USAGE OF ROBOTIC MECHANOTHERAPY FOR MOTOR DISORDERS IN CHILDREN
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
All variety of child’s activity is based on voluntary motions. A voluntary motion is a type of higher nervous activity which is impossible without precise perception of position of the body and its segments in space, as well as without adequate activity of motional analyzer and without appropriate motivation, i.e. aspiration to change the position of the body and its parts. On the basis of spatial perception the movement image is developed, and a voluntary motion is synthesized [1].
Various diseases of central nervous system and spinal and cerebral injuries result in disarrangement of perception of body position in space, and disordered synthesis of voluntary motional response that leads to loss or disorder of motional function and social disadaptation in the patient [1, 2].
Central paralysis as result of spinal and cerebral diseases and injuries refer to severe neurologic or neurosurgical pathology, which results in patient’s disability [1, 3].
It is generally accepted that efficiency of rehabilitation measures depend on early initiation of the rehabilitation process. At the same time, the rehabilitation program should correspond to the specific period of a disease of traumatic disease, and the pattern of course of pathologic process [1, 4].
The chosen group of medical rehabilitation measures must strictly correspond to specific objectives of rehabilitation. The procedures, which are not directed to salvation of specific tasks, are useless, as well as harmful, because of possible complications [1, 4]. Various clinical features of motional disorders require some differentiated approaches to types and methods of restorative treatment [2, 5].
The program of rehabilitation treatment is a combination of some sequential stages. Each consecutive stage testifies achievement of higher level of movement arrangement, increasing randomness of management, and lower dependence of motional functions on external conditions.
Mechanotherapy is a method of remedial gymnastics which is based on realization of dosed motions by means of the specific devices (the devices for passive motions), when motions are realized with the special drive (motor) for simplifying movements, and active motion devices, when the patient brings the device into action by means of muscular force [6, 7].
Mechanotherapy is used for rehabilitative treatment of various motion disorders with necessity for increasing range of motion in the joints and increasing strength in specific muscle groups.
Mechanotherapy is related to the methods of sanogenetic therapy, because it leads to increase in functional adaptation in the patient. For the present day the therapeutic effects of mechanotherapy have been studied and discovered adequately: tonic action, trophic action (replacement and compensation of a defect by means of true (replacement) regeneration, reverse favorable development of atrophic and degenerative processes), development of functional compensations, normalization of functions and integrity of body activity [6].
The positive features of mechanotherapy include the following components: biologic adequacy, since a motion is a physiologic function of the body; versatility, since mechanotherapy produces the effects to all organs through all levels of somatic and vegetative nervous and endocrine system; absence of a negative effect in case of correct dosage of physical exercises; a possibility of long term administration for both remedial and preventive purposes [5, 6].
Mechanotherapy is combined with remedial gymnastics, massage, balneology and physiotherapy [3]. Electronic control systems allow dosing physical load and its variance in dependence on the tiniest changes in functional state of the patient which are not perceived at the level of consciousness.
Objective – to estimate the efficiency of usage of robotic mechanotherapy for treating motor disorders in children.
MATERIALS AND METHODS
We observed 24 children (age of 5-15; median 10 ± 3.3) with motional disorders. There were 13 girls and 11 boys.
The children were distributed into 2 groups (table 1): the group 1 – 12 children, mean age of 10.1 ± 3.93, 5 boys and 7 girls (42 % and 58 % respectively). The greatest proportion was the children at the age of 10-15 (62.7 %), and only 3 kids at the age of 5. The duration of the disease was 2-8 years (on average 7.66 ± 2.59).
| Table 1 | |||
| Distribution of children into the groups | |||
The second group was 12 children, mean age of 9.43 ± 2.76, with equal number of boys and girls. The duration of the disease was from 1 year to 8 years (on average 5.29 ± 3.35).
The motion disorders were associated with traumatic brain injury, stroke and cerebral paralysis. The distribution of the diseases is presented in the figure 1. The group 1 included 58.3 % (n = 7) of children with infantile cerebral paralysis, 33.3 % (n = 4) with consequences of traumatic brain injury, and 8.4 % (n = 1) with restorative period of stroke.
The distribution of the diseases in the group 2 was as indicated below: the greatest proportion was the children with infantile cerebral paralysis – 8 patients (66.6 %); consequences of traumatic brain injury – 3 patients (25 %); 1 kid with restorative period of stroke (8.4 %).
Therefore, distribution of the children according to the age and forms of diseases are almost the same in two groups.
