Н-РЕФЛЕКСОМЕТРИЯ В КЛИНИКЕ НЕРВНЫХ БОЛЕЗНЕЙ

реклама
Î ÃË ß Ä
Î.À. Ëåâàäà1
Ý.È. Ñëèâêî2
Çàïîðîæñêèé ãîñóäàðñòâåííûé
èíñòèòóò óñîâåðøåíñòâîâàíèÿ
âðà÷åé
1
Çàïîðîæñêèé ãîñóäàðñòâåííûé
ìåäèöèíñêèé óíèâåðñèòåò
2
Êëþ÷åâûå ñëîâà: Í-ðåôëåêñ,
íåâðîëîãè÷åñêèå çàáîëåâàíèÿ,
ôóíêöèîíàëüíàÿ äèàãíîñòèêà.
Í-ÐÅÔËÅÊÑÎÌÅÒÐÈß
 ÊËÈÍÈÊÅ ÍÅÐÂÍÛÕ
ÁÎËÅÇÍÅÉ: ÄÈÀÃÍÎÑÒÈ×ÅÑÊÈÅ
ÂÎÇÌÎÆÍÎÑÒÈ ÌÅÒÎÄÀ
Ðåçþìå. Ïðèâåäåíû îñíîâíûå ñâåäåíèÿ î âîçìîæíîñòÿõ ïðèìåíåíèÿ Í-ðåôëåêñîìåòðèè â äèàãíîñòèêå çàáîëåâàíèé öåíòðàëüíîé è ïåðèôåðè÷åñêîé
íåðâíîé ñèñòåìû. Ïîä÷åðêèâàåòñÿ íåîáõîäèìîñòü ñèíäðîìîëîãè÷åñêîãî ïîäõîäà ïðè îöåíêå ðåçóëüòàòîâ èññëåäîâàíèé è òðàêòîâêå ïîëó÷àåìûõ ñ èõ
ïîìîùüþ äàííûõ.
Ýëåêòðîôèçèîëîãè÷åñêèå ìåòîäû èññëåäîâàíèÿ èãðàþò âàæíóþ ðîëü â ôóíêöèîíàëüíîé äèàãíîñòèêå çàáîëåâàíèé íåðâíîé ñèñòåìû. Ñðåäè íèõ
âûñîêîèíôîðìàòèâíûì ìåòîäîì ÿâëÿåòñÿ èññëåäîâàíèå ðåôëåêñà Ãîôôìàíà, èëè Í-ðåôëåêñà (Íîâèêîâà Â.Ï., 1981; Áàäàëÿí Ë.Î., Ñêâîðöîâ È.À.,
1986; Çåíêîâ Ë.Ð., Ðîíêèí Ì.À., 1991; Delwaide P.J.
et al., 1999; Dumitru D., 2000). Í-ðåôëåêñ ïðåäñòàâëÿåò ñîáîé ðåôëåêòîðíûé îòâåò ìîòîðíûõ åäèíèö
èññëåäóåìîé ìûøöû íà ýëåêòðè÷åñêóþ ñòèìóëÿöèþ åå íèçêîïîðîãîâûõ àôôåðåíòíûõ íåðâíûõ
âîëîêîí. Ïî ñòðóêòóðå ñâîåé ðåôëåêòîðíîé äóãè
îí ÿâëÿåòñÿ ìîíîñèíàïòè÷åñêèì, òàê êàê ðàçäðàæàåìûå àôôåðåíòíûå âîëîêíà çàêàí÷èâàþòñÿ ñâîèìè òåðìèíàëÿìè íåïîñðåäñòâåííî íà a-ìîòîíåéðîíàõ (a-ÌÍ).
 îñíîâå êëèíè÷åñêîãî ïðèìåíåíèÿ Í-ðåôëåêñîìåòðèè ëåæèò òîò ôàêò, ÷òî âåëè÷èíà Í-ðåôëåêñà îòðàæàåò ôóíêöèîíàëüíîå ñîñòîÿíèå êàê ÌÍ,
òàê è ïðåñèíàïòè÷åñêèõ àôôåðåíòíûõ òåðìèíàëåé
åãî ðåôëåêòîðíîé äóãè. Êàê èçâåñòíî, ýòî ñîñòîÿíèå ìîæåò ïî-ðàçíîìó èçìåíÿòüñÿ ïðè ïîðàæåíèè
ñåãìåíòàðíûõ è ñóïðàñåãìåíòàðíûõ îòäåëîâ öåíòðàëüíîé íåðâíîé ñèñòåìû.
Ðàçðàáîòàíû ðàçëè÷íûå ìåòîäû èññëåäîâàíèÿ
Í-ðåôëåêñà êàê ïîêàçàòåëÿ ôóíêöèîíàëüíîãî ñîñòîÿíèÿ ñåãìåíòàðíîãî ðåôëåêòîðíîãî àïïàðàòà
(Íîâèêîâà Â.Ï., 1981; Áàäàëÿí Ë.Î., Ñêâîðöîâ È.À.,
1986). Äëÿ êîëè÷åñòâåííîé îöåíêè óðîâíÿ âîçáóäèìîñòè ÌÍ ÷àñòî èñïîëüçóþò èíäåêñ Íìàêñ/Ììàêñ —
îòíîøåíèå ìàêñèìàëüíîé àìïëèòóäû Í-ðåôëåêñà
ê ìàêñèìàëüíîé àìïëèòóäå îòâåòà òåñòèðóåìîé
ìûøöû íà ñòèìóëÿöèþ åå ýôôåðåíòîâ (Ì-îòâåòà).
Èçâåñòíî, ÷òî èíäåêñ Íìàêñ/Ììàêñ îïðåäåëÿåòñÿ îòíîñèòåëüíûì êîëè÷åñòâîì ìîòîðíûõ åäèíèö, àêòèâèðóåìûõ ñòèìóëÿöèåé àôôåðåíòíûõ âîëîêîí, è
ïîýòîìó îí ïîçâîëÿåò ñóäèòü î âîçáóäèìîñòè ÌÍ.
