Stages of rehabilitation measures for osteochondrosis

The target direction of rehabilitation and treatment measures in relation to the patient directly depends on the nature of the course of the process and its duration - accentuation of attention to the disease (pathomorphological substrata of acute manifestations) or on the patient itself (a set of sociosomatopsychic disorders in the individual).

Based on these assumptions and guided by the results of the research, the doctors found it expedient to construct an algorithm that takes into account the differentiated approach to choosing the tactics of restorative treatment and the optimal timing of its conduct. As can be seen from the steps considered in this scheme, all of them satisfy the main tasks mentioned earlier - to relieve the patient of pain, improve the function of the motor link, to anticipate the occurrence of prognostically possible disorders (complications) and, based on this, to affect the motor behavior of the patient.

Clinical and functional examination:

• psychological testing;
• algolic testing;
• Neuroorthopedic diagnostics;
• X-ray diagnostics of the spine (including functional tests);
• ultrasonographic examination of the ligamentous apparatus of the spine;
• electromyographic examination of the muscular system 

[1], [2]

Algorithm of therapeutic measures in the treatment of patients with spine disease 

[3], [4], [5], [6]

The first stage - undifferentiated assistance

Undifferentiated help:

• alteration of algoreactivity of central neuroendocrine formations (analgesics, tranquilizers, etc.);
• decreased activity of mechanosensitive skin afferents in trigger zones, pain irrigation zones (local anesthetics, physiotherapy procedures, massage techniques - stroking, slight rubbing);
• change in the nature of vasoactive local reactions (local heat-cold);
• reduction of loads, immobilization of the motor link (bed rest, correction by position, stabilization of motor links by physical exercises of local character);
• Miorelaxation (medicamental, psychocorrection, physical exercises and massage techniques aimed at relaxation of muscles, PIR).

The second stage is differentiated care (3-10 days)

Fighting pain:

• continuation of the activities of the first stage;
• decrease in the level of activity of central and peripheral systems (beta-blockers);
• activation of afferent impulses from the superior motor links (physical exercises, methods of therapeutic and acupressure, physiotherapy procedures);
• activation of afferent impulses (physical exercises, massage techniques, physiotherapy procedures);
• activation of endogenous mechanisms of mental regulation (formation of an installation for recovery).

Improvement of the functional state of the motor link:

• modeling of movement (impact on the skin of the region of the concerned motor link), muscle stretching techniques, special physical exercises, PIR, "proprioceptive relief" (PNF) techniques;
• reduction of vertical (axial) loads (correction by position, unloading starting positions, orthoses);
• effects on the affected PDS of the spine, bone-tendon formations and muscles surrounding the spine (special physical exercises, methods of point and reflex-segmental massage), traction therapy;
• activation of higher and lower motor links (prevention of congestion of other motor links) - combined effects of various physical rehabilitation tools;
• improvement of vascular support of the motor link (receptions of massage, physiotherapeutic procedures, physical exercises);
• an increase in the volume of movement in the interested link - a reduction in the degree of muscle contraction (physical exercises, PIR, massage techniques, physiotherapy procedures)

The third stage (1-2 months) is the chronic process of the disease

Therapy of chronic pain:

1. decrease of affective reactions to pain (antidepressants, tranquilizers: emotional-stress autogenic training);
2. activation of central neuroendocrine mechanisms of analgesia (synthetic opioids, serotonin blockers, etc.);
3. increased activity of adaptive processes (adaptogens, steroids, breathing exercises, emotional-volitional training);
4. reorganization of the sensory system; ("Neuromotor reeducation", the effect on the skin of the motor area - PIR, receptions segmental-reflex massage

Therapy of violations of the integrity of the motor act:

• reorganization of the motor system ("neuromotor reeducation", impact on muscles, ligaments, osteoarthritis joints - physical exercises, massage);
• restoration of the complete integrity of the motor act (physical exercises, PIR, massage);
• restoration of the integrity of movement in the spine, opposite extremity (impact on muscles, bone-tendon, articular joints);
• prevention of integrity violations of the entire locomotion act (impact on all functional formations of the motor link - physical exercises, PIR, massage, physiotherapeutic procedures)

The fourth stage is the search for an adequate model of a new psychomotor behavioral stereotype

Clinical and functional examination (VTEK):

• psychological testing;
• algological testing;
• manual testing;
• general clinical examination of the state of health;
• functional examination of the musculoskeletal system;
• definition of the forecast;
• modeling possible health changes

Elaboration of an adequate stereotype of behavior:

• correction of mental compliance of the patient type and the chosen model;
• correction of the motor stereotype in accordance with the chosen model;
• symptomatic therapy;
• preventive actions:
  • the exception is the reduction of the traumatic influence of the formed motor stereotype on the preservation of the conditions of the habitual functioning of the motor links;
  • exclusion - reduction of the severity of disability;
  • prevention of secondary disorders associated with changing stereotype

The stage of the survey is directly related to providing patients with emergency care. Four stages of undifferentiated therapy outline all possible etiopathogenetic links associated with the formation of pain:

• Exclusion of psychogeny and activation of central neuroendocrine mechanisms;
• alteration of nociceptive mechanisms at the peripheral site;
• a change in the nature of vasoactive reactions leading not only to improving the microcirculation of the injury zone, but also due to the vastness of the mechanisms of nociceptive and vascular reactions that enclose peripheral neuro-endocrine regulation.

