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7INFLUENCE OF EXTERNAL COUNTER-PULSATION FOR IMPROVING THE EFFICIENCY OF MEDICAL REHABILITATION OF PATIENTS WITH ISCHEMIC
STROKE
EV Kostenko, MA Eneeva,
Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine of Moscow Healthcare
Department
ABSTRACT
In the present article examines the main directions in rehabilitation after suffering an ischemic stroke. Non-medication methods of treatment show the important role along with standard medical therapy. Provide a brief overview of research data on the use of enhanced external counterpulsation in patients after acute disorders of cerebral circulation in foreign and domestic literature. Examined the impact of enhanced external counterpulsation on cerebral blood flow regulation system, the formation of collateral circulation ischemic tissue, as well as cell-humoral effects method. Our experience of using enhanced external counterpulsation confirms the validity of inclusion of this method in complex treatment of patients after ischemic stroke because it contributes to the regress of clinico-neurological and neuropsychological deficits that leads to improved quality of life of the patient.
Keywords: ischemic stroke, medical rehabilitation, cerebral blood flow, auxiliary blood circulation, non-drug methods, enhanced external counterpulsation .
Medical social topicality of the stroke problem is determined by its prevalence among the population of developed countries as well as countries with middle and low income level per capita. So in the last 40 years the stroke incidence has increased by 42% in the developed countries and in the others - by more than 100%. According to wide-scale Russia-based studies, it was determined that stroke incidence remains one of the highest among all kinds of cardiovascular diseases and the death rate is on the second place. On average about 60% of the patients having suffered acute cerebrovascular disorder (ACVD) become disabled, half of which are dependent on others in everyday life [7]. In connection with this, the problem of improving the efficiency of rehabilitation measures is especially topical. One of the most important modern rehabilitation principles is the principle of differential approach and complexity of the rehabilitation programmes, including application of medicamental as well non-medicamental methods of rehabilitation treatment.
It is known that 96-99% of all the strokes fall to the share of ischemic strokes (IS) and only 1-4% of hemorrhagic [5]. Nowadays there are a lot of factors which enhance the development of IS. The results of wide-scale Russia-based studies of the stroke conducted in 2001-2003 in 19 cities with total population of 2398497 people in the age of 25 years and older, revealed incidence fluctuation from 2,6 to 5,37 cases per 1000 people, in the regions with highest incidence such risk factors were revealed as arterial hypertension, stresses and smoking.
Clinical picture, stroke flow and recovery of the functions of the organism in the course of rehabilitation also differ. That is why it is becoming vital for the doctor to stick to the conception of pathogenic heterogeneity IS while determining the therapeutic approach [2]. According to the classification TOAST (Trial of ORG 10172 in Acute Stroke Treatment), 5 pathogenic subtypes of IS are distinguished: atherotrombolic (50% from all IS); cardiovascular stroke; lacunar stroke; hemodynamic stroke (a stroke of other specified etiology); a stroke of non-specified etiology [8]. The knowledge of the peculiarities of pathogenic mechanisms in the development of the stroke enables to form a complex individualized rehabilitation programme.
Motion disorders in the form of unilateral hemiparesis of
different degrees are the most frequent consequences of the stroke. According to the Register of the Stroke of the research institute of neurology of RAMS, by the end of the stroke acute period, hemiparesis was observed by 81,2% of the survived patients, including hemiplegia by 11,2%, rough and frank hemiparesis - 11,1%, light and mild hemiparesis - by 58,9% [11]. According to the data of F. Folkes with co-authors, having gathered a significant data base on the stroke, motion disorders were revealed by 88% of patients. Motion disorders (paralysis, paresis) often match with another neurologic deficit: sensitivity disorder, speech and cerebellar disorders, etc.
Rehabilitation of lost neurologic functions is determined by the mechanisms connected with structural and functional reorganization of the central nervous system, which are marked as 'neuroplasticality' [4]. Reorganization of cortical parts of the brain, increase of the efficiency of usage of saved structures and more active usage of alternative descending ways (collateral sprouting and sinaptogenosis) are the anatomic base of plasticality [3]. The experimental data are evidence of the fact that plasticality processes can be influenced by pharmaceutical means as well as by application of special rehabilitation programmes, based on constant motion stimulation. The key aspect of neuroplasticality, which is of principal importance for rehabilitation, consists in the fact that the character and degree of neuronal links are determined by the amount of strain taken.
