Physical rehabilitation of patients with ligamentous apparatus damage of the spine

Myostatic changes and movement coordination disorders in patients

Damage to the ligamentous apparatus of the spine leads to the formation of pain sources, or more precisely, nociception sources, in various structures of the musculoskeletal system. Their presence is accompanied by an obligatory reflex response in the form of muscle spasm aimed at protecting damaged structures, increasing sympathetic tone as a general reaction of the body to pain stress and the occurrence of fairly clearly localized pain sensations. The most common causes of acute pain are the development of myofascial dysfunction and functional joint blockades with protective muscle spasm, as well as microdamage to various musculoskeletal structures.

In patients with damage to the ligamentous apparatus of the spine, changes in the functioning of the locomotor system occur in the late period of injury. The main goal of these changes is to adapt the biokinematic chain "spine - lower limbs" to functioning in new conditions - conditions of the appearance of a lesion in the spinal-motor system. During this period, latent trigger points (points), foci of myelogelosis, enthesopathy of various muscles, functional blocks, hypermobility (instability) of the joints of the spine can gradually form in the musculoskeletal tissues, which as a result of various reasons, for example, with physical overload, sudden movements can become a source of nociception. Muscle protection is accompanied by limitation of movements in the affected part of the spine.

The immobility of the changed and the redistribution of loads on the preserved PDS do not occur immediately, but gradually. At first, changes in myostatics are observed, and then myodynamics, i.e. the motor stereotype changes. In individuals with an acute onset of the compression factor, a segmental muscular-tonic reaction occurs at first, which enhances its effect. In response to this, a pronounced myofascial symptom complex develops in the body, which serves as the basis for the formation of a new motor stereotype.

A new motor stereotype in individuals with the action of a compression factor is formed in the following way. At first, fairly long new links of the biokinematic chain "spine-limbs" appear (in this case, the spine functions as a single link). Then, a "division" of the spine into separate biokinematic links is observed, consisting of several PDS, but in such a way that the affected PDS is located inside the formed link. Subsequently, the development of complete pronounced local myofixation of the affected PDS and restoration of movements in all unaffected ones are revealed, but with new parameters that allow the spine to function adequately in new conditions.

In the remission stage, organic consolidation of a new motor stereotype is determined. It is expressed in the development of reparative phenomena in the intervertebral disc and ligamentous apparatus of the spine.

Indications	Basic conditions of compensatory reactions
Lesion in the disc	Preservation of impulses from the lesion site
Generalized stage of changes in motor stereotype	Normal functioning of the brain and cerebellar system, absence of pathology of muscle and joint formations
Polyregional stage of changes in motor stereotype	No complications of widespread myofixation and spinal muscles
Regional stage of changes in motor stereotype	No complications of limited myofixation
Intraregional stage of changes in motor stereotype	Absence of complications of local myofixation
Local stage of changes in motor stereotype

Organic fixation healing reactions

The completeness of the defect replacement, as well as the recovery time, depend on the type of damaged tissue (cartilage, ligaments, bone tissue) and its regenerative capabilities.

• The smaller the volume of the defect, the greater the opportunity for the development of complete regeneration, and vice versa.
• The older the patient, the less his regenerative capacity.
• When the nature of nutrition is disrupted and the general reactivity of the body changes, regeneration processes also slow down.
• In a functioning organ (in particular, in the affected PDS), metabolic reactions proceed more actively, which helps to accelerate the regeneration process.

Restorative regenerative processes in cartilaginous and fibrous tissues most often occur under the action of a disinhibition (disfixation) factor. For these types, the onset of complete regeneration is characteristic, as a rule. Therefore, quite often (according to our observations, in 41.5% of cases) in patients with osteochondrosis of the spine, in whom exacerbations of the disease were caused by disfixation disorders in the area of the affected spinal PDS, a year or more after the attack of maladaptation, no changes in the interested PDS are detected on X-rays of the spine and even on functional spondylograms.

In patients with cases of compression factor, recovery processes also develop in the affected tissues. However, incomplete regeneration occurs quite often (37.1%), i.e., scar tissue forms in the area of the affected PDS; such changes are quite widely covered in the literature devoted to surgical methods of treating the spine.