The clinical examination methods were used. Neurologic status was confirmed according to the syndromes. EEG, doppler and radiologic characteristics of child’s state were estimated. Motion disorders were estimated according to degrees of severity of spastic paralysis (table 2). Spasticity was estimated with the scales from Scientific Research Institute of Neurology (Stolyarova L.G., Kadykov A.S., Tkaneva G.R., 1982) (table 3).
| Table 2 | |||||||||||||
| Severity of spastic paralysis according to the scale of Scientific Research Institute of Neurology (Stolyarova L.G., Kadykov A.S., Tkaneva G.R., 1982) | |||||||||||||
| Table 3 | ||||||||||||
| Spasticity estimated with the scale of Scientific Research Institute of Neurology (Stolyarova L.G., Kadykov A.S., Tkaneva G.R., 1982) | ||||||||||||
Hand dynamometry was used for estimation of hand strength. Two measurements for each hand were used, and the best result was recorded. Basic absolute strength was estimated, i.e. the value indicated by the dynamometer.
Besides conventional neurorehabilitation, the children of the first group received robotic mechanotherapy with Artromot-R device. This technique of treatment and all examinations were conducted after obtainment of the written voluntary informed consent from official representatives of the patients. Efficiency was estimated according to restoration of functional activity, decreasing level of spasticity, increasing hand strength estimated by the dynamometer.
The data was analyzed with Statistica 7 software. The reliability of statistic differences was estimated with Student’s test. The critical level of significance was p < 0.05.
The study was approved by the ethical committee of Regional Clinical Center of Miners’ Health Protection. The study corresponds to the ethical standards of Helsinki declaration – Ethical Principles of Medical Research with Human Subjects 2000, and The Rules for Clinical Practice in Russian Federation confirmed by the order of Russian Ministry of Health, 19.06.2003, #266.
RESULTS AND DISCUSSION
The examined children suffered from the following motion disorders: tetraparesis – 7 patients, right-sided hemiparesis – 11, left-sided hemiparesis – 4, lower paraparesis – 2. The table 4 demonstrates distribution of the children according to the forms of motion disorders and contractures.
| Table 4 | ||||||
| Children distribution according to types of motor disorders and contractures | ||||||
The data for the first and the second group correspondingly: tetraparesis – 3/4; right-sided hemiparesis – 6/5; left-sided hemiparesis – 1/3; lower paraparesis – 0/2 cases. Joint contractures were in all children, in half of cases – in 2 and more joints. Contractures in one joint were in 4 children of the first group and in 5 children in the second group; in 2 joints in 5 children of each group; in 3 joints: 2 children in the first group, 3 in the second group.
The table 5 demonstrates the electroencephalographic characteristics.
| Table 5 | ||||
| Electroencephalographic patterns in the groups | ||||
EEG study showed some focal pathologic manifestations in the parietotemporal deflections to the left in 2 children of the group 1, in 1 kid in the group 2; in the temporal region to the right – 1; in the parietofrontal region to the left – 2 children in the group 1; the focus of slow wave activity to the left in 4 children in the group 1; seizure pattern in 6 children, 3 cases in each group; diffuse cerebral changes in 8 children in the group 2.
Therefore, all children with motion disorders showed some pathologic phenomena of cerebral functional activity, with seizure pattern in the quarter of the cases.
Cerebral perfusion was estimated with ultrasonic doppler of cerebral vessels (abs) (Fig. 2).
Figure 2
Ultrasonic doppler examination of cerebral vessels
Ultrasonic doppler of cerebral vessels found some signs of discirculation in the orbital veins in 7 children of the group 1, and 6 in the group 2: hyperkinetic type of perfusion was in 6 children, 3 cases in each group; only in 1 kid of the group 1 – discirculation in the supratrochlear arteries. There were no pathologies in 4 cases: 1 child in the group 1 and 3 children in the group 2.
Therefore, cerebral perfusion changes were of equal frequency in both groups, but they were statistically insignificant. Hyperkinetic type of perfusion was only in the children at the age older 10.
EchoEG characteristics are presented as indicated below: no pathology in 8 cases in the group 1, and in 7 in the group 2. Other children showed some signs of intracranial hypertension, i.e. 4 and 5 cases in the groups 1 and 2 correspondingly.
The table 6 shows the data of brain neurovisualization (MSCT). Cerebral MSCT found hydrocephaly of the degrees 1 and 2; ventriculodilatation; cerebral cysts; atrophic changes in brain cortex. Therefore, hydrocephaly and cysts demonstrate the same rates in both groups, with their combination in 30 %. There was no pathology in 2 cases in the group 2.
| Table 6 | ||||||
| Group distribution of children according to neurovisualization (MSCT) | ||||||
The examination of eye ground found some signs of hypertensive angiopathy in 9 cases including 4 cases in the group 1, and 5 in the group 2; atrophy of papilla nervi optici in 2 cases, 1 case in each group. There were no cases of pathology in other cases.
