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2022
ВЕСТНИК САНКТ-ПЕТЕРБУРГСКОГО УНИВЕРСИТЕТА МЕДИЦИНА
Т. 17. Вып. 2
НЕВРОЛОГИЯ. НЕЙРОХИРУРГИЯ. ПСИХИАТРИЯ
UDC 616.831-009.11
Rehabilitation of patients after stroke using biofeedback and a multidisciplinary approach
E. N. Zharova1, E. A. Vershinina2, A. B. Bondarenko1, O. V. Titova1, N. V. Vlasova1, A. A. Oleynik1, V. G. Nezdorovina1, K. B. Abramov1
1 Almazov Medical National Research Centre,
2, ul. Akkuratova, St Petersburg, 197341, Russian Federation
2 Pavlov Institute of Physiology of the Russian Academy of Sciences, 6, nab. Makarova, St Petersburg, 199034, Russian Federation
For citation: Zharova E. N., Vershinina E. A., Bondarenko A. B., Titova O. V., Vlasova N. V., Oleynik A. A., Nezdorovina V. G., Abramov K. B. Rehabilitation of patients after stroke using biofeedback and a multidisciplinary approach. Vestnik of Saint Petersburg University. Medicine, 2022, vol. 17, issue 2, pp. 70-87. https://doi.org/10.21638/spbu11.2022.201
The high prevalence of vascular diseases of the brain (mainly as a result of atherosclerotic vascular lesions) makes the problem of rehabilitation of patients with motor disorders, post-stroke disorder of higher mental functions — one of the most relevant in modern medicine. Up to 80 % of stroke patients have persistent neurological deficits. About a quarter of these cases are profound disabilities with loss of self-care. The most complete restoration of functions lost after a stroke can be achieved within the first year after the onset of an acute cere-brovascular accident. At the same time, despite the successes of modern neurorehabilitation, up to 80 % of stroke patients remain disabled. In this regard, the timely provision of adequate emergency medical care for stroke and full-fledged rehabilitation are among the most important tasks of the healthcare system, clinical neurology and neurosurgery. In this article, for use in the system of complex rehabilitation, a biofeedback method on the Pablo apparatus and sessions with a psychologist are proposed. The obtained positive effect is shown in the results of the study and can be proposed for practical use in specialized clinics.
Keywords: stroke, rehabilitation, biofeedback, psychotherapy. Relevance
Stroke still remains the most important cause of morbidity and mortality in the population. In Russia, the USA and European countries, it ranks third, second only to myo-cardial infarction and malignant neoplasms. In addition, this disease is the main cause
© St Petersburg State University, 2022
of disability in the population. Besides the unconditional medical and social significance, stroke also causes significant economic damage, affecting the people of working age [1]. This problem is also relevant in Russia. Morbidity and mortality from stroke in our country remain one of the highest in the world. Among all forms of stroke, ischemic stroke predominates, accounting for almost 70 % in the structure of morbidity [2]. In the last decade, special attention has been paid to acute circulatory disorders that have developed against the background of stenosis of the carotid arteries.
In recent years, there has been an increase in the number of people who have had a stroke, while at the same time, mortality in this disease is decreasing [2], which is explained, first of all, by the modernization of care for this category of patients. The introduction of new treatment methods such as thrombolysis, the development of specialized care contributes to the success of stroke treatment and greater patient survival. As the number of survivors increases, so does the number of disabled people in need of rehabilitation. Currently, approaches to the recovery of patients after a stroke are diverse and include the restoration of both movement disorders and higher mental functions [3; 4].
However, without the active involvement of the patient in the proposed programs, rehabilitation remains ineffective [5; 6]. Therefore, in recent years, more and more attention has been paid to post-stroke mental disorders, which, both by behavioral and pathophysi-ological mechanisms, reduce the reverse development neurological defects and the functioning of the patient in everyday life [7]. To the greatest extent, this applies to post-stroke anxiety, depressive and apathetic disorders. An important issue is not only the rehabilitation of a patient who has had a stroke, but also the promotion of his adaptation to new, changed living conditions. Mental disorders that appear after a stroke reduce the patient's adaptation to a new lifestyle, primarily by adversely affecting the quality and quantity of his social connections. In addition, mental disorders after a stroke are the main potentially adjustable factor affecting the quality of life of this group of patients. Post-stroke mental disorders increase mortality, increase the length of hospital stay prevent returning to work. However, despite the importance of identifying post-stroke mental disorders, many of them remain unrecognized [8].
