RU2770595C1 - Method for rehabilitation - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, in particular to the field of rehabilitation, and can be applied in procedures for the development of fine motor skills in order to restore impaired neurological functions in patients, in particular, after a stroke, in medical, preventive institutions, as well as outside the hospital, including outpatient and home conditions. At the same time, the patient is provided with exercises from a set in which each exercise is based on a computer game, using a rehabilitation device, as which a complex for rehabilitation of the musculoskeletal system with biofeedback “ANIKA” is used. At the same time, each exercise from the set as part of a computer game is performed with the first hand, after which the exercise is repeated with the second hand.EFFECT: method provides an increase in the functional activity of the neuronal systems of the affected hemisphere of the brain.4 cl, 1 tbl

Description

The invention relates to medicine, in particular to the field of rehabilitation, and can be used in procedures for the development of fine motor skills in order to restore impaired neurological functions in patients, in particular after a stroke, in medical, preventive institutions, as well as outside the hospital, including in outpatient and home settings.

The mobility of the joints of the hands and arms is reduced or lost due to injuries, damage to the central or peripheral nervous system, paralysis, etc., despite the presence of healthy muscles and bones. This occurs as a result of damage to the substance and neuronal systems of the brain and spinal cord responsible for controlling the affected muscles and musculoskeletal structures. Treatment and rehabilitation in such lesions of the brain and spinal cord due to trauma or other pathological effects are aimed at restoring the lost voluntary motor activity due to the formation of structural and functional changes in the nervous system, and the activation of the sensory system in the periphery is one of the key factors of adaptive neuroplastic changes in the peripheral and the central nervous system. Since nerve fibers and brain cells can grow, be functionally active and regenerate in response to physical activity, modern methods and rehabilitation technologies are based on repeated regular repetition of movements while the patient observes and analyzes his actions displayed on the computer monitor screen, which allows you to consolidate the skills you have developed. . In systems of rehabilitation technologies, tracking of motor acts, including fine motor skills, is traditionally used; imitation of real, everyday movements and skills, such as holding an object, turning, twisting / unscrewing covers, etc.; determination of a change in the patient's condition. It is shown that rehabilitation with the use of virtual game support technology allows to increase the concentration of attention, motivation in patients and contributes to a much more intensive progress in the recovery process than conventional care.

In the tasks of medical rehabilitation, it is important to repeat targeted exercises with continuous feedback. Such feedback can be a visual control of gestures displayed on the monitor screen, or changes in the positions of game objects depending on human movements. The motivation for repeated repetition of certain actions is the interest in the process of computer games.

A number of methods are known for displaying a virtual hand and its movements corresponding to the movements of a human hand on a computer monitor screen, for example, known from US patent 6,452,584 publ. 09/17/2002 real-time computer animation control system, known from US patent 7,205,979 publ. 04/17/2007, a method for displaying a change in the position of virtual objects in accordance with the gestures, position and movement of the operator's hand, known from the PCT patent application WO 2007060667 publ. 05/31/2007, a method of rehabilitation, including processing data corresponding to a complex movement from sensors and obtaining data related to elementary movements, when performing at least one training exercise for the development of elementary movements, a known method of rehabilitation according to the RF patent for an invention 2114594, publ. 07/10/1998, based on visual display of limb movement, known from US patent 6,827,579, publ. 07.12.2004, a rehabilitation method based on visualization on a computer monitor screen of changing the position of sensors attached to the hand while counteracting movements, known from the RF patent for invention No. 2494670, publ. October 10, 2013, a method of rehabilitation, in which, using a computer program, changes in the position of virtual objects are visualized on the computer monitor screen in accordance with the movements of flexion and extension in the joints of the hand, as well as known from the application for the invention of the Russian Federation No. 2018113360, publ. 04/12/2018, a rehabilitation method in which, using a computer program, changes in the position of virtual objects are visualized on the computer monitor screen, displaying complex natural movements, in which the interphalangeal, metacarpophalangeal, radiocarpal, radioulnar joints are jointly involved. These methods are used to train the paretic limb, that is, they provide exercises for only one - the affected - hand. However, it is believed that training only the paretic hand does not take into account the diversity of the entire act of voluntary motor activity of a person in everyday life, which requires combined and coordinated interaction of both hands.

