Summary
     In the examination took part 164 patients with depressing-neurological pathology and 37 healthy people; examination was carried out by means of stabilometry and method of psychometric scales. The patients were examined three times before the treatment was started, in the middle of treatment and on its completion. The patients are divided into four sub-groups: control group – 49 persons, which was given a traditional course of treatment; group “A”, to which there was additionally applied the method of balance therapy; group “B” – 21 persons – where the treatment was complemented by exercise therapy method “Equilibrium” and group “C” – 27 persons - where there was used a combination of balance therapy and exercise therapy “Equilibrium”. The initial postural indices in sub-groups did not have any considerable differences. The control group did not show the dynamics of postural indices during the course of treatment and was characterized by the decrease of stability in main stand. In group “A” there was noticed the improvement of visual-motive (motor) connection, in group “B” – amelioration of proprioreceptive feeling and in group “C” the indices had the least deviation from the norm.

Key words: medical rehabilitation, boundary mental pathology, stabilometry.

Contact information: Skvortsov Dmitry Vladimirovich, 105005, Moscow, Baumanskaya str., 70, tel: 8-916-692-54-19, e-mail: dskvorts63@mail.ru

Introductioin

     Status of patients with some boundary mental states is characterized by change of mental status as well as presence of concomitant somatic violations, including modification of their moving functions. Functional state of nervous system influences the ability to maintain static equilibrium (vertical posture of a human being). Thus, Gurfinkel and joint authors [1] observed the considerable change of stabilometric indices (amplitude of oscillations, their frequency) when the modification of functional state of nervous system under the influence of some pharmaceutical substances (particularly chloral hydrate), alcohol, hypoxia, fatigability. E. P. Ilyin [2] investigated the ability to maintain static equilibrium (in Romberg’s posture) by skiers with different typological peculiarities of nervous system. It turned out that those who had weak nervous system with prevalence of agitation by “outer” and “inner” balance appeared to be unsteady.

     For diagnostics of functional state of body balance control system in main stand the stabilometry method is applied. In accessible literature we could find two investigations which were carried out on similar patients. In one of them [8] no considerable changes of stabilometric indices either before or during the process of treatment were stated. In the other one [9] it was not managed to ascertain the influence of energizers on stability of balance in main stand among the patients with dispersive syndrome. Consequently, the question about the presence and character of motor disturbances under the boundary mental pathology as well as about the possibilities of their amendments remains open.

     The purpose of this article is to study the peculiarities of postural balance of patients with depression and disturbed states during the treatment process and the possibility to amend motor disturbances by means of exercise therapy and stabilotraining with biological feedback.

Material and methods.

     The investigation was carried out on basis of Z.P. Soloviyev clinical hospital _8 “Neurosis clinic”. In total there were examined 164 people of both sexes at the age from 17 to 55 years old, out of which 37 people were healthy and 127 were ill. The characteristic of examined patients according to sex, age and nosological belonging is reflected in table 1.

Table 1. The characteristic of examined patients according to sex, age and nosological affiliation in “Norm” group as well as control and main groups. A, B, C – sub-groups of the main group.

F3 – affective disturbance of mood according to MKB-10, F4 – neurotic, connected with stress and somatoform disturbances according to MKB-10.

3 34 37 - -
     State of patients in all the cases was defined as not psychotic level disorder. Comparative group was composed of 37 healthy people – employees of the clinic at the age from 19 to 55 years old (average age was 34,9 years old), among which there were 3 men and 37 women. Out of 127 patients, the control group was formed by 49 people and 78 people entered into main group which was divided to “A”, “B” and “C” sub-groups depending on the treatment used.

     The patients of control group (49 people, table 1) were given the common treatment usually used in the clinic. It consisted of complex psychotherapy, therapeutic physical training, physiotherapeutic procedures, auto-training and drug treatment. Drug therapy included neuroliptics, energizers, tranquilizer, nootrops, normotimics and symptomatic therapy. Therapeutic physical training consisted of respiratory therapeutic gymnastics and relaxation therapeutic exercises, suggested by [5]. These complexes include series of specially selected postures and therapeutic exercises which influence on cardiovascular, neuromuscular, respiratory systems and emotional-vegetative sphere. The course was composed of 15 work-outs.

