Physical rehabilitation of patients with damage to the ligamentous apparatus of the spine

Myostatic changes and disorders of coordination of movements in patients

Damage to the ligamentous apparatus of the spine leads to the formation of pain sources in different structures of the musculoskeletal system, or more precisely, sources of nociception. Their presence is accompanied by an obligatory reflex response in the form of a muscle spasm aimed at protecting damaged structures, increasing the sympathetic tone as a general reaction of the body to painful stress and the appearance of quite clearly localized pain sensations. The most frequent causes of acute pain are the development of myofascial dysfunction and functional articular blockades with protective muscle spasm, as well as microdamage of various musculoskeletal structures.

In patients with damage to the ligamentous apparatus of the spine, changes in the functioning of the locomotor apparatus occur in the late period of the trauma. The main goal of these changes is to adapt the biokinematic chain "spine - lower extremities" to functioning under new conditions - the conditions of the appearance of the lesion in the spinal-motor apparatus. During this period, latent trigger points (points), myelogelosis foci, enthesopathy of various muscles, functional blocks, hypermobility (instability) of the joints of the spine can gradually form in the musculoskeletal tissues. As a result of various reasons, for example, during physical overload, sudden movements become the source of nociception. Muscular protection is accompanied by restriction of movements in the affected spine.

The immobility of the changed and redistribution of loads to the stored PDS does not arise immediately, but gradually. First, there are changes in myostatics, and then myodynamics, i.e. The motor stereotype changes. In individuals with a sharp onset of the action of the compression factor, a segmental muscular-tonic reaction first appears, which enhances its action. In response, the body develops a pronounced myofascial symptom complex, which serves as the basis for the formation of a new motor stereotype.

A new motor stereotype in persons with the action of the compression factor is formed as follows. At first, new links of the biokinematic chain "spine-limbs" are quite significant in length, with the spine functioning as a single link. Then, the "division" of the spine into individual biokinematic links consisting of several PDS is observed, but in such a way that the affected PDS is located inside the formed link. Subsequently, the development of complete expressed local myofixation of the affected PDS and restoration of movements in all unaffected, but with new parameters that allow the spine to function adequately under the new conditions are revealed.

In the remission phase, the organic fixation of the new motor stereotype is determined. It is expressed in the development of reparative phenomena in the intervertebral disc and ligamentous apparatus of the spine.

Indications	The main conditions of compensatory reactions
The lesion center in the disk	Preservation of impulse from the lesion focus
The generalized stage of changes in the motor stereotype	Normal functioning of the brain and the cerebellar system, the absence of pathology of the muscular and articular formations
The poly-regional stage of changes in the motor stereotype	The absence of complications of widespread myofixation and spinal muscles
The regional stage of changes in the motor stereotype	Absence of complications of limited myofixation
Intraregional phase of changes in the motor stereotype	No complications of local myofixation
Local phase of changes in the motor stereotype

Organic fixative health reactions

From the type of affected tissue (cartilaginous, ligament, bone tissue) and its regenerative capabilities depends the completeness of the replacement of the defect, as well as the recovery time.

• The smaller the defect volume, the more opportunities for the development of complete regeneration, and vice versa.
• The older the patient, the less its regenerative capabilities.
• With a violation of the nature of nutrition and changes in the overall reactivity of the body, the regeneration processes also slow down.
• In the functioning organ (in particular, in the affected PDS), metabolic reactions are more active, which contributes to the acceleration of the regeneration process.

Restorative regenerative processes in cartilaginous and fibrous tissues most often occur when the factor of inhibition (dysfixation) acts. For these species is typical, as a rule, the onset of complete regeneration. Therefore, quite often (according to our observations, in 41.5% of cases) in patients with spinal osteochondrosis, in whom exacerbations of the disease were caused by dysfunctional disorders in the zone of the affected PDS, a year or more after an attack of disadaptation on the radiographs of the spine and even on functional spondylograms, no changes in the PDS are found.

In patients with cases of the compression factor, restorative processes also develop in the affected tissues. However, quite often (37.1%) there is incomplete regeneration, i.e. Scar tissue is formed in the area of the affected PDS, such changes are rather widely covered in the literature on surgical methods of treatment of the spine.

