Method for correction of cognitive impairment accompanying cerebrovascular pathology

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely neurology and may be used in the cognitive function recovery, including optical perception in the patients with a cerebrovascular pathology. A patient is presented with an image on a monitor, and additionally a number of images of sharp traced objects; one of the images shows an 'noisy' object. The patient identifies the 'noisy' object by recognising and selecting the object among the presented versions. The patient is given with a maximum period of time specified by a doctor that when expired is accompanied with evaluating the task and presenting the results on the monitor. The score presented to the patient is directly proportional to a 'noise' density of the image followed by the correct answer of the patient and calculated by formula: $$D=\left(1-\frac{Тresp-Тchange}{Тtest}\right)\ast 100\%,$$ wherein D is a noise density wherein the patient has given the correct answer, %; T resp. is the time taken by the patient to give the correct answer, seconds; T change is a period of time for the image presentation until the noise density is changed by 1 pitch, seconds; T test is a maximum time of test also specified by the doctor. The evaluation is accompanied by the visual and/or audial aids; the correction lessons take for at least 10 days, once a day, with one lesson for no more than 40 min.

EFFECT: method enables improving the patient's motivation to lessons and increasing the rehabilitation effectiveness in an acute and chronic cerebrovascular pathology.

6 cl, 3 tbl, 1 ex

The invention relates to medicine, namely to neurology and can be used in the recovery of cognitive functions, including optical perception in patients with cerebrovascular disease.

Cognitive impairment observed in 87% of patients after a stroke. Primary violations of gnosis (agnosia) develop in the pathology of the posterior regions of the cerebral cortex. The occipital region of large hemispheres of the brain provides the processes of visual perception. This visual gnosis is supported by a secondary departments of the visual analyzer in their relationship with parietal structures. With the defeat of the occipito-parietal brain regions (both the left and right hemisphere) there are various disorders of visuo-perceptual activity, primarily in the form of visual agnosia. Subject agnosia in its expanded form is usually observed with bilateral lesions. The study of the perception of objects and their images, the analysis agnosia and the correction of identified violations that occur in cases of optic agnosia, is of the most important tasks of neuropsychology and neurorehabilitation (1)

The number of known methods for the treatment and rehabilitation of cognitive functions in individuals with cerebrovascular disease.

So there is a method neuropsychological rehabilitation of patients of the Church is brovascular disease with dyscirculatory encephalopathy and stroke (EN 2246971 C1 A61M 21/00, 27.02.2005), carried out by conducting the background of restorative therapy exercises will first determine the standard tests-dominant hemisphere; then perform exercises that consistently involve all higher levels of the nervous system, and include homolateral movement of the limbs, heterolateral movement with eye movements and functional loads on hemisphere - dominant hemisphere with a logical load for subdominant with creative load, and then draw the infinity sign in the air with the right hand, left hand and both hands together, watching an imaginary figure and shifting the center of gravity from one foot to the other; then draw symmetrical shapes at the same time two hands, after gymnastics perform auditory training - create and memorize the way hemispheres working together.

This method is mainly aimed at the restoration of neurodynamic disorders and does not adjust violations optical gnosis functions of perception, processing and synthesis of elementary sensory perceptions into coherent images.

There is a method of treatment of cognitive disorders in persons with cerebrovascular diseases (EN 2268723 C1 A61K 31/4015; A61K 31/522; A61M 21/00; A61P 25/28; 27.01.2006), including the introduction of microcirculatory and IEO is repnik funds in the form of an intravenous infusion for 10 days, then within 1 month enter the oral forms of these drugs, while conducting neuropsychological training aimed at improving important for the patient's household skills associated with remembering names, important dates, medicines and location of household items, more complex jobs as ill success; training duration 30 minutes spend 3 times per week; treatment includes 12 sessions.

There is a method of treatment involves the supervision and participation of highly qualified specialists and cannot be accessed by the patient themselves.

Also known a method of rehabilitation of cognitive functions in patients after stroke in the early recovery period (RU 2392916 C1 A61H 1/00; 27.06.2010), including using dosed exercise, including homolateral, heterolateral and cross-motion, auditory training, unidirectional and multidirectional movement of the eyes, tongue, and extremities, with the patient daily physical exercises "cognitive gymnastics, consisting of the following types of exercises: General developmental exercises, power exercises, exercises that stretch the muscles of the neck in the mode of postisometric relaksatsiya completing the I exercise for relaxation with elements of auditory training and massage techniques, the duration of each exercise is 1-2 min, the rate of exercise slow, smooth; lessons are conducted daily, 2 times a day, in accordance with locomotor mode in the power saving mode class for 10-15 minutes, gently-training - 15-20 min, trainee - 25-30 min, and the starting position - standing, sitting on a chair, and for patients with persistent dizziness - lying; treatment is 15-18 procedures.

