), during or after motor training [34]. Studies on healthy volunteers have shown that only when conducting anodic tDCS before simple motor training (but not during and after) a statistically significant increase in the excitability of the motor cortex of the stimulated hemisphere is revealed [34]. In stroke, it has been shown that an improvement in the performance of a motor task is observed during anodic tDCS before robotic arm mechanotherapy, but not during or after [35]. A meta-analysis of a meta-analysis of 17 randomized trials published in 2016 showed improvements in motor function and motor learning when using tDCS in combination with motor rehabilitation techniques compared to simulated stimulation in patients with subacute and chronic stroke. It is important to note that in this work, a slightly greater effect was revealed when conducting tDCS before motor training [36]. Thus, the currently obtained data indicate the feasibility of performing tDCS prior to motor rehabilitation using other methods.

In stroke patients, the muscles of the paretic limbs can be contracted by applying an electric current, by direct action on the intact peripheral nerves that innervate these muscles, as well as in the projection area of the motor point of the stimulated muscle. The use of neuromuscular electrical stimulation (NMES) during the performance of a motor action aimed at coordinating movement through the action of an electric current on the paretic muscles involved in this motor act is called functional electrical stimulation (FES).

FES - a method that uses a course therapy with electric current impulses to induce a specific pattern of muscle contractions and movements necessary to perform a specific function; muscles are activated as a result of stimulation of the motor point of the muscle, electrical stimulation is combined with the performance of targeted exercises [37].

FES has proven itself well as an independent technique for restoring the motor function of the lower limb [38-40]. For more than 40 years of research on FES, the principles of safe stimulation of nervous muscle tissue, as well as methods aimed at increasing the strength of the affected muscles, which in turn influenced an increase in the motor amplitude in the joints of the paretic limbs in patients after a stroke. Based on these principles, methods have been developed aimed at the rehabilitation of post-stroke patients with motor dysfunction. Several studies have shown the effectiveness of the use of FES for restoring the motor function of the hand [41-44]. According to the clinical recommendations of the Union of Rehabilitologists of Russia for the restoration of motor functions of the hand after a stroke, NMES of the flexors and extensors of the wrist and fingers is proposed as an adjuvant method for use in patients with a stroke duration of up to 6 months. Strength of recommendation B, reliability of evidence - 2a. A recently published systematic review has shown the effectiveness of FES in the upper limb in relation to patient activity in daily life [45].

The most pronounced movement disorders in the arm in stroke patients are observed in the distal regions: the weakness of the muscles responsible for flexion and extension of the fingers does not allow grasping and holding the object in the hand, which is why the flexors and flexors were the most frequently chosen target muscles for FES. extensors of the fingers. The use of FES for the restoration of locomotion is facilitated by a relatively accurate and simple solution for synchronizing the stimulation pulse with the step phase, in the form of a mechanical pressure sensor built into the shoe insole. At the same time, the use of FES to restore hand function leads to significant difficulties in generalizing scientific and clinical data, which is dictated primarily by the lack of a unified paradigm of application due to the absence of a stereotypical and simple hand movement, which is due to the significant complexity of the hand as a functional organ. In addition, it is difficult to synchronize stimulation impulses with any movement.

DISCLOSURE OF THE INVENTION

According to the existing theories and hypotheses of the mechanism of action of FES on the restoration of the motor activity of paretic muscles in patients after stroke, it is important to synchronize an external stimulus with the activation of the motor regions of the cerebral cortex when performing a voluntary target movement. To achieve the necessary conditions and facilitate the activation of the motor structures of the brain, non-invasive brain stimulation can be applied. To date, several papers have been published on the synchronized use of peripheral and transcranial electrical stimulation in patients with post-stroke hemiparesis. In a study by R. Celnik et al. (2009) showed that the combination of peripheral neuromuscular electrical stimulation with anodic TES of the primary motor cortex of the affected hemisphere improves the performance of motor tests compared with the use of each of the methods separately [46]. At the same time, a study by IS Menezes et al. (2017), who evaluated the effect of a single session of EFT in combination with rhythmic peripheral sensory stimulation as a priming to FES, no statistically significant differences were found between the use of stimulating protocols and imitation of stimulation [47]. Finally, when speaking about the study of the long-term effects of the combination of EFT and FES, two studies should be mentioned. N. Shaheiwola et al. (2018) showed that the use of bilateral TES (anode above the primary motor cortex of the affected hemisphere, cathode above the primary motor cortex of the unaffected hemisphere) immediately before FES statistically significantly improves motor recovery compared to imitation of stimulation [48]. In the study by A.R. Salazar et al. (2019) also showed that the use of TPP as a priming before FES can increase the efficiency of the latter [49].

The technical result of the claimed solution is to increase the efficiency of normalizing the kinematic portrait of the paretic hand by selectively correcting the motor synergy of target muscles by the FES method, synchronized by EMG and directed modulation of the excitability of the motor cortex using TES of the brain.

The claimed technical result is achieved by implementing a method for the rehabilitation of movement disorders in the arm in patients who have suffered a stroke, including the stages at which TES of the brain is carried out with a direct current of 2 mA, no more than 15 minutes after TES of the brain, functional electrostimulation of the target muscle is carried out when performing a patient of cyclic movement using a FES trigger as an EMG muscle, which is a synergist of the performed cyclic movement, while the EMG trigger electrode is attached outside the area of muscle activity, functional electrical stimulation is carried out with a pulse current with a pulse duration of 1-3 ms and a pulse amplitude of up to 30 mA, a stimulation frequency 25-30 Hz for inducing tetanic contractions of skeletal muscles or 50-100 Hz for skeletal muscle spasm or 1-10 Hz for toning effect on muscles, while the delay time between fixation of the signal from the trigger electrode and stimulation of the target muscle is 50-900 ms.

In particular cases of implementation of the invention, rehabilitation is carried out in courses consisting of 5-10 sessions.

In particular cases of the implementation of the invention, the TPP is carried out for 18-22 minutes. In particular cases of implementation of the invention, training with FES is carried out for 10-30 minutes.

In particular cases of the invention, TPP is carried out using one of the protocols: anodic TPP of the primary motor cortex of the affected hemisphere, cathodic TPP of the primary motor cortex of the unaffected hemisphere bilateral (simultaneously anodic TPP of the primary motor cortex of the affected hemisphere and cathodic TPP of the primary motor cortex of the unaffected hemisphere).

In a particular case of the invention, the stimulation is carried out in a sitting or reclining position on the back on a special chair.