By the rehabilitation of the patients having suffered the stroke, a special meaning is given to the activity increase of the cerebral structures situated ipso-laterally. This data has clinical proof. It was shown in the experiment that activation of corresponding zones of the opposite hemisphere is marked right on the 3rd day after the stroke and continues till the 14th day, then it starts to decrease, while parallel to this decrease peri-infarction zones of the affected hemisphere begin to become active. Earlier it was considered that one of the aims of the rehabilitation of patients having suffered the stroke, is the application of the techniques which imply that the key point consists in the usage of non-affected limbs for the aim of patients having more independence in everyday life. At the same time affected limbs haven't been strained significantly. Today it is proved that the activation of the affected limbs directly influences the processes of the functional cerebral
reorganization and thus, contributes to the better recovering of the neurologic deficiency [9]. A prolonged (more than 28 days) proprioceptive stimulation by the patients with stroke, which is conducted by making passive movements, is followed by increase of sensomotor and additional motor cortex according to the data of the functional MRT [4,9].
Right after the development of the stroke the muscle tone in the paretic limbs is often decreased; however, after that within 2-3 days it increases, which as a result leads to a characteristic pose with increasing tone in adductors and flexors of the hand and adductors and extensors of the leg. It is worth mentioning that ulterior changes in the motional sphere in the form of some decrease of the muscle strength and animation of the reflexes can be observed as well as on the ipsilateral side. Functional recovering of the leg can undergo even in the course of insignificant or mild increase of muscle strength. The prognosis of rehabilitation of motion functions in the hand is much worse if the plegia occurs in the beginning of the disease, and also in the case if after 4 weeks from the beginning of the disease there is no recovering of the pincer prehension of the hand. There is data which says that if the patient doesn't have active movements in the limbs within the first 2 weeks from the beginning of the stroke, then further there will be no total regress of motional disorder [4].
There is no common opinion on the length of rehabilitation. In the case of independent total recovering of lost motion functions the length of the rehabilitation period, as a rule, is not more than 3 months (usually 1,5-2 months after the stroke). However, in some cases improvement may occur within 6-12 months and even a longer period of time. Some researchers think rehabilitation period lasts no more than 6 months. R. T. Wertz pointed out that the best efficiency is reached when the speech rehabilitation starts within the first 3 months from the moment of the development of the stroke, and is supposed to be carried out no less than 3 hours every week during 5 months and more. According to M. Kelly-Hayers, unlike the period of recovering of motion functions, the critical time for potential speech function recovering varies greatly, and very often the improvement continues over 6 months after the stroke. At the same time others believe that recovering of motion functions may continue within 1 year, and speech functions - 2-3 years [9].
Basic and pathogenic targeted medicamental therapy by IS is oriented on the correction and recovery of the blood circulation functions, normalization of energy metabolism, improvement of general stamina of the organism and decreasing of the degree of neurologic deficiency severity. Such methods as physical therapy, respiratory gymnastics, positioning treatment, vertical orientation, biofeedback, different techniques of massage, acupuncture, ergo-therapy, mechanical therapy, proproicorrection, physiotherapy, informing the patient and his relatives are applied on all the stages of the rehabilitation.
Physical therapy is an important therapy in mixed rehabilitation of the patients having suffered IS, which is necessary for the recovery of the motion functions, stimulation of defensive and adaptive mechanisms. By early implementation of physical therapy into the process of rehabilitation, the operation of the cardiovascular system and the respiratory function improve, muscle tone recovers, motion deficiency
decreases, emotional background restores and as a result, social adaptation of the patient accelerates [5]. Along with the positioning treatment, vertical orientation and physical therapy, massage for prevention of the development of hypertonia in the paralyzed limbs is applied if there are no contraindications. However, it's worth remembering that patients having suffered IS show evidence of selective change of muscle tone. Therefore, different techniques of massage for the muscles of agonist and antagonist must be used [8].
Ergo-therapy takes a special place in the rehabilitation process of the patients having suffered IS. This technique is aimed at improvement of adaptation to the environment, recovery of professional skills and skills of managing free time, correction of defective movement of the upper limb, selection of technical equipment for the easier functioning [8].
Application of the technique of biofeedback (BFB) among the rehabilitation measures gives an opportunity to influence not only the post-stroke motion disruptions, but also the cognitive and psycho-emotional ones.
