RU2826783C1 - Method for differentiated sensorimotor correction in parkinson's disease - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to medical rehabilitation in neurology, physiotherapy. A complex of therapeutic and rehabilitation physical and educational effects on the patient is carried out. A basic complex of sensorimotor correction is carried out, which includes the following individual daily exposures performed in a random sequence: ergotherapy in form of 10 daily 30-minute sessions for training household movements, noted in the claim, and 12 daily sessions of classical medical massage of back muscles, cervical-collar zone (CCZ) and lumbosacral spine (LSS) with total duration of each session of 30 minutes. If the patient has postural deformities with underlying Parkinson’s disease – camptocormia, latero- or anterocollis, Pisa syndrome or no postural deformities – basic complex of sensorimotor correction is supplemented with corresponding actions taking into account the type of postural deformation or its absence in the patient from the following: rhythmotherapy based on the Ronnie Gardiner method, hydrokinesis therapy for 30 minutes at a water temperature in pool of 28–30 °C in the form of performing the corresponding exercises in water, proprioceptive neuromuscular facilitation (PNF) for 30 minutes to perform certain movements at a comfortable pace for the patient.

EFFECT: method provides reduced time of adaptation of PD patients with postural deformities to normal life due to both integrated maintenance of muscle tone, walking, cognitive functions, and differentiated recovery, maintenance of postural function directly in the presence of a certain type of postural deformation in the patient or its absence, as well as further maintenance of the achieved rehabilitation effects in time.

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Description

The invention relates to medicine, medical rehabilitation in neurology, physiotherapy and can be used to improve the quality of life of patients with Parkinson's disease in health resorts and other specialized medical institutions.

Parkinson's disease (PD) is a neurodegenerative disorder that affects more than 6 million people worldwide. It causes the death of neurons that produce dopamine, a substance that regulates movement. This leads to symptoms such as hypokinesia, bradykinesia, postural instability, muscle rigidity, and tremor at rest (J. Parkinson, J. Charcot, 1817). Given the increasing proportion of elderly people, as well as the improvement of medical care for PD patients, an increase in the prevalence of the disease should be expected in the next 20-30 years.

Movement disorders associated with PD are complex problems with a variety of manifestations that may vary significantly depending on the stage and causes of the disease. Research shows that tremor is one of the most characteristic symptoms of PD, starting with a slight shaking of one limb and progressing over time. Muscle rigidity, manifested by increased muscle tone and limited joint mobility, can cause discomfort and hinder natural movements. These symptoms limit the patient's motor functions and negatively affect his quality of life (Schapira A., Chaudhuri K., Jenner P., 2017).

Patients with PD often have postural abnormalities such as camptocormia, Pisa syndrome, latero- and anterocollis. These conditions significantly limit motor functions and impair quality of life.

Camptocormia is characterized by fixation of the spine in a forward-bent position, which leads to limited movement and altered gait. This postural disorder can be observed in a significant proportion of patients with PD, especially in the later stages of the disease. Camptocormia is characterized by a forward bend of the trunk greater than 45º, muscle weakness and fatigue, pain in the neck and lower back, impaired balance and coordination, muscle rigidity, starting disorders, acheirokinesia, and difficulties in performing daily routine activities.

The "Leaning Tower of Pisa" syndrome is manifested by a torso tilt to the side due to increased rigidity of the back and neck muscles, which leads to a disturbance of balance and posture. The patient experiences discomfort due to a torso tilt to the right or left by 10º or more. Gradual and persistent deviation from the vertical axis of the spine, which is not associated with muscle contractures or bone deformities, leads to the inability to straighten the spine through natural efforts, back pain reaches more than 7 points on the VAS. Impaired postural control and frequent falls of patients are observed. In some cases, this syndrome can be caused or aggravated by drug therapy for PD.

Anterocollis is characterized by a forward tilt of the head, which reduces the field of view, impairs motor coordination, and increases the risk of falls and injuries. Although anterocollis is less common than camptocormia and the Leaning Tower of Pisa syndrome, it can still be detected in a significant number of patients with PD, most often in the later stages of the disease (Fursova I.V., Mikhailov V.A., Zakharov D.V., 2018). In this case, patients experience discomfort due to the forward tilt of the head and neck, pain in the cervical-collar zone, dysphagia, breathing difficulties, facial muscle asymmetry, visual and auditory impairment. In some cases, this syndrome can be caused or aggravated by the use of neuroleptics or other drugs for PD.

Another syndrome of postural disorders in PD is laterocollis. In this case, patients experience discomfort due to tilting the head and neck to the right or left, pain in the cervical-collar zone, bradykinesia, asymmetry of the facial muscles, visual and auditory disorders. And, like anterocollis, in some cases laterocollis can be caused or aggravated by the use of neuroleptics or other drugs.

There is also a course of BP without manifestation of the mentioned postural deformities.

Despite extensive research into various aspects of PD, there are no rehabilitation technologies that can effectively influence initial disorders and quality of life in certain postural deformities in patients with PD. Most previous studies were limited to traditional exercise therapy methods and did not include modern differentiated neurorehabilitation techniques in rehabilitation treatment programs.

There are known methods of corrective gymnastics for severe neurological diseases in the form of certain exercise blocks aimed at correcting disorders of static and dynamic coordination, muscle tone and strength, the severity of paresis (Nalobina A.N., Zakharchenko N.V. Methodology for correcting movement disorders in individuals with multiple sclerosis. // Adaptive physical education (APE). 2015. 1 (61). Pp. 25-29), hydrokinesitherapy exercises (HKT) for various lesions of the musculoskeletal system - gait correction, balance therapy, etc. (D.A. Eraskin, A.N. Nalobina, I.V. Krasnov. Experience in using hydrokinesitherapy to restore the skill of independent walking after endoprosthetics of lower limb joints. // Modern issues of biomedicine. 2021. Vol. 5, 2 (15), p. 15; The effect of hydrokinesitherapy on the parameters of the cardiovascular system of patients with traumatic spinal cord disease. // Business. Education. Law. 2020, May, No. 2 (51). P. 314-318; Nazarova K.M. Correction of respiratory system dysfunctions in individuals with traumatic spinal cord disease (TSCD) using hydrokinesitherapy. // Bulletin of the Institute of Natural Science and Sports Technology. Collection of scientific articles. Issue II. M., 2020, pp. 70-77).

