Means of physical rehabilitation in the complex treatment of osteochondrosis

Restorative treatment using physical rehabilitation methods is aimed at:

• to eliminate unfavorable static-dynamic loads on the affected part of the spine, especially during the acute period of injury/disease;
• effects that stimulate the activity of both the fixation structures of the affected part of the spine and the muscles surrounding the spine;
• impact not only on the spine area, but also on extravertebral pathological foci involved in the formation of neurological complications. It is necessary to achieve not just remission, but stable remission, with such a state of connective tissue, muscle, nerve and vascular elements, with such fixation and configuration of the spine that would ensure the prevention of exacerbations.

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

The differentiated use of physical rehabilitation means is based on the degree of damage to the ligamentous-muscular apparatus of the affected part of the spine, based on:

• developed ultrasonographic data on damage to the fixation structures of the spine;
• clinical and biomechanical changes in the musculoskeletal system that occur when the ligaments of the affected spinal musculoskeletal system are damaged;
• period of illness, duration of injury (illness), age and tolerance to physical activity of the patient.

Objectives of FR funds

• Pain relief.
• Strengthening of damaged fixation structures of the injured part of the spine.
• Improving blood and lymph circulation in order to stimulate reparative and regenerative processes in the affected area of the ligamentous apparatus.
• Elimination of pathobiomechanical changes in the locomotor apparatus.
• Restoring the optimal motor stereotype.

To achieve the set objectives in the rehabilitation treatment of patients, the following methodological recommendations for the use of exercise therapy were used:

1. A necessary condition before conducting exercise therapy is the elimination of functional orthopedic defects. Such defects are formed, as a rule, during the period of exacerbation of the disease under the influence of widespread pathogenic decompensated myofixation, vicarious-postural overloads during spontaneous "exit from exacerbation".
2. Preliminary preparation of the muscular-ligamentous apparatus for physical activity involves two stages:

A) general training includes:

• unloading the affected part of the spine (bed rest, fixing corsets);
• correction of the position of the affected part of the spine;
• therapeutic massage of the muscles of the trunk and limbs (in a relaxing mode) is indicated for all patients;
• thermal procedures (not indicated for patients with pronounced dyshemic symptoms);

B) direct preparation includes:

• muscle relaxation - breaking the vicious stato-kinematic stereotype;
• myocorrection - creation of a compensated static-kinematic stereotype;
• myotonization - consolidation of new statolocomotor settings.

3. The implementation of active strengthening and creation of active fixation of ligamentous-muscular structures in the affected spinal ligament is achieved by using the method we proposed for treating traumatic injuries of the ligamentous-muscular apparatus of the spine (patent No. 2162296 dated 01/27/01) and various means of exercise therapy at the inpatient-outpatient stage of treatment.

The use of physical therapy tools at the inpatient and outpatient stage of rehabilitation treatment. It is known that the main provisions of each exercise therapy method are the working systematization of physical exercises, to which we have related: ".

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

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

• in case of exacerbation of the disease, physical exercises aimed at increasing the mobility of the affected spinal cord are contraindicated;
• physical exercises should not cause discomfort or pain in the patient, since in this case decompensation may develop in the biokinematic chain "spine-limbs", which significantly slows down the formation of an adequate response from the ligamentous-muscular apparatus of the affected part of the spine;
• myofixation is a component of the developing motor stereotype;
• Therefore, it is necessary to use exercises in exercise therapy sessions that cover unaffected regions of the locomotor apparatus in order to strengthen muscle-tonic reactions in the affected spinal MDS.

To strengthen damaged ligament structures and increase the body's performance, an important condition is a rational alternation of muscle tension and relaxation. In this case, voluntary relaxation, as well as active muscle tension during isometric efforts, should be considered as a kind of training of the entire locomotor apparatus. Developing a stable and complete skill in patients to voluntarily relax muscles is a prerequisite for using exercises in an isometric mode. It is necessary to take into account that a consistent change in voluntary muscle tension and their relaxation allows you to get the best relaxation effect.

We have developed a method for treating injuries to the ligamentous-muscular apparatus of the spine ("segmental" gymnastics), aimed at strengthening the damaged segment. The method is protected by a patent (No. 2167639 dated 05/27/01) and is schematically presented in two phases:

A) In order to reduce the spasmodic state of the paravertebral muscles in the area of injury, muscle stretching techniques are indicated, which are used in the form of various movements with an amplitude that provides some excess of the mobility available in a particular joint. The intensity of their specific action is dosed by the amount of active tension of the muscles producing the stretching, the sensation of pain, the force of inertia that occurs during fast swinging movements with a certain amplitude, and the initial positions that allow the lever of the moved body segment to be lengthened. Several muscle stretching techniques were used in RG classes:

Passive muscle stretching. If after passive stretching the muscle seems rigid and movement remains limited, then instead of repeating the same procedure, rhythmic stabilization should be performed. The technique of this procedure consists of the patient alternately contracting the agonistic and antagonistic muscle groups. The doctor's hand provides a measured resistance, thus maintaining their isometric contraction. Alternating tension of one or another muscle group promotes gradual lengthening of the affected muscle. This mechanism is based on reciprocal inhibition.

