medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2017-17-82-90medsovet-2152Research ArticleСПАСТИЧЕСКИЕ РАССТРОЙСТВАSPASTIC DISORDERSРЕАБИЛИТАЦИЯ ПАЦИЕНТОВ С ПОСТИНСУЛЬТНОЙ СПАСТИЧНОСТЬЮ НИЖНЕЙ КОНЕЧНОСТИ В РАННИЙ ВОССТАНОВИТЕЛЬНЫЙ ПЕРИОДREHABILITATION OF PATIENTS WITH POST-STROKE SPASTICITYOF THE LOWER LIMB AT AN EARLY RESTORATIVE PERIODКрыловаЛ. В.KrylovaL. V.

Набережные  Челны

Naberezhnye Chelny

ХасановаД. Р.KhasanovaD. R.

Доктор медицинских наук, профессор

MD, Prof.

Отделение медицинской реабилитации пациентов с поражением центральной нервной системы Госпиталя ветеранов войнРоссияMedical Rehabilitation Department of Patients with Central Nervous System Lesion of the War Veterans HospitalRussian FederationКазанский государственный медицинский университет Минздрава РоссииРоссияKazan State Medical University of the Ministry of Health of RussiaRussian Federation2017091120170178290Copyright © Крылова Л.В., Хасанова Д.Р., 20172017Крылова Л.В., Хасанова Д.Р.Krylova L.V., Khasanova D.R.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/2152

Постинсультная спастичность является одним из наиболее  частых двигательных нарушений. Лечение спастичности может улучшить двигательные функции как верхней, так и нижней конечности. В статье представлены результаты изучения эффективности применения ботулинического  токсина типа А в ранний восстановительный период у 27 пациентов со спастичностью нижней конечности. Основная группа (n = 18) в составе комплексной реабилитации получала инъекции ботулотоксина. Пациенты контрольной группы (n  =  9)  получали базовое   реабилитационное  лечение. Исследование проводилось в течение 9 месяцев. Оценивали динамику мышечного тонуса, мышечной силы, болевого синдрома, скорость ходьбы, показатели функционирования по шкалам Ривермид и Бартель. Получены статистически значимые преимущества в основной группе пациентов по снижению мышечного тонуса, боли, увеличению скорости ходьбы, повышению независимости пациентов в повседневной жизни. Обсуждается необходимость включения ботулинического токсина в реабилитационные программы больных с постинсультной спастичностью как верхней, так и нижней конечности, начиная со второго этапа реабилитации.

Post-stroke spasticity is one of the most frequent motor disturbances. Therapy of spasticity can improve motor performance of the upper and lower limb. The article provides results of the study of effectiveness  of type A botulinic toxin at an early restorative period in 27 patients with spastic lower limb. The major group (n = 18) as part of complex rehabilitation received botulotoxin injections. Dynamics of the muscular tonus, muscular strength, walking speed, values of functioning by Rivermid and Bartel scales  were assessed.  The statistical data proving considerable advantages in the major group of patients on reductional of the muscular tonus, pain, increase of the walking speed, increase of patient independence in daily life were obtained. A necessity to include the botulinic toxin in rehabilitation programs of patients with post-stroke spasticity of the upper and lower limb starting from the second stage of the rehabilitation is discussed.