However, the possibility and effectiveness of their differentiated use for specific postural deformities in patients with PD has not been demonstrated.

At the same time, there are studies of various interactions between balance disorders and walking stereotypes, starting difficulties and decreased performance of multitasking actions related to walking in PD. Thus, people with camptocormia have a leftward shift in the center of gravity, and their subjective quality of life is more than twice as low. The average result of the dynamic gait index is almost twice as low as normal, which is the reason for the number of falls. The average number of falls that occur several steps after the start of movement and lead to bruises and fractures is 8±3 times per week. Based on this, people with camptocormia against the background of PD find it more difficult to maintain balance when walking and performing everyday movements than people with PD without postural deformities.

Therefore, it is more appropriate to include more physical exercises in a standing position and walking on unstable surfaces with the performance of various motor and cognitive tasks in physical rehabilitation programs for patients with PD without axial (postural) deviations, while for patients with camptocormia, initial sitting positions are preferable, as well as training in coping strategies when getting up from surfaces of different heights and structures, measures to improve posture, static and dynamic balance and walking in various conditions with the performance of double and triple tasks (Nazarova K.M., Nalobina A.N. The effect of camptocormia on postural control, balance and gait of individuals with Parkinson's disease. // Modern issues of biomedicine. 2024. Vol. 8 (1). DOI: 10.51871/2588-0500_2024_08_01_24).

It is also known that classical massage has a stimulating effect on the parasympathetic channel of regulation in patients with neurological disorders of motor functions (Nalobina A.N., Vakhrina A.S., Ulzhekova N.T. Criteria for determining the optimal focus of rehabilitation measures in children with the consequences of cerebral palsy. // Health-saving technologies, pp. 111-120 [Electronic resource: https://iest-vestnik.mgpu.ru/wp-content/uploads/sites/5/2023/11/nalobina-a-n-vahrina-a-s-ulzhekova-n-t.pdf], which is also relevant in the rehabilitation of patients with PD.

For various disorders developing in PD, it is known to use various types of exercises included in the general complex of rehabilitation and adaptation of patients to everyday life (RU 2723136 C1, Tanashyan M.M. et al., 06/08/2020; RU 2436557 C1, Kamakinova A.B. et al., 12/20/2011; RU 2315632 C1, Gashilova F.F. et al., 01/27/2008; RU 2704236 C1, Afonshin V.E. et al., 10/24/2019; V.A. Rudnev, S.V. Prokopenko. The use of "controlled motor synergies" to restore walking skills in Parkinsonism. // Journal: Neurology and Psychiatry, 2001, 10, pp. 26-28), including reducing the axial load (RU 2197215 C1, Grigoriev AI et al., 27.01.2003), performing special exercises to train balance (RU 2781120 C1, Khizhnikova AE et al., 05.10.2022), using elements of dance movement therapy (mentioned in RU 2519977 C1, Kovalev SP et al., 20.06.2014), using targeted lingual painless high-frequency electrical stimulation (RU 2737995 C1, Kazantseva NV, 07.12.2020), rhythmic music therapy and massage (RU 2557413 C1, Anisimov BN et al., 20.07.2015).

However, these known methods did not provide long-term adaptation to normal life against the background of the above-mentioned specific postural deformities in patients with PD.

A method of occupational therapy of walking is known for the rehabilitation of patients with locomotion disorders, including those with PD symptoms (RU 2794811 C1, Blinova N.M. et al., 04/25/2023), using directed walking between special laser sources. However, this known technique concerns occupational therapy only for walking as a routine motor act and does not affect other numerous movements of everyday life in such patients.

In earlier publications by the co-authors of the present invention, it was also shown that it is advisable to include exercises for spinal traction in various positions, muscle relaxation, and special breathing exercises in rehabilitation programs for patients with movement and posture disorders. In particular, the Pilates system is based on exercises for spinal alignment in combination with awareness, proper breathing, and a gradual increase in loads to prepare muscles for more effective movements. The exercise complexes consist of smooth movements that stretch and strengthen muscles and are performed from different starting positions (SP): from the basic stance and sitting, from a sitting and lying position, from a prone position, on the back, or on the side, depending on the degree of impairment and the nature of the disease (Nazarova K.M., Nalobina A.N. Physical rehabilitation of women with osteochondrosis of the lumbar spine in the postpartum period. // Collection “Step into Science”, materials of the III scientific and practical conf. (I All-Russian) Institute of Natural Science and Sports Technology, Moscow, December 20, 2019, pp. 168-171).

GCT is also actively used in the treatment of similar movement disorders. Being in water significantly increases heat transfer and metabolism, activates hemodynamics, breathing, etc. Swimming and doing physical exercises, playing in water have a general effect on the body, help improve joint mobility (in case of injuries, contractures, coxarthrosis, etc.), increase muscle fitness, relieve pain. Gymnastics in water (special exercises with dumbbells, rubber balls, etc.) helps to restore adaptation to various loads, and also acts as a hardening factor at low water temperatures (23-27 ° C) and causes muscle relaxation when it increases (37-39 ° C) (Nazarova K. M., Nalobina A. N. Physical rehabilitation of women with osteochondrosis of the lumbar spine in the postpartum period. // Collection "Step into Science", materials of the III scientific and practical conf. (I All-Russian) Institute of Natural Science and Sports Technology, Moscow, December 20, 2019, pp. 168-171). Exercises in water can be an independent treatment for the initial manifestations of vertebral pain syndrome, decreased function of the cartilaginous disc, or be an auxiliary means for other similar disorders (Nazarova K.M. Improving the functional state of the respiratory system of individuals with traumatic spinal cord disease (TSCD) in the late recovery period by means of hydrorehabilitation. // "Actual problems of adaptive physical education". Materials of the 1st scientific and practical conf. of the Institute of Natural Science and Sports Technology, Moscow, March 27, 2020, pp. 120-125).

