About the Article
Regular publications, RMJ № 7 of 23.07.2018 pp. 37-40
Authors: Palomar H.1, Isaikin A.I.2, Svet M.S.1, Alekseev A.V.3
1 “P-DTR Rehabilitation and research center”, Geneva, Switzerland
2 Sechenov State Medical University, Moscow
3 LLC “Med-UrConsult”, Moscow
The practical healthcare during recent decades has been marked by the growing popularity of evidence-based medicine when determining methods or means of treatment and/or medical examination. At the same time, however, expenses on non-drug methods of treatment applied in neurology, orthopedics and rehabilitation medicine continue to increase. In recent years, there has been a tendency towards the growing use of osteopathy and applied kinesiology, which have slightly supplanted exercise therapy, manual therapy and physiotherapeutic methods of treatment. Among the methods practiced more and more often over the last years, there is a proprietary method stemmed from applied kinesiology and osteopathy, but based on the classical principles of neurophysiology — the method of proprioceptive deep tendon reflex (P-DTR), elaborated by Jose Palomar. The following article provides the theoretical evidence underlying the method and verified by the results of the neurophysiological research.
Key words: clinical neurophysiology, rehabilitation, proprioceptive deep tendon reflex.
For citation: Palomar H., Isaikin A.I., Svet M.S., Alekseev A.V. Perspectives: practical application of clinical neurophysiology //
RMJ. 2018. № 7. P. 37–40.
The past few decades were marked by an increased interest in the use of evidence-based medicine methods in clinical practice while choosing particular methods or means of treatment and/or diagnostics. Meanwhile, the cost of non-pharmaceutical treatment methods used in neurology, orthopedics and rehabilitation medicine do not actually decrease, but instead continue to increase, with a change of only the most actively used non-pharmaceutical methods. During the past years, a trend to an increased use of osteopathy and applied kinesiology methods was observed; those methods have somewhat displaced the use of treatment exercise, manual therapy and physiotherapy. One of the methods with an increased use during the past few years is a proprietary methodology developed from applied kinesiology and osteopathy, but based on the classic principles of neurophysiology - a method based on the use of proprioceptive deep tendon reflex (P-DTR) developed by Jose Palomar. This article presents theoretical data forming the basis of the method and confirmed by the results of a neurophysiology study conducted.
The relevance of this approach is driven by such approaches as prophylactic, individualized, rehabilitation and sport medicine, developing during the last decades, with partial exchange of methods between them. The hallmark of the methods used is the narrowness of their use and the use for treatment of complex clinical cases, were the possible cause of disorders may be a combination of disorders in different systems, including emotional area. One of the principal difference between the methods actively used in such type of medicine and the classical medicine is the lack of clear pathophysiological mechanisms of action, where the effect is mainly explained based on the subjective clinical change of a certain function. The other significant difference is the lack of clear complaints or their heterogeneity; thus, patients treated using non-pharmacological methods often have complaints corresponding to chronic pain syndrome of low intensity, with complaints frequently being out of scope of classical diagnostic criteria of various diseases; besides various pain syndromes noted above they may include malaise, decreased motivation, general weakness, apathy, deficit of attention; in some cases the patient’s appraisal of complaints would differ significantly from the treating physician appraisal; for athletes, additional complaints may present, such as long period of recovery after an exercise or difficulty in achieving the results needed. Such unclear complaints are often described as functional, i.e., partially linked with anxiety-emotional and motivation components, however, no one can reliably make a claim regarding the absence of any morphological and functional disturbances in such case. Pharmacological treatment in classical medicine employs the use of psychoactive drugs with a complicated choice while the evidence-based support is not always sufficient; the lifestyle recommendations that make a significant impact are often not followed by the patients; the cognitive behavioral therapy with a high level of evidence has its limitations in some disorders both in use and in availability; the recognized issues also include the rationale of the need for treatment for the patients who are often concerned with their own perceptions of disease. The medication therapy for affective disorders correction is often substituted by metabolic, vascular of nootropic medications with lack of confirmed efficacy, but perceived by the patients due to weak popular healthcare education efforts.
