Physiotherapy with cervical osteochondrosis

Developing a special method of therapeutic gymnastics (LH) for various syndromes of cervical osteochondrosis should be based on the following considerations. Treatment of cervical osteochondrosis must first of all be pathogenetic, i.e. Aimed at eliminating the root cause of the disease, rather than symptomatic. Therefore, regardless of the clinical manifestations of the disease during LH, general principles should be observed.

1. In conditions of instability of the PDS of the spine, it is advisable for patients to wear a cotton-gauze collar of the Shants type throughout the course of treatment. This creates relative peace for the cervical spine and prevents subglozsatsiya and microtraumatism of the nerve roots, reduces pathological impulse from the cervical spine to the shoulder girdle.
2. With hyperflexion of the neck, the tension of the spinal roots can be increased and traumatization of the neural formations is especially manifested with deformation of the anterior margin of the cervical canal in connection with the presence of osteophytes and subluxation. Ischemia in the anterior spinal artery system can be the result of a direct compressing effect of the posterior osteophyte at the time of active extensor movements. As a result of periodic or permanent traumatization of the anterior spinal artery, a reflex spasm of the medullary vessels arises, which ultimately leads to a deficit of the spinal circulation of a functionally-dynamic character. According to several authors, in myelography, in some cases, a partial or complete contrast delay is noted in the position of the hyperextension of the neck and disappears with inflection. All this confirms the opinion about traumatization of the spinal cord and its vessels by posterior osteophytes with 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 (rotations, inclinations) performed in 514 patients, suggest that these movements have an adverse effect on the blood flow in the vertebral arteries. It is known that in cerebral vegetative-vascular disorders of cervical genesis, hearing damage occurs quite often, mainly on the side of a headache and has the character of a sound-receiving apparatus. It is a consequence of the violation of hemodynamics in the vertebral artery, which can lead to ischemia in both the cochlea and the nuclei of the VIII nerve in the brain stem. That is why, with vertebral artery syndrome, active head movements can lead to an increase in hearing loss.

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

3. Only during the restoration of impaired functions should be introduced exercises aimed at strengthening the muscles of the neck. To this end, exercises with dosed resistance are used. For example, a patient tries to tilt his head forward or sideways, and the hand of the doctor (methodologist), while resisting, hinders this movement (the exercise is performed in the IP - sitting on a chair or lying down). At the same time, the efforts that the doctor has, naturally, must be dosed, adequate to the state of the patient, the training of his muscles.

The exercises are supplemented by exercises in static head retention and isometric muscle tension.

4. All physical exercises, especially of a static nature, should alternate with respiratory exercises and exercises aimed at relaxing the muscles. Especially persistently should be to relax the trapezius and deltoid muscles, since in this disease they are more often involved in the pathological process and are in a condition of pathological hypertonia (Z.V. Kasvande).

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

• acute;
• subacute;
• restoration of disturbed functions.

[1], [2], [3]

LFK in acute period

General tasks of medical gymnastics :

• reduction of pathological proprioceptive impulses from the cervical spine to the shoulder girdle and upper limbs, from the latter to the cervical region;
• improvement of circulatory conditions, reduction of the phenomena of irrigation in the affected tissues located in the intervertebral foramen;
• increased psychoemotional tone of the patient.

Special tasks of therapeutic gymnastics:

• with shoulder-scapular periarthrosis - reduction of pain syndrome in the shoulder joint and upper limb, prevention of joint stiffness;
• with vertebral artery syndrome - relaxation of the muscles of the neck, shoulder girdle and upper limbs, improving coordination of movements and muscular-articular feelings. Therapeutic gymnastics is appointed on the 1-2 day of admission of the patient to a hospital or to polyclinic treatment.

Absolute contraindications to the appointment of therapeutic gymnastics :

• the general severe condition of the patient due to high temperature (> 37.5 ° C);
• the increase in symptoms (clinical and functional) of cerebral circulation;
• 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 starting position - lying and sitting. Patients are advised to carry out these exercises in the cotton-gauze collar of the Shantz type, and in the shoulder-shoulder periarthrosis syndrome, the affected arm should be laid on a wide scarf.