In case of movement and posture disorders, in particular, in case of traumatic disease of the spinal cord in the cervical region, also known groups of active exercises are used in a complex, which are selected in accordance with the degree of reduction of the functional capacity of the muscles. Thus, facilitation of active movements of the hand and fingers is achieved by sliding the hand along a smooth polished panel, then with a rough surface. Strength exercises are included in the complex of exercises as muscle strength is restored to 3 points and are performed with balls and rollers of various weights, diameters and degrees of compression, expanders and rubber bands of various rigidity, etc. If there is a possibility of finger grip, active exercises are performed, expressed in moving, grasping, holding and rotating with the fingers objects of larger and smaller diameters, various shapes, sizes and weights, first with a rough and then a smooth surface.

A separate method of occupational therapy is training in everyday skills: fastening buttons, buckles, lacing, using a zipper, as well as learning to use adapted pencils, a fork, and a spoon. Working with plasticine, scissors, and paper improves the functional ability of the hand. To improve the pinch grip function, writing exercises were given using pens with different diameters and fillers (D.A. Eraskin, A.N. Nalobina, S.I. Alekseeva, E.Yu. Fedorova, S.N. Bobkova. The Effect of Occupational Therapy on the Restoration of Upper Limb Functions in Patients with Traumatic Disease of the Cervical Spinal Cord in the Late Rehabilitation Period. // Man. Sport. Medicine. 2019. Vol. 19, No. 4. Pp. 117-124).

However, all these known methods do not apply to patients with specific postural deformities in PD, which require the development of more narrowly targeted, differentiated, effective treatment and rehabilitation measures.

The co-authors of the proposed invention previously carried out extensive research work including individual sessions with an occupational therapist, as well as rhythm therapy based on the Ronnie Gardiner method (RGM) in the complex of therapeutic and rehabilitation interventions for PD with postural deformities (Nazarova K. M., Nalobina A. N. Analysis of gait and movement coordination in individuals with Parkinson's disease with different treatment methods // Modern trends, problems and ways of development of physical culture, sports, tourism and hospitality: collection of materials from the XVII Int. scientific and practical conf. November 21-22, 2023. Moscow: NCC Education, 2023. Pp. 21-26; Nazarova K. M., Nalobina A. N. Ergotherapy at an early stage of Parkinson's disease. // Modern issues of biomedicine. 2022. Vol. 6, No. 4 (21). DOI 10.51871/2588-0500_2022_06_04_22); K. M. Nazarova, A. N. Nalobina. Possibilities of occupational therapy to improve the quality of life in Parkinson's disease. // Bulletin of Moscow State Pedagogical Univ. Series: Natural Sciences. 2023. No. 1(49). P. 88-96. - DOI 10.25688/2076-9091.2023.49.1.7; Nazarova K. M., Nalobina A. N. The effect of camptocormia on postural control, balance and gait of individuals with Parkinson's disease. // Modern issues of biomedicine. 2024. Vol. 8. No. 1. DOI: 10.51871/2588-0500_2024_08_01; Nazarova, K. M. Ergotherapy for Parkinson's Disease. // Innovative technologies in sports and physical education of the younger generation: Collection of articles on the materials of the XIII scientific and practical. conf. with international. uch., M., April 21, 2023. Moscow State Pedagogical Univ., 2023. Pp. 224-228).

The publication by the co-authors (K. M. Nazarova, A. N. Nalobina. Possibilities of occupational therapy for improving the quality of life in Parkinson's disease. // Bulletin of Moscow State Pedagogical Univ. Series: Natural Sciences. 2023. No. 1 (49). Pp. 88-96. - DOI 10.25688 / 2076-9091.2023.49.1.7) presents the characteristics of a possible course of comprehensive rehabilitation for postural deformities against the background of PD, where the course would include measures aimed at correcting both motor and non-motor disorders. It is shown that classical rehabilitation methods, such as kinesitherapy, exercise therapy, hydrorehabilitation, massage, are focused mainly on normalizing muscle tone, increasing the range of motion in the joints, positioning the patient and teaching the correct walking pattern, which creates the prerequisites for the restoration of locomotor functions and has a positive effect on the ability to move independently. However, such areas of life as the ability to self-care, communicate, and control one's behavior remain without due attention and significantly affect the quality of life. It is proposed to compensate for this deficit with the help of occupational therapy. It has also been shown that the greatest difficulties in patients with PD are caused by such actions as putting on clothes, eating, taking care of oneself, and writing, which should be the focus of the occupational therapist's efforts.

This source of information can be taken as the closest analogue (prototype) of the invention. Its disadvantages include the lack of development of an exact scheme of treatment and rehabilitation effects, an emphasis on ergotherapy, without taking into account the impact of other treatment factors depending on the presence of a certain postural deformation in a particular patient against the background of PD.

Meanwhile, BP with postural deformities, as emphasized in the listed publications, has a complex nature of disorders, which requires a clear, comprehensive, differentiated approach to rehabilitation, the development of which was the technical task of the present invention.

The technical result of the claimed method is a reduction in the time of effective adaptation of patients with PD with postural deformities to normal life due to both complex maintenance of muscle tone, walking, cognitive functions, and differentiated recovery, maintenance of the postural function itself in the presence of a certain type of postural deformity in the patient, as well as ensuring further maintenance of the achieved rehabilitation effects over time.

To achieve the specified result, a method of differentiated sensorimotor correction in Parkinson's disease is proposed, including a complex of therapeutic and rehabilitation physical and educational effects on the patient. In this case, a basic complex of sensorimotor correction is carried out, which includes the following individual daily effects, performed in a random sequence:

1) occupational therapy in the form of 10 daily 30-minute sessions to practice buttoning and unbuttoning buttons and zippers, preparing and eating food using adapted cutlery, independently brushing and combing teeth, writing with the dominant hand, working at a computer keyboard, methods of grasping objects with one and the other hand, while during the sessions, simultaneously with performing movements, the patient does mental arithmetic at a pace that is comfortable for him;

2) 12 daily sessions of classical medical massage of the back muscles, cervical-collar zone (CCS) and lumbosacral spine (LSS), with a total duration of each session of 30 minutes.

