Indicators of Cerebral Blood Flow Changes in Venous Vessels of Children With ICP in the Course of Physical Rehabilitation Using the Bobath Therapy Method

Размещено на http://www.allbest.ru/

Indicators of Cerebral Blood Flow Changes in Venous Vessels of Children With ICP in the Course of Physical Rehabilitation Using the Bobath Therapy Method

Vitaliy Kashuba,

SEU National University of Physical Education and Sports of Ukraine (c. Kyiv)

Abstract

The article deals with the study of transcranialdopplerography (TCDG) changes on blood vessels of the brain within the course of physical rehabilitation using the Bobath therapy method. TCDG is one of the key innovative methods of diagnosis of the central nervous systemdiseases which are used in the complex with the other methods of instrumental diagnostics such as electroencephalography (EEG), magnetic resonance therapy (MRT), etc. Considerable importance is given to the TCDG results of blood vessels of the brainin the diagnosis of the causes of neurological disorders in infantile cerebral paralysis (ICP).

The authors who carriedout neuroimaging of braindamagein children with ICP showed that cortical subcortical atrophy is the result of arterialischemic, and periventricular - venous and hemorrhagic lesions. And it was found out that vascular lesions of the brain lead to ICP. Among the existing innovative and effective methods of physical rehabilitation, Bobath-therapy distinguishesitself. After the results of the studytraditional methods of physical therapy and the methods of the method Bobath-therapy have a significant effect on the brain venous blood flow.However, scientifically substantiated results that would indicate its influence on the psychomotor development of children with CNS defects, namely, with ICP is not enough, and its effect on the cerebral blood flow is not studied at all.

Key words: transcranial doppler, Bobath- therapy, brain vessels, blood flow, cerebral palsy.

Віталій Кашуба, Божена Буховець. Показники змін мозгового кровотоку у венозних судинах дітей, хворих на ДЦП у курсі фізичної реабілітації з використанням методу Бобат -терапії. У статті досліджено вплив транскраніальної доплерографії (ТКДГ) на судин головного мозку в курсі фізичної реабілітації з використанням методу Бобат-терапії. ТКДГ є одним із провідних інноваційних методів діагностики захворювань центральної нервової системи, що використовуються в комплексі з іншими методами інструментальної діагностики, такими як електроенцефалографія (ЕЕГ), магнітно-резонансна терапія (МРТ) тощо. Суттєвого значення надано результатам ТКДГ судин головного мозку (ГМ) у діагностиці причин неврологічних порушень при дитячому церебральному паралічі (ДЦП). Автори, які проводили нейровізуалізацію ушкоджень ГМ дітей із ДЦП, показали, що корково-підкоркова атрофія є наслідком артеріально -ішемічного, а перивентрикулярна - венозно- геморагічного ураження й визначили, що судинні ураження ГМ призводять до ДЦП. Серед відомих інновацій них та ефективних методів фізичної реабілітації відзначається Бобат-терапія, проте науково обґрунтованих результатів, які б свідчили про її вплив на психомоторний розвиток дітей з ураженнями ЦНС, а саме з ДЦП, замало, а її вплив на мозковий кровотік зовсім не досліджувався. За результатами дослідження, традиційні методи фізичної реабілітації та метод Бобат-терапії мають істотний вплив на кровотік ГМ венозними судинами.

Ключові слова: транскраніальний допплер, Бобат-терапія, судини головного мозку, кровообіг, церебральний параліч.

