Treatment of osteochondrosis: formation of motor skills

The formation of the motor skill is a multistage process. From elementary skills, which form the basis of the expedient motor activity of man and which resulted from repeated repetition of skills, the transition to the synthesis of a number of skills and skills of high order is carried out. This happens through the denial of an elementary skill skill, and then a more perfect skill. The skill in this multi-tiered system of voluntary movements is nothing more than the mastered ability to solve this or that kind of motor tasks.

The first stage of the motor skill is characterized by the irradiation of the nervous process with a generalized external response. The second phase is associated with the concentration of excitation, with the improvement of coordination and the formation of stereotyped motions. The third stage completes the formation of automatism and the stabilization of motor acts.

The element of convention in this approach is primarily connected with the separation of the character of the course of the nervous process into independent phases. Concentration of the nervous process can not have a self-extracting value. It completes the irradiation of the stimulation. The generalization phase in the formation of a new motor skill may coincide with the end of the formation of the previous one. And if phenomenologically, by external signs, it is still possible to judge the completion of a certain stage in the formation of the motor skill, then the processes hidden from visual observation do not lend itself to rigorous phase analysis.

According to NA Berne-Stein, the appearance of automatisms completes the first phase of skill formation. It is characterized by the establishment of a leading level of building the movement, determining the motor composition, the necessary corrections and automating their switching to the lower levels.

The second phase is characterized by the standardization of the motor composition, stabilization (resistance against the action of confounding factors), coordination of the coordination elements of the skill.

At the stage of stabilization of the skill, external, random stimuli do not have a destructive effect on it. The quality of exercise does not affect the complexity of the motor situation. Only a prolonged change in environmental conditions or special destruction of the motor structure, due to a change in the prevailing ideas about the technique of performing physical exercises, can significantly change the motor skill or its individual elements. This to a certain extent applies to correcting errors in motion. If the error has become an integral part of the learned movement, correcting it takes a long time. In a number of cases, the formation of a new motor skill occurs faster than the correction of an error in it.

The physiological basis for the classification of physical exercises can be:

• a mode of muscular activity (static, isotonic, mixed);
• degree of coordination complexity;
• the relation of physical exercises to development of qualities of impellent activity (to physical qualities);
• relative power of work.

Classification of physical exercises on the coordination structure provides for the allocation of groups of exercises on the increasing complexity of the movements of the body and its segments, limbs. The degree of coordination complexity in the movements, for example, of the limbs, will increase from symmetrical movements in one plane to asymmetric, multidirectional and disparate movements.

The basis of the classification according to the levels of movement is the vertical (from the cerebral hemispheres to the trunk portion and the spinal cord) the hierarchical principle of neural regulation of movements. This allows us to distinguish the motor acts caused by nervous formations at the level of the brainstem part of the brain, the nearest subcortical nuclei and cortical projections of the motor analyzer.

Method of performing physical exercises: a) standard; b) non-standard (variative).

So, cyclic exercises are characterized by standard (constant, non-changing) ways of doing. For non-standard exercises are characterized by a constant change in the conditions for the implementation of the movement, and with it the change in the form of movements and their physiological characteristics.

Classification of physical exercises by the level of total energy expenditure was proposed by Dill (1936). On this principle, later classifications were also founded. Lonla (1961) proposed to classify the work according to the individual possibilities of energy exchange in terms of the maximum oxygen consumption (MPC). The work performed with an oxygen request exceeding the MS level is classified by him as very heavy.

Acyclic movements are integral, finished engine acts, not connected with each other, having an independent meaning. These movements are characterized by relative short-term performance and an extraordinary variety of forms. By the nature of the work, these are primarily exercises that maximize the power and speed of muscle contraction. Between individual acyclic movements there is no organic connection, even if they are performed in a certain sequence. The repetition of the acyclic movement does not change its essence, it does not turn it into a cyclic one.

Cyclic movements are characterized by the regular, sequential alternation and interconnection of the individual phases of the integral movement (cycle) and the cycles themselves. The interconnectedness of each cycle i with the previous and subsequent is a significant feature of the exercises of this kind.

The physiological basis of these movements is the rhythmic motor reflex. The choice of the optimal pace for learning the cyclic motions speeds up the process of assimilation of the rhythm of stimulation, as well as the establishment of an optimal rhythm of all physiological functions. It helps to increase the lability and stability of nerve centers to rhythmic stimuli, speeds up workability.

Synergetic exercises. Under normal conditions, the work of synergist muscles leads most often to stabilization of the corresponding joints, which facilitates the performance of the main movement. In addition, synergism consists in the interrelated ratios of agonist stress and antagonists during movement. Synergy is not a constant quality and varies depending on many factors (age, physical condition, illness, etc.). Conditional synergism is created on the basis of reflex arcs. The essence of all synergistic actions is the ability to induce a strain of the topographically distant muscle as a result of the contraction of another dynamic group.

It is necessary to distinguish the following types of synergism: unconditioned, conditional, ipsilateral, contralateral.

