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NEUROPHYSIOLOGICAL EVALUATION OF THE EFFICIENCY OF TRATMENT OF BOTULOTOXIN OF SPASTIC FORMS OF INFANT CEREBRAL PALSY
Khamraev Farhod Sharafovich, The Dean of Medical and Pediatric Facultiy of the Bukhara State Medical Institute, Bukhara, Uzbekistan E-mail: doctorfarkhod@gmail.com
NEUROPHYSIOLOGICAL EVALUATION OF THE EFFICIENCY OF TRATMENT OF BOTULOTOXIN OF SPASTIC FORMS OF INFANT CEREBRAL PALSY
Abstract: 75 patients with infant cerebral palsy (cerebral palsy) were treated and received treatment with a drug based on botulinum toxin-A. Patients are divided into 3 groups. The results of ENMG-examination in the 15th day and after 3 months of treatment showed with sufficient evidence that already at the first stage of the study, the use of local injections of botulinum toxin-A improves the condition of the peripheral neuromuscular device. Positive shifts are most pronounced in patients of the 1st group (with a high rehabilitation potential) and in patients of the 2nd group (who have the skills of independent walking).
Keywords: spasticity, motion, botulotoxin, correction, rehabilitation.
Very important for the treatment ofpatients with spas- boys and 35 girls. The age of the patients ranged from 2
tic forms of cerebral palsy is the possibility of reducing muscle hypertension, which is not an end in itself, but it helps to eliminate and significantly reduce its influence as one of the main factors in the development of contractures and achieve functional improvements in the patient [1].
Despite the fact that there is a sufficiently large number of ways to reduce muscle tone in cerebral palsy, all of them have their shortcomings, side effects, undesirable effects and many contraindications. Most of the techniques require a long-term use, at a time when the effect is kept short enough. Therefore, the search continues for new, more effective, long-term, a traumatic, having a minimum number ofside effects and contraindications, methods ofcorrection of muscle tone. In this sense, the use of local injections of botulinum toxin-A (BT-A) is very attractive [2-4].
The aim of the research was to study the effect of injections of BT-A on the indices of the functional state of the neuromotor apparatus of patients with spastic forms of infant cerebral palsy (ICP) using the methods of global and stimulation electroneuromyography (ENMG) to objectify the evaluation of treatment effectiveness.
Materials and methods. We observed 75 patients suffering ICP who received inpatient treatment at the Republican Children's Psychoneurological Hospital in Tashkent. Among the observed children there were 40
to 14 years, on average 8 ± 6 years.
Taking into account the late formation of the motor habits in children with ICP and the consequent narrowing of the informational space the main task for treatment for our patients is early rehabilitation of their motor sphere. The most important stage is the achievement of the vertical body position and walking capacity. Just this is the target of the most our cases (group 1-20 patients). We could not suggest that in the other part of children the course of rehabilitation resulted in acquiring of independent vertical pose and walking due to more severe retardation of psychomotor development. The purpose for use of BT-A for these children was to acquire other locomotor actions: to turn over, to sit, to creep (group 2-21 patients). Group 3 included children who received injection of BT-A in order to eliminate cosmetic defect and correction of walking (group 3-30 patients). Injection of BT-A was administered in those muscle-agonists which were key in the formation of pathological muscular synergia. The dose was independent not only on muscle size but also degree of spasticity, degree of lesion.
Results and considerations. The results of ENMG studies conducted before the treatment in all patients showed a significant difference in many parameters, in comparison with healthy children.
High levels of bioelectrical activity (BEA) of resting muscles were observed both in the upper and lower extremities. Overstrained in comparison with healthy children, BEA muscle in rest testified to a significant muscle hypertension: - biceps arm muscles - 158.95 mV (116.14% higher than in healthy children); - triceps muscles ofthe shoulder - 191.58 mV (by 162.03% above the norm); - anterior tibial muscle - 157.46 mV (227.9% above the norm); - gastrocnemius muscle - 122.97 mV (55.83% above the norm).
BEA rest in patients with cerebral palsy in extensors is higher than in flexors. In the examined healthy children, BEA rest in the flexor is higher than in the extensors. ENMG with an arbitrary muscle contraction in children with spastic forms of ICP was of the type of tonic tension, it was low-amplitude, high-frequency, slowly increasing at the beginning of the movement and slowly decreasing at the end. BEA in the performance of its function (with arbitrary muscle contraction) is significantly reduced compared with healthy children. According to the surface ENMG data, practically all patients had signs of a violation of supra segmental regulation of muscle tone, which manifested itself in a significant increase in the norm of the reciprocity coefficient (CR) and the adequacy coefficient (CA). The data of monosynaptic testing showed that the ratio of Nmax to Mmax, which characterizes the level of excitability of spinal neurons, before treatment was 15.81% (37.24% in healthy), which indicates a significant decrease in the total number of motor neuron motor units involved in the norm in a reflex reaction. The threshold for the ap-
pearance of the M-response in the examined patients averaged 2.25 mA (4.57 mA in healthy subjects), the threshold of the H-reflex, normalized according to the M-response - 2.08 mA(3mA in healthy), indicating weakening the influence of the pyramidal pathway on segmental motoneurons.