Èññëåäóþò òàêæå êðèâûå âîâëå÷åíèÿ Í-ðåôëåêñà è
Ì-îòâåòà ïðè ïîâûøåíèè èíòåíñèâíîñòè ðàçäðàæàþùåãî ñòèìóëà (Funase K. åt al., 1994).
Äðóãèì ïîäõîäîì ê îöåíêå ñîñòîÿíèÿ ñåãìåíòàðíîãî ðåôëåêòîðíîãî àïïàðàòà ÿâëÿåòñÿ èññëåäîâàíèå
õàðàêòåðà è ñòåïåíè èçìåíåíèÿ Í-ðåôëåêñà ïîä âëèÿíèåì ðàçëè÷íûõ àôôåðåíòíûõ âîçäåéñòâèé. Åùå â
íà÷àëüíûé ïåðèîä èçó÷åíèÿ Í-ðåôëåêñà áûëè ïîëó÷åíû äàííûå î åãî ïîñòàêòèâàöèîííîé äåïðåññèè,
âûÿâëÿåìîé ìåòîäîì ïàðíûõ ñòèìóëîâ, è íèçêî÷àñòîòíîé äåïðåññèè ïðè ðèòìè÷åñêîé ñòèìóëÿöèè
àôôåðåíòîâ. Ýòè ôåíîìåíû è ñåé÷àñ èñïîëüçóþò äëÿ
îöåíêè èçìåíåíèé ôóíêöèîíàëüíîãî ñîñòîÿíèÿ
äâóõíåéðîííîé ðåôëåêòîðíîé äóãè (Van Boxtel A.,
1986; Áðàæíèêîâ À.Í. è ñîàâò., 1989; Floeter M.K.,
Kohn A.F., 1997; Kagamihara Y. et al., 1998).
Ïðåäñòàâëÿåò èíòåðåñ èçó÷åíèå ïðåñèíàïòè÷åñêîãî òîðìîæåíèÿ Í-ðåôëåêñà, âîçíèêàþùåãî ïîä
âëèÿíèåì ñòèìóëÿöèè íåðâà ìûøö-àíòàãîíèñòîâ
(El Tohamy A., Sedgwick E.M., 1983; Berardelli A. et al.,
1987; Ãàôò Ï.Ã. è ñîàâò., 1994) è ïðè âèáðàöèîííîé
ñòèìóëÿöèè ìûøå÷íûõ ðåöåïòîðîâ (Hultborn H.
et al., 1987; Iles J.F., Roberts R.C., 1987).
Ïðè îöåíêå ðåçóëüòàòîâ Í-ðåôëåêñîìåòðèè â
óñëîâèÿõ ïàòîëîãèè áîëåå äîñòîâåðíûì ñ÷èòàåòñÿ
ñèíäðîìîëîãè÷åñêèé (à íå íîçîëîãè÷åñêèé) ïîäõîä, òàê êàê èçìåíåíèÿ ñîñòîÿíèÿ ñåãìåíòàðíîãî
ðåôëåêòîðíîãî àïïàðàòà ìîãóò èìåòü ìåñòî ïðè
ñèíäðîìàõ ðàçëè÷íîãî ãåíåçà (Íîâèêîâà Â.Ï., 1981).
Ïîýòîìó äàëüíåéøåå èçëîæåíèå ïîñâÿùåíî âîçìîæíîñòÿì èñïîëüçîâàíèÿ Í-ðåôëåêñîìåòðèè äëÿ
äèàãíîñòèêè ïèðàìèäíûõ, ýêñòðàïèðàìèäíûõ,
ìîçæå÷êîâûõ íàðóøåíèé è ïîðàæåíèé ïåðèôåðè÷åñêîãî íåéðîìîòîðíîãî àïïàðàòà.
Çíà÷èòåëüíîå ìåñòî çàíèìàåò îöåíêà Í-ðåôëåêñà â âûÿâëåíèè è îáúåêòèâèçàöèè ïèðàìèäíîãî
ñèíäðîìà. Õàðàêòåðíûìè äëÿ íà÷àëüíûõ ïèðàìèäíûõ íàðóøåíèé (ïèðàìèäíîé íåäîñòàòî÷íîñòè)
ÿâëÿþòñÿ: ïîâûøåíèå àìïëèòóäû Í-ðåôëåêñà; óâåëè÷åíèå îòíîøåíèÿ Íìàêñ/Ììàêñ; îòñóòñòâèå ïåðåêðåñòà êðèâûõ íàïðÿæåíèÿ–âðåìåíè Í- è Ì-ïîòåíöèàëîâ â äèàïàçîíå 0,2–0,3 ìñ; îñëàáëåíèå íèçêî÷àñòîòíîé äåïðåññèè Í-ðåôëåêñà; âîçíèêíîâåíèå
ÓÊÐÀ¯ÍÑÜÊÈÉ ÌÅÄÈ×ÍÈÉ ×ÀÑÎÏÈÑ – ¹ 4 (36) – VII/VIII 2003
85
Î ÃË ß Ä
Í-ðåôëåêñà âìåñòî F-âîëíû â ìûøöàõ ñòîïû (Ñòàðîáèíåö Ì.Õ., Âîëêîâà Ë.Ä., 1987).
×òî êàñàåòñÿ âûðàæåííûõ ïèðàìèäíûõ íàðóøåíèé, ïðîÿâëÿþùèõñÿ ñïàñòè÷åñêèìè ïàðåçàìè,
âàæíûì ÿâëÿåòñÿ âîïðîñ î êîððåëÿöèè ïîêàçàòåëåé
Í-ðåôëåêñîìåòðèè ñî ñòåïåíüþ íàðóøåíèé ìûøå÷íîãî òîíóñà. Îòìå÷åíà êîððåëÿöèÿ ìåðû ñïàñòè÷íîñòè ñ àìïëèòóäîé Í-ðåôëåêñà (Milanov I.,
1999). Èíäåêñ Íìàêñ/Ììàêñ, áóäó÷è ïîâûøåííûì ó
òàêèõ áîëüíûõ, ñàì ïî ñåáå ñëàáî êîððåëèðóåò ñ äàííîé êëèíè÷åñêîé õàðàêòåðèñòèêîé (Milanov I., 1999;
Pisano F. et al., 2000). Áîëåå èíôîðìàòèâíûì äëÿ
îöåíêè ñïàñòè÷íîñòè ÿâëÿåòñÿ îïðåäåëåíèå êðèâûõ
âîâëå÷åíèÿ Í-ðåôëåêñà è Ì-îòâåòà ïðè ïîâûøåíèè èíòåíñèâíîñòè àôôåðåíòíîé ñòèìóëÿöèè (Funase K. et al., 1996; Higashi T. et al., 2001).
