Up to 16–20% of patients with a history of traumatic brain injury (TBI), regardless of its severity, suffer from pronounced spasticity, cognitive, vestibular and motor disorders. At the same time, data on the effectiveness of botulinum neurotoxin (BoNT) in the treatment of post-traumatic spasticity is lacking.Objective: to assess the effectiveness of peripheral myorelaxants (botulinum neurotoxin type A) in the treatment of past-traumatic spasticity.Patients and methods. 21 male patients aged 25 to 48 years with post-traumatic spastic hemiparesis (at least 6 months after the injury) were examined. 450 to 850 U (mean – 650 U) of BoNT (incobotulinumtoxin) was injected into the spastic muscles of the upper and lower extremities. The follow-up assessment of spasticity and paresis was performed 24±3 days after BoNT injection. Patterns of spasticity were studied: shoulder adduction, elbow joint flexion, forearm pronation, hand and finger flexion, hip adduction, shin flexion, foot flexion, toe flexion. The following methods were used: original methods of manual testing (MMT) of spasticity, Tardieu scale (TS), modified Ashworth scale (MAS), Medical Research Council Scale (MRCS) to assess paresis.Results and discussion. 24±3 days after incobotulotoxin administration, we observed a significant 1.5–2-fold decrease in spasticity angle (xS) and a reduction in the angle of neuromuscular reactivity (xV3) by 15–30° in all the studied patterns. Changes of xV1 (muscle extensibility) and xA (muscle strength) were not significant. No adverse reactions were observed. The use of MMT and TS has shown its effectiveness and specificity in the evaluation of spasticity and effectiveness of BoNT, and in the dynamics of muscle condition.Conclusion. The study showed the feasibility of using MMT and TS in the evaluation and assessment of spasticity, as well as the effectiveness and safety of incobotulinumtoxin (Xeomin) in dosages from 450 to 850 U in the treatment of spasticity of the upper and lower extremities in patients with the consequences of TBI.

В статье проведён обзор литературы, показаны этиология, патогенез, клиническая картина, диагностика и лечение гемифациального спазма. Акцентировано внимание на этиопатогенетической терапии, имеющей научную доказательную базу и показавшей эффективность в течение полувекового периода применения. The article reviews the literature, shows the etiology, pathogenesis, clinical picture, diagnosis and treatment of hemifacial spasm. Attention is focused on etiopathogenetic therapy, which has a scientific evidence base and has shown effectiveness over a half-century period of application.

Spasticity treatment remains an urgent problem of modern neurorehabilitation. The targeted injection of botulinum neurotoxin (BoNT) into the muscle motor points (MPs) is gaining more and more popularity. But there are insufficient data on the position of MPs, while a MP search methodology has not been worked out yet. Most information about MPs has been obtained on cadaveric material using anatomical dissection or Sihler’s staining technique. Clinical data on the targeted injection of BoNT into the MPs are contradictory, which may be due to the inaccurate determination of their position.Objective: to verify upper and lower limb muscle MPs through electromyography (EMG).Patients and methods. Forty healthy volunteers were examined and underwent anthropometric assessment. Upper and lower limb muscle projections were completely scanned using EMG and ultrasound.Results and discussion. The anatomical localization of MPs in the upper and lower limb muscles involved in spasticity patterns was determined. The position of MPs was found to populationally identical, to have a slight deviation associated with the limb length, and to be unrelated to gender, age, and limb dominance. Original tables and maps for limb MP localization were created.Conclusion. The findings can enhance the efficiency of BoNT administration and improve the quality of rehabilitation measures, since the use of reliable information on the position of MPs will allow targeted BoNT injection in the immediate vicinity of the site of biological action. In clinical practice, this opens a window of opportunity for the early initiation of rehabilitation measures aimed at restoring movement.