постинсультная спастичностьботулинический токсин типа Анейрореабилитацияpost-stroke spasticityType A botulinic toxinneurorehabilitationReferencesWissel J, Manack A, Brainin M. Toward an epidemiology of poststroke spasticity. Neurology, 2013, 80: 13-19. doi: 10.1212/wnl.0b013e3182762448.Wissel J, Manack A, Brainin M. Toward an epidemiology of poststroke spasticity. Neurology, 2013, 80: 13-19. doi: 10.1212/wnl.0b013e3182762448.Гехт А.Б., Бурд Г.С., Селихова М.В., Яшин Ф.К., Беляков В.В. Нарушение мышечного тонуса и его лечение в раннем восстановительном периоде ишемического инсульта. Журнал неврологии и психиатрии, 1998, 10: 248-251.Гехт А.Б., Бурд Г.С., Селихова М.В., Яшин Ф.К., Беляков В.В. Нарушение мышечного тонуса и его лечение в раннем восстановительном периоде ишемического инсульта. Журнал неврологии и психиатрии, 1998, 10: 248-251.Ward AB. A literature review of the pathophysiology and onset of poststroke spasticity. Eur. J. Neurology, 2012, 19: 21-27. doi: 10. 1111/j.1468-1331.2011.03448.x.Ward AB. A literature review of the pathophysiology and onset of poststroke spasticity. Eur. J. Neurology, 2012, 19: 21-27. doi: 10. 1111/j.1468-1331.2011.03448.x.Turcel C, Bowen B, Liu J, Brin M. Pooled analysis of the safety of botulinum toxin type A in the treatment of post stroke spasticity. Arch Phys Med Rehabil, 2006, 87: 786-792. doi: 10.1016/j.apmr.2006.02.015.Turcel C, Bowen B, Liu J, Brin M. Pooled analysis of the safety of botulinum toxin type A in the treatment of post stroke spasticity. Arch Phys Med Rehabil, 2006, 87: 786-792. doi: 10.1016/j.apmr.2006.02.015.Brashear A, Gordon M, Elovic E, Kassiciech V, Marciniak C, Do M, Lee C, Jenkins S. Botox PostStroke Spasticity Study Group. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Eng J Med, 2002, 347: 395-400. doi: 10.1056/nejmoa011892.Brashear A, Gordon M, Elovic E, Kassiciech V, Marciniak C, Do M, Lee C, Jenkins S. Botox PostStroke Spasticity Study Group. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Eng J Med, 2002, 347: 395-400. doi: 10.1056/nejmoa011892.Childers M, Brachear A, Jozetczyk P, Reding M, Alexander D, Good D et al. Dosedependent response to intramuscular botulinum toxin type A for upper-limb spasticity in patients after a stroke. Arch Phys Med Rehabil, 2004, 85: 1063-1069. doi: 10.1016/j.apmr.2003.10.015.Childers M, Brachear A, Jozetczyk P, Reding M, Alexander D, Good D et al. Dosedependent response to intramuscular botulinum toxin type A for upper-limb spasticity in patients after a stroke. Arch Phys Med Rehabil, 2004, 85: 1063-1069. doi: 10.1016/j.apmr.2003.10.015.Simpson DM, Patel AT, Alfaro A, Ayyoub Z, Charles D, Dashtipour K et al. OnabotulinuntoxinA Injection for Poststroke Upper-Limb Spasticity: Guidance for Early Injectors From Delphy Panel Process. PMR, 2017, 9: 136-148. doi:10.1016/j.pmrj.2016.06/016.Simpson DM, Patel AT, Alfaro A, Ayyoub Z, Charles D, Dashtipour K et al. OnabotulinuntoxinA Injection for Poststroke Upper-Limb Spasticity: Guidance for Early Injectors From Delphy Panel Process. PMR, 2017, 9: 136-148. doi:10.1016/j.pmrj.2016.06/016.Olver J , Esquenazi A, Fung V et al. Botulinum toxin assessement, intervention and aftercare for lower limb disoders of movement and muscle tone in adults: international consensus statement. Eur J Neurology, 2010, 17( supl 2): 57-73. doi: 10.1111/j.1468-331.2010.03128.x.Olver J , Esquenazi A, Fung V et al. Botulinum toxin assessement, intervention and aftercare for lower limb disoders of movement and muscle tone in adults: international consensus statement. Eur J Neurology, 2010, 17( supl 2): 57-73. doi: 10.1111/j.1468-331.2010.03128.x.Falco M, Galluso R, Malvicini A. Functional