Physiotherapy for osteochondrosis of the lumbosacral spine

Therapeutic exercise in the osteochondrosis of the lumbosacral spine has different goals and methods in different periods of the disease.

[1], [2], [3], [4], [5], [6]

LFK in acute period

Tasks of the period:

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

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

In acute cases recommend:

• bed rest (within 3 to 5 days);
• correction by position (styling patient).

Bed rest

The bed must be semi-rigid, the head of the patient rests on a low cushion, a cotton-gauze roll is brought under the knees, since in this position the muscles of the lumbar spine and lower extremities can be optimally relaxed, the tension of the roots can be relaxed.

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

[7], [8],

Correction by position (styling patient).

The patient should lie on his back, a small pillow should be placed under his head.

In the case of neuralgia of the sciatic nerve, the patient is laid with the legs bent in the hip and knee joints in order to maximally relax the muscles of the limb and unload the tensioned nerve sheath.

ATTENTION! It should be remembered that the position of the patient lying on the back should not too reduce the lumbar lordosis, from the conservation or restoration of which depends the dislocation of the displaced fragment of the pulpous nucleus.

After the elimination of acute events, which indicates the dislocation of the displaced fragment of the pulpous core within the fibrous ring, it is necessary to reduce the flexion of the lower extremities in the knee and hip joints with the purpose of restoring physiological lordosis and thereby reducing the opening of the intervertebral space posteriorly; under the waist is recommended to put a small pillow or a cotton-gauze roll of small dimensions.

The analysis of scientific publications indicates that at present a wide variety of patient arrangements are used.

At the same time, we do not recommend placing the patient with the raised head end of the bed, because, firstly, there is as it were a "sagging" of the lumbar region and, secondly, kyphosis.

With the improvement of general condition (reduction of pain syndrome, improvement of motor activity), the patient is transferred to the II regime.

[9], [10]

LFK in subacute period

Tasks of the period

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

Receptions aimed at:

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

Contraindications to the prescription of drugs:

• increased pain;
• intolerance of the procedure.

Contraindicated performance of physical exercises:

1. Raising a straight leg (IP - lying on the back).
2. Exercises for stretching the muscles and fibrous tissues of the affected leg (in the presence of neurophoestrophic fibrosis in these tissues).
3. Bending of the trunk more than 20 ° (IP - standing).
4. Extension of the trunk (IP - standing).

Initial position

Studies conducted by a number of authors showed 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 supine position.

This, obviously, is associated with a decrease in pressure in the abdominal cavity in the ips. - sitting and carrying the gravity of the upper half of the trunk directly to the lumbar spine.

In connection with the foregoing in the subacute stage of the disease, physical exercises should be performed in ip. - lying on his back, on his stomach and standing on all fours, i.e. When unloading the spine.

In the initial lying position, the most perfect unloading of the musculoskeletal system from the influence of the body's gravity is achieved:

• The muscles are completely freed from the need to hold the body in an upright position;
• unloading of the spine and limbs from the pressure on it of the heaviness of the overlying parts of the body is ensured.

With movements performed by the head, shoulder girdle, limbs in this itp, the muscles of the trunk, creating the appropriate support, produce static work. In such cases, the muscles of the trunk are trained to endure static efforts.

ATTENTION! Movement of the head, trunk, limbs in the p. Lying can be carried out with a different dosage, which, on the one hand, promotes the endurance of the muscles of the trunk to the subsequent isometric work and, on the other hand, the dosed traction of these muscles of various bone structures of the spine.

In the initial lying position it is possible to achieve an isolated voltage of the muscular groups with the deactivation of muscles that do not require strengthening.

These initial provisions include:

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

Unloading corsets

Provide a reduction in the axial load on the spine due to the transfer of part of the body mass to the ilium. Wearing a corset reduces the pressure in the intervertebral disc by about 24% (A. Jak).

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

Exercises aimed at relaxing the muscles

As a result of reflexively developing muscular-tonic tension, fixation of the affected PDS of the spine is provided. It can be carried out mainly by intertransverse muscles, rotators with interstitial muscles, and also by the corresponding sections of long muscles (sub-lumbar, multiple-partitioned, etc.) in the zone of the affected PDS.

However, such local myofixation is formed in the late stages of sanogenesis. At first, in response to pain signals from the area of the affected disc, a general tonic reaction arises that involves the muscles of the entire spine, the muscles associated with the limbs. This is a common, vertebral-ekstevertebral myofixation. Therefore, in order to reduce muscular-tonic tension, it is recommended to use breathing exercises (dynamic and static nature) and exercises in voluntary relaxation of skeletal muscles.

[11]

Breathing exercises

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

Breathing exercises contribute to strengthening the inhibitory process. It should be distinguished:

• breathing to relax the muscles;
• breathing while performing physical exercises;
• Breathing exercises performed after isometric exercises.

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

ATTENTION! Dynamic breathing exercises increase the stress of the paravertebral muscles, as when performing them, the magnitude of all physiological curvatures of the spine changes, including lumbar lordosis (especially when inhaled in combination with hand movements upwards).

Static breathing exercises in the chest type of breathing:

• relax the strained muscles of the back;
• improve the blood supply of paravertebral muscles due to rhythmic contractions of the thoracic part of the ileal-rib muscle.

Static breathing exercises in the abdominal breathing type (diaphragmatic breathing) increase the tone of the paravertebral muscles, while increasing the compression of the nerve roots. Therefore, it is recommended to include this type of respiratory exercises in LH sessions only after the pain subsides.

Breathing in the process of carrying out static efforts, i.e. In conditions difficult for performing normal breathing movements, is a means of training the diaphragmatic muscles. Therefore, when they are included in LH sessions, the general requirement for breathing will be its uniformity, depth and some elongation of the exhalation phase.

ATTENTION! It should be borne in mind that the correct rational breathing is 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

This is an actively performed physical exercise with the maximum possible reduction in the tonic tension of the muscles. It is known that the ability to actively relax the muscles is much more difficult than the ability to strain them, since in the process of ontogeny this type of muscular activity is largely exposed to development.

A distinctive physiological feature of these exercises is their distinct inhibitory effect on the central nervous system. The work of the motor apparatus of man is entirely subordinated to the central nervous system: excitation of motor centers causes contraction of muscles and their tonic tension, and inhibition of the centers causes relaxation of muscles. And 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, relaxation of the musculature can not be regarded as only a local phenomenon, since the muscles are a reflexogenic zone of wide significance. To assess the mechanisms of the effect of relaxation, it should be borne in mind that the level of proprioceptive afferentation is sharply reduced. Consequently, the relaxation of muscles not only minimizes the energy expenditure in these muscles, but also helps to strengthen the inhibition of nerve centers. By the mechanism of motor-visceral reflexes, this, naturally, affects various vegetative functions. These mechanisms determine in many ways the physical and tonic activity and blood supply to the muscles surrounding the spine, and the muscles of the limbs.