In a particular case of the invention, the cyclic movement is the achievement of a remotely located object of a spherical or cylindrical shape, followed by its capture by extension and flexion of the wrist joint and / or fingers

In a particular case of the invention, the cyclic movement is the achievement of a remotely located object by bringing and flexing the arm at the shoulder joint and extending the arm at the elbow joint.

During the execution of the cyclic movement, the stimulating electrode is located on the muscle, which is responsible for the cyclic movement, the trigger electrode is located on the muscle, which is the main one during synergistic movement, and the fixation of the EMG signal from it indicates the occurrence of pathological synergy. The patented technique makes it possible to reprogram pathological motor patterns at the peripheral level with an enhancement of the effect due to the directed modulation of the excitability of the motor cortex using TES. Thus, an increase in the efficiency of normalization of the motor kinematic portrait in the paretic hand is achieved. In addition, the use of modern devices for conducting FES and TES, with a friendly interface and intuitive software, will contribute to the successful interaction of the patient and the therapist.

DESCRIPTION OF DRAWINGS

Further, the solution is explained with reference to the drawings, which show the following.

FIG. 1 - Protocol parameters for bilateral stimulation of the primary motor cortex of the affected and unaffected hemispheres in right-sided post-stroke paresis.

FIG. 2 - Parameters of the protocol for cathodic stimulation of the primary motor cortex of the unaffected hemisphere in right-sided post-stroke paresis. FIG. 3 - Diagram of the sequence of the execution of movements when training a ball grip.

FIG. 4 - Diagram of the sequence of movements during the training of a cylindrical grip.

IMPLEMENTATION OF THE INVENTION Indications for carrying out the proposed method:

• the presence of mild or moderate paresis of the hand according to clinical examination;

• period after a stroke - 3 months or more.

Contraindications:

• cancer (currently or in history);

• decompensated somatic pathology, severe pathology of the cardiovascular system;

• presence of metal elements in the area of the procedure, pacemaker, any other electronic implants;

• heart rhythm disturbances;

• the presence of a defect in the bones of the skull or titanium implants of the skull;

• history of epileptic seizures;

• pregnancy;

• damage or disease of the skin at the location of the electrodes;

• detection of generalized epileptiform activity on screening EEG;

• the presence of nonunited fractures and significant osteoporosis with an increased risk of fractures;

• contractures and limited range of motion (the degree of spasticity in the flexors of the elbow, wrist joints and fingers of the hand is 3 or more points on the Ashworth scale);

• presence of pressure sores or open wounds in the treatment area;

• dislocation / subluxation of the shoulder joint in anamnesis;

• patients with an infectious lesion in the area of the electrode;

• gross sensory or motor aphasia or severe cognitive impairment that makes it difficult to follow instructions;

• the presence of hyperkinesis;

• severe visual impairment that prevents you from following visual instructions;

• gross violation of deep sensitivity, neglect, according to neurological examination. TDCS technique.

1) Before starting the procedure, it is necessary to measure the girth of the head and select a helmet of the appropriate size (using a helmet that is too large leads to an insufficient tight fit of the electrodes to the surface of the head and a displacement of their localization relative to the brain structures, and using a helmet that is too small is uncomfortable for the patient).

2) The helmet must be worn in accordance with the international scheme for the arrangement of electrodes "Yu-20%".

3) To ensure optimal contact with the scalp, it is recommended to use thin sponges soaked in 0.9% sodium chloride solution or a special adhesive paste for EEG. When using sponges soaked in electrolyte solution, it is important to maintain a balance: an insufficiently moistened sponge can cause unpleasant sensations in the form of burning and tingling in the stimulated area, while an excessively moistened sponge will lead to the formation of "bridges" between the electrodes. Special preparation of the skin, in particular with the use of abrasive pastes, is not required. If necessary, it is possible to cleanse and degrease the skin using alcohol solutions.

4) It is necessary to warn the subject in advance about the possibility of tingling and burning sensations and the need to inform the person conducting the stimulation about this.

5) A device for transcranial electrostimulation of the brain, developed within the framework of the project "Development of a new generation of assistive devices and technical means of rehabilitation using neurotechnologies to improve the effectiveness of treatment and rehabilitation, as well as improve the quality of life of people," LLC "Neurobotics", Moscow, Zelenograd). A special feature of the device is the ability to graphically and quantitatively control impedance and current distribution during stimulation.

6) Choice of stimulation protocol.

• Stimulation intensity: 2 mA.

• Stimulation mode: DC (direct current, constant current stimulation, “soft” current ramp mode).

• Duration of one session: 20 minutes.

• Total number of sessions: 5-10.

• It is possible to carry out anodic TPP of the primary motor cortex of the affected hemisphere, cathodic TPP of the primary motor cortex of the unaffected hemisphere, or bilateral TPP. The location of the electrodes for different mounting options depending on the side of the lesion is shown in Table 1. FIG. Tables 1 and 2 show examples of the settings for the stimulation protocol in the electrostimulator control program for right-sided hemiparesis (lesion of the left hemisphere).

Table 1 - Location of electrodes for different types of stimulation depending on the side of the lesion in patients with post-stroke paresis

7) Stimulation is carried out in a sitting or reclining position on the back on a special chair. It is necessary to create the most comfortable conditions for the patient. It is possible to use a pillow or roller. It is recommended to avoid sudden movements of the patient's head due to the risk of displacement of the electrodes.

8) During the stimulation, the patient must be under the supervision of medical personnel (a doctor or nurse, provided that a doctor is available to provide assistance). All specialists participating in the TPP should have sufficient knowledge about the physical and physiological foundations of the method, as well as about possible undesirable effects and the algorithm of action during their development. In case of intense pain and other undesirable effects, it is necessary to immediately stop stimulation and stop contact of the electrode with the skin.

9) After each EFT session, it is advisable to fill out a questionnaire to assess the tolerance of the procedure and undesirable effects.

10) Before and after each TES session, it is necessary to control blood pressure and heart rate.

11) During the course of TES, the patient should be under the supervision of a neurologist.

In the Federal State Budgetary Scientific Institution "Scientific Center of Neurology", a randomized double-blind controlled study was carried out aimed at studying the effectiveness and tolerance of various EFT protocols in patients with post-insular paresis. Screening of 67 patients with previous ischemic or hemorrhagic cerebral circulation disorder more than 3 months old and post-stroke hemiparesis was carried out. In 24 patients at the screening stage, non-inclusion criteria were identified, another 2 patients dropped out before the end of the study due to logistical problems. In addition, 2 patients dropped out due to the development of adverse events (AEs). The final analysis included data from 38 patients.