LFK in subacute period

General tasks of medical gymnastics:

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

Special tasks of therapeutic gymnastics:

• an increase in the amplitude of movements in the joints of the affected limb;
• increasing the vestibular apparatus's resistance to physical exertion.

To solve these problems, the most diverse forms and means of therapeutic physical training are used, which, when osteochondrosis of the spine is a pathogenetic factor of therapy.

• The rationalization of the patient's movement during the day, which is an essential element of treatment.

The basis of the motor regime is based on two principles:

1. providing the maximum mobility for stimulation of the general motor activity of the patient;
2. the maximum use of those forms of movements that prevent the development of pathological stereotypes.

System of analytical gymnastics for patients with spine disease. This is a joint gymnastics, the purpose of which is the development of movements (passive, active-passive) in certain segments of the limbs and spine, the education of active relaxation and reciprocal contractions of the muscles-antagonists.

All systems of analytical gymnastics include four main components:

• receptions aimed at relaxing individual muscle groups;
• techniques that improve mobility in the joints;
• education of the active tension of certain muscles;
• the formation of the right coordinative relationship between the muscles-antagonists and integral motor acts.

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

In the classroom exercises are used to relax the muscles performed by the patient in the ip. Lying and sitting. For relaxation of the muscles, the neck is used, in particular, by the i.p. Lying on the back, on the side, while it is advisable to put a cotton-and-gauze pad of the C-shaped under the neck. You can offer the patient in the IP. Sitting on a chair to take a pose that provides partial discharge of the cervical spine, shoulder girdle and upper limbs, due to support of the head and back.

To relax the muscles of the shoulder girdle, a number of methods are suggested:

• i.p. Lying on his back or on his side;
• breathing exercises provided that the weight of the hands is removed (they are put on support);
• slight shaking of the shoulder girdle by the methodologist's hand over the area of the upper third of the patient's shoulder in the p. Lying on his side, sitting or standing.

To relax the muscles of the upper limbs, it is advisable to lightly shake the hand, forearm, flapping movements with incomplete amplitude and with a slight inclination of the trunk toward the affected limb.

Exercises for muscle relaxation should alternate with respiratory (of a static and dynamic nature), gymnastic exercises of isotonic character for the distal parts of the limbs.

Exemplary exercises for distal limbs:

1. Put your elbows on the table. Tilt your hands in all directions. Repeat 10 times.
2. Fold your hands together and pull out in front of you. Dilute the wrists to the sides, not wringing the wrists. Repeat 10-15 times.
3. Pull your hands forward and tighten your fingers tightly in a fist, then release them sharply, trying to keep your fingers as far back as possible (You can squeeze a small rubber ball or a carpal expander.) Repeat 12-15 times.
4. Fold your hands together. Dilute and reduce fingers. Repeat 5-10 times.
5. Close four fingers. With your thumb, do your moves to yourself and yourself. Repeat 8-10 times with each hand.
6. Hook your fingers together. Rotate the thumbs one around the other. Repeat 15-20 times.
7. Spread your fingers apart. Having tightly squeezed four fingers, press them on the base of the thumb, on the middle of the palm, on the base of the fingers. Repeat 5-10 times.
8. To stir the spread fingers in all directions. Stretch the fingers of the left hand with the right hand brush, and vice versa. Freely shake hands, hands up.