The results of the ENMG survey conducted by us on the 15th day after treatment showed with sufficient evidence that already at the first stage of the study, the use of local injections of BT-A improves the condition of the peripheral neuromuscular device. This was manifested in reliable positive dynamics, obtained from ENMG data. The amplitude of BEA IM in rest decreased by 34.4%, BEE PMM at rest decreased by an average of 46.9%, which was clinically manifested in a decrease in the tonus of the calf muscles.
Positive shifts are more significant not in injected muscles, but in muscle antagonists, which is apparently due to the normalization of reciprocal relationships, as evidenced by the positive dynamics ofCR and SC. The CR dropped by an average of 30.9%, CA - by 30.3%. These changes in the coefficients determining the degree of regulation of the muscle tone were almost always accompanied by an increase in the amplitude of BEA in the agonist muscles. Those patients who noted these changes showed less co-contraction ofthe antagonists, involvement of the muscles in pathological synergies, and as a result, the function of the agonist improved, which was manifested in an increase in the amplitude of its BEA when performing an arbitrary physiological effort, but was clinically observed improvement of motor abilities of patients.
Figure 1. Change of BEA in the rest of m. gastrocnemius before and on the 15th day of treatment withBT-A
NEUROPHYSIOLOGICAL EVALUATION OF THE EFFICIENCYOF TRATMENT OF BOTULOTOXIN OF SPASTIC FORMS OF INFANT CEREBRAL PALSY
Figure 2. Change of the reciprocal coefficient parameters before and after treatment
the values registered in healthy children (38.4 ± 1.4%).
Monosynaptic testing data showed a positive dynamics of the ratio of Nmax /Mmax, which characterizes the level of excitability of spinal neurons, which indicates an increase in the total number of motor neuron units involved in the reflex response. In 1 group of patients (with high rehabilitation potential), this indicator approached
The biggest jump of this indicator occurred in the 2nd group (patients with severe degree of lesion) - by 77.8%. In the third group of patients with independent walking skills, the Nmax / Mmax ratio increased by 37.6%.
Table 1.- Comparative analysis of dynamics of ENMG indices before treatment, on the 15th day and in the distant period
ENMG indicators Before treatment On the 15 th day In 4-6 months
BSP BEA in the rest 145.2 ± 13.4 89.6 ± 7.3** 97.7 ± 10.9*
BEA in contraction 590.3 ± 56.0 755.9 ± 79.2 590.3 ± 31.1
Musculus gastroc- BEA in the rest 135.3 ± 12.7 88.7 ± 8.5* 91.8 ± 11.6*
ne-mius BEA in contraction 423.0 ± 41.4 591.9 ± 45.5* 583.6 ± 57.9*
Reciprocal coefficient 0.65 ± 0.07 0.45 ± 0.04* 0.33
Adequacy coefficient 0.87 ± 0.02 0.55 ± 0.03*** 0.38
N/M% 15.4 ± 3.5 20.7 ± 3.7 28.9 ± 6.0
M-response threshold 2.29 ± 0.17 2.71 ± 0.29 4.64 ± 0.73**. а
H-reflex threshold 2.10 ± 0.10 2.29 ± 0.18 3.50 ± 0.52*. а
Note: * - Reliable with respect to data before treatment: *** - P < 0.001. a - reliably with respect to data on
Conclusions:
1. The results of ENMG studies on the background of treatment with BT-A indicate a significant decrease in the tone of not only injected muscles but also in muscle antagonists and agonists, which is expressed in a decrease in BEA resting of the calf muscles, on average, by 36.7%.
2. As a result of treatment with local BTA injections, the arbitrary activity of the leg muscles increases due to an increase in BEA on average by 40.6% in performing its
* - P < 0.05; **- P < 0.01; day 15 treatment: a- P < 0.05
function, which clinically manifests itself in the development of new motor skills.
3. Already on the 15th day of treatment with BTA, the reciprocal relationship between muscle antagonists improves, which is reflected in a decrease in CR and SC on average by 30.6%.
4. Positive changes are most pronounced in patients with high rehabilitation potential.
References:
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2. Klochkova O. A., Klochkova A. L., Namazova-Baranova L. S. et al.The concept of "key muscles" and the early onset ofbotulinotherapy with spastic forms of infantile cerebral palsy // Questions of modern pediatrics.- 2017; 16 (1): 39-48.
3. Valencia D. Colombian experiences with botulinum toxin type A in children with cerebral palsy. 5 World Congress of the International Society of physical and rehabilitation medicine. 13-17.06.2009. Istanbul. - 1252 p.
4. De Araujo I. F., Carazzato M. S., Aoki S. S. Comparison between peripheral nerve block with phenol 5% and with botulinun toxin type A on hip adductor muscles in patients with cerebral palsy // 5 World Congress of the International Society of physical and rehabilitation medicine. 13-17.06.2009. Istanbul - 1253 p.