After signing a voluntary informed consent, provided that the study participant met the inclusion criteria and did not include the non-inclusion criteria, the blind envelope method was randomized into one of four groups.

• Group A - anodic tDCS of the primary motor cortex of the affected hemisphere.

• Group B - anodic tDCS of the primary motor cortex of the affected hemisphere and cathodic tDCS of the primary motor cortex of the unaffected hemisphere.

• Group C - cathodic tDCS of the primary motor cortex of the unaffected hemisphere.

• Group S - sham-stimulation (simulated stimulation; the position of the electrodes is the same as for anodic tDCS, however, real stimulation is carried out only during the first and last 30 seconds of a 20-minute session).

Each patient included in the study underwent 5 EFT sessions using the prototype expert station of the transcranial stimulation apparatus. The intensity of stimulation is 2 mA, the duration of one session is 20 minutes. Reusable CS22 electrodes made of Ag / AgCl composite 22 mm in diameter were used for stimulation. The current density was 0.53 mA / cm ² (5.3 A / m ² ). The “soft” mode was used with a 30-second rise and fall of the current value at the beginning and end of the session, respectively. After each stimulation session, patients completed a questionnaire to assess the tolerability of EFT.

Assessment using clinical scales (Fugle-Meier scale, modified Ashworth scale) was carried out before the 1st and after the 5th session of stimulation by a blinded investigator with respect to the stimulation protocol to assess the effect of stimulation on motor function of the hand. In addition to TPP, all patients underwent motor rehabilitation aimed at restoring movements in paretic limbs, reducing muscle tone and improving household adaptation.

The final analysis included data from 38 patients randomized into 4 groups: group A (n = 7), group B (n = 10), group C (n = 10), and group S (n = 11). The groups did not differ statistically significantly in terms of age, duration of cerebral impairment. blood circulation before inclusion in the study, the total score on the Fugle-Meier scale, the sum of points for the sections of the Fugle-Meier scale for the upper limb and hand, the severity of spasticity in the arm according to the modified Ashworth scale. However, there was a trend towards a statistically significant difference in the age of stroke (p = 0.07; Kruskal-Wallis test).

Efficiency of TPP. When analyzing the effect of EFT on the motor function of the hand in all groups, a statistically significant increase in the sum of points on the Fugle-Meier scale and the section of the Fugle-Meier scale for the upper limb was revealed. In addition, in groups B and S, there was a statistically significant increase in the sum of points according to the section of the Fugle-Meier scale for the hand. There were no statistically significant differences between the groups in the change in the total score on the Fugle-Meir scale, the sum of points on the Fugle-Meier scale section for the upper limb and hand, as well as in the assessment of the severity of spasticity according to the modified Ashworth scale. There were no statistically significant differences between the groups in the change in the total score on the Fugle-Meir scale, the sum of points on the section of the Fugle-Meier scale for the upper limb and hand, as well as in the assessment of the severity of spasticity according to the modified Ashworth scale. Also, there were no differences in the effect of EFT on the motor function of the hand, depending on the presence / absence of WMO from the muscles of the paretic hand (p> 0.05 in all cases). In addition, there was no statistically significant correlation between the effect of EFT on the motor function of the hand and such indicators as the initial severity of paresis (according to the Fugle-Meier scale) and the period after stroke.

FES technique

FES is carried out immediately after tDCS. The maximum time interval between procedures should be no more than 15 minutes.

Disposable adhesive electrodes with a push-button connector are used for muscle stimulation and EMG. Any muscle that is a synergist of the cyclic movement performed can be used as an EMG trigger of FES. In the "Muscle Stimulator" module, the possibility of simultaneous registration of two EMG channels is available, each of which can serve as a FES trigger. To ensure the most accurate EMG registration, it is necessary to attach an additional reference electrode outside the area of muscle activity. Before training with the Muscle Stimulator, it is necessary to determine the target muscles for stimulation, as well as the muscle used as an EMG trigger for stimulation. Depending on the time parameters of activation of the trigger muscle, it is subsequently performed software adjustment of the stimulation delay to ensure the most accurate synchronization of the FES.

After fixing the EMG electrodes and stimulation, the EMG is calibrated, for this the subject is instructed to "relax the hand", and then press the button

5 "Calibration", for zero calibration of EMG sensors. The EMG window of the Muscle Stimulator software displays the intensity of the electromyogram of each channel in real time. The maximum intensity indicator of the recorded EMG corresponds to an amplitude of 500 μV, which also corresponds to the maximum displayed intensity of 100%. In the absence of changes in the EMG scale at

10 arbitrary muscle tension, it is necessary to check the tightness of the electrodes and the attachment point of the reference electrode. Changing the position of the slider sets the minimum threshold for voluntary muscle effort, after which electrical stimulation is activated. To select the EMG channel used as a trigger, it is recommended to perform several test movements and select the EMG channel with

15 with the largest recorded amplitude.

The selection of stimulation parameters includes the choice of parameters of a single pulse (pulse shape, pulse amplitude, pulse duration, delay duration) and parameters of a single pulse (stimulation frequency, stimulation duration, trigger delay, delay after)

20 Pulse shape. For electrostimulation of the motor apparatus, impulses of various shapes are used. According to the research of G.F. Kolesnikov, V.I. Kiy, A.A. Pavlenko (1963), the optimal signals, in which the muscles contracted almost painlessly, are sharp-pointed impulses filled with a sinusoidal or rectangular signal.

25 Pulse amplitude. The amplitude most used for electrical stimulation does not exceed 100 mA. For training, it is recommended, by gradually increasing, to select the most comfortable pulse amplitude for the patient, at which active muscle contraction will be observed (up to 30 mA).

Stimulation frequency. Frequency response of stimulation should be selected

VO based on the goals of influencing the muscle during training. So, according to many domestic authors (A.P. Novikov (1964), A. Nikolova (1975), Nikolaev (1999)), a pulse current with a frequency of 25-30 Hz has an exciting effect on motor nerves and causes tetanic contractions of skeletal muscles; pulse current with a frequency of 50-100 Hz causes skeletal muscle spasm; impulse current with a frequency of 1-10 Hz causes "muscle gymnastics", which has a tonic effect on the muscles and can be used for spasticity.

Duration of stimulation. When choosing a pulse duration, it should be borne in mind that a stimulating pulse duration of less than 1 ms may not be sufficient to completely cover all muscle fibers by excitation, and a pulse duration of more than 3 ms is energetically disadvantageous and not physiologically justified. The duration of the impulse should be selected in such a way that the excitation has time to cover all muscle fibers of the target muscle.

