Physical therapy for cervical osteochondrosis

When developing a private method of therapeutic gymnastics (TG) for various syndromes of cervical osteochondrosis, the following considerations should be taken into account. Treatment of cervical osteochondrosis should primarily be pathogenetic, i.e. aimed at eliminating the underlying cause of the disease, rather than symptomatic. Therefore, regardless of the clinical manifestations of the disease, general principles should be followed when performing TG.

1. In conditions of instability of the spinal PDS, it is advisable for patients to wear a cotton-gauze collar of the Shantz type during the entire course of treatment. This creates relative rest for the cervical spine and prevents subluxation and microtraumatization of the nerve roots, and reduces pathological impulses from the cervical spine to the shoulder girdle.
2. With hyperflexion of the neck, the tension of the spinal roots can increase and traumatization of the nerve formations is especially evident with deformation of the anterolateral sections of the cervical canal due to the presence of osteophytes and subluxation. Ischemia in the anterior spinal artery system can be a consequence of the direct compressive effect of the posterior osteophyte at the time of active extension movements. As a result of periodic or constant traumatization of the anterior spinal artery, a reflex spasm of the medullary vessels occurs, which ultimately leads to a deficit in spinal blood circulation of a functional-dynamic nature. According to a number of authors, in myelography in some cases, partial or complete delay of the contrast is noted in the position of neck hyperextension and disappears with flexion. All this confirms the opinion about traumatization of the spinal cord and its vessels by posterior osteophytes during active movements in the cervical region and the possibility of acute development of pathology, up to the phenomena of transverse myelitis, especially with hyperextension movements.

Functional REG tests with active head movements (turns, tilts) performed in 514 patients indicate that these movements have an adverse effect on blood flow in the vertebral arteries. It is known that in cerebral vegetative-vascular disorders of cervical genesis, hearing loss occurs quite often, mainly on the side of the headache and has the character of damage to the sound-perceiving apparatus. It is a consequence of hemodynamic disturbances in the vertebral artery, which can lead to ischemia both in the cochlea and in the region of the VIII nerve nuclei in the brainstem. This is why active head movements in vertebral artery syndrome can lead to an increase in hearing loss.

Based on the above, active movements in the cervical spine should be completely excluded during the initial and main periods of the treatment course.

3. Only during the period of recovery of impaired functions should exercises aimed at strengthening the neck muscles be introduced. For this purpose, exercises with dosed resistance are used. For example, the patient tries to tilt his head forward or to the side, and the doctor's (methodologist's) hand, providing a certain resistance, prevents this movement (the exercise is performed in the initial position - sitting on a chair or lying down). In this case, the efforts that the doctor makes, naturally, should be dosed, adequate to the patient's condition, the training of his muscles.

The classes are supplemented with exercises in static head holding and isometric muscle tension.

4. All physical exercises, especially static ones, should alternate with breathing exercises and exercises aimed at muscle relaxation. Particularly persistent efforts should be made to relax the trapezius and deltoid muscles, since in this disease they are more often than others involved in the pathological process and are in a state of pathological hypertonicity (Z.V. Kasvande).

The choice of tasks, means and methods of exercise therapy depends on the clinical course of the underlying disease. It is necessary to distinguish the following periods:

• spicy;
• subacute;
• restoration of impaired functions.

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Physical therapy in the acute period

General objectives of therapeutic gymnastics:

• reduction of pathological proprioceptive impulses from the cervical spine to the shoulder girdle and upper limbs, from the latter to the cervical spine;
• improvement of blood circulation conditions, reduction of irritation phenomena in the affected tissues located in the intervertebral foramen;
• increasing the patient's psycho-emotional tone.

Special tasks of therapeutic gymnastics:

• in case of scapulohumeral periarthritis - reduction of pain in the shoulder joint and upper limb, prevention of joint rigidity;
• in case of vertebral artery syndrome - relaxation of the muscles of the neck, shoulder girdle and upper limbs, improvement of coordination of movements and muscular-articular sense. Therapeutic gymnastics is prescribed on the 1-2nd day of the patient's admission to the hospital or for outpatient treatment.

Absolute contraindications to the prescription of therapeutic exercises:

• general severe condition of the patient caused by high temperature (>37.5°C);
• increase in symptoms (clinical and functional) of cerebrovascular accident;
• persistent pain syndrome;
• compression syndrome requiring surgical intervention.

