RU2821772C1 - Method for medical rehabilitation of patients with spastic paraplegia due to spinal cord injury at thoracic and thoracolumbar level - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: before each training session in an exoskeleton, spastic muscles are exposed to a low-intensity low-frequency alternating magnetic field, and weakened muscles are exposed to a low-frequency pulse current. After magnetic therapy and electromyostimulation, the patient performs therapeutic exercises. Procedures are performed sequentially with a minimum interval of 10 to 15 minutes. Training course in the exoskeleton "Exoathlet" includes three blocks of 5–6 sessions. Transition to each subsequent block is performed when mastering the skill of the previous block, as well as when the indicators characterizing the absence of signs of fatigue and/or increase in the spasticity of the muscles of the lower extremities according to the Ashworth scale are achieved.

EFFECT: method provides more effective medical rehabilitation of patients with spastic lower paraplegia by improving self-care ability, enhanced mobility and socialization.

1 cl, 2 tbl, 2 ex

Description

The invention relates to medicine, namely to medical rehabilitation, and can be used for the rehabilitation treatment of patients with severe motor dysfunction in the form of spastic paraplegia due to trauma to the thoracic and thoracolumbar spine.

The main cause of spinal cord damage and loss of motor function of the lower extremities, both in our country and abroad, is spinal cord injury (SCTI). Injuries to the spine and spinal cord account for 10-17% of all musculoskeletal injuries. (Nowrouzi B, Assan-Lebbe A et all, 2017; Liu X et all, 2018). About 40 million people worldwide suffer spinal cord injury every year, the majority of them (up to 80%) are young men aged 20 to 35 years. In the USA, the total number of cases of spinal cord injury is about 12 thousand per year [Sumida M et all, 2001]. In Russia, about 8 thousand people suffer spinal cord injuries every year, of which 70-80% of the victims remain with severe disability (groups 1 and 2) due to the severity of spinal cord damage according to the ASIA type A and B scale. In 65-78% of victims, traumatic disease of the spinal cord occurs with the development of spastic syndrome, and lower spastic paraplegia (20-30% of patients) leads to persistent, significant loss of ability to work. An extremely difficult task for rehabilitation specialists is the restoration of movement functions in this category of patients. To date, unified approaches to the selection of means and methods for implementing the rehabilitation process have not been defined, which significantly reduces its effectiveness [Khaibullina Z.R. 2009; Gumarova L.Sh., Bodrova R.A. 2014; Prudnikova O.G. et al. 2019].

Rehabilitation measures for this category of patients are aimed at combating physical inactivity, creating conditions for the restoration of lost functions and the formation of compensatory motor acts; performing social skills and self-care; correction of dysfunctions of the pelvic organs. An important habilitation component for wheelchair users is improving the quality of life, their everyday and social adaptation, and returning to work.

There are a large number of methods for medical rehabilitation of patients with diseases and consequences of injuries of the spine and spinal cord with paraplegia and paraparesis.

Thus, there is a known method of using the Atlant pneumatic suit to form a vertical posture and walking in patients with para- and tetraparesis by performing a set of physical exercises in the pneumatic suit by the patient (Method of forming a vertical posture and walking in patients with para- or tetraparesis / Konovalova N.G. , Lyakhovetskaya V.V., Filatov E.V. Patent for invention No. 2572550 C1, published: 01/20/2016 Bulletin No. 2).

The advantages of this method are that the suit provides external fixation and correction of vertical posture, and also provides a measured load on the muscles. As a result of this effect, the patient develops muscle-joint sensation, and pathological reflexes are extinguished. Training in a pneumatic suit provides neurophysiological conditions for the restructuring of supraspinal motor control systems close to the physiological norm, contributes to maintaining posture and performing movements.

The disadvantages of the method include the impossibility of its use in patients with severe neurological deficit according to ASIA type A, B, since even when a vertical posture is fixed, independent walking is impossible.

