Vol 26, No 3 (2019)

Interest in the rehabilitation of Parkinson’s disease (PD) has increased significantly in the past two decades. Such interest is most likely due to many factors, of which, we believe, the most important are the increase in the life expectancy of people, the desire to improve its quality; and also to draw more and more attention to the issues of non-drug treatment in connection with the existing limitations of PD pharmacotherapy. In addition, the observed technical progress is associated with the development of new methods and equipment for neurorehabilitation of PD patients. The article presents an overview of current approaches to treatment and problems of rehabilitation of PD patients, and describes some features of the management and rehabilitation of patients against the background of neurostimulation of subcortical structures.

Modern neurorehabilitation, based on the principles of evidence-based medicine, makes us move away from the GRADE-concept (model of successive rehabilitation). There were grounds for the beginning of rehabilitation in the emergency room in the first 24-48 hours. Proper organization of the stroke compartment reduces mortality and disability. Prerequisites are the presence of a rehabilitation team (level A), whose members are: a neurologist, a physiotherapist, an ergotherapist, a speech therapist, as well as a psychologist and a social worker; regular consultations with leading neurologists and other doctors to determine and document the therapy, its dynamics; cognitive screening; discussion of the results of the examination and treatment plan with relatives. Rehabilitation activities are based on the use of the International Classification of Functioning, Vital Activity and Health (ICF) and are performed at structural and functional levels (for example, muscle strength, tone, breathing), differ in goals, types of activity, patient participation and should be easily measured and painted time, to enable the patient to be motivated, as well as to be relevant to his condition (level A). On the other hand, the rehabilitation assessment at the early stages may also have predictive value (the Bartel index is within 5 days), based on the use of standard scales. The use of various therapeutic techniques that have a level of evidence of IA-III is performed in various combinations in each individual patient, depending on the existing pathological syndromes. There is evidence of the positive effects of levodopa and selective serotonin reuptake inhibitors (class II - III, level B - C), as well as specific peptide complexes - Cerebrolysin at a dose of 30 ml in a course of 3 weeks or more (class II, level B). Rehabilitation in the long term can be carried out at home, even a year after a stroke, balance exercises, gait training using different methods, training for the upper limbs are effective (grade B) and contribute to the reduction of disability.

Background. The optimal management of patients with chronic pain is one of the priorities of modern medicine. In order to improve the quality and effectiveness of pain management, the tactics of an individual approach in pain medicine, including taking into account differences in the level of sex hormones, is required. Objective. Evaluation of the role of sex hormones (testosterone and chorionic gonadotropin drugs) in the pain management in male patients with androgen deficiency and concomitant nonspecific chronic back pain. Methods. 68 male patients were examined during visit an urologist and an endocrinologist. The study duration is 2015-2017. The study included 2 stages: 1) evaluation of the structure of pain syndromes in male patients during visiting an urologist and an endocrinologist; 2) assesment of the possible effect of increase in patient’s blood total testosterone level on the level of pain and other clinical indicators with the use of testosterone and/or chorionic gonadotropin preparations. Results. The prevalence of pain syndromes among male patients was 66%. The structure of pain syndromes was represented by headache in 24% of patients; back pain in 20% of patients; joint pain in 14% of patients; and muscle pain in 8% of patients. Correction of androgen deficiency in male patients with concomitant nonspecific chronic back pain statistically significantly reduced the pain severity, the degree of daily living activity impairment, the level of depression and situational anxiety. The most favorable target blood total testosterone level in male patients, corresponding to the absence or minimal pain complaints, was ≥ 22.0 nmol/L. Conclusion. The results suggest that the practical use of drugs that increase blood testosterone level (testosterone and/or human chorionic gonadotrophins) to optimize the pain management in male patients with androgen deficiency and associated nonspecific chronic back pain is promising.

Background. Nummular headache is one of the rare types of primary cephalgia, characterized by pain in a limited area of a round or oval shape on the scalp. The pathogenesis of the disease is not well understood, the treatment has not been developed. Objective. Evaluation of the clinical features of nummular headache and treatment options. Methods. Observational cohort study included6 patients with nummular headache aged from 24 to 67 years. Half of the patients were treated with gabapentin for 21 days. Results. Among the patients with nummular headache women were prevalent (5 of 6). In all cases, the pain was localized in the parietal region of the scalp and was categorized by patients as intense (7-8 points according to the Numerical Rating Scale). In three cases an increased level of anxiety was observed; in three patients the disease was comorbid with vascular pathology (arterial hypertension, atherosclerosis of the brachiocephalic arteries). Some patients had sensitive disorders in the area of pain, and for their registration we proposed a mapping study of pain sensitivity on the scalp skin. As a result of treatment with gabapentin, regression or a significant reduction in pain is noted. Conclusion. The pathogenesis of nummular headache is currently unknown; its possible neuropathic genesis is being actively studied. Given the role of central sensitization in the pathogenesis of this type of cephalgia, the presence of clinical features of peripheral neuropathic pain, treatment with anticonvulsants, in particular, gabapentin, in the form of a short course is justified.

Background. Rehabilitation measures based on the neuroplasticity phenomenon are important for recovery of patients after ischemic stroke (IS), and the recovery rate after IS is primarily determined by functional activity and effective use of existing neuronal connections. Objective. Evaluation of the effect of Cytoflavin on the functional recovery rate when it is included in the complex therapy of patients in the early and late recovery periods of IS. Methods. The study include 60 patients with IS, randomized to 2 groups with or without the use of Cytoflavin as part of a comprehensive rehabilitation therapy for 35 days. Clinical and neurophysiological examination was carried out before and after the course of therapy. Results. The use of Cytoflavin in the complex therapy of patients after IS led to a significant reduction in neurological deficit, improvement of activity and patient independence, which was accompanied by a significant improvement in the functional activity of the efferent and afferent conduction systems (according to data obtained using neurophysiological examination methods) and contributed to an increase in plasticity of the whole system of voluntary motor activity, increasing the efficiency of further neurorehabilitation process and the likelihood of better recovery and a good outcome. Conclusion. The data obtained allow to recommend the use of Cytoflavin in addition to the background therapy of patients in the early and late recovery periods of IS.