The high frequency of mental disorders in the post-stroke period indicates the importance of a complete psychiatric examination of patients in the acute period of stroke in order to identify among them individuals with psychopathological syndromes that began even before the stroke, or that arose after a brain catastrophe. In order to more accurately diagnose them and predict their course, a psychopathological examination of patients in the first 3 days of a stroke is necessary. In order to reduce the incidence of post-stroke depression, cognitive psychotherapeutic intervention is indicated in the most acute period of stroke, as well as the use of psychopharmacotherapy in risk groups. The study of psychiatric aspects of mental pathology that develops after a stroke should also include a more extensive follow-up study that considers the dynamics of changes in the clinical picture of disorders after a longer time after a stroke. Finally, carefully organized studies are needed to assess the effectiveness of differentiated therapeutic interventions in the population of patients who have had a stroke, as well as the identification of psychopathological markers of the effectiveness of a particular therapeutic intervention [9].
The physiological basis for the recovery of functions after a vascular or traumatic brain injury is neuroplasticity [10] and neurogenesis [11; 12]. Recovery activity strongly depends on a number of factors: the size, localization and lateralization of the lesion, the
initial somatic state of the patient, and age [10]. The last factor remains controversial. The processes of neuroplasticity tend to decrease with age, but this does not mean that age is the only determining factor in recovery. There is no consensus among researchers about the effect of age on the recovery of motor functions: some consider old age to be one of the main adverse factors [13; 14], while others deny the importance of this factor [15]. Most authors agree that with the same initial severity of motor disorders, the same size and localization of focal lesions, the degree of recovery of range of motion in the paretic limb does not depend on age [10; 16].
The concept of plasticity occupies a central place in the work of neurorehabilitolo-gists. Many methods used in rehabilitation are based on thev knowledge of the innate mechanisms of plasticity [17].
Innovative methods of movement therapy created using modern principles of neu-rorehabilitation include forced training of paretic limbs, robotic methods, virtual reality technology, mechanical stimulation of foot support zones, brain-computer interface technology, non-invasive methods of brain stimulation [18].
Active neurorehabilitation in the acute period of stroke (the first 3-4 weeks of hos-pitalization) is possible with stabilization of hemodynamics and the absence of somatic contraindications, as a rule, from the fifth day from the onset of the disease [17; 19]. Kine-siotherapy is one of the basic methods of complex treatment of patients with strokes. With its help, they successfully solve motor problems and improve psychological, biochemical and physiological processes, which is important in the rehabilitation of this category of patients. Kinesitherapy includes not only special individually selected methods of therapeutic exercises and the use of special corrective postures — positional treatment. It also includes varieties of massage (classical therapeutic, with elements of manual therapy, massage in an electrostatic field), robotic mechanotherapy (restoration of walking), simulators of various directions (cyclic, power, inertial, rotational, etc.) with a built-in symmetry control system and biological feedback communication, physiotherapy. However, not all of the above methods are applicable in the specified period.
Thus, the data of literary sources demonstrate the possibility of neurorehabilitation of patients with motor disorders in the acute period of stroke. The advantage is the combined implementaion of kinesitherapy and active-passive mechanotherapy using robotic simulators. A promising technique is the artificial correction of movements using functional electromyostimulation.
Purpose: to evaluate the effectiveness of complex neurorehabilitation in restoring physical and psychological skills with the inclusion of a biofeedback method and sessions with a psychologist in the course compared with a group of patients who received only kinesitherapy, massage and physiotherapy methods within a period not exceeding a year after an acute cerebrovascular accident (ACVI).
Materials and methods
A randomized controlled trial included patients within a period not exceeding a year after a stroke, treated at a neurosurgical institute in 2019-2020. Patients were randomly divided into two groups: group 1 (73 patients) received biofeedback therapy (BFT) and sessions with a psychotherapist in addition to the standard treatment protocol; Group 2 (71 patients) — received only conventional drug therapy and methods of non-
drug rehabilitation without inclusion the course of classes on the apparatus with BFT and a psychotherapist. The distribution by sex in the groups was approximately the same, male patients predominated in both groups (Table 1).
The average age of patients in the first group was 55.78 ± 14 (M ± SD) years, in the second group it was 58.18 ± 11.8 (M ± SD) years. In both groups, patients with moderate severity of stroke prevailed, the data are presented in Table 2.