Exemplary exercises for the shoulder joint:

1. I.p. - lying on the back, hands along the trunk with the palms down. Rotate the palms up and down again (rotation of the arms around the axis); at each turn, then the palm, then the back of the brush touch the bed. Breathing is arbitrary.
2. Take your hands to the sides, put your sick hand on a smooth surface with your palm down - inhale; return to it. - Exhalation.
3. Raise your right arm up, left along the trunk, change the position of your hands. Breathing is arbitrary.
4. Raise a sore hand up, bend at the elbow and, if possible, wind it over your head - breathe in, return to the i.p. - Exhalation. You can get both hands behind your head, healthy helping the patient. I.p. - lying on a healthy side, hands along the trunk.
5. Bend in the elbow a sick hand, supporting with a healthy hand, take your shoulder - inhale, return to the ip. - Exhalation. I.p. - lying on his back, hands along the trunk.
6. Grab your hands on the back of the bed and gradually take your hands to the sides - down until the hand of the sick hand touches the floor. Breathing is arbitrary.

Therapeutic exercises with shoulder-scapular periarthrosis

In the first days of the gymnastics period, it is advisable to spend in the spa. Lying (on the back, on the side). Movements in the affected joint are performed with a shorter lever, with the help of a methodologist, with the help of a healthy arm.

Typical exercises for the shoulder joint

As the pain subsides in the shoulder joint, exercises with an external and somewhat later and internal rotation of the shoulder are added. Restoration of the lead function also begins with cautious mahovye movements in the horizontal plane with a hand bent at the elbow joint and a slight inclination of the trunk towards the affected arm (etc. Sitting). After reaching a painless flexion of the shoulder at 90-100 ° and withdrawing it by 30-40 °, exercise should be performed in the i.p. Standing. The following exercises are added:

• "Putting hands behind your back" (training the inner rotation of the shoulder). The patient should touch the back as high as possible (stretching the subacute muscle);
• "Getting the mouth wound by the head with his hand" (training the shoulder and turning it out). The retention of the arm in this position is accompanied by a significant contraction of the muscles that divert the shoulder, and the muscles that rotate the shoulder. When the subacute muscle is injured, the patient's fingers reach only the ear (normally the tips of the fingers reach the midline of the mouth);
• "Stretching the anterior portion of the deltoid muscle." I.p. - sitting, the affected arm is straightened. The patient withdraws this arm by 90 °, then rotates it outward and pulls back.

In these terms, exercises using reciprocal relationships are also recommended.

These exercises are performed simultaneously by two extremities. In this case, the following are possible:

• the same exercises for both hands;
• simultaneous execution of antagonistic movements (for example, one hand produces flexion - reduction - external rotation, another - extension - retraction - internal rotation);
• simultaneous execution of multidirectional movements (for example, one hand performs bending - reduction - external rotation, another - bending - retraction - external rotation or extension - reduction - internal rotation).

Gradually, exercises are included in the exercises with gymnastic objects (gymnastic sticks, light dumbbells, clubs and balls), at the gymnastic wall, on a special table, etc.

Exercises with a gymnastic stick.

1. I.p. - legs wider than shoulders, arms in front of the chest: 1 - turn left, inhale; 2 - bend to the left leg, touching it with the middle of the stick, exhaling; 3-4 - straighten up, return to the ip, inhale. The same, on the right side. Repeat 4-5 times in each direction.
2. I.p. - feet on the width of the shoulders, the stick behind vertically along the spine, the left hand holds it by the upper end, the right hand over the lower end: 1-2 - take the right hand to the side; 3-4 - return to the IP. The pace of movement is slow, breathing is arbitrary. Repeat 4 times in each direction. The same, changing hands: the left - at the bottom, the right - at the top.
3. I.p. - feet are shoulder-width apart, hands are lowered down and hold the stick with a grip on top of the ends: 1-2 - stick forward - up; 3-4 - back - down (to the buttocks), as if twisting the hands, smoothly, without jerking; 1-4 - return to the IS. Breathing is arbitrary. Repeat 6 times.
4. I.p. - the legs are wider than the shoulders, the stick on the elbow folds behind the back (at the level of the lower corner of the scapula), the head is raised: 1 - straighten shoulders, inhale; 2 - turn the body to the left, exhale; 3-4 - the same in the other direction. Repeat 6 times.

During this period, exercises in the treatment pool are recommended.