The exercises include static breathing exercises (chest and diaphragmatic breathing) and exercises to relax the muscles of the neck, shoulder girdle and upper limbs, performed in the initial position - lying and sitting. Patients are recommended to perform these exercises in a cotton-gauze collar of the Shantz type, and in case of scapulohumeral periarthritis syndrome, the affected arm should be placed on a wide sling.

Physical therapy in the subacute period

General objectives of therapeutic gymnastics:

• improving visceral regulation;
• adaptation of all body systems to increasing physical activity.

Special tasks of therapeutic gymnastics:

• increasing the range of motion in the joints of the affected limb;
• increasing the resistance of the vestibular apparatus to physical stress.

To solve these problems, a variety of forms and means of therapeutic exercise are used, which is a pathogenetic factor in therapy for spinal osteochondrosis.

• Rationalization of the patient’s motor regimen throughout the day, which is a necessary element of treatment.

The motor regime is based on two principles:

1. ensuring maximum mobility to stimulate the patient's overall motor activity;
2. maximum use of those forms of movement that prevent the development of pathological stereotypes.

A system of analytical gymnastics applied to patients with spinal diseases. This is joint gymnastics, the purpose of which is to develop movements (passive, active-passive) in individual segments of the limbs and spine, to cultivate active relaxation and reciprocal contractions of antagonist muscles.

All systems of analytical gymnastics include four main components:

• techniques aimed at relaxing individual muscle groups;
• techniques to improve joint mobility;
• development of active tension in certain muscles;
• formation of correct coordinating relationships between antagonist muscles and integral motor acts.

Physical exercises of an isotonic and isometric nature, aimed at increasing the patient’s overall activity, strengthening muscles, and restoring the dynamic stereotype.

The exercises use muscle relaxation exercises performed by the patient in the initial position lying and sitting. In particular, the initial position lying on the back, on the side is used to relax the neck muscles, while it is advisable to place a C-shaped cotton-gauze pad under the neck. The patient can be asked to take a position in the initial position sitting on a chair that provides partial unloading of the cervical spine, shoulder girdle and upper limbs, due to the support of the head and back.

To relax the muscles of the shoulder girdle, a number of methodical techniques are offered:

• i.p. lying on your back or on your side;
• breathing exercises with the weight of the arms removed (they are placed on a support);
• light shaking of the shoulder girdle with the hand of the practitioner in the area of the upper third of the patient's shoulder in the initial position lying on the side, sitting or standing.

To relax the muscles of the upper limbs, it is advisable to lightly shake the hand, forearm, swing movements with incomplete amplitude and with a slight tilt of the body towards the affected limb.

Muscle relaxation exercises should be alternated with breathing exercises (static and dynamic), and isotonic gymnastic exercises for the distal parts of the limbs.

Sample exercises for the distal extremities:

1. Place your elbows on the table. Tilt your hands in all directions. Repeat 10 times.
2. Place your hands palms together and stretch them out in front of you. Spread your hands to the sides without unlocking your wrists. Repeat 10-15 times.
3. Stretch your arms forward and clench your fingers into a fist, then quickly unclench them, trying to move your fingers as far back as possible. (You can squeeze a small rubber ball or a wrist expander.) Repeat 12-15 times.
4. Place your palms together. Spread and bring your fingers together. Repeat 5-10 times.
5. Close four fingers. Move your thumb towards you and away from you. Repeat 8-10 times with each hand.
6. Interlock your fingers. Rotate your thumbs around each other. Repeat 15-20 times.
7. Spread your fingers apart. Squeeze four fingers tightly and press them on the base of the thumb, the middle of the palm, and the bases of the fingers. Repeat 5-10 times.
8. Wiggle your spread fingers in all directions. Knead your right hand with the fingers of your left hand, and vice versa. Freely shake your hands, raising your arms up.