Èçâåñòíî, ÷òî ó ïàöèåíòîâ ñî ñïàñòè÷åñêîé ãåìèïëåãèåé âèáðàöèÿ àõèëëîâà ñóõîæèëèÿ ïîäàâëÿåò
Í-ðåôëåêñ êàìáàëîâèäíîé ìûøöû â ìåíüøåé ñòåïåíè, ÷åì ó çäîðîâûõ ëþäåé (Delwaide P.J., 1973). Ó
òàêèõ áîëüíûõ îñëàáëåíî è òîðìîæåíèå Í-âîëíû,
âûçûâàåìîå ñòèìóëÿöèåé àôôåðåíòíûõ âîëîêîí
íåðâî⠗ àíòàãîíèñòîâ íèæíåé (El Tohamy A., Sedgwick E.M., 1982) è âåðõíåé (Aymard C. et al., 2000)
êîíå÷íîñòåé. Óñòàíîâëåíî, ÷òî âûðàæåííîñòü ýòèõ
ýôôåêòîâ êîððåëèðóåò ñ ìûøå÷íîé ñïàñòè÷íîñòüþ
(Bour L.J., De Visser B.W. Ongerboer, 1988; Ãàôò Ï.Ã.
è ñîàâò., 1994; Aymard C. et al., 2000). Íàáëþäàåòñÿ
òàêæå êîððåëÿöèÿ ìåæäó ìåðîé ìûøå÷íîãî ãèïåðòîíóñà ó ïàöèåíòîâ ïîñëå èíñóëüòà è îñëàáëåíèåì
ïîñòàêòèâàöèîííîé äåïðåññèè Í-ðåôëåêñà (Áðàæíèêîâ À.Í. è ñîàâò., 1989).
Èçâåñòíî, ÷òî ó áîëüíûõ ñî çíà÷èòåëüíîé ñïàñòè÷íîñòüþ àìïëèòóäà Í-ðåôëåêñà íå ìîäóëèðóåòñÿ â öèêëå õîäüáû, îñòàâàÿñü ïîñòîÿííî ïîâûøåííîé, â îòëè÷èå îò çäîðîâûõ ëèö è ïàöèåíòîâ ñ ìèíèìàëüíûì ïîâûøåíèåì ìûøå÷íîãî òîíóñà (Fung J.
et al., 1990; Garret M., Bin Shakoor S., 1991).
Áûëà èññëåäîâàíà çàâèñèìîñòü ìåæäó èçìåíåíèÿìè ïîêàçàòåëåé Í-ðåôëåêñîìåòðèè è ëîêàëèçàöèåé
ïîðàæåíèÿ ïîëóøàðíûõ ñòðóêòóð ïðè ìîçãîâîì èíñóëüòå (Ëåâàäà Î.À., Ñëèâêî Ý.È., 1998; Ñëèâêî Ý.È.
è ñîàâò., 1998). Óñòàíîâëåíî, ÷òî êàê ïðåñèíàïòè÷åñêîå òîðìîæåíèå, òàê è ïîñòàêòèâàöèîííàÿ äåïðåññèÿ
Í-ðåôëåêñà íàèáîëåå îñëàáëåíû ïðè íàëè÷èè î÷àãîâ
ïîðàæåíèÿ â îáëàñòè çàäíåãî áåäðà âíóòðåííåé êàïñóëû; ïîëíîå ïîâðåæäåíèå çàäíåãî áåäðà ïðàêòè÷åñêè âñåãäà ïðèâîäèò ê èõ èñ÷åçíîâåíèþ. Ïðè ëåíòèêóëÿðíûõ ïîâðåæäåíèÿõ è ôîêóñàõ ñ ÷àñòè÷íûì ïîðàæåíèåì çàäíåãî áåäðà âíóòðåííåé êàïñóëû ïðîèñõîäèò çíà÷èòåëüíîå, õîòÿ è ìåíåå âûðàæåííîå
óìåíüøåíèå òîðìîæåíèÿ è ïîñòàêòèâàöèîííîé äåïðåññèè Í-ðåôëåêñà.  òî æå âðåìÿ ïðè íàëè÷èè î÷àãîâ êîðêîâî-ïîäêîðêîâîãî óðîâíÿ áåç âîâëå÷åíèÿ
âíóòðåííåé êàïñóëû è ëåíòèêóëÿðíîé îáëàñòè, à òàêæå òàëàìè÷åñêèõ ôîêóñîâ íå íàáëþäàåòñÿ ñóùåñòâåííîãî ñíèæåíèÿ èõ ãëóáèíû. Äàííàÿ çàêîíîìåðíîñòü
ìîæåò áûòü îáóñëîâëåíà ðàçíîé ñòåïåíüþ âîâëå÷åíèÿ
â ïàòîëîãè÷åñêèé ïðîöåññ ýêñòðàïèðàìèäíûõ âîëî86
êîí, ñîïðîâîæäàþùèõ êîðòèêî-ñïèíàëüíûé òðàêò è
óñèëèâàþùèõ ïðåñèíàïòè÷åñêîå òîðìîæåíèå.
Ó áîëüíûõ â âîñòàíîâèòåëüíûé è ðåçèäóàëüíûé
ïåðèîä ñïèíàëüíîé òðàâìû ïðè íàëè÷èè ñïàñòè÷åñêèõ ïàðåçîâ óñòàíîâëåíî óìåíüøåíèå íèçêî÷àñòîòíîé äåïðåññèè Í-ðåôëåêñà, à òàêæå êîððåëÿöèÿ èçìåíåíèé âîçáóäèìîñòè Í-ðåôëåêñà ñ àäàïòàöèåé
íåéðîìûøå÷íîé ñèñòåìû ïîñëå òðàâìû (SchindlerIvens S., Shields R.K., 2000). Ñíèæåíèå ïîñòàêòèâàöèîííîé äåïðåñèè Í-ðåôëåêñà âûÿâëÿþòñÿ ó áîëüíûõ ñî ñïàñòè÷åñêèìè ïàðåçàìè âñëåäñòâèå ðàññåÿííîãî ñêëåðîçà (Orsnes G. et al., 2000).