Features of mechanical influences of the aquatic environment are explained by the laws of Archimedes and Pascal. By reducing 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 seizures, a reduction in pain and muscle tension. This improves blood circulation and lymph circulation, decreases the resistance of the entire periarticular apparatus of the joints, which contributes to better realization of motor function. The increase in the motor function in the treatment pool has a stimulating effect on the patient, which helps him to engage with more energy in the process of subsequent exercise and development of movements.

It should be borne in mind that the dynamic exercises for the shoulder joints, firstly, contribute to the improvement of blood supply to the nerve roots of the cervical spinal cord due to the fact that large muscle groups participate in the work, which is extremely necessary for all patients, regardless of 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 contributing to the reduction of clinical manifestations of the disease in patients with periarthritis, epicondylitis syndrome and radicular syndrome (MVV. Deviatova).

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

Therapeutic gymnastics in patients with spinal artery syndrome

P ol unconditioned tonic reflexes in the formation of voluntary movements

Congenital motor reflexes ensure the preservation of normal posture, balance, coordinate the posture with the position of the head in relation to the trunk. In accordance with the existing classification, congenital motor reflexes are divided into:

• reflexes, which determine the position of the body at rest (reflexes of position);
• Reflexes that ensure the return to the initial position (adjusting reflexes).

Reflexes of position. Occur when the head tilts or turns due to irritation of the nerve endings of the neck muscles (cervical-tonic reflexes) and 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 extremities, ensuring the preservation of 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 installation of the trunk in a symmetrical position relative to the head. At the same time, the tonus of the extensor extends to the extremities toward which it is produced, and the tonus of the flexors of the opposite side increases.

In changing the position of the head in space and in analyzing these changes, an important role belongs to the vestibular apparatus. The excitation of the receptor formations of the vestibular apparatus with the turns of 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 setting of the trunk in relation to the head. Such a redistribution of the tone is necessary for the effective performance of many physical and domestic exercises and movements associated with rotation.

Setting reflexes. Ensure the preservation of the pose when it deviates from its normal position (for example, straightening the trunk).

The chain of rectifying reflexes begins with the raising of the head and the subsequent change in the position of the trunk, which ends with the restoration of the normal posture. Vestibular and visual apparatus, proprioceptors of muscles, skin receptors participate in the implementation of rectifying mechanisms (reflexes).

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

The reflexes of rotation are characterized by a slow deviation of the head in the direction opposite to the movement, and then by a rapid return to the normal position relative to the trunk (head nystagmus). The eyes make similar movements: a quick turn in the direction of rotation and a slow one in the direction opposite to the rotation.

Exercise is associated with a constant correction of congenital motor reflexes. Central regulatory influences provide the necessary muscle tone in accordance with the nature of arbitrary movements.

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

For this purpose tests are recommended.

The variety of reactions that appear when the vestibular apparatus is stimulated is due to its anatomical and functional connection to the vegetative nuclei, and through them to the internal organs.

So, with irritation of the vestibular apparatus, there may be:

• vestibulo-somatic reactions (changes in the tone of the skeletal musculature, "protective" movements, etc.);
• vestibulo-vegetative reactions (changes in heart rate, blood pressure and respiration, nausea, etc.);
• vestibulo-sensory reactions (sensation of rotation or counter-rotation).

Our experience shows that the means of physical rehabilitation (and in particular, physical exercises) can influence the vestibular analyzer, carrying out "vestibular training".

The use of special vestibular training in the complex treatment of patients with osteochondrosis of the cervical spine helps to restore stability, orientation in space, reduce vestibulo-vegetative reactions, improve the general condition of patients, adapt to physical stress 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 by performing exercises aimed at increasing the amplitude of movements in the shoulder joint, stimulation of the circulation of the nerve roots should be promoted in order to reduce the phenomena of irrigation in them. To solve this problem, first of all, the exercises for the restoration of stato-kinetic and vestibulo-vegetative resistance contribute. Widely used in practice exercises of a special nature can be combined into several groups.