In cases where muscle fixation ends with organic and complete tissue regeneration, i.e. restoration of all structural parts of the affected spinal cord, then it is possible to restore the functioning of the spine in full.

Organic fixation develops and reaches its completion usually within six months from the beginning of remission. For its completion, the following conditions must be present:

• stabilization of the affected spinal cord.
• phenomena of normalization in trophic systems;
• activation of metabolic processes in the affected spinal cord.

If the patient does not create stabilization in the affected PDS, then the displacements that periodically occur in it will destroy the immature restorative structures and prolong the healing time.

Without normalization phenomena in trophic systems, the development of regenerative processes in the affected PDS is significantly hampered. Therefore, both the systems that control trophism and the systems that provide and implement it must function normally. Usually, damage in the area of the affected PDS through the flow of impulses contributes to the violation of its integrity. This, in turn, cannot be reflected in the state of the higher regulatory centers that affect the trophic control system.

In the intensification of metabolic processes, i.e. metabolism in the affected PDS, great importance belongs to physical and everyday loads. However, excessive loads on the affected PDS can aggravate the patient's condition, especially in individuals with indications of compression of the receptors of the sinuvertebral nerve. Only in individuals with the action of dyshemic and inflammatory factors, intense loads on the affected PDS help to reduce the action of these factors, and also stimulate the intensity of metabolism, therefore, many specialists use passive fixation devices in order to enhance the coordination of physical loads on the affected part of the spine in patients with compression phenomena: orthopedic collars, corsets/orthoses, crutches and other fixing devices. This approach allows for loads on the affected PDS without causing an increase in the effect of the compressing factor in it. The use of these recommendations helps to ensure that the formation of a new optimal motor stereotype is not stimulated in patients. If the patient has not formed an optimal motor stereotype, i.e. it cannot adapt to the lesion in the spinal PDS, then it experiences overloads in the upper and lower PDS. This, in turn, causes the subsequent development of dystrophic processes in them. A kind of "scissors" arises: on the one hand, it is necessary to increase the load on the affected PDS, and on the other hand, this is impossible without its appropriate fixation. Fixation by passive means, despite the fact that it makes it possible to load the affected segment, prevents the development of an optimal motor stereotype, which subsequently leads to the development of damage in adjacent PDS of the spine.

Thus, it is advisable to use not direct physical influences, but indirect ones in the form of massage techniques, physical exercises for small joints and muscle groups, and physical methods of treatment to intensify metabolic processes in a dystrophically altered PDS with the influence of a compressing factor.

It is known that the ligamentous apparatus performs a biomechanical function. V.V. Serov et al. (1981) put forward the concept of "biomechanical control of morphogenesis". According to this concept, there should be a correspondence between the biomechanical function and the organization of the tissue structure. Usual reparative reactions in ligaments/tendons with dystrophic (traumatically) changes are carried out along the lines of force loads. If there are no physical effects on the ligamentous apparatus during the reparative reactions, the foci of reparation will be located across the ligament/tendon, which will undoubtedly complicate the implementation of its function in the future. If, however, dosed loads adequate to the patient are carried out during the development of reparations, they occur along the ligament/tendon, which leads to its strengthening. This, naturally, subsequently allows us to prevent the development of maladaptation under the influence of various physical and everyday loads on the affected ligaments/tendons.

Ligament/tendon tissue has a high reparative capacity. In neurotendinous dystrophy, excessive development of connective tissue is observed. It is known that in the regulation of reparations in connective tissue, a significant role belongs not only to external but also to internal factors. According to V.V. Serov et al. (1981), there is a mechanism of self-regulation of connective tissue growth. In patients with neurotendinous dystrophy, complete remission can also occur immediately, when there are no clinical manifestations from the affected area of the PDS. This can occur with complete reparation or with incomplete reparation, if receptor endings did not reach the lesion. Otherwise, before the death of the receptor endings, the patient will have various clinical manifestations of foci of neurotendinous fibrosis.

At present, specialists treating patients with damage to the ligamentous apparatus of the spine, osteochondrosis, face the problem of stimulating complete reparative reactions in the patient. The development of such reactions contributes to the practical recovery of patients.