Èññëåäîâàíèå ïàðàìåòðîâ Í-âîëíû ÿâëÿåòñÿ
èíôîðìàòèâíûì äëÿ èçó÷åíèÿ ýêñòðàïèðàìèäíîé
íåäîñòàòî÷íîñòè, îñíîâíûì ïðèçíàêîì êîòîðîé
ÿâëÿåòñÿ àêèíåòèêî-ðèãèäíûé ñèíäðîì. Âûÿâëåíî,
÷òî ïðè ïàðêèíñîíèçìå ðàçëè÷íîé ýòèîëîãèè íàáëþäàþòñÿ ñëåäóþùèå èçìåíåíèÿ Í-ðåôëåêñà: ñíèæåíèå åãî àìïëèòóäû è óâåëè÷åíèå ïðîäîëæèòåëüíîñòè; óâåëè÷åíèå ëàòåíòíîãî ïåðèîäà; ïîâûøåíèå
èíòåíñèâíîñòè ñòèìóëà, íåîáõîäèìîãî äëÿ âûçûâàíèÿ ïîòåíöèàëà ìàêñèìàëüíîé âåëè÷èíû; ñíèæåíèå ñîîòíîøåíèÿ Íìàêñ/Ììàêñ.
Ýòè ïîêàçàòåëè, îòðàæàþùèå ñíèæåíèå âîçáóäèìîñòè äâóõíåéðîííîé ðåôëåêòîðíîé äóãè, ñ÷èòàþòñÿ ïàòîãíîìîíè÷íûìè äëÿ àêèíåòèêî-ðèãèäíîãî ñèíäðîìà (Ìàíüêîâñêèé Í.Á. è ñîàâò., 1980; Ñòàðèêîâ À.Ñ., 1993; Êðûæàíîâñêèé Ã.Í. è ñîàâò., 1995).
Ñõîäíûå èçìåíåíèÿ Í-ðåôëåêñà íàáëþäàþòñÿ òàêæå ó ïðàêòè÷åñêè çäîðîâûõ ïàöèåíòîâ ñòàðøèõ âîçðàñòíûõ ãðóïï, ïî-âèäèìîìó, âñëåäñòâèå íàëè÷èÿ ó
íèõ ñêðûòîé ýêñòðàïèðàìèäíîé íåäîñòàòî÷íîñòè
(Ìà÷åðåò Å.Ë. è ñîàâò., 1989; Ìàíüêîâñêèé Í.Á. è
ñîàâò., 1990; Êðûæàíîâñêèé Ã.Í. è ñîàâò., 1995). Òó
æå íàïðàâëåííîñòü èçìåíåíèé ïàðàìåòðîâ Í-âîëíû
âûÿâèë Ê.Ë. Þðüåâ (2000) ó ïàöèåíòîâ ìîëîäîãî âîçðàñòà, ïîäâåðãøèõñÿ èîíèçèðóþùåìó èçëó÷åíèþ.
 òî æå âðåìÿ ó îáëó÷åííûõ ïàöèåíòîâ ñòàðøèõ âîçðàñòíûõ ãðóïï àâòîð íàáëþäàë ïîêàçàòåëè Í-ðåôëåêñà, ñâèäåòåëüñòâóþùèå î ïîâûøåíèè âîçáóäèìîñòè
ñïèíàëüíûõ ÌÍ. Óñòàíîâëåíî òàêæå, ÷òî ó ïàöèåíòîâ ñ áîëåçíüþ Ïàðêèíñîíà ñíèæàåòñÿ ïîðîã Ì-îòâåòà. Îí ñòàíîâèòñÿ ðàâíûì ïîðîãó Í-ðåôëåêñà èëè
íèæå åãî (Kushnir M. et al., 2001).
Äðóãèì ýêñòðàïèðàìèäíûì ñèíäðîìîì ÿâëÿåòñÿ ãèïåðêèíåòè÷åñêèé. Íà ïðèìåðå ïàöèåíòîâ ñ
äðîæàòåëüíî-ðèãèäíûìè ôîðìàìè ãåïàòîöåðåáðàëüíîé äåãåíåðàöèè ïðîñëåæèâàåòñÿ òåíäåíöèÿ ê
ñíèæåíèþ ñóììàðíîé ðåôëåêòîðíîé âîçáóäèìîñòè âñåãî ïóëà a-ÌÍ, ÷òî ïðîÿâëÿåòñÿ ñíèæåíèåì
ìàêñèìàëüíîé àìïëèòóäû Í-ðåôëåêñà ïðè íåèçìåíåííîé äëèòåëüíîñòè ëàòåíòíîãî ïåðèîäà è îòíîøåíèÿ Íìàêñ/Ììàêñ. Îäíàêî ÷àñòü ÌÍ, ôîðìèðóþùèõ äðîæàòåëüíûé ãèïåðêèíåç, íàõîäèòñÿ â ñîñòîÿíèè ïîâûøåííîé ðåôëåêòîðíîé âîçáóäèìîñòè, î
÷åì ñâèäåòåëüñòâóåò âîçìîæíîñòü âûçûâàíèÿ Í-âîëíû áîëåå íèçêèìè ïîðîãîâûìè ñòèìóëàìè (Ñòàðèêîâ À.Ñ., 1996). Òå æå äàííûå ïîëó÷åíû è äëÿ äðîæàòåëüíîãî ãèïåðêèíåçà â ñòðóêòóðå ïàðêèíñîíèçìà
ÓÊÐÀ¯ÍÑÜÊÈÉ ÌÅÄÈ×ÍÈÉ ×ÀÑÎÏÈÑ – ¹ 4 (36) – VII/VIII 2003
Î ÃË ß Ä
(Ñòàðèêîâ À.Ñ., 1993).  òî æå âðåìÿ ïðè ãèïåðêèíåòè÷åñêè-ãèïîòîíè÷åñêîì ñèíäðîìå âûÿâëÿþòñÿ ïîêàçàòåëè Í-âîëíû, õàðàêòåðèçóþùèå ïîâûøåíèå
âîçáóäèìîñòè ÌÍ (Áàäàëÿí Ë.Î., Ñêâîðöîâ È.À.,
1986). Ó áîëüíûõ ñ õîðååé Ãåíòèíãòîíà îòìå÷åíî ñíèæåíèå ðåöèïðîêíîãî òîðìîæåíèÿ Í-ðåôëåêñà
ìûøö ïðåäïëå÷üÿ (Priori A. et al., 2000).
