Physical therapy for lumbosacral spine osteochondrosis

Therapeutic exercise for osteochondrosis of the lumbosacral spine has different goals and methods at different periods of this disease.

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Physical therapy in the acute period

Tasks of the period:

• reduction of pain syndrome;
• relaxation of the paravertebral muscles and muscles of the affected limb.

The decisive role in the treatment of spinal osteochondrosis belongs to the cessation of loads along the axis of the spine and ensuring rest for the affected disc.

In acute cases, it is recommended:

• bed rest (for 3-5 days);
• correction by position (positioning the patient).

Bed rest

The bed should be semi-rigid, the patient's head should rest on a low pillow, a cotton-gauze roller should be placed under the knees, since in this position optimal relaxation of the muscles of the lumbar spine and lower extremities is possible, reducing the tension of the roots.

Bed rest in acute cases, in addition to stopping the load on the disc, creates conditions for scarring of cracks and ruptures of the fibrous ring, which can be the key to a long light interval and even clinical recovery with full restoration of working capacity.

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Correction by position (positioning the patient).

The patient should lie on his back with a small pillow under his head.

In case of sciatic nerve neuralgia, it is recommended to lay the patient with the legs bent at the hip and knee joints in order to maximally relax the muscles of the limb and relieve the tension on the nerve sheath.

ATTENTION! It should be remembered that the patient's position lying on his back should not reduce the lumbar lordosis too much, the preservation or restoration of which determines the dislocation of the displaced fragment of the nucleus pulposus.

After the elimination of acute phenomena, which indicates the dislocation of the displaced fragment of the nucleus pulposus within the fibrous ring, it is necessary to reduce the flexion of the lower limbs in the knee and hip joints in order to restore physiological lordosis and thereby reduce the posterior opening of the intervertebral space; it is recommended to place a small pillow or a small cotton-gauze roller under the lower back.

An analysis of scientific publications shows that a wide variety of patient positions are currently used.

At the same time, we do not recommend laying the patient with the head end of the bed elevated, since, firstly, it causes a kind of “sagging” of the lumbar region and, secondly, its kyphosis.

When the general condition improves (pain syndrome decreases, motor activity improves), the patient is transferred to regimen II.

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Physical therapy in the subacute period

Tasks of the period

• Reduction of pain syndrome.
• Relaxation of postural and strengthening of phasic muscles.
• Improvement of trophic processes in the affected spinal cord.
• Adaptation of all systems and organs to increasing physical activity.

Techniques aimed at:

• relaxation of tense muscles;
• strengthening relaxed muscles;
• muscle stretching (inactivation of active TT).

Contraindications to the use of exercise therapy:

• increased pain;
• intolerance to the procedure.

Contraindicated physical exercises:

1. Straight leg raise (starting position - lying on your back).
2. Exercises to stretch the muscles and fibrous tissues of the affected leg (if there are signs of neuroosteofibrosis in these tissues).
3. Torso flexion more than 20° (starting position - standing).
4. Trunk extension (starting position - standing).

Starting position

Studies conducted by a number of authors have shown that the pressure inside the disc: a) is maximum in the sitting position; b) decreases by 30% in the standing position; c) decreases to 50% in the lying position.

This is obviously associated with a decrease in pressure in the abdominal cavity in the initial position - sitting and with the transfer of the weight of the upper half of the body directly to the lumbar spine.

In connection with the above, in the subacute stage of the disease, physical exercises should be performed in the initial position - lying on the back, on the stomach and standing on all fours, i.e., while unloading the spine.

In the initial lying position, the most complete unloading of the musculoskeletal system from the influence of body weight is achieved:

• the muscles are completely freed from the need to hold the body in an upright position;
• The spine and limbs are relieved from the pressure of the weight of the overlying parts of the body.

During movements performed by the head, shoulder girdle, and limbs in this initial position, the muscles of the trunk, creating the appropriate support, perform static work. In such cases, the muscles of the trunk are trained for endurance to static efforts.

ATTENTION! Movement of the head, torso, and limbs in the supine position can be performed with different dosages, which contributes, on the one hand, to the development of the endurance of the torso muscles for subsequent isometric work and, on the other hand, to the dosed traction of these muscles of various bone structures of the spine.

In the initial lying position, it is possible to achieve isolated tension of muscle groups by excluding muscles that do not require strengthening.

These initial positions include:

• i.p. - lying on the stomach, which is used mainly for exercises that strengthen the muscles of the shoulder girdle and back;
• i.p. - lying on the side is used for unilateral strengthening of the back and abdominal muscles (hypermobility or instability of the affected PDS should be excluded);
• i.p. - lying on your back is used to strengthen the abdominal muscles.

Unloading corsets

Provides a reduction in the axial load on the spine by transferring part of the body weight to the iliac bones. Wearing a corset reduces the pressure in the intervertebral discs by approximately 24% (A. Dzyak).

ATTENTION! Wearing a corset is mandatory for the entire course of treatment; it should be combined with therapeutic exercises to avoid progressive weakening of the trunk muscles.

Exercises aimed at muscle relaxation

As a result of the reflexively arising muscular-tonic tension, fixation of the affected spinal MDS is ensured. It can be carried out mainly by the intertransverse muscles, rotators, interspinous muscles, as well as the corresponding sections of the long muscles (iliopsoas, multifidus, etc.) in the area of the affected MDS.

However, such local myofixation is formed at the later stages of sanogenesis. At first, in response to pain signals from the affected disc area, a general tonic reaction occurs, which involves the muscles of the entire spine, the muscles of the extremities associated with it. This is a common, vertebral-extavertebral myofixation. Therefore, to reduce muscle-tonic tension, it is recommended to use breathing exercises (dynamic and static) and exercises in voluntary relaxation of skeletal muscles in exercise therapy.

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Breathing exercises

The afferent system (receptors) of motor-visceral reflexes are located in all tissues of the locomotor apparatus. The influence of proprioceptors on the respiratory organs is carried out through various levels of the brain and with the participation of the reticular formation. The muscle tone that changes during physical exercise also becomes (thanks to proprioception) a reflex regulator of the internal organs, the activity of which changes in accordance with the muscle tone.

Breathing exercises help to strengthen the braking process. It is necessary to distinguish:

• breathing to relax muscles;
• breathing during exercise;
• breathing exercises performed after isometric exercises.

Usually, when performing isotonic exercises, breathing is combined with individual phases of physical exercise. This is justified from the standpoint of physiology, since respiratory movements in their structure represent natural locomotion of a cyclic nature.

ATTENTION! Dynamic breathing exercises increase the tension of the paravertebral muscles, since when they are performed, the magnitude of all physiological curvatures of the spine changes, including the lumbar lordosis (especially when inhaling in combination with upward arm movements).

Static breathing exercises in the chest type of breathing:

• relax tense back muscles;
• improve blood supply to the paravertebral muscles due to rhythmic contractions of the thoracic part of the iliac-costal muscle.

Static breathing exercises in the abdominal type of breathing (diaphragmatic breathing) increase the tone of the paravertebral muscles, increasing the compression of the nerve roots. Therefore, this type of breathing exercises is recommended to be included in exercise therapy only after the pain has subsided.

Breathing during static efforts, i.e. in conditions difficult to perform normal breathing movements, is a means of training the diaphragmatic muscles. Therefore, when they are included in exercise therapy, the general requirement for breathing will be its uniformity, depth, and some lengthening of the exhalation phase.

ATTENTION! It is necessary to take into account that correct rational breathing is quite easily combined with low-intensity isometric exercises. Such exercises do not actually change breathing and the development of rational breathing gives a positive relaxing effect.