1. Special exercises with the primary effect on the semicircular canals: exercises with angular accelerations and decelerations (movements of the trunk, head in three planes, respectively direction of the semicircular canals - frontal, sagittal and horizontal).

• Standing on your toes (legs together), perform 5 torso torsions forward to the horizontal position (ma-whisker movements); one slope per second.
• Feet on one line (right before the left), hands on the waist, perform 6 torso torso to the left and right (ma-whisker movements); one slope per second.
• Standing on your toes (legs together), maximally tilt your head back; hold this position for 15 seconds. The same, but with closed eyes; 6 sec.
• Heels and socks together, hands on the waist, eyes closed; stand 20 s.
• Stops on one line (right before the left), hands on the waist; stand 20 s. The same, but with closed eyes; stand 15 seconds.
• Legs together, hands on the waist, rise on their toes; stand 15 seconds. The same, but with closed eyes; stand 10 seconds.
• Hands on the waist, bend the left leg, tearing off the floor, to rise on the toe of the right foot; stand 15 seconds. The same with the other leg. The same, but with closed eyes; stand 10 seconds.
• Standing on your toes, perform 6 springing movements head to the left and right; one movement per second.
• Standing on the toe of the right foot, hands on the waist, perform 6 sweep movements with your left foot forward and backward (with full amplitude of movements). The same with the other leg.
• Standing on your toes, perform 10 quick head inclinations forwards and backwards.
• To rise on the toe of the right leg, bend the left leg, tearing off the floor, tilt the head as much as possible, close your eyes; stand 7 seconds. The same with the other leg.

In the first days of the exercise with turns and inclinations, the trunks are performed in a small volume, at a calm pace, in and out. Sitting and standing. The patient produces exercises for each channel, i.e. In the indicated planes - frontal, sagittal and horizontal, necessarily starting from the plane in which they are made freer, it is easier.

ATTENTION! The slopes and turns of the head are contraindicated for 1.5-2 weeks.

Special exercises for semicircular canals need to be alternated with respiratory and general restorative exercises so as not to cause the phenomena of re-irritation of the vestibular apparatus.

If the head moves in all planes with a stop in the "straight" position, the patient performs quite freely, then these movements are included in the exercises of therapeutic gymnastics. In the beginning, it is recommended that the head be moved to the i.p. Lying on his back, stomach, on his side.

2. Special exercises with an effect on the otolith apparatus. These exercises include elements of rectilinear motion with decelerations and accelerations (walking, squats, running at different tempo, etc.).

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

3. To train the ability of orientation in space, exercises are applied to balance, i.e. Restoring one of the main functions of the vestibular analyzer.

In the first half of the treatment course, exercises for the upper limbs and trunk are recommended in a standing position on the floor, first with widely spaced legs (wider than the shoulders), and then gradually bringing the foot closer together and reducing the foot area (feet at the width of the shoulders, feet together, one leg in front of the other standing on toes, on the heels, on one leg).

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

4. To improve coordination of movements, exercises in throwing and catching various objects (ball, medical-bola) in combination with hand movements, walking, etc., performed in the i.p. - sitting, standing and walking.
5. Orientation in space is carried out with the participation of vision. Therefore, his exclusion from all the exercises above increases the requirements for the vestibular apparatus.
6. According to the method of B.Bobath and K.Bobath, equilibrium training is conducted based on the use of the cervical tonic asymmetric reflex.

Cervical-tonic reflex: when the head moves, most patients have an increase in the tone of the extensor or flexor group of the muscles. This reflex is often accompanied by the emergence of a labyrinthine-tonic reflex (an increase in the tone of the extensor muscles in the IV lying on the abdomen). Therefore, it is not always possible to distinguish between what influences the tension of a particular muscle group occurs when the head moves.

Correction of pathological postural reflexes is achieved by the fact that, when certain limb movements are performed, a position opposite to the posture that arises under the influence of cervical and labyrinth-tonic reflexes is attached.