Another number of well-known methods of rehabilitation was developed based on the consideration that training a healthy hand together with a paretic hand leads to a functional improvement in a paretic hand due to the involvement of the neuronal systems of both hemispheres of the brain in the training process and, at the same time, intensification of the cross-connection of neurons in the mirror motor areas of the brain .

The effectiveness of the bimanual method of rehabilitation of patients after a stroke was also confirmed by the studies of the authors (see E.V. Ekusheva, A.A. Komazov, The use of the Anika rehabilitation glove by patients after a stroke: the possibility of increasing functional recovery. Farmateka, No. 13, 2019. pp. 30-33).

A method of rehabilitation is known (US patent No. 10071280, publ. 09/11/2018), which involves, during training, grabbing and squeezing the rehabilitation device with both hands, while the patient must use a stronger hand to help a weaker hand. Also known (US patent No. 9311789, publ. April 12, 2016) is a bimanual rehabilitation method that provides during training using both hands to promote the use of the affected limb and limit the use of the unaffected limb in the corresponding exercises.

In the well-known (US patent No. 8852129, publ. 07.10.2014) bimanual method of rehabilitation, when using both hands during training using a computer game, the movements of a healthy hand are displayed on the computer monitor screen as a reference, while the task of training is to match the movements of the affected hands to a digital standard. In another well-known (US patent No. 9123256, publ. 09/01/2015), active-passive bilateral therapy is carried out using a device that mechanically connects both hands, while patients actively perform rhythmic flexion-extension of the non-paretic wrist, and mirror-symmetrical movements paretic arms are generated using a mechanical connection. There is known (US patent No. 9028258, publ. 05/12/2015) a method in which training in a game form using both hands is carried out using a device for training while standing, while measuring various parameters of motor reactions and the "error" of movement compared to given sample. In a method for treating a nervous system injury (US application No. 20160067136, published March 10, 2016), training of the affected hand is carried out using specific information from an unaffected part of the body, which stimulates the activation of similar muscle groups on the affected part of the body. The disadvantages of these methods are the focus on training specific hand movements or individual motor acts, such as finger movements or squeezing the hand, as well as the lack of feedback during rehabilitation due to the lack of visualization of changes in the position and orientation in space of the fingers, hand and forearm.

There is known (US patent No. 10004660, publ. 06/26/2018) a method of rehabilitation using a game system with a specialized two-handed game controller, which requires the patient to use both hands for control. The game system provides a series of interactive computer games that provide tactile feedback to the patient's affected hand, where the tactile feedback is provided in response to events in the game. The system registers the patient's training statistics, which is transmitted to the doctor for analysis. The disadvantage of this method is the need to ensure contact of the human hand with a special stationary game controller, as well as a tactile feedback form, which may not provide enough information when exposed to a paretic hand.

Known (US application No. 20120157263, published on June 21, 2012) is a rehabilitation method that involves exercises of both hands during a computer game. Each patient's hand is placed in adjustable input devices made in the form of a glove with bend sensors built into it, which are located on the index, middle and ring fingers, in addition, the fourth bend sensor is placed along the back of the thumb to measure the abduction of the thumb relative to the palm and fingers. of the patient, and a fifth sensor is placed along the back of the hand near the patient's wrist to measure wrist flexion and extension. They provide a neutral position of the wrists and a natural maximum comfortable position of the hands, for which the patient's hands are supported by adjustable splints. The disadvantage of this method is that cumbersome input devices made with bending sensors based on the Hall effect limit the variety of movements only by flexion/extension of the wrists and four of the five fingers (the sensor is not provided for the little finger), in addition, to implement the method using such a device insertion requires the attachment of magnets to each of the gloves, which limits the freedom of movement of the patient.

The closest analogue of the developed method of rehabilitation is the method known by US patent No. 10722784 (published on July 28, 2020) for the invention "Bimanual integrative virtual rehabilitation system and methods", which provides for the patient to perform exercises from the set using a device for rehabilitation, in in which each exercise is based on a computer game. The rehabilitation device is connected to a computer, the patient's hand is contacted with the sensors of the rehabilitation device, while the patient is performing exercises with both the first and second hands, the position and orientation of the parts of both the first and second hands of the patient are determined, and changes in the position and orientation of the parts are displayed on the computer monitor. patient's first and second hands.