Trigger delay. It is set individually, depending on the timing of activation of the trigger muscle and the stimulated muscle during the physiological performance of the trained movement.

Delay after. The delay between the end of the stimulation and the beginning of the response to the trigger is set depending on the speed of the training movement. When setting this parameter, it is worth considering the time required to complete the movement and relax the stimulated muscle.

The training program, target and trigger muscle groups are determined by the severity of paresis and the degree of spasticity in the paretic muscles of the arm according to the Fugle-Meier, ARAT and Ashworth clinical scales.

The first training protocol is recommended for use in the following patients: motor deficit in the paretic arm according to the Fugle-Meier scale from 57 to 65 points, which corresponds to mild impairment of motor function; motor deficit in the hand on the ARAT scale from 51 to 57 points, which corresponds to mild fine motor impairment; spasticity according to the Ashworth scale: in the flexor muscles of the wrist joint and hand - 0-1 points, in the flexor muscles of the elbow joint - 0-1 points.

The second training protocol is recommended for use in the following patients: motor deficit in the paretic arm according to the Fugle-Meier scale from 47 to 56 points, which corresponds to moderate impairment of motor function; motor deficit in the hand on the ARAT scale from 41 to 50 points, which corresponds to moderate impairment of fine motor skills; spasticity on the Ashworth scale: in the flexor muscles of the wrist joint and hand - 0-1 points, in the flexor muscles of the elbow joint - 0-1 points)

The use of the technique for mild paresis in the hand (motor deficit in the paretic hand according to the Fugle-Meier scale from 57 to 65 points, which corresponds to a slight impairment of motor function; motor deficit in the hand according to the ARAT scale from 51 to 57 points, which corresponds to a slight impairment of fine motor skills ; spasticity according to Ashworth scale: in the flexor muscles of the wrist joint and hand - 0-1 points, in the flexor muscles of the elbow joint - 0-1 points).

Target muscle groups: m. extensor digitorum superficialis, m. flexor digitonun communis.

Workout. Due to the fact that in patients with mild paresis, motor dysfunctions in the paretic hand are mainly represented by a decrease in strength in the hand and fingers, the technology in this case is used to restore various types of grip and prepare the hand for them.

Purpose: the training is aimed at correcting the pathological stereotype in the hand, increasing functionality, increasing the grip strength and range of motion in the fingers of the hand.

Stage 1 (1-5 days of training !.

Target muscle group: m. extensor digitorum superficialis;

Trigger muscle: T. deltoideus anterior;

Target movements: reaching a distant object: ball (10 minutes), glass (10 minutes);

Grip type: spherical grip, cylindrical grip;

Trained movement: extension of the wrist joint and fingers;

Duration of one workout: 20 minutes;

Training goal: to restore the function of preparation for the capture in the paretic hand.

Training description:

Patient 1 is seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). At arm's length, individually for each patient, in the frontal plane on the table 4, a ball 2 with a diameter of 10 cm is installed. In front of patient 1 there is a monitor screen, which displays the success of the performed movement. The patient is asked to perform a motor task: to reach the ball, grab it, move it along the table, put the ball on a stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes. Fig. 3 schematically shows the sequence of performing the movements in this exercise.

In this case, during the execution of the movement, reaching a remotely located ball, the trigger electrode is located at m. deltoideus anterior, this muscle is of one of the main muscles of the flexor of the shoulder during this movement, as you know, normally, flexion of the shoulder reaches its maximum, by the end of reaching the object, and it is at this moment that the hand is prepared for gripping, that is, extension in the wrist joint and fingers of the hand, which begins at 70 % and reaches its maximum at 90% of the completed movement. The movement time in patients with mild paresis does not differ significantly from normal and averages -1000 ms. To stimulate the extension of the wrist joint and fingers to prepare for grasping in patients with mild paresis, the stimulating electrode is located at m. extensor digitorum superficialis, while the delay between EMG reading from the trigger electrode and stimulation of hand extension is -550 ms. It should be noted that due to the close location of the extensor muscles of the wrist and fingers, the stimulation of this movement occurs simultaneously and in a coordinated manner.

When the movement is performed correctly, the screen displays the movement of the virtual hand in the pronation position and the extension of the fingers of the hand, providing the patient with biofeedback on the movement of the extension of the wrist joint and fingers of the hand.

In the second part of the workout, patient 1 is also sitting on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). At arm's length, individually for each patient, in the frontal plane on the table 4, a glass 3 with a diameter of 8 cm is installed. A monitor screen is placed in front of the patient, which displays the success of the performed movement. The patient is asked to perform a motor task: reach for the glass, grab it, move it along the table, put the glass in the stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes. Figure 4 schematically shows the sequence of performing movements in this exercise.

In this case, during the execution of the movement to reach the remotely located glass, the trigger electrode is also located on m. deltoideus anterior. To stimulate the extension of the wrist joint and prepare for the seizure in patients with mild paresis, the stimulating electrode is located at m. extensor digitorum superficialis, while the delay between EMG reading from the trigger electrode and stimulation of hand extension is -550 ms. It should be noted that this movement causes supination of the forearm, which distinguishes this type of capture from the previous one and fixation of the EMG signal from m. supinator brevis would be more revealing as a trigger for stimulation extension of the wrist joint and fingers of the hand, however, the deep location of this muscle does not allow recording its activity with cutaneous electrodes, which is why it is advisable to choose m as a trigger point. deltoideus anterior.

If the movement is performed correctly, the screen displays the movement of the virtual hand in the middle position of pronation / supination and extension of the fingers of the hand, which tells the patient about the correct movement of extension of the wrist joint and fingers.

Stage 2 (5-10 days of training!

Target muscle group: m. flexor digitorum superficialis;

Trigger muscle: T. deltoideus anterior or T. extensor digitorum superficialis;

Target movements: reaching a distant object: ball (10 minutes), glass (10 minutes);

Grip type: spherical grip, cylindrical grip;

Trained movement: flexion of the fingers;

Duration of one workout: 20 minutes;

Training goal: to restore grip function and strength in the fingers of the paretic hand.

