Vlasenko S.V., Denega V.I., Ponomarenko E.N.
Yevpatoriya Central Children's Clinical Resort
Ministry of Defence (Yevpatoriya).
Crimea State Medical University named after S.I. Georgeevskiy (Simferopol)
Department of Nervous Diseases with the Course of Neurology PEF.
One of the leading places in the problem of rehabilitation of various forms of cerebral palsy (CP) is assigned to the questions of effective impact on various pathological neuro-orthopedic syndromes developing due to perverted innervation of muscles. Pathological muscle innervation, as a clinical sign of suprasegmental structures of central nervous system lesions in the early stages of ontogenesis, along with the constant activity of unreduced tonic reflexes, leads to the distorted formation of functional propulsion of a child, development of faulty limb installations, that in turn supports and reinforces the pathological motor stereotype [1,4]. On the whole, the early physiological development of locomotion contributes to changing the whole system of the central regulation of movement, stimulates the development of higher mental functions of the child.  In general, by the age of 3-4 neurologists face severe motor disabilities, the development of both primary and secondary deformations due to compensatory accessories for the maintenance of stable vertical position. Currently, there are many techniques of physiotherapy using different simulators allowing significantly to increase the possibility of movement of a sick child [1, 2, 4]. The aim of our study was to investigate the influence of training on a specialized stationary bike on the condition of the musculoskeletal system and correction of pathological motor stereotype.
We observed 30 patients with cerebral palsy, spastic diplegia aged from 2 to 5. All children moved independently. It must be emphasized that rehabilitation activities had been carried out for the patients from an early age. In a specialized department of a sanatorium different types of spa treatments were used: pelloidotherapy, thalassotherapy, hydrocolonotherapy in thermal-mineral pool, sand baths, physiotherapy and reflexology sessions with teacher- correctors.
In order to clarify the extent of damage to the neuromuscular system, the participation of certain muscles in the formation of pathological postures stimulus and total electromyography (EMG) was prescribed. Total EMG was performed by the standard procedure for patients with cerebral palsy, i.e., with a detection of bioelectrical activity level of the limbs’ muscles and the degree of disturbance of coordination relations between them.
The biomechanics of standing was investigated on the computer stabilographic complex with an assessment of root-mean-square (rms) deviation of the center of gravity in the sagittal and other planes, moving speed of the center of gravity and the total area of the center of mass migration. Additional methods of research were also prescribed after treatment.
A test group of 10 people, who were the patients with this form of the disease, underwent a traditional course of sanitaria and health resort treatment.
By clinical examination all patients showed that neurological status occurred non-reduction tonic reflexes: cervical and labyrinth, as well as their combination. Pathologic posture was characterized by different provisions of vicious lower limb formation of pathological synergies, syndromes (rectus - , adductor- and gamstring-syndromes), equine-varus or valgus deformity of the foot.
According to the EMG maximum pathological activity was recorded in adductor of the thighs, sural muscles of the calves. EMG examination showed a significant increase in the bioelectric activity in the adductor muscles of the thigh, shin flexors (semimembranosus, semitendinosus), triceps tibia with a sharp decrease in the bioelectric activity of antagonist muscles (gluteus maximus, biceps femoris, tibialis anterior).
According to the stabilographic test the area of the projection common center of mass was displaced in all patients, especially anteriad (80%), the degree of stability of standing was dramatically reduced; in all planes increased root-mean-square (rms) deviation of the center of gravity was 2.5 times, mainly in the sagittal plane. The weight on the forefoot was up to 75%.
The stationary bike exercises (patent priority receipt 200 500 583 from 14.05.2005) in the main group were carried out for 2-3 hours daily for 30 days as an independent riding in the open space, on the background of the complex of traditional rehabilitation, which includes various types of physical therapy, massages, electrotherapy, pelloidotherapy, hydrocolonotherapy, climatic therapy, balneotherapy.
Design features of the bike are of the following characteristics:
1. The only exercise bike adapted for patients with severe neurological disorders. It allows the possibility of riding in the open space for children, who can not move or move only in a wheelchair.
2. It takes into account the peculiarities of child’s psychology: not monotonous riding in the gym, but riding outside, which stimulates cognitive activity of a sick child, requires a program of movement around the open space and strictly adhere to its implementation, develops ideas about the world, expands the range of communication, allows you to communicate with healthy children, which greatly improves the psychological status, specifically stimulates the frontal lobes of the brain. The child develops a desire to do other kinds of treatment and rehabilitation.
3. Designed for various neuro-orthopedic syndromes: a height-adjustable device for fastening the back allows setting children with the most severe lesions in vertical position, reduces the pathological stereotype of head down tilt, works out an independent control over the surrounding space that contributes to the development of spatial representations, hemispheric interaction stimulates the occipital parts of the brain.
Changing of the level of stress on the muscles allows developing an individual program based on the present neuro-orthopedic status and adjusting it to a child's development state.
Specially designed steering handle straps allow fixing the child's hands, which promotes cylindrical and plucking grip of objects, development of stereognosis and two-dimensional spatial sense, thereby stimulating the parietal-temporal regions of the brain.
4. Possibility to convert the stationary exercise bike at home, allowing parents to continue purposeful work with a child at home. It does not associate them with the need for continued stay in the specialized institutions, prevents the development of the syndrome of "hospitalism" of children, it contributes to a more fulfilling social adaptation.
Clinically positive dynamics in patients engaged in a specialized bike, compared with the test group was more pronounced. Children of the main group started to move independently much earlier, thus improving the efficiency of physical therapy and re-orienting the instructor to conduct exercises that produce the correct stereotype of walking and more complex movements, which was achieved much later in the test group. The children in the test group were only noted to increase the volume of passive movements, without significant increase of active movements.
The reduction of spastic guidelines had a positive effect on the state of the higher mental functions of a child - improved praxis, somatognozis and reciprocal relationships and, as a consequence - the spatial representation, the teacher-corrector’s work became more effective. In the test group, the positive dynamics in neuropsychological status was not pronounced that much.
In the main group the EMG re-examination revealed a significant increase in the bioelectric activity of antagonist muscles to an average of 40% of the initial values (at average amplitude of bioelectric potentials) and a decrease in the bioelectric activity of spastic muscles. In the test group the signs of recovery reciprocal synergistic interaction between the antagonists and synergists were insignificant.
According to the stabilographic research improvement of static comfortable standing posture corresponded the consistent decrease in the area of migration of the common center of mass to 10% (in the test group to 3%).
The offset to the center axis of a coordinate decrease and the mean-square deviation of the center of gravity in the sagittal plane were noticed at 25% (test group - 12%) and the load weight on the forefoot 30% (control group - 16%).
1. Using an exercise bike in the complex sanatoria and health resorts’ treatment promotes earlier recovery of motor activity, more rapid adaptation and development of a new correct motor stereotype.
2. Neurologists and orthopedists together, using different types of EMG research, must determine indications for training on the simulators, depending on the predominance of one or the other pathological muscle synergies.
3. Exercising on the simulator is to be optimally performed after procedures aimed at reducing muscle tone (pelloido- , thalasso-, hydrokinesitherapy in thermal-mineral pool, sand baths).
This tactics prevents pain reflex syndromes, painful muscle spasms, promotes better mobility in the joints, which increases the effectiveness of the taken actions in general.
4. At home, it is recommended to conduct exercises after paraffin applications on spastic muscles.