Мобильная версия

Журнал «Здоровье ребенка» Том 18, №4, 2023

Залежність функції м’язів верхніх кінцівок від перфузії при прогнозуванні ефективності реабілітації в посттравматичному періоді в дітей

Авторы: L. Vakulenko (1), O. Obolonska (1), O. Nekhanevych (1), V. Golyk (2), T. Obolonska (3)
(1) — Dnipro State Medical University, Dnipro, Ukraine
(2) — Technical Officer, Disability and Rehabilitation, WHO Country Office in Ukraine, Dnipro, Ukraine
(3) — MEI “Scientific Medical Lyceum “Dnipro” of DRC, Dnipro, Ukraine

Рубрики: Педиатрия/Неонатология

Разделы: Клинические исследования

Актуальність. Несприятлива соціальна ситуація в Україні та збільшення кількості травмованих дітей призводить до навантаження на травматологічні відділення й реабілітаційні центри. Пошук простих методів, що допоможуть виявити порушення компенсаторних механізмів, таких як централізація кровообігу, й порушення перфузії на рівні периферичного мікроциркуляторного русла є надзвичайно актуальним. Матеріали та методи. Проведено комплексне клініко-функціональне обстеження 44 пацієнтів віком 10–15 років: 21 з переломами верхніх кінцівок побутового характеру (основна група), 23 умовно здорові дитини становили контрольну групу. Усім дітям проводився тест «Коробка та кубики» (ТКК) та вимірювання перфузійного індексу (ПІ) на кінцівках. Результати. Особливостями ТКК в дітей 10–15 років, які проходили реабілітаційне лікування, було зниження результату на ураженій кінцівці в 1,6 раза порівняно з показниками недомінуючої руки у здорових дітей та в 1,3 раза — на здоровій кінцівці проти домінуючої. Особливістю ПІ в пацієнтів основної групи, яким проводилось реабілітаційне лікування з приводу травм верхніх кінцівок, було його зниження у спокої до 2,52 ± 0,58 проти 3,49 ± 0,34 (p < 0,05) у здорових дітей. При виконанні вправ у хворих дітей відбувалось зниження ПІ до 1,57 ± 0,56 проти 2,93 ± 0,91 (p < 0,05) у здорових. Динаміка відновлення також відрізнялась і становила 2,82 ± 0,45 у хворих проти 4,00 ± 0,64 (p < 0,05) у контрольній групі. Діти з ПІ до 1,5 ± 0,4 мали значно нижчі показники ТКК на початку тренування. При рівні ПІ < 1,5 можна прогнозувати зниження м’язових функцій, уповільнення загоювання ран та потребу в знеболюванні. За умови зростання ПІ протягом тренування до 2,40 ± 0,54 діти виконували ТКК краще, а пацієнти, у яких перфузія знизилась до 0,98 ± 0,20 (p < 0,05), проходили тест вдвічі повільніше. У результаті дослідження виявлено зв’язок між фізичним навантаженням, змінами ПІ й показників ТКК. Висновки. ТКК характеризувався зниженням значень у 1,6; 2,0 та 1,8 раза під час першого, другого та третього вимірювання відповідно порівняно з показниками здорових дітей. Особливістю перфузійного індексу було його статистично значуще зниження до й протягом виконання вправ, а також зменшення динаміки відновлення. Кореляція між ПІ і ТКК доводить спорідненість процесів реабілітації та відновлення кровотоку.