     All the patients of the main group got the generally applied treatment. They were divided into sub-groups: “A” (27 people) – patients who were additionally given the course of stabilotraining with biofeedback (BFB), on average 12 procedures; “B” (21 people) – those who were additionally suggested to take a course of exercise therapy method “Equilibrium” according to a method developed by us; “C” – patients (27 people) given the additional course of stabilotraining with BFB and exercise therapy method “Equilibrium” simultaneously.

     The initial checkup of the patients involved evaluation of their clinical state, filling in the psychometric scales by physicians and patients and stabilometric investigation.
Foe inclusion of patients to the investigation group there were used the following criterions: age not older then 55 years old; belonging of the illness to class F3, F4 in accordance with MKB-10; absence of chronic somatic illnesses in acute condition, coarse orthopedic or neurological pathology, extensive myopia (short-sightedness).

     For estimation of changes in psychic status of the investigated patients along with clinical methods there were also used diagnostic and psychometric scales, the scale of M. Hamilton for appraisal of degree of depression intensity (HDRS) [6,7] and hospital scale of anxiety and depression (HADS). For estimation of functional state of motor system we applied the method of stabilometry [4].

     Stabilometric investigation was carried out with the help of “MBN-STABILO” complex (NMF “MBN”, Moscow). There was used the complicated Romberg test: feet put together, eyes closed – hands outstretched. Registration of projection of the focal point (center of gravity), that is the center of pressure (CP) on support surface and its fluctuations was executed during 51 second in each position – with eyes opened and closed. To present the data there was used European frame of reference of a patient. There were the following stabilometric parameters analyzed: Romberg coefficient (QR) – relation of statokineziogram area in position “eyes closed” to the similar parameter in position “eyes opened”; pressure center coordinate (PC) in sagittal (Y) plane; conveying speed of CP (V) in mm/sec; statokineziogram (s95) area in mm2; measure of stability Stab.

     Stabilometric examination was implemented right on the day of patient’s arrival to the clinic before the treatment with psychoactive drugs was started. In the end of the treatment course (on the 30-s day) there was carried out the final complex examination of the patients.
     In the stabilotraining course with BFB there were used the particularized equilibrium simulators, which form the part of “MBN-STBILO” complex.
     The developed course of therapeutic exercises “Equilibrium” is directed to amend the main postural problems that we managed to find out: increase of stability of vertical position, training of proprioreceptive sensibility and vestibular apparatus, improvement and strengthening of visual-motor relations. The basis of “Equilibrium” complex – exercises aimed at proprioreception training as well as training of oculomotor muscles and vestibular apparatus. To complicate the functioning of proprioreceptive system some exercises are accomplished on high (20 cm) soft (foam-rubber) rugs.
     Static processing was fulfilled by standard means of variation statistics with the use of paired and unpaired Student’s “t” coefficient.

Results.

     The first examination was implemented on the day of patient’s arrival to a ward for treatment psychoactive drugs therapy was started.
     The results of the first examination and its comparison with the “Norm” group of healthy people are represented in table 2.

Table 2. Average values +/- standard error of the investigated parameters in group of patients (n=127) in comparison with the norm.

Sign * designates indices which have reliable differences from similar indices in norm, p< is a level of confidence probability.

     The table above evidently shows that many stabilometric examination indices of the patients arrived for treatment have reliable differences from the indices of healthy people. Conveying speed of PC with opened and closed eyes exceed the norm, when eyes are closed the area of statokineziogram exceed the norm; when eyes are closed the stability index is less then norm. Romberg coefficient also exceeds the norm.

     Based on the results the patients were divided into control group and main group.

     The results of stabilometric examination in control group on completion of treatment and their comparison with the initial data are reflected in table 3.

Table 3. Average values +/- standard error of the investigated parameters in group of patients (n=49) in comparison with the norm.

Sign * designates indices which have reliable differences from similar indices of the first examination, p – is a level of confidence probability.       