influence of botulinum neurotoxin type A treatment (xeomin) of multifocal upper and lower limb spasticity on chronic hemiparetic gait. Neurology International, 2012, 4: 32-34. doi: 10.4081/ni.2012.e8.Falco M, Galluso R, Malvicini A. Functional influence of botulinum neurotoxin type A treatment (xeomin) of multifocal upper and lower limb spasticity on chronic hemiparetic gait. Neurology International, 2012, 4: 32-34. doi: 10.4081/ni.2012.e8.Foley N, Murie-Fernandez M, Speechley M et al. Does the treatment of spastic equinovarus deformity following stroke with botulinum toxin improve gait velocity? A systematic review and meta-analysis. Eur J Neurology, 2010, 17(12): 1419-1427. doi: 10.1111/j.1468-334.2010.03084.x.Foley N, Murie-Fernandez M, Speechley M et al. Does the treatment of spastic equinovarus deformity following stroke with botulinum toxin improve gait velocity? A systematic review and meta-analysis. Eur J Neurology, 2010, 17(12): 1419-1427. doi: 10.1111/j.1468-334.2010.03084.x.Костенко Е.В., Петрова Л.В. Постинсультная спастичность нижней конечности: комплексная реабилитация пациентов с применением ботулотоксина (онаботулинумтоксин А). Журнал неврологии и психиатрии, 2014, 10: 39-48.Костенко Е.В., Петрова Л.В. Постинсультная спастичность нижней конечности: комплексная реабилитация пациентов с применением ботулотоксина (онаботулинумтоксин А). Журнал неврологии и психиатрии, 2014, 10: 39-48.Ryuji Kaji, Yuka Osako, Kazuaki Suyama, Toshio Maeda, Yasuyuki Uechi, Masaru Iwasaki. Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebocontrolled, trial. J Neurology 2010; 257:1330-1337. doi:10. 1007/s 00415-010-5526-3.Ryuji Kaji, Yuka Osako, Kazuaki Suyama, Toshio Maeda, Yasuyuki Uechi, Masaru Iwasaki. Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebocontrolled, trial. J Neurology 2010; 257:1330-1337. doi:10. 1007/s 00415-010-5526-3.Hesse S, Krajnik J, Luecke D, Jahnke MT, Gregoric M, Mauritz KH. Ankle muscle activity before and after botulinum toxin yherapy for lower limb extensor spasticity in chronic hemiparetic patients. Stroke, 1996, 27: 455-460. doi:10.1161/01.str.27.3.455.Hesse S, Krajnik J, Luecke D, Jahnke MT, Gregoric M, Mauritz KH. Ankle muscle activity before and after botulinum toxin yherapy for lower limb extensor spasticity in chronic hemiparetic patients. Stroke, 1996, 27: 455-460. doi:10.1161/01.str.27.3.455.Burbaud P, Wiart L, Dubos JL et al. A randomised, double blind, placebo controlled trial of botulinum toxin in the treatment of spastic foot in hemiparetic patients. J Neurol Neurosurg Psychiatry, 1996, 61: 265-269. doi:10.1136/jnnp.61.3.265.Burbaud P, Wiart L, Dubos JL et al. A randomised, double blind, placebo controlled trial of botulinum toxin in the treatment of spastic foot in hemiparetic patients. J Neurol Neurosurg Psychiatry, 1996, 61: 265-269. doi:10.1136/jnnp.61.3.265.Kirazli Y, On AY, Kismali B, Aksit R. Comparison of phenol block and botulinum toxin type A in the treatment of spastic foot after stroke: a randomized, double-blind trial. Am J Phys Med Rehabil, 1998, 77: 510-515. doi:10.1097/00002060-199811000-00012.Kirazli Y, On AY, Kismali B, Aksit R. Comparison of phenol block and botulinum toxin type A in the treatment of spastic foot after stroke: a randomized, double-blind trial. Am J Phys Med Rehabil, 1998, 77: 510-515. doi:10.1097/00002060-199811000-00012.Richardson D, Sheean G, Werring D et al. Evaluating the role of botulinum toxin in the management of focal hypertonia in adults. J Neurol Neurosurg Psychiatry, 2000, 69: 499-506. doi:10.1136/jnnp.69.4.499.Richardson D, Sheean G, Werring D et al. Evaluating the role of botulinum toxin in the management of focal hypertonia