Background. The adverse social situation in Ukraine and an increase in the number of injured children lead to a burden on trauma departments and rehabilitation centers. Looking for simple methods to help detect violations of compensatory mechanisms, one of which is the centralization of blood circulation, and impaired perfusion at the microcirculatory periphery level is of great current relevance. Materials and methods. A comprehensive clinical and functional examinations were applied to 44 children aged 10–15 years, 21 of them had home-related upper extremity fractures (main group), 23 otherwise healthy children served as the control group. All the children underwent the Box and Block Test (BBT), and the perfusion index (PI) from the extremities was recorded. Results. The BBT performance was characterized by a 1.6-fold decrease (p < 0.05) in the affected extremity of children aged 10–15 years under the rehabilitation treatment compared to that of the non-dominant extremity in healthy children and a 1.3-fold decrease (p < 0.05) in the healthy extremity compared to the dominant one. PI decreased to 2.52 ± 0.58 at rest in the main group children who underwent upper extremity rehabilitation treatment for injuries compared to 3.49 ± 0.34 (p < 0.05) in healthy children. PI reduced to 1.57 ± 0.56 in injured children at exercise loads versus 2.93 ± 0.91 (p < 0.05) in healthy children. The dynamics of recovery also differed and amounted to 2.82 ± 0.45 in the main group versus 4.00 ± 0.64 in the control group. Children with PI up to 1.5 ± 0.4 had significantly lower BBT scores at the beginning of exercise training. PI reduction to less than 1.5 allowed predicting a decrease in muscle functions, delayed wound healing, and the need for analgesia. With an increase in PI to 2.40 ± 0.54 during exercise training, children performed BBT better, while those who had a decrease in perfusion up to 0.98 ± 0.20 performed it twice as slowly (p < 0.05). As a study result, an association between the physical exercise load, changes in PI and BBT has been revealed. Conclusions. BBT scores were characterized by a 1.6-, 2.0- and 1.8-fold (p < 0.05) reduction during the first, second and third measurements, respectively, compared to those of healthy children. Characteristic feature of perfusion index was a statistically significant decrease before and during exercise training as well as slow dynamics of recovery. The correlations between perfusion index and BBT have proven the association of the rehabilitation processes and blood flow restoration.

Ключевые слова

діти; травма кінцівок; перфузійний індекс; коробковий тест; реабілітація дітей

children; extremity injury; perfusion index; Box and Block Test; rehabilitation of children

doi: http://dx.doi.org/10.22141/2224-0551.18.4.2023.1599

Introduction

According to the statistical data for 2020, the percentage of childhood injuries as a cause of hospitalization was 30 % in the structure of injuries for the total Ukrainian population [1], but these rates have increased significantly since the beginning of military operations. According to international statistics, 80 % of all fractures in children occur in the upper extremity, 86 % of which respond to a conservative treatment [2].

The quality and success of lost function restoration is an extremely important constituent part of the rehabilitation process [3, 4]. There are quite a lot of criteria for identifying the recovery dynamics, but the degree of a child’s adaptation to loads, in particular, movement loading, is determined mainly by a physician experience and is quite subjective. Therefore, it is particularly relevant today to address implementation issues related to evidence-based rehabilitation medicine [5]. Currently, many tests have been developed to evaluate muscle function in normal conditions and in various pathology. The most common and convenient one is the Box and Block Test (BBT) that measure upper extremity functional performance in children [6, 7].

On the other hand, the most pressing and yet most neglected aspect of recovery assessment is determining the state of volumetric blood flow, as a pledge of normal muscle oxygenation and response of organs and systems to changes in blood circulation. The non-invasive and easy-to-use tool for detecting the degree of blood flow adequacy using the perfusion index (PI) as well as its diagnostic capabilities were analyzed in adults with various pathology [8]. But from the currently available literature, we have not found data on an association between PI and muscle function in children.

The purpose of the study was to determine the perfusion state influence on the muscle functioning for predicting the efficiency of therapeutic exercise use when providing rehabilitative care for children with musculoskeletal injuries of traumatic origin.

Materials and methods

A single-center, prospective, open study was conducted at the Medical Rehabilitation and Physical Therapy Department of the CE “Regional Medical Family Health Center” of DRC from September to November 2022. A comprehensive clinical and functional examination involving 44 patients aged 10–15 years was performed. Group I included 21 children with home-related upper extremity injuries: 8 with a shoulder fracture, and 13 with a forearm fracture. Group II (controls) consisted of 23 otherwise healthy children of the same age. All examined children were right-handed. In group I, frequency of injuries of the left and right extremities was identical.

Inclusion criteria: the upper extremity injuries, written informed consent signed by parents prior to participation of their children in the study, rehabilitation period.

Exclusion criteria: concomitant cardiovascular and nervous system diseases, somatic diseases, immobilization of the affected extremity, polytrauma.

All the children of group I underwent rehabilitative courses, which included therapeutic gymnastics aimed at improving muscle function, work on a functional desk to improve motor control of the arm.