transcranial doppler ultrasonography cerebral vessel

Виталий Кашуба, Божена Буховец. Показатели изменений мозгового кровотока в венозных сосудах детей, больных ДЦП, в курсе физической реабилитации с использованием метода Бобат -терапии. В статье исследуются влияние транскраниальной допплерографии (ТКДГ) на сосуды головного мозга (ГМ) в курсе физической реабилитации с использованием метода Бобат -терапии. ТКДГ является одним из ведущих инновационных методов диагностики заболеваний центральной нервной системы, используемых в комплексе с другими методами инструментальной диагностики, такими как электроэнцефалография (ЭЭГ), магнитно-резонансная терапия (МРТ) и др. Существенное значение придается результатам ТКДГ сосудов ГМ в диагностике причин неврологических нарушений при детском церебральном параличе (ДЦП). Авторы, которые исследовали нейровизуализацию повреждений ГМ детей с ДЦП, показали, что корково-подкорковая атрофия является следствием артериальноишемического, а перивентрикулярная - венозно-геморрагического поражения, и определили, что сосудистые поражения ГМ приводят к ДЦП. Среди существующих инновационных и эффективных методов физической реабилитации отмечается Бобат-терапия, однако научно обоснованных, результатов свидетельствующих о ее влиянии на психомоторное развитие детей с поражениями ЦНС, а именно с ДЦП, недостаточно, а ее влияние на мозговой кровоток вовсе не исследовалось. По результатам исследования, традиционные методы физической реабилитации и метод Бобат-терапии оказывают существенное влияние на кровоток ГМ по венозным сосудам.

Ключевые слова: транскраниальная допплер, Бобат-терапия, сосуды головного мозга, кровообращение, церебральный паралич.

Formulation of Scientific Problem and its Significance

The Transcranial Doppler (TCDG) of the brain vessels is one of the leading methods for diagnosing CNS diseases that are used in combination with other methods of instrumental diagnostics (EEG, MRI, etc,), based on its results in combination with the diagnosis of neurological status and psychophysical state, it is possible to determine the prognosis and to make a program of physical rehabilitation of the patient [1]. The significance is attached to the results of the TBC of the cerebral vessels in the diagnosis of the causes of neurological disorders with children's cerebral palsy [2; 11]. Indeed, despite of the fact that the main factors of the development of cerebrospinal fluid are perinatal, a significant number of researchers consider the leading intrauterine lesions of the fetus (37-60 %) against the background of hypoxia. Most often it is vascular-ischemic, or hemorrhagic lesions, in which the most vulnerable is the subcortical and periventricular white matter of the brain. The authors who conducted neuroimaging in lesions of children with cerebrospinal fluid showed that cortical subcortical atrophy is the result of arterial-ischemic, and periventricular - venous and hemorrhagic lesions. Vascular lesions of the brain, as a factor in cerebral palsy, are put by other authors on the first place. Some authors have proven that the regulation of arterial and venous blood circulation is related to the compensation of blood circulation in the brain tissues, which occurs in conditions of increase or reduction of inflow and outflow of blood [12; 14]. It shows the connection between venous and liquor pressure, Significant reserve capabilities of the venous system of the brain, which differs in the diversity of the structure of vessels of different caliber, large capacity, the possibility of outflow in two directions, are also stated. [1]. That is, the method of TCDG, which investigates the arterial and venous system of the brain at the extra and intracranial levels, can reveal their occlusion-stenosing lesions, deformations, anomalies of vascular development, arterial and venous aneurysms, arteriovenous malformations, venous circulatory disorders and their hemodynamic evaluation significance is important in predicting the possibility of compensation for lost functions [3; 6; 7; 8]. By analyzing the changes of TCDG in the main clinical forms of cerebral palsy, the authors has showen that at spastic diplegia, neurophysiological disorders are more moderate than in other forms of cerebral palsy, and with double hemiplegia marked decrease in cerebral blood circulation and increase intracranial pressure. At the same time, attention was paid to the fact that in spastic forms of cerebral palsy motor disorders are combined with a decrease in the linear velocity of blood circulation in the anterior and median cerebral arteries, which is accompanied by a significant increase in vascular resistance [17].

Among the existing innovative and effective methods of physical rehabilitation, Bobath therapy was established, It was created in the 30s of the XXth century by the practicing physiotherapist Bertha and the physician psychiatrist Carl Bobath. The concept of the method was substantiated in the 1940s, and in the 1950s, in addition to treating by the pose and implementing a complex of specialized physical exercises; the areas of speech therapy, gaming activity, selfcare and child care education with lesion of central nervous system (CNS) were enriched, However, scientifically grounded results that would indicate its impact on the state of children with CNS lesions is too little [4; 6; 16].