Ñíèæåíèå àìïëèòóäû Í-ðåôëåêñà èëè åãî èñ÷åçíîâåíèå ñ÷èòàåòñÿ õàðàêòåðíûì ïðèçíàêîì ïàðîêñèçìîâ êàòàïëåêñèè (Overeem S. et al., 1999;
Lammers G.J. et. al., 2000).
Âîâëå÷åíèå â ïàòîëîãè÷åñêèé ïðîöåññ ìîçæå÷êà
è åãî ïóòåé ñîïðîâîæäàåòñÿ ñíèæåíèåì âåëè÷èíû
Í-ðåôëåêñà, îñîáåííî çíà÷èòåëüíûì ïðè íåêîòîðûõ
ãåðåäèòàðíûõ çàáîëåâàíèÿõ (Íîâèêîâà Â.Ï., 1981).
Ïîðàæåíèÿ ïåðèôåðè÷åñêîé íåðâíîé ñèñòåìû
ñîïðîâîæäàþòñÿ õàðàêòåðíûìè èçìåíåíèÿìè Í-ðåôëåêñà â âèäå ïîâûøåíèÿ åãî ïîðîãà, ñíèæåíèÿ àìïëèòóäû è îòíîøåíèÿ Íìàêñ/Ììàêñ, à òàêæå óâåëè÷åíèÿ
ëàòåíòíîãî ïåðèîäà (Íîâèêîâà Â.Ï., 1981; Ñòàðîáèíåö Ì.Õ., Âîëêîâà Ë.Ä., 1984). Òàêèå èçìåíåíèÿ ïàðàìåòðîâ Í-ðåôëåêñà çàðåãèñòðèðîâàíû, â ÷àñòíîñòè,
ïðè äèàáåòè÷åñêèõ ïîëèíåéðîïàòèÿõ (Íåðåòèí Â.ß.
è ñîàâò., 1997; Ozge A. et al., 2000), òîêñè÷åñêèõ ïîðàæåíèÿõ ïåðèôåðè÷åñêèõ íåðâîâ (Pal P.K., 1999), öåðâèêàëüíûõ ðàäèêóëîïàòèÿõ (Abdulwahab S.S., 1999;
Abdulwahab S.S., Sabbahi M., 2000).
Âûøåïåðå÷èñëåííûå ïîêàçàòåëè Í-ðåôëåêñà
ìîæíî èñïîëüçîâàòü äëÿ îöåíêè ñòåïåíè òÿæåñòè è
äèíàìèêè ïîðàæåíèÿ ïåðèôåðè÷åñêîãî ìîòîíåéðîíà, à òàêæå äëÿ êîíòðîëÿ ëå÷åíèÿ (Íîâèêîâà Â.Ï.,
1981; Abdulwahab S.S., Sabbahi M., 2000; Bradnam L.
et al., 2000). Ñëåäóåò îòìåòèòü, ÷òî èíäåêñ Íìàêñ/Ììàêñ
ìîæåò íå èçìåíÿòüñÿ ïðè ïàòîëîãè÷åñêèõ ïðîöåññàõ
ïåðèôåðè÷åñêîé íåðâíîé ñèñòåìû âñëåäñòâèå òîãî,
÷òî íàðÿäó ñî ñíèæåíèåì àìïëèòóäû Í-ðåôëåêñà
ñíèæàåòñÿ àìïëèòóäà Ì-îòâåòà.  òàêèõ ñëó÷àÿõ
ïðåäïî÷òèòåëüíåå èñïîëüçîâàòü äðóãèå, óïîìÿíóòûå
âûøå õàðàêòåðèñòèêè (Íîâèêîâà Â.Ï., 1981).
Ïðè ñî÷åòàííûõ ñåãìåíòàðíî-ñóïðàñåãìåíòàðíûõ ïîðàæåíèÿõ íåðâíîé ñèñòåìû (áîêîâîé àìèîòðîôè÷åñêèé ñêëåðîç, ñèðèíãîìèåëèÿ, öåðâèêàëüíàÿ ìèåëîèøåìèÿ è äð.) èçìåíåíèÿ ïàðàìåòðîâ
Í-âîëíû çàâèñÿò îò ïðåèìóùåñòâåííîãî âîâëå÷åíèÿ â ïàòîëîãè÷åñêèé ïðîöåññ íèñõîäÿùèõ êîíòðîëèðóþùèõ ïóòåé èëè ñåãìåíòàðíîé ðåôëåêòîðíîé äóãè (Íîâèêîâà Â.Ï., 1981; Ñòàðîáèíåö Ì.Õ.,
Âîëêîâà Ë.Ä., 1984).
 çàêëþ÷åíèå ñëåäóåò îòìåòèòü, ÷òî ïðåäñòàâëåííûå â îáçîðå âîçìîæíîñòè ïðàêòè÷åñêîãî èñïîëüçîâàíèÿ Í-ðåôëåêñîìåòðèè íå ÿâëÿþòñÿ èñ÷åðïûâàþùèìè.  íàñòîÿùåå âðåìÿ âî ìíîãèõ íåéðîôèçèîëîãè÷åñêèõ ëàáîðàòîðèÿõ âíåäðÿþòñÿ ìíîãèå
äðóãèå îðèãèíàëüíûå ìåòîäèêè èññëåäîâàíèÿ Í-âîëíû ñ öåëüþ èçó÷åíèÿ òåõ èëè èíûõ íåâðîëîãè÷åñêèõ ñèíäðîìîâ. Îäíàêî, íå ÿâëÿÿñü îáùåïðèçíàííûìè, äàííûå ïîäõîäû íóæäàþòñÿ â îñìûñëåíèè
è ïîäòâåðæäåíèè ïåðåä âíåäðåíèåì â øèðîêóþ
êëèíè÷åñêóþ ïðàêòèêó. Ïðèçíàâàÿ çíà÷åíèå Í-ðåô-
ëåêñîìåòðèè êàê îäíîé èç íàèáîëåå òîíêèõ è èíôîðìàòèâíûõ ïàðàêëèíè÷åñêèõ ìåòîäèê, â òî æå
âðåìÿ ñëåäóåò ïðåäîñòåðå÷ü îò åå ïåðåîöåíêè è ïîä÷åðêíóòü íåîáõîäèìîñòü îáÿçàòåëüíîãî ó÷åòà êëèíè÷åñêîé êàðòèíû áîëåçíè.