Muscle function was determined according to the standard method of ergotherapeutic BBT, which was performed based on the technique described by Mathiowetz et al. [9]. Children were seated in a chair with their feet planted on the floor, in front of a testing box placed on a table and partitioned into two compartments, one of which contained 150 cubes. The box was positioned lengthwise and along the midline of participants, who were instructed to put their hands on the sides of the box, and the compartment with cubes corresponded to the hand being tested. The goal was to grasp one cube at a time with the testing hand and move it over a divider to the other compartment of the box as fast as possible. The test results were evaluated by the total number of cubes transported in 1 minute [9]. All the participants were tested 3 times with the unaffected upper extremity first and repeated the same process with the affected one. At the beginning of each extremity testing, a 15-second practice period was provided. Elbows were constantly located at the table height level. Mean values of the obtained results were calculated for the analysis.

PI was measured to evaluate volumetric blood flow functionality using photoplethysmography with a Masimo SET Radical pulse oximeter. The blood oxygen saturation index (SpO2) was additionally analyzed to rule out systemic blood circulation and respiratory disorders. The group of otherwise healthy children was examined for setting normative values of PI.

The first PI recordings were performed at rest, the se–cond measurements — after 10-minute physical activity (ten squats, walking), and the third ones — five minutes after exercising. The examined participants were sitting, and the first PI measurements were obtained after a 5-minute rest using the pulse oximeter. The fingernails were without any polish, and there was no any temporary or permanent tattoo on the fingers. The pulse oximeter probe was attached to the middle finger of each hand one by one. The findings were taken after one minute of attachment to the finger for not less than three seconds and saved for further evaluation [10].

In group I, the PI was compared between the affected and unaffected extremities, in group II — between the non-dominant (left-hand finger) and the dominant (right-hand finger) measurements.

Methods of non-parametric statistics were used for statistical processing of the obtained data.

The study was carried out in accordance with the requirements of bioethics, which are given in the World Medical Association’s Declaration of Helsinki “Ethical Principles for Medical Research Involving Human Subjects” and the “Universal Declaration on Bioethics and Human Rights” (UNESCO), approved by the Ethics Commission for scientific research, experimental developments and scientific works of Dnipro State Medical University (Minutes No. 8, 26.04.23). All parents provided written informed consent for examination of their children and publication of the study results.

Results

The mean age of the examined children was 13.8 ± 2.2 years in group I and 13.6 ± 2.1 years in group II. The groups were representative in terms of the body weight and sex. The examinations were performed 19 ± 4 days after the extre–mity injury following cast removal.

There were no statistically significant differences in the results depending on the age of the children. Table 1 shows the scores of BBT performance.

We have found that BBT scores for unaffected extre–mity in group I were statistically significantly lower than those of healthy children. The first BBT in children aged 10–15 years who underwent rehabilitation treatment was cha–racterized by a 1.6-fold decrease (p < 0.05) in scores of the affected extremity performance compared to those for the non-dominant left extremity in healthy children.

The second measurement has detected amplified chan–ges in group II since BBT scores decreased significantly compared to the first measurement (p < 0.05) and were more than 2 times lower than those for the non-dominant hand (p < 0.05). The third measurement has shown a medium BBT scores in group I, since it was 1.8 times decreased (p < 0.05) compared to that in healthy children.

Post-treatment BBT scores for the unaffected upper extremity were also statistically significantly lower compared to those in the control group (p < 0.05). The third measurement has revealed the greatest difference in findings considering 1.4 times lower BBT scores (p < 0.05) compared to the healthy children. This resulted in the need to further examine the children with upper extremity injuries.

The following data were obtained by determining PI in children of groups I and II (Table 2).

PI statistically significant decreased in group I patients aged 10–15 years who underwent upper extremity rehabilitation treatment compared to values in healthy children: 2.52 ± 0.58 versus 3.49 ± 0.34 (p < 0.05) at rest, 1.57 ± 0.56 versus 2.93 ± 0.91 (p < 0.05) during physical exercises, and 2.82 ± 0.45 versus 4.00 ± 0.64 (p < 0.05) during the recovery process, respectively.