Table 1. Distribution of patients in groups by sex
Group Sex N %
1 Female 29 40.3
Male 43 59.7
Total 72 100
2 Female 34 47.9
Male 37 52.1
Total 71 100
Table 2. Distribution of patients in groups according to the severity of stroke
Group Severity N %
1 Mild 5 6.9
Moderate 49 68.1
Severe 18 25
Total 72 100
2 Mild 5 7
Moderate 57 80.3
Severe 9 12.7
Total 71 100
Patients had speech, motor and coordination disorders (Table 3).
Table 3. Distribution of patients according to neurological symptoms
Group Neurological desorders N %
Cranial nerves (1, 3, 7) 9 12.5
Speech 18 25
1 Swallowing 5 7
Coordination 49 68.1
Walking pattern 50 69.4
Cranial nerves (1, 3, 7) 8 11.3
Speech 18 25.3
2 Swallowing 5 7
Coordination 49 69
Walking pattern 49 69
Table 4. Distribution of patients by degree and side of motor paresis
Group Degree of paresis N %
1 2 9 12.5
3 23 31.9
3.5 2 2.8
4 29 40.3
4.5 9 12.5
Paresis side
Right 41 56.9
Left 31 43.1
Total 72 100
2 2 10 14.1
3 27 38
3.5 2 2.8
4 24 33.8
4.5 8 11.3
Paresis side
Right 39 54.9
Left 32 45.1
Total 71 100
According to the Table 3, it can be seen that neurological symptoms were represented by the cranial nerves violation, mainly optic, oculomotor and facial; swallowing, speech and coordination disorders. The detection of symptoms was approximately the same in both groups. On average, almost 70 % of patients had impaired coordination, 25 % had speech disorders, 12 % had cranial nerves violation, and 7 % of cases had swallowing disorders. The walking pattern was violated due to hemiparesis in almost all the patients, and impaired coordination also had an effect. The degree and side of the paresis varied (Table 4).
The number of patients with right-sided paresis prevailed in both groups. Muscle strength initially ranged from 2 to 4.5 points. Upon admission, patients were assessed according to the modified Rankin scale, the assessment data are presented in Table 5.
When assessed according to the modified Rankin scale (MRS), upon admission to rehabilitation, in both groups patients with moderate disability were dominated — 3 points according to the MRS (self-moving and able to serve themselves, i. e. dress/undress, go to the toilet, etc.), however, requiring some help with complex activities — cooking, cleaning the house, going to the store for shopping, managing financial affairs, etc.). Such patients can and should be treated with a biofeedback device. With this level of neurological deficit, they are able to perform various exercises to increase the range of motion of the paretic limbs. Given the various cognitive and behavioral disorders in patients after stroke, they were recommended to have classes with a psychotherapist. Patients with mild disability — 2 points on the MRS could not perform the activity that they were engaged in before the disease (driving a car, reading, writing, dancing, working, etc.), but they could
Table 5. Initial distribution of patients according to the modified Rankin scale (MRS)
Group MRS N %
2 6 8.3
1 3 51 70.8
4 15 20.8
Total 72 100
2 5 7
2 3 57 80.3
4 9 12.7
Total 71 100
Table 6. Distribution of patients according to the rehabilitation routing scale (RRS) at baseline
Group RRS N %
3 6 8.3
1 4 50 69.5
5 16 22.2
Total 72 100
3 5 7
2 4 57 80.3
5 9 12.7
Total 71 100
fully take care of themselves and live at home alone for a week or more without outside help. Patients with severe disability — 4 points according to the MRS could not walk independently, cope with their physical needs without outside help, but with the help of an exercise therapy instructor they could exercise on a biofeedback apparatus.
Patients were admitted in accordance with the scale of rehabilitation routing, the data of the initial assessment are presented in Table 6.
Patients with a CRM score of 3 to 5 were admitted for rehabilitation, patients with a CRM score of 4 prevailed in both groups. For all parameters, initially px2 > 0.05. Both groups were treated with medication in accordance with the available clinical protocols: massage, physiotherapy exercises, if necessary, classes with a speech therapist-aphasiolo-gist, and physiotherapy methods were used, a list of which is presented in Table 7.
According to the Table 7, it can be seen that the majority of patients in both groups were prescribed magnetic stimulation procedures, because. the method is evidence-based in the treatment of the consequences of stroke (level of evidence — 1, level of evidence — A) and has worked well in patients with central paresis.