An obligatory physiological condition for maximum arbitrary relaxation is a convenient starting position. The sensation can be caused in the patient in contrast to the previous stress, as well as the available methods of auto-training (such as "now the hand is resting", "the hands are relaxed, they hang freely, they are warm, they rest", etc.).

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

Exercise in relaxation is an excellent way to control and train the braking reactions. They are also used as a means to reduce physical activity during classes, to restore impaired coordination, normalize muscle tone with its prolonged increase.

It is recommended that the relaxation training be carried out in the original lying position, when a significant static load is removed for the muscles of the trunk (and in particular for the paravertebral muscles), and then carry out these exercises in other initial positions.

In the technique of LH with spinal injury, relaxation exercises are used in the development of muscle contractures, to equalize the tone of the muscles surrounding the spine, to restore disturbed movement coordination, to affect the central nervous system.

Additional techniques that facilitate an arbitrary relaxation are shaking, rocking, and swinging movements. When combined with a massage, in order to enhance the relaxing effect, stroking and vibration techniques are used.

Examples of typical exercises in muscle relaxation:

• i.p. - lying on his back, hands along the trunk, legs straightened. Complete voluntary relaxation of the muscles of the trunk and extremities: "All muscles are relaxed, warm, rest. The legs are heavy, warm, but they rest. Hands warm, heavy. The abdominal muscles are relaxed. A full, deep and relaxing holiday. " Hands raise slowly upward - stretch - return to the i.p.
• i.p. - also. Bend the right leg slowly in the knee joint, shake to the right and left, relax the muscles of the leg. The same with the left foot.
• i.p. - the same, the arms are bent at the elbow joints. Shake hands and relax one by one in the right and left hands.
• i.p. - lying on his stomach, hands under his chin. Bend the legs in the knee joints, alternately touching the heels of the buttocks, then relax and "drop" alternately the right and left shins.
• i.p. Standing. Raise your hands up, relax your hands, relax and lower your arms down along the trunk, relax slightly to tilt your body forward, shake with relaxed hands.

[12], [13], [14]

Exercises isotonic

Dynamic exercises in this period are performed in:

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

The degree of muscle tension is regulated by:

• the length of the lever and the speed of movement of the body segment being moved;
• facilitating and eliminating the strain of some muscles by transferring the load to others (for example, when lifting the affected leg with a healthy one);
• the use of movements, committed in whole or in part by gravity;
• different intensity of volitional muscle tension.

The listed types of physical exercises provide:

• improvement of blood circulation and metabolism in individual segments of limbs or trunk;
• 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 extremities.

Hip joint.

Movement in the joint:

• flexion and extension,
• lead and lead,
• rotation outside and inside.

For all movements in the hip joint, the abdominal muscles and back muscles play an important role, providing, along with the muscles surrounding the joint, the symmetrical, correct position of the pelvis. Therefore, working on restoring the movements in the hip joint, in parallel it is necessary to strengthen the weakened muscles of the abdominal press (with the elimination of pain and back muscles), seeking to normalize the tone of the muscles that stabilize the pelvic girdle.

Exemplary exercises for the hip joint.

1. I.p. Lying on his back. Flexion and extension of the legs, sliding on the surface of the couch.
2. I.p. - also. With your hands, pull up your bent legs (with your knees to your chest), straighten your legs, sliding on the surface of the couch with your feet.
3. I.p. - also. Maximum bend the legs, bringing your knees closer to the chest - dilute your knees, straighten your legs, relax your muscles, "toss" them on the surface of the couch.
4. I.p. Standing. Flight movements with a straight leg back and forth, to the sides. The exercise is performed alternately from the i.p. - standing face or sideways to the gymnastic wall.

Recommended for the hip joint and exercise with the greatest possible relief of the lower limb.

Exercises when unloading a limb allow:

• increase the range (volume) of movements in the joint;
• to act in an isolated way on different muscle groups (for example, abduction, adductor muscles).

Knee-joint.

Movement - flexion and extension.

Exercises are performed in the i.p. Patient - lying on his back, on his stomach.

Exemplary exercises for the knee joint.

1. I.p. Patient - lying on his back. Variable and simultaneous extension of the legs in the knee joints.
2. I.p. - also. Active pulling of the patella.
3. I.p. Patient - lying on his stomach. Alternating flexion and extension of the legs in the knee joints.

These exercises can be complicated by:

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

Ankle joint. Exemplary exercises in the first 2-3 days of the period:

• flexion and extension of the toes (alternately and simultaneously),
  • rear and plantar flexion of feet,
  • rotation of the foot,
• flexion and extension of the leg in the knee joint (alternately and simultaneously),
  • the removal and reduction of the shin, sliding it over the platen,
• pulling the bent leg to the chest (with the help of hands),
  • flexion and extension of the leg in the hip joint, sliding on the shin by the shin. The exercise is done only alternately.

If it is impossible to carry out active movements of the lower limbs, they are performed under light conditions (bringing the sliding plane to the limb, using roller skids, etc.).

As the pain syndrome decreases, the movements that encompass all joints and muscle groups of the lower extremities are added to the exercises, increasing the amplitude of movement, dosage.

When carrying out isotonic exercises for the lower extremities, the following guidelines should be adhered to (according to MVDevyatova):

Exercises for the ankle are performed in the i.p. - lying on his back:

• with a flattened lordosis - with the legs bent in the hip and knee joints, feet on the surface of the couch;
• at the expressed lordosis - at the legs straightened in large joints, with some restriction of plantar flexion;
• when scoliotic installation - should take into account the motor capabilities of the patient.

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

Exercises for the hip joint:

• i.p. - lying on his side,
• at kifozirovanie a lumbar department it is necessary to limit an extension of a femur,
• when strengthening lordozirovaniya - it is necessary to limit the bend, so as not to increase pain, do not cause tonic tension of the muscles surrounding the joint.

Contraindicated exercises that can cause tension involved in the process of rootlets and nerve trunks:

• Exercises for hip joints performed by straight legs (both on weight and gliding along the plane of the couch);
• Extension of feet with straight legs;
• rotation of the straight legs.

These exercises are recommended to include in the classes of LH with a reduction in pain in the lumbar spine, at the end of the period.

