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Восстановление пациентов проходит при помощи разработанного аппаратно-программного лечебно-диагностического комплекса «Вертикаль», сочетающего кровать-тренажер с возможностью поэтапной вертикализации пациента и оборудованный электродвигателями для осуществления пассивного или активного сгибания-разгибания ног в коленных суставах в различных режимах, одновременно включая функциональную мионейростимуляцию.
Нейрореабилитация пациентов, перенесших мозговой инсульт, черепно-мозговую травму, травму с повреждением спинного мозга складывается из трех этапов. В результате проведенных исследований установлено, что ранняя реабилитация с использованием комплекса «Вертикаль» в сочетании с методом ФЭС имеет значительные преимущества перед ЛФК и электростимуляции в покое, благодаря высокой избирательности, точности воздействия и эффектам быстрого восстановления координации движений. В целом сроки реабилитации на этом этапе могут быть сокращены в 2 раза.
Данный комплекс включен в стандарты высокотехнологичных методов лечения в России –«Функциональная мионейростимуляция с последующей вертикализацией»(№А.17.02.002) На IX международном салоне промышленной собственности «Архимед-2006» данный комплекс был награжден золотой медалью.(Патент на изобретение №2352316 Устройство для восстановления функции нижних конечностей от 20 апреля 2009 г.)
THE STEP-BY-STEP REHABILITATION PROGRAMM OF PATIENTS AFTER STROKE.
The major goal of neurological rehabilitation is restoration of mobility. For the long period the problem of the restoration of lost motor functions in patients because of an acute disorder of the cerebral circulation (stroke) was treated by therapeutic exercises, physiotherapy. This program is successfully used in neurological and rehabilitation department.
Neurological rehabilitation of patients after stroke consists of three stages. The first stage begins in the intensive care department. This stage starts directly when the acute period of stroke is over when the main parameters of hemodynamics (arterial pressure, pulse rate, consciousness) return to normal. Therapeutic exercises and gymnastics are widely applied during this period. The next stage begins when a patient goes to the neurological department of hospital. The unique program of medical rehabilitation for these patients was created by a group of scientist of the Central clinical hospital of Russian Academy of Sciences. The main goals of this stage are:
- To restore functional activity of the remaining motoneurones and assist the functional reorganization of brain structures
- to increase force of affected muscles
- to reduce affected muscles spasticity
- prophylaxis of contraction of affected extremities’ joints
- to prepare the body for an upright position
For the early of activation of the processes of brain connections reorganization as a result injury of central nervous system it is needed to use abilities of the functional electrical stimulation (FES). Besides a new locomotor stereotype often occurred during walking in the condition of significant muscle forces deficit. This stereotype is different from one of healthy people and it sticks to a patient and can hardly be corrected. The course of FES should be applied before walking in upright position. This course is aimed at muscle reinforcement and formation of a correct walking pattern. Such training must begin in supine position and should be combined with the gradual patient verticalization.
For these purposes the hardware-based-programmed complex “Vertical” for treatment and diagnostics was designed and constructed in our hospital. The method of using this complex in rehabilitation was also created. Complex “Vertical” was included in to the standards of advanced technology methods of treatment in Russia (№А.17.02.002). It was awarded with a gold medal in the IX International salon of industrial property “Archimed-2006”.
The hardware-based-programmed complex “Vertical” for treatment and diagnostics includes a functional bed-trainer, which is equipped with drivers for leg movements and can be turned 30 degrees to the horizontal plane. Phase-dependent functional electrical stimulation is used for restoration of functions of affected muscles. The leg and trunk muscles are stimulated simultaneously. Depending on the parameters of FES stimulation can result in muscle strengthening, muscle relaxing or anesthetization. According to FES the process of restoration of muscle functions is directed not on a separate muscle but on a combined functionally-coordinated act of movements (walking) in repeated sessions. Functional electrical stimulation improves motor recovery of the lower extremity, improves functional state of muscles and contributes to a formed the correct locomotor pattern. Training begins with passive walking in the supine position with the help of electro-drivers and at a later time gradually changing to the semi-passive and active movements. Gradual verticalization of a patient during treatment is achieved with the help of inclination of a bed-trainer. At the same time a patient imitates walking movements on the spot. The duration of the procedure is one hour and the course of the first stage consists of 15-20 procedures.