Special parameters were assessed before the start of rehabilitation treatment in both groups: FCI index (force control index), cylindrical grip of the hand, pinching of the fingers, flexion/extension/abduction/adduction angles in the elbow and shoulder joints of the paretic arm. In addition, walking function was assessed before and after the course of treatment. The distribution of the calculated mean values of indicators before treatment in both groups is presented in Table 8.
Table 7. Distribution of physiotherapy methods in groups
Group Stroke severity N %
Magnetic stimulation 31 43.1
Elecrtostimulation 8 11.1
1 Photochromostimulation 21 29.2
Lazerotherapy 9 12.5
Darsonvalization 3 4.2
Total 72 100
Magnetic stimulation 32 45.1
Elecrtostimulation 8 11.3
2 Photochromostimulation 21 29.6
Lazerotherapy 8 11.3
Darsonvalization 2 2.8
Total 71 100
Table 8. Average values of upper limb mobility in both groups at baseline
Indicators 1 2
FCI index 23.53 ± 15.2 % 24.85 ± 12.6 %
Cylindrical grip of the paretic hand 15.496 ± 22 kg 6.352 ± 8.3 kg
Abduction/adduction angles in shoulder joints of the paretic arm 72.83 ± 47.3° 72.70 ± 48.0°
Pinching of the fingers 4.858 ± 7.3 kg 3.479 ± 3.1 kg
Flexion/extension in the elbow joints of the paretic arm 73.0 ± 42.3° 79.15 ± 41.9°
Special indicators measured before the start of classes on the apparatus with biofeedback showed approximately the same severity in patients in both groups. The initial parameters were evaluated in dynamics after the end of the course of treatment.
The course of treatment took 2 weeks. Patients of the 1st group received individual tasks on the device with BFT, the type and volume of which depended on the degree and localization of paresis. Additionally, classes were held with a psychotherapist, who, based on testing at the first lesson, selected a program aimed at correcting memory, attention, constructive thinking and other cognitive skills.
Statistical processing methods
Data are presented as percentages and distributions of nominal and ordinal scales, mean, standard deviations, and errors of means for ordinal and metric variables. The graphs show the means ± error of the means.
Frequencies and distributions of variables were analyzed using the x2 test and/or Fisher's exact test.
When checking the influence of the group (with BFB / without BFB) and methods of physiotherapy (PT): magnetic stimulation (m/s), photochromotherapy (PCT), laser therapy (LT), electrical stimulation (e/s) on neurological parameters, as well as to identify
treatment effect (pre-treatment/after-treatment) Mixed ANOVA followed by Bonferroni post hoc comparisons was used. In addition, the differences between the values after treatment and the initial values of neurological parameters were calculated for their subsequent comparison between groups, including using the Mann — Whitney test. Correlations were calculated using the Pearson and Spearman coefficients.
Statistical decisions were made at the 5 % level. The data were analyzed using the SPSS Inc software package [20].
Results
72 patients of the main group of different ages took part in psychological rehabilitation. At the first stage, primary psychodiagnostic testing was carried out in order to determine the intellectual and pathocharacterological characteristics of the patients' personality. Wechsler memory scales (1946) and the symptomatic questionnaire SCL-90-R (Symptom Checklist-90-Revised) were used [21; 22]. Primary testing was carried out before rehabilitation activities and was a diagnosis of the weaknesses of the intellect, which were targets for the work of specialists (speech therapist, psychologist) in the framework of the rehabilitation direction, and the strengths of the intellect — resources for the development of cognitive abilities. Several cases are presented in Table 9.
Table 9. The results of the primary psychodiagnostic study on the Wechsler memory scale in subtests
No. 1 2 3 4 5.1 5.2 6 7
B % B % B % B % B % B % B % B %
1 5 83 5 83 5 71 8 35 6 67 2 25 17.5 83 7 50
2 6 100 5 83 6 86 16.5 72 6 67 4 50 12 86 13,5 64
3 6 83 5 83 6 86 7.5 33 7 78 5 63 8 57 13 62
4 6 83 5 83 6 86 11 48 7 78 4 50 12 86 18 86
5 6 83 4 67 6 86 5 22 6 67 5 63 8 57 11 50
6 6 83 3 50 6 86 2 9 5 56 2 25 0 0 5,5 26
7 6 83 4 67 6 86 5 22 6 67 5 63 8 57 11 50
8 6 83 5 83 6 86 13 57 7 78 5 63 13 93 16 76
Note: B — points, % — percentage of correct answers. Subtests: 1 — orientation and awareness, 2 — orientation in time and space, 3 — mental control, 4 — logical memory, 5.1 and 5.2 — reproduction of rows of words in forward and reverse order, 6 — reproduction of geometric shapes, 7 — reproduction of paired associations.