However, in the closest analogue, a special game controller is used as a rehabilitation device, and when performing exercises, it is necessary to hold the specified controller in the hands to ensure contact of the patient's hands with the sensors of the rehabilitation device, which does not allow changing the relative position of the fingers and is difficult for the paretic hand. In addition, the exercises are performed by both the first and second hands at the same time, which leads to the predominance of the non-paretic hand and, accordingly, less training of the paretic hand due to inhibition of the neuronal systems of the affected area of the brain by functionally more active systems of the healthy area of the brain.

The technical problem to be solved by the developed invention is the creation of a rehabilitation method that provides an increase in the functional activity of the neuronal systems of the affected hemisphere of the brain by reducing the inhibition of its affected areas caused by the activity of the neuronal systems of healthy cerebral areas involved in the process of restoring motor acts in the paretic hand patient.

The technical result is to increase the possibility and efficiency of restoring voluntary motor acts of the paretic hand of patients with impaired neurological functions, in particular, after a stroke.

The technical result is achieved by the fact that in the developed method of rehabilitation, just like in the closest analogue, it is provided for the patient to perform exercises from the set using the device for rehabilitation, in which each exercise is based on a computer game. The rehabilitation device is connected to the computer, both the first and second hands of the patient are contacted with the sensors of the rehabilitation device, while in the course of the patient performing exercises with both the first and second hands, the position and orientation of the parts of both the first and second hands of the patient are determined. Changes in the position and orientation of parts of both the first and second hands of the patient are displayed on the computer monitor by correspondingly changing the positions on the computer monitor of virtual objects in the corresponding computer game.

What is new in the developed method of rehabilitation is that the set of exercises includes the first group of exercises that involve performing the actions of flexion and extension of the fingers, flexion and extension of the wrist, pronation and supination, as well as the second group of exercises that involve performing natural complex hand movements. As a device for rehabilitation in the developed method, a complex for the rehabilitation of the musculoskeletal system with biofeedback "ANIKA" is used, the contact of both the first and second hands of the patient with the sensors of the device for rehabilitation is ensured by fixing the sensors of the specified complex on the distal the middle part of the hand, on the forearm of both the first and second hands of the patient. After performing each exercise with the first hand, a repetition of the same exercise with the second hand is provided.

In a specific implementation of the rehabilitation method, both the first and second groups of exercises consist of five exercises.

In another specific implementation of the rehabilitation method, the first hand is the patient's paretic hand.

It is advisable to perform a separate exercise with each hand for at least two minutes.

In the developed method, the inclusion in the set of exercises of both exercises of elementary movements: flexion and extension of the fingers, flexion and extension of the wrist, pronation and supination, and exercises of complex natural hand movements increases the patient's motivation, provides an increase from session to session during rehabilitation, the volume and intensity of movements thus increasing the efficiency of the recovery process. The use of the complex for the rehabilitation of the musculoskeletal system with biofeedback "ANIKA" as a device for rehabilitation allows you to track an extended range of movements, while visualizing both elementary and complex natural coordinated hand movements. Performing the prescribed exercises alternately with both hands allows you to involve both the unaffected areas of the brain and the neuronal structures of the affected areas of the brain in the rehabilitation process. Performing each exercise first of all with the paretic hand, and only after that with the healthy hand enhances the indicated result.

The method of rehabilitation using the complex for the rehabilitation of the musculoskeletal system with biofeedback "ANIKA" is carried out as follows.

Initially, a device of a suitable size for the patient is selected. As part of the complex for rehabilitation of the musculoskeletal system with biofeedback "ANIKA" there is an overlay in the form of a hand with a cuff, designed to attach sensors to it, which simplifies the placement and fixation of the sensors on the patient's arm. The design of the "ANIKA" complex and overlays for it are disclosed in the patents of the Russian Federation, respectively, No. 198065 and 192463 for utility models "Device for rehabilitation" and "Base of the device for rehabilitation".