Isotonic exercises for the joints and muscles of the lower limbs are already carried out in the midst of the period. - lying down, standing. Active exercises with dosed burdening, exercises with rubber shock absorbers are used. Motions are shown (possibly first with the help of a methodologist) on an inclined plane.

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

1. Standing, feet shoulder-width apart. Slow turns of the trunk to the right and left, with simultaneous dilution of the hands to the sides - inhale. Lower your hands - in voshchokh. Repeat 4-6 times.
2. Standing, feet shoulder-width apart, hands on waist. Take your elbows back - inhale, return to the starting position - vshchokh. Repeat 6-8 times.
3. Lying on the back, legs straightened, hands along the trunk. To bend a foot, as much as possible bringing it to a stomach, - vshchoh, to straighten a leg - a breath. The same with the other leg. Repeat 4-6 times.
4. Lying on the back, legs bent, right arm on the abdomen, left along the trunk. During the inhalation, stick out the belly, during the exhalation it is strong to draw it. Repeat 4-6 times.
5. Lying on the back, legs bent, hands along the trunk. Gliding his heels along the floor, stretching his legs - inhaling, just as slowly bend them - in voshchokh. Repeat 4-6 times.
6. Lying on one side, legs straightened. One hand is on the belt, the other is behind the head. Bend the leg, lying on top, - exhale, unbend - inhale. The same with the other foot, turning on the other side. Repeat 4-6 times.
7. Lying on one side, legs bent. During the inspiration, "stick out" the belly, during the exhalation it is strong to draw it. Repeat 6-8 times.
8. Standing, feet shoulder width apart, hands to shoulders .. Circular movements elbows 8-10 times forward and backward. Breathing is arbitrary.
9. I.p. - hands along the trunk, legs bent at the knees, heels slightly closer to the buttocks, divorced to the width of the shoulders. Deep breathe deeply; during the exhalation, alternately tilt the knees inward, touching them with the mattress (the pelvis remains motionless). Repeat 10-12 times with each foot.
10. 10.I. - Hands along the trunk, legs together. Deeply inhale, pull up the knee bent in the knee; during an exhaled exhalation 2-3 times press it on the chest. Repeat 3-4 times. The same with the other leg.

B. Exercises for the muscles of the abdomen.

EMT results - studies showing a decrease in the potential of abdominal wall muscle tension, indicates the need for restoring muscle balance, stabilizing the spine in the lumbar region, by optimally strengthening the abdominal muscles.

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

In the classes LH include exercises of isotonic nature, performed in the IP. - lying on the back, the legs are bent in the hip and knee joints (i.e., when unloading the affected spine and relaxing the paravertebral musculature). With this position, the lumbar lordosis is corrected somewhat, the intervertebral space increases, and the nerve roots are unloaded.

Examples of typical exercises.

• I.p. Lying on his back. Pulling the knees to the chin with simultaneous lifting of the head and shoulders. In this movement, which is performed in accordance with the force of gravity, kyphosis occurs in the lumbar region and, as a result, sprain of the muscles of the back. Simultaneously with the movement of the head towards the chest (the movement is performed against the force of gravity), the rectus abdominal muscles work.
• Exercise - lifting the pelvis is quite effective for training the rectus abdominis and stretching the paravertebral muscles (in the lumbar region.

[15], [16], [17], [18], [19],

Exercises aimed at "stretching" the spine

The "extension" of the spine along the axis is accompanied by:

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

[20]

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

I. Exercises for the lower extremities.

1st diagonal.

A. Movement from the bottom up.

I.p. Patient - lying on his back, legs straightened, one leg set aside, foot pierced.

The doctor stands on the side of the affected lower limb, grabbing the foot with one hand so that the four fingers are on the inner edge of the foot; The other hand is located on the inner surface of the thigh.

Movement is performed sequentially:

• extension of toes;
• dorsal flexion of the foot;
• her supination;
• reduction;
• flexion and rotation of the thigh inside.

ATTENTION! The entire motion pattern is performed with the measured resistance.

B. Movement from top to bottom.

From the final position of the movement: bottom-up should be performed:

• flexion of toes;
• extension of the foot;
• extension, retraction and rotation of the thigh to the outside.

2nd diagonal.

A.I. Patient - lying on his back, one leg lies on the other, slightly rotated outwards; the foot is in the extension and supination, the fingers are bent.

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

Movement is performed sequentially:

• extension of toes;
• dorsal flexion and pronation of the foot;
• flexion of the hip with its retraction and rotation to the outside.

ATTENTION! As with the 1-st diagonal, the motion is carried out at its maximum amplitude.

B.I. - also.

When the movement from top to bottom of the 1st diagonal ends, the extension of the thigh with knee flexion continues. At reverse movement it is carried out in the beginning:

• extension in the knee joint;
• flexing the hip and turning it to the inside, from the moment it rises from the plane of the couch.

II. Exercises for the torso.

I.p. Patient - lying on his back, his hands are connected to the lock behind his head and are diverted a few to the right (to the left) from the axis of the body.

Movement: the arms and body of the patient make a bend in the opposite direction (to the left), imitating a pile of firewood.

• I.p. Patient - lying on his side (in the absence of contraindications).

The doctor is behind the patient, one hand is placed on the forehead, the other is located in the patient's knee joint area (to resist the general bending of the trunk).

Movement: possible bending of the body due to the inclination of the head, shoulder girdle and lower limbs.

• I.p. Patient - lying on his side (in the absence of contraindications).

The doctor stands in front of the patient, putting one hand on his head, and the other - in the lower third of the thigh (to provide resistance to extension of the trunk).

Movement: extension of the body by tilting back the head, shoulder girdle and lower limbs.

• I.p. Patient - lying on his back.

The doctor is in front of the patient, putting both hands on his shoulders (to resist when trying to bend the torso forward).

Movement: flexing the body forward by tilting the shoulder girdle.

• I.p. Patient - lying on his stomach.

The doctor has his hands in the area of the patient's shoulders (resistance to the movement of the deviation of the shoulder girdle back).

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

• I.p. Patient - lying on his back.

The doctor's hands fix the patient's shoulders. The patient makes an attempt to make a turn of the trunk due to the movement of the right or the left shoulder, the doctor's hands alternately resist this movement.

• I.p. Patient - lying on his stomach. The same movements.

ATTENTION! Exercises for the trunk are performed:

• at the maximum resistance;
• Diagonally and in conjunction with rotational movements.

III. Symmetrical movements.

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

Motion during resistance is performed for the lower extremities:

• when brought and rotated inside;
• lead and turn to the outside.