Sample exercises for the shoulder joint:

1. I.P. - lying on your back, arms along the body, palms down. Turn your palms up and down again (rotate your arms around the axis); with each rotation, either the palm or the back of the hand touches the bed. Breathing is voluntary.
2. Move your arms to the sides, place the sore arm on a smooth surface, palm down - inhale; return to the starting position - exhale.
3. Raise your right hand up, your left hand along your body, change the position of your hands. Breathing is voluntary.
4. Raise the sore arm up, bend it at the elbow and, if possible, place it behind your head - inhale, return to the starting position - exhale. You can place both hands behind your head, helping the sore one with the healthy one. Starting position - lying on the healthy side, arms along the body.
5. Bend the sore arm at the elbow, supporting it with the healthy arm, move the shoulder away - inhale, return to the starting position - exhale. Starting position - lying on your back, arms along the body.
6. Grasp the back of the bed with your hands and gradually move your arms to the sides and down until the hand of the sore arm touches the floor. Breathing is voluntary.

Therapeutic exercises for scapulohumeral periarthritis

In the first days of the period, it is advisable to carry out therapeutic exercises in the initial position lying down (on the back, on the side). Movements in the affected joint are performed with a shortened lever, with the help of a methodologist, with the help of a healthy hand.

Typical exercises for the shoulder joint

As the pain in the shoulder joint subsides, exercises with external and, somewhat later, internal rotation of the shoulder are added. Restoration of the abduction function also begins with careful swinging movements in the horizontal plane with the arm bent at the elbow and a slight tilt of the body towards the affected arm (s.p. sitting). After achieving painless flexion of the shoulder by 90-100° and its abduction by 30-40°, exercises should be performed in the starting position standing. The following exercises are added:

• "Putting your hand behind your back" (training internal rotation of the shoulder). The patient should touch the back as high as possible (stretching the infraspinatus muscle);
• "reaching the mouth with the hand behind the head" (training the shoulder abduction and outward rotation). Holding the hand in this position is accompanied by a significant contraction of the muscles that abduct the shoulder and the muscles that rotate the shoulder. If the infraspinatus muscle is affected, the patient's fingers only reach the ear (normally the fingertips reach the midline of the mouth);
• "stretching the anterior portion of the deltoid muscle". I.P. - sitting, the affected arm is straightened. The patient abducts this arm by 90°, then rotates it outward and abducts it back.

During these periods, exercises using reciprocal relationships are also recommended.

These exercises are performed simultaneously by both limbs. In this case, the following is possible:

• the same exercises for both arms;
• simultaneous execution of antagonistic movements (for example, one arm performs flexion - adduction - external rotation; the other - extension - abduction - internal rotation);
• simultaneous performance of multidirectional movements (for example, one arm performs flexion - adduction - external rotation; the other - flexion - abduction - external rotation or extension - adduction - internal rotation).

Exercises with gymnastic equipment (gymnastic sticks, light dumbbells, clubs and balls) are gradually included in the classes, along the gymnastic wall, on a special table, etc.

Exercises with a gymnastic stick.

1. I.p. - feet wider than shoulder-width apart, hands in front of chest: 1 - turn to the left, inhale; 2 - bend toward the left leg, touching it with the middle of the stick, exhale; 3-4 - straighten up, return to I.p., inhale. The same, to the right side. Repeat 4-5 times in each direction.
2. I.p. - feet shoulder-width apart, stick vertically behind the spine, left hand holds its upper end, right - the lower: 1-2 - move the right hand to the side; 3-4 - return to I.p. The pace of movements is slow, breathing is arbitrary. Repeat 4 times in each direction. The same, changing hands: left - below, right - above.
3. I.P. - feet shoulder-width apart, arms down and holding the stick with an overhand grip by the ends: 1-2 - stick forward - up; 3-4 - back - down (towards the buttocks), as if twisting the wrists, smoothly, without jerking; 1-4 - return to I.P. Breathing is arbitrary. Repeat 6 times.
4. I.P. - feet wider than shoulder-width apart, stick on elbow bends behind back (at the level of lower angle of shoulder blades), head raised: 1 - straighten shoulders, inhale; 2 - turn torso to the left, exhale; 3-4 - same in other direction. Repeat 6 times.

During this period, exercises in a therapeutic pool are recommended.

The peculiarities of the mechanical effects of the water environment are explained by the laws of Archimedes and Pascal. Due to the reduction in the weight of the affected limb, it is easier to perform movements. In addition, the temperature factor (heat) contributes to a lesser manifestation of reflex excitability and cramps, a decrease in pain and muscle tension. At the same time, blood circulation and lymph circulation improve, the resistance of the entire periarticular apparatus of the joints decreases, which contributes to better implementation of the motor function. An increase in motor function in a therapeutic pool has a stimulating effect on the patient, which helps him to engage in the process of subsequent exercise and development of movements with greater energy.