Exercises in voluntary relaxation of skeletal muscles

These are actively performed physical exercises with the maximum possible reduction of tonic tension of the muscles. It is known that the ability to actively relax muscles is much more difficult than the ability to tense them, since in the process of ontogenesis this type of muscle activity is significantly subject to development.

A distinctive physiological feature of these exercises is their distinct inhibitory effect on the central nervous system. The work of the human motor apparatus is entirely subordinated to the central nervous system: excitation of the motor centers causes muscle contraction and tonic tension, and inhibition of the centers causes muscle relaxation. Moreover, the completeness of muscle relaxation is directly proportional to the depth and degree of the developed inhibitory process.

In the light of modern physiological concepts, muscle relaxation cannot be regarded as only a local phenomenon, since muscles represent a reflexogenic zone of wide significance. To assess the mechanisms of the influence of relaxation, it should be taken into account that the level of proprioceptive afferentation is sharply reduced. Consequently, muscle relaxation not only minimizes energy expenditure in these muscles, but also promotes increased inhibition of nerve centers. According to the mechanism of motor-visceral reflexes, this naturally affects various vegetative functions. These mechanisms largely determine the physical and tonic activity and blood supply of the muscles surrounding the spine and the muscles of the extremities.

A mandatory physiological condition for maximum voluntary relaxation is a comfortable starting position. The sensation can be evoked in the patient by contrast with the previous tension, as well as by available auto-training techniques (such as, for example, "now the hand is resting", "the hands are relaxed, hanging freely, they are warm, they are resting", etc.).

When performing exercises in relaxation, not only a decrease in the tone of skeletal muscles is achieved, but also a simultaneous decrease in the tone of smooth muscles of internal organs in the zone of segmental innervation.

Relaxation exercises are an excellent means of controlling and training inhibitory reactions. They are also used as a means of reducing physical stress during exercise, to restore impaired coordination, and to normalize muscle tone when it has increased over a long period of time.

It is recommended to conduct relaxation training in the initial lying position, when significant static load is removed from the muscles of the trunk (and in particular, from the paravertebral muscles), and then conduct these exercises in other initial positions.

In the method of exercise therapy for spinal lesions, relaxation exercises are used in the case of the development of muscle contractures, to equalize the tone of the muscles surrounding the spine, to restore impaired coordination of movement, and to influence the central nervous system.

Additional techniques that facilitate voluntary relaxation include shaking, rocking, and swinging movements. When combined with massage, stroking and vibration techniques are used to enhance the relaxing effect.

Examples of typical muscle relaxation exercises:

• I.P. - lying on your back, arms along your body, legs straight. Complete voluntary relaxation of the muscles of the trunk and limbs: “all muscles are relaxed, warm, resting. Legs are heavy, warm, but they are resting. Arms are warm, heavy. Abdominal muscles are relaxed. Complete, deep, calm rest.” Raise arms slowly upward - stretch - return to I.P.
• I.P. - the same. Slowly bend the right leg at the knee joint, swing it right and left, relax the leg muscles. The same with the left leg.
• I.P. - the same, arms bent at the elbows. Shake your hands and relax, dropping your right and left hands alternately.
• I.P. - lying on your stomach, hands under your chin. Bend your legs at the knees, alternately touching your buttocks with your heels, then relax and "drop" your right and left shins alternately.
• I.P. - standing. Raise your arms up, relax your hands, relax and lower your arms down along your body, while relaxing slightly tilt your body forward, swing your relaxed arms.

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Isotonic exercises

Dynamic exercises in this period are performed in:

• the form of movements in individual joints and individual segments of the body (fingers, hands, feet, forearm, shin, etc.);
• in the form of joint movements of the arms and torso, legs and arms, head and torso, etc.

The degree of muscle tension is regulated by:

• the length of the lever and the speed of movement of the moving segment of the body;
• relieving and eliminating tension in some muscles by transferring the load to others (for example, when lifting the affected leg up with the help of the healthy one);
• the use of movements performed entirely or partially due to the action of gravity;
• varying intensity of volitional muscle tension.

The listed types of physical exercises provide:

• improving blood circulation and metabolism in individual segments of the limbs or torso;
• restoration of reduced strength and speed of contraction of working muscles;
• restoration of limited mobility in individual joints;
• stimulation of regeneration processes.

A. Exercises for the lower limbs.

Hip joint.

Movements in the joint:

• flexion and extension,
• abduction and adduction,
• external and internal rotation.

For all movements in the hip joint, the abdominal and back muscles play an important role, ensuring, along with the muscles surrounding the joint, a symmetrical, correct position of the pelvis. Therefore, when working on restoring movements in the hip joint, weakened abdominal muscles should be strengthened in parallel (while eliminating pain syndrome and back muscles), achieving normalization of the tone of the muscles that stabilize the pelvic girdle.

Sample exercises for the hip joint.

1. I.p. - lying on your back. Bending and unbending your legs, sliding your feet along the surface of the couch.
2. I.P. - the same. Use your hands to pull up your bent legs (knees to your chest), straighten your legs, sliding your feet along the surface of the couch.
3. I.P. - the same. Bend your legs as much as possible, bringing your knees to your chest - spread your knees, straighten your legs, relaxing your muscles, "throw" them onto the surface of the couch.
4. I.p. - standing. Swinging movements with a straight leg forward and backward, to the sides. The exercise is performed alternately from I.p. - standing facing or sideways to the gymnastic wall.

Recommended for the hip joint and exercises with maximum possible unloading of the lower limb.

Exercises to unload the limb allow you to:

• increase the range (volume) of motion in the joint;
• to act on different muscle groups in isolation (for example, abductor, adductor muscles).

Knee joint.

Movements - flexion and extension.

The exercises are performed in the patient's initial position - lying on his back, on his stomach.

Sample exercises for the knee joint.

1. Patient's initial position - lying on the back. Alternating and simultaneous extension of the legs at the knee joints.
2. I.p. - the same. Active pulling up of the patella.
3. Patient's initial position - lying on the stomach. Alternating flexion and extension of the legs at the knee joints.

These exercises can be made more difficult by:

• dosed resistance by the doctor's hand;
• dosed resistance with a rubber expander;
• a light weight fixed to the lower third of the shin (for example, a cuff with sand weighing 0.5-1 kg).

Ankle joint. Approximate exercises for the first 2-3 days of the period:

• flexion and extension of the toes (alternately and simultaneously),
  • dorsiflexion and plantar flexion of the feet,
  • foot rotation,
• flexion and extension of the leg at the knee joint (alternately and simultaneously),
  • abduction and adduction of the lower leg, sliding it along the roller,
• pulling the bent leg to the chest (using the hands),
  • bending and unbending the leg at the hip joint, sliding the shin along the roller. The exercise is performed only alternately.

If it is impossible to perform active movements of the lower limbs, they are performed under simplified conditions (placing a sliding plane under the limb, using roller trolleys, etc.).

As the pain syndrome decreases, movements are added to the exercises that cover all joints and muscle groups of the lower extremities, while increasing the range of motion and dosage.

When performing isotonic exercises for the lower extremities, the following guidelines should be followed (according to M.V. Devyatova):

Exercises for the ankle joint are performed in the initial position - lying on your back:

• with a smoothed lordosis - with the legs bent at the hip and knee joints, the feet on the surface of the couch;
• with pronounced lordosis - with the legs straightened at the large joints, with some limitation of plantar flexion;
• in case of scoliotic installation, the patient's motor capabilities should be taken into account.