This method has a high efficiency in relation to recovery of cognitive deficits, but this is not specific to a particular cognitive function, particularly in relation to the optical gnosis functions of perception, processing and synthesis of elementary sensory perceptions into coherent images.

Famous visual assessment of gnosis in the way of a comprehensive mental health assessment (EN 2294215 C1 A61M 21/00; 27.02.2007), which includes a study of the parameters and, respectively disorders: "holistic analysis" fragmentation, "optical-spatial gnosis" - ignoring the left and right sides of space, "subject gnosis" and "facial recognition" - agnosia, paranoia.

The known method is not readily available for General use because it requires the participation of a specialist neuropsychologist, is basically a diagnostic method, not the method to the correction of cognitive functions.

The closest in technical essence and purpose for the proposed method is the method of study of visual perception, which consists in the recognition of the image in terms of "noise". "Visual noise" is achieved by the image of the subject outline or silhouette with the application of patterns or stylized images, the perception of which may be known difficulties. The authors showed that the degree of "noise" in the picture you can dispense. This method can be considered to be sensitised for the study of subtle forms of disorders of visual perception (tonkonogy IM, Tsukkerman I.I. Clinic disturbances of visual perception and recognition images // Bionics. M, 1965).

The disadvantages of this method are its complexity, high cost of time, lack of ability to objectively monitor and evaluate the effectiveness of the method, a large number of didactic material, high skill requirements neurologist or neuropsychologist, the opportunity to explore the function and not train it.

The objective of the invention is improving the efficiency of correction of cognitive impairment, including optical gnosis, cerebrovascular pathology.

The task to solve due to the fact that in the treatment of cognitive disorders in cerebrovascular pathology, Inc is committed to providing patient image of the subject on "noisy picture with dosage levels of "noise", recognition of patients given image according to the claimed invention, the image is "noisy image" provide the patient on the monitor screen, while additionally provide a number of images of objects made by clear lines, one of which depicted the subject with noisy images, the recognition of the subject depicted in "noisy picture the patient is realized through the recognition of the object from the given options, the job take time, the maximum interval determined by the doctor, and after which assess job with the demonstration of patient outcomes (evaluation) on the monitor screen, when the difficulty of the choice task easier by periodic step-by-step reduction of the density of "noise", asked the doctor the time interval for the images to change the density of the noise at step 1, with the demonstrated patient scoring directly proportional to the density of "noise" pictures, in which the patient gives the correct answer and which is calculated by the formula:

$$P=\left(1-\frac{T\mathrm{about}t\mathrm{in}-T\mathrm{with\; a}mens}{Tte\mathrm{with\; a}\mathrm{the}\mathrm{and}}\right)\ast 100\%$$where

P is the density of degradation, in which the patient gave a correct answer, %;

T resp. the time for which the patient gave the answer in seconds.

T-change - asked by decision of the doctor, the time interval for the images to change the density of the noise at 1 step per second;

T test - the maximum time can also be set by the decision of the physician;

withdrawal assessment is accompanied by visual and/or audible means, lessons correction is carried out in a period of not less than 10 days, 1 times a day, with a duration of one lesson is not more than 40 minutes

"Noisy image" can be done by veiling the image of the subject by the ticking of small dots and/or thin stripes.

"The noise level of the image can be made with the possibility of its reduction every 5 seconds.

Visual and/or audible means may be provided in the form of "bonus" and/or "comforting" label, and/or sounds and/or images.

Withdrawal assessment may be accompanied by a video.

The correction method is as follows. The patient provide an image of the object on the computer screen, which is veiled, applied on top of the image pattern, for example, the ticking of Melk is x pixels, thus, the perception of the object depicted in the picture is quite complex. Above this "noisy image" provided a number of images - a few items, one of which is shown in the picture. During testing (classes) the patient must find and select the object from the provided options. To do this, move the cursor and left mouse button to choose the corresponding image. The job done on time.

If the patient cannot recognize the image content, step by step, every few seconds the background density of patterns is reduced, thereby facilitating the job. When you reduce the level of "noise" decreases in proportion to expose the patient assessment points (from a maximum at the instant the job is to 0 when failed attempt or completion time of the job). Upon completion of the job evaluation points earned at the job, is displayed on the monitor screen the Successful identification of the object (if any nonzero attempt) may be encouraged by the applause of the "behind the scenes"when it receives 0 points, may sound comforting sigh". Remedial classes are conducted for 10 days 1 time per day for an average of 20-25 minutes.