Background. Depressive disorders (DDs) are a frequent concomitant symptom in patients with Alzheimer’s disease (AD). DDs worsen the quality of life of AD patient, worsen the course of dementia. Difficulties in diagnosing DDS are associated with insufficient use of screening scales specifically designed for AD patients in the practice. Treatment of DDs should combine antidementia drugs with antidepressants. The choice of antidepressant is based on safety, good tolerability and favorable interaction with antidementia drugs. Objective. 1. Identification of the features of the manifestation of DDs in AD patients. 2. Evaluation of the diagnostic capabilities of the geriatric depression scale (GDS) and the Cornell Scale for Depression in Dementia (CSDD) in patients with mild to moderate dementia. 3. Assessment of the quality of life, cognitive status of patients during combined therapy. Methods. Dynamic clinical follow-up of 130 patients with AD (mild to moderate dementia syndrome) with DDs with an assessment of the effectiveness of combined antidepressant and antidementia therapy on the quality of life of patients. Criteria for assessing dementia according to the MMSE scale (Folstein M.F., 1975): mild dementia - 24 to 20 points, moderate dementia - 19-11 points. The study included outpatients who were referred for consultation at the City Center for Dementia Control SRITPM -a Branch of the Institute of Cytology and Genetics of the Siberian Branch of the Russian Academy of Sciences, Novosibirsk, and previously followed-up by district psychiatrist or therapist; they were, divided into 2 subgroups according to the dementia severity: subgroup 1 (n=88) - with mild dementia, and subgroup 2 (n=42) - with moderate dementia. All patients received antidementia therapy for 1.4±0.4 years. Of these, 42 patients received cholinesterase inhibitors - rivastigmine patch 9.5 mg/ day (18 patients) or donepezil 10 mg/day (24 patients); 88 patients received memantine at a dose of 20 mg/day. Criteria for assessing the DD severity were carried out using the Geriatric Depression Scale (GDS). Also, the Cornell Scale for Depression in Dementia (CSDD) was used; it takes into account the data of clinical observation of the specialist and information from the caregiver, which ensures its independence from the dementia severity. Total scores on both scales at the beginning and end of therapy were analyzed. In addition, sertraline at a dose of 100 mg/day, an antidepressant from the group of selective serotonin reuptake inhibitors, was prescribed to all patients with DDs. Evaluation of the effectiveness of treatment in subgroups was carried out on the Clinical Global Impression Scale (CGI-I) after treatment with an antidepressant, and the cognitive status was evaluated according to the MMSE scale at the beginning and end of antidepressant therapy. The side effects of the therapy used were recorded. Results. DDs and dementia are often combined with each other, mutually reinforcing the impact on the patient’s daily life. For the diagnosis of DDs in AD, it is better to use screening scales specifically designed for patients with dementia and involving a survey of caregivers. Combined antidepressant therapy with antidementia drugs in the mild and moderate stages gives effect and relieves DDs (reduction of the starting total GDS score by 18.8%; CSDD by 19.2%). At the stage of mild dementia, there was a positive trend in 91% of cases (according to the doctor’s and relatives’ opinion), and at the stage of moderate dementia - in 43%.

Background. Anticoagulant therapy (AT) is the main method of primary and secondary prevention of ischemic stroke (IS) in patients with atrial fibrillation (AF). However, its too early initiation after IS is associated with a high risk of hemorrhagic transformation (HT), and too late initiation - with recurrent IS and systemic embolism. In this regard, the issue of the timing of the initiation of AT in patients with IS and AF is actively discussed by leading world experts, since evidence-based facts are still missing. Objective. Prediction of hemorrhagic transformation (HT) using the Hemorrhagic Transformation Index (HTI) score to refine possible timing for anticoagulation in patients with atrial fibrillation (AF) and acute ischemic stroke (AIS) in the middle cerebral artery (MCA) territory. Methods. Clinical, laboratory, and brain imaging data were analyzed in 304 consecutive patients with any AF. The patients were randomized into derivation (DC) and validation (VC) cohorts. To make the HTI more convenient for a refinement of anticoagulation timing, its initial scores were grouped into fewer categories. As a result, 4 models were created which were tested in the DC by comparing against each other and the current standard, the Diener's rule, using binary logistic regression (BLR) and receiver operating characteristic (ROC) analysis. After choosing the final model, the same set of tests was done in the VC. Possible timing for anticoagulation was matched between the Diener's rule and the final model using predicted HT probabilities. As an illustration of the results, a clinical case was described. Results. The most optimal predictive ability was determined in the HTI model with the score arrangement as follows: 0-1, 2-3, 4-5, 6-8. The results of BLR and ROC-analysis were equal in the DC and VC; thus, the HTI reliability was validated. Moreover, the HTI score could distinguish a group of patients who were at very high risk of HT. The low-risk patients (HT probability of <50%; the HTI score of 0-1 or 2-3) could be advised to start anticoagulation from the day 3 to 6 after the AIS onset, and the high-risk group (HTprobability of 50-80%; the HTI score of 4-5) - in 12 days. Conclusions. The Diener's rule and the HTI score are compatible tools for HT prediction in MCA AIS patients within 2 weeks after the index stroke onset. Further researches are needed in patients who are at very high risk of HT (HT probability of >80%, the HTI score of 6-8) to refine their timing for anticoagulation.