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

1. Exercise is recommended to relieve spasm of the muscle-extensors of the trunk, arising in connection with the labyrinthine reflex in the p. Lying on his back.

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

2. Exercise is recommended for correcting the pathological position of the legs.

I.p. - lying on his back, his straight legs are spread apart. The methodologist keeps the patient's legs during the exercise - a transition to the i.p. Sitting. In the future, the patient himself tries to keep them while doing the exercise.

3. Exercises recommended for correction of hands.

I.p. - lying on his stomach, arms stretched along the trunk. The methodologist helps the patient to take his direct hands back to the outside, then the patient raises his head and shoulder girdle.

ATTENTION! This technique, aimed at extending the muscles of the shoulder girdle and back, prevents the buildup of muscle flexors.

For dosing the load on the vestibular apparatus, special importance is acquired by:

• the starting position from which this or that movement is made;
• the volume of these movements in one or simultaneously in several planes;
• turning off the view.

Methodical instructions

1. The initial position at the beginning of the course of treatment is only lying and sitting, since in most cases the orientation in space is disturbed in patients, the equilibrium function.
2. To the initial position of standing and then to the exercises in walking can go with the improvement of the patient's condition.
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, reaching a maximum volume in the second half of the course of treatment.
4. A significant increase in the load in a special training is achieved by exercises performed simultaneously in different planes with their full volume, i.e. Exercises with rotational movements (head and trunk).
5. Exercises with the eyes off are recommended to be applied in the second half of the course of treatment, thereby increasing the requirements for the vestibular analyzer against the background of already obtained positive results of training the vestibular apparatus.
6. At the beginning of the course of treatment, equilibrium exercises should not be performed after exercises with a rotation of the head or trunk, as this can worsen the equilibrium function.

In the second half of the course of treatment, the results of training can be evaluated by performing exercises for balance after rotational movements.

1. The first days are spent only individual exercises of therapeutic gymnastics, because at these times the opportunities for doing exercises are small (patients are not sure of their movements, often lose their balance, vestibular disorders are accompanied by unpleasant sensations).
2. When carrying out vestibular training, patient's insurance is necessary, because the applied physical exercises change the reactivity of the vestibular apparatus, at any moment there may be imbalances with pronounced vestibulo-vegetative reactions.

9. If during the training of therapeutic gymnastics patients have a slight dizziness, it is not necessary to interrupt lessons. He needs to give a 2-3-minute rest in the IP. Sitting or offer to perform a breathing exercise.

LFK during the restoration of impaired functions

Objectives of exercise therapy:

• Improve trophic tissue of the neck, shoulder and upper extremities;
• strengthening the muscles of the neck and trunk, limbs;
• restoration of the patient's capacity for work.

The peculiarity of this period of treatment is as follows.

1. For the duration of exercise LFK cotton-gauze collar type Shantsa removed.
2. To strengthen the muscles of the neck, shoulder girdle and upper limbs, static exercises are introduced. The initial exposure is 2-3 seconds. Static exercises can be grouped as follows:
   • isometric tension of the neck muscles at the pressure of the occiput (IP - lying on the back), the frontal part of the head (IP - lying on the abdomen) on the plane of the couch;
   • static retention of the head, head and shoulder girdle in the i.p. - lying on his back, on his stomach;
   • isometric tension of the muscles of the neck and shoulder girdle with dosed resistance by the hand of a doctor or methodologist (IP - lying and sitting);
   • static retention of the upper limb (with gymnastic objects without them.
3. Isometric muscle strains are combined with exercises aimed at relaxing the muscles of the neck, shoulder girdle and upper limbs, muscle relaxation is carried out by:
   • special breathing exercises, provided the weight of the hands is removed (put them on the support);
   • slight shaking of the hands in the easy tilt of the trunk (IP - sitting and standing);
   • free falling of allotted hands (IP - sitting and standing);
   • free falling of the raised shoulder girdle at fixing of hands (to put them on a support).
4. The possibility of using exercises for the shoulder, elbow joints in full allows you to complicate the exercises for coordinating movements.