All these measures are carried out with the maximum possible relaxation of the muscular apparatus and the position of the trunk and extremities in the maximum achievable position (correction by position). The most effective means of muscle relaxation at the stage of acute pain of somatogenic nature are pharmacotherapy, the potentiating effect of central analgesics, tranquilizers; relaxation and stretching of muscles, psychological correction.

The three-day period allocated for the first stage is explained not only by the need to obtain detailed diagnostic data, but also by the low speed of adaptive-reparative processes, the need to achieve a certain cumulation of therapeutic effects. Naturally, this term can be reduced to 1-2 days under favorable circumstances (normalization of the patient's condition). In this case, the patient undergoes general preventive measures taking into account the volume of prescription of the primary lesion focus.

Absence of the therapeutic effect automatically means the transition to the next, the second stage, determines the need for differentiated care both for pains and for aggravated disturbances in the function of the motor link.

It is known that plasticity of nociceptive processes is determined by reverse transport, slow activity of nerve terminals, perverted activity of sympathetic formations. In connection with this, at the level of continuation of therapy with central analgesics and tranquilizers, various blockades can be successfully used. Proceeding from the concept of "gate control", one of the possible mechanisms for suppressing nociceptive integrative activity is the involvement of fast-flowing nerve fibers resulting from muscular and tendon-ligamentous structures. Such stimulation can be carried out with the help of physical exercises, massage techniques on the motor links that are higher in relation to the focus concerned. As well as carrying out synergistic exercises in the key of biological feedback, which ensure the effective restoration of downward impulses, any therapeutic intervention needs adequate verbal mediation.

In this case, we are talking about the necessary suggestion instructions, anticipating any action of a specialist, understandable to the patient and relieving the stress of the procedure itself. This same goal is also devoted to the activation of endogenous mechanisms of mental regulation - the formation of an installation for recovery, mental readaptation.

Compared with the first stage, the importance of restorative therapy aimed at improving the function of the motor link increases, as well as the speedy reconvalescence. The given sequence of separate target directions is enough reasoning illustrates the formation of a pattern of physiological reactions, beginning with the skin sensory zone and ending with therapeutic effects on bone-tendon joints, PDS of the spine, joints of the extremities. Naturally, these activities can be concentrated in one session, and the duration of the whole phase will be regulated by the number of procedures necessary to achieve a recovery effect. Provided that despite all efforts, there is no improvement, and the period from the day of the appearance of the first signs of violations is calculated in weeks, we have to state the chronicity of the process of the disease and move on to the third stage, which is characterized by finding the best way out of the situation. Indeed, it is at this level that the adequacy of previous measures acquires special significance, since they can go along with sanogenic reactions, indicating the direction of subsequent inadequacy of their intervention to introduce disorganization into adaptive processes in the body. It is quite natural that the duration of this stage is more significant than all the previous ones, because all tasks and actions require a certain time, direct, active participation of the patient himself in the treatment process, his focus on achieving a therapeutic effect.

Absence of positive dynamics and at this stage practically means disability of the patient and, consequently, a re-detailed, sufficiently detailed clinical and physiological examination that is already solving not so much problems of pathology diagnosis as real assessment of the dynamics of adaptive processes in the body that occurred under the influence of restorative treatment , the degree of loss of health, working capacity, social independence.

At the fourth stage, the terms of which can not be determined for sufficiently clear reasons, the main direction of rehabilitation therapy is to develop a more complete model of prognostic disorders in the patient-environment system. This task can be solved by various means of physical rehabilitation.

Given that the chronization of the process has led to such persistent pathological changes that have determined disability, active intervention on the affected motor vein loses its usefulness. Therapy acquires a symptomatic character, providing a basis for targeted rehabilitation and prophylactic measures, among which the means of therapeutic physical training (LFK) come to the forefront. Their main goal is to return patients social activity, providing this path with qualified help in determining the most adequate compensation for impaired (lost) functions by correcting them.

The basic concept that allows to carry out successful corrective measures is the idea that any action takes place within a certain time continuum and in an environment of simultaneously changing conditions, which requires remedial corrections. Each lesson on correction of impaired functions is systematic, not compressed in time, the training of skills modeled by the doctor on the basis of the individual capabilities of the patient.

The proposed scheme of rehabilitation in connection with the shutdown of the affected PDS of the spine from the kinematic chain "spine-limb" sets itself basically re-adaptation and resocialization tasks, the peculiarity of which is to develop a new (optimal) motor stereotype, strengthen the affected spine and locomotor apparatus as a whole, returning the patient to their previous work activity.