And if the patient has postural deformities against the background of Parkinson's disease, the basic complex of sensorimotor correction is supplemented with the following effects, taking into account the type of postural deformity in the patient:

A) during camptocormia the following is performed:

i) 8 daily sessions of rhythm therapy (RT) based on the Ronnie Gardiner method, in which the patient is shown conventional symbols-designations of the upper and lower extremities of the left and right sides of the body, stimulating him to perform a sequence of given movements in a given direction: steps while sitting and standing, dance steps, clapping hands,

and when performing a given movement, the patient pronounces the given name of the symbol of this movement in a given musical rhythm,

ii) 4 daily sessions of hydrokinesitherapy (HKT) for 30 minutes at a water temperature in the pool of 28-30°C, in the form of performing the following exercises in water:

- walking in water with weights on your feet,

- balance exercises - weight transfer, standing on one leg with eyes open and closed, stepping over an obstacle at the bottom,

- exercises for coordination of limb movements,

- exercises to strengthen the back muscles using dumbbells and water noodles,

- free swimming;

B) in case of the "Leaning Tower of Pisa" syndrome, the following is performed:

i) 5 daily sessions of proprioceptive neuromuscular facilitation (PNF) for 30 minutes to perform the following movements at a pace comfortable for the patient:

- anterior and posterior lifting and lowering of the scapula,

- anterior and posterior lifting and lowering of the pelvis,

- sequential flexion-adduction-internal rotation of the hip,

- sequential extension-abduction-external rotation of the hip,

in this case, each movement is carried out using the following PNF techniques: rhythmic initiation, dynamic reverse, stabilizing reverse;

ii) 5 daily GCT sessions of 30 minutes each at a pool water temperature of 28-30°C, in the form of performing the above-mentioned exercises in water;

B) in the presence of laterocollis, the following is performed:

i) 6 daily PNF sessions of 30 minutes each performing the following movements at a pace comfortable for the patient:

- anterior and posterior lifting and lowering of the scapula,

- anterior and posterior lifting and lowering of the pelvis,

- sequential flexion-adduction-internal rotation of the hip,

- sequential extension-abduction-external rotation of the hip,

in this case, each movement is carried out using the following PNF techniques: rhythmic initiation, dynamic reverse, stabilizing reverse;

ii) 6 daily GCT sessions of 30 minutes each at a pool water temperature of 28-30°C, in the form of performing the above-mentioned exercises in water;

D) in the presence of anterocollis, the following is performed:

i) 4 daily PNF sessions of 30 minutes each performing the following movements at a pace comfortable for the patient:

- anterior and posterior lifting and lowering of the scapula,

- anterior and posterior lifting and lowering of the pelvis,

- sequential flexion-adduction-internal rotation of the hip,

- sequential extension-abduction-external rotation of the hip,

in this case, each movement is carried out using the following PNF techniques: rhythmic initiation, dynamic reverse, stabilizing reverse;

ii) 4 daily GCT sessions of 30 minutes each at a pool water temperature of 28-30°C, in the form of performing the above-mentioned exercises in water,

iii) 4 daily RT sessions according to the Ronnie Gardiner method for 30 minutes each day, during which the patient is shown conventional symbols-designations of the upper and lower extremities of the left and right sides of the body, stimulating him to perform a sequence of given movements in a given direction: steps while sitting and standing, dance steps, clapping hands,

and when performing a given movement, the patient pronounces the given name of the symbol of this movement in a given musical rhythm,

and if the patient does not have the listed postural deformities against the background of Parkinson's disease, in addition to the basic course of correction, the following is carried out:

i) 9 daily RT sessions according to the Ronnie Gardiner method for 30 minutes, during which the patient is shown conventional symbols-designations of the upper and lower extremities of the left and right sides of the body, stimulating him to perform a sequence of given movements in a given direction: steps while sitting and standing, dance steps, clapping hands, in a given musical rhythm,

and when performing a given movement, the patient pronounces the given name of the symbol of this movement,

ii) 3 GCT sessions of 30 minutes each at a pool water temperature of 28-30°C, in the form of performing the above-mentioned exercises in water.

The sequence of daily sessions with different effects was not studied and was random.

The number of certain sessions of a particular type of exposure was selected in the process of long-term work with patients. It was found that the effectiveness of a different number of sessions of a certain type of sensorimotor correction varies depending on the specific type of postural disorders. For example, the inclusion of rhythm therapy (RT) sessions was most effective for such postural deformities as camptocormia and anterocollis, as well as in the absence of postural deformities, with initially suffering from movement coordination disorders. But it did not particularly affect the effectiveness of correction of other postural deformities in patients.

At the same time, GCT classes were effective with various postural deformations and in their absence. However, the study found that for various postural deformations or in their absence, a different number of GCT classes can be used - from 3 to 6, after which noticeable improvements were already observed, in connection with which a further increase in the number of such GCT classes seemed inappropriate.

Similarly, the effectiveness of a differentiated number of PNF sessions was established for certain postural disorders or their absence in patients with PD.

We believe that such differentiation of the effects of exposure is justified by the mechanism of various disorders in a particular postural deformity, on which the differentiated effects we propose, accordingly, have a pathogenetic effect.

In the process of rhythm therapy (RT), musical compositions with different rhythmic patterns are used. At the same time, when choosing the rhythm in classes and increasing its frequency, the patient's existing level of tolerance to physical activity, the patient's subjective assessment of his starting disorders (which environmental factors cause him to freeze), the number of falls per day and fear when walking are taken into account.