It should be borne in mind that dynamic exercises for the shoulder joints, firstly, help improve the blood supply to the nerve roots of the cervical spinal cord due to the fact that large muscle groups are involved in the work, which is extremely necessary for all patients, regardless of the clinical syndrome of the disease. Secondly, they improve the blood supply to the muscles of the joints, ligaments, periosteum of the tubular bones of the upper limbs, thereby helping to reduce the clinical manifestations of the disease in patients with scapulohumeral periarthritis, epicondylitis and radicular syndromes (M.V. Devyatova).

Exercises for the shoulder girdle and upper limbs alternate with exercises for the torso and lower limbs. In this case, small, medium, and then large joints and muscle groups are sequentially involved in the movements.

Therapeutic exercises for patients with vertebral artery syndrome

The role of unconditioned tonic reflexes in the formation of voluntary movements

Innate motor reflexes ensure the maintenance of normal posture, balance, and coordinate the posture with the position of the head in relation to the body. According to the existing classification, innate motor reflexes are divided into:

• reflexes that determine the position of the body at rest (position reflexes);
• reflexes that ensure a return to the initial position (righting reflexes).

Position reflexes. Occur when the head is tilted or turned due to irritation of the nerve endings of the neck muscles (cervical-tonic reflexes) and the labyrinths of the inner ear (labyrinth reflexes). Raising or lowering the head causes a reflex change in the tone of the muscles of the trunk and limbs, ensuring the maintenance of a normal posture.

Turning the head to the side is accompanied by irritation of the proprioceptors of the muscles and tendons of the neck and the placement of the body in a symmetrical position in relation to the head. At the same time, the tone of the extensors of the limbs towards which it is performed increases, and the tone of the flexors of the opposite side increases.

The vestibular apparatus plays an important role in changing the position of the head in space and in analyzing these changes. Excitation of the receptor formations of the vestibular apparatus when turning the head leads to a reflex increase in the tone of the neck muscles on the side of the turn. This contributes to the appropriate positioning of the body in relation to the head. Such a redistribution of tone is necessary for the effective performance of many physical and everyday exercises and movements associated with rotation.

Righting reflexes. Ensure the maintenance of posture when it deviates from the normal position (for example, straightening the torso).

The chain of righting reflexes begins with raising the head and subsequent change in the position of the body, ending with the restoration of the normal posture. The vestibular and visual apparatus, muscle proprioceptors, and skin receptors participate in the implementation of righting mechanisms (reflexes).

The movement of the body in space is accompanied by statokinetic reflexes. During rotational movements, vestibular receptors are excited due to the movement of endolymph in the semicircular canals. Centripetal impulses, entering the vestibular nuclei of the medulla oblongata, cause reflex changes in the position of the head and eyes during rotational movements.

Rotational reflexes are characterized by a slow deviation of the head to the side opposite to the movement, followed by a rapid return to the normal position relative to the body (cephalic nystagmus). The eyes perform similar movements: a quick turn in the direction of rotation and a slow turn in the direction opposite to rotation.

Performing physical exercises is associated with constant correction of innate motor reflexes. Central regulatory influences provide the necessary muscle tone in accordance with the nature of voluntary movements.

Before conducting exercise therapy sessions with this group of patients, it is necessary to determine the nature of vestibular disorders, sense of balance, as well as the degree of their severity.

Tests are recommended for this purpose.

The variety of reactions that occur when the vestibular apparatus is irritated is due to its anatomical and functional connection with the autonomic nuclei, and through them, with the internal organs.

Thus, when the vestibular apparatus is irritated, the following may occur:

• vestibulo-somatic reactions (changes in skeletal muscle tone, “protective” movements, etc.);
• vestibular-vegetative reactions (changes in pulse, blood pressure and respiration, nausea, etc.);
• vestibulosensory reactions (sensation of rotation or counter-rotation).

Our experience shows that physical rehabilitation methods (and in particular physical exercises) can influence the vestibular analyzer, implementing “vestibular training”.

The use of special vestibular training in the complex treatment of patients with osteochondrosis of the cervical spine helps restore stability, spatial orientation, reduce vestibular-vegetative reactions, improve the general condition of patients, adapt to physical activity and various changes in body position.