Training description:

Patient 1 is seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). At an arm's length, individually for each patient, in the frontal plane on the table, a ball 2 with a diameter of 10 cm is placed. A monitor screen is placed in front of the patient, which displays the success of the performed movement. The patient is asked to perform a motor task: to reach the ball, grab it, move it along the table, put the ball in a stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes. Fig. 3 schematically shows the sequence of performing the movements in this exercise. It is worth noting that in the process of training the ball-shaped grip at the second stage, the task becomes more difficult for the patient from training to training, and the weight of the ball being grasped consistently increases over 5 days (from 50 to 300 g). This is necessary to gradually increase the gripping force, since more effort is needed to hold a heavier object.

In this case, during the execution of the movement, reaching a remotely located ball, the trigger electrode can be located in two positions. The first position is location at m. deltoideus anterior, a muscle that is one of the main flexors of the shoulder during this movement. In this case, the delay time will be increased to ~ 900 ms. This is due to the fact that normally, shoulder flexion begins at the very beginning of the movement, and, starting from 90% of the movement time, the capture process occurs. To stimulate the flexion of the fingers of the hand and make a grip in patients with mild paresis, the stimulating electrode is located at m extensor digitorum superficialis.

The second possible position of the trigger electrode is the location on the extensor digitorum superficialis, this location allows you to reduce the delay time between stimulation of the target muscle group and increase the accuracy of the stimulus delivery to the target muscle group m. flexor digitorum superficialis. Extension in the wrist joint and fingers of the hand begins at 70% and reaches its maximum at 90% of the movement performed, and starting at 90%, the gripping process takes place. When the trigger electrode is located on the extensor muscles of the wrist and fingers, the delay time is set to ~ 300 ms.

In the second part of the workout, patient 1 is also sitting on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). At arm's length, individually for each patient, in the frontal plane on the table, a glass 3 with a diameter of 8 cm is installed. In front of the patient, there is a monitor screen, which displays the success of the performed movement. The patient is asked to perform a motor task: reach for the glass, grab it, move it along the table, put the glass in the stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes. Figure 4 schematically shows the sequence of performing movements in this exercise. It is worth noting that in the process of training the cylindrical grip at the second stage, the patient's task becomes more difficult from training to training, the weight of the grasped glass increases sequentially over 5 days (from 50 to 200 g,), and the glass is filled with water, which is necessary to improve the accuracy of the movement performed and encourages the patient not to spill its contents while performing the movement. Also, during training, the grip strength gradually increases, since more effort is needed to hold a heavier object.

The arrangement of the electrodes corresponds to that described for the spherical grip, despite the fact that the achievement of the object with these types of grip is different (with performing a cylindrical grip, supination of the forearm occurs), the trigger muscles remain the same, since the fixation of the EMG signal from m. supinator brevis is difficult due to its deep position.

The use of the technique in case of moderate paresis in the hand (motor deficit in the paretic hand according to the Fugle-Meier scale from 47 to 56 points, which corresponds to moderate impairment of motor function; motor deficit in the hand according to the ARAT scale from 41 to 50 points, which corresponds to moderate impairment of fine motor skills ; spasticity on the Ashworth scale: in the flexor muscles of the wrist joint and hand - 0-1 points, in the flexor muscles of the elbow joint - 0-1 points)

Target muscle groups: m. thoracic major, t. triceps brahii, t. extensor digitorum superficialis, m. flexor digitorum communis.

Workout:

Due to the fact that in patients with moderate paresis, motor dysfunction in the paretic hand is represented by a decrease in strength in the proximal parts of the hand, as well as the hand and fingers, the technology in this case is used to restore movement in the proximal parts, as well as various types of grip and preparation of the hand. to them.

Purpose: the training is aimed at correcting the pathological stereotype in the proximal parts of the arm and hand, increasing functionality, increasing grip strength and range of motion.

Stage 1 (1-5 days of training !.

Target muscle group: m. thoracic major, t triceps brahii;

Trigger muscle: T. deltoideus medius, T. deltoideus anterior;

Target movements: reaching a distant object: ball (10 minutes), glass (10 minutes);

Grip type: spherical grip, cylindrical grip;

Trained movement: adduction and flexion of the arm in the shoulder joint, extension in the elbow joint;

Duration of one workout: 20 minutes;

Training goal: restoration of movement, achievement of a remotely located object, correction of the main components of pathological synergy in the proximal parts of the arm (abduction in the shoulder joint, flexion in the elbow joint).

Training description:

Patient 1 is seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). On the At arm's length, individually for each patient, a ball 2 with a diameter of 10 cm is installed in the frontal plane on the table 4. A monitor screen is placed in front of the patient, which displays the success of the performed movement. The patient is asked to perform a motor task: to reach the ball, to grab it, move it along the table, put the ball in a stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes. Fig. 3 schematically shows the sequence of performing the movements in this exercise.

In this type of grip, the main movements are normally flexion of the shoulder joint and extension of the elbow, the component of abduction of the shoulder joint in this case is not pronounced (in comparison with the execution of a cylindrical grip). The main pathological component of flexion synergy during this movement is a violation of extension in the elbow joint, this is due to the weakness of the triceps muscle of the shoulder, which is why it is chosen as the target for stimulation. During the execution of the movement, reaching a remotely located ball, the trigger electrode is located at m. deltoideus anterior, this muscle is one of the main flexor muscles of the shoulder during this movement, as you know, normally shoulder flexion begins at the very beginning and reaches its maximum, by the time the object is reached. Simultaneously and coordinated with this movement, extension occurs in the elbow joint, these components constitute the main part of the synergy “riching”. However, in patients with post-stroke paresis, full extension in the elbow joint does not occur during movement, therefore the stimulating electrode is located on m. triceps brachii, which is responsible for the extension of the elbow joint. In this case, the delay time is set to a minimum of ~ 50 ms. This is due to the fact that the movements of flexion of the shoulder joint and extension of the elbow joint occur simultaneously.

When the movement is performed correctly, the screen displays the forward movement of the virtual hand in the pronation position, which tells the patient about the correct movement.

In the second part of the training, patient 1 is also sitting on a chair, at a table, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). At arm's length, individually for each patient, a glass 3 with a diameter of 8 cm is installed in the frontal plane on the table 4 in front of the patient. There is a monitor screen in front of the patient, which displays the success of the performed movement. The patient is asked to perform a motor task: reach for the glass, grab it, move it along the table, put the glass in the stand and return your hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes. Figure 4 schematically shows the sequence of performing movements in this exercise.

