Staging 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 - the emphasis on the disease (pathomorphological substrates of acute manifestations) or on the patient himself (a set of sociosomatopsychic disorders in an individual).

Based on these premises and focusing on the research results, doctors considered it appropriate to build an algorithm that takes into account a differentiated approach to choosing the tactics of rehabilitation treatment and the optimal timing of its implementation. As can be seen from the stages considered in this scheme, they all satisfy the main tasks specified earlier - to relieve the patient from pain, improve the function of the motor link, foresee the occurrence of prognostically possible disorders (complications) and, based on this, influence 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 study of the muscular system

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

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The first stage is undifferentiated assistance

Undifferentiated assistance:

• changes in the algoreactivity of central neuroendocrine formations (analgesics, tranquilizers, etc.);
• reduction of the activity of mechanosensory cutaneous afferents in trigger zones, pain irritation zones (local anesthetics, physiotherapy procedures, massage techniques - stroking, light rubbing);
• change in the nature of vasoactive local reactions (local heat-cold);
• reduction of loads, immobilization of the motor link (bed rest, positional correction, stabilization of the motor links with local physical exercises);
• muscle relaxation (medicinal; psychocorrection; physical exercises and massage techniques aimed at muscle relaxation; PIR).

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

Pain Management:

• continuation of the activities of the first stage;
• reducing the level of activity of the central and peripheral systems (beta-blockers);
• activation of afferent impulses from higher motor links (physical exercises, therapeutic and acupressure massage techniques, physiotherapeutic procedures);
• activation of afferent impulses (physical exercises, massage techniques, physiotherapeutic procedures);
• activation of endogenous mechanisms of mental regulation (formation of an attitude towards recovery).

Improving the functional state of the motor link:

• movement modeling (impact on the skin of the area of the involved motor link), muscle stretching techniques, special physical exercises, PIR, “proprioceptive facilitation” techniques (PNF);
• reduction of vertical (axial) loads (positional correction, unloading initial positions, orthoses);
• effects on the affected spinal joints, bone-tendon formations and muscles surrounding the spine (special physical exercises, point and reflex-segmental massage techniques), traction therapy;
• activation of higher and lower motor links (prevention of overload of other motor links) - combined effect of various means of physical rehabilitation;
• improving the vascular supply of the motor link (massage techniques, physiotherapy procedures, physical exercises);
• increasing the range of motion in the affected link - reducing the degree of muscle contraction (physical exercises, PIR, massage techniques, physiotherapy procedures)

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

Chronic pain therapy:

1. reduction 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. increasing the activity of adaptive processes (adaptogens; steroids; breathing exercises; emotional-volitional training);
4. reorganization of the sensory system; ("neuromotor re-education"); impact on the skin of the motor link area - PIR, methods of segmental-reflex massage

Therapy for disorders of the integrity of the motor act:

• reorganization of the motor system (“neuromotor re-education”; impact on muscles, ligaments, bone-tendon joints - physical exercises, massage);
• restoration of the fullest possible integrity of the motor act (physical exercises, PIR, massage);
• restoration of the integrity of movement in the spine, opposite limb (impact on muscles, bone-tendon, joint articulations);
• prevention of violations of the integrity of the entire locomotor 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 health status;
• functional examination of the musculoskeletal system;
• definition of prognosis;
• modeling possible changes in health status

Developing an adequate behavioral stereotype:

• correction of mental correspondence between the patient type and the selected model;
• correction of the motor stereotype in accordance with the selected model;
• symptomatic therapy;
• preventive measures:
  • exception - reduction of the traumatic influence of the formed motor stereotype on the preservation of the conditions of the usual functioning of the motor links;
  • exception - reduction of the stress-related nature of disability;
  • prevention of secondary disorders associated with changes in stereotypes

The examination stage 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;
• changes in nociceptive mechanisms in the peripheral area;
• changes in the nature of vasoactive reactions, leading not only to an improvement in the microcirculation of the damaged area, but also due to the extensive mechanisms of nociceptive and vascular reactions, including peripheral neuroendocrine regulation.