B) To improve blood supply in the affected area (trauma, degenerative-dystrophic condition of the ligamentous apparatus) in order to stimulate regenerative-reparative processes, electrical stimulation of the paravertebral muscles and local gymnastics in combination with acupressure in the area of the affected spinal ligamentous apparatus are used.

During exercise therapy sessions, we paid attention to the presence of local algic trigger points (points) in patients not only in muscle but also in ligament structures. In order to inactivate trigger points (TP), ischemic puncture analgesia was used in the procedures, the essence of which was the compression effect of fingertips on areas of local muscle hypertonicity - myofascial pain trigger points. This effect is dosed in accordance with the individual characteristics of the patient and the degree of expression of MFPS.

It is known that algic trigger points can be localized in ligamentous structures. They can realize their contractile properties in complete isolation without the participation of muscles, forming local compaction zones. The rate of formation of local ligamentous hypertonus does not correspond to the rate of formation of local muscular hypertonus, but both of these processes are neurophysiological and clinical reality. The ligamentous component of this process is incomparably longer than the muscular one. This is supported by the results of our treatment. After, for example, PIR, local muscular hypertonus disappears, but often hyperechoic foci of various diameters are visualized in ligamentous structures during ultrasound examination, which corresponds to trigger points TT, which are localized in the examined ligaments of the affected spinal PDS (patent No. 2167604 dated 05/27/01). In this case, pain in ligamentous TT has several aspects:

• Irritation of nociceptors by biologically active substances in the trigger zone, i.e. by those agents that caused it. However, the action of these agents is limited in time: tissue buffer systems cause the neutralization of these substances, reducing their activity to a minimum.
• Participation of mechanisms of interaction of various afferent systems. The area of hypertonicity of the ligament becomes a place of persistent deformation of the proprioceptive system with a change in the qualitative characteristics of the afferent interaction in the spinal cord segment. As a result of this interaction, a determinant algic system is formed, the generator of which is the ligamentous trigger (LT). The experiment proved that the violation of trophism of the ligaments occurs 2-2.5 times more often and earlier than it occurs in muscles with a larger range of adaptive-compensatory capabilities. This is the fundamental difference between the formation of the LT and the MTP.

Thus, in order to increase the effectiveness of restorative treatment of patients with damage to the ligamentous apparatus of the spine, we have developed a program for the use of various physical exercise methods (physical exercises, PIR, PRMT and ischemic puncture analgesia) to influence the muscular-ligamentous apparatus of the affected part of the spine:

• relaxation of spasmodic muscles in the affected area (exercises and massage techniques aimed at muscle relaxation, PIR techniques);
• relaxation of spasmodic muscles with simultaneous activation of antagonist muscles using PRMT, PNR;
• inactivation of myofascial trigger pain points using ischemic puncture analgesia;
• strengthening the ligamentous apparatus of the affected part of the spine with the help of special physical exercises, electrical stimulation, acupressure techniques, and physiotherapy procedures;
• creation of a “muscle” corset using physical exercises in isometric muscle contraction mode, training on exercise equipment;
• stimulation of blood and lymph circulation in the area of the affected spinal cord with the aim of improving regenerative and reparative processes (physical exercises, massage techniques, PIR, ischemic puncture analgesia, electrical stimulation, physiotherapeutic procedures).

Psychological correction is one of the rehabilitation methods, including therapeutic self-hypnosis, self-knowledge, neurosomatic training, sedative and activating psychotraining, carried out in conditions of muscle relaxation and leading to self-education and mental self-regulation of the body. In addition, psychocorrection is considered one of the necessary and effective forms of exercise therapy, using general developmental, special, breathing and other physical exercises to regulate muscle tone, which, being a reflected reflex manifestation of higher nervous activity, actively influences the processes of mobilization and reduction of the level of excitation in the central nervous system, and, consequently, 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 striated and smooth muscles of the trunk and limbs or differentiated muscle relaxation or increased tone of individual muscle groups;
• acquisition of the skill of rhythmic breathing through mental regulation of the intervals of the inhalation and exhalation phases;
• mastering the skills of reduced, slow, shallow breathing, as well as physical differentiated sensation of parts of one’s body.

Timing of application of physical rehabilitation means at the stages of rehabilitation treatment

Degree of damage	Stationary stage	Outpatient stage
1st century	10-14 days	7 days
II century	4-5 weeks*	8-10 weeks
III century	5-6 weeks	16-20 weeks
IV century	Ligamentous apparatus plastic surgery

* Reparative and regenerative processes in the affected spinal cord are monitored by clinical and ultrasonographic studies.

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

Massage is much more effective than simple warming up of the muscle. To inactivate certain active TPs, the doctor must use very specific massage techniques. Massage without specifying its type can apparently be used only in cases where the TP is weakly active and causes minimal reflected pain. At the same time, it should be remembered that any vigorous massage of hyperirritable TPs can cause a negative reaction with the emergence of pain phenomena. We recommend using "longitudinal" massage. The massage therapist, immersing his hands in the muscle mass, slowly slides along it from the distal end towards the TP, making a kind of "milking motion". Repeated movements with increased finger pressure gradually reduce the density of the TP until it is completely eliminated and inactivated.

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