Exercises are held at the end of the session, when the patient has already used his ability to force with simple exercises - with maximum resistance.

ATTENTION! With these exercises, the resistance is much less than with simple exercises.

Corrective exercises

This group includes special physical exercises that provide correction of the deformities of the spine due to the selection of exercises and muscle traction in the opposite defect direction. All corrective exercises are carried out in the initial position, in which the spine is in the position of the lowest static tension; The best conditions for correction are in the supine position on the back and on the abdomen. However, this does not exclude the possibility of performing corrective exercises in the supine position on the side with simultaneous use of the corrective spinal column state.

Corrective exercises are divided:

• on symmetrical exercises;
• asymmetrical exercises.

Symmetrical corrective exercises. These include such physical exercises, in which the middle position of the line of spinous processes remains. By itself, maintaining the symmetrical arrangement of body parts relative to the spine and holding it in the middle position is a complex physiological task for a patient with spinal cord injury. Indeed, often in the pathogenesis of diseases of the spine, an important role is played by the asymmetry of the muscles surrounding the spine. Electromyographic studies, in particular, show that in the curvature of the spine in any of its departments, the electrical activity of the muscles on both sides of the spine is always different. Consequently, maintaining the medial position of the spine, resisting its deflection toward stronger muscles will cause more stress on the side where the muscles are weakened, i. E. Symmetric in the nature of the exercise, in terms of muscle tone, are asymmetric in nature.

When carrying out symmetrical exercises, a gradual equalization of the muscle tone occurs, its asymmetry is eliminated, and the muscular contracture that appears on the side of the concavity of the curvature arc weakens.

The advantages of symmetric corrective exercises are to stimulate compensation processes in patients, in the comparative simplicity of their selection.

ATTENTION! When conducting symmetrical corrective exercises, the doctor (methodologist) should be able to constantly monitor the position of the line of the spinous processes of the patient's spinal column.

Asymmetric corrective exercises. Such exercises allow you to pick the starting position and muscle traction of the corresponding muscles specifically on this segment of the spinal column. For example, in IP. - lying on the right side lumbar curvature, the straight leg's sideways to the side reduces the arc of curvature due to the change in the position of the pelvis and the traction of the muscles. Varying the position of the pelvis and shoulder girdle, the angle of the arm or leg lead, taking into account the biomechanics of movements, you can quite accurately pick up an asymmetric exercise for the maximum possible reduction of deformation.

ATTENTION! When selecting asymmetric exercises, you should take into account the data of radiography (in the supine and standing position). The patterned application of asymmetric exercises can lead to increased deformation and progression of the process.

Examples of typical asymmetric corrective exercises:

• i.p. Patient - lying on his stomach, hand from the concavity of the thoracic region raised, the other arm bent at the elbow, a brush under the chin. Raise the head and shoulders - return to the ip;
• i.p. Patient - lying on his stomach, hands under his chin. Remove the straight leg in the direction of the convexity of the lumbar spine, raise the head and shoulders with the simultaneous extension of the arm from the concavity of the thoracic spine to return to the ipl;
• i.p. Patient - standing on all fours. Raise your arm up on the side of the concavity of the thoracic spine, pull back the straightened leg on the concave side of the lumbar spine.

A special place among the corrective exercises is occupied by exercises for sub-saber-lumbar muscle.

In the pathogenesis of the deformation of the spine in the thoracolumbar region, these muscles, with an uneven length, cause the deviation of the corresponding segment of the spine from the midline. Therefore, based on the biomechanical characteristics of the lumbar region, an 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 XII thoracic and I lumbar vertebrae (Th12-L1), the ileum part from the inner surface of the ilium. Connecting in the cavity of the large pelvis, the iliac-lumbar muscle goes obliquely downward, passes under the inguinal ligament and is attached to the small trochanter of the femur. The muscle is the hip flexor when the position of flexion in the hip joint is more than 90 °, and at a fixed thigh is the flexor of the trunk. With the strain of the iliac-lumbar muscle lordosis increases, and when relaxed - decreases. The muscle plays a role in walking, running.

Biomechanical analysis of the work of the muscle showed that its contraction causes tension in three directions - down, to the side and forward. Together, the combination of these forces displaces the vertebrae of the concave part of the lumbar arch of the curvature to the midline, reducing curvature, and also destroys it. Simultaneously with this action of the ilio-lumbar muscle, the corrective effect is exerted by the tension of the muscles of the back and the abdominal press when the femur is bent in the hip joint.

Taking into account these data, the method of muscle training provides the following.

Procedure 1

• I.p. The patient - lying on his back, the leg is bent at the knee and hip joints at an angle of 90 °;
• with the help of the cuff on the lower third of the thigh and the block through which the draft from the cuff to the load is thrown, the femur is bent with bringing it to the stomach;
• muscle training begins with 15-20 flexions at a weight of 3-5 kg, then gradually increase the number of flexions.

Method 2

It provides for the work of the muscle in the isometric mode when the load is held.

• I.p. The patient is the same. On the block the cargo is fixed from 6 to 10 kg;
• the patient is encouraged to hold the load without making any foot movements;
• the initial fixing time is 10 s, gradually bringing the exposure up to 30 s.

We modified procedure 1, inviting the patient to perform the training of the sub-saber-lumbar muscle on a special table - the "loop complex".

The most effective use of asymmetric exercises for ilio-lumbar muscle at the top of the curvature from Th10 to L1. With this condition, the muscle is stretched on the concave side of the curvature and its training gives a fairly clear effect. With a lower location of the arc of curvature, the muscle stretches out on the convex side and its training will give an increase in the arc of curvature.

Consequently, asymmetrical exercises for the iliac-lumbar muscles are contraindicated when the curvature is localized with the apex of the arch above Th10 and below the L1 vertebrae. They are shown at the apex of the curvature at the level of Th10-L1 vertebrae.

[21]

Exercises aimed at increasing the mobility of the spine

Limitation of mobility in the affected PDS of the spine is one of the clinical manifestations of compensation. Therefore, the purpose of the exercise to increase the mobility of the spine is possible only with the preliminary development of sufficient strength endurance of the muscles of the trunk and active stabilization, under constant medical supervision and with extreme caution.

We had to observe patients in whom the early and massive application of exercises in increasing the mobility of the spine led to a short-term decrease in the scoliotic arch followed by a noticeable progression.

Conversely, exercises in mobilizing the spine greatly facilitate correction. To mobilize the spine, increase its mobility, exercises are used in crawling on all fours, in mixed and clean vises, and on an inclined plane.