ËÈÒÅÐÀÒÓÐÀ
Ápàæíèêîâ À.Í., Ãàôò Ï.Ã., Êàïåpêî Â.Ï., Êîòëèê Á.À.,
Ñëèâêî Ý.È., Øåâ÷åíêî Ë.À. (1989) Ãîìîñèíàïòè÷åñêàÿ äåïðåññèÿ ìîíîñèíàïòè÷åñêîãî ñïèíàëüíîãî ðåôëåêñà ó çäîðîâûõ ëèö è áîëüíûõ, ïåðåíåñøèõ ìîçãîâîé èíñóëüò. Íåéðîôèçèîëîãèÿ, 21 (4): 555–558.
Áàäàëÿí Ë.Î., Ñêâîðöîâ È.À. (1986) Êëèíè÷åñêàÿ ýëåêòðîíåéðîìèîãðàôèÿ. Ìåäèöèíà, Ìîñêâà, 389 ñ.
Ãàôò Ï.Ã., Êîòëèê Á.À., Ñëèâêî Ý.È., Øåâ÷åíêî Ë.À. (1994)
Îñëàáëåíèå òîðìîæåíèÿ Í-påôëåêñà ó áîëüíûõ, ïåðåíåñøèõ
ìîçãîâîé èíñóëüò, è åãî ñâÿçü ñî ñïàñòè÷íîñòüþ ñêåëåòíîé ìóñêóëàòóðû. Æópí. íåâpîïàòîëîãèè è ïñèõèàòpèè, 1: 16–17.
Çåíêîâ Ë.Ð., Ðîíêèí Ì.À. (1991) Ôóíêöèîíàëüíàÿ äèàãíîñòèêà íåðâíûõ áîëåçíåé: Ðóêîâîäñòâî äëÿ âðà÷åé. Ìåäèöèíà, Ìîñêâà, 640 ñ.
Êðûæàíîâñêèé Ã.Í., Êàðàáàíü È.Í., Ìàãàåâà Ñ.Â., Êàðàáàíü Í.Â. (1995) Êîìïåíñàòîðíûå è âîññòàíîâèòåëüíûå ïðîöåññû ïðè ïàðêèíñîíèçìå. Êèåâ, 192 ñ.
Ëåâàäà Î.À., Ñëèâêî Ý.È. (1998) Îñëàáëåíèå òîðìîæåíèÿ
Í-ðåôëåêñà ó áîëüíûõ ñ ðàçëè÷íîé ëîêàëèçàöèåé ïîëóøàðíîãî èíñóëüòà. ˳ê. ñïðàâà, 6: 64–67.
Ìàíüêîâñêèé Í.Á., Âàéíøòîê À.Á., Îëåéíèê Ë.È. (1980)
Ðîëü ñïèíàëüíûõ ìåõàíèçìîâ â âîçíèêíîâåíèè âîçðàñòíûõ
èçìåíåíèé ìûøå÷íîãî òîíóñà. Ãåðîíòîëîãèÿ è ãåðèàòðèÿ.
Åæåãîäíèê: Îïîðíî-äâèãàòåëüíà ñèñòåìà, Êèåâ, ñ. 103–107.
Ìàíüêîâñêèé Í.Á., Êàðàáàíü È.Í., Ìÿëîâèöêàÿ Å.À. (1990)
Öåíòðàëüíûå ìåõàíèçìû ðàçâèòèÿ äâèãàòåëüíûõ íàðóøåíèé
ïðè ñòàðåíèè ÷åëîâåêà. Ôèçèîë. æóðí. ÀÍ ÓÑÑÐ, 5: 62–70.
Ìà÷åðåò Å.Ë., Çàìîñòüÿí Â.Ï., Ëûñåíþê Â.Ï. (1989) Ñòàðåíèå è äâèãàòåëüíûå âîçìîæíîñòè. Èçä-âî ÊÃÓ, Êèåâ, 173 ñ.
Íåðåòèí Â.ß., Êîòîâ Ñ.Â., Ïåòèíà Ë.Â., Êàìûíèíà Ò.Ñ.
(1997) Êëèíèêî-ýëåêòðîôèçèîëîãè÷åñêîå èçó÷åíèå ñîñòîÿíèÿ
íåðâíî-ìûøå÷íîé ñèñòåìû ó áîëüíûõ ñàõàðíûì äèàáåòîì
I è II òèïîâ. Æóðí. íåâðîïàòîëîãèè è ïñèõèàòðèè èì. Ñ.Ñ. Êîðñàêîâà, 2: 34–38.
Íîâèêîâà Â.Ï. (1981) Âîçìîæíîñòè è ãðàíèöû ìåòîäà
èññëåäîâàíèÿ Í-ðåôëåêñà â äèàãíîñòèêå çàáîëåâàíèé íåðâíîé
ñèñòåìû. Æóðí. íåâðîïàòîëîãèè è ïñèõèàòðèè èì. Ñ.Ñ. Êîðñàêîâà, 12: 1804–1810.
Ñëèâêî Ý.È., Ðóäíåâà È.Í., Ëåâàäà Î.À. (1998) Äëèòåëüíàÿ äåïðåññèÿ Í-ðåôëåêñà ïîñëå ãîìî- è ãåòåðîíèìíîé ñòèìóëÿöèè àôôåðåíòíûõ íåðâíûõ âîëîêîí ó çäîðîâûõ ëþäåé è
ïîñòèíñóëüòíûõ áîëüíûõ. Æóðí. ÀÌÍ Óêðà¿íè, 2: 288–296.
