Space technology application for patients with congenital and acquired central nervous system diseases rehabilitation

18.06.12

Space technology application for patients with congenital and acquired central nervous system diseases  rehabilitation

Grigoriev A., Kozlovskaja I., Semionova Ks., Voronov A., Kurenkov A., Sokolov P.,   Semionov A., Titarenko N.

Scientific Child Health Center of Russian Academy of Medical Sciences, “Ogoniok” LTD

Сerebral palsy (CP) is  one of the most widely spread severe and hardly treated   central nervous system (CNS) diseases. Three main factors constitute its pathogenesis basis: 1. pre- and postnatal dysontogenesis and motor activity control structures development pathology, 2. reflex sphere pathology –  righting and posture reflexes development and tonic reflexes reduction delay, 3. functional anti-gravity system  (FAS) and especially its main link – vestibular apparatus,  development  pathology and delay.

All known rehabilitation systems dealing with CP patients treatment are aimed at the first and the second above mentioned factors correction. Only some elements of B.& K. Bobath’s and V. Vojta’s complexes of  exercises therapy are aimed at FAS activity correction.

Meanwhile, neurophysiologic analysis, based on CP clinical features, EEG, ENMG and SSER data correlation, testifies to the possibility of vestibular system pathology and development disorders formation in both prenatal and postnatal ontogenesis. According to B.N. Klossovsky’s  investigations, just vestibular system activity determines all other brain functional systems activity.

As FSA plays one of the main roles in all other brain functional systems activity, its pathology leads to permanent motor activity disorders, hardly treated and previously reduced   motor activity disorders relapse.

Minding FAS role in CP pathogenesis, we had proposed to utilize the suit for cosmonauts “Penguin”, used in space medicine for FAS correction in the state of weightlessness. The main idea of this suit is that specially designed load on anti-gravity muscles, spine and lower limbs joints is changing the proprioceptive  afferentation thus making it similar to that of gravity state. That is why it is possible to normalize FAS and other motor activity control structures activity.

CP most distinguishing clinical feature, – motor skills development delay and  gradual development of  pathologic motor pattern after the birth is mainly due to FAS failure. That was the main reason of our proposal to use “Penguin” for CP patients’ rehabilitation. This suit was adopted for children and called “Adeli”.

The courses of special treatment with “Adeli” repeated 2-5-8 times for different patients lead to considerable improvement of motor activity and speech in 40-50% of all cases. This improvement was stable during 3-4 months, but afterwards the relapse of tonic reflexes and movement disorders was evident.  EEG, ENMG, SSER and less ENyG data tended to the same dynamics.

Because of this reason we changed “Penguin” construction using the new functional element – special reclinator, enabling gradual reduction of musculus pectoralis major hyrertension (picture1).  This muscle is the trigger for tonic reflexes resulting in hypertenson of the shoulder and pelvic girdle flexors in patient’s vertical position.

Changed  “Penguin” was called “Gravistat”. This special medical overalls was reflex-loading device, while “Penguin” itself – simply loading device. “Gravistat” enables to correct all three main factors of CP pathogenesis. The method was called  dynamic proprioceptive correction (DPC), because it was used only when the patient was moving.

Videoanalysis of the movements and the assessment of walking kynematic profile   of the patients treated by  “Gravistat” revealed the possibility of nearly physiological movements formation despite of patients age (in our series it ranged from 4 till 18 years) and CP form. After DPC course hip joint flexion-extension amplitude increased from 26+-4  up to 32+-6 (p  0.05), knee joint movements amplitude increased from 59+-4  up to 67+-7 (p  0.05) and ankle joint (with initial equines position) – from 16+-4  up to 21+-5 (p  0.05) (picture 2).

Before DPC course double step cycle bearing phase took up 72+-6% of  relative time and after the course – 67+-8%, testifying to walking biomechanical structure improvement (picture 3).    Relative time of double- and single-bearing step periods correlation before and after the treatment course revealed double-bearing time period decrease from 41+-6% up to 34+-8% (p  0,05), testifying to patients statokynetic stability improvement.

After the first 1-3 DPC courses patients’ vertical position formation began, muscle hypertension reduced, step movements appeared. Upper extremities movements volume and   muscles strength increased and fingers manipulation improved in 70% of cases.

This dynamics was noted simultaneously with equilibrium function and postural stability improvement. These were investigated by means of computed stabilography. The coordinates of the center of patients’ pressure (CrP) on the bearing squire for vertical position preservation were determined before and after DPC course. CrP deviation average decrease (from 41,3+-14,1mm up to 29,6+-15,5mm; n-22, p 0,05), CrP displacement average speed diminution (from 47+-16,2mm up to 36,4+-16,6mm), statokynesiogram diminution (from 368,9+-67,4 sq mm up to 229,8+-72,5 sq mm, p  0,05) testified to postural control quality improvement.

The analysis of the above mentioned data and clinical data concerning static and locomotion improvement after  “Gravistat” application (pictures 4, 5)   enables the following conclusion: consecutive ontogenetic FAS formation with simultaneous or consecutive tonic reflexes reduction are necessary for vertical position formation  and its further preservation. Tonic reflexes availability even with some FSA development signs leads to further motor development arrest or pathologic motor pattern development.

Motor activity controlling structures state is changing with  tonic reflexes reduction and FAS development. SSER data revealed thalamo-cortical afferentation increase resulting in cortex functional activity improvement (picture 6).

CP patients EEG-patterns (cortical electrogenesis development delay, slow-wave activity increase, cortical rhythm deteriorations, regional and hemisphere asymmetry) reflect morphological and functional CNS disorders. DPC courses (even in  CP residual-phase patients aged 25-35) resulted in EEG gradual normalization of different degree and quality in patients with different disease’s forms and severity.

Cortex functional activity improvement led to both – cortex motor activity control and gnostic functions connected with motor activity improvement. Brain structures function normalization after 3-8 DPC courses resulted in their seniority activity as for spinal cord normalization. Reciprocal interrelations in “agonist-agonist” limb muscle system became normal, concordant tonic activity of pathologic synergy muscles reduced, pathologic synergy ratio decreased from 1,47+-0,76 up to 1,07+-0,40(p  0.05).

H-reflex indices evaluation revealed maximal H-reflex amplitude – maximal M-response  amplitude  ratio decrease from 65,1+-14,3% up to 56,5+-15,3% after the treatment course, thus indicating motoneuronal pool units, involved in reflex reaction diminution. H-reflex depression with low-frequency rhythm stimulation (3 hertz) increased from 10,2+-14,1% up to 17,3+-21,2% being evidence of increased pyramidal tract control on lower motor neurons and internuncial neurons, probably due to presynaptic inhibition enhancement.

In 78% of all treated with  “Gravistat” patients (mainly with spastic diplegia) the indices of great motor nuerons involvement became normal after 3-8 treatment courses, thus testifying to monoaminergic neurotransmitter system enhancement.  Minor motor nuerons’ indices normalization  testified to  cholinergic neurotransmitter system harmonization.

Motor activity controlling structures functional state changes after DPC-treatment courses resulted in immune system controlling structures’ changes. The new approach to neurimmune reactions evaluation enabled new data, concerning the evidence of slow autoimmune brain inflammation process in CP patients, acquisition and antigen-specific reactions’ dynamics demonstration. This dynamics correlated with initial clinical state and treatment effectiveness indices in 67% of all cases..