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WO2021118382A1 - Procédé d'augmentation de l'efficience d'une réhabilitation consécutive à des troubles moteurs dans la main suite à un avc - Google Patents

Procédé d'augmentation de l'efficience d'une réhabilitation consécutive à des troubles moteurs dans la main suite à un avc Download PDF

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Publication number
WO2021118382A1
WO2021118382A1 PCT/RU2019/000915 RU2019000915W WO2021118382A1 WO 2021118382 A1 WO2021118382 A1 WO 2021118382A1 RU 2019000915 W RU2019000915 W RU 2019000915W WO 2021118382 A1 WO2021118382 A1 WO 2021118382A1
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Prior art keywords
muscle
stimulation
motor
stroke
movement
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PCT/RU2019/000915
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English (en)
Russian (ru)
Inventor
Илья Сергеевич БАКУЛИН
Александра Георгиевна ПОЙДАШЕВА
Антон Сергеевич КЛОЧКОВ
Анастасия Евгеньевна ХИЖНИКОВА
Наталья Александровна СУПОНЕВА
Михаил Александрович ПИРАДОВ
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Federalnoe Gosudarstvennoe Biudzhetnoe Nauchnoe Uchrezhdenie "nauchnyi Tsentr Nevrologii"
Obshchestvo S Ogranichennoj Otvetstvennost'yu "nejrobotiks"
Original Assignee
Federalnoe Gosudarstvennoe Biudzhetnoe Nauchnoe Uchrezhdenie "nauchnyi Tsentr Nevrologii"
Obshchestvo S Ogranichennoj Otvetstvennost'yu "nejrobotiks"
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Priority to PCT/RU2019/000915 priority Critical patent/WO2021118382A1/fr
Publication of WO2021118382A1 publication Critical patent/WO2021118382A1/fr
Anticipated expiration legal-status Critical
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/20—Applying electric currents by contact electrodes continuous direct currents
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation

Definitions

  • the invention relates to medicine, namely to methods of rehabilitation of patients who have suffered a stroke.
  • Stroke is the most important medical and social problem around the world [1]. Stroke is characterized, on the one hand, by high mortality, and on the other, by the persistence of residual neurological deficit in the majority of surviving patients, which is the cause of disability after the end of the acute period [2]. Stroke occurs in about 16.9 million people worldwide every year [3]. According to the official statistics of the Ministry of Health, 428,053 cases of stroke were registered in the Russian Federation in 2017, the incidence was 291.55 per 100,000 population [4]. Hand dysfunctions in patients with stroke are detected with a frequency of up to 80% and are one of the most significant factors in the decline in the quality of life, disturbances in everyday and social adaptation [5]. Improving rehabilitation methods for patients with post-stroke movement disorders is the most important direction in reducing the social and economic burden of stroke [6,
  • the main and most common method of EFT is transcranial direct current stimulation (tDCS).
  • TPP transcranial direct current stimulation
  • the device for TPP includes a generator and two electrodes. Typically, a current strength of 0.5 to 2 mA and a stimulation duration of 10 to 30 minutes are used [17].
  • tDCS With tDCS, one of the electrodes is the anode and the other is the cathode. Experimental studies have shown that tDCS causes a subthreshold change in the membrane potential, which, in turn, leads to a change in the excitability of neurons, depending on the polarity of the stimulating electrode [17-20].
  • an incoming (towards the electrode) current is generated in the nerve tissue, which causes a displacement of the membrane potential in the positive direction - depolarization of the membrane, which facilitates (makes more likely) the formation of adhesions.
  • TMS transcranial magnetic stimulation
  • non-invasive brain stimulation to improve hand function in stroke is based on modern concepts of the structural and functional reorganization of the motor system caused by its unilateral damage.
  • restoration of impaired functions occurs primarily due to a decrease in cerebral edema and regression of inflammatory changes.
  • neuroplasticity processes are of the greatest importance, providing functional reorganization of cortical motor areas with recruitment to perform the function of preserved neurons in the perifocal region of the affected hemisphere and / or homologous pathways and areas of the unaffected hemisphere [22-24].
