Means of physical rehabilitation in complex treatment of osteochondrosis

Rehabilitation treatment by means of physical rehabilitation is directed:

• on the exclusion of unfavorable static-dynamic loads on the affected spine, especially in the acute period of trauma / illness;
• an effect that stimulates the activity of both the fixation structures of the affected spine and the muscles surrounding the spine;
• impact not only on the spine area, but also on extravertebral pathological foci involved in the formulation of neurological complications. It is necessary to achieve not only remission, but remission of a stable, with such a state of connective tissue, muscle, nervous and vascular elements, with such fixation and configuration of the spine that would ensure the prevention of exacerbations.

It is known that in the area of spinal segment injury, dystrophic (necrotic) processes are initially observed. Then within the first 1-2 months. From the moment of injury, a granulation tissue is formed, consisting of young fibroblasts, which actively synthesize prosteoglycans and type III collagen. And only after 3-5 months. Regenerate acquires a resemblance to a dense fibrous connective tissue. Thus, the reparative and regenerative processes in the affected segment terminate on average by 3-5 months, and therefore the treatment of damaged spinal cord ligaments should be continuous and continuous, during which various means of physical rehabilitation should be used.

The differentiated application of physical rehabilitation facilities is based on the degree of damage to the ligamentous muscle of the affected spine on the basis of:

• developed ultrasonographic data of lesion of fixation structures of the spine;
• Clinico-biomechanical changes in ODD arising from damage to the ligaments of the affected PDS of the spine;
• the period of the disease, the duration of the traumatization (disease), age and tolerance to the physical loads of the patient.

Objectives of the FR

• Management of pain syndrome.
• Strengthening of damaged fixation structures of the damaged spine.
• Improvement of blood and lymph circulation in order to stimulate reparative-regenerative processes in the affected area of the ligamentous apparatus.
• Elimination of pathobiomechanical changes in the locomotor apparatus.
• Restoration of the optimal motor stereotype.

To implement the tasks set in the rehabilitation treatment of patients the following methodical recommendations for the use of LFK were used:

1. A prerequisite before exercise LFK is the elimination of functional orthopedic defects. Similar defects are formed, as a rule, in the period of exacerbation of the disease under the influence of a widespread pathogenizing decompensated myofixation, vicar-postural overloads with spontaneous "exiting from an exacerbation."
2. Preliminary preparation of the musculoskeletal device for physical activity involves two stages:

A) general preparation includes:

• unloading of the affected spine (bed rest, fixing corsets);
• correction of the position of the affected spine;
• therapeutic massage of the muscles of the trunk and extremities (in a relaxing mode) is shown to all patients;
• thermal procedures (not shown to patients with severe disgemic symptoms);

B) direct training includes:

• miorelaxation - breaking the vicious stato-kinematic stereotype;
• myocorrection - creation of a compensated stato-kinematic stereotype;
• myotonization - fixing of new stato-locomotor installations.

3. The active reinforcement and the active fixation of the ligamentous muscular structures in the affected PDS of the spine are achieved by using the method of treatment for traumatic injuries of the lumbar spine apparatus (patent No. 2162296 of January 27, 01) and the various drugs of the exercise therapy at the stationary polyclinic stage of treatment.

The use of RF in the stationary-polyclinic stage of rehabilitative treatment. It is known that the main provisions of each technique of exercise therapy is the working systematization of physical exercises, to which we relate: ".

• special exercises;
• exercises that perform auxiliary functions;
• definition of unacceptable and contraindicated types of motor activity;
• The exercises that help restore the optimal motor stereotype.

When choosing physical exercises aimed at strengthening the ligamentous and muscular apparatus of the affected spine, we adhered to the following provisions:

• when the disease is aggravated, physical exercises aimed at increasing the mobility of the affected PDS of the spine are contraindicated;
• physical exercises should not cause discomfort or pain sensations in the patient, since in this case development of decompensation in the biokinematic chain "spine-limbs" is possible, which considerably slows down the formation of an adequate reaction from the ligamentous-muscular apparatus of the affected spine;
• myofixation is a component of the developing motor stereotype;
• therefore it is necessary to use exercises in LH exercises that cover unaffected regions of the locomotor apparatus, in order to strengthen muscular-tonic reactions in the affected PDS of the spine.

To strengthen damaged ligamentous structures, increase the working capacity of the body, an important condition is the rational alternation of muscle strains and relaxation. At the same time, volitional relaxation, as well as active muscle tension under isometric efforts, should be considered as a kind of training of the entire locomotor apparatus. The development in patients of a stable and full-fledged skill to arbitrarily relax the muscles is a prerequisite for the application of exercises in isometric mode. In this case it is necessary to take into account that the successive change of an arbitrary muscle tension and their relaxation makes it possible to obtain the best relaxation effect.

We have developed a method for treating damage to the lumbar spine (segmental gymnastics), aimed at strengthening the damaged segment. The procedure is protected by a patent (No. 2167639 dated May 27, 01) and is schematically represented by two phases:

A) In order to reduce the spasmodic state of paravertebral muscles in the area of damage, methods of stretching the muscles are shown, which are used in the form of various movements with an amplitude that provides some excess of the mobility available in one or another joint. The intensity of their specific action is measured by the magnitude of the active tension of the muscles that produce the stretching, the pain sensation, the force of inertia that occurs with rapid flap movements with a certain amplitude, and the starting positions allowing the lengthening of the lever of the moving segment of the body. We used several methods of stretching the muscles in the exercises LH:

Passive stretching of the muscle. If, after passive stretching, the muscle seems rigid and the movement remains limited, then instead of repeating the same procedure, rhythmic stabilization should be performed. The technique of this procedure is that the patient alternately reduces agonistic and antagonistic muscle groups. The doctor's hand, however, has a dosed resistance, thus maintaining their isometric contraction. The alternating tension of one or the other group of muscles contributes to the gradual lengthening of the affected muscle. This mechanism is based on reciprocal inhibition.