Medical interventions may be classified according to a degree of risk, where the risk is directly related to the level of invasiveness of a medical procedure; thus, the most risky manipulations with a high level of invasiveness would include medication blocks, surgical interventions, diagnostic punctures and biopsy; the pharmaceutical treatments would have an intermediate position, and the least dangerous would be non-invasive contact treatment methods. Indications play a significant role in rationale for use of one or another method; thus, if there are significant indications, such as saving a patient’s life, invasive and pharmacological methods would be justified; while discussing the level of intervention in patients with complaints described above we have to face the possibility of adverse events of pharmaceutical treatment and, moreover, of invasive procedures. Meanwhile, according to the modern requirements, all the medications undergo a mechanism of approval and several levels of laboratory and clinical trials; however, the statistics of adverse drug reactions shows their high significance in the structure of potential pharmacological treatment effects.
One of the reasons of an increased interest in non-pharmaceutical treatment approaches is their expected safety, however, it should be noted that the treatment method needs to be effective besides being safe. Regarding this, a large amount of research work should be noted related to physiotherapy treatment methods, treatment exercises, manual therapy methods and acupuncture, thew results of which would often satisfy the researchers’ expectations, while the results of some works would disprove the efficacy of non-pharmaceutical treatment methods. In some cases the clinical trials of the method efficacy would show an effect even in cases where no clear pathophysiological explanation of a mechanism of action could be established and even for methods being indistinguishable from spurious manipulations, which, however, would not preclude from including those methods into clinical recommendations in various disorders.
Non-pharmacological treatment methods with different efficacy rates are used in treatment of musculoskeletal pain syndromes, headaches, neuropathy pain syndromes, tunnel neuropathy and all the unclear and nonspecific complaints listed above. Unfortunately, an increased interest in osteopathy and applied kinesiology did not transform into an increased number of research and clinical work regarding efficacy of osteopathy and applied kinesiology. Meanwhile it should be noted that the major part of non-pharmacological treatment methods is based on using reflex mechanisms - reflectory muscle tone decrease, reflectory muscle tone increase; the methods used in rehabilitation medicine often employ early childhood reflexes; the methods of treatment of refractory pain syndromes include techniques with action based on and explained by the theory of neuromatrix and multisystem (multisensory) interaction.
The reflex theory itself and the theory of neuromatrix including conceptions of multisensory interaction is the base of any conscious or unconscious activity. The basis of neurophysiology has empirically descriptive origins, with some considering Galen (130-200 AD) as an originator of the experimental neurophysiology, while some considering it to be Erasistratus (310-250 BC), who has classified nerves into motor and sensor. Some of the further theories were proved while the other were disproved and justly regarded as false. Thus, Descartes (1596-1650) was developing a theory of a vital spirit, while Galvani, who discovered the presence of electricity in animal tissues, has just substituted the vital spirit with animal electricity. It was only du Bois Reymond, who linked the electricity and the nerve impulses . The essence of the reflex activity is the typical reaction of a live organism to a stimulus. Appearing in multicellular organisms (although certain elements of reflex activities may be observed in unicellular organisms as well), the reflectory activity is the main form of nervous system activity. The conception of reflectory activity in the modern science have appeared due to Descartes works describing the interaction between the external stimuli and the internal changes, although he did not proposed the term itself. I.M. Sechenov have developed the hypothesis of a totally reflectory basis of the higher areas of the central nervous system. I.P. Pavlov has developed the ideas of I.M. Sechenov, classifying reflexes into unconditional, based on innate mechanisms, and conditional, developing during the lifetime. C.S. Sherrington played in important role in developing understanding of the significance of reflexes in integrative activity of a human by determining a possibility of mutual suppression or activation of certain reflexes. In 1906 he published a work titled “The Integrative Action of the Nervous System”, and in 1932 he became a Nobel laureate in physiology and medicine for discoveries related to neuron functions along with E.E. Douglas, one of the first electrophysiologists studying the physiology of nervous activity . In Russian scientific school, the conception of an integrative function of the central nervous system forming a unified motivated action of a living organism, after I.M. Sechenov was developed not only by I.P. Pavlov, but also by A.A. Ukhtomsky, N.A. Bernstein, P.K. Anokhin and G.N. Kryzhanovsky. A theory of functional systems by P.K. Anokhin distinguishes the following steps: afferentation synthesis, developing the action program and formation of the acceptor of the action result (feedback), the action itself or efferent synthesis and, finally, a comparison of the obtained result with a needed or expected result (so-called “needed future model”, a term of N.A. Bernstein, 1928). This theory, besides its use and development in neurophysiology, is actively used currently in programming and digital algorithms development . A.A. Ukhtomsky supplemented the theory of functional systems by a term of “Dominance”, basically determining the allocation and domination of a certain functional system due to reciprocal inhibition directed to an actual action currently needed. This has practically defined a conception of plasticity of nervous activity.