  • These processes lead to complex and insufficiently unexplored changes in interhemispheric interactions. It is the modulation of interhemispheric interactions with the induction of neuroplastic changes that is the main point of application for a number of modern methods of neurorehabilitation, including EFT [22].
  • tDCS When tDCS is used in combination with motor rehabilitation methods, it is extremely important to have a definite optimal temporal pattern of such a combination.
  • tDCS can be used before motor training (as a priming, to prepare for training), during or after motor training [34].
  • Studies on healthy volunteers have shown that only when conducting anodic tDCS before simple motor training (but not during and after) a statistically significant increase in the excitability of the motor cortex of the stimulated hemisphere is revealed [34].
  • stroke it has been shown that an improvement in the performance of a motor task is observed during anodic tDCS before robotic arm mechanotherapy, but not during or after [35].
  • the muscles of the paretic limbs can be contracted by applying an electric current, by direct action on the intact peripheral nerves that innervate these muscles, as well as in the projection area of the motor point of the stimulated muscle.
  • NMES neuromuscular electrical stimulation
  • FES functional electrical stimulation
  • FES - a method that uses a course therapy with electric current impulses to induce a specific pattern of muscle contractions and movements necessary to perform a specific function; muscles are activated as a result of stimulation of the motor point of the muscle, electrical stimulation is combined with the performance of targeted exercises [37].
  • FES has proven itself well as an independent technique for restoring the motor function of the lower limb [38-40].
  • Several studies have shown the effectiveness of the use of FES for restoring the motor function of the hand [41-44].
  • NMES of the flexors and extensors of the wrist and fingers is proposed as an adjuvant method for use in patients with a stroke duration of up to 6 months.
  • Strength of recommendation B reliability of evidence - 2a.
  • a recently published systematic review has shown the effectiveness of FES in the upper limb in relation to patient activity in daily life [45].
  • the technical result of the claimed solution is to increase the efficiency of normalizing the kinematic portrait of the paretic hand by selectively correcting the motor synergy of target muscles by the FES method, synchronized by EMG and directed modulation of the excitability of the motor cortex using TES of the brain.
  • the claimed technical result is achieved by implementing a method for the rehabilitation of movement disorders in the arm in patients who have suffered a stroke, including the stages at which TES of the brain is carried out with a direct current of 2 mA, no more than 15 minutes after TES of the brain, functional electrostimulation of the target muscle is carried out when performing a patient of cyclic movement using a FES trigger as an EMG muscle, which is a synergist of the performed cyclic movement, while the EMG trigger electrode is attached outside the area of muscle activity, functional electrical stimulation is carried out with a pulse current with a pulse duration of 1-3 ms and a pulse amplitude of up to 30 mA, a stimulation frequency 25-30 Hz for inducing tetanic contractions of skeletal muscles or 50-100 Hz for skeletal muscle spasm or 1-10 Hz for toning effect on muscles, while the delay time between fixation of the signal from the trigger electrode and stimulation of the target muscle is 50-900 ms.
  • rehabilitation is carried out in courses consisting of 5-10 sessions.
  • the TPP is carried out for 18-22 minutes.
  • training with FES is carried out for 10-30 minutes.
  • TPP is carried out using one of the protocols: anodic TPP of the primary motor cortex of the affected hemisphere, cathodic TPP of the primary motor cortex of the unaffected hemisphere bilateral (simultaneously anodic TPP of the primary motor cortex of the affected hemisphere and cathodic TPP of the primary motor cortex of the unaffected hemisphere).
  • the stimulation is carried out in a sitting or reclining position on the back on a special chair.
  • the cyclic movement is the achievement of a remotely located object of a spherical or cylindrical shape, followed by its capture by extension and flexion of the wrist joint and / or fingers
  • the cyclic movement is the achievement of a remotely located object by bringing and flexing the arm at the shoulder joint and extending the arm at the elbow joint.