in adults. J Neurol Neurosurg Psychiatry, 2000, 69: 499-506. doi:10.1136/jnnp.69.4.499.Pittock SJ, Moore AP, Hardiman O et al. A double-blind randomised placebo-controlled evaluation of three doses of botulinum toxin type A in the treatment of spasytic equinovarus deformity after stroke. Cerebrovasc Dis, 2003; 15: 289-300.Pittock SJ, Moore AP, Hardiman O et al. A double-blind randomised placebo-controlled evaluation of three doses of botulinum toxin type A in the treatment of spasytic equinovarus deformity after stroke. Cerebrovasc Dis, 2003; 15: 289-300.Stoquart GG, Detrembleur C, Palumbo S, Deltombe T et al. Effect of botulinum toxin injection in the rectus femoris on stiff-knee gait in people with stroke: a prospective observational study. Arch Phys Med Rehabil, 2008, 89: 56-61. doi:10.1016/j/apmr.2007.08.131.Stoquart GG, Detrembleur C, Palumbo S, Deltombe T et al. Effect of botulinum toxin injection in the rectus femoris on stiff-knee gait in people with stroke: a prospective observational study. Arch Phys Med Rehabil, 2008, 89: 56-61. doi:10.1016/j/apmr.2007.08.131.Caty GD, Detrembleur C, Bleyenheuft C Deltombe T et al. Effect of simultaneous botulinum toxin injections into several muscles on impairment, activity, participation and quality of life among stroke patients presenting with a stiff knee gait. Stroke, 2008, 39: 2803-2808. doi:10.1161/strokeaha.108.516153.Caty GD, Detrembleur C, Bleyenheuft C Deltombe T et al. Effect of simultaneous botulinum toxin injections into several muscles on impairment, activity, participation and quality of life among stroke patients presenting with a stiff knee gait. Stroke, 2008, 39: 2803-2808. doi:10.1161/strokeaha.108.516153.Robertson JV, Pradon D, Bensmail D, Fermanian C et al. Relevance of botulinum toxin injections and nerve block of rectus femoris to kinematic and functional parameters of stiff knee gait in hemiplegic adults. Gait Posture, 2009, 29: 108-112. doi:10.1016/j.gaitpost.2008.07.005.Robertson JV, Pradon D, Bensmail D, Fermanian C et al. Relevance of botulinum toxin injections and nerve block of rectus femoris to kinematic and functional parameters of stiff knee gait in hemiplegic adults. Gait Posture, 2009, 29: 108-112. doi:10.1016/j.gaitpost.2008.07.005.Johnson CA, Burridge JH, Strike PW, Wood DE, Swain ID. The effect of combined use of botulinum toxin electric stimulation in the treatment of spastic drof foot after stroke: a preliminary investigation. Arch Phys Med Rehabil, 2004, 85: 902-909. doi:10.1016/j/apmr.2003.08.081.Johnson CA, Burridge JH, Strike PW, Wood DE, Swain ID. The effect of combined use of botulinum toxin electric stimulation in the treatment of spastic drof foot after stroke: a preliminary investigation. Arch Phys Med Rehabil, 2004, 85: 902-909. doi:10.1016/j/apmr.2003.08.081.Ryuji K, Yuka O, Kazuaki S, Toshio M, Yasuyuki U. Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebo-controlled trial. J Neurol, 2008, 257: 1330-1337. doi:10.1007/s00415-010-5526-3.Ryuji K, Yuka O, Kazuaki S, Toshio M, Yasuyuki U. Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebo-controlled trial. J Neurol, 2008, 257: 1330-1337. doi:10.1007/s00415-010-5526-3.Santamato A, Micello MF, Panza F et al. Safety and efficacy of incobotulinum toxin type A (NT 201-Xeomin) for the treatment of post-stroke lower limb spasticity: a prospective open-label study. Eur J Phys Rehabil Med, 2013, 49(4): 483-489. doi:10.1007/s00702-012-0892-x.Santamato A, Micello MF, Panza F et al. Safety and efficacy of incobotulinum toxin type A (NT 201-Xeomin) for the treatment of post-stroke lower limb spasticity: a prospective open-label study. Eur J Phys Rehabil Med, 2013, 49(4): 