The PI dynamics at the time of physical exercise was different in the two groups of children. Group I demonstrated a 1.6-times (p < 0.05) statistically significantly decrease compared to the first PI measurement, which could have been caused by the presence of upper extremity vasospasm, but post-exercise PI recovered to the low baseline values in 5 minutes. In the meantime, PI moderately decreased in group II during a 10-minute physical exercises and then increased statistically significantly (by 1.4 times; p < 0.05) compared to the baseline.

There were no statistically significant differences in SpO2 between the two groups of children considering SpO2 normal ranges during the examination.

In addition, extremely low PIs (less than 1.5) in group I patients during the second measurement (after the 10-mi–nute physical exercises) were analyzed. These children had not only difficulties with muscle functions, but also delayed wound healing, a longer and more pronounced pain syndrome that needed supplementary analgesia and was accompanied by efforts in motor extremity movements as well as a decrease in muscle function when performing BBT (Table 3).

Patients with decreased PI as low as 1.5 ± 0.4 had significantly lower BBT scores at the beginning of exercise training. Children performed the test better if there was an increase in PI during exercise training to 2.40 ± 0.54, while those whose PI were decreased to 0.98 ± 0.20, performed the BBT twice slower (p < 0.05).

The following results were obtained after conducting a correlation analysis between the PI and the BBT scores. A strong direct correlation has been found between these parameters at each measurement on the affected and unaffected extremities in group I children (Table 4).

Discussion

Examination and treatment of injured pediatric patients requires a multidisciplinary approach and well-organized rehabilitation support. First of all, it should be aimed at ensuring the complete restoration of blood circulation and hemodynamics [11].

Another aspect to which attention should be paid is that fractures not only significantly limit motor activity of children, but also have further socio-economic implications [2]. And since the principal goal of any rehabilitation is to improve dexterity function, we decided to use the BBT in our evaluations. It is one of the widely used dexterity assessments (manual dexterity tests) to evaluate the ability to quickly perform extremity movements in children. Even though these manual dexterity tests do not provide direct assessment of extremity function in daily life, they may be useful as additional tools to assess rehabilitation effectiveness in clinical trials [6, 7, 12, 13].

Nowadays, the test is becoming more widely used in pediatric practice. The BBT is now attributed to one of the most common and convenient tests that measure extre–mity function in children [6]. It is suitable for pediatric patients for several reasons. Firstly, the BBT is the method to evaluate the basic components of manual dexterity, including grasping, holding, transferring, and releasing. Secondly, the instructions are simple to explain, and the test is easy to understand. Thirdly, the whole test takes only one minute to complete, so most children have enough attention to perform it. Conclusively, repeated measurements have been reported to be proper for estimating the motor improvements during rehabilitation programs [12].

Currently, the largest number of publications is related to the use of the BBT to evaluate the effectiveness of neurorehabilitation programs in children with cerebral palsy [12–15].

Similar to our work, Zapata-Figueroa V. et al. have found no correlations between BBT scores and age [13].

The results of our work obtained through the use of the BBT have suggested decreased muscle functions in children with the upper extremity injuries, which were progressively worsened during the test and maximally reduced at the se–cond measurement. At the same time, the dynamics moved in the opposite direction at the second measurement in the control group that was clear from the best and highest results shown by the children.

Like many earlier studies, our analysis has shown that the BBT is a reliable, valid, and user friendly test that can be applied to evaluate treatment and rehabilitation outcomes in children with upper extremity injuries.

Since the scores of the BBT performed by the unaffected extremity were also different and statistically significantly lower compared to those in the control group, it then became necessary to evaluate peripheral circulation disorders in these children.

Today, there is an opportunity to use simple and avai–lable techniques with regard to rapid diagnosis of peri–pheral blood circulation disorders [10, 16]. Since it is PI that provides information about the state of peripheral blood flow, it has become an idea of applying it in this work to predict the effectiveness of rehabilitation in children with fractures of the upper extremities in resource-constrained settings.

PIs taken from measuring the ratio between the pulsatile signal during arterial blood flow in the peripheral tissue and the non-pulsatile signal with a pulse oximeter are indirect indicators of peripheral perfusion [10, 17].

The value of PI depends on such factors as the intensity of volumetric peripheral blood circulation, blood fil–ling of the microcirculatory bed, capillary density networks [10, 16].