  • the stimulating electrode is located on the muscle, which is responsible for the cyclic movement
  • the trigger electrode is located on the muscle, which is the main one during synergistic movement
  • the fixation of the EMG signal from it indicates the occurrence of pathological synergy.
  • the patented technique makes it possible to reprogram pathological motor patterns at the peripheral level with an enhancement of the effect due to the directed modulation of the excitability of the motor cortex using TES.
  • an increase in the efficiency of normalization of the motor kinematic portrait in the paretic hand is achieved.
  • the use of modern devices for conducting FES and TES with a friendly interface and intuitive software, will contribute to the successful interaction of the patient and the therapist.
  • FIG. 1 Protocol parameters for bilateral stimulation of the primary motor cortex of the affected and unaffected hemispheres in right-sided post-stroke paresis.
  • FIG. 2 Parameters of the protocol for cathodic stimulation of the primary motor cortex of the unaffected hemisphere in right-sided post-stroke paresis.
  • FIG. 3 Diagram of the sequence of the execution of movements when training a ball grip.
  • FIG. 4 Diagram of the sequence of movements during the training of a cylindrical grip.
  • a device for transcranial electrostimulation of the brain developed within the framework of the project "Development of a new generation of assistive devices and technical means of rehabilitation using neurotechnologies to improve the effectiveness of treatment and rehabilitation, as well as improve the quality of life of people," LLC “Neurobotics", Moscow, Zelenograd).
  • a special feature of the device is the ability to graphically and quantitatively control impedance and current distribution during stimulation.
  • Stimulation mode DC (direct current, constant current stimulation, “soft” current ramp mode).
  • FIG. Tables 1 and 2 show examples of the settings for the stimulation protocol in the electrostimulator control program for right-sided hemiparesis (lesion of the left hemisphere).
  • Table 1 Location of electrodes for different types of stimulation depending on the side of the lesion in patients with post-stroke paresis
  • Stimulation is carried out in a sitting or reclining position on the back on a special chair. It is necessary to create the most comfortable conditions for the patient. It is possible to use a pillow or roller. It is recommended to avoid sudden movements of the patient's head due to the risk of displacement of the electrodes.
  • the blind envelope method was randomized into one of four groups.
  • Group S - sham-stimulation (simulated stimulation; the position of the electrodes is the same as for anodic tDCS, however, real stimulation is carried out only during the first and last 30 seconds of a 20-minute session).
  • the intensity of stimulation is 2 mA
  • the duration of one session is 20 minutes.
  • Reusable CS22 electrodes made of Ag / AgCl composite 22 mm in diameter were used for stimulation.
  • the current density was 0.53 mA / cm 2 (5.3 A / m 2 ).
  • the “soft” mode was used with a 30-second rise and fall of the current value at the beginning and end of the session, respectively.
  • the groups did not differ statistically significantly in terms of age, duration of cerebral impairment.
  • p 0.07; Kruskal-Wallis test.
  • FES is carried out immediately after tDCS.
  • the maximum time interval between procedures should be no more than 15 minutes.
  • Disposable adhesive electrodes with a push-button connector are used for muscle stimulation and EMG. Any muscle that is a synergist of the cyclic movement performed can be used as an EMG trigger of FES.
  • EMG EMG trigger of FES.
  • the "Muscle Stimulator" module the possibility of simultaneous registration of two EMG channels is available, each of which can serve as a FES trigger. To ensure the most accurate EMG registration, it is necessary to attach an additional reference electrode outside the area of muscle activity. Before training with the Muscle Stimulator, it is necessary to determine the target muscles for stimulation, as well as the muscle used as an EMG trigger for stimulation. Depending on the time parameters of activation of the trigger muscle, it is subsequently performed software adjustment of the stimulation delay to ensure the most accurate synchronization of the FES.
  • the EMG After fixing the EMG electrodes and stimulation, the EMG is calibrated, for this the subject is instructed to "relax the hand", and then press the button
  • the EMG window of the Muscle Stimulator software displays the intensity of the electromyogram of each channel in real time.
  • the maximum intensity indicator of the recorded EMG corresponds to an amplitude of 500 ⁇ V, which also corresponds to the maximum displayed intensity of 100%.