Implementation of physiotherapeutic techniques into the complex of the rehabilitation measures for the patients after IS is pathogenically reasoned on all the stages of the treatment. There are following physical factors applied for the recovering treatment:
1. Pathogenic physical factors oriented on the activation of the processes of sanogenesis and recovery of the lost functions. To the pathogenically reasoned methods of physiotherapeutic treatment one can refer the application of pulsation magnetic field based on transcranial technology on the device 'Cascade'; alternating magnetic field; complex-modulated magnetic fields; low-frequency wide-band electromagnetic field; laser therapy; transcutaneous beaming with infrared laser; medicamental electrophoresis and galvanization; high-intensity surge magnetic therapy; UHF.
2. Symptomatic physical factors are oriented on the intensity decrease of the neurologic deficit. The following methods of physiotherapeutic treatment which are aimed at the correction of clinically significant evidences of IS are the most common ones: running magnetic field, diadynamic therapy, fluctuorization, electric stimulation, cryotherapy, darsonvalization, phonophoresis, seismotherapy, DDT, magnetic therapy, SMT-therapy, thermotherapy, phonophoresis.
3. Urgent physical factors are used in cases of acutely co-occurring pathosis or acute exacerbations of chronic diseases (bedsores, thrombophlebitis, ARVI, apostasis, exacerbations of COPD, chronic pancreatitis, etc.). In such situations the following methods are widely used: UHF, microwave therapy, IR laser beaming, phonophoresis, supra-sonic ablution, inhalations, etc.
For the rehabilitation of the ambulance function mechanic therapy has been used along with physical therapy for many years. Nowadays apart from usual exercises with an instructor, walking with cane and man-trailing, the following devices are being used: training devices with 'treadmills', platforms with BFB, unstable devices. Combination of walking workouts with application of electromechanical devices and kinesiotherapy significantly improves ambulance and increases the ability of independent moving. Such trivial robotic devices as MOTOMED, LOKOMAT, THERAVITAL, KINETEK gave a
good account of themselves. There are also such devices which are aimed at the development of the fine motor skills of the hand. By the analysis of the efficiency of the rehabilitation measures it's important to take into account three levels of rehabilitation of motion disorders among the patients having suffered ACVD: total recovery of motion and a comeback to the baseline - a genuine recovery, functional alteration with participation of new, earlier not engaged structures - compensation, adaptation to the already formed deficit - readaptation [3].
The first year after the stroke is considered to be the most resultative period for rehabilitation. This is the very time when it is best possible to include the method of intensified external counter-pulsation (MIEC) to the complex of rehabilitation measures. For many years this method was being used solely in cardiology. However, as a result of numerous studies, from the 1980s there has been received information about significant improvement of cerebral blood flow while using MIEC [10]. This method has been widely used since 2003 after the end of three largest random studies in China. As a result of the studies, clinically significant effect and also improvement of rheologic characteristic of the blood were observed among all patients having suffered IS and having received MIEC along with the standard therapy. Nowadays four mechanisms of MIEC operation have been studied: cardiac, peripheral, cellular-humoral and hemodynamic [6].
The increase of the cerebral blood flow occurs because of the risen diastolic pressure in the aorta by compression and decompression of lower limbs with the help of wristbands filled with air. Impact on legs is explained by the presence of great amount of vessels in the lower limbs, which take part in the formation of the general peripheral resistance, pre- and afterload of the heart. Baroreceptors situated in the vessels of legs, form and direct the impulses in the vasoconstrictive centre of the brain, which leads to reflexive vascular distention, and thus, to the decrease of systemic arterial pressure. Understanding of the peculiarities of myocardial perfusion with the phase of the cardio cycle lies in the base of the principle of the MIEC device operation. Three pairs of cuffs are worn on the lower limbs of the patient (calves, hips, gluteal regions). Air delivery into the cuffs happens consecutively bottom-up. Under pressure of 200350 mm of vacuum there is vessel constriction of lower limbs, kindling of retrograde pulse wave and increase of diastolic pressure in the aorta, which leads to the increase of the coronary perfusion pressure and coronary blood flow. Deflation is started automatically with the beginning of myocardium contraction, which leads to the decrease of system vascular resistance and post-strain. This contributes to the decrease of resources for the heart work of the myocardium's oxygen use. The return of black blood doesn't cause a rise of central intravenous pressure as far as the organism in the course of MIEC is still able to regulate it. This fact is proved by research and has a significant importance because MIEC is more often used for elderly patients having co-existing chronic obstructive lung diseases with lung perfusion disorder [1]. During MIEC procedure there is a production increase of growth factors, that is HGF (hepatocyte growth factor), FGF (fibroblast growth factor), VEGF (vascular endothelial growth factor), and the mechanism of angiogenesis is also triggered. MIEC facilitating the formation of collateral blood flow, participates in the processes of blow flow recovery
in ischemic tissues.