AIM:To study the electromiographic (EMG) parameters and to evaluate the therapeutic efficacy of a combination of central (baclofen, baclosan) and peripheral (incobotulotoxinA, xeomin) muscle relaxants in the treatment of post-stroke spasticity (PSS).MATERIAL AND METHODS:Ninety-six patients with PSS of upper and lower limbs were divided into 2 groups: the first group (n=56) was treated with xeomin and the second (n=40) received combined therapy of xeomin and baclofen. Xeomin was administered according to the pattern of spasticity. The total dosage reached 800 U. Baclofen was used orally in a dose of 10 mg 3 times a day. The scales of paresis and spasticity assessment (MRCS, MAS and Tardieu), activity and participation of patients in everyday life (Bartel, Rankin, Rivermead mobility Index, comfortable walking test, LASIS) were used. EMG and transcranial magnetic stimulation (TMS) were performed. M-response, H-reflex, F-wave, central conduction time were determined. The total duration of the study was 120 days. Patients were assessed at 4 points.RESULTS AND CONCLUSION:Potentiation of peripheral and central muscle relaxants and prolongation of the effect of xeomin was revealed (it was expressed in the reduction of the number of injection sessions from 7-8 to 5-6). The use of xeomin in a total dosage of up to 800 U has shown its efficacy and safety for the treatment of spasticity of the upper and lower limbs. The results of EMG and TMS shed a light on the mechanisms of the therapeutic effect of combined (xeomin+baclosan) and monotherapy (xeomin) spasticity.

КОМПЛЕКснАЯ МЕДиКАМЕнТОЗнАЯ ТЕРАПиЯ В ЛЕЧЕнии ПОсТинсуЛьТнОй сПАсТиЧнОсТи

AIM To study the informative nature of manual therapy for differential diagnosis of migraine and cervicogenic headache (CH). MATERIAL AND METHODS The authors analyze two clinical cases of patients with a previously established diagnosis of migraine, with the duration of the disease of over ten years and neuroimaging signs of degenerative-dystrophic changes in the upper cervical spine. In both cases, there was no hereditary history and low efficacy of the previous drug therapy was noted. The informative value of the tests performed by methods of manual medicine followed by manipulation procedures of neck structures for the differential diagnosis of migraine and CH was assessed. RESULTS Despite the absence of complaints, both patients demonstrated the limitation of the volume of neck movements during the tests performed by methods of manual medicine. After a course of manipulation procedures, headaches in both patients were completely stopped for a period of six to ten months. The analysis of literature suggests that manipulative effects on neck structures in cases of migraine can reduce the intensity and the duration of pain, and the frequency of attacks by no more than 20%. The therapeutic effectiveness of manual therapy for CH is much higher; this method provides an opportunity to reduce the severity of these pain characteristics by 30-80%. These results are the basis for changing the previously established diagnosis to CH. CONCLUSION The complex of diagnostic and therapeutic techniques of manual therapy is an important tool for the differential diagnosis of migraine and CH.

Diagnosis, treatment and rehabilitation of patients with spasticity remain a challenge, in which standard methodological approaches have not yet been developed. One of the most promising solutions to this problem is the use of the Modified Tardieu scale (MTS). The article describes the method of working with MTS tested in the examination, treatment and rehabilitation of patients with acute cerebrovascular accident (n=112) and patients with multiple sclerosis (n=17). The original version of MTS has been translated into Russian. The use of MTS assessment system allows the diagnosis of the main elements of the clinical picture of the damage to the central nervous system, such as paresis, spasticity, violation of proprioception, as well as the qualitative and quantitative assessment of the dynamics of rehabilitation and treatment of spasticity with botulinum neurotoxin (BoNT).

Treatment and rehabilitation of patients with upper limb spasticity remains a challenging task that still does not have standard, widely accepted methods. The specific instruments used to measure the impact of spasticity on everyday life occupy an important place in the measurement of treatment effectiveness. The article presents scales and tests used to access the impact of spasticity and paresis on the arm activity. LASIS has been translated into Russian by the authors. The clinical case of treatment of arm muscle spasticity with the botulinum neuro toxin and its assessment with MRCS, MAS, Tardie, LASIS, Frenchai, Bartel, Rankin scales are presented. It provides the unique algorithm for measurement of muscle spasticity in forearm and wrist.