A study by Wang J. et al. was aimed at evaluating the effect of PI on predicting the success of supraclavicular brachial plexus block in children under general anesthesia with different drugs. The authors have revealed that the comparison of PI on the blocked and non-blocked sides could be helpful to evaluate the effect of nerve block postoperatively in children with upper extremity fractures [18].

So far only one study in the available literature has evaluated the effectiveness of PI measurement in pediatric trauma patients. This study was conducted in Turkey and included 91 injured children aged 28 days to 18 years who had severe upper extremity injuries and were hospitalized to a pediatric intensive care unit. The researchers have concluded that PI could be used to objectively assess the state of peripheral perfusion in addition to hemodynamic markers. And besides, the mean PI of all trauma patients was 1.53 ± 0.91, whilst the median value was 1.3 in this study [11].

In this paper, we have concluded that decreased muscle functions, delayed wound healing, and the need for additional analgesia could be predicted in children with injured upper extremities at PI below 1.5.

We have demonstrated that the use of PI measurement in injured children is the non-invasive, easy-to-use and real-time method allowing timely prediction of delayed recovery processes and maladaptive response to exercise. Moreover, in our study, we have found correlations of PI and BBT scores proving the association between rehabilitation processes and restoration of blood flow (namely, capillary filling).

In our assessment, the capillary filling index along with traditional indicators, such as heart rate and blood oxygen saturation, can be used to assess adaptation me–chanisms and the rehabilitation outcomes. The reason for these conclusions was the findings obtained from children with PI decreased to 0.98 ± 0.20, since they performed the BBT 2 times slower (p < 0.05) than controls. The BBT scores at the beginning of exercise training were slightly better, if the values of PI were decreased to 1.5 ± 0.4. At the same time, children who had decreased PI during exer–cise training only up to 2.40 ± 0.54 showed the best BBT performance.

Thus, PI and BBT scores are reliable criteria that can be more commonly used to assess the mechanisms of adaptation and the rehabilitation outcomes in children with upper extremity injuries.

Conclusions

1. The BBT scores in children aged 10–15 years who underwent rehabilitation treatment for upper extremity fractures have been found to be 1.6 times lower (p < 0.05) compared to those of the non-dominant hand in healthy children and 1.4 times (p < 0.05) lower for the unaffected extremity compared to the dominant one in healthy children.

2. Characteristic feature of perfusion index in children aged 10–15 who underwent rehabilitation treatment for upper extremity fractures was its statistically significant decrease before exercise training to 2.52 ± 0.58 versus 3.49 ± 0.34 (p < 0.05) in healthy children; during exerci–ses — to 1.57 ± 0.56 versus 2.93 ± 0.91 (p < 0.05), as well as different recovery dynamics: 2.82 ± 0.45 versus 4.00 ± 4.64 (p < 0.05), respectively.

3. Capillary filling index is a reliable indicator in assessing adaptation mechanisms and the rehabilitation outcomes. Perfusion index lower than 1.5 can be used to predict decreased muscle functions, delayed wound healing, and the need for analgesia.

4. The correlations of perfusion index and BBT scores have proven the association between the processes of rehabilitation and blood flow restoration.