There is a known method for the rehabilitation of patients with lower mono- and paraparesis with peripheral nerve damage by neuromodulation of the spinal cord (RU 2506970, Federal State Budgetary Institution "Russian Scientific Center "Restorative Traumatology and Orthopedics" named after Academician G.A. Ilizarov", 02.20.2014). In the described method, electrical stimulation is carried out using an electrode that is inserted through a puncture into the epidural space at the level of the affected segment of the spinal cord or through a cutaneous electrode that is placed in the projection of the autonomous region of the innervated muscles. Simultaneously with electrical stimulation, locomotor training is carried out on the Lokomat robotic complex.

The disadvantage of this method is that the patient undergoes an invasive procedure for installing an electrode, and also that one cutaneous electrode can only affect one muscle group.

A method for the rehabilitation of patients after injuries and damage to the spinal cord at the level of the lumbar spine is described (RU 2614890, S.A. Volovets, E.Yu. Sergeenko, Yu.A. Yashinina, V.I. Chilikin, O.V. Volkova Russian National Research Medical University named after . N.I. Pirogov, Ministry of Health of Russia, March 30, 2017), in which cutaneous functional electrical stimulation is performed synchronously with walking on the Lokomat robotic complex. The active electrode of the pair is placed on the muscle belly, and the indifferent electrode is distal to the location of the active electrode. Electrodes of a pair are applied skinwise on both sides during paraparesis perpendicular to the course of muscle fibers on the gluteus maximus, quadriceps femoris, gastrocnemius and posterior thigh muscles. Training on the Lokomat complex is carried out with an initial unloading of the patient’s body weight of 30%, followed by an increase in load.

The disadvantage of this method is that the training is carried out by passively walking in place on the treadmill of the simulator, without the active participation of the patient in maintaining a vertical posture. Also missing is the fact of the patient’s movement in space, as the main factor in walking.

The closest is the method of restorative treatment of patients with deep flaccid lower mono- or paraparesis. (Patent for invention No. 2650210 Method for rehabilitation of patients after injuries and lesions of the thoracic and lumbar spine / S.A. Volovets, E.Yu. Sergeenko, Yu.A. Yashinina, I.S. Rubeykin, A.I. Sedov, O .V. Volkova Patent holder: Federal State Budgetary Educational Institution “Russian National Research Medical University named after N.I. Pirogov” of the Ministry of Health of the Russian Federation). This method includes simultaneous locomotor training and transcutaneous electrical stimulation of the muscles of the trunk and lower extremities (erector spinae, gluteus maximus, quadriceps and gastrocnemius muscles) on both sides through active and indifferent electrodes. Motor training is carried out using the Exoathlete exoskeleton; during therapy, the step length is gradually increased and the interval between steps is reduced to walking without an interval. The disadvantage of this method is the danger of its use in a group of patients with spinal cord injury according to the ASIA type A, B scale, with spastic paraplegia of the lower extremities - a possible increase in muscle spasticity under these training conditions can lead to injury to the patient.

The objective (technical result) of the proposed invention is to increase the efficiency of medical rehabilitation of patients with spastic lower paraplegia by improving the ability to self-care, expanding mobility and socialization opportunities.

The problem is solved by the fact that the method of medical rehabilitation of patients with spastic paraplegia due to spinal cord damage at the thoracic and thoracolumbar levels includes the use of multichannel electromyostimulation and locomotor therapy using the active exoskeleton "Exoathlete". In accordance with the proposed invention, before each training session in the exoskeleton, spastic muscles are exposed to a low-intensity, low-frequency alternating magnetic field, weakened muscles are exposed to low-frequency pulsed current using the electromyostimulation method; after sequential magnetic therapy and electromyostimulation, the patient performs special therapeutic exercises, including exercises to correct muscle tone and increase tolerance to subsequent physical activity in the exoskeleton. The procedures are carried out sequentially, with a minimum break of 10 to 15 minutes. The “Exoathlete” exoskeleton training course includes three blocks of 5-6 sessions, while in the first session of the first block the patient acquires the skill of getting up from a sitting position and sitting on a chair in the exoskeleton; in the second or third session of the first block, “standing” exercises are added parallel bars" and "walking in place on parallel bars" with a step setting of "short and low" and an interval between steps of 1 second. In the second training block of 4-5 sessions, the training process includes walking on parallel bars with the help of an assistant, increasing the total training time from 20 to 30 minutes and changing the ratio of time standing to walking on parallel bars from 1:1 to 1:2. The third training block includes 5-6 sessions, the main exercises being parallel bars walking with the help of an assistant and independently, while simultaneously selecting an individual optimal step pattern.