The results of a preliminary analysis of changes in the parameters of TCDG using the Bobath method for children with cerebral palsy have allowed us to show that the most marked were intravenous circulation venous sinus (CVS). Namely, according to the algorithm developed by us for the estimation of violations, at the beginning of the course, only 2,9 % of children had deviations up to 70 % increase, the variants of increase of blood circulation were 150-190 %, which were recorded in 37,1 % cases, even in 14,3 % of children had an increase in blood circulation of more than 190 %. That is, in more than half from all children there is a marked increase in blood circulation to PVA. At the end of the course, most children (62,9 %) recorded changes within the 70 % increase [15]. The obtained data prompted us to investigate the absolute parameters of blood circulation changes in the venous system of the brain,

Link with Scientific Plans, Topics. The work was performed in accordance with the research plan of the State University of Physical Education «National University of Physical Education and Sports of Ukraine» and it's a part of the research on the topic: «Theoretical and methodological foundations of the health forming technologies in the process of physical education of different population groups» (state registration number 0116U001615).

The purpose of this research was to determine how the venous brain blood circulation of polio children will change due to the 6-month course of different approaches to physical rehabilitation, including using the Bobath method.

Objectives of the Study:

1. According to the scientific and methodological literature, study and generalize approaches to the development of technologies aimed at increasing the effectiveness of the process of physical rehabilitation for children witch using traditional methods or Bobath therapy.

2. Determine the effect of the Bobat-therapy method on cerebral blood flow in venous vessels in the course of physical rehabilitation.

Research Methods, To accomplish the tasks, the following research methods were used: analysis of scientific and methodological literature and documentary materials; instrumental diagnostic method for cerebral blood flow with TCDG.

Presentation of the Main Material and the Substantiation of the Results of the Study

For the determination of BBC of children of preschool age with various CNS lesions (tabl. 1) for the influence of the physical therapy using the Bobath's method, 35 children aged 4,1 ± 1,1 years (at the beginning of the course) were examined. That was the main group (MG). All of 72 procedures were conducted. There was also a control group (CG), the results of the BBC had been studied and analyzed in 34 children aged 3,8 ± 0,9 years who were undergoing rehabilitation using standard methods.

During registering TCDG, probes of continuous and pulsed radiation of 2, 4 and 8 MHz frequency were used. Measured linear velocity of blood circulation (LVBF) - systolic, middle and diastolic - with the following indices: Stuart (systole-diastolic index) (ISD), Gosling pulsatory index (PI). Resource Purselo index (RI) reflecting elastic-lens properties, vascular tone and their peripheral resistance. In order to characterize the changes in venous blood circulation, parameters of internal jugular veins (DPV), vertebral venous plexus (HRV). Rosenthal veins (BP) and direct venous sinus (PVS) were analyzed, in which the most significant changes in blood circulation were observed. [1].

Table 1 The Distribution of Children with CNS lesions in the form of Cerebral Palsy

The course of Bobath therapy included: the provision of treatment using specialized child's body position, the reduction of the influence of pathological reflexes (ASSHT, lip reflex (snot reflex), sucking, search, Moreau, cross extensor reflex, etc,) on the musculoskeletal system and implementation, the complex of the exercises for the formation of elementary motor skills and the development of basic physical qualities [4].

During the treatment, provision referred to «stacking» the limb or limbs, and sometimes to the entire body of the child in the defined position correction using specialized devices or their imitations . The main indication for the usage of this area are prevention or blocking the action of pathological re flexes that were result in abnormal positions of the joints and muscle groups and complicate the formation of basic motor skills; prevention of contracture and deformation formation; adaptation of the body to different positions relative to the gravity force, [13].