B) To optimize blood supply in the affected area (trauma, degenerative-dystrophic condition of the ligamentous apparatus), to stimulate regenerative-reparative processes, electrostimulation of paravertebral muscles and local gymnastics in combination with a point massage in the area of the affected PDS of the spine are used.

During the exercise of exercise therapy, we paid attention to the presence in patients of local algic trigger points (points) not only in the muscular, but also in the ligament structures. In order to inactivate the trigger points (TT), ischemic puncture analgesia was used in the procedures, the essence of which was the compression action of finger pads on the sites of local muscle hypertonus - myofascial pain trigger points. This exposure is dosed in accordance with the individual characteristics of the patient and the degree of severity of the MFBS.

It is known that algic trigger regions can be localized in ligamentous structures. They can completely realize their contractive properties completely without the involvement of muscles, forming local compaction zones. The rate of formation of local ligament hypertension does not correspond to the rate of formation of local muscle hypertonia, but both of these processes are neurophysiological and clinical reality. The ligament component of this process is incomparably longer than the muscle component. This is supported by the results of our treatment. After, for example, PIR, local muscle hypertonicity disappears, but often in ligamentous structures, ultrasound examines hyperechoic foci of different diameters, which corresponds to triginal CT points that are localized in the examined ligaments of the affected PDS of the spine (patent No. 2167604 of May 27, 01) . In this case, tenderness in ligamentous TT has several aspects:

• Irritation of nociceptors with biologically active substances in the trigger zone, i.e. Those agents who called him. However, the action of these agents is limited by time: tissue buffering systems cause neutralization of these substances, reducing their activity to a minimum.
• Participation of mechanisms of interaction of various afferent systems. The site of the hypertension of the ligament becomes the place of stable deformation of the proprioceptive system with a change in the qualitative characteristics of the afferent interaction in the segment of the spinal cord. As a result of this interaction, a deterministic algic system is formed, the generator of which is the ligament trigger (TP). The experiment proved that the trophism of the ligaments occurs 2-2.5 times more often and earlier than it occurs in muscles that have a greater range of adaptive-compensatory possibilities. This is the fundamental difference in the formation of STF from MTP.

Thus, in order to increase the effectiveness of rehabilitation treatment of patients with damage to the ligamentous apparatus of the spine, we developed a program for the use of various FF agents (physical exercises, PID, PRMT, and ischemic puncture analgesia) to affect the musculoskeletal apparatus of the affected vertebral column:

• relaxation of spasmodic muscles in the affected area (exercises and massage techniques aimed at relaxation of muscles, methods of PID);
• relaxation of spasmodic muscles with simultaneous activation of antagonist muscles with PRMT, PNR;
• inactivation of myofascial trigger pain points by means of ischemic puncture analgesia;
• strengthening of the ligamentous apparatus of the affected spine with the help of special physical exercises, electrostimulation, acupressure, physiotherapeutic procedures;
• the creation of a "muscular" corset with the help of physical exercises in the isometric mode of muscle contraction, training on the training apparatus;
• stimulation of blood and lymph circulation in the area of the affected PDS of the spine in order to improve regenerative and reparative processes (physical exercises, massage techniques, PID, ischemic puncture analgesia, electrostimulation, physiotherapy procedures).

Psychological correction - one of the methods of rehabilitation, including therapeutic self-hypnosis, self-knowledge, neurosomatic training, sedative and activating psycho-training, performed in conditions of muscle relaxation and leading to self-education and mental self-regulation of the body. In addition, psychocorrection is considered as one of the necessary and effective forms of exercise therapy, using general, special, respiratory and other physical exercises for the regulation of muscle tone, which, as reflected reflex manifestation of higher nervous activity, actively affects the mobilization and lowering of excitation in the central nervous system , and consequently, on the activity of all organs and systems of the human body.

The physical aspects of psychocorrection are as follows:

• development of the ability to regulate the tone of the striated and smooth muscles of the trunk and extremities or differentiated muscle relaxation or increase the tone of individual muscle groups;
• the acquisition of the habit of rhythmic breathing due to the mental regulation of the intervals of the phases of inspiration and exhalation;
• mastering the skills of reduced, slow surface breathing, as well as the physical differentiated sensations of parts of his body.

Timing of the use of physical rehabilitation at the stages of rehabilitation treatment

Degree of damage	Stationary stage	The polyclinic stage
I Art.	10-14 days	7days.
II century.	4-5 weeks *	8-10 weeks.
III century.	5-6 weeks.	16-20 weeks.
IV century.	Laparoscopy

* Reparative and regenerative processes in the affected PDS of the spine are monitored by clinical ultrasound.

The task of psychocorrection is not only to teach the patient to create a dominant, but, most importantly, to subordinate it to his will, to control the dominant in order to suppress pathological impulses from the diseased organ or hearth. Therefore, the determining and basic element is the training of muscle relaxation, on the basis of which all methods of autogenic exposure are realized.

Massage is much more effective than simply warming up the muscle. In order to inactivate certain active TTs, the doctor must use absolutely certain massage techniques. Massage without clarification of its kind can apparently be used only in those cases when the TT is weakly active and causes minimal reflected pain. However, it should be remembered that any vigorous massage of hyper-irritable TT can cause a negative reaction with the occurrence of painful phenomena. We recommend the use of "longitudinal" massage. The masseur, immersing his hands in the muscle mass, slowly slides along it from the distal end towards the TT, performing a kind of "mellowing movement". Repeated movements with increased finger pressure gradually reduce the density of the TT until it is completely eliminated and inactivated.

[1], [2], [3]