The first RT lesson begins in a sitting position on a chair to a musical composition with a rhythm of 41 beats per minute. Only one musical composition with this rhythm is used during the entire first lesson. During the second lesson, a new composition is used with an increase in rhythm by 5-7 beats per minute. At the same time, the correctness of the patient's performance of the task is assessed: if there are more than 10% errors in performing movements, then we return to the first musical composition with a rhythm of 41 beats per minute. If there are less than 10% errors, then after successfully completing the task, already in the same second lesson, the next musical composition from the list is used with a step of subsequent increase in rhythm by 5-7 beats per minute. If there are no errors at all, then during subsequent lessons you can choose musical compositions with a step of increasing the rhythm by 10-15 beats per minute for performing movements, and also use a step platform to perform movements and complicate them.

As a given name of a symbol of a specific movement in the process of its execution in a given musical rhythm, one can use short combinations of letters, memorization and rhythmic repetition of which in this case simultaneously trains, among other things, the cognitive function of attention, as well as clarity of speech. For example, when moving the left leg, the patient should pronounce "chick", with the right - "boom", when clapping the hands - "clap", etc.

As for the use of PNF, it is known for its use in the treatment and rehabilitation of PD (Adler S.S., Beckers D., Bak M. PNF in Practice, 4th ed., 2014, 2015, pp. 73-91, ch. 6. Basic procedures, [Electronic resource: https://vk.com/doc8830455_492721120?hash=590oopgrk7t3DAkpYdb8SKPyTZ4akThjvzuVuwuITzw&dl=ltc5ySuk4FJHyVZXVrcfcxOvvAzbCxxjnZPzNjlaG1T]; and also https://rehabscience.ru/pnf-obzor-metoda/). In this case, we have selected specific movements for a specific effect on postural deformities against the background of BP, which are performed using the known principles of PNF, to strengthen certain muscles and improve their function - muscles related to maintaining the correct posture of the patient. The patterns of the scapula and pelvis are carried out in two diagonals: anterior rise - posterior lowering and posterior rise - anterior lowering. The movement along the diagonals is an arch that repeats the curve of the patient's torso. When the scapula or pelvis moves within the diagonal, the patient does not fall forward or backward or rotate around one vertebral segment. Thus, an approximate pattern can be: pull the shoulder to the cheekbone - pull the scapula to the lower back - this is called the first diagonal, pull the scapula by the ear - to the navel - this is the second diagonal. Performed first on one side (all patterns), then on the other (see above: Adler S.S., Beckers D., Buck M. PNF in Practice, 4th ed., 2014, 2015, pp. 73-91, ch. 6. Basic procedures).

They also perform sequentially flexion-adduction-internal rotation of the hip, extension-abduction-external rotation of the hip.

Moreover, when performing each of the listed movements, the following PNF techniques are used sequentially (https://rehabscience.ru/pnf-obzor-metoda/): rhythmic initiation, dynamic reverse, stabilizing reverse.

Rhythmic initiation consists of 4 moments:

1. Passive movements to teach the patient a new movement so that he feels how his limb moves and with what force.

2. The patient’s assistance in our movement, i.e. he must help to perform a new movement that we teach him, and not perform it independently (active-passive movement).

3. Completely independent (active) movement. The main goal of this technique is motor learning.

4. Independent movement against the resistance of a specialist.

Dynamic reversal involves changing one movement pattern to the opposite one with resistance from the therapist without pause or relaxation.

Stabilizing reversal involves actively changing the position of the hands - grips with different directions of movement, while fixing the pattern in a certain position. The therapist resists isometric contraction of a group of agonist muscles. The patient maintains the position of the body part, trying not to move. The resistance is slowly increased as the patient makes an effort. When the patient reacts with the whole body, the therapist moves one hand to begin to resist the antagonistic movement. Example: forward lift - posterior lowering of the scapula. Initial position: the patient lies on his side, knees are brought to the stomach, the lower hand is under the ear, the upper hand is bent at the elbow, lies on the body.

The forward phase then begins: the patient performs an upward movement with the shoulder towards the cheekbone, with resistance from the therapist. This activates the muscles responsible for scapular protraction, such as the serratus anterior. The backward phase follows, with the therapist moving one hand towards the lower edge of the scapula (i.e. distally): the patient smoothly and continuously moves the scapula towards the lower back. This activates the muscles responsible for scapular retraction, such as the rhomboids and the middle part of the trapezius.

Then the alternation of movements occurs: the patient repeats the alternation of these two movements in a continuous and rhythmic tempo, it is important to maintain a smooth transition between protraction and retraction without stopping, the therapist must resist the direction in which the patient leads the scapula, not allowing it to relax. Breathing control: the patient should breathe evenly and rhythmically, synchronizing the breath with the movements. For example, inhale during protraction and exhale during retraction.

Neither the patient nor the therapist relaxes during the change of movement. The new resistance builds up slowly. When the patient responds, the therapist moves his other hand to also provide antagonistic resistance to the movement.

The PNF session is conducted for 30 minutes daily, with parallel implementation of other indicated effects of the complex in the number of sessions indicated for specific cases of the patient's postural deformities.

During the implementation of GCT, walking exercises in water with weights on the legs are performed in various directions randomly selected by the patient.

To train balance, in water, transfer weight from one leg to another, from heel to toe and back, stand on one leg for as long as possible, then on the other, first with open eyes, then with closed eyes, step over obstacles of different heights lying on the bottom of the pool. The lower the water level, the harder it is to perform the exercises, since the presence of the patient's body in water reduces the effect of gravity.

Exercises for coordination of limb movements include various exercises in which the upper and lower limbs are crossed across the sagittal plane of the body (for example, patting the right knee with the left hand and the left knee with the right hand, or grabbing the opposite heel from behind, turning the body, with or without the participation of the head (the head in the opposite direction from the turn of the body), touching the opposite side of the waist with the palm, etc.).

When performing exercises to strengthen the back muscles, dumbbells and water noodles are used.