In this type of grip, the main movements in the norm are flexion of the shoulder joint and extension of the elbow. At the very beginning of the movement, the abduction component is normally present in the shoulder joint, but it lasts only ~ 100 ms. and is subsequently replaced by a cast. The main pathological component of flexion synergy during this movement is abduction in the shoulder joint; in patients with moderate paresis, it is replaced by adduction much later than in healthy patients. During the execution of the movement, reaching a remotely located glass, the trigger electrode is located at m. deltoideus medius, this muscle is the main one in the abduction of the shoulder joint and fixation of the EMG signal from it indicates the occurrence of pathological synergy. In this case, the stimulating electrode is located at m. thoracic major, which is responsible for adduction and flexion of the shoulder joint. The delay time between the fixation of the signal from the trigger electrode and the stimulation of the target muscle is set at - 100 ms. This is due to the fact that abduction in the shoulder joint is also present normally, but in a shorter period of time. Figure 14 shows the ratio of the movement components, the achievement of a remotely located object is normal, for a clear understanding of the delay time (arrows indicate the start time of shoulder abduction and the start time of shoulder adduction).

Stage 2 (5-10 days of training !.

Target muscle group: m. flexor digitorum superficialis;

Trigger muscle: T. deltoideus anterior or T. extensor digitorum superficialis;

Target movements: reaching a distant object: ball (10 minutes), glass (10 minutes);

Grip type: spherical grip, cylindrical grip;

Trained movement: flexion of the fingers;

Duration of one workout: 20 minutes;

Training goal: to restore grip function and strength in the fingers of the paretic hand.

It is worth noting that in patients with moderate paresis, movement disorders of the wrist and hand are associated with weakness in the muscles of the paretic arm and impaired coordination, spasticity in this case is not significantly expressed. To address this problems in this group of patients, training should be aimed at increasing the strength of various grips.

Training description:

Patient 1 is seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). At arm's length, individually for each patient, a ball 2 with a diameter of 10 cm is placed in the frontal plane on the table 4. In front of the patient, there is a monitor screen, which displays the success of the performed movement. The patient is asked to perform a motor task: to reach the ball, to grab it, move it along the table, put the ball in a stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes. Fig. 3 schematically shows the sequence of performing the movements in this exercise.

In this case, during the execution of the movement, reaching a remotely located ball, the trigger electrode can be located in two positions. The first position is the location on m. deltoideus anterior, a muscle that is one of the main flexors of the shoulder during this movement, the delay time will be increased to -900 ms. This is due to the fact that normally shoulder flexion reaches its maximum at 90% of the movement performed, starting from 90% the grip process takes place. To stimulate the flexion of the fingers of the hand and make a grip in patients with mild paresis, the stimulating electrode is located at m extensor digitorum superficialis.

The second possible position of the trigger electrode is the location on the extensor digitorum superficialis, this location allows you to reduce the delay time between stimulation of the target muscle group and increase the accuracy of the stimulus delivery to the target muscle group m. flexor digitorum superficialis. As mentioned above, extension in the wrist joint and fingers of the hand begins at 70% and reaches its maximum at 90% of the movement performed, starting from 90% the capture process takes place. When the trigger electrode is positioned on the extensor muscles of the wrist and fingers, the delay time is set to -300 ms.

When the movement is performed correctly, the screen displays the forward movement of the virtual hand in the pronation position and flexion of the fingers, which tells the patient about the correct movement.

In the second part of the training, the patient is also seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the brush is on the table). At arm's length, individually for each patient, in the frontal plane on the table, a glass with a diameter of 8 cm is placed. A monitor screen is placed in front of the patient, which displays the success of the performed movement. The patient is asked to perform a motor task: reach for the glass, grab it, move it along the table, put the glass in the stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes. Figure 4 schematically shows the sequence of performing movements in this exercise.

The location of the electrodes corresponds to that described for the spherical grip, despite the fact that reaching the object with these types of grip is different (when the cylindrical grip is performed, the forearm is supined), the trigger muscles remain the same, since the fixation of the EMG signal from m. supinator brevis is difficult due to its deep position.

It is important to emphasize that the patented technique allows you to modify the FES and TES protocols used depending on the severity of the patient's paresis and his functional capabilities, thus providing a personalized approach to post-stroke rehabilitation. The patented technique makes it possible to reprogram pathological motor patterns at the peripheral level with an enhancement of the effect due to the directed modulation of the excitability of the motor cortex using TES. Thus, an increase in the efficiency of normalization of the motor kinematic portrait in the paretic hand is achieved. In addition, the use of modern devices for conducting FES and TES, with a friendly interface and intuitive software, will contribute to the successful interaction of the patient and the therapist.

LIST OF USED SOURCES

1. Feigin, V.L. Atlas of the Global Burden of Stroke (1990-2013): The GBD 2013 Study / V.L. Feigin, G.A. Mensah, B. Norrving et al. // Neuroepidemiology -2015. - Vol. 45, JV 3. -P. 230-236.

2. Katan, M. Global Burden of Stroke / M. Katan, A. Luft // Semin. Neurol. - 2018. - Vol. 38, Xs 2. -P.208-211.

3. Feigin VL, Forouzanfar MH, Krishnamurthi R et al. Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) and the GBD Stroke Experts Group. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010 / VL Feigin, MH Forouzanfar, R. Krishnamurthi et al. // Lancet. - 2014. - Vol. 383, Ns 9913 - P. 245-254.

4. Statistical collection 2017 [Electronic resource] / Min. healthy. - 2018. -

Access mode: https://www.rosminzdrav.ru/ministry/61/22/stranitsa-

979 / statisticheskie-iinformatsionnye-materialy / statisticheskiy-sbomik-2017-god, free.

5. Langhome, R. Motor recovery after stroke: a systematic review / P. Langhome, F. Coupar, A. Pollock // Lancet. Neurol. - 2009. - Vol. 8, Ns 8. - P. 741-754.

6. Pollock, A. Interventions for improving upper limb ftmction after stroke / A. Pollock, S. E. Farmer, M.C. Brady et al. // Cochrane database Syst. Rev. - 2014. - Ns 11. - CD010820c.

7. Hatem, S.M. Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery / S.M. Hatem, G. Saussez, M. Della Faille et al. // Front. Hum. Neurosci. - 2016. - Vol. 10. - P. 442.

8. Hlustik, P. Paretic hand in stroke: from motor cortical plasticity research to rehabilitation / P. Hlustik, M. Mayer // Cogn. Behav. Neurol. - 2006. - Vol. 19, Ns 1. - P. 34-40.

9. Jones, T.A. Motor compensation and its effects on neural reorganization after stroke / T. A. Jones // Nat. Rev. Neurosci. - 2017. - Vol. 18, Ns 5. - P. 267-280.

