Disorders of the Static-Dynamic Function During Prosthetic Replacement of Limbs in Patients with Cerebral Neurological Pathology: Mechanisms and Clinical Significance

The investigation is devoted to the study of mechanisms of disorders of static-dynamic function during lower extremity prosthesis in patients with postamputation defects accompanied by cerebral neurological pathology of various etiologies — posttraumatic, vascular, and diabetic. The relevance of the work is due to the high prevalence of combined injuries of the extremities and head, as well as the significant frequency of cerebral pathology in patients with obliterative arterial diseases and diabetes mellitus, which substantially complicates the process of rehabilitation and prosthesis. For the first time, the structure of concomitant cerebral neurological pathology in disabled persons with postamputation defects of the lower extremities has been investigated, factors limiting the restoration of static-dynamic function during the prosthesis process have been identified, and pathogenetically justified contraindications to prosthesis have been developed, taking into account the character of neurological syndromes and the tactics of preparation for prosthesis.

Relevance of the Investigated Problem

The observed increase in road-traffic and industrial trauma gives rise to a growing incidence of combined injuries of the extremities and head. Post-traumatic sequelae account for disability in 15.2% of cases [47]. It is characteristic that combined damage to the extremities and traumatic brain injury is identified in 20–45% of cases [81]. Two to four months after traumatic brain injury, even of mild severity, various post-traumatic cerebral pathology is detected in 70% of patients [139]. Various injuries and their consequences are among the principal causes of lower extremity amputation [121, 136].

Despite the advances in recent years in the fields of angiosurgery and pharmacotherapy, mortality and disability rates among patients with obliterating arterial diseases of the lower extremities remain high [117, 230]. The most frequent cause of loss of the lower extremity is obliterating arterial disease [43, 52, 118, 205]. Due to generalization and a tendency toward progressive course, obliterative atherosclerosis involves combined lesions of the arteries of the lower extremities and cerebral vessels [115, 149], which leads to the development of cerebrovascular pathology [133, 159, 224].

In terms of early disability and mortality, the problem of diabetes mellitus and its complications acquires increasing significance [5, 26, 100], and the presence of diabetes mellitus increases the risk of loss of the lower extremity by tens of times [74, 89, 107, 225]. The probability of cerebral pathology is quite high in this category of patients due to the development of diabetic micro- and macroangiopathy [31, 54, 116, 173].

Persons following lower extremity amputation due to obliterating arterial diseases, traumatic injuries, and complications of diabetes mellitus constitute the principal contingent of disabled persons requiring prosthesis [4, 49, 60, 74, 107].

Rehabilitation of disabled persons with postamputation defects of the lower extremities of posttraumatic, vascular, and diabetic etiology who have concomitant cerebral neurological pathology represents an important medico-social task, many aspects of which remain insufficiently studied. Only in isolated scientific publications is the fact of the presence of cerebral neurological pathology in disabled persons with postamputation defects of various etiologies noted [24, 59, 76, 127], but variants of its manifestation and their influence on the outcome of motor rehabilitation are not specified. Systematized data and specific recommendations on fundamental aspects of primary prosthesis, such as the list of contraindications, tactics, and methods of rational preparation for prosthesis, taking into account specific factors limiting the restoration of locomotor function, are virtually absent. Difficulties in the development of rational rehabilitation methods for patients with postamputation defects are largely attributable to insufficient knowledge regarding the significance of cerebral neurological pathology in the pathogenesis of disorders of static-dynamic function. It is known that following amputation of the extremity at the level of the leg or thigh, static-dynamic function is limited by the presence of an anatomical defect, and without the implementation of special medical-technical measures, the functional deficit cannot be compensated. However, the role of concomitant cerebral neurological pathology in the mechanisms underlying the pathogenesis of these disorders and its influence on the restoration of support and locomotion function during the process of lower extremity prosthesis remain unclear.

Thus, the investigation of mechanisms of disorders of static-dynamic function during the process of lower extremity prosthesis in the presence of concomitant cerebral neurological pathology and the development on their basis of pathogenetically justified contraindications to prosthesis constitutes a relevant task.

Objective of the Investigation

To establish the mechanisms of disorders of static-dynamic function and their clinical significance during lower extremity prosthesis in patients with concomitant cerebral neurological pathology.

Tasks of the Investigation

1. To investigate the structure of cerebral neurological pathology in patients with postamputation defects of the lower extremities of posttraumatic, vascular, and diabetic etiology.

2. To investigate the mechanisms of disorders of static-dynamic function in patients with postamputation defects of the lower extremities in the presence of concomitant cerebral neurological pathology and to determine factors limiting its restoration during the process of prosthesis.

3. To study the early and distant results of motor rehabilitation in patients with concomitant cerebral neurological pathology.

4. To develop pathogenetically justified contraindications to prosthesis in patients with postamputation defects of the lower extremities and concomitant cerebral neurological pathology.