  • the selection of stimulation parameters includes the choice of parameters of a single pulse (pulse shape, pulse amplitude, pulse duration, delay duration) and parameters of a single pulse (stimulation frequency, stimulation duration, trigger delay, delay after)
  • Pulse shape For electrostimulation of the motor apparatus, impulses of various shapes are used. According to the research of G.F. Kolesnikov, V.I. Kiy, A.A. Pavlenko (1963), the optimal signals, in which the muscles contracted almost painlessly, are sharp-pointed impulses filled with a sinusoidal or rectangular signal.
  • Pulse amplitude The amplitude most used for electrical stimulation does not exceed 100 mA. For training, it is recommended, by gradually increasing, to select the most comfortable pulse amplitude for the patient, at which active muscle contraction will be observed (up to 30 mA).
  • Stimulation frequency Frequency response of stimulation should be selected
  • a pulse current with a frequency of 25-30 Hz has an exciting effect on motor nerves and causes tetanic contractions of skeletal muscles; pulse current with a frequency of 50-100 Hz causes skeletal muscle spasm; impulse current with a frequency of 1-10 Hz causes "muscle gymnastics", which has a tonic effect on the muscles and can be used for spasticity.
  • Duration of stimulation When choosing a pulse duration, it should be borne in mind that a stimulating pulse duration of less than 1 ms may not be sufficient to completely cover all muscle fibers by excitation, and a pulse duration of more than 3 ms is energetically disadvantageous and not physiologically justified.
  • the duration of the impulse should be selected in such a way that the excitation has time to cover all muscle fibers of the target muscle.
  • Trigger delay It is set individually, depending on the timing of activation of the trigger muscle and the stimulated muscle during the physiological performance of the trained movement.
  • the training program, target and trigger muscle groups are determined by the severity of paresis and the degree of spasticity in the paretic muscles of the arm according to the Fugle-Meier, ARAT and Ashworth clinical scales.
  • the first training protocol is recommended for use in the following patients: motor deficit in the paretic arm according to the Fugle-Meier scale from 57 to 65 points, which corresponds to mild impairment of motor function; motor deficit in the hand on the ARAT scale from 51 to 57 points, which corresponds to mild fine motor impairment; spasticity according to the Ashworth scale: in the flexor muscles of the wrist joint and hand - 0-1 points, in the flexor muscles of the elbow joint - 0-1 points.
  • the second training protocol is recommended for use in the following patients: motor deficit in the paretic arm according to the Fugle-Meier scale from 47 to 56 points, which corresponds to moderate impairment of motor function; motor deficit in the hand on the ARAT scale from 41 to 50 points, which corresponds to moderate impairment of fine motor skills; spasticity on the Ashworth scale: in the flexor muscles of the wrist joint and hand - 0-1 points, in the flexor muscles of the elbow joint - 0-1 points)
  • Target muscle groups m. extensor digitorum superficialis, m. flexor digitonun communis.
  • the training is aimed at correcting the pathological stereotype in the hand, increasing functionality, increasing the grip strength and range of motion in the fingers of the hand.
  • Stage 1 (1-5 days of training !.
  • Target muscle group m. extensor digitorum superficialis
  • Trigger muscle T. deltoideus anterior
  • Target movements reaching a distant object: ball (10 minutes), glass (10 minutes);
  • Grip type spherical grip, cylindrical grip
  • Duration of one workout 20 minutes;
  • Training goal to restore the function of preparation for the capture in the paretic hand.
  • Patient 1 is seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). At arm's length, individually for each patient, in the frontal plane on the table 4, a ball 2 with a diameter of 10 cm is installed.
  • a monitor screen In front of patient 1 there is a monitor screen, which displays the success of the performed movement. The patient is asked to perform a motor task: to reach the ball, grab it, move it along the table, put the ball on a stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes.
  • Fig. 3 schematically shows the sequence of performing the movements in this exercise.