Received 09.04.2023

Revised 20.04.2023

Accepted 02.05.2023

Список литературы

Литвинова Л.О., Донік О.М., Гречишкіна Н.В. Аналіз динаміки дитячого травматизму в Україні. Сучасні медичні технології. 2020. 2. 49-53.
Merckaert S., Chaibi E., Meriem S., Kwiatkowski B., Divjak N., Zambelli P.Y. Epidemiology of Pediatric Upper Extremity Fractures in a Tertiary Care Center in Switzerland. Pediatr. Emerg. Care. 2021. 37(12). e825-e835. doi: 10.1097/PEC.0000000000002047.
World Health Organization: Rehabilitation: key for health in the 21st century. Available from: https://cdn.who.int/media/docs/default-source/documents/health-topics/rehabilitation/call-for-action/keyforhealth21stcentury.pdf?sfvrsn=43cebb7_5.
Frontera W.R., Stucki G., Engkasan J.P., Francisco G.E., Gutenbrunner C., Hasnan N. et al. European Academy of Rehabilitation Medicine; Association of Academic Physiatrists; International Society of Physical and Rehabilitation Medicine. Advancing Academic Capa–city in Physical and Rehabilitation Medicine to Strengthen Rehabilitation in Health Systems Worldwide: A Joint Effort by the European Academy of Rehabilitation Medicine, the Association of Academic Physiatrists, and the International Society of Physical and Rehabilitation Medicine. J. Rehabil. Med. 2022 Jul 6. 54. jrm00310. doi: 10.2340/jrm.v54.3510.
Negrini S. Evidence in Rehabilitation Medicine: Between Facts and Prejudices. Am. J. Phys. Med. Rehabil. 2019 Feb. 98(2). 88-96. doi: 10.1097/PHM.0000000000001033.
Козявкін В.І., Качмар О.О., Гасюк М.Б., Матюшенко О.А., Кушнір А.Д. Методи оцінки функції руки при неврологічній патології. Огляд літератури. Міжнародний неврологічний журнал. 2018. 1(95). 53-62. doi: 10.22141/2224-0713.1.95.2018.127408.
Kontson K., Marcus I., Myklebust B., Civillico E. Targeted box and blocks test: normative data and comparison to standard tests. PLoS One. 2017. 12(5). e0177965. doi: 10.1371/journal.pone.0177965.
Курсов С.В. Перфузионный индекс в практике анестезиологии и интенсивной терапии (oбзор литературы). Медицина неотложных состояний. 2015. 7(70). 20-25.
Mathiowetz V., Volland G., Kashman N., Weber K. Adult norms for the box and block test of manual dexterity. Am. J. Occup. Ther. 1985. 39. 386-91.
Swain S.M., Lata M., Kumar S., Mondal S., Behera J.K., Mondal H. A Cross-Sectional Study on the Agreement of Perfusion Indexes Measured on Different Fingers by a Portable Pulse Oximeter in Healthy Adults. Cureus. 2022. 14(5). e24853. doi: 10.7759/cureus.24853.
Alakaya M., Arslanköylü A.E. Evaluation of perfusion index in pediatric trauma patients. Ulus Travma Acil Cerrahi Derg. 2022. 28(5). 593-598. doi: 10.14744/tjtes.2021.68145.
Liang K.J., Chen H.L., Shieh J.Y., Wang T.N. Measurement properties of the box and block test in children with unilateral cerebral palsy. Sci. Rep. 2021. 11(1). 20955. doi: 10.1038/s41598-021-00379-3.
Zapata-Figueroa V., Ortiz-Corredor F. Assessment of Ma–nual Abilities Using the Box and Block Test in Children with Bila–teral Cerebral Palsy. Occup. Ther. Int. 2022. 2022. 9980523. doi: 10.1155/2022/9980523.
Araneda R., Ebner-Karestinos D., Paradis J., Saussez G., –Friel K.M., Gordon A.M., Bleyenheuft Y. Reliability and responsiveness of the Jebsen-Taylor Test of Hand Function and the Box and Block Test for children with cerebral palsy. Dev. Med. Child Neurol. 2019. 61(10). 1182-1188. doi: 10.1111/dmcn.14184.
Figueiredo P.R.P., Mancini M.C., Feitosa A.M., Teixeira C.M.M.F., Guerzoni V.P.D. et al. Hand-arm bimanual intensive therapy and daily functioning of children with bilateral cerebral palsy: a randomized controlled trial. Dev. Med. Child Neurol. 2020. 62(11). 1274-1282. doi: 10.1111/dmcn.14630.
Футуйма Ю.М., Беденюк А.Д., Кульбаба І.Я. Значення перфузійного індексу для швидкої діагностики різних форм синдрому діабетичної стопи в виборі адекватної патогенетичної тактики хірургічного лікування. Здобутки клінічної і експериментальної медицини. 2021. 2. 168-173. doi: 10.11603/1811-2471.2021.v.i2.12220.
Ozakin E., Yazlamaz N.O., Kaya F.B., Karakilic E.M., Bilgin M. Perfusion Index Measurement in Predicting Hypovolemic Shock in Trauma Patients. J. Emerg. Med. 2020. 59(2). 238-245. doi: 10.1016/j.jemermed.2020.04.010.
Wang J., Deng L., Xu A. Evaluation of prediction effect of perfusion index for supraclavicular brachial plexus block in children: protocol for a randomized trial. Trials. 2022. 23(1). 629. doi: 10.1186/s13063-022-06597-y.