The results of the primary psychodiagnostic study on the Wechsler memory scale indicated that the majority of patients with a history of stroke in the past year were oriented in personal and social data, in time and space, and had sufficient mental control. The minimum values for subtest 4 "logical memory" and subtest 5.1 "reverse repetition of numbers" indicated that the patients had pronounced difficulties in consciously mastering the material due to a decrease in the quality of active attention.
In addition, the vast majority of male patients in the early recovery period had suicidal thoughts. This required additional psychotherapeutic analysis and classes.
Repeated testing was carried out after rehabilitation measures and was a diagnostic of those aspects of intelligence that were targets in the work of specialists. A comparative analysis of the results of the initial and repeated testing made it possible to assess the dynamics of the cognitive functions of patients and the effectiveness of the rehabilitation program, and also indicated that the logical perception of the material is less amenable to psychological correction. There was no positive dynamics in 67 % of patients undergoing rehabilitation. According to our observations, associative memory responded better to psychological correction. Positive dynamics was observed in 63 % of patients. For example, patient S., 45 years old, initially completed tasks on "logical memory" by 45 % and by 53 % after a course of rehabilitation, improving his own results by 8 %. The results for subtest 5 "repetition of numbers" (in reverse order) after rehabilitation were unchanged (0 %). Tasks for associative memory (subtest 7) at the initial stage of rehabilitation were completed by 65 %, while after rehabilitation they were completed by 83 %, i. e. positive dynamics was 18 %.
Analysis of the results of the study of pathocharacterological features of the personality of patients using the SCL-90 symptomatic questionnaire showed that the majority of patients with focal brain lesions in anamnesis up to 1 year tended to anosognosia: patients presented a minimum number of complaints and symptoms of distress, were not inclined to fix their attention to the symptoms, did not attach any importance to it. It can be assumed that patients were not fully aware of the severity of their condition, which led to later seeking medical help and severe consequences.
The decrease in moderate and severe mental processes, the deficiency of the volitional component of activity and the anosognosic type of attitude of patients with the consequences of stroke to the disease make it necessary for family members to participate in the rehabilitation program in order to increase its effectiveness [23-25]. Relatives were informed about the features of cognitive impairment in patients and received recommendations for the development of cognitive functions at home. Psychological rehabilitation as part of complex treatment contributed to the restoration of impaired cognitive functions, increased the level of positive emotions, motivated them to recover, and thereby contributed to the prevention of recurrent stroke.
In addition to psychological testing in patients in both groups, the dynamics of neurological deficit and indicators on the Pablo apparatus were assessed. All parameters studied on Pablo (FCI, pinch grip, arm flexion/extension/abduction) in both groups correlated with muscle strength and degree of paresis after stroke.
Table 10 presents the main significant effects in the application of mixed analysis of variance. For all neurological parameters, the treatment effect was very significant in total for both groups and for PT methods, p < 0.001. In addition, the dimensions of the n2 criterion (dispersion explained by the factor) are rather high.
As for Effect*Group factor interactions, they are significant for neurological parameters (trend for cylindrical grip of the paretic arm), with the exception of elbow flexion/ extension of the paretic arm and pinch grip of the paretic arm. This means that the behavior of variables in a group with BFB is different from the behavior of variables in a group without BFB. Comparisons between groups are detailed by comparing treatment effects, i. e. differences between post-treatment and baseline values (Table 10).
Due to large data spreads and small group sizes, as well as the application of a strict Bonferroni correction, we obtained few differences between the various FT methods.