10. Piradov, M. Brain plasticity and modern technologies of neurorehabilitation /

M. A. Piradov, L. A. Chernikova, N. A. Suponeva // Bulletin of the Russian Academy of Sciences - 2018 .-- T. 88, Ns 4. - P. 299-312.

11. Grefkes, C. Noninvasive brain stimulation after stroke: it is time for large randomized controlled trials! / C. Grefkes, G. R. Fink // Curr. Opin. Neurol. - 2016. - Vol. 29, Ns 6. - P. 714-720.

12. Klomjai, W. Repetitive transcranial magnetic stimulation and transcranial direct current stimulation in motor rehabilitation after stroke: an update / W. Klomjai, A. Lackmy-Vallee,

N. Roche et al. // Ann. Phys. Rehabil. Med. - 2015. - Vol. 58, Ns 4 - P. 220-224.

13. Hsu W.Y. Effects of repetitive transcranial magnetic stimulation on motor functions in patients with stroke: a meta-analysis / W.Y. Hsu, C.H. Cheng, K.K. Liao et al. // Stroke - 2012. - Vol. 43, Ns 7. -P. 1849-1857.

14. Lefaucheur, J.P. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) / J.P. Lefaucheur, N. Andre-Obadia, A. Antal et al. // Clin. Neurophysiol. -2014. - Vol. 125, Ns 11. -P. 2150-2206.

15. Zhang, L. Low-Frequency Repetitive Transcranial Magnetic Stimulation for Stroke-Induced Upper Limb Motor Deficit: A Meta-Analysis / L. Zhang, G. Xing, S. Shuai et al. // Neural Plast. - 2017 .-- 2017 - 2758097. 16. Valero-Cabre, A. Transcranial magnetic stimulation in basic and clinical neuroscience: A comprehensive review of fundamental principles and novel insights / A. Valero-Cabre, J.

L. Amengual, C. Stengel et al. // Neurosci. Biobehav. Rev. - 2017. - Vol. 83. - R 381-404.

17. Woods, A. J. A technical guide to tDCS, and related non-invasive brain stimulation tools / A.J. Woods, A. Antal, M. Bikson et al. // Clin. Neurophysiol. - 2016. - Vol. 127, Ne 2.-R 1031-1048.

18. Nitsche, M. Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation / M. Nitsche, W. Paulus // J. Physiol. - 2000. - Vol. 527, Pt 3 - P. 633-639.

19. Priori, A. Polarization of the human motor cortex through the scalp. / A. Priori, A. Berardelli, S. Rona et al. // Neuroreport - 1998. - Vol. 9. - P. 2257-2260.

20. Yavari, A. Jamil, M. Mosayebi Samani et al. // Neurosci. Biobehav. Rev. -2018. -Vol. 85. -P. 81-92c.

21. Giordano, J. Mechanisms and Effects of Transcranial Direct Current Stimulation / J. Giordano, M. Bikson, E. S. Kappenman et al. // Dose-Response - 2017. - Vol. 15, N ° 1. -155932581668546.

22. Plow, E.B. Models to Tailor Brain Stimulation Therapies in Stroke / E.B. Plow, V. Sankarasubramanian, D.A. Cunningham et al. // Neural Plast. - 2016. - Vol. 2016 .-- 4071620.

23. Dodd, K.C. Role of the Contralesional vs. Ipsilesional Hemisphere in Stroke Recovery / K. C. Dodd, V. A. Nair, V. Prabhakaran // Front. Hum. Neurosci. - 2017. - Vol. 11. - P. 469.

24. Alia, C. Neuroplastic Changes Following Brain Ischemia and their Contribution to Stroke Recovery: Novel Approaches in Neurorehabilitation / C. Alia, C. Spalletti, S. Lai et al. // Front. Cell. Neurosci. - 2017. - Vol. 11. - P. 76.

25. Murase, N. Influence of Interhemispheric Interactions on Motor Function in Chronic Stroke / N. Murase, J. Duque, R. Mazzocchio, L. G. Cohen // Ann. Neurol. - 2004. - Vol. 55, JSfo 3. - P.400-409.

26. Rehme, A.K. Activation likelihood estimation meta-analysis of motor-related neural activity after stroke / A.K. Rehme, S.B. Eickhofif, C. Rottschy et al. // Neuroimage - 2012. - Vol. 59, Xa 3._ p. 2771-2782.

27. McDonnell, M.N. TMS measures of motor cortex function after stroke: A meta-analysis /

M.N. McDonnell, C.M. Stinear // Brain Stimul. - 2017. - Vol. 10, III 4. - P. 721-734.

28. Eisner, B. Transcranial direct current stimulation (tDCS) for improving fimction and activities of daily living in patients after stroke. / B. Eisner, J. Kugler, M. Pohl, J. Mehrholz // Cochrane database Syst. Rev. -2013. -N ° 11. - CD009645.

29. Tedesco Triccas, L. Multiple sessions of transcranial direct current stimulation and upper extremity rehabilitation in stroke: A review and meta-analysis / L. Tedesco Triccas, J.H. Burridge, A.M. Hughes et al. // Clin. Neurophysiol. - 2016. - Vol. 127, .Ng 1.-R 946-955.

30. Eisner, B. Transcranial direct current stimulation (tDCS) for improving activities of daily living and physical and cognitive fimctioning in people after stroke (Review) / B. Eisner, J. Kugler, M. Pohl, J. Mehrholz // Cochrane database Syst. Rev. -2016. -JVb 3. -CD009645

31. O'Brien, A.T. Non-invasive brain stimulation for fine motor improvement after stroke: a meta-analysis / A.T. O'Brien, F. Bertolucci, G. Torrealba-Acosta // Eur J Neurol. - 2018. - Vol. 25, m. - P.1017-1026.

32. Feng, W. Transcranial Direct Current Stimulation for Poststroke Motor Recovery: Challenges and Opportunities / W. Feng, S.A. Kautz, G. Schlaug et al. // PM R. - 2018. - Vol. 10 (9 Suppl 2). - P. 157-164.

33. Bakulin, I.S. Transcranial electrical stimulation to improve hand function in stroke / I.S. Bakulin, A.G. Poydasheva, N.A. Pavlov et al. // Advances in physiological sciences. - 2019.- T. 50, N ° 1.- S. 90-104.

34. Cabral, M.E. Transcranial direct current stimulation: before, during, or after motor training? / M.E. Cabral et al. // Neuroreport. - 2015. - Vol. 26, Ns 11.-P. 618-622.