For the purposes of checking the efficiency of the method was examined in 20 patients in the restorer of the om period of ischemic stroke, with cognitive impairment of varying severity, 10 man study group, which carried out the correction of cognitive impairment in accordance with the inventive method and 10 control group, in which classes correction is not performed. All patients received standard medical therapy, taking into account existing comorbidities. The age of the patients ranged from 50 to 75 years. To correct the claimed method the patients in the control and study groups did not differ in severity of cognitive impairment.

The diagnosis of stroke surveyed patients was confirmed KG or brain MRI. Exclusion criteria were: Opticheskie violation of moderate and severe; bulbar syndrome, dysarthria severe; the total score on the MMSE scale 19 and less.

Before and after the correction has been examined by a doctor-neurologist using the methods of neurological examination and neuropsychological testing for common neurological scales.

Assessment of cognitive functions in patients study and control groups was carried out in the recovery period of ischemic stroke (30-365 days from the date of onset of symptoms), a re-evaluation of cognitive impairment was performed 10 days after the beginning of the course q the functions of cognitive impairment on the proposed method in the study group. To evaluate a correction of cognitive functions used the following methods: table Schulte, a brief scale for assessing mental status (MMSE), a battery of tests of frontal dysfunction (FAB), test drawing hours. Simultaneously evaluated in the dynamics of motor, sensory and other neurological disorders in stroke scale National Institute of health (NIHSS).

Correction of the results of cognitive impairment of the studied groups are shown in table 1.

As can be seen from tables 1 and 2 on the background of correctional practice using the proposed method was showed a significant regression of the severity of cognitive and motor disorders in the study group. About significant improvement of cognitive functions in the background of the studies conducted witnessed the positive results of most neuropsychological tests (scale FAB and Test drawing hours), which was used in the study. Improved function of the visual gnosis, concentration and focus. In comparison with the control group there was a statistically more pronounced positive effect correction of cognitive impairment.

The proposed method is based on the principle of biofeedback, which greatly increases the motivation of the patient to the practice and increases the efficiency of the rehabilitation process in acute and chronic cerebrovascular pathology.

Below is an example of how correctionally disorders in cerebrovascular disease.

Example. Patient K., aged 65, male. Diagnosis: Ischemic stroke in the basin of the right posterior cerebral artery leading syndrome of the left-sided hemiparesis, early recovery period.

Background: Hypertension 3. Risk 4. Cerebral atherosclerosis.

Related: Diabetes mellitus type 2, moderate severity, stage of compensation.

From the anamnesis: Suddenly, February 15, 2010, against the background of HELL 180/100 mmHg there is a weakness in the left extremities, an ambulance delivered in 1 KB No. 6. March 6, enrolled in neurorehabilitation center RCCs FMBA for the course musculoskeletal rehabilitation.

Secondary special education. Pensioner.

In neurological status at admission: clear Consciousness. Oculomotor, bulbar no violations. The asymmetry of the left nasolabial folds. The tongue in the midline. Left-sided hemiparesis with muscle strength in the hand in the proximal 26., distal 1-1,56, at the foot of 3,5-46. Muscle tone in the left extremities increased by spastic type. Tendon reflexes S>D. Sensitive, coordinatory, pelvic disorders no. Meningeal signs.

According to the results of further evaluation:

MRI of the brain in the parietal, occipital and temporal lobes of the right, intra - and subcortical areas of ischemia, with irregular indistinct contours from 1.5 to 3.0, see MPA vessels of the brain is - option development Willisau circle. Moderate asymmetry of blood flow in the visible sections of the vertebral arteries. Asymmetry of blood flow in the visible internal carotid artery, middle cerebral arteries.

XC 6.35mm; b-PL 28; LDL 2,81; HDL Cholesterol 1,04; KA 2.87; 1 G 0,99 fundus: hypertensive angiopathy.

To correct the claimed method the patient was performed neuropsychological testing To assess cognitive impairment used the following methodology: a brief scale for assessing mental status (MMSE), a battery of tests of frontal dysfunction (FAB), test drawing hours, "correction table" (modification of samples NR. Amatuni). Simultaneously evaluated in the dynamics of motor, sensory and other neurological disorders in stroke scale National Institute of health (NIHSS).

The patient comes into contact, at the place and time oriented, spontaneous speech activity is saved. Dynamic praxis - the difficulties of learning and retention of motor programs (fist-edge-palm), its simpler and slower pace, mainly in the left hand.

Visually subject gnosis - difficulty recognizing objects. Auditory nonverbal gnosis - play rhythms broken. Impaired spatial gnosis (test drawing hours, redraw the figures).