As a set of exercises in water up to the level of the middle of the chest, you can use, for example, the following:

- IP standing, transfer body weight, alternating, to the right and left leg through return to IP, repeat 12 times;

- IP standing, support on the right leg, hands on the waist for 5 seconds, then the same for the left leg, repeat 12 times for each leg;

- IP standing, 1 kg dumbbells in hands, raising arms with dumbbells to the sides until horizontal (so that arms are under water), 10 times;

- IP standing, 1 kg dumbbells in hands, raising arms with dumbbells forward to horizontal, 10 times;

- IP standing, performing movements with the hands that imitate boxing, for 20 seconds, at the maximum frequency (speed) possible for the patient;

- IP standing, noodle in hands at chest level, push noodle forward (in water, i.e. under water) 8-10 times;

- IP lying on the water with your stomach down, holding onto the pool handrail with your hands, body position is straight, inhale - face above the water, then - face in the water, exhale into the water, simultaneously raising your legs up (arching your back), repeating the breathing cycle 8-10 times;

- IP standing facing the side of the pool, holding onto the handrail with your hands, alternately moving your straight legs to the sides, 8 times with each leg;

- IP lying on the water, noodle under the chest, imitation of the work of the legs when swimming crawl, 20 seconds;

- IP walking in the pool along the handrail (without support for the handrail) for 2 minutes, can be made more difficult by walking with weighted cuffs;

- IP standing, walking with stepping over a step platform under water, with weighted cuffs on the legs, it is necessary to overcome the obstacle 8 times with each leg.

On average, a lesson in water lasts 30 minutes. The course - depending on the presence or absence of a specific postural deformation against the background of BP.

In the process of occupational therapy, they generally train basic everyday activities - transfers within the bed and with different levels of body movements, eating, visiting the toilet, with training in the control of physiological functions, training in putting on different types of clothing and shoes, getting into a car. They also adapt the environment and personal items to the needs of a specific patient.

Conduct training:

- instrumental activities (writing, cooking, working on a computer, various ways of grasping objects),

- at the patient’s request - productive activities (caring for animals, helping family members, working for money and volunteering),

- at the patient’s request - a hobby (selection of a new hobby or adaptation of an existing one).

Each session can include training in different types of activities, taking into account the patient's wishes, and lasts approximately 30 minutes daily. The initial course takes 10 days, then independently, since the patient has already been trained and can apply the skills in life, without performing them as exercises.

The patient's mental counting during each lesson during training of movements and activities, facilitating the distribution of attention and shifting its emphasis, allows for the movements to gradually become automatic, while simultaneously training the attention function.

Occupational therapy exercises to improve hand function may include:

- buttoning and unbuttoning buttons on the ergo-apron;

- fastening zippers on trousers;

- eating with a weighted spoon;

- working with kitchen utensils - an adaptive or regular knife and cutting board, using a whisk, spoon or fork to stir food;

- transfer of small objects using 10 different methods of grasping the patient's hand;

- adaptation (lengthening) of the toothbrush for independent tooth brushing by the patient;

- adaptation of the comb by lengthening the handle.

Before starting any type of activity, the patient is asked to perform 3-5 high-amplitude arm and/or leg swings to train the muscles and relieve muscle tension. Such fast, explosive movements are aimed at eliminating one of the four main motor symptoms in PD, such as bradykinesia, hypokinesia, muscle rigidity, and tremor at rest.

Classic medical massage of the back muscles, cervical spine and posterior spinal column is usually performed at the end of the entire complex of actions: 10 minutes each for massage of the back, cervical spine and posterior spinal column. The course is 12 days. Classic techniques are used - stroking, rubbing, kneading and vibration, aimed at improving the functions of the muscles responsible for maintaining a person's vertical posture, taking into account the tone level of specific muscles.

The entire primary rehabilitation course in the form of a complex of all the above-mentioned effects lasts 12 days. At the same time, patients are recommended to continue performing RT exercises according to R. Gardiner (if they are indicated given the presence of certain postural deformities in the patient) and occupational therapy (see above, item 1) at home, which is supportive for long-term preservation of the effects obtained during the direct rehabilitation course.

Thus, using the listed therapeutic and rehabilitation effects, the technology of specific, differentiated sensorimotor training, correction in PD is implemented. Such correction can be called sensorimotor because both the patient's sensory channels of perception (rhythm, postural functions, vision, kinesthetics, etc.) and purely motor functions (training of movements, coordination, walking, everyday motor acts) are involved and trained.

To evaluate the results of the work carried out, 6 groups were formed: 5 main groups (according to the number of combinations of differentiated effects proposed by us in the invention formula for specific syndromes of patients: in the presence of captocormia, the "Leaning Tower of Pisa" syndrome, latero- or anterocollis and without postural deformities) and one comparison group (patients received all of the listed effects in a total course of 10 daily sessions for each effect).

The immediate, upon completion of the course, and remote, 4 months after its completion, results of the effectiveness of the developed technology were assessed based on the results of testing the functional independence and activity of daily life of patients.

The following research methods were used before, after and 4 months after the end of the 12-day course:

1. Functional testing:

- stabilometry using the COBS complex (PHYSIOMED Elektromedizin AG, Germany);

- analysis of gait and movement coordination using the augmented virtual reality C-Mill VR+ (Motek, Netherlands);

2. General clinical and instrumental methods:

- computer optical topography on the Biokinect® Bodyscanner 3D complex (Neurocor, Russia);

3. Assessment of cognitive functions using the MoCA scale.

4. Assessment of quality of life and functional independence:

- Functional Independence Test (FIM);

- Rivermead Activities of Daily Living Scale (S. Whiting, N. Lincoln, 1980; D. Wade, 1992);

- quality of life questionnaire EQ-5D-3L;

- diary of falls.

In the framework of an open prospective controlled study, at the time of application, 70 people with PD (men and women) with stages 2-4 according to the classification of Hoehn and Yahr (1967) were examined, all study participants received levodopa drugs in an individual dosage selected by a neurologist-Parkinsonologist; 50 patients had separate various postural deformities - anterocollis, laterocollis, camptocormia, the "Leaning Tower of Pisa" symptom, 10 patients had no postural deformities.

All subjects were divided into corresponding main groups of 10 people, and a comparison group of 20 people (with or without various postural deformities).