35. Giacobbe V. Transcranial direct current stimulation (tDCS) and robotic practice in chronic stroke: the dimension of timing / V. Giacobbe et al. // NeuroRehabilitation. - 2013. - Vol. 33, Jfe l. -P. 49-56.

36. Kang, N. Transcranial direct current stimulation facilitates motor learning post-stroke: a systematic review and meta-analysis / N. Kang, J.J. Summers, J.H. Cauraugh // Journal of neurology, neurosurgery, and psychiatry. - 2016. - Vol. 87, Jfs 4. - P. 345-355.

37. Klochkov, AC Modern technologies of functional electrical stimulation in central paresis. Klochkov, A.E. Khizhnikova, A.M. Kotov-Smolensky et al. // Human Physiology. 2019. - V. 45,

3. - S. 129-136.

38. Pereira, S. Functional Electrical Stimulation for Improving Gait in Persons With Chronic Stroke / S. Pereira et al. // Topics in Stroke Rehabilitation. 2012. - Vol. 19, N ° 6. - P. 491-498.

39. Robbins, S.M. The therapeutic effect of fimctional and transcutaneous electric stimulation on improving gait speed in stroke patients: a meta-analysis / S.M. Robbins et al. // Archives of physical medicine and rehabilitation. 2006. - Vol. 87 (6). - P. 853-9.

40. Roche, A. Surface-applied fimctional electrical stimulation for orthotic and therapeutic treatment of drop-foot after stroke - a systematic review / A. Roche et al. // Physical Therapy Reviews. - 2009. - Vol. 14, Ns 2. - P. 63-80.

41. Popovic, M. B. Functional electrical therapy (fet): clinical trial in chronic hemiplegic subjects / M.B. Popovic, D.B. Popovic, L. Schwirtlich, T. Sinkjaer // Neuromodul. Technol. Neural Interface. - 2004. - Vol. 7, Ws 2. - P. 133-140.

42. Popovic, M. R. Neuroprosthesis for retraining reaching and grasping ftmctions in severe hemiplegic patients / M.R. Popovic, T.A. Thrasher, V. Zivanovic // Neuromodulation. - 2005. - Vol. 8, Jfe 1 .. - R 58-72.

43. Nussbaum, E.L. Neuromuscular electrical stimulation for treatment of muscle impairment: Critical review and recommendations for clinical practice / E.L. Nussbaum, P. Houghton,

J. Anthony et al. // Physiother Can. - 2017. - Vol. 69, JV ° 5. - P. 1-76.

44. Guesta-Gomez, A. The use of ftmctional electrical stimulation on the upper limb and interscapular muscles of patients with stroke for the improvement of reaching movements: A feasibility study. / A. Guesta-Gomez, F. Molina-Rueda, M. Carratala-Tejada et al. // Front Neurol. -2017. - Vol. 8. -P. 186

45. Eraifej, J. Effectiveness of upper limb ftmctional electrical stimulation after stroke for the improvement of activities of daily living and motor ftmction: a systematic review and meta- analysis / J. Eraifej, W. Clark, B. France et al. // Syst Rev. - 2017. - Vol. 6, N ° 1. - P. 40.

46. Celnik, P. Effects of Combined Peripheral Nerve Stimulation and Brain Polarization on Performance of a Motor Sequence Task After Chronic Stroke / P. Celnik, N.J. Paik, Y.

Vandermeeren et al. // Stroke. - 2009. - Vol. 40,

5. - P. 1764-71.

47. Menezes, I.S. Combined Brain and Peripheral Nerve Stimulation in Chronic Stroke Patients With Moderate to Severe Motor Impairment / I.S. Menezes, L.G. Cohen, E.A. Mello et al. // Neuromodulation. - 2017. - Vol. 21, J b 2. - P. 176-83. 48. Shaheiwola, N. Using tDCS as an Add-On Treatment Prior to FES Therapy in Improving

Upper Limb Function in Severe Chronic Stroke Patients: A Randomized Controlled Study / Shaheiwola, B. Zhang, J. Jia, D. Zhang // Front Hum Neurosci. - 2018. - Vol. 12. - P. 233.

49. Salazar, A.P. Bi-cephalic transcranial direct current stimulation combined with ftmctional electrical stimulation for upper-limb stroke rehabilitation: A double-blind randomized controlled trial / A.P. Salazar, V. Cimolin, G.P. Schifino et al. // Ann Phys Rehabil Med. - 2019. - May 31. pii: SI 877-0657 (19) 30070-3.

Claims

CLAIM

1. A method for the rehabilitation of movement disorders in the arm in patients after a stroke, including the stages at which TES of the brain is carried out with a constant current of 2 mA, no more than 15 minutes after TES of the brain, functional electrical stimulation of the target muscles is carried out when the patient performs a cyclic movement using as an EMG trigger of FES, a muscle that is a synergist of the performed cyclic movement, while the EMG trigger electrode is attached outside the area of activity of the stimulated muscle, functional electrical stimulation is carried out with a pulse current with a pulse duration of 1-3 ms and a pulse amplitude of up to 30 mA, a stimulation frequency of 25-30 Hz to induce tetanic contractions of skeletal muscles or 50-100 Hz for skeletal muscle spasm or 1-10 Hz for a tonic effect on muscles, while the delay time between the fixation of the signal from the trigger electrode and stimulation of the target muscle is 50-900 ms.

2. The method according to claim 1, characterized in that the rehabilitation is carried out in courses consisting of 5-10 sessions.

3. The method according to claim 1, characterized in that the thermal power plant is carried out for 18-22 minutes.

4. The method according to claim 1, characterized in that the FES is carried out for 10-30 minutes.

5. The method according to claim 1, characterized in that TPP is carried out using one of the protocols: anodic TPP of the primary motor cortex of the affected hemisphere, cathodic TPP of the primary motor cortex of the unaffected hemisphere, bilateral (simultaneously anodic TPP of the primary motor cortex of the affected hemisphere and cathodic TPP of the primary motor cortex of the unaffected hemisphere) TPP.

6. The method according to claim 1, characterized in that the TPP is carried out in a sitting or reclining position on the back on a special chair.

7. The method according to claim 1, characterized in that the cyclic movement is the achievement of a remotely located object of a spherical or cylindrical shape, followed by its capture by extension and flexion of the wrist joint and / or fingers

8. The method according to claim 1, characterized in that the cyclic movement is reaching a remotely located object by flexion and adduction of the arm at the shoulder joint and extension of the arm at the elbow joint.

SUBSTITUTE SHEET (RULE 26)