Diagnosis of osteochondrosis: the state of the muscular system

With external examination, the degree and uniformity of musculature development, its relief is noted. The degree of development of the musculature is assessed as good, satisfactory and weak.

With a small amount of muscle, lack of relief (when the "figure" of the muscles is not contoured through the skin) and reduced muscle tone (reduced plastic resistance of the muscles when squeezing and palpation), the development of muscles is assessed as weak.

The average development of muscles is determined with a medium-expressed volume, a satisfactory tone of the muscles, with a little pronounced relief.

Good muscle development is a well-defined relief, volume and muscle tone.

At a clinical examination, it should be noted whether the musculature is evenly developed, which groups of muscles are worse developed, which are better.

When evaluating the state of skeletal muscles, along with the visual one, their kinesthetic investigation is necessary, which allows to determine the tonus of muscles (T), hypotrophy (HT), the number of palpable painful knots (CG), tenderness (B), duration of soreness (PB), degree of pain irradiation palpation (SI). To quantify the data obtained in the study of data, F. A. Khabirov and co-author. (1995) proposed the index of muscular syndrome (IMS), determined by the sum of scores of subjective and objective characteristics. The quantitative expression of the scores in the scores is given in Table 3.1, which is based on the most significant signs in the clinic of the muscular syndrome:

IMS = VVS + T + YY + B + PB + SI + KU.

In norm or rate IMS = 1 (at the healthy person the tonus of muscles is equal 1 point). On the basis of IMS, 3 degrees of severity of muscular syndrome were identified: 1st (mild) - up to 8 points; 2nd (middle) - from 9 to 15 points; 3rd (heavy) -more than 15 points (Salikhov IG et al., 1987).

It is known that muscles do not strain at the moment of rapproachement of attachment points, but rather when they stretch, keeping the body from falling. As the torso or head tilts to 20-30 °, the paravertebral muscles become more strained. With pathological impulses, in particular, from the posterior longitudinal ligament receptors, capsules of joints or other tissues, muscle density (its tone) can be detected already at rest. The excitability of these receptors or other parts of the reflex arc can be judged from the density of the muscle at rest and under tension. The reaction of muscle and fibrous tissues to tension is the most important indicator of their dystrophic state (Popelyanskii Ya.Yu., 1989). In addition to increased density, the stretching of these tissues is also manifested by soreness.

Thus, it is possible to judge vertebrogenic dystrophic disorders of muscles and fibrous tissues (neurohistomefibrosis), first, by the compression reaction (muscle tone), by the pain response to stretching; secondly, on soreness in palpation. Pain during palpation can be of different severity.

Determining the soreness of the paravertebral region and palpation of it in general are carried out by relaxing the corresponding muscles. This is possible in IP. The patient - lying down, and standing - in the position of extension, when thrust is provided to the back by gravitational forces.

The determination of the functional capacity of the support and movement organs includes the study of the strength and endurance of the muscles. The first impression of the strength of the muscles being studied is created by the doctor when assessing the nature of the active movement performed by the patient. In clinical practice, a 6-point assessment of the muscle condition is generally accepted.

The strength of the patient's muscles is also judged by the strength of the counter-movement he is giving, and by the ability to lift and move the weight of a certain mass.

Muscular force is also determined with the help of dynamometry and dynamography. The greatest value of the evaluation of the hand's working capacity is the measurement of the strength of the muscles - the flexors of the fingers of the hand. For this, dynamometers of various designs are used. The most accurate data are obtained using a manual spring-loaded dynamometer (DRP); it gives a reading (in kg) from 0 to 90.

Assessment of the state of muscles on a six-point scale

Executed motion	Score in points
Complete loss of muscle function	0
Muscle tension, not accompanied by motor effect	1
The ability to perform a certain movement involving the muscle under study in conditions of facilitating the function	2
Movement is carried out under normal conditions	3
Movement is carried out under counteraction conditions	4
Muscle strength is normal	5

In the study of muscle tone, the greatest interest is not the absolute data relating to muscle tone in the state of rest, but the ratio of the indications of the tone of the strained and relaxed muscle, since this to a certain extent characterizes the contractile ability of the muscle. The greater the interval between the indices of the tone of the muscle in a state of tension, and the indications of muscle tone in a relaxed state, the greater its ability to relax and strain and, in connection with this, its contractility is higher.