  • the trigger electrode is located at m. deltoideus anterior, this muscle is of one of the main muscles of the flexor of the shoulder during this movement, as you know, normally, flexion of the shoulder reaches its maximum, by the end of reaching the object, and it is at this moment that the hand is prepared for gripping, that is, extension in the wrist joint and fingers of the hand, which begins at 70 % and reaches its maximum at 90% of the completed movement.
  • the movement time in patients with mild paresis does not differ significantly from normal and averages -1000 ms.
  • the stimulating electrode is located at m.
  • extensor digitorum superficialis while the delay between EMG reading from the trigger electrode and stimulation of hand extension is -550 ms. It should be noted that due to the close location of the extensor muscles of the wrist and fingers, the stimulation of this movement occurs simultaneously and in a coordinated manner.
  • the screen displays the movement of the virtual hand in the pronation position and the extension of the fingers of the hand, providing the patient with biofeedback on the movement of the extension of the wrist joint and fingers of the hand.
  • patient 1 is also sitting on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table).
  • a glass 3 with a diameter of 8 cm is installed at arm's length, individually for each patient, in the frontal plane on the table 4, a glass 3 with a diameter of 8 cm is installed.
  • a monitor screen is placed in front of the patient, which displays the success of the performed movement.
  • the patient is asked to perform a motor task: reach for the glass, grab it, move it along the table, put the glass in the stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes.
  • Figure 4 schematically shows the sequence of performing movements in this exercise.
  • the trigger electrode is also located on m. deltoideus anterior.
  • the stimulating electrode is located at m. extensor digitorum superficialis, while the delay between EMG reading from the trigger electrode and stimulation of hand extension is -550 ms. It should be noted that this movement causes supination of the forearm, which distinguishes this type of capture from the previous one and fixation of the EMG signal from m.
  • supinator brevis would be more revealing as a trigger for stimulation extension of the wrist joint and fingers of the hand, however, the deep location of this muscle does not allow recording its activity with cutaneous electrodes, which is why it is advisable to choose m as a trigger point. deltoideus anterior.
  • the screen displays the movement of the virtual hand in the middle position of pronation / supination and extension of the fingers of the hand, which tells the patient about the correct movement of extension of the wrist joint and fingers.
  • Target muscle group m. flexor digitorum superficialis
  • Trigger muscle T. deltoideus anterior or T. extensor digitorum superficialis;
  • Target movements reaching a distant object: ball (10 minutes), glass (10 minutes);
  • Grip type spherical grip, cylindrical grip
  • Trained movement flexion of the fingers
  • Duration of one workout 20 minutes;
  • Training goal to restore grip function and strength in the fingers of the paretic hand.
  • Patient 1 is seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). At an arm's length, individually for each patient, in the frontal plane on the table, a ball 2 with a diameter of 10 cm is placed. A monitor screen is placed in front of the patient, which displays the success of the performed movement. The patient is asked to perform a motor task: to reach the ball, grab it, move it along the table, put the ball in a stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes.
  • Fig. 3 schematically shows the sequence of performing the movements in this exercise.
  • the trigger electrode can be located in two positions.
  • the first position is location at m. deltoideus anterior, a muscle that is one of the main flexors of the shoulder during this movement.
  • the delay time will be increased to ⁇ 900 ms. This is due to the fact that normally, shoulder flexion begins at the very beginning of the movement, and, starting from 90% of the movement time, the capture process occurs.
  • the stimulating electrode is located at m extensor digitorum superficialis.
  • the second possible position of the trigger electrode is the location on the extensor digitorum superficialis, this location allows you to reduce the delay time between stimulation of the target muscle group and increase the accuracy of the stimulus delivery to the target muscle group m. flexor digitorum superficialis. Extension in the wrist joint and fingers of the hand begins at 70% and reaches its maximum at 90% of the movement performed, and starting at 90%, the gripping process takes place. When the trigger electrode is located on the extensor muscles of the wrist and fingers, the delay time is set to ⁇ 300 ms.
  • patient 1 is also sitting on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table).
  • a glass 3 with a diameter of 8 cm is installed.