In parallel with the relaxation of the muscles of the neck, shoulder girdle and upper limbs, as well as the performance of exercises aimed at increasing the range of motion in the shoulder joint, it is necessary to promote the stimulation of blood circulation in the nerve roots to reduce the phenomena of irritation in them. The solution of this problem is facilitated primarily by exercises to restore statokinetic and vestibular-vegetative stability. Exercises of a special nature widely used in practice can be combined into several groups.

1. Special exercises with a predominant effect on the semicircular canals: exercises with angular accelerations and decelerations (movements of the body, head in three planes, according to the direction of the semicircular canals - frontal, sagittal and horizontal).

• Standing on your toes (feet together), perform 5 forward bends of the torso to a horizontal position (pendulum-like movements); one bend per second.
• Feet in one line (right in front of left), hands on waist, perform 6 torso tilts to the left and right (pendulum-like movements); one tilt per second.
• Standing on your toes (feet together), tilt your head back as far as possible; hold this position for 15 sec. The same, but with your eyes closed; 6 sec.
• Heels and toes together, hands on waist, eyes closed; stand for 20 sec.
• Feet in line (right in front of left), hands on waist; stand for 20 sec. Same, but with eyes closed; stand for 15 sec.
• Feet together, hands on waist, rise on toes; stand for 15 sec. Same, but with eyes closed; stand for 10 sec.
• Hands on the waist, bend the left leg, lifting it off the floor, rise on the toe of the right leg; stand for 15 sec. The same with the other leg. The same, but with your eyes closed; stand for 10 sec.
• Standing on your toes, perform 6 springy movements with your head to the left and right; one movement per second.
• Standing on the toe of your right foot, hands on your waist, perform 6 swinging movements with your left leg forward and backward (with full range of motion). Do the same with the other leg.
• Standing on your toes, perform 10 quick forward and backward head tilts.
• Rise up on the toe of your right leg, bend your left leg, lifting it off the floor, tilt your head back as far as possible, close your eyes; stand for 7 seconds. Do the same with the other leg.

In the first days, exercises with turns and bends of the body are performed in a small volume, at a calm pace, in the initial position sitting and standing. The patient performs exercises for each channel, i.e. in the specified planes - frontal, sagittal and horizontal, necessarily starting from the plane in which they are performed more freely and easily.

ATTENTION! Tilting and turning the head is contraindicated for 1.5-2 weeks.

Special exercises for the semicircular canals must be alternated with breathing and general strengthening exercises in order to avoid over-irritation of the vestibular apparatus.

If the patient performs head movements in all planes with a stop in the "straight" position quite freely, then these movements are included in the therapeutic exercises. At first, it is recommended to perform head movements in the initial position lying on the back, stomach, on the side.

2. Special exercises with an impact on the otolith apparatus. These exercises include elements of linear movement with decelerations and accelerations (walking, squats, running at different speeds, etc.).

ATTENTION! It should be remembered that irritation of the otolith apparatus increases vegetative disorders, therefore, when using these exercises, it is necessary to carefully monitor the patient's reactions.

3. To train the ability to orientate in space, balance exercises are used, i.e., restoring one of the main functions of the vestibular analyzer.

In the first half of the course of treatment, exercises for the upper limbs and torso are recommended in a standing position on the floor, initially with legs wide apart (wider than shoulder-width apart), and then gradually bringing the feet closer together and decreasing the area of support (feet shoulder-width apart, feet together, one leg in front of the other, standing on toes, on heels, on one leg).

In the second half of the treatment course, exercises are performed on a narrow support area at a height, on a gymnastic bench (first on a wide base, and then on a gymnastic bench rail, exercise machines and other gymnastic equipment).

4. To improve coordination of movements, exercises in throwing and catching various objects (balls, medicine balls) in combination with arm movements, walking, etc., performed in the initial position - sitting, standing and walking, are recommended.
5. Orientation in space is carried out with the participation of vision. Therefore, its switching off in all the above exercises increases the demands on the vestibular apparatus.
6. According to the method of B. Bobath and K. Bobath, balance training is carried out based on the use of the cervical tonic asymmetric reflex.