For the research, various designs of tonometers are proposed - the spring tonometer of Sermai and Geller, the electrotone meter, the Efimova sclerometer, the Ufland gauge, etc. The principle of operation of these devices is based on the depth of immersion of the metal pin in the tissue: the softer and more pliable the tissue, the greater the depth of immersion. This is reflected on the scale of the device.

The method of investigation is as follows: the device is placed on the muscle or muscle group being studied and the scale readings are determined (the state of muscle or muscle relaxation). Then, the patient is offered to contract the muscle (a state of muscle tension) and again determine the readings (in myotons) on the scale of the device. By the magnitude of the difference in indices judge the contractile ability of the muscle. Comparison of the obtained data in the dynamics makes it possible to judge the change in the functional state of the muscles.

Muscle tone can be defined and palpable:

• 1 st degree - the muscle is soft;
• 2 nd degree - a muscle dense, palpating her finger plunges into it only partially and with difficulty;
• The third degree is the muscle of stony density.

Endurance , i.e. The ability to prolong the preservation of working capacity and increased resistance to fatigue under various loads, improves under the influence of physical exertion. The endurance of the neuromuscular apparatus is judged by the duration of retention of muscle tension or by performing any dynamic work with a certain muscular effort. Endurance in static work is investigated with the help of dynamographs (VNIIMP-CITO, etc.). First determine the maximum strength of the muscle being examined, and then offer to keep 50-75% of the maximum possible effort before the onset of fatigue. In healthy individuals, the duration of retention is inversely proportional to the magnitude of the muscular effort. Endurance to dynamic work is determined with the help of an ergograph. The movements of a certain segment of the limb are weighed down by a load of a certain magnitude, the rhythm of the movement is set by means of a metronome and judged by the ergogram of the onset of fatigue. If the motions are carried out without burdening, then according to the ergogram one can estimate the frequency or speed of an arbitrary motion. Within a certain time, the maximum number of movements is made by the segment of the limb, and then the indices are compared with the data of the study of a healthy limb.

The electromyographic method of investigation is also used to characterize the neuromuscular apparatus. This method allows to determine the changes in the bioelectrical activity of the muscle depending on the level of damage, the type of immobilization, it also serves as an objective criterion for the positive effect of physical exercises on the muscular apparatus.

Manual muscle testing (MMT), introduced into practice at the beginning of the present century by R. Lovett, despite the introduction of modern electrodiagnostic and tensodimometric methods for assessing the state of muscles, has not lost its importance for the clinic, and especially for rehabilitation therapy.

In muscle testing, a specific movement called the test movement is used for each muscle or muscle group. The MMT method is a developed and systematized movement for individual muscles and muscle groups, with each movement taking place from a precisely defined starting position - the test position. By the nature of the test movement, the resistance, which is overcome, judge the strength and functional capabilities of the muscles being examined.

The basic principles of MMT - an assessment of the degree of violation (scale of 6 degrees), the use of gravity and manual resistance as criteria have been preserved to date. At the same time MMT was supplemented with tests including new muscle groups, adequate initial positions and more accurate test movements. All this provided an opportunity to determine with great accuracy the degree of weakening or total loss of strength of a given muscle or muscle group, and also to differentiate the smallest substitution movements.

The main provisions used at MMT:

• initial position of the patient during testing (test position);
• test movement;
• the severity of the part of the body moved by the muscles under investigation;
• applied by the doctor manual resistance;
• evaluation of muscle strength.

A. The initial position (test position) is selected in such a way as to provide conditions for the isolated execution of the tested motion. To correctly assess the condition of the muscles being tested, it is necessary to fix one of the attachment points (always proximal). This can be done using several methods. First of all, the test position and severity of the body are sometimes sufficient to stabilize the segments, which are the proximal attachment point of the muscle being studied (for example, with flexion of the hip joint). Another way to stabilize is the additional fixation of the proximal parts of the body by the physician's hand (for example, with abduction in the hip joint, knee joint extensionality). The third method of additional stabilization, used in testing the rotation of the shoulder and hip joint, is the so-called counter-contraction. With its help, the tested segment is maintained in the correct position, allowing for an axial rotation, fixing a possible violation of the initial position due to the application of manual resistance.