  • monitor screen In front of the patient, there is a monitor screen, which displays the success of the performed movement. The patient is asked to perform a motor task: reach for the glass, grab it, move it along the table, put the glass in the stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes.
  • Figure 4 schematically shows the sequence of performing movements in this exercise.
  • the weight of the grasped glass increases sequentially over 5 days (from 50 to 200 g,), and the glass is filled with water, which is necessary to improve the accuracy of the movement performed and encourages the patient not to spill its contents while performing the movement.
  • the grip strength gradually increases, since more effort is needed to hold a heavier object.
  • the arrangement of the electrodes corresponds to that described for the spherical grip, despite the fact that the achievement of the object with these types of grip is different (with performing a cylindrical grip, supination of the forearm occurs), the trigger muscles remain the same, since the fixation of the EMG signal from m. supinator brevis is difficult due to its deep position.
  • Target muscle groups m. thoracic major, t. triceps brahii, t. extensor digitorum superficialis, m. flexor digitorum communis.
  • the training is aimed at correcting the pathological stereotype in the proximal parts of the arm and hand, increasing functionality, increasing grip strength and range of motion.
  • Stage 1 (1-5 days of training !.
  • Target muscle group m. thoracic major, t triceps brahii;
  • Trigger muscle T. deltoideus anterior, T. deltoideus anterior;
  • Target movements reaching a distant object: ball (10 minutes), glass (10 minutes);
  • Grip type spherical grip, cylindrical grip
  • Trained movement adduction and flexion of the arm in the shoulder joint, extension in the elbow joint;
  • Duration of one workout 20 minutes;
  • Training goal restoration of movement, achievement of a remotely located object, correction of the main components of pathological synergy in the proximal parts of the arm (abduction in the shoulder joint, flexion in the elbow joint).
  • Patient 1 is seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). On the At arm's length, individually for each patient, a ball 2 with a diameter of 10 cm is installed in the frontal plane on the table 4. A monitor screen is placed in front of the patient, which displays the success of the performed movement. The patient is asked to perform a motor task: to reach the ball, to grab it, move it along the table, put the ball in a stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes.
  • Fig. 3 schematically shows the sequence of performing the movements in this exercise.
  • the main movements are normally flexion of the shoulder joint and extension of the elbow, the component of abduction of the shoulder joint in this case is not pronounced (in comparison with the execution of a cylindrical grip).
  • the main pathological component of flexion synergy during this movement is a violation of extension in the elbow joint, this is due to the weakness of the triceps muscle of the shoulder, which is why it is chosen as the target for stimulation.
  • the trigger electrode is located at m. deltoideus anterior, this muscle is one of the main flexor muscles of the shoulder during this movement, as you know, normally shoulder flexion begins at the very beginning and reaches its maximum, by the time the object is reached.
  • extension occurs in the elbow joint, these components constitute the main part of the synergy “riching”.
  • the stimulating electrode is located on m. triceps brachii, which is responsible for the extension of the elbow joint.
  • the delay time is set to a minimum of ⁇ 50 ms. This is due to the fact that the movements of flexion of the shoulder joint and extension of the elbow joint occur simultaneously.
  • the screen displays the forward movement of the virtual hand in the pronation position, which tells the patient about the correct movement.
  • patient 1 is also sitting on a chair, at a table, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table).
  • a glass 3 with a diameter of 8 cm is installed in the frontal plane on the table 4 in front of the patient.
  • monitor screen in front of the patient, which displays the success of the performed movement.
  • the patient is asked to perform a motor task: reach for the glass, grab it, move it along the table, put the glass in the stand and return your hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes.
  • Figure 4 schematically shows the sequence of performing movements in this exercise.
  • the main movements in the norm are flexion of the shoulder joint and extension of the elbow.
  • the abduction component is normally present in the shoulder joint, but it lasts only ⁇ 100 ms. and is subsequently replaced by a cast.
  • the main pathological component of flexion synergy during this movement is abduction in the shoulder joint; in patients with moderate paresis, it is replaced by adduction much later than in healthy patients.