     On completion of treatment the patients of control group have reliable changes of some indices. Pressure center shifted backwards. When eyes are opened the index of statokineziogram area extended. The dynamic of other indices which have considerable differences from the norm was not revealed.
The results of the sub-groups of the main group are shown in table 4.

Stab (%)

Table 4. Average values +/- standard error of the investigated parameters in sub-groups A, B, C.

A1, B1, C1 – the results of stabilometry before the treatment, A2, B2, C2 – on its completion.

Sign * designates parameters of the 2nd examination which have reliable differences from similar parameters of the first examination, p – is a level of confidence probability.

     Making an analysis of stabilometry results let us note that in all the sub-groups there was the dynamic of indices noticed. In sub-group “A” there was a shift of PC backwards with closed and opened eyes. When eyes were opened the conveying speed of PC increased and the area of statokineziogram decreased, but these changes do not reach statically reliable level of significance. It can be characterized as a positive tendency to the increase of stability of the patients of sub-group “A” with their eyes opened.

     The majority of patients of sub-groups “B” and “C” have the similar dynamics of stabilometry indices. When eyes are closed there is a reliable decrease of statokineziogram area noticed, the increase of stability. When eyes are opened the average values of the statokineziogram area are less then initial ones, but these changes are not reliable and testify only positive tendencies to the increase of stability.

     The comparison of the results, acquired in sub-groups of the main group on completion of treatment, with the results of the control group is reflected in table 5.

Table 5. Average values +/- standard error of the investigated parameters in comparison with the control group. A2, B2, C2

– the results of the second examination in sub-groups A, B, and C; K-2 – the last examination in the control group.

Sign * designates indices which have reliable differences from similar parameters of the control group.

     On completion of treatment we found out the reliable differences of stabilometric parameters from the control group in sub-groups A and B. In sub-group “A” the Romberg coefficient value is higher then the value of the same coefficient in the control group. PC with opened eyes is switched backwards. In sub-group “B” there was detected the less value of speed of CP with the eyes closed. However, it should be mentioned that when the eyes were opened in all the sub-groups the average value of statokineziogram area was less then the same value in the control group. It can be considered as a positive tendency to the increase of stability in the positions “eyes opened” in the main group. In contrast to the control group where there was a negative dynamics of this index noticed. The statokineziogram area when eyes were closed in sub-groups “B” and “C” is also less (though it is no6t reliable) then the similar index in the control group, that testifies the tendency to increase of stability in these sub-groups during the treatment process.
Dynamic of psychic status of the patients in the groups examined is shown in table 6.

Table 6. The test results in sub-groups A, B and C before the treatment course started (1) and on its completion (2) in comparison with the control group.

The results are shown in points. HADS-A – sub-scale “anxiety”, HADS-D – sub-scale “depression”.

Sign * signifies indices which are different from the control, p &Mac178; 0,05. Sign & denotes indices on completion of treatment which are different from the similar ones at the beginning of treatment, p<0,05.

     Looking at the table it becomes obvious that in the process of treatment in the considered groups of patients there was a positive dynamics of psychic status noticed by physicians as well as by patients themselves. Before the treatment according to Hamilton scale there were no reliable differences between psychic status of the patients of subgroups “A”, “B” and “C” and control group found. Total average value of the points shows that most of the patients are in depression state. On completion of treatment the average value of the points in the groups of patients has reliably decreased that witness to the improvement of mental state of the patients. Moreover, in sub-group “B” there was noticed a reliably less value of the points in comparison with the control group, that shows that the patients of this group had more considerable improvements of mental state and that their depression state lessened. Giving the subjective estimate of their state patients of all the groups, as well as of sub-groups “A”, “B” and “C”, reliably mentioned the decrease of anxiety and depression after the treatment course in comparison with the control group.

Discussion.

     Acquired results show that patients with boundary mental pathology have typical postural disturbances. The extension of statokineziogram area in position “eyes closed” tells us about the decrease of amending influence of proprioreceptive field that results in stress of balance control system and becomes apparent in the increase of Romberg coefficient. The presence of this stress is proved by accelerated, in comparison with the norm, conveyance speed of CP that is true to both positions – with eyes closed and opened. On the whole, significance of visual analyzer of the examined patients increases with the decrease of proprioreceptive function. And nevertheless with the decrease of balance function the amendment of visual analyzer stays insufficient - that is proved by extension of statokineziogram area in position “eyes opened”. This is why the level of visual-motor connections of patients does not let them reach normative stability.