B. The test movement is the work of the muscles under investigation, in which they act on a certain segment of the limb, in a strictly defined direction and amplitude of motion. For example, usually the volume of test movement for single-joint muscles is, as a rule, the total volume of motion of the joint to which they act. When testing, it should be borne in mind that the inability to complete the required movement in full can be associated not only with muscle weakness, but also with mechanical defects, for example, shortening the ligaments of the antagonist muscles, with fibrosis of the capsule, with incongruent articular surfaces, etc. This is why , before proceeding to testing, the doctor should check by passive movement, whether the joint is free.

B. The severity of the part of the body moved by the muscles under test (gravity). Depending on the initial position of the patient, the test movement can be directed vertically upwards, against gravity, i.e. Be antigravitational. Accordingly, the position is called anti-gravity. In this case, the test muscles must develop a force greater than the gravity of the segment being moved, in order for the movement to take place.

The ability of the tested muscles to perform antigravity movement in full is generally considered to be one of the main criteria in the evaluation of MMT - a satisfactory grade (3 points) indicates a functional threshold, on the occupied middle position between the loss of muscle function and the normal muscle layer. At the same time, the gravity factor can not be decisive in determining the degree of muscle strength, for example, a person (here facial expressions are important, since there are no joints and amplitude of motion), pro-nators and supinators of the forearm.

G. Manual resistance, which the doctor renders during testing, is another basic criterion for evaluating muscle strength. Typically, the place of resistance is the distal part of the segment that the test muscle moves (for example, when testing flexion of the knee joint, the distal part of the shin). This allows the doctor to use the longest lever arm and thus use less force to overcome the tested muscles.

There are three methods of applying manual resistance:

• continuous uniform resistance in the volume of the entire test movement; it can not be used for stiffness, joint contractures, pain syndrome, etc .;
• a test of "prevarication". The patient makes a test movement, counteracting the initial light and gradually increasing chiropractic resistance on the part of the doctor. In the future, resistance increases to a degree that allows you to overcome the strength of the tested muscles, overcome it. It is the resistance necessary for overcoming it, which is the criterion of muscular strength;
• isometric test. The patient makes an attempt to perform a test movement, counteracting the adequate, fixed resistance on the part of the doctor. Resistance should be slightly greater than the strength of the muscles being tested, so the latter will be in isometric contraction.

D. The evaluation of muscle strength is made according to 6 degrees.

For a group of muscles in which gravity is the main criterion for testing, the evaluation is performed as follows.

• Degree 5, normal, normal (N), determines the strength of the corresponding normal muscle. It can complete the entire volume of motion, counteracting gravity and maximum manual resistance.
• Degree 4, favorable, good (G). The muscle is able to complete the entire volume of motion, counteracting gravity and moderate manual resistance. Corresponds to approximately 75% of normal muscle strength.
• Degree 3, satisfactory, fair (F). The muscle can make a full volume of motion, counteracting gravity (no additional resistance is used). Corresponds to approximately 50% of normal muscle strength.
• Degree 2, weak, poor (P). The muscle is able to complete the entire volume of motion, but with eliminated gravity. Can not overcome the gravity of the test part of the body. Corresponds to approximately 25-30% of normal muscle strength.
• Degree 1, traces of movement, twitching, trace (T). When you try to make a movement, you see a visible and palpable contraction of the muscle, but not enough strength to make any kind of movement by the test segment. Corresponds to approximately 5-10% of normal muscle strength.
• Degree 0, nula (Nu). When trying to make movement, the muscle does not give any visible palpation contraction.

Degrees 5, 4 and 3 are also called functional.

For a group of muscles in which gravity is not a decisive factor in evaluation, degrees 5 and 4 are characterized by the amount of manual resistance provided by the physician. Degree 3 expresses the fulfillment of the total volume of motion, and the degree of 2 is incomplete.

With facial musculature, especially where there are no joints and, accordingly, there is no volume of movement, the only criterion is the specific mimicry of the muscle being tested. Due to the fact that objective assessment is difficult, a reduced evaluation scheme was proposed: normal, satisfactory, traces and zero.