Table 10. Main effects of mixed analysis of variance
Parameter Treatment effect Effect*Group Method PT/group
A F(1.135) = 645, p < 0.001, n2 = 0.827 F(1.135) = 6.26, p = 0.014, n2 = 0.040 F(3.135) = 3.83, p = 0.011, n2 = 0.079 FT
B F(1.135) = 80.34, p < 0.001, n2 = 0.375 F(1.135) = 5.08, p = 0.027, n2 = 0.036 -
C F(1.135) = 24.44, p < 0.001, n2 = 0.153 F(1.135) = 3.34, p = 0.070, n2 = 0.024 F(1.135) = 8.1, p = 0.005, n2 = 0.056 Group
D F(1.135) = 113.13, p < 0.001, n2 = 0.456 F(1.135) = 10.123, p = 0.002, n2 = 0.070 F(3.135) = 5.16, p = 0.002, n2 = 0.103 FT
E F(1.135) = 17.78, p < 0.001, n2 = 0.116 - -
F F(1.135) = 125.82, p < 0.001, n2 = 0.482 - F(3.135) = 2.139, p = 0.098, n2 = 0.045 FT
Note: A — muscle strength, B — FCI index, C — cylindrical grip of the paretic arm, D — abduction/adduction of the shoulder of the paretic arm, E — pinch grip of the paretic arm, F — flexion/extension of the elbow joint of the paretic arm.
Table 11. Comparison of treatment effect in groups
Parameter Group N Mean SE SD Min Max P
A With BFT 72 0.840 0.0294 0.249 0 1.0 0.001
Without BFT 71 0.655 0.0432 0.364 0 1.0
B With BFT 71 8.61 1.197 10.09 -23 35 0.004
Without BFT 71 5.66 0,57 4.81 -18 20
C With BFT 72 6.97 1.67 14.14 -9.0 77.0 0.059
Without BFT 71 3.44 0.76 6.37 -7.0 32.0
D With BFT 72 19.0 2.15 18.2 -12.0 84.0 0.017
Without BFT 71 10.45 0.77 6.46 0 27.0
E With BFT 72 2.28 0.66 5.63 -12.4 32.0 -
Without BFT 71 1.45 0.24 2.01 0 11.0
F With BFT 72 16.67 1.6 13.55 -18.0 70.0 0.059
Without BFT 71 14.30 1.85 15.6 -30.0 102.0
Note: A — muscle strength, B — FCI index, C — cylindrical grip of the paretic arm, D — abduction/ adduction of the shoulder of the paretic arm, E — pinch grip of the paretic arm, E — flexion/extension of the elbow joint of the paretic arm.
However, it should be noted that when comparing groups with BFT and without BFT for individual PT methods, significant differences in the effect of treatment are more often observed in the group with BFB, namely: in subgroups of e/s for FCI, capture of the paretic hand. Highly significant differences were noted for LT in the group with biofeedback, subgroups cylindrical grip of the paretic hand.
Since analysis of variance reveals a significant effect of treatment in all cases, but does not show clearly significant differences between groups, treatment effects were calculated as the difference between values after treatment and at baseline. The results of their comparison between groups in total for all PT methods are presented in Table 11 and Fig. 1.
Fig. 1. Effects of treatment in groups: A — muscle strength, B — FCI index, C — cylindrical grip of the paretic arm, D — abduction/adduction of the shoulder of the paretic arm, E — pinch grip of the paretic arm, F — flexion/extension of the elbow joint of the paretic arm (BFT — biofeedback)
After treatment, a more pronounced increase in muscle strength was noted in the group exercising on the apparatus with biofeedback: p = 0.011 (Fig. 2).
Fig. 3 shows that a more significant increase in the FCI index was observed in the BFB group (p = 0.004), which directly correlated with the improvement in muscle strength.
As can be seen from the graphs in Fig. 4, the cylindrical grip of the paretic hand increased in the main group, while in the control group it practically did not change (p = 0.059 trend).
The same data were obtained in the study of the pinched grip of the paretic hand — strengthening of the muscles of the hand and fingers prevailed in the group receiving biofeedback therapy (Fig. 5).
Improving the functioning of the paretic hand is an important task in the process of rehabilitation after focal brain damage. The inclusion of various methods in the early period prevents the development of pain contractures, improves everyday skills, which increases the independence of patients.