ATTENTION! Compliance with these conditions is necessary to prevent tension on the lumbosacral spinal cord roots.

Exercises for the hip joint:

• i.p. - lying on your side,
• in case of kyphosis of the lumbar region, hip extension should be limited,
• when increasing lordosis, it is necessary to limit flexion so as not to increase pain and not to cause tonic tension in the muscles surrounding the joint.

Exercises that can cause tension in the roots and nerve trunks involved in the process are contraindicated:

• exercises for the hip joints, performed with straight legs (both suspended and sliding along the plane of the couch);
• extension of the feet with straight legs;
• straight leg rotation.

It is recommended to include these exercises in exercise therapy sessions when pain in the lumbar spine decreases, at the end of the period.

Isotonic exercises for joints and muscles of the lower extremities are already performed in the middle of the period in the initial position - lying down, standing. Active exercises with dosed weighting, exercises with rubber shock absorbers are used. Movements are shown (possibly with the help of a methodologist at first) on an inclined plane.

Examples of typical exercises for the first 5-7 days of the period.

1. Standing, feet shoulder-width apart. Slowly turn your torso to the right and left while simultaneously spreading your arms to the sides - inhale. Lower your arms - exhale. Repeat 4-6 times.
2. Standing, feet shoulder-width apart, hands on waist. Move elbows back - inhale, return to starting position - exhale. Repeat 6-8 times.
3. Lying on your back, legs straight, arms along the body. Bend your leg, bringing it as close to your stomach as possible - exhale, straighten your leg - inhale. Do the same with the other leg. Repeat 4-6 times.
4. Lying on your back, legs bent, right hand on your stomach, left hand along your body. Push your stomach out while inhaling, pull it in strongly while exhaling. Repeat 4-6 times.
5. Lying on your back, legs bent, arms along the body. Sliding your heels along the floor, stretch your legs - inhale, bend them slowly - exhale. Repeat 4-6 times.
6. Lying on your side, legs straight. One hand is on your waist, the other is behind your head. Bend the leg lying on top - exhale, straighten - inhale. Do the same with the other leg, turning to the other side. Repeat 4-6 times.
7. Lying on your side, legs bent. While inhaling, “stick out” your stomach, while exhaling, pull it in strongly. Repeat 6-8 times.
8. Standing, feet shoulder-width apart, hands to shoulders. Circular movements with elbows 8-10 times forward and backward. Breathing is arbitrary.
9. I.P. - arms along the body, legs bent at the knees, heels slightly closer to the buttocks, shoulder-width apart. Inhale deeply; while exhaling, alternately bend your knees inward, touching the mattress with them (the pelvis remains motionless). Repeat 10-12 times with each leg.
10. 10. I.P. - arms along the body, legs together. Inhale deeply, pull up the leg bent at the knee with your hands; during an intense exhalation, press it onto the chest 2-3 times. Repeat 3-4 times. The same with the other leg.

B. Exercises for abdominal muscles.

The results of the EMT study, indicating a decrease in the potential for tension in the abdominal wall muscles, indicate the need to restore muscle balance that stabilizes the spine in the lumbar region by optimally strengthening the abdominal muscles.

ATTENTION! It should be remembered that by strengthening the abdominal wall muscles, we simultaneously relax the back muscles, since during tension of the agonist muscles, the antagonists relax.

Exercises of an isotonic nature are included in the therapeutic exercise sessions, performed in the initial position - lying on the back, legs bent at the hip and knee joints (i.e., unloading the affected part of the spine and relaxing the paravertebral muscles). In this position, the lumbar lordosis is somewhat corrected, the intervertebral space increases, and the nerve roots are unloaded.

Examples of typical exercises.

• I.p. - lying on your back. Pulling your knees up to your chin while simultaneously lifting your head and shoulders. With this movement, which is performed in accordance with gravity, kyphosis of the lumbar region occurs and, as a result, the back muscles are stretched. Simultaneously with the movement of the head towards the chest (the movement is performed against gravity), the rectus abdominis muscles work.
• The pelvic lift exercise is quite effective for training the rectus abdominis muscle and stretching the paravertebral muscles (in the lumbar region.

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Exercises aimed at "stretching" the spine

“Stretching” of the spine along the axis is accompanied by:

• increase in the intervertebral space,
• increase in the diameter of the intervertebral foramen (decompression of the nerve root).

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"Proprioceptive facilitation" (G.Kabat method), or PNF

I. Exercises for the lower limbs.

1st diagonal.

A. Movement from bottom to top.

Patient's initial position: lying on the back, legs straight, one leg abducted, foot pronated.

The physician stands on the side of the affected lower limb, grasping the foot with one hand so that the four toes are on the inner edge of the foot; the other hand is placed on the inner surface of the thigh.

The movement is performed sequentially:

• extension of the toes;
• dorsiflexion of the foot;
• its supination;
• advent;
• flexion and internal rotation of the hip.

ATTENTION! The entire movement pattern is performed with measured resistance.

B. Movement from top to bottom.

From the final position of the movement: from bottom to top, you should perform:

• flexion of the toes;
• foot extension;
• extension, abduction and external rotation of the hip.

2nd diagonal.

The patient's A.I. position is lying on his back, one leg lies on the other, slightly rotated outward; the foot is in extension and supination, the toes are bent.

The doctor grasps the leg in the same way as in the 1st diagonal, only his hand is placed on the outer surface of the thigh.

The movement is performed sequentially:

• extension of the toes;
• dorsiflexion and pronation of the foot;
• hip flexion with abduction and external rotation.

ATTENTION! As with the 1st diagonal, the movement is performed at its maximum amplitude.

B. I.p. - the same.

When completing the movement from top to bottom of the 1st diagonal, the hip extension continues with knee flexion. When performing the reverse movement, first:

• extension of the knee joint;
• flexion of the hip and its rotation inward, from the moment it rises from the plane of the couch.

II. Exercises for the trunk.

Patient's initial position: lying on his back, hands clasped behind his head and moved slightly to the right (left) of the body axis.

Movement: the patient's arms and torso bend in the opposite direction (to the left), simulating chopping wood.

• The patient's initial position is lying on his side (in the absence of contraindications).

The doctor stands behind the patient, one hand is placed on the forehead, the other is located in the area of the patient's knee joints (to resist general flexion of the torso).

Movement: possible bending of the trunk by tilting the head, shoulder girdle and lower limbs.

• The patient's initial position is lying on his side (in the absence of contraindications).

The doctor stands in front of the patient, placing one hand on the back of the patient's head and the other on the lower third of the thigh (to resist extension of the torso).

Movement: extension of the torso by tilting the head, shoulder girdle and lower limbs backwards.

• Patient's initial position: lying on his back.

The doctor stands in front of the patient, placing both hands on his shoulders (to provide resistance when attempting to bend the torso forward).

Movement: bending the torso forward by tilting the shoulder girdle.

• The patient's initial position is lying on his stomach.

The doctor places his hands in the area of the patient's shoulders (resisting the movement of the shoulder girdle tilting backwards).

Movement: backward deviation of the shoulder girdle (extension of the trunk).

• Patient's initial position: lying on his back.

The doctor's hands fix the patient's shoulders. The patient attempts to turn the torso by moving first the right, then the left shoulder, the doctor's hands alternately resist this movement.

• Patient's initial position - lying on stomach. Same movements.

ATTENTION! Exercises for the torso are performed:

• at maximum resistance;
• diagonally and in combination with rotational movements.