Inhibition special exercises, which reduced or blocked the effect of pathological reflexes, has contributed to the formation of basic motor skills, etc. Carried out during physical activity, expert in physical rehabilitation and child were sent to inhibition (blockage) or eliminate abnormal motor patterns, stereotypes, promoted to more correct movements by stimulation, inhibition, facilitation, rotation, as well as the usage of positions that suppressed the action of pathological reflexes. When the inhibition was understood - blocking abnormal movements (tremors, associated and athetoid movements without dissociation), body positions (flexion or extension) and reflections that hinder the development of normal movement (corresponding to the biologic al age of the Ochild). Facilitation is the facilitating the implementation of correct (normal) movements and the relationship between a child and a specialist in physical rehabilitation and facilitates the implementation of physiological movements. Facilitation includes propriorecipe, cognitive, perceptual and emotional aspects and is an active sensorimotor learning process. Stimulation is carried out with the help of tactile and kinesthetic stimuli necessary for the child to feel better the correct movements and positions of his own body in space [9].

Exercises, which were carried out, were taken into account the individual abilities of the child. Standard approaches to the rehabilitation of preschool children with CNS lesions envisaged conducting lessons for physical therapy and pediatric massage [10].

Sufficiently informative were the changes in blood venous circulation due to the influence of using methods Bobath therapy, which, in comparison with the traditional approach, had certain differences. Comparison of the effect on blood flow in the extraction vessels of the intracranial venous system, which according to many authors is decisive in the development of hemodynamic disorders in cerebral palsy, First of all, it refers to the blood flow in the internal jugular veins, which collect blood from the sinuses of the solid cerebellum, where blood flow from the surface veins of the brain, which in turn collects blood from the cerebral cortex, Changes in the system of left IJV in the MG children (table 2) concerned a significant increase (p <0,05) of LVBFmin from 7,81 (6,95; 8,68) to 9,55 (7,81; 10,40) cm/s with the fact that LVBFmax and LVBFaver significantly (p <0,05) decreased from 52,9 (48,6; 64,2) to 46,8 (41,6; 55,5) and from 30,3 (21,7; 33,8) to 25,1 (22,5; 28,6) cm/s, respectively, The blood flow in the right IJV (table 2) increased (p <0,05) by LVBFmin and LVBFaver from 6,08 (5,21; 8,68) to 7,81 (6,08; 7,82) cm/s and from

21.7 (17,3; 28,6) to 26,9 (20,8; 29,5) cm/s, respectively, Characteristic was decreased (p <0,05) of the vascular resistance in terms of Ri from 0,87 (0,83; 0,88) to 0,81 (0,79; 0,85) on the left, with 0,88 (0,83; 0,89) to 0,84 (0,82; 0,87) to the right and to RI from 1,72 (1,58; 2,15) to 1,44 (1,37; 1,71) to the right, which testified Significant improvement of venous current in the system of jugular veins, The influence of the traditional method of physical rehabilitation on blood circulation in the IJV was somewhat different and related, in the first place, to a significant increase (p <0,01) LVBFaver on the left from 19,1 (17,3; 20,8) to

23.8 (22,5; 29,5) cm/s and its significant (p <0,05) increase to the right of 21,2 (18,2; 25,1) to 25,1 (23,4; 27,7) cm/s, At the same time, the resistance of blood circulation to the left IJV also decreased significantly (p <0,01) from 0,87 (0,84; 0,87) to 0,81 (0,79; 0,84) for RI, from 1,89 (1,75; 2,16) to 1,38 (1,29; 1,62) for RI and the vessel tone from 7,40 (6,30; 7,83) to 5,10 (4,86; 6,25) for ISD, in contrast to the right, the decrease in vascular resistance in which was significant but less significant (p <0,05) for RI from 0,84 (0,81; 0,85) to 0,81 (0,80; 0,85) for PI with 1,76 (1,45; 2,00) to 1,37 (1,21; 1,52) and vascular tone (p <0,05) for ISD with 6,13 (5, 33; 6,86) to 5,27 (4,89; 6,10).

Table 2 Changes in Blood Flow in IJV of Children in the MG and the CG During the Course of Rehabilitation, M (25; 75)

# - p <0,05; ## - p <0,01 - between MG and CG data.

* - p <0,05; ** - p <0,01 - between the data at the beginning and at the end.

Characterizing changes in the blood flow in the IJV can be stated that due to the rehabilitation measures in the MG and the CG there is a marked improvement in blood flow, however, which is more balanced in CG.