483-489. doi:10.1007/s00702-012-0892-x.Wu Tao, Dong Yan, Jian-Hua Li et al. Gait improvement by low-dose botulinum toxin A injection treatment of the lower limbs in subacute stroke patients. J Phys Ther Sci, 2015, 27: 759-762. doi:10.1589/jpts.27.759.Wu Tao, Dong Yan, Jian-Hua Li et al. Gait improvement by low-dose botulinum toxin A injection treatment of the lower limbs in subacute stroke patients. J Phys Ther Sci, 2015, 27: 759-762. doi:10.1589/jpts.27.759.Dressler D, Saberi FA, Kollewe K, Schrader C. Safety aspects of incobotulinumtoxinA highdose therapy. J Neural Transm, 2015, 122(2): 327-333. doi:10.1007/s00702-014-1252-9.Dressler D, Saberi FA, Kollewe K, Schrader C. Safety aspects of incobotulinumtoxinA highdose therapy. J Neural Transm, 2015, 122(2): 327-333. doi:10.1007/s00702-014-1252-9.Jorg Wissel, Djamel Bensmail, Joaquim J, Ferreira et al. Safety and efficacy of incobotulinumtoxin A doses up 800 U in limb spasticity: The TOWER study. Neurology, 2017, 88: 1-8. doi:10.1212/wnl.0000000000003789.Jorg Wissel, Djamel Bensmail, Joaquim J, Ferreira et al. Safety and efficacy of incobotulinumtoxin A doses up 800 U in limb spasticity: The TOWER study. Neurology, 2017, 88: 1-8. doi:10.1212/wnl.0000000000003789.Esquenazi A, Alfaro A, Ayyoub Z, Charles D, Dashtipour K et al. OnabotulinuntoxinA for Lower-Limb Spasticity : Guidance from a Delphi Panel Approach. PMR, 2017. doi:10.1016/j.pmrj.2017.02/014.Esquenazi A, Alfaro A, Ayyoub Z, Charles D, Dashtipour K et al. OnabotulinuntoxinA for Lower-Limb Spasticity : Guidance from a Delphi Panel Approach. PMR, 2017. doi:10.1016/j.pmrj.2017.02/014.Fieztzek U, Kossmehl P, Schelosky L, Wissel J. Early botulinum toxin treatment for spastic pes equinovarus – a randomized double-blind placebo-controlled study. Eur J Neurol, 2014, 21: 1089-1095. doi:10.1111/ene.12381.Fieztzek U, Kossmehl P, Schelosky L, Wissel J. Early botulinum toxin treatment for spastic pes equinovarus – a randomized double-blind placebo-controlled study. Eur J Neurol, 2014, 21: 1089-1095. doi:10.1111/ene.12381.Lindsay C, Simpson J et al. The early use of botulinum toxin in post-stroke spasticity: study protocol for a randomised controlled trial. Trials, 2014, 15: 12. doi:10.1186/1745-6215-15-12.Lindsay C, Simpson J et al. The early use of botulinum toxin in post-stroke spasticity: study protocol for a randomised controlled trial. Trials, 2014, 15: 12. doi:10.1186/1745-6215-15-12.Bohannon RW, Smith MBO. Inter-rater reliability of a modified Ashworth Scale of muscle spasticity. Phys Ther, 1987, 67: 206-7.Bohannon RW, Smith MBO. Inter-rater reliability of a modified Ashworth Scale of muscle spasticity. Phys Ther, 1987, 67: 206-7.Pandyan AD, Johnson GR, Price CIM, Curless RH, Barnes MP, Rodgers H. A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity. Clin Rehabil, 1999, 13: 373-83. doi: 10.1191/026921599677595404.Pandyan AD, Johnson GR, Price CIM, Curless RH, Barnes MP, Rodgers H. A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity. Clin Rehabil, 1999, 13: 373-83. doi: 10.1191/026921599677595404.Ozcakir S, Sivrioglu K. Botulinum toxin in poststroke spasticity. Clin Med Res, 2007, 5: 132-138. doi:10.3121/cmr.2007.716.Ozcakir S, Sivrioglu K. Botulinum toxin in poststroke spasticity. Clin Med Res, 2007, 5: 132-138. doi:10.3121/cmr.2007.716.Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assesment of handi-cap in stroke patients. Stroke, 1988, 19: 604-607. doi: 10.1161/01.str.19.5.604.Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assesment of handi-cap in stroke patients. Stroke, 1988, 19: 604-607. doi: 10.1161/01.str.19.5.604.

The authors declare that there are no conflicts of interest present.