III. Symmetrical movements.

These movements are performed by limbs located symmetrically in one of the two diagonal systems. In this movement, the doctor grasps and, therefore, provides dosed resistance only in the area of the lower third of the shin (or foot area).

Movement against resistance is performed for the lower limbs:

• during adduction and internal rotation;
• abduction and outward rotation.

The exercises are carried out at the end of the session, when the patient has already used his ability to exert effort in simple exercises - at maximum resistance.

ATTENTION! The resistance in these exercises is significantly less than in simple exercises.

Corrective exercises

This group includes special physical exercises that provide correction of spinal deformities by selecting exercises and muscle traction in the direction opposite to the defect. All corrective exercises are performed in the initial position, in which the spine is in the position of the least static tension; the best conditions for correction are in the supine and prone positions. However, this does not exclude the possibility of performing corrective exercises in the side-lying position with the simultaneous use of pads that correct the condition of the spine.

Corrective exercises are divided into:

• for symmetrical exercises;
• asymmetrical exercises.

Symmetrical corrective exercises. These include physical exercises that maintain the median position of the spinous process line. Maintaining a symmetrical arrangement of body parts relative to the spine and keeping it in the median position is a complex physiological task for a patient with spinal damage. Indeed, asymmetry of the muscles surrounding the spine often plays a major role in the pathogenesis of spinal diseases. Electromyographic studies, in particular, show that with curvature of the spine in any of its sections, the electrical activity of the muscles on both sides of the spine is always different. Consequently, maintaining the median position of the spine, resisting its deviation towards stronger muscles will cause greater tension on the side where the muscles are weak, i.e. exercises that are symmetrical in nature in terms of muscle tone are asymmetrical in nature.

When performing symmetrical exercises, muscle tone gradually equalizes, its asymmetry is eliminated, and muscle contracture that occurs on the concavity side of the curvature arc is partially weakened.

The advantages of symmetrical corrective exercises are the stimulation of compensation processes in patients and the comparative simplicity of their selection.

ATTENTION! When performing symmetrical corrective exercises, the doctor (physical therapy specialist) must be able to constantly monitor the position of the line of the spinous processes of the patient's spinal column.

Asymmetrical corrective exercises. Such exercises allow you to select the starting position and muscle traction of the corresponding muscles specifically for a given segment of the spinal column. For example, in the initial position - lying on the right-sided lumbar curvature, abduction of the straight leg to the side reduces the arc of curvature due to the change in the position of the pelvis and muscle traction. By varying the position of the pelvis and shoulder girdle, the angle of abduction of the arm or leg, taking into account the biomechanics of movements, you can quite accurately select an asymmetrical exercise for the maximum possible reduction of deformation.

ATTENTION! When selecting asymmetric exercises, it is necessary to take into account the X-ray data (in the lying and standing positions). The routine use of asymmetric exercises can lead to an increase in deformation and progression of the process.

Examples of typical asymmetrical corrective exercises:

• patient's initial position - lying on the stomach, the arm on the side of the concavity of the thoracic region is raised upwards, the other arm is bent at the elbow, the hand is under the chin. Raise the head and shoulders - return to initial position;
• patient's initial position - lying on the stomach, hands under the chin. Move the straight leg to the side of the convexity of the lumbar spine, raise the head and shoulders while simultaneously stretching the arm upward from the side of the concavity of the thoracic spine, return to initial position;
• patient's initial position - standing on all fours. Raise the arm up on the side of the concavity of the thoracic spine, move the straightened leg back on the side of the concavity of the lumbar spine.

A special place among corrective exercises is occupied by exercises for the iliopsoas muscle.

In the pathogenesis of spinal deformation in the thoracolumbar region, these muscles, with uneven length, cause deviation of the corresponding segment of the spine from the midline. Therefore, based on the biomechanical features of the lumbar region, isolated training of these muscles was proposed.

The lumbar part of the muscle originates from the transverse processes of the lumbar vertebrae and the lateral surface of the 12th thoracic and 1st lumbar vertebrae (Th12-L1), the iliac part - from the inner surface of the ilium. Connecting in the cavity of the greater pelvis, the iliopsoas muscle is directed obliquely downwards, passes under the inguinal ligament and is attached to the lesser trochanter of the femur. The muscle is a flexor of the hip when the hip joint is flexed more than 90°, and when the hip is fixed, it is a flexor of the trunk. When the iliopsoas muscle is tense, lordosis increases, and when relaxed, it decreases. The muscle plays a certain role in walking and running.

Biomechanical analysis of the muscle's work showed that its contraction causes tension in three directions - downwards, to the side and forwards. Together, the combination of these forces shifts the vertebrae of the concave part of the lumbar arch of curvature to the midline, reducing the curvature, and also derotates it. Simultaneously with this action of the iliopsoas muscle, the corrective effect is also exerted by the tension of the back and abdominal muscles when bending the thigh at the hip joint.

Taking these data into account, the muscle training methodology provides for the following.

Method 1

• Patient's initial position: lying on his back, leg bent at the knee and hip joints at an angle of 90°;
• using a cuff on the lower third of the thigh and a block through which a pulley is thrown from the cuff to the load, the thigh is flexed and brought to the stomach;
• muscle training begins with 15-20 bends with a load of 3-5 kg, then gradually increases the number of bends.

Method 2

Involves working the muscle in isometric mode while holding a load.

• Patient's initial position is the same. A weight of 6 to 10 kg is attached to the block;
• the patient is asked to hold the load without making any movements with the leg;
• The initial fixation time is 10 s, gradually increasing the exposure to 30 s.

We modified Method 1 by asking the patient to perform iliopsoas muscle training on a special table - the “loop complex”.

The most effective use of asymmetric exercises for the iliopsoas muscle is at the apex of the curvature from Th10 to L1. In this condition, the muscle is stretched on the concave side of the curvature and its training gives a fairly clear effect. With a lower localization of the curvature arc, the muscle is stretched on the convex side and its training will increase the curvature arc.

Therefore, asymmetrical exercises for the iliopsoas muscles are contraindicated when the curvature is localized with the apex of the arc above the Th10 and below the L1 vertebrae. They are indicated when the apex of the curvature is at the level of the Th10-L1 vertebrae.

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Exercises aimed at increasing spinal mobility

Limitations of mobility in the affected spinal vertebral joint are one of the clinical manifestations of compensation. Therefore, the appointment of exercises to increase spinal mobility is possible only with the preliminary development of sufficient strength endurance of the trunk muscles and active stabilization, under constant medical supervision and with extreme caution.

We have observed patients in whom early and massive use of exercises to increase spinal mobility led to a short-term reduction in the scoliotic arc, followed by noticeable progression.

On the contrary, exercises in mobilizing the spine significantly facilitate correction. To mobilize the spine, increase its mobility, exercises in crawling on all fours, in mixed and pure hangs, exercises on an inclined plane are used.

In all these exercises, in addition to the active muscular component, there is an impact of the weight of one's own body on the spine, which, if the strength endurance of the muscles is insufficient, carries the risk of overstretching the ligamentous apparatus of the spine.

Examples of typical exercises.

1. Patient's initial position: standing on all fours (supported by hands and knees). Walking on all fours.
2. Patient's initial position: standing on all fours (support on forearms and knees). Semi-deep crawling.
3. The patient’s initial position is to hang on a gymnastic wall and hold this position for (a specified period of time).
4. Patient's initial position - mixed hanging on a gymnastic wall (support on the 1st-2nd rail, grip with hands above the head, facing the wall). Movement along the gymnastic wall to the right and left.
5. In the starting position of a simple hand hang:
   1. spread your straight legs to the sides and bring them together;
   2. bend and lower your leg alternately.