At admission all patients were examined for intensity of paralysis and spasticity (the scale from Scientific Research Institute of Neurology, Stolyarova L.G., Kadykov A.S., Tkaneva G.R., 1982).
According to our data, the degree of intensity of paresis was 3.45 ± 0.69 points in the group I, 3.33 ± 0.65 in the group 2; spasticity was 3.27 ± 0.65 in the group 1, 3.0 ± 0.74 in the group 2.
Hand dynamometry was used for estimation of absolute strength (kg) (Fig. 3).
Figure 3
The results of absolute strength (kg) estimated with hand dynamometry before treatment
The standard program of neurorehabilitation was used for treating all children. Additionally, the children of the group 1 received robotic mechanotherapy with Artromot-R for joint mobilization. Artromot-R-K2 PRO CHIP was used for the knee and hip joints (5 children), Artromot-R –F – for hands and fingers (2 children), Artromot-R-H – for wrist joint (3 children), Artromot-R-S3 – for shoulder joint (2 children). The treatment course included 10 sessions. All children tolerated the procedures properly and without complications.
After mechanotherapy the following results were achieved:
All children showed increasing volume of motion in the affected extremities (Fig. 4). Mechanotherapy resulted in increasing hand strength: from 3.0 ± 0.77 to 4.91 ± 0.83 kg to the left, more than 1.5 times in comparison with the basic values (p = 0.015); 5.0 ± 0.89 to 9.45 ± 0.93 kg to the right, almost 2 times higher in comparison with the basic values in the group 1 (p = 0.001).
Figure 4
The results of absolute strength (kg) estimated with hand dynamometry after treatment
Realization of only traditional therapy in the group 2 also resulted in increasing hand strength 2 weeks after beginning of treatment, but insignificantly (p > 0.05) (table 7). Moreover, the outcomes are better for the right hand in comparison with the left one: from 4.92 ± 0.99 to 5.26 ± 0.75 kg (p = 0.37) for the right hand; the same level for the left hand: 3.67 ± 1.44 at the basic level and 3.83 ± 1.40 kg (p = 0.78).
| Table 7 | |||||||||||||||
| Severity of spastic paralysis in 2 groups according to the scale of Scientific Research Institute of Neurology (Stolyarova L.G., Kadykov A.S., Tkaneva G.R., 1982) | |||||||||||||||
The degrees of intensity and severity of spastic paralysis after treatment are presented in the table 7. Therefore, intensity of paresis decreased from 3.45 to 2.73 points in the group 1, while standard therapy resulted in persistent paresis at the level of 3 points (p = 0.03).
The degree of spasticity decreased in both groups, but after completion of mechanotherapy the difference was 0.44 points, while traditional therapy resulted in 0.27 points (p > 0.05).
The electroencephalographic values changed only a little after realization of mechanotherapy. It is associated with the fact that positive dynamics of EEG values is often time-delayed in comparison with clinical signs, and it does not contradict the literature data. The values of ultrasonic doppler examination of cerebral vessels after mechanotherapy were as indicated below: the first group demonstrated some signs of discirculation in the orbital veins, 2 patients with hyperkinetic type of circulation, 1 child with hypokinetic type of circulation, 4 children without pathology. In the second group the values of cerebral ultrasonic doppler examination did not alter significantly before and after treatment.
Motion disorders are conditioned by development of cysts and hydrocephaly [3, 6]. Robotic mechanotherapy prevents immobilizing injuries and formation of contractures, activates general and local perfusion, restores motion functions and takes tonic effects. According to the literature data [3, 7], robotic mechanotherapy is successfully used for rehabilitation of infantile cerebral paralysis in restorative period of traumatic brain injury and stroke.
The figures 5-7 demonstrate treatment of children with use of mechanotherapy method.
Figure 5
Robotic mechanotherapy with Artromot-R–F and Artromot-R-H for hand joints and fingers
Figure 6
Robotic mechanotherapy with Artromot-R-S3 for shoulder joints
Figure 7
Robotic mechanotherapy with Artromot-R-K2 PRO CHIP for ankle joints
Therefore, implementation of high-tech medical and rehabilitation techniques into clinical practice of medical facilities allows maximal increasing efficiency of complex rehabilitation programs. Significant diagnostic possibilities (neurovisualization, neurofunctional studies, dynamometry, videoanalysis etc.) allow estimating the quality of conducted therapy and also make some prerequisites for development of new methodologic approaches of restorative treatment.
CONCLUSION
Robotic mechanotherapy decreased severity of paresis by 0.8 points (5 point scale). Also it resulted in evident increase of absolute strength estimated with hand dynamometry: 1.5 times for the left hand, 2 times for the right hand in comparison with the basic values. Motion therapy with Artromot device is efficient for promoting restoration of joint mobility and achievement of good functional outcomes.