One of the significant conceptions to understand the role of reflective activity in rehabilitation treatment is a conception of advance excitation or righting activity, a preset; in other words, a probabilistic forecast or aperception, appearing in repeated automated excitations. In sensory signal functioning, the preset is directed towards the set of a better perception of afferent step and preparation to efferent step activity. Advance excitation is in fact a genetically determined ability of a nervous system to adaptation, the possibility of a nervous system to learn and to use the gained experience in familiar and unfamiliar settings . However, besides positive adaptive meaning of an advance excitation, it may be proposed that this phenomenon also plays a role in pathological mechanisms, such as chronic pain. This happens not only due to the well-recognized mechanisms of chronic pain that will be described later, but also due to a preset change of the level of excitation of sensory components of nociceptive signals transduction, such as receptors, ganglia ans synapses; and also due to a change in the level of excitation of motor reflective components. This leads to chronization of pathological reflex circuits: muscle tension of skeletal muscles, postural reflexes, etc. Detecting the sensory signal, even considering the overlapping fields with numerous links to other cytoarchitectonic areas, is likely related to the afferent signal primary reception in a certain area of somatosensory system with low-threshold receptors, thus providing spatial organization of sensory information. Evolutionary, the main task of processing of any sensory stimulus is to resolve an issue of avoiding potential damage, where answering the question “where” is the key; only after that the stimulus detection is formed, answering the question “what” was the stimulus. Experimental excision of the I somatosensory area of the cortex or parts of it leads to a loss of ability to localize the stimulus, while the ability to sense the type of sensory stimulus remains .
The questions of integration of sensory information were extensively discussed previously and continue to generate interest. At the same time, there are multiple descriptions of reciprocal interactions in different types of sensor fibers. For example, for visual analyzer, a hypothesis of the presence of afferent fibers of the retina was first proposed by R. Cajal in 1911, who described the similar fibers in birds. In later experimental works, similar data were reproduced multiple times already as a theory of possible mechanisms of modulation of sensitivity and activity of retina cells depending on additional incoming stimuli, including the ones from other special types of sensitivity . There are multiple studies of significance and mechanisms of effector reactions changing the number of active receptors of retina, skin and tongue. Such changes in receptor settings were called a functional mobility of the receptors. Such works, among other, were related to functional mobility of receptors on transplanted areas of the skin, with sensitivity recovery after 10-13 months, although the functional mobility recovers in 6-8 months . Changes of skin temperature receptors mobility in patients during fever were observed by L.M. Kurilova and M.D. Martkoplishvili. . Functional mobility of the taste receptors is affected in glossalgias. An increased sensitivity and decreased mobility were also noted, various taste stimuli were confused by the patients . However, not just the changes in activity of different receptors is response to one or the other stimuli, but an assessment of sympathetic receptor reactions is of the most interest. Thus, for example, adaptive changes of the retina to insufficient illumination were revealed in cold stimulation of the skin of the back, with a reverse effect in warm stimulation of the skin of the back. Meanwhile, an illumination of the skin without thermal stimuli also changes the receptor activity of the retina in response to an increased illumination .
Such reactions may also be noted within a single sensory system - thus, stimulation of tactile receptors of some areas of the skin leads to a change in activity of tactile receptors of distant areas of the skin, which may be confirmed electrophysiologically. During that, a clear reciprocal interactions between symmetrical areas of the skin of the rear paws were observed .
Such works suggest a double role of a receptor itself: affector role, triggering the afferent arch of the reflex and effector role, the end step of the reflex arch, realized by a change in receptor activity and sensitivity .
Thus, lack of water triggers ADH secretion and increases the behavioral reaction of the search for water .
So, any motor or behavioral act is a result of synthesis of multiple afferent stimuli. With that, a rate of validity of a behavioral act is a result of a comprehensive assessment of the afferent flow concluded by a control activity of the brain cortex. Meanwhile, integration of sensory stimuli occurs as well due to a presence of multisensory convergence in a single neuron of the brain cortex, accepting sensory information of different modalities .