The article presents modern views on the pathophysiology of spasticity, which is a frequent disabling consequence to the upper motor neuron (UMN) damage. Morphological and functional system of motion organization and the changes after the UMN damage is considered. The authors analyze existing definitions of spasticity. Stages of spasticity development are described in the context of neuroplasticity as well as in the framework of pathogenesis and sanogenesis. Existing ideas of its pathogenesis are compared with the typical clinical symptoms. The occurring pathological processes in muscles, tendons and joints that can aggravate the development of spasticity and complicate the diagnosis are considered. In addition, the main pathological spasticity patterns are described and the current development of diagnostic techniques is estimated. A review of main methods of spasticity treatment is presented. Special attention is paid to the botulinum neurotoxin type A (BoNT) preparations and central action muscle relaxants. The pathophysiological basement for complex treatment of spasticity as a part of the general rehabilitation process is given, so that the BoNT can be considered as the obligatory element of standard rehabilitation programs.

AIM:To develop and test a method of examination of patients with lower limb spasticity, to describe lower limb spasticity patterns in patients with brain damage and to assess the efficacy of abobotulinumtoxin A (dysport) in the rehabilitation of patients with stroke.MATERIAL AND METHODS:Spasticity rating scales (MAS and Tardieu), the Barthel index, the Rankin scale , the Rivermead Mobility Index, the Hauser Ambulation Index, a comfortable walking test were used. Treatment satisfaction was assessed with the Visual analogue scale. Abobotulinumtoxin A (dysport) was used for treatment of lower limb spasticity.RESULTS AND CONCLUSION:Two most common patterns (dynamic and static) were identified in patients with post-stroke spasticity and the method of testing spasticity was developed. The prevalence of spasticity in individual muscles of the lower extremity was estimated as well. An analysis of the efficacy of dysport and a sensitive analysis of the scales used in the study were carried out.

5% of all dental pathology account for diseases of the salivary glands. From 3% to 5% of all tumors of the maxillofacial region accounted for tumors of the salivary glands. Among them parotid gland tumors account for up to 92%. The most frequent complications after surgery in the parotid region are salivary fistula and sialocele. There is no single treatment protocol for these complications. The first reports on the successful use of local injections of botulinum toxin for closing of salivary fistula appeared in 1999. For today, foreign colleagues’ studies confirm the efficacy and safety of botulinum toxin in the treatment of salivary fistula. Despite this, still remain to be illuminated following problems: the lack of developed algorithm the prevention and treatment of salivary fistula and sialocele; the lack of comparative assessment of treatment of salivary fistula by using Botulinum and other methods; the lack of long-term observations, the deficiency of information about side effects.

AIM:To study the location and verification of motor points (MP) of the upper limbs for targeting botulinum toxin (BT) type A injections in the treatment of spasticity.MATERIAL AND METHODS:Twenty healthy people were examined. Using electromyography a complete study of the muscles of the upper limbs was conducted.RESULTS:Anatomical localization of MP was performed. The location of MP is identical and does not depend on sex, age and the dominant limb. Tables and maps of MP locations are presented.CONCLUSION:MP in the flexor muscles of the arm were identified. A surface map with MP location was created. This data may improve the clinical efficacy and feasibility of MP targeting, when injecting BT in spasticity.