Torso bends, in which the rotation point passes through the lumbar spine, increase intradiscal pressure: the greater the amplitude of the movement, the higher the pressure inside the disc. The greatest increase in pressure is demonstrated when bending the torso forward (flexio) and the smallest when bending backward (extensio). This is explained by the fact that during this movement not only the force of contraction of the back muscles increases, but also the horizontal size of the nucleus pulposus, therefore, its supporting surface decreases.

In the initial standing position, the force of contraction of the trunk muscles required to hold the body in an upright position is less than in the initial position - sitting. If we take into account the attachment points of the muscles involved in this act, and consider the relationship of the sacrum, pelvis and spine as a lever system with a rotation point in the lumbosacral region, it becomes clear that the active lever arm in the initial standing position is longer than in the initial sitting position. Consequently, less effort is required to hold the same weight.

This was reflected in the intradiscal pressure readings, which in all patients in the standing position was lower than in the sitting position. In this position, the true load on the lumbar discs is 1.4-2.5 times greater than the estimated weight above the disc level. Therefore, during this period, it is recommended to conduct therapeutic exercise in the patient's initial position - lying (on the back, on the stomach, on the side), on all fours and standing.

ATTENTION! In the patient's initial position - lying on the side, the average pressure inside the disc fluctuates from 2.3 to 5.1 kg/cm2 ^; in case of pain syndrome or discomfort in the lumbar region, the intradiscal pressure clearly increases. Based on this, in this initial position it is inappropriate to use exercises aimed at increasing mobility.

When prescribing exercises aimed at increasing the range of motion of the spine, the following should be taken into account:

• features of the biomechanics of the spinal column;
• "lumbopelvic rhythm".

A. Features of the biomechanics of the spine when bending the torso.

When bending the torso, the following occurs:

• stretching of the posterior longitudinal ligament and fibers of the posterior part of the disc annulus;
• relative posterior displacement of the disc nucleus, increasing tension of the posterior semiring;
• stretching of the yellow and interspinous ligaments;
• widening of the intervertebral foramen and tension of the capsule of the intervertebral joints;
• tension of the muscles of the anterior abdominal wall and relaxation of the extensor muscles of the back;
• tension of the dura mater and roots.

ATTENTION! It should be remembered that in the patient's initial position - standing, the active function of the back muscles ceases after the body is tilted by 15-20°; with further tilting, the muscles and fibrous tissues are stretched, which manifests itself as pain.

As a result, forward bends of the torso should be performed during this period with caution, smoothly, to a bending angle of 15-20°, gradually increasing the degree of bending, from the starting position - lying on the back and on the side.

When the torso is extended, the following occurs:

• stretching of the anterior half-ring of the disc;
• relative anterior displacement of the disc nucleus;
• contraction of the yellow ligaments (their shortening) and relaxation of the interspinous ligaments;
• narrowing of the intervertebral foramina;
• stretching of the muscles of the anterior abdominal wall and tension of the paravertebral muscles;
• relaxation of the dura mater and roots.

In general, the amplitude of extension of the lumbar spine is less than the amplitude of flexion, which is due to the tension of the anterior longitudinal ligament, abdominal muscles, and the “closure” of the spinous processes.

B. Lumbar-pelvic rhythm.

Torso tilts (flexion-extension) also depend on the so-called “lumbar pelvic rhythm”/

Any changes in this rhythm due to a violation of statics and dynamics can eventually lead to the occurrence of pain, for example, sacralgia, which occurs due to an incorrect motor stereotype when returning the torso from a flexion position to an extension position.

Consequently, with increasing extension in the lumbar region, the pressure on the posterior sections of the fibrous ring and the posterior longitudinal ligament, which is richly innervated, increases, and in some cases on the nerve root (with a decrease in the diameter of the intervertebral opening), which is manifested by pain syndrome, tension of the paravertebral muscles of the back, limitation of the amplitude of movement of the spine. In this regard, in the first days of the period, physical exercises aimed at extension of the lumbar spine in the initial position - standing should not be included in exercise therapy. Only exercises of an extension nature are possible, performed in the initial position - lying on the stomach (with a small pillow placed under the stomach). Due to this, when performing exercises associated with some extension of the trunk, hyperextension in the lumbar spine will not occur.

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Physical exercises in an aquatic environment (therapeutic pool)

The peculiarities of mechanical influences of the aquatic environment are explained by the laws of Archimedes and Pascal. Due to the decrease in the weight of the affected limb (torso), the execution of movements becomes easier. In addition, the temperature factor (heat) contributes to a lesser manifestation of reflex excitability and spasticity of muscles, and pain relief. At the same time, blood supply and lymph circulation improve, the resistance of the entire periarticular apparatus of the joints decreases, which contributes to better implementation of the motor function. Therefore, physical exercises in the aquatic environment allow using the limited muscle strength of the affected (weakened) muscle groups, which is difficult to detect in normal conditions.

The method of therapeutic swimming pool therapy consists of performing exercises using the simplest exercise equipment.

ATTENTION! Poorly coordinated movements in water will not only not give the desired effect, but in some cases can worsen the condition of the spine.

Walking

Walking is the main natural form of cyclical movement, a way of moving the body in space.

Correct walking is characterized by a free, natural position of the body, with a symmetrical arrangement of its parts relative to the spine, cross-coordination of the arms and legs, placing the stepping foot on the heel with a subsequent roll onto the toe, straightness and uniformity of the step length.

Biomechanical analysis of the movements of the spine and pelvis indicates the following:

1. in the frontal plane, the pelvis rotates and tilts toward the leg behind, and the thoracic spine shifts toward the supporting leg. At the moment the leg is moved forward, the position of the pelvis is leveled, and at the same moment the spine straightens. The entire cycle of movements of the pelvis and spine in the frontal plane is completed in one double step;
2. in the sagittal plane during walking, the pelvis tilts forward and backward, these movements are insignificant and do not exceed 3°;
3. in the horizontal plane during walking the spine is tilted forward, lumbar lordosis slightly decreases and thoracic kyphosis increases with an increase in cervical lordosis. The shape of the spine changes smoothly during walking, the same happens with the rotation of the spine along the axis. When leaning on the right leg, the pelvis rotates clockwise, on the left - counterclockwise. The pelvis and the upper thoracic spine rotate in different directions, the lumbar spine rotates in the same direction as the pelvis, the lower thoracic spine remains neutral. The movements in the horizontal plane are greatest in the thoracic spine, in the frontal and sagittal - in the lumbar spine.

According to the movements of the spine and pelvis during walking, muscle activity changes:

• at the initial moment of the step, as the load on the supporting leg increases and the pelvis rotates in the opposite direction, and the spine - towards the supporting leg, the activity of the gluteus medius muscle on the side of the support and the muscle that straightens the spine on the opposite side increases, then the activity of the muscles decreases and increases again on the opposite side when changing the supporting leg;
• The hip flexors develop the greatest activity at the border of the support period, stabilizing the hip joint and extending it.

When statics are disturbed, the nature of the spine and pelvis movements and the work of the muscles change. Although they retain the general patterns of walking of a healthy person, "tuning" lateral movements of the spine appear, directed towards the concavity of the curvature of the thoracic region, i.e. the arc of curvature decreases.

The presented studies allow the use of walking exercises as a special exercise for restoring impaired statics in patients to reduce pain in the lumbar spine.

Walking can be included in all sections of the lesson (primarily in the introductory and final sections).