Ñòàpîáèíåö Ì.Õ., Âîëêîâà Ë.Ä. (1984) Äèàãíîñòèêà ñèíäðîìîâ ïîðàæåíèÿ íåðâíîé ñèñòåìû ïî ñîîòíîøåíèþ êðèâûõ íàïðÿæåíèÿ–âðåìåíè öåíòðàëüíûõ è ìîòîðíûõ îòâåòîâ
ìûøö ãîëåíè è ñòîïû. Æóðí. íåâðîïàòîëîãèè è ïñèõèàòðèè
èì. Ñ.Ñ. Êîðñàêîâà, 11: 1642–1648.
Ñòàpîáèíåö Ì.Õ., Âîëêîâà Ë.Ä. (1987) Ïpîãpàììà ýëåêòpîìèîãpàôè÷åñêîãî èññëåäîâàíèÿ ïpè ïîäîçpåíèè íà ñêpûòóþ
ïèpàìèäíóþ íåäîñòàòî÷íîñòü. Æópí. íåâpîïàòîëîãèè è
ïñèõèàòpèè èì. Ñ.Ñ. Êîðñàêîâà, 8: 1126–1133.
Ñòàðèêîâ À.Ñ. (1993) Ýëåêòðè÷åñêàÿ âîçáóäèìîñòü ïåðèôåðè÷åñêèõ ìîòîíåéðîíîâ ïðè ïàðêèíñîíèçìå. Æóðí. íåâðîïàòîëîãèè è ïñèõèàòðèè èì. Ñ.Ñ. Êîðñàêîâà, 6: 11–15.
Ñòàðèêîâ À.Ñ. (1996) Ôóíêöèîíàëüíîå ñîñòîÿíèå ñåãìåíòàðíûõ ìîòîíåéðîíîâ ïðè ãåïàòîöåðåáðàëüíîé äèñòðîôèè
Âèëüñîíà–Êîíîâàëîâà. Æóðí. íåâðîïàòîëîãèè è ïñèõèàòðèè
èì. Ñ.Ñ. Êîðñàêîâà, 3: 72–75.
Þðüåâ Ê.Ë. (2000) Îñîáåííîñòè ñïèíàëüíûõ ìåõàíèçìîâ
ðåàëèçàöèè äâèãàòåëüíûõ íàðóøåíèé ó îáëó÷åííûõ âñëåäñòâèå ×åðíîáûëüñêîé êàòàñòðîôû ñ òî÷êè çðåíèÿ âîçðàñòíûõ
èçìåíåíèé. Óêð. ìåä. ÷àñîïèñ, 6(20): 107–113.
ÓÊÐÀ¯ÍÑÜÊÈÉ ÌÅÄÈ×ÍÈÉ ×ÀÑÎÏÈÑ – ¹ 4 (36) – VII/VIII 2003
87
Î ÃË ß Ä
Abdulwahab S.S. (1999) Treatment based on H-reflexes testing improves disability status in patients with cervical radiculopathy. Int. J. Rehabil. Res., 22(3): 207–214.
Abdulwahab S.S., Sabbahi M. (2000) Neck retractions, cervical root decompression, and radicular pain. J. Orthop. Sports Phys.
Ther., 30(1): 4–9.
Aymard C., Katz R., Lafitte C., Lo E., Penicaud A., Pradat-Diehl P.,
Raoul S. (2000) Presynaptic inhibition and homosynaptic depression: a
comparison between lower and upper limbs in normal human subjects
and patients with hemiplegia. Brain, 123(Pt. 8): 1688–1702.
Berardelli A., Rotwell J.C., Day B.L., Marsden C.D. (1987)
Evidence favouring presynaptic inhibition between antagonist muscle afferents in the human foream. J. Physiol., 391: 71–83.
Bour L.J., De Visser B.W. Ongerboer (1988) The cumulative
vibratory index of the soleus H-reflex: A new quantitative measure
for spasticity. In: Electrophysiol. Kinesiol., Enschede, 20–23 June,
1988. Amsterdam, p. 361–365.
Bradnam L., Rochester L. Vujnovich A. (2000) Manual cervical traction reduces alpha-motoneuron excitability in normal subjects. Electromyogr. Clin. Neurophysiol., 40(5): 259–266.
Delwaide P.J. (1973) Human monosynaptic reflexes and presynaptic inhibition. New development in electromyography and
clinical neurophysiology. Basel, Karger, p. 508–522.
Delwaide P.J., Pepin J.L., Rapisarda G. (1999) Spinal reflex
studies enable to analyze supraspinal dysfunctions. Electroencephalogr. Clin. Neurophysiol. Suppl., 50: 373–376.
Dumitru D. (2000) Comparison of three methods for recording tibial H reflex: a clinical note. Am. J. Phys. Med. Rehabil.,
79(3): 311–315.
El Tohamy A., Sedgwick E.M. (1982) Spinal inhibitory mechanisms in spasticity. Electroencephalogr. Clin. Neurophysiol.,
53(1): 1P–4P.
El Tohamy A., Sedgwick E.M. (1983) Spinal inhibition in man:
depression of the soleus H-reflex by stimulation of the nerve to the
antagonist muscle. J. Physiol., 337: 497–508.
Floeter M.K., Kohn A.F. (1997) H-reflexes of different sizes
exhibit differential sensitivity to low frequency depression. Electroencephalogr. Clin. Neurophysiol., 105(6): 470–475.
Funase K., Higashi T., Yoshimura T., Imanaka K., Nishihira Y. (1996)
Evident difference in the excitability of the motoneuron pool between
normal subjects and patients with spasticity assessed by a new method
using H-reflex and M-response. Neurosci. Lett., 203(2): 127–130.
Funase K., Tanaka K., Nishihira Y. (1994) Excitability of the soleus
motoneuron pool revealed by the developmental slope of the H-reflex as
reflex gain. Elecromyogr. Clin. Neurophysiol., 34(8): 477–489.