Fig. 2. The change in muscle strength in different groups: A — before treatment, B — after treatment (BFT — biofeedback, M/st — magnetic stimulation, PCT — photochromotherapy, LT — laser therapy,
E/st — electrical stimulation)
Fig. 3. The change in the FCI index in different groups: A — before treatment, B — after treatment (BFT — biofeedback, M/st — magnetic stimulation, PCT — photochromotherapy, LT — laser therapy, E/st — electrical stimulation)
M/st PCT LT E/st M/st PCT LT E/st
Method Method
Fig. 4. Cylindrical grip of the paretic hand in both groups: A — before treatment, B — after treatment (BFT — biofeedback, M/st — magnetic stimulation, PCT — photochromotherapy, LT — laser therapy, E/st — electrical stimulation)
M/st PCT LT E/st M/st PCT LT E/st
Method Method
Fig. 5. Pinch grip of the paretic hand in both groups: A — before treatment, B — after treatment (BFT — biofeedback, M/st — magnetic stimulation, PCT — photochromotherapy, LT — laser therapy,
E/st — electrical stimulation)
Fig. 6. The patient is engaged in the Pablo apparatus
The games offered for the development of paretic limbs on the Pablo apparatus help the patient improve motor function (Fig. 6). There are also games aimed at improving cognitive functions, which, together with the work of a psychotherapist, can improve the attention, memory and perception of victims.
Physiotherapy methods for all neurological signs worked better in the group treated with biofeedback (p < 0.001). At the same time, in both groups, a significantly better result in the study of muscle strength was observed during treatment with low-frequency magnetic stimulation, which was used to treat paresis and spasticity (p = 0.007), photochromotherapy (p = 0.082 trend) and laser therapy (p = 0.090 trend), which were used to reduce pain syndromes, Table 12, Fig. 7.
A significant effect was obtained in the group that received additional treatment with BFT in total for all methods of PT, p = 0.002, and the most pronounced effect was obtained with the use of magnetic stimulation (p = 0.007).
Fig. 7. Distribution of differences after treatment and initially in percentage for muscle strength in different groups: A — magnetic stimulation, B — photochromotherapy, C — laser therapy,
D — electrical stimulation
Table 12. Distribution of differences after treatment and at baseline in percent for muscle strength in
groups A with BFB and B without BFB
PT, % MS* PHТ LT ES Total**
А B А B А B А B А B
0.0 0 18.8 4.8 19.0 0 0 0 12.5 1.4 15.5
0.5 16.1 31.3 42.9 47.6 41.7 50.0 25.0 25.0 29.2 38.0
1.0 83.9 50.0 52.4 33.3 58.3 50.0 75.0 62.5 69.4 46.5
Note: *p = 0.007, **p = 0.002.
Table 13. Dynamics of values on the Rankin scale in both groups, % (people)
Rankin scale Mane group Control group
Before treatment After treatment Before treatment After treatment
1 - 11.1 (8) - -
2 8.3 (6) 45.8 (33) 7 (5) 29.6 (21)
3 70.9 (51) 41.7 (30) 80.3 (57) 57.7 (41)
4 20.8 (15) 1.4 (1) 12.7 (9) 12.7 (9)
Total 100(72) 100 (72) 100 (71) 100 (71)
When evaluating the clinical picture, it was noted that according to the modified Rankin scale, the best dynamics was observed in the main group (p < 0.001). Rankin scale scores in both groups correlated with rehabilitation routing scale scores (Table 13).
During the evaluation process, it turned out that the pattern of treatment, namely the positive result of treatment, was maintained in both groups, but the effect of the treatment was different. It was confirmed by statistical processing methods that the result of treatment was better in younger patients in the main group, however, in the group where BFB classes were not conducted, the result was better in older patients, which can be explained by the fact that the older contingent was more responsible for other activities (exercise
therapy, PT, speech therapist-aphasiologist) than younger patients who were more interested in doing the Pablo device.
The discussion of the results
As a result, patients who received complex rehabilitation with the use of additional biofeedback and sessions with a psychotherapist showed an improvement in cognitive functions, such as memory, attention, logical and constructive thinking, and a more pronounced improvement in motor skills of paretic limbs. When comparing the influence of physical factors in both groups, the best effect was obtained when exposed to low-frequency magnetic stimulation (Fig. 8).
Fig. 8. Influence of different physical factors on the effect of treatment on muscle strength in both groups (BFT — biofeedback, M/st — magnetic stimulation, PCT — photochromotherapy, LT — laser therapy, E/st — electrical stimulation)
The inclusion of biofeedback therapy and sessions with a psychotherapist in the rehabilitation course made it possible to improve the values obtained by assessing the modified Rankin scale and optimize the rehabilitation routing scale to the level of 1.2, i. e. further rehabilitation of patients can be carried out in a day hospital and in an outpatient clinic, which allows us to conclude that the complex rehabilitation treatment is cost-effective.