The exercises are made more difficult by maintaining correct posture, combining walking with breathing, and including various movement options:

• on toes, on heels, on the inner and outer edges of the feet, with a roll from heel to toe, with high raising of the hips, in a half-squat, with a cross and side step;
• walking with stepping over small obstacles, going around various objects;
• walking for precision of step, stepping on transverse lines or tracks;
• walking up and down stairs;
• walking with open and closed eyes over a limited area, a certain distance, in a certain direction, changing speed, tempo and rhythm on command.

ATTENTION! In all types of exercises, pay attention to the transfer of the body's center of gravity to the supporting leg, the leg being brought forward. The body should not lag behind the movement of the leading leg.

Physical therapy during the recovery period

Contraindications

• The occurrence of pain syndrome.
• Increased tension in the paravertebral muscles, disruption of the statics of the spine.

The main task of the period is to restore the dynamic stereotype.

To solve it, physical exercises are used that are aimed at:

• strengthening the abdominal muscles, back, and pelvic girdle muscles;
• strengthening the muscles of the lower limbs;
• developing correct posture (both during work and in everyday life).

Increasing the strength and tone of the abdominal muscles increases the efficiency of the mechanism for transferring mechanical loads from the skeleton to the muscular system (increasing the tone and strength of the abdominal muscles leads to an increase in intra-abdominal pressure, due to which part of the forces acting on the lower intervertebral discs are transferred to the pelvic floor and diaphragm).

Another consequence of increasing abdominal muscle strength is the stabilization of the spinal column, which is not a stable structure in itself. In the lumbar region, the spine is supported from behind by the erector spinae, in the anterolateral region by the lumbar muscle, and in the front by the intra-abdominal pressure created by the tension of the abdominal muscles.

The stronger these muscles are, the greater the force that stabilizes the lumbar spine (the above muscles also control all movements of the spine.

Strengthening of the abdominal muscles should be accomplished through their isometric contractions (movements of the spine are excluded) and isotonic exercises performed in the initial position - lying down, standing.

Isometric exercises

It is known that static efforts (isometric nature of exercises), accompanied by a continuous flow of proprioceptive afferentation, cause pronounced changes in the functional state of the central nervous system and are significantly more tiring than isotonic exercises. This is explained by the rapid fatigue of nerve cells under conditions of continuous activity of the motor nerve centers, providing constant muscle tension during isometric effort.

The longer duration of isometric tension compared to dynamic tension with the same number of exercise repetitions allows one to achieve a greater volume of strength work from a physiological point of view.

Another aspect is also important. When individual muscles are weakened, other, larger ones take over some of their functions when performing isotonic exercises. In this case, weakened muscle groups are outside the training effects and their function at best does not increase, and may even worsen. Exercises in isometric mode, allowing to minimize the compensatory efforts of unaffected muscles, provide targeted strength training of weakened muscle groups.

Of undoubted interest is the fact that the preceding isometric muscle tension has a positive effect on subsequent isotonic work, the increase of which increases by an average of 18.7-20% compared to dynamic work without preliminary static tension, and the aftereffect does not appear immediately after isometric tension. The first isotonic contraction still shows signs of inhibition, but already with the second movement the force increases sharply compared to the initial one.

When performing isometric exercises, mechanical work is practically reduced to zero. However, as with isotonic work, with isometric tensions, physiological changes occur in the body, which are taken into account when characterizing static efforts:

• static efforts are aimed at maintaining a certain position of the body or its segments in space when performing physical exercises;
• static efforts are aimed at maintaining the patient's natural posture in everyday life.

Physiological mechanisms of regulation of static postures have significant differences depending on the tonic or tetanic mode of muscle activity:

• maintaining the patient's natural body posture is achieved through economical, low-fatigue tonic muscle tension;
• static positions encountered during physical exercise are maintained by tetanic muscle tension.

ATTENTION! When performing isometric exercises, the intercostal muscles are involved in maintaining a certain posture. In this case, the patient is forced to switch from chest to diaphragmatic breathing.

Isometric tensions are performed with breath holding and straining. This condition is especially noted in patients at the initial stages of learning these exercises.

These exercises exert a certain load on the abdominal muscles and paravertebral muscles, practically without increasing the intradiscal pressure. At the same time, their use requires a certain amount of caution for people with concomitant cardiovascular disease due to the fact that static exercises cause the so-called Valsalva effect - an increase in intrathoracic pressure leads to a decrease in blood flow to the heart (due to "compression" of the vena cava) and a decrease in the number of heartbeats.

As training progresses, patients' breath holding and straining become less pronounced. This is due to the fact that the act of breathing becomes a component of the motor skill. Being included in the system of conditioned reflex connections, it facilitates the effective performance of physical exercises.

ATTENTION! Energy expenditure during static work is less intense than during isotonic work.

Of great interest is the vegetative support of static activity, characterized by a number of features. First of all, this is a delay in the development of vegetative shifts, the maximum of which occurs not during the static effort, but in the first minutes of the recovery period.

The intensification of physiological functions after isometric tensions observed in the first stages of training is associated with the special nature of the central regulation of vegetative functions. Persistent excitation of motor centers during static activity causes, by the mechanism of negative induction, the suppression of the nerve centers regulating the respiratory and cardiovascular systems (the Lindgard phenomenon).

After the end of the static effort, the excitability of the respiratory and blood supply regulation centers increases. Cardiac productivity and gas exchange increase, and oxygen consumption increases.

Of known importance in the occurrence of the phenomenon of static effort is the change in the conditions of blood circulation in isometrically strained muscles. After performing static work, the products of anaerobic muscle metabolism are freely carried out into the general circulation. The buffer function of the blood is activated. Binding of excess lactic acid by bicarbonates leads to an increase in the content of CO2 _in the blood and increased respiration.

ATTENTION! The phenomenon of static effort is transient. After a course of exercise therapy with the inclusion of isometric exercises, it is smoothed out or disappears completely.

Thus, isometric exercises contribute to the improvement and expansion of motor skills of patients, providing an increase in general strength training and specific endurance to static effort. These exercises are aimed at increasing the functional capacity of the entire locomotor apparatus (primarily the muscular system), improving its regulation by the central nervous system. This causes not only an increase in muscle strength and endurance to static effort, but also creates the prerequisites for developing the skill of full voluntary relaxation of skeletal muscles, which is of fundamental importance in the regulation of muscle tone. Therefore, the improvement of these motor skills pursues the tasks of full physical rehabilitation of patients.

Methodological recommendations for performing exercises in isometric mode.

• The duration of static effort in each exercise depends on its intensity and is in inverse proportion to it. Low-intensity exercises are performed for 30-60 sec, moderate and average intensity - 5-25 sec, higher intensity - no more than 2-7 sec.
• During the execution of exercises in the isometric mode of low intensity, breathing should be uniform, deep, with some lengthening of the exhalation phase; short-term exercises of significant intensity are performed in the exhalation phase.

ATTENTION! When performing isometric exercises, involuntary holding of the breath during the inhalation phase is not recommended.

• After each repetition of exercises in isometric mode, breathing exercises (static and dynamic) and exercises in voluntary muscle relaxation are mandatory.

Using resistance and weights to master active movements

To strengthen the muscles of the trunk and limbs, resistance and weighted exercises are used in RG classes. Dosed yielding and directing resistance has a mainly local effect on a certain group of muscles; however, this effect is short-term. The effect of weighting is more extensive and lasts longer.

Resistance exercises.

These exercises aim to selectively influence the execution of certain movements in order to increase their range of motion, dosage of force stress, development of the support capacity of the limbs and strength of the acting muscles.