In all these exercises, in addition to the active muscle component, there is an effect on the spine of the mass of the body's own body - that, with insufficient strength endurance of the muscles, contains the danger of overgrowing the ligamentous apparatus of the spine.

Examples of typical exercises.

1. I.p. Patient - standing on all fours (support on the hands and knees). Walking on all fours.
2. I.p. Patient - standing on all fours (support on forearms and knees). Semi-deep crawl.
3. I.p. Patient - on the gymnastic wall and hold in this position for (the set time).
4. I.p. Patient - mixed hanging on the gymnastic wall (support on the 1-2-st rail, grip hands over his head, face to the wall). Movement on the gym wall to the right and left.
5. In the IS. Simple visas on hands:
   1. to plant in the sides and to connect straight legs;
   2. alternately bend and lower the leg.

Torso torso, in which the point of rotation passes through the lumbar spine, increases the intra-disc pressure: the greater the amplitude of motion, the higher the pressure inside the disc. The greatest increase in pressure is demonstrated when the body tilts forward (flexio) and the smallest - with the back tilt (extensio). This is explained by the fact that during this movement, not only the strength of the contraction of the muscles of the back increases, but also the horizontal dimension of the pulpous nucleus, hence its support surface decreases.

In the initial position, the standing force of contraction of the muscles of the trunk, which is necessary for holding the body in the vertical position, is less than in the i.p. - sitting. If we take into account the points of attachment of the muscles participating in this act, and the relationship of the sacrum, pelvis and spine to be considered as a system of a lever with a point of rotation in the lumbar-sacral region, it becomes clear that the active arm of the lever is longer at the initial standing than in the initial position sitting. Consequently, less effort is required to keep the same weight.

This was reflected in the indications of internal disk pressure, which in all patients in the p. - standing was lower than in the ip. - sitting. In this position, the true load on the lumbar discs is 1.4-2.5 times the estimated weight above the disk level. Therefore, in this period it is recommended to conduct LH sessions in the patient's starting position - lying (on the back, on the stomach, on the side), standing on all fours and standing up.

ATTENTION! In the IS. Patient - lying on its side, the average pressure inside the disc varies from 2.3 to 5.1 kg / cm ²; with pain syndrome or discomfort phenomena in the lumbar region, the internal disk pressure clearly increases. Proceeding from this in this i.p. It is inappropriate to apply exercises aimed at increasing mobility.

When assigning exercises to increase the volume of movements of the spine, you should consider:

• features of biomechanics of the spinal column;
• "Lumbar-pelvic rhythm."

A. Features of biomechanics of the spine with the torso inclinations.

When bending the trunk occurs:

• stretching of the posterior longitudinal ligament and fibers of the back of the disc ring;
• relative displacement of the back of the disk nucleus, increasing tension of the rear half-ring;
• stretching of yellow and intercostal ligaments;
• the widening of the intervertebral foramen and the tension of the capsule of the intervertebral joints;
• muscle tension of the anterior abdominal wall and relaxation of the muscles - extensors of the back;
• tension of the dura mater and roots.

ATTENTION! It should be remembered that in i.p. Patient - standing the active function of the back muscles stops after the torso is 15-20 °; with further slope, there is a stretching of muscles and fibrous tissues, which is manifested by pain.

Because of this, the torso of the trunk should be carried forward during this period with caution, smoothly, to the angle of flexion of 15-20 °, gradually increasing the degree of inclination, from and. Lying on his back and on his side.

When the trunk is unbent, the following occurs:

• stretching the front half-circle of the disk;
• relative displacement of the disk nucleus anteriorly;
• Reduction of yellow ligaments (their shortening) and relaxation of interstitial ligaments;
• narrowing of intervertebral apertures;
• 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 caused by the tension of the anterior longitudinal ligament, the abdominal muscles, and by the "closing" of the spinous processes.

B. Lumbar-pelvic rhythm.

The inclination of the trunk (flexion-extension) also depends on the so-called "lumbar pelvic rhythm" /

Any changes in this rhythm due to a violation of the statics and dynamics may eventually lead to the onset of pain, for example sacralgia, arising from an incorrect motor stereotype when the trunk is returned from the position of flexion to the position of extensionality.

Consequently, when the extension is increased in the lumbar region, the pressure on the posterior sections of the fibrous ring and the posterior longitudinal ligament, richly innervated, and in some cases also on the nerve root (with a decrease in the diameter of the intervertebral foramen) increase, which manifests itself in the pain syndrome of the paravertebral muscles of the back, movement of the spine. In this regard, in the early days of the period, physical exercises aimed at the extension of the lumbar spine in the ips. Standing. Only exercises of extensional nature performed in the IP are possible. - lying on his stomach (with small pads under his stomach). Due to this, in carrying out exercises associated with some extension of the trunk, there will be no overextension in the lumbar spine.

[22], [23], [24]

Physical exercises in the aquatic environment (therapeutic pool)

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 (trunk), it is easier to perform movements. In addition, the temperature factor (heat) contributes to a lesser manifestation of reflex excitability and spasticity of muscles, easing of pain. This improves blood supply and lymph circulation, reduces the resistance of the entire periarticular apparatus of the joints, which contributes to better realization of motor function. Therefore, physical exercises in the aquatic environment make it possible to use the limited muscular strength of the affected (weakened) muscle groups, which is difficult to detect under normal conditions.

The technique of LH in the treatment pool is to perform exercises using the simplest exercises.

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

Walking

Walking is the basic natural form of cyclic 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 arms and legs, the setting of a walking foot on the heel, followed by a roll to the toe, straightness and uniformity of the length of the step.

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

1. in the frontal plane, the pelvic rotation and inclination towards the rear leg occur, and the thoracic spine is displaced towards the support leg. When the leg is moved forward, the position of the pelvis is equalized, and at the same time the spine is straightened. The whole cycle of movements of the pelvis and spine in the frontal plane takes place in one double step;
2. in the sagittal plane, while 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, the lumbar lordosis slightly decreases and the thoracic kyphosis increases with cervical lordosis. The shape of the spine changes smoothly during walking, the same happens with the rotation of the spine along the axis. With the support of the right leg, the pelvis rotates clockwise, the pelvis rotates counterclockwise. The pelvis and upper thoracic spine rotate in different directions, the lumbar spine rotates unidirectionally with the pelvis, the lower thoracic region remains neutral. Movement in the horizontal plane is greatest in the thoracic spine, in the frontal and sagittal - in the lumbar region.