Neck-tonic reflex: when moving the head, most patients experience an increase in the tone of the extensor or flexor muscle group. This reflex is often accompanied by the emergence of a labyrinthine-tonic reflex (increased tone of the extensor muscles in the SP when lying on the stomach). Therefore, it is not always possible to distinguish due to what influences the tension of a particular muscle group occurs when moving the head.

Correction of pathological postural reflexes is achieved by the fact that when performing certain movements, the limb is given a position opposite to the pose that arises under the influence of the cervical and labyrinthine-tonic reflexes.

The proposed typical physical exercises are aimed at inhibiting pathological postural tonic reflexes.

1. The exercise is recommended to relieve spasm of the extensor muscles of the trunk, which occurs in connection with the labyrinthine reflex in the SP lying on the back.

I.p. - lying on the back, arms crossed on the chest (palms are located in the area of the shoulder joints), legs bent at the hip and knee joints. With the help of the methodologist, the patient slowly moves to the I.p. sitting.

2. The exercise is recommended for correcting the pathological position of the legs.

I.p. - lying on your back, straight legs spread apart. The therapist holds the patient's legs while doing the exercise - transition to I.p. sitting. Later, the patient himself tries to hold them while doing the exercise.

3. Exercises recommended for hand correction.

I.p. - lying on the stomach, arms extended along the body. The methodologist helps the patient to move straight arms back outward, then the patient lifts the head and shoulder girdle.

ATTENTION! This technique, aimed at extending the muscles of the shoulder girdle and back, prevents the increase in tone of the flexor muscles.

For dosing the load on the vestibular apparatus, the following are of particular importance:

• the initial position from which a particular movement is made;
• the volume of these movements in one or several planes simultaneously;
• vision loss.

Methodological instructions

1. Initial positions at the beginning of the course of treatment are only lying and sitting, since in most cases patients have impaired spatial orientation and balance function.
2. The initial standing position and then walking exercises can be moved on to when the patient's condition improves.
3. The volume of special exercises at the beginning of the course of treatment should be limited. The amplitude of movement gradually increases during the training process, reaching the maximum volume in the 2nd half of the course of treatment.
4. A significant increase in the load in special training is achieved by exercises performed simultaneously in different planes with their full volume, i.e. exercises with rotational movements (head and torso).
5. It is recommended to use exercises with switched off vision in the 2nd half of the course of treatment, thereby increasing the demands on the vestibular analyzer against the background of the already obtained positive results of vestibular apparatus training.
6. At the beginning of the treatment course, balance exercises are not recommended after exercises with head or trunk rotation, as this may worsen balance function.

In the 2nd half of the treatment course, the results of the training can be assessed by performing balance exercises after rotational movements.

1. During the first days, only individual therapeutic exercise sessions are conducted, since during these periods the opportunities for performing exercises are limited (patients are not confident in their movements, often lose their balance, vestibular disorders are accompanied by unpleasant sensations).
2. When conducting vestibular training, it is necessary to insure the patient, since the physical exercises used change the reactivity of the vestibular apparatus; imbalance with pronounced vestibular-vegetative reactions may occur at any moment.

9. If patients experience slight dizziness during therapeutic exercise, the exercise should not be interrupted. They should be given a 2-3 minute rest in a sitting position or asked to do a breathing exercise.

Exercise therapy during the period of restoration of impaired functions

Objectives of exercise therapy:

• improving tissue trophism in the neck, shoulder girdle and upper limbs;
• strengthening the muscles of the neck, trunk, and limbs;
• restoration of the patient's ability to work.

The peculiarity of this period of treatment is as follows.

1. During exercise therapy sessions, the cotton-gauze collar of the Shants type is removed.
2. To strengthen the muscles of the neck, shoulder girdle and upper limbs, static exercises are introduced. Initial exposure is 2-3 sec. Static exercises can be grouped as follows:
   • isometric tension of the neck muscles with pressure from the back of the head (s.p. - lying on the back), the frontal part of the head (s.p. - lying on the stomach) on the plane of the couch;
   • static holding of the head, head and shoulder girdle in the initial position - lying on the back, on the stomach;
   • isometric tension of the muscles of the neck and shoulder girdle with measured resistance from the hand of a doctor or a methodologist (s.p. - lying and sitting);
   • static hold of the upper limb (with or without gymnastic apparatus.
3. Isometric muscle tension is combined with exercises aimed at relaxing the muscles of the neck, shoulder girdle and upper limbs; muscle relaxation is achieved through:
   • special breathing exercises, provided that the weight of the arms is removed (put them on a support);
   • light shaking of the arms with a slight tilt of the body (starting position - sitting and standing);
   • free fall of outstretched arms (starting position - sitting and standing);
   • free fall of the raised shoulder girdle while fixing the arms (put them on a support).
4. The ability to use exercises for the shoulder and elbow joints in full allows you to complicate exercises for coordination of movements.