In cases where muscle fixation is completed by organic and complete tissue regeneration, i.e. Restoration of all structural parts of the affected PDS, then it is possible to restore the functioning of the spine in its entirety.

Organic fixation develops and reaches its completeness, usually six months after the onset of remission. To complete it, you must have the following conditions:

• stabilization of the affected PDS of the spine.
• the phenomena of normalization in trophic systems;
• activation of metabolic processes in the affected PDS of the spine.

If the patient does not create a stabilization in the affected PDS, the periodically occurring bias in it will destroy the immature reducing structures, extend the healing time.

Without the phenomena of normalization in trophic systems, the development of regeneration processes in the affected PDS is greatly hampered. Therefore, both the systems controlling the trophic system and the systems that provide and implement it should function normally. Usually, damage in the area of the affected PDS through the flow of impulses contributes to a violation of its integrity. This, in turn, can not affect the state of the higher regulatory centers that affect the trophic management system.

In the intensification of metabolic processes, i.e. Metabolism in the affected PDS, great importance belongs to physical and household stresses. However, excessive loads on the affected PDS can exacerbate the patient's condition, especially in people with indications of compression of the sinuvertebral nerve receptors. Only in persons with the effect of the disgamic and inflammatory factors, intensive loads on the affected PDS contribute to a decrease in the effect of these factors, and also stimulate the intensity of the metabolism, therefore, many specialists use passive fixation to improve the coordination of physical exertion on the affected spinal column in patients with compression phenomena: orthopedic collars, corsets / orthoses, crutches and other fixing devices. This approach allows you to allow loads on the affected PDS and do not induce in it an increase in the effect of the compressing factor. The application of these recommendations contributes to the fact that patients are not encouraged to form a new optimal motor stereotype. If the patient does not have an optimal motor stereotype, i.e. He can not adapt to the lesion focus in the PDS of the spine, then he has overloads in the above and below the PDS. This, in turn, determines the development in them of subsequent dystrophic processes. There is a kind of "scissors": on the one hand, it is necessary to strengthen the load on the affected PDS, and on the other - this is impossible without the appropriate fixation. Fixation by passive means, in spite of the fact that it makes it possible to load the affected segment, impedes the development of the optimal motor stereotype, which subsequently leads to the development of lesions in adjacent PDS of the spine.

Thus, it is expedient to intensify the metabolic processes in the dystrophically altered PDS with the influence of the compressing factor, not indirect physical effects, but mediated in the form of massage techniques, physical exercises for small joints and muscle groups, physical methods of treatment.

It is known that the ligamentous apparatus carries out a biomechanical function. VVSerov et al. (1981) advanced the concept of "biomechanical control of morphogenesis". According to this concept, there must be a correspondence between the biomechanical function and the organization of the tissue structure. Conventional reparative reactions in ligaments / tendons dystrophic (traumatic) altered along the lines of force loads. If in the process of reparative reactions there are no physical effects on the ligamentous apparatus, the foci of reparations will be located across the ligament / tendon, which, undoubtedly, in the future will make it difficult to exercise its function. If, in the process of development of reparations, dosed, adequate loads are met, then they arise along the ligament / tendon, which leads to her / his strengthening. This, of course, in the future allows you to prevent the development of maladaptation under the influence of various physical and household stresses on the affected ligaments / tendons.

The ligament / tendon tissue has a high reparative capacity. With neurotodendrophy, excessive development of connective tissue is observed. It is known that in the regulation of reparations in connective tissue an important role belongs not only to external factors, but also to internal factors. According to the opinion of V.V. Serov with co-workers. (1981), there is a mechanism of self-regulation of connective tissue growth. In patients with neurotodendrophy, complete remission can also occur immediately, when there are no clinical manifestations from the VDS lesion zone. This can occur when complete reparation occurs, or when incomplete, if receptor endings do not reach the lesion focus. Otherwise, before the death of the receptor endings, the patient will have various clinical manifestations of the neurotendofibrosis foci.

At present, the problem of stimulating the patient's complete reparative reactions is facing the specialists dealing with the treatment of patients with damage to the ligamentous apparatus of the spine, with osteochondrosis. The development of such reactions contributes to the practical recovery of patients.