Accordingly, the movements of the spine and pelvis during walking changes the activity of the muscles:

• 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 middle gluteal muscle increases on the support side and the muscle that straightens the spine on the opposite side, then the activity of the muscles decreases and rises again the opposite side when changing the supporting leg;
• hip flexors develop the greatest activity at the boundary of the reference period, stabilizing the hip joint and unbending it.

In cases of static disorders, the nature of the spinal and pelvic movements and the work of the muscles change. Although they preserve the general patterns of walking of a healthy person, there are "tuning" lateral movements of the spine, directed toward the concavity of the curvature of the thoracic region, i.e. The arc of curvature decreases.

These studies allow you to use exercises in walking with a decrease in pain in the lumbar spine in walking as a special exercise for restoring the disturbed statics in patients.

Walking can be included in all sections of classes (mainly in the opening and closing sessions).

Exercise is complicated due to the correct posture, the combination of walking with breathing, the inclusion of various options for movement:

• on the toes, on the heels, on the inner and outer edges of the feet, with a roll from the heel to the toe, with a high hip lifting, in a half-squat, with a cross and a step;
• walking with overstepping through small obstacles, bypassing various objects;
• walking on the accuracy of the step, stepping on transverse lines or tracks;
• walking down and up the stairs;
• walking with open and closed eyes over a limited area, a certain distance, in a certain direction, changing the speed, pace and rhythm by command.

ATTENTION! In all types of exercises, pay attention to the transfer of the center of gravity of the body to the support - the forward leg. The trunk should not lag behind the movement of the guiding leg.

LFK in the recovery period

Contraindications

• The onset of pain syndrome.
• Increased tension of paravertebral muscles, violation 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 to:

• strengthening the muscles of the abdomen, back, pelvic floor muscles;
• strengthening the muscles of the lower limbs;
• the development of correct posture (both during work and in everyday life).

Increasing the strength and tone of the abdominal muscles increases the efficiency of the mechanism of transferring mechanical loads from the skeleton to the muscular apparatus (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 is transferred to the pelvic floor and diaphragm).

Another consequence of the increase in the strength of the abdominal muscles is the stabilization of the spinal column, which in itself is not a stable structure. In the lumbar region, the spine is supported behind the body straightener, in the anterior-lateral region by the lumbar muscle, and in front by the intra-abdominal pressure created by the tension of the abdominal muscles.

The stronger these muscles, the greater the forces that stabilize the lumbar spine (the above muscles also control all the movements of the spine.

Strengthening of the abdominal muscles should be carried out by means of their isometric contractions (spine movements are excluded at the same time) and isotonic exercises performed in the IP. - 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 much more tedious than isotonic exercises. This is due to the rapid fatigue of nerve cells in conditions of continuous activity of motor nerve centers, which provides constant muscular tension with isometric effort.

The long duration of isometric stresses in comparison with dynamic ones with the same number of repetitions of exercises makes it possible to achieve a larger volume of force work from the physiological point of view.

Another aspect is also important. When the individual muscles are weakened, the other, larger ones, take over part 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, or may worsen. Exercises in isometric mode, allowing to minimize the compensatory efforts of uninfected muscles, provide directional strength training for weakened muscle groups.

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

When carrying out exercises isometric nature, the mechanical work is practically reduced to zero. However, as in isotonic work, with isometric stresses physiological changes occur in the body, which are taken into account when characterizing static forces:

• 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 preserving the natural posture of the patient in everyday life.

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

• maintenance of a natural posture of a patient's body is carried out by economical, little tiring tonic tension of muscles;
• The static positions encountered in performing physical exercises are supported by the tetanic muscle tension.

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

Isometric stresses are carried out with a delay in breathing and straining. This condition is especially noted in patients in the initial stages of learning these exercises.

These exercises have a certain load on the abdominal muscles and paravertebral muscles, almost without increasing the internal disk pressure. However, their use requires some caution for individuals with concomitant disease of the cardiovascular system due to the fact that static exercises cause the so-called Valsalva effect - an increase in intra-arterial pressure leads to a decrease in the influx of blood to the heart (due to "squeezing" of the hollow veins ) and the decrease in the number of cardiac contractions.

As training, breathing delay and straining in patients 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 promotes the effective performance of physical exercises.

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

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

Intensification of physiological functions after isometric stresses, observed at the first stages of training, is associated with a special character of the central regulation of autonomic functions. Steady excitation of motor centers during static activity causes, by the mechanism of negative induction, the suppression of the nerve centers of regulation of the respiratory and cardiovascular systems (Lindard's phenomenon).

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

A known value in the occurrence of the phenomenon of static force is the change in circulatory conditions in isometrically strained muscles. After performing the static work, the products of anaerobic muscle metabolism are freely transferred to the general circulation. The buffer function of blood is activated. The binding of excess lactic acid with bicarbonates leads to an increase in the content of CO ₂ in the blood and increased respiration.

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

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

Methodical recommendations for performing exercises in isometric mode.

• The duration of the static effort in each exercise depends on its intensity and is in inverse proportion to it. Exercises of low intensity are performed 30-60 seconds, moderate and medium intensity - 5-25 seconds, higher intensity - no more than 2-7 seconds.
• In the process of performing exercises in low-intensity isometric mode, breathing should be uniform, deep, with a certain elongation of the exhalation phase; short-term exercises of considerable intensity are carried out during the exhalation phase.

ATTENTION! When performing isometric exercises, it is not recommended to involuntarily hold the breath during the inspiratory phase.

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

The use of resistance and burden for the mastery of active movements

To strengthen the muscles of the trunk and extremities are used in the exercises LH exercises with resistance and burdening. Dosage conceding and directing resistance has mainly a local effect on a certain group of muscles; at the same time, this action is short-lived. The action of burdening is more extensive and more prolonged.

Exercises with resistance.

These exercises are designed to selectively affect the performance of certain movements to increase their volume of movements, dosage of power stresses, the development of the limb's limb and the strength of the acting muscles.

Resistance occurs when the patient:

• movements in the joints of the limbs or
• movements of different segments of the trunk.

When providing resistance to the patient, it is necessary to take into account his capabilities, by agreeing the force of influence with the efforts of the patient.

ATTENTION! It is necessary to observe how the exercise is perceived by the patient, whether there are signs of fatigue or replacement of patients with the required movement of the tension of other muscles or movements of other segments of the body.

The physician (methodologist) in the provision of resistance must direct and correct movements, change the load, increasing or decreasing the frequency of repetitions, changing the resistance force.

Exercises with local dosage resistance are performed with the help of a doctor's hand, a rubber shock absorber or a block with a load.

