Н-РЕФЛЕКСОМЕТРИЯ В КЛИНИКЕ НЕРВНЫХ БОЛЕЗНЕЙ
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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 Â 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 íàïðÿæåíèÿâðåìåíè Í- è Ì-ïîòåíöèàëîâ â äèàïàçîíå 0,20,3 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 íåðâîâ 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. 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(2000) Low frequency depression of H-reflexes in humans with acute and chronic spinal-cord injury. Exp. Brain Res., 133(2): 233241. 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): 551568. 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