Fung J., Blunt R., Barbeaw H. (1990) The soleus H-reflex
modulation pattern in spastic paretic subjects during standing and
walking. Disord. In: Posture and Gait, 10th int. Symp. Soc. Postural and Gait Res., Munchen, September 2–6, 1990. Stuttgart, New
York, p. 398–401.
Garret M., Bin Shakoor S. (1991) Changes in the excitability
of the Hoffman reflex during walking in hemiplegic man. J. Physiol., 432: 29.
Higashi T., Funase K., Kusano K., Tabira T., Harada N.,
Sakakibara A., Yoshimura T. (2001) Motoneuron pool excitability
of hemiplegic patient: Assessing recovery stages by using H-reflex
and M-response. Arch. Phys. Med. Rehabil., 82(11): 1604–1610.
Hultborn H., Meunier B., Morin C., Pierrot-Deseilligny E.
(1987) Assesing changes in presynaptic inhibition of Ia fibers: a study
in man and in the cat. J. Physiol., 389: 729–756.
Iles J.F., Roberts R.C. (1987) Ihibition of monosynaptic reflexes in the human lower limb. J. Physiol., 385: 69–87.
Kagamihara Y., Hayashi A., Okuma Y., Nagaoka M., Nakajima Y.
Tanaka R. (1998) Reassessment of H-reflex recovery curve using the
double stimulation procedure. Muscle Nerve, 21(3): 352–360.
Kushnir M., Klein C., Rabey J.M. (2001) H-reflex behavior in
Parkinson’s disease patients and patients with extrapyramidal and
pyramidal sings combined. J. Neurol. Sci., 186(1–2): 101–105.
Lammers G.J., Overeem S., Tijssen M.A., van Dijk J.G. (2000)
Effects of startle and laughter in cataplectic subjects: a neurophysiological study between attacks. Clin. Neurophysiol., 111(7): 1276–1281.
88
Milanov I. (1999) Clinical and neurophysiological correlations
of spasticity. Funct. Neurol., 14(4): 193–201.
Orsnes G., Crone C., Krarup C., Petersen N., Nielsen J. (2000)
The effect of baclofen on the transmission in spinal pathways in spastic
multiple sclerosis patients. Clin. Neurophysiol., 111(8):1372–1379.
Overeem S., Lammers G.J., van Dijk J.G. (1999) Weak with
laughter. Lancet, 354(9181): 838.
Ozge A., Saracoglu M., Gurtekin Y., Erenoglu N.Y., Akyatan M. (2000) The sensitivity of sympathetic skin responses and
standard electrophysiological methods in diagnosis of diabetic neuropathy. Electromyogr. Clin. Neurophysiol., 40(1): 37–43.
Pal P.K. (1999) Clinical and electrophysiological studies in vincristine induced neuropathy. Electromyogr. Clin. Neurophysiol.,
39(6): 323–330.
Pisano F., Miscio G., Del Conte C., Pianca D., Candeloro E.,
Colombo R. (2000) Quantitative measures of spasticity in post-stroke
patients. Clin. Neurophysiol., 111(6):1015–1022.
Priori A., Polidori L., Rona S., Manfredi M., Berardelli A.
(2000) Spinal and cortical inhibition in Huntington’s chorea. Mov.
Disord., 15(5): 938–946.
Schindler-Ivens S., Shields R.K. (2000) Low frequency depression of H-reflexes in humans with acute and chronic spinal-cord
injury. Exp. Brain Res., 133(2): 233–241.
Van Boxtel A. (1986) Differential effects of low-frequency depression, vibration-inhibition and post-tetanic potentiation on
H-reflex and tendon jerks in the human soleus muscle. J. Neurophysiol., 55(3): 551–568.
Í-ÐÅÔËÅÊÑÎÌÅÒÐ²ß Â Ê˲Ͳֲ
ÍÅÐÂÎÂÈÕ ÇÀÕÂÎÐÞÂÀÍÜ:
IJÀÃÍÎÑÒÈ×Ͳ ÌÎÆËÈÂÎÑÒ² ÌÅÒÎÄÓ
Î.À. Ëåâàäà, Å.². Ñë³âêî
Ðåçþìå. Íàâåäåí³ îñíîâí³ â³äîìîñò³ ïðî ìîæëèâîñò³
âèêîðèñòàííÿ Í-ðåôëåêñîìåò𳿠äëÿ ä³àãíîñòèêè
çàõâîðþâàíü öåíòðàëüíî¿ òà ïåðèôåðè÷íî¿ íåðâîâî¿
ñèñòåìè. ϳäêðåñëþºòüñÿ íåîáõ³äí³ñòü ñèíäðîìîëîã³÷íîãî ï³äõîäó äî îö³íêè ðåçóëüòàò³â äîñë³äæåíü òà
òðàêòóâàííÿ îòðèìàíèõ ç ¿õ äîïîìîãîþ äàíèõ.
Êëþ÷îâ³ ñëîâà: Í-ðåôëåêñ, íåâðîëîã³÷í³ çàõâîðþâàííÿ, ôóíêö³îíàëüíà ä³àãíîñòèêà.
H-REFLEXOMETRY IN NEUROLOGICAL
CLINIC: THE DIAGNOSTIC POTENTIALITIES
OF THE METHOD
O.A. Levada, E.I. Slivko
Summary. The basic data concerning potentialities of the
H-reflex examination method in diagnosing of the diseases
of the central and peripheral nervous system are presented in the review. It is concluded the necessity of using the
syndromological approach to the evaluation and interpretation of investigation results.
Key words: H-reflex, neurological diseases, functional
diagnostics.
Àäðåñ äëÿ ïåðåïèñêè:
Ëåâàäà Îëåã Àíàòîëüåâè÷
69096, Çàïîðîæüå, áóëüâ. Âèíòåðà, 20
Çàïîðîæñêèé ãîñóäàðñòâåííûé èíñòèòóò
óñîâåðøåíñòâîâàíèÿ âðà÷åé èì. Ì. Ãîðüêîãî,
êàôåäðà íåðâíûõ áîëåçíåé
ÓÊÐÀ¯ÍÑÜÊÈÉ ÌÅÄÈ×ÍÈÉ ×ÀÑÎÏÈÑ – ¹ 4 (36) – VII/VIII 2003
Скачать