Consecutive implementation of low-frequency magnetic therapy, cutaneous electromyostimulation and special therapeutic exercises before the start of locomotor therapy in the exoskeleton ensures correction of muscle tone in patients with severe neurological deficits and increases tolerance to subsequent physical activity in the exoskeleton, and prevents the increase in spasticity during training.

Verticalization and walking in an exoskeleton significantly increases the functional activity and mobility of the patient, has a positive effect on the function of the pelvic organs, and in combination with transcutaneous electromyostimulation and therapeutic exercises ensures strengthening of the muscular corset and strength of the muscles of the upper extremities, which leads to optimization of movement in a wheelchair. Walking with the help of an external robotic device has a positive effect on the patient's psychological state, enhances social functioning and improves mental health indicators. Dividing exercises in the exoskeleton into 3 blocks allows you to prepare the patient’s muscular and vestibular apparatus for long-term vertical loads and prevents the likelihood of fractures of the bones of the lower extremities. In this group of patients there is always a decrease in bone density, so prevention of fractures is very important.

The present invention is illustrated in Tables 1 and 2, which present the modes of locomotor training for patients L. and S., respectively.

Using this method, 64 patients were treated with the consequences of spinal cord injury at the thoracic and lumbar levels in the form of lower spastic or mixed paraplegia due to complete disruption of spinal cord conduction (ASIA type A) or incomplete with preservation of sensitivity (but not movements) (ASIA type IN). After complex rehabilitation based on walking in an exoskeleton, all patients experienced increased stability in an upright position, increased endurance of the back muscles, and increased strength in the arm muscles, which contributed to improved physical condition and increased mobility and physical activity. Daily verticalization with the ability to walk with the help of an external device had a positive effect on the psychological health of 76.6% of patients; their subjective self-assessment of their health status improved, their satisfaction with the results of rehabilitation and the desire to actively participate in the rehabilitation process increased. The achieved therapeutic effects persisted for at least 3 months after the rehabilitation course.

The industrial applicability of the proposed method is confirmed by clinical examples.

Clinical example 1.

Patient L., 32 years old, Dz: Consequences of SCI. Artificial bone-metal block at the Th11-L1 level. Traumatic disease of the spinal cord, late period. Lower paraplegia, violation of the central type of physical activity. ASIA A. Injury 4 years ago; decompressive and stabilizing surgery was performed at the Th11-L1 level on the first day after the injury. He regularly undergoes medical rehabilitation courses 2-3 times a year with little positive effect. During this time, the patient adapted to a wheelchair, mastered independent catheterization, and was independent in everyday life.

Upon admission: lower paraplegia, increased muscle tone of the lower extremities according to the pyramidal type (2 points on the Ashforth scale); muscle strength of the lower extremities on the right and left: hip abduction/adduction 0/0 points, shin flexion/extension 0/0; in feet 0 points. It is possible to abduct the hips using the gluteal and back muscles. To assess the strength of the back muscles, the time of holding the torso from a prone position was recorded, which was 2 minutes 23 seconds. Passive movements in the joints of the lower extremities in full. Hypotrophy of the muscles of the lower extremities. Conduction type anesthesia from the L1 segment on both sides. Abdominal reflexes are sluggish, quickly depleted, knee reflexes from the legs are not evoked, high Achilles, pathological foot signs, D=S. Urination is impaired according to the central type (intermittent catheterization). Stool after drug stimulation, 2 times a week. The patient moves independently in a wheelchair, transfers from the wheelchair to the bed and back, and moves independently within the bed. The SCIM III score for basic social and life functions was 63 points, and the SF-36 Short Form for Psychological Well-Being was 66 points and physical functioning was 39 points.