The questions of sensory interactions have long raised interest in physiologists, psychologists ans physicians. Already in 1950s, a research was performed to study the aspects of sensory deprivation and even isolation in context of the work of an operator with an increased emotional stress regarding the productivity and the interaction of his sensory systems .
That is why the issues of “sensory homeostasis” (a term, proposed by Melzak), intensively discussed previously and developed in the works of various researchers , including V.V. Alekseev, a student of A.M. Vein, and in works of G.A. Ivanichev, acquire a new and, which is most important, an exclusively practical meaning in medicine. It is the adequate integration of sensory systems that supports the normal functioning of efferent systems, thus maintaining the balance and the health of a individual [3, 14]. Besides the general and special types of sensitivity that were noted above, it is worth mentioning that there is another type of stimulus that is reflected in our central nervous system, although it does not formally belong to sensory stimuli, but is perceived by a separate organ. Cognitive evoked potential P300 is detected in stimulation with a visual or audial impulse with an amplitude higher than was used earlier. The symbols used in the background allow researchers to visualize the response of conductive structures, while only a more strong stimulus, recognized by the mind, is a reflection of a cognitive part. As many other research methods, P300 method of examination depends significantly on the affective state of the patient and the intensity of anxiety and depression disorders . However, the stimulus recognized by the patient lacks the affective component. As in situations described above, an afferent step of a cognitive stimulation is studied, while assessment and research of efferent steps of cognitive stimulation would be of much interest. It is unlikely that a single recognized stimulus would have some kind of a clinically significant muscular efferent; a study of other possible efferents on the first step would be impractical. The possibility of practical use of studies of autonomous responses to cognitive stimuli is unlikely. But determination of sensory efferents would have a clear scientific interest with a non-obvious clinical significance. Studying muscular efferent in cognitive and affective stimuli of various modalities would be of great significance and clinical meaning. A subsequent topographical efferent mapping should be performed.
In summary to the described particularities of practical use of neurophysiological principles and their potential for a future development it should be noted that based on the laws noted above, a method was developed based on using sensory stimuli of various modalities and assessment of their effects in the motor sphere. The method is currently named after its author Jose Palomar, Mexican orthopedist and traumatologist, who has based his work on one of the major reflexes, a deep proprioceptive tendon reflex (P-DTR). It is notable that unlike the representatives of osteopathy and applied kinesiology mentioned earlier, the followers of Jose Palomar and the P-DTR method are devoted to researching its mechanisms and proving it according to the evidence-based medicine criteria. Thus, one of the main postulates, a change of the muscle tone in response to sensory stimuli, was illustrated in the work titled “Characteristics of electroneuromyography parameters in patients with locomotor pain syndromes before and after treatment with a proprioceptive deep tendon reflex (P-DTR) method” conducted by a Department of neurology, physiotherapy and reflexotherapy of a Division of additional professional education of Smolensk State Medical University. An assessment of a bioelectrical activity of a musculocutaneous receptor field and its changes depending on manipulations performed within the P-DTR method was performed. The effect of P-DTR manipulations on a muscle was studied. Due to the study design, the immediate effects before and after manipulations were assessed. Thus, in over a hundred patients, the changes were found including the simultaneous changes between sensory fields: during stimulation of a primary receptor field, a direct interaction was observed between the increased amplitude of evoked potentials of bioelectric activity of the primary and secondary receptor fields; during stimulation of the secondary receptor field, an inverse relationship is observed between the increase of amplitudes of the primary and secondary receptor fields, which may suggest a compensatory role of the secondary dysfunctional field in relation to a primary one. The influence of those receptor fields on the index muscle was also studied. The changes observed were regarded by the researchers as the sign of muscle inhibition; during a muscle test in the scope of P-DTR method, a decrease in EMG parameters was observed. The current results may be regarded as illustrating the interaction between the mentioned sensory fields and their action on a muscle, that are interrelated only in the scope of the P-DTR conception . A more detailed assessment of the results obtained as well as the assessment of clinical effects of P-DTR use and elucidation of physiological mechanisms underlying the specific manipulation are yet to be performed; however, based on the data obtained, conclusions may be already drawn that the reflex therapy as the proposed base of the P-DTR method may provide the treatment effect and has a big potential for practical use.
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