It should not be forgotten that the MMT score is relative and, most importantly, functional. It does not directly compare the level of the absolutely preserved muscle strength of two different muscle groups, for example, the upper and lower extremities or the muscles of different patients.

Myofascial pain syndrome. It is known that the skeletal musculature is more than 40% of the body weight of a person. Most researchers, based on data from the Basel anatomical nomenclature, allocate 696 muscles, of which 347 are paired and 2 are unpaired. In any of these muscles, myofascial trigger points (TT) can be formed, from which pain and other symptoms are transmitted, as a rule, to distant parts of the body.

Normally, the muscles do not contain TT, they do not have seals, they are not palpable in palpation, do not give convulsive reactions and do not reflect the pain during compression.

Myofascial trigger point is a site of increased irritability (usually within strained bundles of skeletal muscles or in the muscle fascia). It is painful during compression and can reflect pain, sensitivity and vegetative manifestations in its characteristic zones. There are active and latent TTs:

• active TT causes pain;
• latent TT can persist for many years after the defeat of ODC, periodically causing acute pain attacks even with a slight overstretch, overload or hypothermia of the muscle.

Myofascial pain, reflected from a particular muscle, has a zone of distribution (pattern) specific for this muscle:

• spontaneous pain is rarely localized in the TT responsible for it - the pain is dull and long-lasting;
• pain reflected from myofascial TT is non-segmental: it is not distributed according to familiar neurological zones or with painful irradiation zones from visceral organs.

The intensity and prevalence of the reflected pain pattern depends on the degree of irritability of the TT, and not on the volume of the muscle;

TTs are directly activated when:

• acute overload;
• physical overwork;
• direct damage;
• cooling muscles;

TTs are indirectly activated:

• other trigger points;
• visceral diseases (diseases of internal organs);
• articular arthritis, arthrosis;
• emotional disorders;

Secondary TTs are evidently formed in an adjacent or synergistic muscle that is constantly overloaded, as it is in a state of "protective" spasm, which reduces the burden on the hypersensitive shortened and weakened muscle containing the primary TT

Myofascial CT causes stiffness and weakness of the affected muscles.

Patient examination:

• in the presence of active TT in the muscle, its active or passive stretching causes increased pain;
• the movements associated with the stretching of the affected muscle are limited; when trying to increase the amplitude of this movement there is a strong pain;
• pain intensifies when overcoming a muscle contracting dosed resistance (for example, a doctor's hand).

When palpation of the affected muscle:

• the intensity of the muscle fibers located in the immediate vicinity of the TT is revealed;
• TT is felt as a clearly limited area with acute soreness, which is less pronounced even a few millimeters from the boundary of this point;
• Pushing a finger on an active TT usually causes a "jump symptom";
• a moderate continuous pressure on a rather irritable TT causes or intensifies pain in the area of reflected pain.

Method of palpation:

• Tick-borne palpation - the abdomen of the muscle is caught between the thumb and other fingers, squeezes it and then "rolls" the fibers between the fingers to reveal tight bands; After revealing the strand, it is felt along the entire length for the purpose of determining the point of maximum soreness, i.е. TT;
• palpation deep sliding - moving the tip of the finger of the skin across the muscle fibers. This movement allows you to determine the changes in the underlying tissues. The doctor with the tip of the finger shifts the skin to one side of the palpable fibers and then makes them sliding across these fibers, creating a skin fold on the other side of the fibers. Any densified structure (tight cord) in the muscle with such a palpation is felt as "something rotating under the fingers";
• pinch palpation - the tip of the finger is placed against a strained cord at a right angle to its direction and sharply lowered into the depth of the tissue, then the finger is quickly lifted and the hooks are "hooked". The movements of the finger are the same as in the twitching of a guitar string. Such palpation is most effective for provoking a local convulsive response.

ATTENTION! In order to weave a tight cord, the muscle should be stretched 2/3 of its normal extension. The palpable throat is felt as a tight cord among normally weakened fibers;

• zigzag-shaped palpation - the doctor alternately shifting the tip of the finger then one or the other side of the muscle fibers, moving it along the muscle.

ATTENTION! Zigzag palpation reveals a tight cord, which includes TT, deep palpation along these fibers reveals the localization of the CT itself as a nodule.

[1], [2], [3], [4], [5]