ОДИНАК М. М., КОВАЛЕНКО П. А., ЕМЕЛЬЯНОВ А. Ю., ДЫСКИН Д. Е., БАЗИЛЕВИЧ С. Н. ... (c) КОЛЛЕКТИВ АВТОРОВ, 2003 ... УДК 616.813-001-06:616.839-07 ... ОДИНАК М. М., заслуженный врач РФ, профессор, полковник медицинский службы ... КОВАЛЕНКО П. А., заслуженный врач РФ, кандидат медицинских наук, полковник медицинской службы ... ЕМЕЛЬЯНОВ А. Ю., доктор медицинских наук, полковник медицинской службы ... ДЫСКИН Д. Е., кандидат медицинских наук ... БАЗИЛЕВИЧ С. Н., кандидат медицинских наук, майор медицинской службы ... ОСНОВНЫМ компонентом в лечении эпилепсии являются антиэпилептические препараты (АЭП). Однако значительных результатов можно добиться только при правильном определении типа и вида припадков, формы эпилепсии и, главное, при точном выборе и назначении доз антиконвульсантов в виде моно- или (при необходимости) политерапии, благодаря чему у большинства больных удается не только достичь контроля над припадками, но и снизить риск возникновения осложнений - психозов, изменений личности, эпилептического статуса. На основании данных зарубежных авторов и собственного опыта работы в клинике нервных болезней ВМедА предлагаем основные принципы и положения лечения эпилепсии АЭП. ... 1. Лечение начинают только при клинически обоснованном диагнозе эпилепсии на основании достоверного факта припадка при наличии изменений на электроэнцефалограмме (ЭЭГ) и/или структурных нарушений по данным компьютерной томографии (магнитно-резонансной то- ... стр. 26 ... мографии). Не целесообразно назначение АЭП в случаях ситуационно обусловленного припадка, а также с целью профилактики эпилепсии после заболеваний или травм головного мозга у пациентов с изменениями ЭЭГ без припадков. ... 2. Раннее применение - постановка диагноза эпилепсии служит абсолютным показанием для немедленного назначения АЭП. ... 3. Монотерапия - на начальном этапе заболевания эффективна для абсолютного большинства форм эпилепсии. При этом не возникает проблем взаимодействия между двумя и более АЭП, меньше частота побочных эффектов и ниже стоимость лечения. ... 4. Выбор АЭП в соответствии с формой эпилепсии и классом (типом, видом) эпилептических припадков. Для абсолютного большинства форм эпилепсии и типов припадков препаратами первого ряда являются карбамазепин и вальпроаты. При отсутствии указанных препаратов или их низкой эффективности возможно назначение барбитуратов, дифенина, клоназепама и новых АЭП. ... 5. Назначение АЭП в дозах, обеспечивающих терапевтический эффект, до максимально переносимых. Средней терапевтической дозы достигают постепенно и индивидуально. ... 6. Предпочтительность использования ретардных форм - создавая постоянный уровень концентрации препарата в крови, они легче переносятся больными, обладают меньшими побочными эффектами и являются более удобными для приема (1 - 2 раза в сутки). ... Оптимальный режим доз чаще используемых АЭП приводим в таблице. ... 7. Переход на политерапию, когда при монотерапии не удается достичь контроля над припадками - к основному АЭП дополнительно назначают один из препаратов второго ряда (синергизм). ... 8. Определение концентрации АЭП в крови - позволяет повысить эффективность лечения и уменьшить частоту побочных эффектов. ... 9. Недопустимость одномоментной отмены или замены АЭП (кроме случаев индивидуальной непереносимости) из-за опасности резкого учащения припадков или развития эпилептического статуса. ... 10. Длительность и непрерывность лечения. Во-первых, постоянную терапию необходимо продолжать на этапах нестойкой и стойкой ремиссии эпилептических припадков (соответственно до одного и более одного года после последнего припадка); во-вторых, постепенное уменьшение дозы АЭП вплоть до его полной отмены возможно лишь на этапе ремиссии эпилепсии, наступающей не ранее трех-пяти лет от последнего припадка; в-третьих, основанием для установления ремиссии эпилепсии являются исчезновение специфических и большинства неспецифических изменений по данным повторных ЭЭГ, регресс изменений личности, нормализация уровня аутоантител к нейрорецепторам глутамата, уменьшение выраженности метаболических нарушений в эпилептическом очаге по данным позитронной эмиссионной томографии и магнитно-резонансной спектрографии. ... 11. Неукоснительное выполнение социальных рекомендаций: соблюдение режима сна, отказ от употребления спиртных и тонизирующих напитков, исключение воздействия экстремальных физических ... Оптимальный режим доз наиболее часто используемых АЭП ... Препараты ... Терапевтическая доза, мг/кг/сут ... Кратность приема в сутки ... Средняя терапевтическая доза, мг ... Возможная (рабочая) доза, мг ... Фенобарбитал ... 2 - 3 ... 1 - 2 ... 120 ... 60 - 240 ... Бензонал ... 4 - 6 ... 2 - 3 ... 300 ... 100 - 800 ... Дифенин ... 4 - 6 ... 1 - 2 ... 300 ... 100 - 700 ... Этосуксимид ... 15 - 30 ... 1 - 3 ... 1000 ... 500 - 2000 ... Антелепсин ... 0,04 - 0,06 ... 3 ... 4 ... 2 - 8 ... Карбамазепин ... Простая форма - 3 ... 10 - 15 ... Ретардная форма - 1 - 2 ... 600