The therapeutic exercise procedure is supplemented by exercises with shock absorbers.

• I.p. - lying on your stomach, straight legs together, arms along the body. Stretch your arms forward, bend, raise your straight arms up - inhale, return to I.p. - exhale.
• Perform movements with your arms as if swimming breaststroke: arms forward - inhale; arms to the sides, back - exhale (keep your arms suspended).
• Move to a position standing on all fours. Breathing is voluntary. Raise your right arm as high as possible and simultaneously stretch your left leg - inhale; return to a position standing on all fours - exhale. Do the same with the other arm and leg.
• Rise up on your toes, slowly raise your hands up, clasped together, stretch, bending back and trying to look at your hands, and slowly return to the starting position. Repeat 5-6 times.
• Bend your elbows and join your palms in front of your chest so that your fingertips are up. Press your palms together with force. Repeat 10 times. Without unclenching your palms, turn your hands with your fingers first toward you, then away from you. Repeat 10 times.
• Stand half a step away from the wall and lean your palms against it. Spread your elbows out to the sides, slowly bend your arms, then straighten them, pushing yourself away from the wall. As you approach the wall, turn your head to the right and then to the left. Repeat 8-10 times.
• Bend your arms at the elbows in front of your chest, and firmly grasp your wrists with your fingers. Make sharp pushes with your arms towards each other, straining your chest muscles. Repeat 10 times.
• Squat down, resting your palms on the seats of two chairs. Then slowly push up on your hands, lifting your feet off the floor. Repeat 10 times with rest breaks.
• Place your fingers on your shoulders, move your elbows back and forth, bringing your shoulder blades together. Make circular movements with your shoulders forward and then back, trying to make the circle bigger. Repeat 4-6 times in each direction.

5. The possibility of using exercises that increase the stability of the vestibular apparatus is expanding. More complex turns and rotations of the body while walking and sitting on a rotating chair are added to the previously proposed exercises, the exercises are made more complex by reducing the support area, as well as by using gymnastic equipment, introducing elements of height and, finally, by including vision during physical exercises.

Sample exercises on a gymnastic disc:

• I.p. - standing on the disk with both feet. Turning the body to the right and left with the use of the arms.
• The same, holding onto the bar with your hands, which makes it possible to increase the amplitude and speed of movements.
• I.p. - standing with one foot on the disk, hands on the waist. Rotate the leg around the vertical axis.
• I.p. - standing, lean your hands on the disk standing on the floor. Rotate the disk with your hands, turning your body as much as possible to the right and left.
• I.p. - kneeling on the disk, hands on the floor. Turn the torso to the right and left.
• I.P. - sitting on a disk installed on a chair, hands on the waist. Rotate the disk to the right and left, turning the body and helping yourself with your legs (do not lift your legs off the floor).
• I.p. - sitting on a disk standing on the floor, rest your hands on the floor. Without moving your hands, rotate the disk to the right and left.
• I.P. - standing on the disk with both feet, lean forward and grab the support with your hands. Rotate the disk with your feet to the right and left.
• I.P. - standing with your feet on two disks. Rotate both disks with your feet simultaneously in one direction, then in different directions.
• I.p. - standing on the disks, hold hands. Turn the body to the right and left.

6. "Proprioceptive facilitation" (Y.Kabat method).

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Exercises for the upper limbs

1st diagonal.

A. Movement from bottom to top.

The patient's initial position is lying on his back, arm extended along the body, palm towards the plane of the couch, fingers spread apart, head turned towards the arm.

The doctor is on the side of the working upper limb, his hand (left - for the left upper limb, right - for the right upper limb) clasps the patient's hand.

The third, fourth and fifth fingers of the patient's hand are grasped between the thumb and index finger of the doctor's hand, the middle and ring fingers of the doctor are placed between the index and thumb of the patient, while the little finger grasps the first metacarpal bone. The doctor's other hand grasps the patient's shoulder in the area of the upper third of the shoulder.