  • the trigger electrode is located at m. deltoideus maxims, this muscle is the main one in the abduction of the shoulder joint and fixation of the EMG signal from it indicates the occurrence of pathological synergy.
  • the stimulating electrode is located at m. thoracic major, which is responsible for adduction and flexion of the shoulder joint.
  • the delay time between the fixation of the signal from the trigger electrode and the stimulation of the target muscle is set at - 100 ms. This is due to the fact that abduction in the shoulder joint is also present normally, but in a shorter period of time.
  • Figure 14 shows the ratio of the movement components, the achievement of a remotely located object is normal, for a clear understanding of the delay time (arrows indicate the start time of shoulder abduction and the start time of shoulder adduction).
  • Stage 2 (5-10 days of training !.
  • Target muscle group m. flexor digitorum superficialis
  • Trigger muscle T. deltoideus anterior or T. extensor digitorum superficialis;
  • Target movements reaching a distant object: ball (10 minutes), glass (10 minutes);
  • Grip type spherical grip, cylindrical grip
  • Trained movement flexion of the fingers
  • Duration of one workout 20 minutes;
  • Training goal to restore grip function and strength in the fingers of the paretic hand.
  • Patient 1 is seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the hand is on the table). At arm's length, individually for each patient, a ball 2 with a diameter of 10 cm is placed in the frontal plane on the table 4. In front of the patient, there is a monitor screen, which displays the success of the performed movement. The patient is asked to perform a motor task: to reach the ball, to grab it, move it along the table, put the ball in a stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes.
  • Fig. 3 schematically shows the sequence of performing the movements in this exercise.
  • the trigger electrode can be located in two positions.
  • the first position is the location on m. deltoideus anterior, a muscle that is one of the main flexors of the shoulder during this movement, the delay time will be increased to -900 ms. This is due to the fact that normally shoulder flexion reaches its maximum at 90% of the movement performed, starting from 90% the grip process takes place.
  • the stimulating electrode is located at m extensor digitorum superficialis.
  • the second possible position of the trigger electrode is the location on the extensor digitorum superficialis, this location allows you to reduce the delay time between stimulation of the target muscle group and increase the accuracy of the stimulus delivery to the target muscle group m. flexor digitorum superficialis.
  • extension in the wrist joint and fingers of the hand begins at 70% and reaches its maximum at 90% of the movement performed, starting from 90% the capture process takes place.
  • the delay time is set to -300 ms.
  • the screen displays the forward movement of the virtual hand in the pronation position and flexion of the fingers, which tells the patient about the correct movement.
  • the patient is also seated on a chair, at table 4, with armrests for both hands. Hands are placed on the armrests, palms down (the brush is on the table).
  • a glass with a diameter of 8 cm is placed at arm's length, individually for each patient, in the frontal plane on the table.
  • a monitor screen is placed in front of the patient, which displays the success of the performed movement.
  • the patient is asked to perform a motor task: reach for the glass, grab it, move it along the table, put the glass in the stand and return the hand to its original position. Then the patient needs to repeat this movement in the same order from the starting position; the duration of this part of the training is 10 minutes.
  • Figure 4 schematically shows the sequence of performing movements in this exercise.
  • the location of the electrodes corresponds to that described for the spherical grip, despite the fact that reaching the object with these types of grip is different (when the cylindrical grip is performed, the forearm is supined), the trigger muscles remain the same, since the fixation of the EMG signal from m. supinator brevis is difficult due to its deep position.
  • the patented technique allows you to modify the FES and TES protocols used depending on the severity of the patient's paresis and his functional capabilities, thus providing a personalized approach to post-stroke rehabilitation.
  • the patented technique makes it possible to reprogram pathological motor patterns at the peripheral level with an enhancement of the effect due to the directed modulation of the excitability of the motor cortex using TES.
  • an increase in the efficiency of normalization of the motor kinematic portrait in the paretic hand is achieved.
  • the use of modern devices for conducting FES and TES with a friendly interface and intuitive software, will contribute to the successful interaction of the patient and the therapist.