The procedure of therapeutic gymnastics is supplemented by exercises with shock absorbers.

• I.p. - lying on his stomach, straight legs together, hands along the trunk. Pull your hands forward, bend, raise your straight arms up - inhale, return to the i.p. - Exhalation.
• Carry out the hands of movement, like when swimming style "breaststroke": hands forward - inhale; hands in the sides, back - exhale (hands holding on weight).
• Go to the standing position on all fours. Breathing is arbitrary. As high as possible, raise the right hand and simultaneously pull out the left leg - inhale; return to the standing position on all fours - exhale. The same, with the other hand and foot.
• Having risen on socks, slowly to lift up hands, connected in "lock", to be stretched, bending back and trying to look at hands, as slowly to return in i.p.. Repeat 5-6 times.
• Bending his arms in the elbows, connect his hands in front of the chest so that the tips of his fingers are on top. With effort, press your palms against each other. Repeat 10 times. Without opening your hands, turn your fingers first to yourself, then from yourself. Repeat 10 times.
• Stand at a distance of half a step from the wall, rest in it with your hands. While stretching your elbows to the sides, slowly bend your hands, and then straighten them, pressing away from the wall. Approaching the wall, turn your head then to the right, then to the left. Repeat 8-10 times.
• Bending your arms in the elbows before your chest, tightly grasp your wrists with your fingers. Do sharp jerks with your hands towards each other, straining your chest muscles. Repeat 10 times.
• Sit down, palms resting on the seats of two chairs. Then, slowly press on your hands, tearing your legs off the floor. Repeat 10 times with breaks to rest.
• Put your fingers on your shoulders, pull your elbows through the sides back, taking your shoulder blades. Circular motion shoulders forward, and then back, trying to make the circle turned out more. Repeat 4-6 times in each direction.

5. The possibility of using exercises that increase the stability of the vestibular apparatus is widening. To the previously proposed exercises, more complex twists and turns of the trunk are added when walking and sitting on a rotating chair, exercises become more complicated and by reducing the support area, as well as using gymnastic equipment, introducing height elements and finally turning on the view during exercise.

Exercise exercises on a gymnastic disk:

• I.p. - standing on the disk with both feet. Turning the trunk to the right and left with the participation of hands.
• The same, holding hands behind the crossbar, which makes it possible to increase the amplitude and speed of movements.
• I.p. - standing with one foot on the disc, hands on the belt. Turn the leg around the vertical axis.
• I.p. - Standing, lean your hands against the disc, standing on the floor. Rotating the disk with your hands, turn your body as much as possible to the right and left.
• I.p. - kneeling on the disk, hands on the floor. Turns the trunk to the right and left.
• I.p. - sitting on the disc, mounted on a chair, hands on the belt. Rotate the disk to the right and left, turning the torso and helping yourself with the legs (do not tear off the legs from the floor).
• I.p. - sitting on the disc, standing on the floor, hands on the floor. Without moving your hands, rotate the disk to the right and left.
• I.p. - standing on the disk with two legs, lean forward and take hold of the support. To turn the disc to the left and to the right with your feet.
• I.p. - standing with his feet on two discs. Both feet rotate both disks simultaneously in one, then in different directions.
• I.p. - standing on the discs, join hands. Turns the trunk to the right and left.

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

[4], [5], [6],

Exercises for the upper limbs

1st diagonal.

A. Movement from the bottom up.

I.p. The patient - lying on his back, the arm is stretched along the trunk, palm to the plane of the couch, the fingers of the hand are parted, the head is turned towards the hand.

The doctor is on the side of the operating upper limb, his arm (left for the upper left limb, right for the upper upper limb) covers the patient's arm.

III, IV and V, the patient's fingers are grasped between the thumb and forefinger of the physician's hand, the middle and unnamed fingers of the doctor are located between the thumb and thumb of the patient, while the little finger encircles the first metacarpal bone. The other hand of the doctor grasps the patient's shoulder in the upper third of the shoulder.