All these activities are carried out with the maximum possible relaxation of the muscular system and the position of the trunk and limbs 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, potentiating the effect of central analgesics, tranquilizers; muscle relaxation and stretching, psychological correction.

The three-day period allotted 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 period 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 duration of the primary lesion.

The absence of a therapeutic effect automatically means a transition to the next, second stage, and determines the need to provide differentiated care both for pain and for worsening motor dysfunction.

It is known that the plasticity of nociceptive processes is determined by reverse transport, slow activity of nerve terminals, and perverted activity of sympathetic formations. In this regard, at the level of continuing therapy with central analgesics and tranquilizers, various blockades can be successfully used. Based on the concept of "gate control", one of the possible mechanisms for suppressing nociceptive integrative activity is the involvement of fast-conducting nerve fibers from muscle and tendon-ligament formations. Such stimulation can be carried out with the help of physical exercises, massage techniques on motor links located above the affected focus. As well as synergistic exercises in the key of biological feedback, ensuring effective restoration of descending impulses, any therapeutic intervention requires adequate verbal mediation.

In this case, we are talking about the necessary suggestive instruction preceding any action of the specialist, understandable to the patient and relieving the stress of the procedure itself. The same goal is dedicated to the activity of activating the endogenous mechanisms of mental regulation - the formation of an attitude towards recovery, mental readaptation.

Compared with the first stage, the importance of rehabilitation therapy aimed at improving the function of the motor link and speedy recovery increases. The given sequence of individual target areas sufficiently convincingly illustrates the formation of a pattern of physiological reactions, starting with the skin sensory zone and ending with therapeutic effects on the bone-tendon joints, the spinal PDS, and the joints of the extremities. Naturally, these activities can be concentrated in one session, and the duration of the entire stage will be regulated by the number of procedures necessary to achieve a restorative effect. Provided that, despite all efforts, there is no improvement, and the period from the day the first signs of disorders appear is calculated in weeks, it is necessary to state the chronicity of the disease process and move on to the third stage, characterized by the search for an optimal way out of the current situation. Indeed, it is at this level that the adequacy of previous measures acquires special significance, since they can proceed in parallel with sanogenic reactions, outlining the directions of subsequent interventions by their inadequacy and introducing disorganization into the adaptive processes in the body. It is quite natural that the duration of this stage is more significant than all the previous ones, due to the fact that all tasks and actions require a certain amount of time, direct, active participation of the patient himself in the treatment process, and his focus on achieving a therapeutic effect.

The absence of positive dynamics at this stage practically means the patient's disability and, therefore, a repeated, sufficiently detailed clinical and physiological examination becomes especially relevant, which already solves not so much the issues of diagnosing the pathology, but a 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, ability to work, social independence.

At the fourth stage, the timing of which cannot 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 a variety of physical rehabilitation methods.

Considering that the chronicity of the process has led to such persistent pathological changes that determined disability, active intervention on the affected motor vein loses its expediency. Therapy acquires a symptomatic nature, providing a basis for targeted rehabilitation and preventive measures, among which the leading positions are taken by means of therapeutic physical culture (LFK). Their main goal is to return social activity to patients, providing this path with qualified assistance in determining the most adequate compensation for impaired (lost) functions by correcting them.

The basic concept that allows for successful corrective measures is the idea that any action occurs within a certain time continuum and in a setting of parallel changing conditions, which requires moment-by-moment corrections. Each lesson on correcting impaired functions is a systematic, not compressed in time, development of skills modeled by the doctor based on the individual capabilities of the patient.

The proposed rehabilitation scheme in connection with the exclusion of the affected spinal musculoskeletal system from the “spine-limbs” kinematic chain sets itself mainly readaptation and resocialization tasks, the peculiarity of which consists in the development of a new (optimal) motor stereotype, strengthening of the affected section of the spine and the locomotor apparatus as a whole, and the return of the patient to his previous work activity.