  • Hsu W.Y Effects of repetitive transcranial magnetic stimulation on motor functions in patients with stroke: a meta-analysis / W.Y. Hsu, C.H. Cheng, K.K. Liao et al. // Stroke - 2012. - Vol. 43, Ns 7. -P. 1849-1857.
  • Woods, A. J. A technical guide to tDCS, and related non-invasive brain stimulation tools / A.J. Woods, A. Antal, M. Bikson et al. // Clin. Neurophysiol. - 2016. - Vol. 127, Ne 2.-R 1031-1048.
  • Nitsche M. Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation / M. Nitsche, W. Paulus // J. Physiol. - 2000. - Vol. 527, Pt 3 - P. 633-639.
  • tDCS Transcranial direct current stimulation

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Abstract

L'invention relève du domaine de la médecine et concerne notamment des procédés de réhabilitation de patients ayant subi un AVC. Le résultat technique de la présente invention consiste en une augmentation de l'efficacité de normalisation du portrait cinématique moteur de la main parétique grâce à une modulation dirigée de l'excitabilité du cortex moteur en utilisant une EST du cerveau et une modification des protocoles employés d'une ESF synchronisée avec des mouvements aléatoires via une EMG en fonction de la gravité de la parésie du patient et de ses capacités fonctionnelles. Ce résultat technique est atteint grâce à la mise en oeuvre d'un procédé de réhabilitation des troubles moteurs de la main chez des patient ayant subi un AVC, lequel comprend les étapes consistant à: effectuer une EST du cerveau puis effectuer une électrostimulation fonctionnelle avec un courant à impulsions du muscle cible pendant que le patient effectue un mouvement cyclique à l'aide dudit muscle tout en effectuant une électromyographie dudit muscle en utilisant comme EMG de déclenchement de l'ESF, le muscle qui est synergique pour le mouvement cyclique à effectuer; l'électrode de déclenchement de l'EMG est fixée dans la zone d'activité du muscle à stimuler.
PCT/RU2019/000915 2019-12-09 2019-12-09 Procédé d'augmentation de l'efficience d'une réhabilitation consécutive à des troubles moteurs dans la main suite à un avc Ceased WO2021118382A1 (fr)

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Cited By (1)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN119327040A (zh) * 2024-12-24 2025-01-21 瓯江实验室 一种脑卒中后功能康复及预警系统

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US7725175B2 (en) * 2002-12-04 2010-05-25 Kinetic Muscles, Inc. System and method for neuromuscular reeducation
US8706241B2 (en) * 2005-10-19 2014-04-22 Advanced Neuromodulation Systems, Inc. System for patent interactive neural stimulation with robotic facilitation of limb movement
US20140222113A1 (en) * 2004-07-15 2014-08-07 Advanced Neuromodulation Systems, Inc., D/B/A St. Jude Medical Neuromodulation Division Systems and methods for enhancing or affecting neural stimulation efficiency and/or efficacy
EP2709522B1 (fr) * 2011-05-20 2016-09-14 Nanyang Technological University Système pour la réhabilitation neurophysiologique et/ou le développement fonctionnel synergique

Patent Citations (4)

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Publication number Priority date Publication date Assignee Title
US7725175B2 (en) * 2002-12-04 2010-05-25 Kinetic Muscles, Inc. System and method for neuromuscular reeducation
US20140222113A1 (en) * 2004-07-15 2014-08-07 Advanced Neuromodulation Systems, Inc., D/B/A St. Jude Medical Neuromodulation Division Systems and methods for enhancing or affecting neural stimulation efficiency and/or efficacy
US8706241B2 (en) * 2005-10-19 2014-04-22 Advanced Neuromodulation Systems, Inc. System for patent interactive neural stimulation with robotic facilitation of limb movement
EP2709522B1 (fr) * 2011-05-20 2016-09-14 Nanyang Technological University Système pour la réhabilitation neurophysiologique et/ou le développement fonctionnel synergique

Cited By (1)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN119327040A (zh) * 2024-12-24 2025-01-21 瓯江实验室 一种脑卒中后功能康复及预警系统

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