Resistance is shown when the patient performs:

• movements in the joints of the limbs or
• movements of various segments of the body.

When providing resistance to a patient, it is necessary to take into account his capabilities, coordinating the force of impact with the patient’s efforts.

ATTENTION! It is necessary to observe how the patient perceives the exercise, whether there are any signs of fatigue or whether the patient substitutes the required movement with tension in other muscles or movements of other body segments.

When providing resistance, the doctor (methodologist) must direct and correct movements, change the load, increase or decrease the frequency of repetitions, and change the force of resistance.

Exercises with local dosed resistance are performed using the therapist's hand, a rubber shock absorber or a block with weight.

Sample resistance exercises.

1. Exercises with resistance provided by the doctor’s hand:

• when bending and unbending the leg at the knee joint, pressure is applied to the lower leg in the direction opposite to the movement;
• When abducting and adducting the hip, pressure is applied to the lower third of the thigh in the direction opposite to the movement.
• When training correct posture in various starting positions, pressure is applied to the patient's shoulders by both hands of the doctor. The patient responds to this by slightly extending the spine and moving the shoulder girdle backwards.

2. Exercises with overcoming the resistance of a rubber band (expander) and a weight in the patient's initial position - lying and standing.
3. Isotonic exercises

During this period, classes use dynamic exercises to:

• upper limbs;
• upper limbs and shoulder girdle;
• shoulder girdle and back;
• torso;
• abdominal press and pelvic girdle;
• lower limbs.

The classes include active exercises:

• with gymnastic equipment;
• with gymnastic equipment;
• on the shells.

During this period, most patients experience further weakening of the gluteal muscles, knee and ankle extensors, back and abdominal muscles.

Gluteal muscles. The functional state of the gluteal muscles plays a decisive role and their strengthening is absolutely necessary both for learning how to stand and walk correctly and for correcting gait.

It is recommended to begin training in contraction of the gluteal muscles with associated contractions of other muscles.

For example, from the patient's initial position - lying on his stomach - lifting his head. At the same time, the patient's attention is drawn to the accompanying tension of the gluteal muscles.

The same thing happens when raising the pelvis from the starting position - lying on your back (“half bridge”).

The following exercises are used to contract the gluteal muscles:

• patient's initial position - lying on the stomach - active-passive (active) extension of the leg at the hip joint, followed by the task of holding it in this position (isometric tension, exposure - 5-7 s);
• patient's initial position - lying on stomach - abduction and adduction of the straight leg;
• patient's initial position - lying on stomach - lifting straight legs 10-150 from the plane of the couch;

At the same time as strengthening the gluteus maximus muscles, you should exercise the gluteus medius and minimus muscles.

• patient's initial position - lying on the side corresponding to the healthy leg; abduction of the affected leg, bent at the knee joint;
• patient's initial position is the same; straight leg abduction;

The same exercises with weights and resistance.

Quadriceps femoris. In some cases, patients do not know how to use the quadriceps femoris as an extensor of the lower leg, and when attempting this movement, flexion in the hip joint is usually noted. To master the extension of the lower leg, it is necessary to teach the patient to relax the muscles of the knee joint, then, against the background of relaxed muscles, teach rhythmic movements of the patella. Only after the patient has mastered these motor techniques can one move on to the sequential alternation of flexion and extension in the knee joint, focusing the patient's attention on the relaxation of the antagonist muscles during the movement.

Further exercises aimed at strengthening the quadriceps muscles are recommended:

• flexion and extension of the knee joint without lifting the foot from the sliding plane;
• flexion and extension of the knee joint with the feet lifted off the plane of the couch (alternately and simultaneously);
• leg movements that imitate "riding a bicycle";
• flexion and extension of the knee joint with weights (cuffs weighing from 0.5 kg), resistance (the doctor’s hand, rubber band, etc.);
• a combination of isotonic exercise with isometric tension.

Muscles that produce dorsiflexion in the ankle joint. The extensors of the foot, due to neurological complications of the spinal disease, are often not included in static activity and walking. In addition, 2.4% of patients have a discoordination of the functions of these muscles. In some cases, when attempting to dorsiflex the foot, the long extensor of the fingers is significantly strained, while the anterior tibial muscle is weakened, and the tension of the long extensor of the big toe is insignificant. In this case, when attempting to extend, the foot assumes a predominantly pronated position.

Other observations revealed that the anterior tibialis muscle and the long extensor of the big toe actively contract while the long extensor of the fingers weakens. Then the foot assumes a varus position.

In these cases, it is necessary to strive to establish the combined work of the muscles. If the function of these muscles is possible, the patient will quickly master the correct movement. First, the dorsiflexion of the foot is performed with the leg bent at the knee and hip joints, and then with the leg straightened.

Ankle dorsiflexion exercises are closely related to improving the weight-bearing capacity of the legs.

Abdominal muscles. To strengthen the oblique abdominal muscles, exercises with bends and turns of the torso in different starting positions are used.

For the rectus abdominis muscles, the following are recommended:

• in the patient's initial position - lying on his back, rhythmic contraction of muscles,
• (fixation of feet) attempt to turn the body;
• in the patient's initial position - lying on the side, raise and slowly lower the straight leg, raise both straight legs by 10-15° and slowly lower, using the leg swing, turn from the back to the stomach and back, arms extended along the body.

In physical therapy classes it is possible to use weights and resistance; exercises performed on an inclined plane, on exercise machines.

Back muscles. Strengthening the back muscles and developing correct posture is an essential prerequisite for restoring a normal walking pattern.

The exercises are performed with the patient lying on his stomach and standing. The sessions include exercises performed on an inclined plane, on or near a gymnastic wall, with weights and resistance. A combination of isotonic exercises with isometric tension of the back muscles is recommended.

The condition of the lumbar intervertebral discs changes depending on the patient's posture, whether in motion or at rest.

Posture determines the strength and duration of mechanical loads acting on the lumbar discs, which are constantly compressed. Compression forces reach their greatest value in the lower intervertebral discs of the lumbar region. They decrease to almost zero in the lying position when the muscles are relaxed and increase rapidly when moving to a sitting or standing position. When performing physical exercises, especially with the use of gymnastic apparatus and equipment (with the use of a lever mechanism).

In the initial standing position, the body weight is evenly distributed between the vertebral bodies and intervertebral discs (intervertebral discs are the only soft tissue that takes part in the supporting function of the spine, which bears the weight of the body).

Loads are transmitted through the central part of the intervertebral discs, the pulpous nuclei of which distribute forces evenly in all directions (balancing the forces that tend to bring the vertebral bodies closer to each other).

As soon as the spine goes beyond the vertical plane during bending, the lever system immediately begins to operate, as a result of which the forces acting on the intervertebral discs increase many times over. This occurs not only due to the connection of the lever mechanism, but also due to the change in the plane of their distribution. As a result, these forces are directed not at a right angle to the intervertebral discs and vertebral bodies, but at an acute angle. The dislocation of the intervertebral discs and vertebral bodies is prevented by the resistance of the intervertebral discs, ligaments, articular processes, as well as the action of the muscles stabilizing the spine.

In connection with the above, it seems to us appropriate to include in exercise therapy exercises torso bends in the initial standing position only after strengthening the muscles that stabilize the spine.

Exercises with gymnastic apparatus:

Exercises with gymnastic equipment: with sticks, clubs, dumbbells, balls, shock absorbers in therapeutic use are a variety of exercises with local and dosed force tension, for stretching muscles, their relaxation, for coordination of movements, corrective and breathing.