Exemplary exercises with resistance.

1. Exercises with resistance provided by the doctor's arm:

• when flexing and unbending the leg in the knee joint, the pressure is on the shin in the opposite direction;
• when the hip is withdrawn and adjusted, the pressure is on the lower third of the thigh in the opposite direction to the movement.
• when training the correct posture in different initial positions, the pressure is placed on the patient's shoulders by the doctor's two hands. To this the patient responds by some extension of the spine, by the retraction of the back of the shoulder girdle.

2. Exercises to overcome the resistance of the rubber band (espander) and cargo in the i.p. Patient - lying down and standing.
3. Isotonic exercises

In this period, the exercises use dynamic exercises for:

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

Activities include active exercises:

• with gymnastic objects;
• with gymnastic shells;
• on shells.

In this period, in most patients there is still a weakening of the gluteus muscles, knee and ankle extensors, back muscles and abdominal muscles.

Gluteus muscles. The functional state of the gluteus muscles plays a decisive role and their strengthening is absolutely necessary both for training the right standing and walking, and for correcting the gait.

Training to reduce gluteal muscles is recommended to begin with friendly cuts of other muscles.

For example, from i.p. Patient - lying on his stomach - lifting his head. This draws the attention of the patient to the accompanying tension of the gluteal muscles.

The same occurs when lifting the pelvis from the ips. - lying on the back ("hemicroscope").

To reduce the gluteal muscles, the following exercises are used:

• i.p. Patient - lying on the abdomen - active-passive (active) leg extension in the hip joint with the subsequent task to keep it in this position (isometric tension, exposure - 5-7 s);
• i.p. The patient - lying on his stomach - withdrawing and bringing a straight leg;
• i.p. Patient - lying on his stomach - lifting 10-150 from the plane of the couch straight legs;

Simultaneously with the strengthening of the gluteus maximus muscles, you should exercise medium and small gluteus muscles.

• i.p. Patient - lying on his side, corresponding to a healthy leg; retreat of the affected leg bent at the knee joint;
• i.p. The patient is the same; retraction of the straight leg;

The same exercises with weights and resistance.

The quadriceps muscle of the thigh. In a number of cases, patients do not know how to use the four-headed hamstrings as the extensor of the lower leg, and when attempting this movement, bending in the hip joint is usually noted. To master the extension of the shin, it is necessary to teach the patient to relax the muscles of the knee joint region, then to teach rhythmic movements of the patella against the background of relaxed muscles. Only after the assimilation of these motor techniques by the patient can one proceed to the successive alternation of flexion and extension in the knee joint, fixing the patient's attention to relaxation of the antagonist muscles during the movement.

In the future, recommended exercises aimed at strengthening the four head of the muscle:

• flexion and extension in the knee joint, without lifting the feet from the sliding plane;
• flexion and extension in the knee joint with detachment of the feet from the plane of the couch (alternately and simultaneously);
• foot movements, imitating "riding a bicycle";
• flexion and extension in the knee joint with burdening (cuffs with a weight of 0.5 kg), resistance (doctor's arm, rubber band, etc.);
• a combination of isotonic exercise with isometric stress.

Muscles producing back flexion in the ankle joint. Extensor stops due to neurological complications of the spine are often not included in static activities and walking. In addition, 2.4% of patients have discoordination of the functions of these muscles. In some cases, when trying to back the bending of 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 thumb is insignificant. In this case, the foot assumes a predominantly pronation position when attempting to unbend.

In other observations, it was revealed: the anterior tibialis muscle and the long extensor of the thumb are actively contracting with the weakening of the long extensor of the fingers. Then the foot assumes a varus position.

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

Exercises for back flexion in the ankle are closely related to improving the leg's ability to support.

Muscles of the abdominal press. To strengthen the oblique muscles of the abdomen, exercises with tilts and turns of the trunk are applied in different initial positions.

For straight muscles of the abdomen are recommended:

• in i.p. Patient - lying on his back rhythmic contraction of muscles,
• (fixation of feet) attempt to turn the trunk;
• in i.p. Patient - lying on his side raise and slowly lower his straight leg, raise both straight legs by 10-15 ° and slowly lower them using the swing legs, turn from back to belly and back, arms stretched along the trunk.

In the classes of LH it is possible to use weights and resistances; exercises performed on an inclined plane, on simulators.

Muscles of the back. Strengthening the back muscles and fostering proper posture is an essential prerequisite for restoring a normal walking pattern.

Exercises are performed in the starting position of the patient lying on his stomach and standing. The exercises 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 intervertebral discs of the lumbar region changes depending on the posture inherent in the patient in motion or at rest.

Posture determines the strength and duration of mechanical stresses acting on the discs of the lumbar region, which are constantly compressed. The compression forces reach the greatest value in the lower intervertebral discs of the lumbar region. They decrease almost to zero in the supine position when the muscles relax and increase rapidly when they move to the sitting or standing position. When performing physical exercises, especially with the use of gymnastic objects and shells (with the connection of the mechanism of the lever).

In the initial position, standing body weight is evenly distributed to the vertebral bodies and intervertebral disks (intervertebral disks are the only soft tissue that takes part in the supporting function of the spine bearing the body mass).

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

As soon as the spine is out of the vertical plane when the spine is tilted, the lever system immediately acts, so that the forces acting on the intervertebral discs increase many times. This is not only due to the connection of the mechanism of the lever, but also in connection with the change in the plane of their propagation. As a result, these forces are not directed at right angles to the intervertebral discs and vertebral bodies, but under the sharp ones. The dislocation of the intervertebral discs and vertebral bodies impedes the resistance of intervertebral discs, ligaments, articular processes, and the action of the muscles that stabilize the spine.

In connection with the foregoing, it seems expedient for us to include the torso in the initial standing position in LH exercises only after strengthening the muscles that stabilize the spine.

Exercises with gymnastic objects:

Exercises with gymnastic objects: with sticks, maces, dumbbells, with balls, shock absorbers for therapeutic use are types of exercises with local and dosed force tension, stretching of muscles, their relaxation, coordination of movements, corrective and respiratory.

The therapeutic effect of exercises with objects is enhanced in comparison with similar exercises without objects due to the weight of the object, improving the lever of the moving body segment, increasing the inertial forces arising during the swinging and pendulum-to-different movements, complicating the requirements for coordination of movements, etc. The factor that increases the effectiveness of exercises is their emotionality, especially if they are conducted with musical accompaniment.