The sensors of the rehabilitation device are placed and fixed on the patient's arm either directly or using a cuff pad. If there are two rehabilitation devices, it is possible to fix the sensors on both hands at once, if only one device is available, after performing the exercise with the first hand, the rehabilitation device is transferred to the second hand. Exercises are performed with the first and second hand alternately, while in order to obtain a greater effect, it is advisable to start each exercise first with the paretic and then with the healthy hand.

The device is connected to the USB port of the computer and the installed program is launched. Changes in the position of virtual objects are displayed on the computer monitor screen in accordance with the movements of the fingers, hand and forearm of the patient.

The set of exercises includes ten exercises, each of which is in the form of a computer game, the exercises are performed in order of increasing difficulty. It is advisable to perform the exercises for at least two minutes with each hand.

The first group of exercises (1-5) is composed of five games involving the following movements of the parts of the hand: flexion and extension of the fingers, flexion and extension of the wrist, pronation and supination. Virtual objects in these games are controlled by the movements of one of these pairs. So, for example, in the first of the five games of this group (“Cars” game), the virtual car moves to the right and left when, respectively, flexion and extension of the fingers, or during flexion and extension of the wrist, or during pronation and supination. For each game, one or another pair of movements is selected and the choice is indicated in the game settings.

1. "Cars" - an exercise in which you need to control a moving virtual car along a given track. When moving parts of the hand, the virtual car on the computer monitor screen moves to the right and left.

2. "Bombardier" - an exercise in which you need to move the sight and drop the bomb on the target. In this case, with one of the selected pair of movements, the virtual sight moves forward, with the other - back. The control of dropping virtual bombs is selected from the movements not involved in the control of the movement of the sight.

3. "Volleyball" - an exercise in which you need to control a virtual volleyball player, trying to hit the ball. In this case, with one movement from the selected pair, the virtual object moves forward, with the other - backward.

4. "Bubbles" - an exercise in which you need to control the flight of a virtual helicopter, trying to shoot down bubbles. Two game modes are provided: movement only vertically (up/down) or movement both vertically and horizontally (up/down and forward/backward). When selecting the mode with horizontal and vertical movement, the control is performed by any combination of pairs of movements of the parts of the hand.

5. "Square" - an exercise in which you want to control a virtual brush, painting over a rectangular area on the screen. Shading of the screen area is carried out by horizontal (forward / backward) or vertical (up / down) movements. When selecting the mode with horizontal and vertical movement, the control is performed by any combination of pairs of movements of the parts of the hand.

The second group of exercises (6-10) is composed of other five games that provide for the display of virtual hand movements on the computer monitor screen, repeating the movement of the patient's hand. The exercises are designed to work out the natural voluntary movements of the hand, in which interphalangeal, metacarpophalangeal, radiocarpal, radioulnar joints are involved, while the entire complex of musculoskeletal structures of the patient's hand is involved. The exercises provide for the following arbitrary acts of the parts of the hand with the participation of the thumb and one or more other fingers of the hand: holding the position of the fingers and other parts of the hand relative to each other, moving the hand and wrist while holding a certain position of the parts of the hand, bending the fingers in the way that is necessary to grasping and lifting the object, as well as extending the fingers as needed to release the object. Flexion and extension, as well as other finger movements, can be either smooth, such as in the game "Twist the lid", or sharp, such as in the game "Bowling", while the patient does not hold any objects in his hands. , and compression forces are not trained.

6. "Collect items", which requires you to control the virtual hand to collect and carry virtual items on the screen.

7. "Pyramid", in which you need to control a virtual hand to put cylindrical objects into a pyramid. The virtual objects that make up the pyramid have different diameters, so the movements are trained with different positions of the parts of the hand.

8. "Twist off the lid", which requires you to control a virtual hand to unscrew the lid from one virtual jar, transfer and screw on another virtual jar.

9. "Glass", in which you need to control a virtual hand in order to hold a virtual glass, collect small virtual objects and pour them into a large container.

10. "Bowling", in which you need to control a virtual hand in order to knock out cubes from the playing field on the screen using a ball.