The results of the blood flow data in the VVP (table 3) are supplemented with evidence of a pronounced decrease (p <0,01) of LVBFmax to the left of 14,7 (13,8; 15,6) to 13,0 (12,1; 13,8) cm/s using the Bobath method, while the traditional approach caused a significant increase (p <0,05) in LVBFmax from 12,1 (11,2, 15,6) to 13,9 (12,1; 16,5) cm/s. The same multidirectional effects of changes in blood flow to the right. The children in the MG have had LVBFmin and LVBFaver decreased from 4,34 (3,47; 5,21) to 4,29 (3,47; 4,34) cm/s and from 7,81 (6,08; 9,55) to 7,80 (6,08; 7,81) cm/s, respectively, and in children CG their significant (p <0,05) increase from 4,34 (3,47; 6,08) to 5,65 (4,34; 12,3) cm/s and 9,12 (8,68; 9,55) to 9,55 (7,81; 15,2) cm/s respectively. At the same time, the resistance and tone of the vessels VVP probably have not changed in both the MG and the CG. With the exception of a decrease (p <0,05), the vascular resistance of the PI index to the left from 1,10 (1,00, 1,30) to 0,96 (0,90, 1,14). That is, the changes in blood flow of children in MG are more favorable, Significant blood flow changes of the CG children accompanied by an increase in LVBF, which may indicate a violation of the elastic-elastic properties of blood vessels in the studied area.

Table 3 Changes in Blood Circulation in VVP of Children in the MG and the CG During the Course of Rehabilitation, M (25; 75)

# - p <0,05; ## - p <0,01 - between the MG and the CG data.

* - p <0,05; ** - p <0,01 - between the data at the beginning and the end.

The effect on blood flow in RV (table 4), which in the MG almost has not changed except for significant (p <0,05) increase of LVBFmax to the left from 13,3 (12,0; 13,5) to 13,5 (12,0; 14,2) cm/s, and of children in CG was characterized by a significant (p <0,05) reduction of LVBFmax, LVBFmin and LVBFaver on the left from 12,8 (11,2; 15,0) to 11,2 (9,8; 14,2) cm/s, from 3,76 (3,01; 6,02) to 3,01 (1,50; 4,51) cm/s and from 7,90 (6,77; 9,02 ) to 6,74 (3,76; 9,02) cm/s, respectively, and less significant (LVBFmin only) to the right of 4,14 (3,01; 4,51) to 3,01 (2, 26; 4,40), p<0,05 was informative, It should be noted that according to the average data LVBFmax was within the age limit. They also recorded a significant (p <0,05) increase in vascular tone by ISD from 3,13 (3,00; 4,00) to 3,75 (3,25; 4,50) and 3,71 (2,67; 4,67) to 4,00 (3,75; 5,00) left and right, respectively.

The influence on the blood flow in the DVS through which the outflow of venous blood from the vascular plexus and the inferior regions of the brain is carried out (table 5) was characterized by more significant (p <0,05) changes in MG children, which related to LVBFmax reduction from 71,4 (60,1; 81,2) to 62,4 (54,1; 72,1) cm/s and LVBFaver with 37,6 (30,0; 39,1) to 32,3 (28,5; 35,3) cm/s against the background of an increase in LVBFmin from 6,02 (3,76; 7,52) to 6,77 (6,00; 8,27) cm/s. At the same time, in CG children, LVBFmax was also significantly decreased (p <0,05) from 70,3 (52,6; 88,7) to 61,6 (55,6; 72,9) cm/s and LVBFaver was 34,9 (30,0; 42,1) to 31,6 (30,0; 35,0) cm/s, At the same time, in the MG the resistance decreased from 0,92 (0,91; 0,94) to 0,89 (0,88; 0,92) and the blood vessel tone from 12,50 (10,80; 16,20) to 9,09 (8,09; 11,80) for the Ri and ISD indices respectively, whereas in the CG they remained intact.

Table 4. Changes in blood Circulation in RV in Children From the MG and the CG During the Course of Rehabilitation, M (25; 75)