When performing densitometry, the T-criterion was -2.5, which allows rehabilitation measures to be carried out according to the proposed method. Before training walking using the Exoathlete exoskeleton, physiotherapeutic procedures were also carried out to correct the muscle tone of the lower extremities. Before each training session in the exoskeleton, magnetic therapy procedures for spastic muscles and multichannel electrical myostimulation of antagonist muscles, individual therapeutic exercises were carried out sequentially with an interval between procedures of 10-15 minutes. Training using the Exoathlete exoskeleton was carried out in stages (see Table 1). The first 5 lessons are to develop the skill of getting up, sitting down, and standing on parallel bars. Formation of the skill of controlling the center of gravity and moving it arbitrarily. The duration of the lesson ranged from 15 minutes on the 1st day to 30 minutes on the 5th day of training. Upon mastering the skills of getting up, sitting down, standing on parallel bars, as well as achieving indicators characterizing the absence of signs of fatigue and/or increasing spasticity of the muscles of the lower extremities according to the Ashforth scale, the patient was transferred to the second block of the training course. Sessions 6-10 consisted of standing and walking in place on parallel bars. The walking mode pattern is a short step with a low leg lift, the interval between steps is 1 s.

The duration of the lesson is from 20 to 30 minutes by the 10th day of training. After mastering the skills of standing and walking in place on parallel bars, as well as achieving indicators characterizing the absence of signs of fatigue and/or increasing spasticity of the muscles of the lower extremities according to the Ashforth scale, the patient was transferred to the third block of the training course. Lessons 11-15 consisted of parallel bars walking with the support of an instructor, selection of the optimal walking pattern, lesson duration from 20 to 40 minutes.

As a result of the course, the endurance of the back muscles increased, which makes it easier to use a wheelchair (the time of holding the body from a lying position increased by 30 seconds - from 2 minutes 23 s to 2 minutes 53 s), the patient began to stand on the parallel bars while fixing the lower extremities with splints, an increase in functional physical activity was achieved (the total score on the SCIM III scale increased from 63 to 65) and an improvement in psychological state (the score on the SF-36 questionnaire increased from 66 to 70).

Clinical example 2.

Patient S., 39 years old, Dz: Consequences of spinal cord injury. Traumatic disease of the spinal cord, late period. Lower paraplegia. Dysfunction of the pelvic organs. ASIA A. Trauma 9 years ago, two-stage decompression and stabilization surgery was performed at the level of Th5-Th9 vertebrae on the first day after the injury. Upon admission: lower paraplegia, increased muscle tone of the lower extremities according to the pyramidal type (2 points on the Ashforth scale); muscle strength of the lower extremities on the right and left: hip abduction/adduction 0/0 points, shin flexion/extension 0/0; in feet 0 points. To assess the strength of the back muscles, the time of holding the torso from a prone position was recorded, which was 2 minutes 40 seconds. Passive movements in the joints of the lower extremities in full. Painful and tactile hypoesthesia from the Th8 level symmetrically, anesthesia from the Th9 level. Abdominal reflexes are sluggish, knee reflexes are reduced, Achilles are not evoked, pathological foot signs, foot clonus, D=S. Urination is impaired according to the central type (intermittent catheterization). Stool after drug stimulation. The patient moves independently in a wheelchair, transfers from the wheelchair to the bed and back, and moves independently within the bed. Basic social and life function scores were 64 points on the Spinal Cord Injury Independence Measure (SCIM III), and 65 points on the SF-36 Short Form Health Assessment for psychological well-being and 33 points on physical functioning. When carrying out densitometry, the T-criterion was 2.1, which allows rehabilitation measures to be carried out according to the proposed method.