After the patient has completed the exercises, it is possible to analyze their results using reports generated on the computer, designed to view the results for each part of the hand: fingers, wrist or elbow of the selected patient's exercises in a graphical form.

Rehabilitation is assessed as successful when the patient is able to perform all the exercises from the set, at the same time, it is obvious that at the beginning of rehabilitation, performing some exercises from the set, especially more complex exercises from the second group, is difficult for the patient, and sometimes inaccessible, so that positive dynamics can also be established by the patient performing those exercises that were previously inaccessible to him. An example of rehabilitation according to the developed method.

10 people were selected: 6 patients with left-sided and 4 with right-sided hemiparesis. Diagnosis: acute ischemic cerebrovascular accident in the basin of the left/right middle cerebral artery, early recovery period after a stroke. Left-sided/right-sided hemiparesis 3.5-4 points. Moderately pronounced pain syndrome, most pronounced in the shoulder joint, impaired fine motor skills, moderately pronounced anxiety and depressive disorders.

For each patient, rehabilitation was carried out according to the claimed method using the complex for the rehabilitation of the musculoskeletal system with biofeedback "ANIKA". The results of changes in the dynamics of patient indicators are shown in the table; for each patient, the values of the indicators are given before the procedures (D) and after the procedures (P). The dynamics of indicators were evaluated according to the following tests and scales (the serial number corresponds to the number in the results table).

1. Pain syndrome - visual analogue scale (VAS: 0-10).

2. A comprehensive original scoring questionnaire for assessing the severity of movement disorders.

3. Modified Nottingham scale for assessing sensory disorders in the upper limb.

4. Study of fine motor skills of the hand (L).

5. Modified Frenchay scale.

6. Modified FIM functional independence scale.

7. Scale for assessing violations of individual parameters of movement of the upper limb FMA-UE.

8. Test for assessing the recovery of motor deficit of the hand ARAT.

9. Test "nine pegs and nine holes", sec.

10. Barthel index.

11. Spielberger-Khanin anxiety scale T-reactive.

12. Hospital scale of anxiety and depression / D.

13. Hospital scale of anxiety and depression / T.

Analyzing the data, we can conclude that all patients showed an improvement in fine motor skills in the paretic limb, a decrease in the severity of pain, an increase in the volume of daily activity, an increase in motivation for further rehabilitation and an improvement in the emotional background.

The application of the method is thus aimed at restoring, first of all, the functional state of the neuronal systems of the part of the brain affected, for example, by the focus of a stroke. A more complete and effective recovery of the affected part of the brain is ensured by performing exercises in turn, due to which there is no increase in the activation of conditionally healthy parts of the brain, but the structures of the affected cerebral areas are activated when performing exercises with the affected hand.

Claims (4)

1. A method for the rehabilitation of patients with neurological disorders, which provides for the patient to perform exercises from a set using a rehabilitation device, in which each exercise is based on a computer game, while the rehabilitation device is connected to a computer, and both the first and second hands of the patient are in contact with sensors devices for rehabilitation, in the course of the patient performing exercises with both the first and second hands, determine the position and orientation of the parts of both the first and second hands of the patient, display on the computer monitor changes in the position and orientation of the parts of both the first and second hands of the patient by correspondingly changing the position on the monitor computer of virtual objects in the corresponding computer game, characterized in that the set of exercises includes the first group of exercises, involving flexion and extension of the fingers, flexion and extension of the wrist, pronation and supination, as well as the second group of exercises, involving the performance of natural complex movements of the hand, which combine flexion and extension of the fingers, flexion and extension of the arm in the wrist and radioulnar joints, pronation and supination, while the ANIKA complex for the rehabilitation of the musculoskeletal system with biofeedback is used as a rehabilitation device, the sensors of said complex are fixed on the distal phalanges of the fingers, on the middle part of the hand, on the forearm of both the first and second hands of the patient, while after performing each exercise with the first hand, this exercise is repeated with the second hand. 2. The rehabilitation method according to claim 1, characterized in that the first and second groups of exercises consist of five exercises each. 3. The rehabilitation method according to claim 1, characterized in that the first hand is the patient's paretic hand. 4. The method of rehabilitation according to claim 1, characterized in that the duration of the individual exercise with each hand is at least two minutes.