The therapeutic effect of exercises with objects is enhanced in comparison with similar exercises without objects due to the weight of the object, improvement of the leverage of the moving body segment, increase in inertial forces arising from swinging and pendulum-like movements, complication of requirements for movement coordination, etc. A factor that increases the effectiveness of exercises is their emotionality, especially if they are performed with musical accompaniment.

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Exercises on gymnastic apparatus

Exercises on gymnastic apparatus: on a gymnastic wall, on special apparatus and devices have an effect similar to exercises with dosed tension, with weights, on muscle stretching, in balance. Depending on the method of execution, they provide a preferential or isolated effect on individual segments of the musculoskeletal system or muscle groups, on the function of certain internal organs, on the vestibular function, etc.

Exercises on gymnastic apparatus in the form of hangs, supports, pull-ups are characterized by a short-term high intensity of the overall impact and can be accompanied by holding the breath and straining.

Special equipment and devices used for various manifestations of pathology in the form of block, spring devices, united by the name "mechanotherapeutic", as well as exercise machines provide an increase in the therapeutic effect due to better localization and, as a rule, a longer action of exercises, a more accurate dosage of the load, an increase in the stretching effect or intensity of tension, etc. Separate devices allow performing passive movements or movements with the help of. The general effect of the exercise used is determined by its intensity.

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Exercises for developing and consolidating the skill of correct posture

Posture is a motor skill that is formed on the basis of reflexes of posture and body position and ensures the maintenance of the usual positions of the head, torso, pelvis and limbs. Good posture ensures the most complete functional and cosmetic mutual arrangement of individual segments of the body and the arrangement of the internal organs of the chest and abdominal cavities.

Exercise therapy sessions should include the following exercises:

• increasing the tone and strength of the muscles of the neck, back, abdomen and limbs;
• forming ideas about the relative positions of individual body segments with correct posture;
• reinforcing these ideas and creating the skill of correct posture;
• reinforcing the skill of correct body position during various muscular activities.

In case of spinal deformities and postural defects, special exercises are used in combination with corrective exercises. The overall effect of exercises aimed at restoring correct posture corresponds to moderate intensity loads.

These exercises occupy a special place in the method of exercise therapy for spinal diseases, since normal or corrected posture is, ultimately, the goal of treatment measures.

For the formation of the skill of correct posture, the proprioceptive muscular sense is of primary importance, i.e. the sensation of the position of one's own body in space, received by the patient due to impulses in the central nervous system from numerous receptors embedded in the muscles. Therefore, when forming and consolidating correct posture, constant attention is paid to the position of the body when performing exercises and in the initial positions.

Formation of correct posture is impossible without a clear mental and visual representation of it.

A mental representation is formed from the words of a doctor (physical therapy methodologist) as an ideal diagram of the body’s location in space - the position of the head, shoulders, chest, back, pelvic girdle, abdomen, and limbs.

The mental representation of correct posture is inextricably linked with the development of its visual image. Patients should see correct posture not only in drawings and photographs, but also in classes.

Finally, using mirrors, patients should learn to adopt correct posture and correct any defects they notice.

Visual control and self-control play an important role in adopting and maintaining the correct posture and, therefore,

Patient's initial position: hanging with his back against the wall. Pull knees to chest, lower.

Patient's initial position: standing facing the wall, legs apart on the lower bar, hands on the bar at waist level. Without bending your legs, grab the bar higher and lower with your hands.

Patient's initial position: standing on the lower bar on the toes, feet together, hands on the bar at chest level. Alternately moving the legs, rise and fall on the toes.

Patient's initial position - standing facing the wall at a distance of a step, hands on the crossbar at waist level. Springy bends, arms and legs do not bend.

Patient's initial position: lying on his back on an inclined plane, toes under the crossbar, hands behind his head. Move to a sitting position.

Patient's initial position: lying on stomach, legs under the lower crossbar, hands behind head. Bending, lift the torso up, without lifting the hips off the floor.

Patient's initial position: standing with his back to the wall. Circular movements with his arms in front of him.

I.P. - the same. Arching forward without bending your arms. The same at a distance of a step from the wall.

Patient's initial position: standing facing the wall at a distance of a step, take hold of the handles of the upper expander. Bend over without bending your arms. Do the same, bending backwards.

I.p. - the same. Imitation of hand movements as when skiing.

Patient's initial position - lying on his back on an inclined plane, grasp the crossbar with straight arms. Bend your legs at the knee joints, straighten them upwards, and lower them slowly.

Patient's initial position: lying on his back on an inclined plane, take hold of the handles of the lower expander with his hands. Raise and lower his hands alternately.

Patient's initial position - lying on the back. Pulling the cord with straight arms, simultaneously pull the legs up to an angle of 45 and 90°.

Patient's initial position is the same. Pulling the cord with straight arms, pull up and lower first one, then the other straight leg.

I.p. - the same. Pulling the cord alternately with one hand, then the other, pull the legs bent at the knees one by one as close to the chest as possible. Also - both legs together with the help of both hands.

Patient's initial position - lying on the right side, left arm up. Lowering the left arm to the right thigh, pull the left leg up as much as possible. The same on the left side.

Patient's initial position - lying on the stomach. Lowering the arms down and without lifting the pelvis off the floor, pull the legs bent at the knees up.

Patient's initial position is the same. Lowering the arms down, raise the upper part of the body and straight legs up.

The largest group of means for forming and strengthening correct posture are special physical exercises.

Examples of typical physical exercises.

1. Patient's initial position - standing against a wall or a gymnastic wall. Adopt the correct posture, touching the wall with your back (wall). The shoulder blades, buttocks, calves and heels should touch the wall, the head raised.
2. Patient's initial position: standing at the gymnastic wall, assume correct posture. Rise up on your toes, hold this position for 3-5 seconds, return to the starting position.
3. Patient's initial position is the basic stance. Adopt the correct posture. Slowly squat down, spreading your knees to the sides and keeping your head and back straight. Slowly return to the starting position.
4. Patient's initial position - lying on the back with the trunk and limbs symmetrically positioned. Bend the left leg at the knee and hip joints, clasp the knee with your hands, press it to the stomach, and simultaneously press the lumbar region to the couch. Return to the initial position. The same with the right leg.
5. Patient's initial position - standing, placing a bag of sand (up to 0.5 kg) on his head. Slowly squat down, trying not to drop the bag. Return to the starting position.
6. I.p. - the same. Walking with a bag on the head:
   • with stops to check correct posture;
   • with stepping over various obstacles;
   • with the performance of a specific task: in a half-squat, with high knee lifts, cross-step, sideways side step, etc.
7. Patient's initial position is the basic position.

Take the correct posture. Then sequentially relax the muscles of the neck, shoulder girdle, back and abdomen. Close your eyes and, on command, take the correct body position again. Open your eyes and check your posture.

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Sports and applied exercises

Sports-applied exercises are exercises that have a therapeutic effect and promote the rehabilitation of integral motor actions or their elements. Such exercises include grasping, squeezing and moving various objects, everyday and work movements, walking, running, throwing, swimming, skiing, cycling, etc.

The form and direction of movements, the work of muscles in these exercises are determined by the essence of the performed motor act. The choice of exercises depending on the tasks of their therapeutic use often presents significant difficulties, since against the background of a holistic action it is necessary to ensure an effect on pathologically altered functions.

Exercises in performing elements of applied and sports movements or holistic everyday and industrial movements help improve joint mobility, restore strength to certain muscle groups, increase coordination and automatism of elementary everyday and industrial motor acts, form compensatory movements, and restore the patient's adaptation to muscular activity.