[25], [26],

Exercises on gymnastic projectiles

Exercises on gymnastic shells: on a gymnastic wall, on special shells and apparatus act like exercises with dosed voltage, with weights, stretching muscles, in balance. Depending on the method of implementation, they provide a preferential or isolated effect on individual segments of the musculoskeletal system or group of muscles, on the function of certain internal organs, on the vestibular function, etc.

Exercises on gymnastic projectiles in the form of vises, stops, pull-ups are characterized by a short-term high intensity of the general impact and can be accompanied by a delay in breathing and straining.

Special shells and apparatus used for various manifestations of pathology in the form of block, spring devices, united by the name "mechanotherapy", as well as simulators provide enhanced therapeutic effect due to better localization and, as a rule, longer action of the exercises, more accurate loading dosage, increase tensile influence or intensity of stress, etc. Individual devices allow you to perform passive movements or movements using. The overall effect of the exercise is determined by its intensity.

[27]

Exercises for the formation and consolidation of the habit of correct posture

Posture is a motor skill formed on the basis of reflexes of the posture and position of the body and ensuring the preservation of the usual positions of the head, trunk, pelvis and extremities. Good posture provides the most complete in a functional and cosmetic sense the interposition of individual segments of the body and the location of the internal organs of the thoracic and abdominal cavities.

In the exercises of exercise therapy should include the following exercises:

• increasing the tone and strength of the muscles of the neck, back, abdomen and extremities;
• Forming representations about an arrangement of separate segments of a body at a correct bearing;
• They reinforce these ideas and create the habit of correct posture;
• The ability to fix the correct position of the body with a variety of muscular activities.

With spinal deformities and postural defects, special exercises are used in conjunction with corrective exercises. The general effect of exercises aimed at restoring correct posture corresponds to loads of moderate intensity.

These exercises occupy a special place in the technique of LH in the disease of the spine, since normal or corrected posture is, in the final analysis, the purpose of therapeutic interventions.

For the formation of the habit of correct posture, the proprioceptive muscular sense is of paramount importance; sensation of the position of one's own body in space, obtained by the patient due to the impulse in the central nervous system from the numerous receptors incorporated in the muscles. Therefore, when forming and fixing the correct posture, constant attention is paid to the location of the body during the exercise and in the starting positions.

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

The mental representation is formed from the words of the physician (methodologist LFK) as an ideal scheme of the location of the body in space - the position of the head, the shoulder, chest, back, pelvic girdle, abdomen, extremities.

An idea of the correct posture is inextricably linked with the education of its visual image. Patients should see the correct posture not only in pictures, photos, but also in class.

Finally, using mirrors, patients must learn to take correct posture and correct the defects noted.

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

I.p. Patient - with his back to the wall. Pull your knees to your chest, lower it.

I.p. Patient - standing facing the wall, legs apart on the lower crossbar, hands on the crossbar at the level of the belt. Without bending legs, grab the crossbar above and below.

I.p. Patient - standing on the lower crossbar on his toes, legs together, hands on the crossbar at the chest level. Alternately rearrange your legs, rise and fall on your toes.

I.p. Patient - standing facing the wall at a distance of a step, hands on the crossbar at the level of the belt. Springing inclinations, arms and legs do not bend.

I.p. Patient - lying on his back on an inclined plane, socks under the crossbar, hands behind his head. Go to the sitting position.

I.p. Patient - lying on his stomach, legs under the bottom crossbar, hands behind his head. Arched, lift the trunk upward, without lifting the hips from the floor.

I.p. Patient - standing with his back to the wall. Circular motion with your hands in front of you.

I.p. - also. Leaning forward, bending forward, bending forward. The same is a step away from the wall.

I.p. Patient - standing facing the wall at a distance of a step, grasp the handle of the upper expander. Bend over without bending arms. The same, bent back.

I.p. - also. Imitation of the movements of the hands as when walking on skis.

I.p. Patient - lying on his back on an inclined plane, to take straight hands by the crossbar. Bend the legs in the knee joints, straighten up, slowly lower.

I.p. Patient - lying on his back on an inclined plane, grasp the handles of the lower expander. Alternately raise and lower hands.

I.p. Patient - lying on his back. Tensioning the cord with straight hands, simultaneously pull your legs up to an angle of 45 and 90 °.

I.p. The patient is the same. Stringing the cord with straight hands, pull and lower that one or the other straight leg.

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

I.p. Patient - lying on the right side, left hand on top. Lowering the left hand to the right thigh, pull the left leg up as far as possible. The same on the left side.

I.p. Patient - lying on his stomach. Lowering his hands down and not tearing the pelvis off the floor, pull up the knees bent at the knees.

I.p. The patient is the same. Lowering his hands down, raise the upper part of the trunk and straight legs up.

The largest group of funds for the formation and consolidation of proper posture are special physical exercises.

Examples of typical physical exercises.

1. I.p. Patient - standing against the wall or gymnastic wall. Take the correct posture by touching the back (wall) of the wall. In this case, the shoulder blades, buttocks, legs and heels should touch the wall, the head is raised.
2. I.p. Patient - standing at the gymnastic wall, take a correct posture. To rise on socks, keeping in this position 3-5 with, to return to a starting position.
3. I.p. The patient is the main stance. Take correct posture. Slowly sit down, spreading the knees to the sides and keeping the forward position of the head and back. Slowly return to the starting position.
4. I.p. Patient - lying on his back with a symmetrical arrangement of the trunk and extremities. To bend the left leg in the knee and hip joints, clasping the knee with his hands, pressing to the stomach, while pressing the lumbar region to the couch. Return to the starting position. The same with the right foot.
5. I.p. Patient - standing, putting on his head a bag of sand (up to 0.5 kg). Slowly sit down, trying not to drop the bag. Return to the starting position.
6. I.p. - also. Walking with a bag on your head:
   • with stops for control of correct posture;
   • stepping over various obstacles;
   • with the fulfillment of a specific task: in a semi-squat, with a high rise of knees, a cross step, side step, etc.
7. I.p. The patient is the main stance.

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

[28], [29]

Sport-applied exercises

Sport-applied exercises-exercises, which have therapeutic effect and contribute to the rehabilitation of integral motor actions or their elements. Such exercises include grasping, squeezing and moving various objects, household and labor movements, walking, running, throwing, swimming, skiing, cycling, etc.

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

Exercises in the implementation of elements of applied and sports movements or integral household and production movements contribute to improving mobility in the joints, restoring the strength of certain muscle groups, increasing coordination and automatism of elementary domestic and industrial motor acts, forming compensatory movements, restoring patient adaptation to muscle activity.