Before training walking using the Exoathlete exoskeleton, individual therapeutic gymnastics classes were carried out, as well as physiotherapeutic procedures to correct muscle tone of the lower extremities according to the claimed method. 10-15 minutes after magnetic therapy and electrical stimulation, the lesson from the first block was carried out (see Table 2). Training using the Exoathlete exoskeleton was carried out in stages. During the training, the patient's condition was assessed - the presence of signs of fatigue and/or an increase in spasticity of the muscles of the lower extremities according to the Ashforth scale. The first 5 lessons are to develop the skill of getting up, sitting down, and standing on parallel bars. Formation of the skill of controlling the center of gravity and moving it arbitrarily. The duration of the lesson ranged from 15 minutes on the 1st day to 30 minutes on the 5th day of training. When mastering the skills of getting up, sitting down, standing on parallel bars, as well as when achieving indicators characterizing the absence of signs of fatigue and/or increasing spasticity of the muscles of the lower extremities according to the Ashforth scale, the patient was transferred to the second block of the training course. Sessions 6-10 consisted of standing and walking in place on parallel bars. The walking mode pattern is a short step with a low leg lift, the interval between steps is 1 s. The duration of the lesson is from 20 to 30 minutes by the 10th day of training. Upon mastering the skill of standing and walking in place on parallel bars, as well as upon achieving indicators characterizing the absence of signs of fatigue and/or increasing spasticity of the muscles of the lower extremities according to the Ashforth scale, the patient was transferred to the third block of the training course. Lessons 11-13 consisted of parallel bars walking with the support of an instructor, selection of the optimal walking pattern, lesson duration from 20 to 40 minutes. The last 5 classes consisted of independent walking on parallel bars for 20 to 40 minutes.

As a result of the course, the endurance of the back muscles increased (the time of holding the torso from a lying position increased by 40 seconds - from 2 minutes 40 s to 3 minutes 20 s), the patient began to stand and move on the parallel bars while fixing the lower extremities with splints, an increase in functional physical activity was achieved (total score on the SCIM III scale increased from 64 to 70) and improvement in physical condition (increase in the score on the SF-36 questionnaire from 33 to 36), mental health improved, as evidenced by an increase in the score of the psychological component of health on the SF-36 questionnaire from 65 to 69 points. The function of the pelvic organs did not significantly improve, but the patient noted the appearance of a feeling of fullness in the bladder and rectum.

Claims (1)

A method of medical rehabilitation of patients with spastic paraplegia due to spinal cord injury at the thoracic and thoracolumbar level, including the use of multichannel electromyostimulation and locomotor therapy using an active exoskeleton, characterized in that before each training session in the exoskeleton, the spastic muscles are exposed to a low-intensity, low-frequency alternating magnetic field , weakened muscles are exposed to low-frequency pulsed current using the electromyostimulation technique; after sequential magnetic therapy and electromyostimulation, the patient performs therapeutic exercises, including exercises to correct muscle tone and increase tolerance to subsequent physical activity in the exoskeleton, and the procedures are carried out sequentially, with a minimum break of 10 to 15 minutes; the “Exoathlete” exoskeleton training course includes three blocks of 5-6 sessions, while in the first session of the first block the patient acquires the skill of getting up from a “sitting” position and sitting on a chair in the exoskeleton; in the second or third session of the first block, “standing” exercises are added parallel bars" and "walking in place on parallel bars" with a step setting of "short and low" and an interval between steps of 1 second; in the second training block of 4-5 sessions, the training process includes walking on parallel bars with the help of an assistant, increasing the total training time from 20 to 30 minutes and changing the ratio of time standing to walking on parallel bars from 1:1 to 1:2; the third training block includes 5-6 lessons, the main exercises being parallel bars walking with the help of an assistant and independently with the simultaneous selection of an individual optimal step pattern, and the transition to each subsequent block is performed when mastering the skill of the previous block, as well as when achieving indicators characterizing no signs of fatigue and/or increasing spasticity of the muscles of the lower extremities according to the Ashforth scale.