According to literature information, patients after MIEC show evidence of slowdown of atherogenesis processes. It gives prerequisites for using the MIEC method for the aim of prevention of degenerative obliterating cardio- and cerebrosclerosis. The influence of MIEC on the production of nitrogen oxide also contributes to vasodilation, angiogenesis, has anti-platelet, anti-thrombotic, anti-inflammatory and anti-proliferative effect.
All this data was gathered in the result of analysis of a great amount of studies carried out abroad. In Russia in 2009 the application of MIEC method among patients having suffered IS in the early rehabilitation period was studied at the premises of the branch №7 of State Autonomous Agency 'Moscow scientific and production centre of medical rehabilitation, recovery and sports medicine' in Moscow Department of Healthcare (earlier a policlinic of recovery treatment №7). 86 patients were divided into 3 groups. Patients of the first group (37 people) have received 17 procedures of intensified external counter-pulsation, second group (38 people) - 35 procedures. The duration of the treatment with the device lasted 1 hour. The third group of patients consisted of 10 people, whose overall rehabilitation didn't include this treatment method. All participants of the research were comparable according to the duration of the disease, neurologic deficit evidence, age, gender. In all the groups regardless of the application of MIEC method, patients received standard medicamental treatment, physiotherapy, physical treatment, massage, robotic and mechanic therapy. After the analysis of the gathered results, a change in linear velocity of blood flow (LVBF)in magistral arteries of the head was pointed out. The patients of the second group showed maximal growth of LVBF - by 24,0% on ICA (p<0,05) and on CCA - by 14,5% (p<0,05). Patients of the first group had less evident changes. With the help of semiquantative tests using questionnaires HADS and CAH, decrease in evidence of depression demonstration among the patients having received MIEC in the process of rehabilitation was revealed. Similar results were received in the course of evaluation of cognitive functions with the help of the MMSE scale. However, the data gained by the analysis of motion disorders is of greater interest. So, in the first group the degree of paresis evidence has decreased by 20%, in the second - by 24,3%, while by the patients of the experimental group - by 14,7%. In the framework of conducted counter-pulsation, spasticity of the affected limbs has also changed. In the first group the spasticity decrease has made 50%, in the second - 69,6%, and in the experimental group - 41,7%. By evaluation of activity in everyday life and patient's adaptation on Bartel scale, maximal index growth (6,9%) was observed among the patients of the second group getting 35 procedures of MIEC in the course of treatment. In the first group the index growth has made 5,1% and in the experimental group 2,7% [1]. Gathered findings enable to recommend this device-based method of treatment in the early rehabilitation period of IS. It is also necessary to take into account that MIEC shows better results in longer periods of treatment. The optimal alternative is considered to be a treatment period from 3 to 7 weeks, 5 procedures a week. Nowadays studies on the effects of intensified external counter-pulsation among the patients having suffered IS are still being
carried out, in early rehabilitation period as well as in the later one. In more than 30 countries of the world MIEC is used for curing patients with CAD and CVD. According to literature information in 1995 this method was approved by FDA (Food and Drug Administration of the USA) [6].
Knowing the pathogenic mechanisms of cerebrovascular diseases and analyzing the data gathered in the course of research, one can consider MIEC an effective method in mixed rehabilitation in the early recovery period of IS.
Thus, implementation of non-medicamental means of treatment, that is intensified external counter-pulsation, into the rehabilitation programme of the patients having suffered acute cerebrovascular disorder, leads to a significant improvement of motional and hemodynamic functions of the organism. Differential, mixed and individual selection of rehabilitation programs based on individually-personal approach, which is determined not only by medical factors (pathology kind, character and degree of disturbed functions, presence of complex diseases and deficits, etc.), but by biological characteristics (sex, age), contributes to the increase of the efficiency of conducted rehabilitation measures. It is reasonable to conduct the rehabilitation process in the conditions of specialized neurorehabilitation departments and centres with the participation of qualified staff, which has undergone a special professional preparation, which will enable to realize modern approaches of medical rehabilitation.
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