     The analysis of the results got from the control group during the treatment shows the absence of dynamics of most of the parameters as well as the extension of statokineziogram area in the position “eyes opened”. Consequently, in the process of typical treatment course there noted the clinical improvements of patients’ state, the decrease of anxiety level and depression. However, there is no amendment of discovered postural disturbances. The reason for it might be the use of psychotropic drug therapy. However, as it was mentioned in previous work [3], and as it is stated in similar investigations [8,9], it was not possible to find out the real influence of psychotropic drugs.

     For the patients of test group the main regularities of treatment dynamics are characterized by the following. On completion of balansotherapy course among the patients of group “A” the role of visual analyzer increased in the stability of balance. Taking into account the main visual component in BFB therapy the result in existence is achieved by means of increase of the role of visual-motor connections. The switch of PC in this sub-group as a result of BFB-therapy happened because of intentional placing of PC in this position. During the initial analysis of control group’s data there existed a supposition that PC switched forward from the normal position. By virtue of this circumstance one of the purposes of BFB-therapy was to bring PC to normal position that is to switch PC backwards which was successfully realized. In the position “eyes closed” – in sub-group “A” there were no considerable dynamics of studied parameters mentioned.

     As a result of application of methodic of therapeutic exercises “Equilibrium” developed by us the stability of vertical position of the patients in sub-group “B” increased at the expense of increase of proprioreceptive sensibility and its participation in position regulation, because the significant changes of parameters were noticed only in position “eyes closed”. When eyes were opened there was also mentioned the positive tendency in stability increase that testifies increase of the role of visual analyzer in supporting the vertical posture. Before the therapeutic exercises course “Equilibrium” and stabilotraining course with BFB were started the patients of “A” and “B” sub-groups did not show any differences of the parameters concerned. On completion of the amendment courses there appeared a reliable decrease of Romberg coefficient in sub-group “B”.

     Thus, by means of BFB-therapy it is possible to increase the influence of visual-motor connections and with the help of therapeutic exercises “Equilibrium” – the influence of proprioreception. This is why the best result can be achieved when these methods are used simultaneously, which is realized in group “C”. The results which sub-group “C” shows display the reliable improvement of stability for both positions “eyes opened” and “eyes closed” in comparison with the control group and with the similar positions in sub-groups “A” and “B”.

     Psychic status. The patients of the main group on completion of treatment show the reliable improvement of physical state. The patients of sub-groups “A”, “B” and “C” differed from the control group by subjective estimate of their state, characterized by lower level of anxiety and depression. It undoubtedly can be considered as the prove of effectiveness of the amendment methods used, which not only amend functional motor changes but also provide psychotherapeutic effect, decrease the feeling of anxiety, lower the intensity of depression, directing patients to recovery. The results of clinical testing of the patients of group “C” show more effectiveness of the treatment method applied for improvement of patients’ physical state.

Conclusion.

1. Functional state of motor system of the patients with depressive and anxious state is characterized by stress in body balance control system, dysfunction of visual-motor connection, decrease of proprioreceptive sensibility, prevalence of visual analyzer in maintaining static equilibrium.

2. In the process of typical treatment of such patients there is no amendment of changes in functional state of motor system. Exciting insignificant decrease of stability in the position “eyes opened” might be the consequence of psychotropic drugs influence.

3. Application of stabilotraining with BFB gives the possibility to increase the stability of vertical position mainly due to strengthening of visual control.

4. Application of therapeutic exercises “Equilibrium” complex contributes to increase of stability of vertical state of patients due to both visual control strengthening and optimization of visual-motor connections.

5. Combination of therapeutic exercises “Equilibrium” and stabilotraining with BFB is the optimal for amendment of discovered changes that permits to achieve postural parameters of the norm.

6. Amendment of functional state of motor system of patients makes for improvement of psychotherapeutic state, provides psychotherapeutic influence, lowers down the feeling of anxiety and reduces depression.

Literature.
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