Scientific Novelty

For the first time, the structure of concomitant cerebral neurological pathology in patients with postamputation defects of the lower extremities of posttraumatic, vascular, and diabetic etiology has been investigated. It has been demonstrated that it manifests in the form of consequences of craniocerebral trauma and cerebrovascular pathology.

For the first time, the influence of concomitant cerebral neurological pathology on the restoration of static-dynamic function in patients with postamputation defects of the lower extremities has been studied, as well as the mechanisms of its disorders and their clinical significance during prosthesis. Factors limiting the restoration of locomotor function during motor rehabilitation have been determined.

Features of the stabilometric picture in patients with cochleovestibular syndrome, parkinsonian syndrome, and post-stroke hemiparesis have been described.

For the first time, pathogenetically justified contraindications to lower extremity prosthesis have been developed depending on the character of manifestations of concomitant cerebral neurological pathology, and the tactics of preparation for prosthesis have been determined, taking into account factors limiting the restoration of locomotor function.

Practical Significance

The investigation was conducted within the framework of IR 05-97 (State Registration No. 01.9.70.007305) "Development of Tactics of Preparation for Prosthesis and Prosthesis of Disabled Persons with Postamputation Defects of the Lower Extremities in the Presence of Concomitant Dyscirculatory, Posttraumatic, and Diabetic Encephalopathy," carried out in accordance with the plan of scientific-research and experimental-design work of the Ministry of Labor and Social Development of the Russian Federation within the Federal Target Program "Development and Production of Prosthetic Devices, Construction, Reconstruction, and Technical Reequipping of Prosthetic-Orthopedic Enterprises."

Factors limiting the possibilities of motor rehabilitation have been established, and the tactics of preparation for lower extremity prosthesis have been determined depending on factors limiting the restoration of static-dynamic function in persons with postamputation defects of the lower extremities and concomitant cerebral neurological pathology. Pathogenetically justified contraindications to prosthesis of the extremities in persons with postamputation defects have been developed depending on the character of manifestation of concomitant cerebral neurological pathology.

Statements Submitted for Defense:

1. Concomitant cerebral neurological pathology in patients with postamputation defects of the lower extremities manifests in the form of a wide spectrum of neurological syndromes, which can be divided into four groups: those not influencing the restoration of support and locomotion function; those indirectly limiting the function of support and locomotion; those directly limiting the function of support and locomotion; and those aggravating neurological disturbances in the process of restoration of support and locomotion function.

2. The mechanisms of disorders of static-dynamic function in patients with postamputation defects of the lower extremities and concomitant cerebral neurological pathology are due to: in cochleovestibular syndrome — disruption of static stability, equilibrium, and coordination of movements; in parkinsonian syndrome — postural and locomotor disturbances in the form of hyperstability and hypomobility; in psychoorganic syndrome — disruption of motivation for walking with a prosthesis. In patients with postamputation defects of the lower extremities and post-stroke hemiparesis, the mechanism of disorder of static-dynamic function is determined by the lateralization of paresis in relation to the postamputation defect, as well as by reduced load-bearing capacity of the residual limb in the presence of paresis on the side of the residual limb.

3. When establishing contraindications to prosthesis in patients with postamputation defects and cerebral neurological pathology, the following are taken into account: a) the presence of neurological syndromes limiting the possibility of restoration of static-dynamic function (post-stroke paresis on the side of the residual limb, cochleovestibular and parkinsonian syndromes, psychoorganic syndrome with reduced level of motivation); b) the possibility of occurrence of transient or acute cerebral circulation disorders during physical exertion in the process of walking with a prosthesis.

Presentation of the Work

The materials of the dissertation were presented at: the Second Interregional Scientific-Practical Conference "Questions of Medical Prevention and Health of Man in Siberia" (Omsk, 1993); the International Conference "Health Protection of the Population of Coal-Mining Regions" (Leninsk-Kuznetsky, 1997); II Mediterranean Congress of Physical Medicine and Rehabilitation (Valencia, Spain, 1998); the Second Northwestern Scientific-Practical Conference on Problems of Sudden Death (Saint Petersburg, 1998); 18th World Congress of the International Union of Angiology (Tokyo, Japan, 1998); the All-Russian Conference "Diagnosis and Treatment of Polytrauma" (Leninsk-Kuznetsky, 1999); the Scientific-Practical Conference "Actual Problems of Rehabilitation of Disabled Persons" (Novokuznetsk, 2003); the Eighth Russian National Congress "Man and His Health" (Saint Petersburg, 2003).

Publications

Fifteen scientific works have been published on the materials of the dissertation.

Volume and Structure of the Dissertation

The dissertation is presented on 149 pages of typed text and contains the following sections: introduction, literature review, description of material and methods of investigation, 3 chapters presenting the results of original investigations, conclusion, conclusions, practical recommendations, and list of references. The work contains 37 tables and 6 figures. The list of references includes 235 sources, of which 157 are works by domestic and 78 by foreign authors.