Modal nonspecific mental Nar the decision hard to digest new information, broken play.

The test Schulte at different days and times of classes varied from 86 to 120 seconds.

Thus, neuropsychological symptoms indicates a dysfunction of the deep midline structures of the brain, the occipital-parietal departments crust.

Conducted the standard medical therapy taking into account comorbidities and rehabilitation using the proposed method of correction within 10 days 1 time per day, the duration of sessions was 20-25 minutes. The patient was before computer screen, which was presented to the "noisy image" - the image of the object is veiled by the ticking of small dots. Above it to the attention of the patient presents 4 different subject, one of which is encrypted on the "noisy picture. The patient needed to know and to choose the subject of the 4 options. For this he summed up the cursor and the left mouse button was selected the appropriate image. If the patient could not recognize the object immediately, step by step, every 5 seconds, the density of the background ticking decreased - the job easier. Once the patient has learned the subject in the picture, he chose one of the 4 options. If the answer was correct, then appeared on the screen scoring (10 instant when the task with the minimum level of "noise" applause "behind the scenes"). If the answer was unsuccessful, then appeared a score of 0 and a comforting sigh". In one session held on 3 series of tasks, each of which had to learn 10 pictures.

After completion of the course correction was performed repeated neuropsychological testing by those methods.

As a result of rehabilitation was significantly improved cognitive function, as evidenced by the positive dynamics of the majority of neuropsychological tests used in the study.

The results of the correction of cognitive impairment in a patient K. using the proposed method are shown in table 3.

As follows from the data presented, the patient had improved visual-object and visual-spatial gnosis, increased levels of active attention, decreased the degree of disturbance in Executive functions,

Thus, the inventive method of correction of cognitive disorders in cerebrovascular pathology allows you to:

- to adjust neuropsychological disorders, including optical gnosis;

- to control the process of correction by changing the time of holding classes within a given interval, change the time interval for execution of a job, change of interval time spent on images of different densities of"noise";

- update "games" motivation of patients (execution of tasks in the form of the game with the demonstration of results - evaluation and its accompanying visual and/or audible means)that makes the rehabilitation process more attractive, increases the effectiveness of rehabilitation treatment;

- hold classes in the presence of the General practitioner, instructor, physical therapy or relative of the patient, because the method is simple-to-use;

- to regulate the degree of load;

to eliminate the need to use a large number of teaching material.

1. Burlacu, L. F. a Dictionary of psycho-diagnostics. / L. F., Burlacu, S.M. Morozov // S-IB., Peter, 1999. - 528 S.

1. Treatment of cognitive disorders in cerebrovascular disease, including the provision of patient image of the subject on "noisy image" injection density of "noise", the recognition of patients given image, wherein the image is "noisy image" provide the patient on the monitor screen, at the same time, additionally provides several images of objects made by clear lines, one of which depicted the subject with noisy images, the recognition of the subject depicted in "noisy picture, the patient carries out by means of recognition of the object from the given options, the job take time, maximum the interval determined by the doctor, and after which assess job with the demonstration of patient assessment on the screen of the monitor, thus demonstrating a patient scoring directly proportional to the density of "noise" pictures, in which the patient gives the correct answer, and which rely on the form of the e:
$$P=\left(1-\frac{T\mathrm{about}t\mathrm{in}-T\mathrm{with\; a}mens}{Tte\mathrm{with\; a}t\mathrm{and}}\right)\cdot 100\%,$$
where P is the density of degradation, in which the patient gave a correct answer, %;
T resp - time during which the patient responded with;
T-change - asked by decision of the doctor, the time interval for the images to change the density of the noise at step 1, with;
T test - the maximum time that may be decided by the doctor,
withdrawal assessment is accompanied by visual and/or audible means, lessons correction is carried out in a period of not less than 10 days, 1 times a day, with a duration of one lesson is not more than 40 minutes

2. The correction method according to claim 1, characterized in that when the difficulty of the choice task easier by periodic step-by-step reduction of the density of "noise" asked the doctor the time interval for the images to change the density of the noise on step 1.

3. The correction method according to claim 1, characterized in that the "noisy" picture made by veiling the image of the subject by the ticking of small dots and/or thin stripes.

4. The correction method p is 1, characterized in that the "noisy" images were made with a step-by-step reduction every 5 sec.

5. The correction method according to claim 1, characterized in that the visual and/or audible means are presented in the form of "bonus" and/or "comforting" label, and/or sounds and/or images.

6. The correction method according to claim 1, characterized in that the removal assessment accompany the video.