Inclusion criteria for the groups: voluntary informed consent of individuals with PD to participate in the study; age from 45 to 75 years, stage 2-4 PD according to Hoehn-Yahr, absence of other neurological, orthopedic and oncological diseases, absence of severe cognitive impairment.

Criteria for exclusion from the study:

- age under 45 and over 75 years;

- persons suffering from mental disorders;

- refusal to sign informed consent to participate in the study;

- all diseases, including infectious ones, in the acute stage, chronic diseases in the acute stage, other neurological diseases.

Criteria for exclusion of patients from the study:

- voluntary refusal of the patient to participate in the program;

- failure of the patient to comply with the study protocol;

- development of severe adverse reactions or severe diseases/conditions not related to treatment, requiring discontinuation of therapy;

- development during treatment of conditions associated with exclusion criteria that were not present at the time of inclusion in the study.

Patients of the main groups received the entire proposed complex of interventions specified in the formula of the invention for differentiated correction of the corresponding postural deformity or in its absence against the background of PD.

20 patients in the comparison group received all of the above treatments for 10 days (occupational therapy, classical back massage, cerebral cortex and cerebral cortex, gastroenterology, neurophysiology, and RT according to Gardiner).

Statistical processing of the results was carried out in Microsoft Statistica 11.0, using nonparametric criteria (analysis of normal distribution was not carried out).

Using the above-listed clinical research methods, it was found that only in patients of the five main groups it was possible to statistically significantly (p<0.05) correct (reduce) all existing postural deformities (if any), overcome pain syndromes in the back, neck and lower back, starting disorders (disorders at the beginning of movements), improve attention function (according to the MoCA scale), including in the group with no postural deformities in patients. Moreover, during the control examination after 4 months, the achieved results (provided that the patients continued to independently perform occupational therapy exercises) were maintained in all main groups.

At the same time, in the comparison group, even though all the above-mentioned effects were carried out in a larger number of course sessions, the results were not so complete. Thus, according to the control stabilometry data and the study on C-Mill VR+, postural disorders became statistically significantly less pronounced only in 5 people (25%), while pain syndromes in the cervical spine and posterior spinal column remained, there were no significant improvements according to the results of the Rivermead and MoCA scales of activities of daily living. We believe that such results are, among other things, due to the lack of a differentiated approach to the selection of more narrowly targeted effects depending on the specific syndromes present in the patient.

Improvements in stabilometry and C-Mill VR+ testing were observed in only half of the patients in this group.

In addition, after 4 months from the end of the course, the comparison group showed a return of a number of postural deformities and a decrease in the indicators of postural functions according to stabilometry and C-Mill VR+ testing, which was not observed in patients in the main groups.

Thus, we believe that it is the proposed complex of differentiated physical effects depending on the presence or absence of certain postural deformities that promotes sensorimotor correction of patients with PD, including specific training of both elementary movements, walking, and directly postural functions, with simultaneous training of attention and speech of patients and their adaptation to direct basic movements of everyday life, allowing to maintain the achieved results, subject to regular training over a number of months without repeating the rehabilitation course.

The implementation of the developed technology is not burdensome in implementation and involves the use of music, various visual reference points and everyday objects adapted by the occupational therapist. All this allows us to recommend the developed technology for wide application in various medical and preventive institutions of the neurological profile, including in the conditions of sanatorium-resort treatment and home rehabilitation of persons with PD.

Clinical example.

Patient I., 60 years old. Primary diagnosis: Parkinson's disease, stage 3, has been suffering from it for 4 years. There is postural deformity (camptocormia), muscle tone and tendon reflex disorders, gait, slurred speech, difficulties with eating, writing, dressing, pain in the cervical spine. Notes falls due to loss of balance during the day - 3-4 falls. Concomitant diseases: coronary heart disease, hypertension stage 1, chronic gastritis outside of exacerbation, osteochondrosis of the cervicothoracic spine.

Against the background of appropriate drug therapy (levodopa and drugs indicated for cardiovascular status), a course of treatment was administered according to the proposed method in the main group of patients (group (A) according to the formula of the invention):

1) occupational therapy in the form of 10 daily 30-minute sessions on training in buttoning and unbuttoning buttons and zippers, preparing and eating food using adapted cutlery, independently brushing teeth and combing hair, writing with the dominant hand, working at the computer keyboard, methods of grasping objects with one and the other hand, while during the sessions, simultaneously with performing movements, the patient did mental arithmetic at a pace comfortable for him to train his attention.

2) 12 daily sessions of classical medical massage of the back muscles, cervical spine and pelvic floor muscles, with a total duration of 30 minutes for each session.

3) 8 daily rhythm therapy sessions based on the Ronnie Gardiner method, during which the patient was shown conventional symbols-designations of the upper and lower extremities of the left and right sides of the body, stimulating him to perform a sequence of given movements in a given direction: steps while sitting and standing, dance steps, clapping hands,

and while performing a given movement, the patient pronounced the given name of the symbol of this movement in a given musical rhythm.

4) 4 daily hydrokinesitherapy (HKT) sessions for 30 minutes at a water temperature in the pool of 28-30°C, in the form of performing the following exercises in water:

- walking in water with weights on your feet,

- balance exercises - weight transfer, standing on one leg with eyes open and closed, stepping over an obstacle at the bottom,

- exercises for coordination of limb movements,

- exercises to strengthen the back muscles using dumbbells and water noodles,

- free swimming.

After completing the course, the patient also continued independent ergotraining.

Rhythmotherapy was performed in the form of performing a sequence of movements to the right, then to the left: rhythmic steps (stepping over with the whole foot) while sitting on a chair and from a standing position, dance steps (mambo, pivot, V-step), clapping (left palm on the right, right palm on the left), while the patient pronounced aloud the given name of the symbol of a specific movement in the process of its execution in a given rhythm: for each movement with the left leg - "chick", right - "boom", clapping the palm - "clap", with the left hand - "chuck", with the right hand - "bang".