The absolute contra-indications for the rehabilitation on the complex “Vertical” are the following:
non-malignant and malignant neoplasms,
intolerance to electric currant,
cardiovascular system diseases in the stage of decompensation
thrombosis in an acute period,
skin injuries or diseases in the place where electrode is applied,
The relative contra-indications for the rehabilitation on the complex “Vertical” are diseases, which are accompanied by high temperature or inflammatory blood changes
- an acute disorder of the cerebral circulation (stroke) with the hemiparesis of different degree of intensity in sub-acute period.
-residual stroke effects with the hemiparesis of different degree of intensity.
-peripheral paresis of different etiologies (polyneuropathy )
-consequences of cerebral spastic infantile paralysis,
-correction of locomotor pattern at Parkinson disease
The second stage of treatment is carried out during the earlier rehabilitation period in the rehabilitation department.
The main targets of this stage are:
- to restore of functional activity of remaining motoneurones and assist the functional reorganization of brain structures
- to reduce affected muscles spasticity
- to restore force of affected muscles, and assist a patient to be able of control for these muscles
- to help a patient to learn a correct upright posture and correct locomotor pattern
Depending on patient’s state and the degree of extremity paresis the treadmill training with a partial body-weight support (Biodex Medical Systems, USA) is used for the learning of correct gait pattern during the second stage of rehabilitation. In several cases a patient can be trained on treadmill independently of body-weight support, using only parallel bars hand-rail. During such training patient is learning correct, rational movements. All these procedures assist functional electrical stimulation of leg and trunk muscles as well. A special individual costume was designed for the convenient imposition and fixing of electrodes and switches on a patient’s body. The procedure lasts for one hour (including putting on a special costume) and the course of the second stage of treatment is 15-20 procedures.
Two modifications of mioneurostimulator were developed by a group scientist of Central clinical hospital of Russian Academy of Sciences. This is a 16-channel stimulator (MNS-16М) and 8-channel stimulator (МNS-8). Both mioneurostimulators are portable and accumulator powered. The mass of MNS-16М is approximately 0,5 kg, the mass of MNS-8 is 0,2 kg. Stimulators are supplied with microprocessor and radio-channel for connection with controller computer. The controller computer is applied for the stimulation parameters initial set-up by orders a doctor, for an influence level fitting and for a control of stimulation process. After this a stimulator is worked independently and it is not needed of computer соntrol.
The main targets of the third stage are:
- to keep and further strengthen a force of muscles
- further reduce affected muscles spasticity
- to correct locomotor pattern
When the second rehabilitation period is over a treatment can be continued at home. It is also concerned to a patient, which has different difficulties to come to a hospital. For these purposes a stimulator can write of individual set-ups in a memory. Thus, a stimulator becomes an individual device and it can be used to a patient without assistance. The stimulator is accumulator powered, it sizes are small: 150mm х 70mm х 25mm and it weight is 300-400g. Doctors of rehabilitation department adjust a stimulation costume to a patient and learn for a patient to use stimulator correctly.
Thus, the step-by-step program of medical rehabilitation for patients after stroke and coordinated doctors’ work allow to reduce rehabilitation period, to achieve a better effect, as compared to standard rehabilitation methods, and to sustain this effect by stimulation at home. It has found that a early rehabilitation with using the complex “Vertical” and functional electrical stimulation have significant advantages to therapeutic exercises, gymnastics and electrostimulation at rest condition. It was due to a high accuracy influence and due to effects of faster restoration of movement coordination. As a whole rehabilitation time could be reduced in two times.