Motion. The patient's shoulder describes movement diagonally, as if something is throwing across the opposite shoulder. In this case, the shoulder is withdrawn forward, rotates outward and is retracted: the arm in the elbow joint slightly bends. The patient's head rotates in the opposite direction. During the movement the doctor exerts resistance to all its components, gradually increasing resistance.

B. Movement from top to bottom.

From the end position of the 1st diagonal, the upper limb is reset to its original position, performing the same movements in the reverse order: rotation to the inside, extension and withdrawal of the shoulder, pronation of the forearm, extension of the arm, extension and dilution of the fingers of the hand.

The doctor renders the measured resistance at the level of the grip of the palm, and the other hand - on the backside of the patient's shoulder.

For the muscles surrounding the elbow joint

Before the end of the movement from the bottom to the top, the physician exerts resistance to the flexion of the arm in the elbow joint. Movement follows the same pattern so that when the movement is completed, the hand with the bent fingers is at the ear level (opposite side).

When moving from the bottom up, the resistance is stretching the arm in the elbow joint.

2nd diagonal.

A. Movement from top to bottom.

I.p. The patient - lying on his back, the arm is pulled up (up to 30 °), the forearm is in the maximum possible pronation, the fingers of the hand are unbent.

The doctor is on the side of the operating upper limb. The patient's brush is grasped in the same way as with the I diagonal. With the other hand, the doctor exerts resistance on the shoulder.

Motion. The fingers are bent, then the wrist, the forearm is brought to the supination position, the upper limb is turned, it turns inwards and bends.

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

At the end of the movement, the thumb is bent and matched.

Thus, the patient's working arm describes a movement along a large diagonal to the opposite hip, as if grabbing an object over his head to hide it in the "opposite pocket of trousers".

B. Movement from the bottom up.

From the end position, the patient's hand is brought to the starting position, with the extension of the fingers of the hand, the pronation of the forearm, the withdrawal, extension and turning of the shoulder outside.

For the muscles surrounding the elbow joint

On the second half of the trajectory of movement from the bottom up, resistance is bending the arm in the elbow joint so that the shoulder is withdrawn to the horizontal level.

From this position, the movement resumes - extension of the arm in the elbow joint to the initial position.

With reverse movement, the resistance is extended to the forearm.

[7], [8], [9]

For extensor muscles and wrist flexors

Movements are carried out across the entire range of circuits, and the resistance appears to correspond to movements within these circuits.

ATTENTION! The average position of the 1st diagonal - the elbow of the patient rests on the stomach of the doctor, all joints of the limb are slightly bent. With one hand, the doctor grasps the patient's forearm.

[10], [11]

For fingers

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

Methodical instructions

1. Resistance provided by the hands of a physician (methodologist) is not constant and varies throughout the volume during the movement of contracting muscles.
2. Always given maximum resistance to the power capabilities of the muscles so that, overcoming it, the muscles make movements in the joint.
3. When providing the greatest possible resistance, it is necessary to observe that the resistance is not excessive, which will lead to the cessation of movements in the joint.
4. Resistance should not be too small, as this will lead to easier work of the muscles, which will not help restore their strength.
5. The power capabilities of individual links of the complex motor act are different (shoulder-forearm-hand); the strength of individual links may be greater in the flexor muscles of the forearm, smaller in flexor muscles of the shoulder and quite small in the flexor muscles of the hand. This circumstance requires a correct distribution of the resistance during the complex motion.
6. Providing the maximum possible resistance, the physician (methodologist) forces the patient's muscles to work throughout the movement with equal force, i.e. In isotonic mode.
7. With the alternation of muscular work, the isometric muscle tension becomes isotonic. With a change in the type of muscular work, the physician (methodologist) can significantly reduce the resistance in order to facilitate the patient's rapid change in the nature of the effort. With the onset of active movement (isotonic mode), the doctor brings the resistance to the maximum.
8. Alternation of types of muscular work is carried out several times throughout the movement.