Conclusions
Based on the study, it is possible to recommend the inclusion of classes on the Pablo biofeedback apparatus in the course of rehabilitation of patients after stroke. Comprehensive treatment together with a psychotherapist and biofeedback contributes in a playful way to more effectively expand the range of motion of paretic limbs. In addition, the study showed that even clinically healthy patients could have a pronounced cognitive deficit,
which can only be fixed with the help of special tests. Only a psychotherapist can correct cognitive dysfunction, which was confirmed during the course of rehabilitation in the main group of subjects [26].
References
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Received: June 25, 2022 Accepted: July 14, 2022
Authors' information:
Elena N. Zharova — MD; garlen@inbox.ru
Elena A. Vershinina — Researcher; ver_elen@mail.ru
Anastasia B. Bondarenko — Physiothrapist; nastjberezkina@yandex.ru
Olga V. Titova — Neurologist; t1.olga@mail.ru
Natalya V. Vlasova — Medical Psychologist; Vlasova_NV@almazovcentre.ru Anna A. Oleynik — PhD in Medicine; Oleinik_AA@almazovcentre.ru Victoria G. Nezdorovina — PhD in Medicine; Nezdorovina_VG@almazovcentre.ru Konstantin B. Abramov — PhD in Medicine; KB_Abramov@almazovcentre.ru
Реабилитация пациентов после инсульта с применением биологической обратной связи и мультидисциплинарного подхода
Е. Н. Жарова1, Е. А. Вершинина2, А. Б. Бондаренко1, О. В. Титова1, Н. В. Власова1, А. А. Олейник1, В. Г. Нездоровина1, К. Б. Абрамов1
1 Северо-Западный федеральный исследовательский центр им. В. А. Алмазова, Российская Федерация, 197341, Санкт-Петербург, ул. Аккуратова, 2
2 Институт физиологии им. И. П. Павлова,
Российская Федерация, 199034, Санкт-Петербург, наб. Макарова, 6
Для цитирования: Zharova E. N., Vershinina E. A., Bondarenko A. B., Titova O. V., Vlasova N. V., Oleynik A. A., Nezdorovina V. G., Abramov K. B. Rehabilitation of patients after stroke using biofeedback and a multidisciplinary approach // Вестник Санкт-Петербургского университета. Медицина. 2022. Т. 17. Вып. 2. С. 70-87. https://doi.org/10.21638/spbu11.2022.201
Большая распространенность сосудистых заболеваний головного мозга (преимущественно в результате атеросклеротического поражения сосудов) делает проблему реабилитации больных с двигательными нарушениями, постинсультным расстройством высших психических функций — одной из наиболее актуальных в современной медицине. До 80 % перенесших инсульт пациентов имеют стойкий неврологический дефицит. Около четверти из этих случаев составляет глубокая инвалидность с потерей возможности самообслуживания. Наиболее полного восстановления утраченных после инсульта функций удается добиться в течение первого года после возникновения
острого расстройства мозгового кровообращения. При этом, несмотря на успехи современной нейрореабилитации, до 80 % больных, перенесших инсульт, остаются инвалидами. В связи с этим своевременное оказание адекватной экстренной медицинской помощи при инсульте и полноценная реабилитация относятся к важнейшим задачам системы здравоохранения, клинической неврологии и нейрохирургии. В данной статье для применения в системе комплексной реабилитации предложен метод биологической обратной связи на аппарате Pablo и занятия с психологом. Полученный положительный эффект описан в качестве результата исследования, а сам метод может быть предложен для практического применения в специализированных клиниках. Ключевые слова: инсульт, реабилитация, биологическая обратная связь, психотерапия.
Статья поступила в редакцию 25 июня 2022 г., рекомендована к печати 14 июля 2022 г.
Контактная информация:
Жарова Елена Николаевна — д-р мед. наук; garlen@inbox.ru Вершинина Елена Андреевна — науч. сотр.; ver_elen@mail.ru
Бондаренко Анастасия Борисовна — врач-физиотерапевт; nastjberezkina@yandex.ru Титова Ольга Валерьевна — врач-невролог; t1.olga@mail.ru
Власова Наталья Вячеславовна — медицинский психолог; Vlasova_NV@almazovcentre.ru Олейник Анна Анатольевна — канд. мед. наук; Oleinik_AA@almazovcentre.ru Нездоровина Виктория Геннадьевна — канд. мед. наук; Nezdorovina_VG@almazovcentre.ru Абрамов Константин Борисович — канд. мед. наук; KB_Abramov@almazovcentre.ru