Before the start of the session, the patient's heart rate was 72 bpm; the musical accompaniment was the Carpenters' Close to You, with a rhythm frequency (percussion notes) of 41. For subsequent sessions, a musical composition was used, initially with the same percussion rhythm, then later selecting faster ones (increasing the rhythm in increments of 5-7 beats): Jason Mraz - Have It All, Lucky; Fool's Garden - Lemon Tree (see Fig. 1 with examples of the proposed musical compositions with the corresponding percussion rhythm).

Hydrokinesitherapy was carried out daily at a water temperature in the pool of 28-30°C (it varied from lesson to lesson within this range), with a lesson duration of 30 minutes.

Classes using PNF techniques were conducted in accordance with the invention formula.

The sequence of individual sessions with different effects was randomized daily.

The results were relief of cervical pain syndrome, elimination of camptocormia, improvement of stabilometry indices and C-Mill VR+ examination results. Similarly, indices on the MoCA, FIM scales, Rivermead scale of activities of daily living, EQ-5D-3L quality of life questionnaire significantly improved. The patient notes the ease of performing a number of daily household activities.

The number of falls, according to the diary, has decreased - 0-1 per day.

During the follow-up examination (the patient continued independent occupational therapy sessions for 4 months), the achieved results of sensorimotor correction were maintained. There was no deterioration.

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Claims (43)

A method of differentiated sensorimotor correction in Parkinson's disease, including a complex of therapeutic and rehabilitation physical and educational effects on the patient, characterized in that a basic complex of sensorimotor correction is carried out, which includes the following individual daily effects, performed in a random sequence: 1) occupational therapy in the form of 10 daily 30-minute sessions on training in buttoning and unbuttoning buttons and zippers, preparing and eating food using adapted cutlery, independently brushing and combing teeth, writing with the dominant hand, working at the computer keyboard, methods of grasping objects with one and the other hand, while during the sessions, simultaneously with performing movements, the patient does mental arithmetic at a pace that is comfortable for him; 2) 12 daily sessions of classical medical massage of the back muscles, cervical-collar zone (CCS) and lumbosacral spine (LSS), with a total duration of each session of 30 minutes; and if the patient has postural deformities against the background of Parkinson's disease, the basic sensorimotor correction complex is supplemented with the following interventions, taking into account the type of postural deformity in the patient: A) during camptocormia the following is performed : i) 8 daily sessions of rhythm therapy (RT) based on the Ronnie Gardiner method, in which the patient is shown conventional symbols-designations of the upper and lower extremities of the left and right sides of the body, stimulating him to perform a sequence of given movements in a given direction: steps while sitting and standing, dance steps, clapping hands, and when performing a given movement, the patient pronounces the given name of the symbol of this movement in a given musical rhythm, ii) 4 daily sessions of hydrokinesitherapy (HKT) for 30 minutes at a water temperature in the pool of 28-30°C in the form of performing the following exercises in water: - walking in water with weights on your feet, - balance exercises - weight transfer, standing on one leg with eyes open and closed, stepping over an obstacle at the bottom, - exercises for coordination of limb movements, - exercises to strengthen the back muscles using dumbbells and water noodles, - free swimming; B) in case of the "Leaning Tower of Pisa" syndrome, the following is performed : i) 5 daily sessions of proprioceptive neuromuscular facilitation (PNF) for 30 minutes to perform the following movements at a pace comfortable for the patient: - anterior and posterior lifting and lowering of the scapula, - anterior and posterior lifting and lowering of the pelvis, - sequential flexion-adduction-internal rotation of the hip, - sequential extension-abduction-external rotation of the hip, in this case, each movement is carried out using the following PNF techniques: rhythmic initiation, dynamic reverse, stabilizing reverse; ii) 5 daily GCT sessions of 30 minutes each at a pool water temperature of 28-30°C in the form of performing the above-mentioned exercises in water; B) in the presence of laterocollis, the following is performed : i) 6 daily PNF sessions of 30 minutes each performing the following movements at a pace comfortable for the patient: - anterior and posterior lifting and lowering of the scapula, - anterior and posterior lifting and lowering of the pelvis, - sequential flexion-adduction-internal rotation of the hip, - sequential extension-abduction-external rotation of the hip, in this case, each movement is carried out using the following PNF techniques: rhythmic initiation, dynamic reverse, stabilizing reverse; ii) 6 daily GCT sessions of 30 minutes each at a pool water temperature of 28-30°C in the form of performing the above-mentioned exercises in water; D) in the presence of anterocollis, the following is performed : i) 4 daily PNF sessions of 30 minutes each performing the following movements at a pace comfortable for the patient: - anterior and posterior lifting and lowering of the scapula, - anterior and posterior lifting and lowering of the pelvis, - sequential flexion-adduction-internal rotation of the hip, - sequential extension-abduction-external rotation of the hip, in this case, each movement is carried out using the following PNF techniques: rhythmic initiation, dynamic reverse, stabilizing reverse; ii) 4 daily GCT sessions of 30 minutes each at a pool water temperature of 28-30°C in the form of performing the above-mentioned exercises in water, iii) 4 daily RT sessions according to the Ronnie Gardiner method for 30 minutes each day, during which the patient is shown conventional symbols-designations of the upper and lower extremities of the left and right sides of the body, stimulating him to perform a sequence of given movements in a given direction: steps while sitting and standing, dance steps, clapping hands, and when performing a given movement, the patient pronounces the given name of the symbol of this movement in a given musical rhythm, and if the patient does not have the listed postural deformities against the background of Parkinson's disease, in addition to the basic course of correction, the following is carried out: i) 9 daily RT sessions according to the Ronnie Gardiner method for 30 minutes, during which the patient is shown conventional symbols-designations of the upper and lower extremities of the left and right sides of the body, stimulating him to perform a sequence of given movements in a given direction: steps while sitting and standing, dance steps, clapping hands in a given musical rhythm, and when performing a given movement, the patient pronounces the given name of the symbol of this movement, ii) 3 GCT sessions of 30 minutes each at a pool water temperature of 28-30°C in the form of performing the above-mentioned exercises in water.