Movement. The patient's shoulder describes a diagonal movement, as if throwing something over the opposite shoulder. In this case, the shoulder is brought forward, rotated outward and abducted: the arm at the elbow joint is slightly bent. The patient's head turns in the opposite direction. During the movement, the doctor resists all its components, gradually increasing the resistance.

B. Movement from top to bottom.

From the final position of the 1st diagonal, the upper limb is brought to the starting position, performing the same movements in reverse order: inward rotation, extension and abduction of the shoulder, pronation of the forearm, extension of the arm, extension and abduction of the fingers.

The doctor applies measured resistance at the level of the palm of the hand, and with the other hand - on the posterior outer surface of the patient's shoulder.

For the muscles surrounding the elbow joint

Before completing the movement from bottom to top, the doctor resists the bending of the arm at the elbow joint. The movement is performed according to the same scheme so that when completing the movement, the hand with bent fingers is at ear level (opposite side).

When moving from bottom to top, resistance is provided to the extension of the arm at the elbow joint.

2nd diagonal.

A. Movement from top to bottom.

The patient's initial position is lying on his back, the arm is extended upward (up to 30°), the forearm is in the maximum possible pronation, the fingers are extended.

The doctor is on the side of the working upper limb. The patient's hand is grasped in the same way as in the first diagonal. With the other hand, the doctor provides resistance on the shoulder.

Movement: The fingers are bent, then the hand, the forearm is brought into a supination position, the upper limb is brought, turned inward and bent.

ATTENTION! During the movement, the muscles surrounding the elbow joint area must be relaxed.

At the end of the movement, the thumb is flexed and aligned.

Thus, the patient's working hand describes a movement along a large diagonal to the opposite hip, as if grabbing some object located above the head in order to hide it in the "opposite trouser pocket".

B. Movement from bottom to top.

From the final position, the patient's hand is brought to the initial position, with extension of the fingers, pronation of the forearm, abduction, extension and outward rotation of the shoulder.

For the muscles surrounding the elbow joint

In the second half of the trajectory of movement from bottom to top, resistance is provided by bending the arm at the elbow joint so that the shoulder is abducted to a horizontal level.

From this position, the movement is resumed - extension of the arm at the elbow joint to the starting position.

During the reverse movement, resistance is provided to the extension of the forearm.

[ 7 ], [ 8 ], [ 9 ]

For the extensor and flexor muscles of the wrist

The movements are carried out across the entire range of patterns, and the resistance is provided in accordance with the movements within these patterns.

ATTENTION! The middle position of the 1st diagonal is the patient's elbow resting on the doctor's stomach, all joints of the limb are slightly bent. The doctor grasps the patient's forearm with one hand.

[ 10 ], [ 11 ]

For fingers

In addition to the general schemes, the re-education of finger movements is carried out separately, forcing all the muscles, especially those interested, to tense up according to their specific action with the maximum possible resistance.

Methodological instructions

1. The resistance provided by the doctor’s (methodologist’s) hands is not constant and changes throughout the entire volume during the movement of the contracting muscles.
2. Maximum resistance to the strength capabilities of the muscles is always given so that, overcoming it, the muscles perform movements in the joint.
3. When applying maximum possible resistance, it is necessary to ensure that the resistance is not excessive, which will lead to the cessation of movement in the joint.
4. The resistance should not be too low, as this will result in the muscles working more easily, which will not help restore their strength.
5. The strength capabilities of individual links of the complex motor act are different (shoulder-forearm-hand); the strength of individual links can be greater in the forearm flexor muscles, less in the shoulder flexor muscles, and very small in the hand flexor muscles. This circumstance requires the correct distribution of resistance during the complex movement.
6. By providing maximum possible resistance, the doctor (methodologist) forces the patient's muscles to work throughout the entire movement with the same force, i.e. in an isotonic mode.
7. When alternating muscle work, isometric muscle tension turns into isotonic movement. When changing the type of muscle work, the doctor (methodologist) can significantly reduce the resistance to make it easier for the patient to quickly change the nature of the effort. With the onset of active movement (isotonic mode), the doctor increases the resistance to the maximum.
8. The alternation of types of muscle work is carried out several times throughout the movement.