• Unconditional synergy is a neuromuscular reaction, congenital, fixed in the process of phylogenesis, manifested to a greater or lesser degree in each patient. For example: a) in the lower limb - this is the straightening of the foot with the resistance of the hands of the doctor, causing tension of the four heads of the thigh muscles; b) in the upper limb - the back flexion in the wrist joint in the position of pronation, which leads to tension of the triceps brachium muscle. With palmar flexion in the same joint in the supine position, the biceps muscle of the shoulder strains; c) in the field of the trunk - lifting of the head in the sagittal plane in the ips. - lying on the back determines the tension of the rectus abdominis muscle. Raising the head in the i.p. - lying on the stomach causes tension of the gluteus maximus muscles. Unconditional synergy is used in LH procedures to activate weakened muscle groups of certain body segments (limbs).
• Conditional synergism exists independently of unconditional synergism and is fundamentally different from it. The most common conditioned reflex synergies are revealed:
• For the quadriceps femoris:
  • flexion in the hip joint;
  • the removal and bringing of the leg in the hip joint;
  • back and plantar flexion in the ankle joint.

ATTENTION! All the movements indicated in points "a-c" refer to the same-named limb.

• transition from the i.p. - sitting in the ip. - lying and reverse motion;
• rotational movements in the hip joint.

• For the gluteal muscles:
  • flexion in the knee joint;
  • torso bend back in and out. Etc. - lying on his stomach;
  • bringing the same-named upper limb into the i.p. Lying on his stomach.

The therapeutic effect of the use of conditioned reflex synergy after a while after the start of exercise can gradually decrease. Therefore, every two weeks it is necessary to change the movement, stimulating a synergistic contraction in the muscle being exercised.

• Ipsilateral synergism is used in exercises performed in neighboring limb joints to cause muscle tension in the same-named limb.
• Contralateral synergism is the basis of exercises in which movement in the opposite limb is used to excite the muscle.

There are three conditions for the correct implementation of synergistic exercises: a) the exercises should cover as much as possible the number of dynamic groups responsible for the "transfer" of excitement; b) must be performed with maximum resistance; c) be carried out until complete fatigue.

The therapeutic effect with the help of synergistic effects can be achieved by doing the exercises 4 times a day.

Therapeutic physical culture as a method of restorative therapy for diseases of the nervous system

Over the past 30-40 years, a large number of methodical techniques have been created aimed at activating the activity of the paretic (weakened) muscles and restoring the control of the anatomically intact muscle by the remaining, but inhibited, motor centers of the spinal cord.

There are three main directions in the development of methods of exercise therapy:

1. Systems of functional therapy aimed at increasing the overall activity of the patient, instilling in him strong-willed qualities, striving to overcome stiffness, general weakness, mastering of everyday habits, despite motor disabilities and deformations in individual joints.
2. Systems of analytical gymnastics, which are based on correction of certain deformities, decrease in muscle tone, increase in the volume of voluntary movements in individual joints without taking into account the general motor stereotype of the patient.
3. The system of using complex movements.

Functional Therapy Systems

A number of authors believe that the method of curative gymnastics (LH) is determined by the nature of the lesion, the intensity of muscular recovery and the stage of the disease. At the same time, active movements should be used as the most valuable stimulants of the neuromuscular system. Passive movements are used to stretch the shortened (postural) antagonist muscles, improve the function of the joints and to develop reflex connections. It is envisaged to impose special tires, rollers, wearing orthopedic shoes, training proper posture, correct setting of feet, etc. In order to prevent the development of perverse provisions in a patient. Mandatory systematic use of massage for many years (NA Belaya).

For functional restoration of the affected limbs are considered necessary:

• optimal starting positions for obtaining the maximum amplitude of movements of both healthy and paretic limbs;
• passive movements with the purpose of preserving the function of the joints with the involvement of paretic musculature. These movements help to shorten the paretic (weakened) muscles and lengthen their antagonists, which is important for the prevention of contractures;
• active movements of healthy and affected limbs. If it is not possible to perform active exercises, a volitional premise of impulses is used to reduce paretic muscles (ideomotor exercises) or muscle tension of healthy limbs - isometric exercises) for reflexively increasing the tone of the paretic musculature;
• elementary active motions from facilitated initial positions, without overcoming the severity of the limb;
• exercises for the development of substitutive functions due to abnormally functioning musculature or re-education of certain muscle groups;
• active exercises in the aquatic environment;
• active exercises with free moving movements, without power voltage:
  • friendly (at the same time with a healthy limb);
  • anti-friendly (separately for weakened muscle groups);
• exercises with increasing stress;
• exercises for the development of coordination of movements and support functions.

Integrative use of various methods in complex physical and analytical gymnastics in physiotherapy exercises , methods of Bobat's technique (strengthening of static-dynamic functions training), methods of editing by F. Pokorny and N.Malkova (exteroceptive relief), Kabat techniques (proprioceptive relief) a number of diseases of the nervous system (in particular, with osteochondrosis of the spine).

Of the foreign methods of therapeutic gymnastics, the technique of Kenya (1946) was widely used. Especially widely this method is widespread in the Czech Republic (F. Pokorny, N. Malkova). Treatment according to this method consists of the following sections:

• Hot wraps that improve blood circulation in the affected tissues;
• The stimulation of the muscles is carried out in the form of rapidly repeating rhythmic passive movements with simultaneous gentle vibration towards the affected muscles. During stimulation, irritation of numerous proprioceptors of muscles and tendons occurs. As a result, the sending of afferent impulses to the posterior horns of the spinal cord increases, and thence to the motor cells of the anterior horns of the spinal cord, which facilitates the rapid restoration of the motor function of the affected muscles;
• Reedukatsiya (education of movements) is a passive and passive-active movement, produced without vibration, but with the impact on the tactile, visual and auditory analyzers. The re-design consists of several components: first the instructor should explain and show the patient what movement will be performed. After that, he makes a slight stroking of the fingers in the direction of movement on those muscles that will contract, and only then proceeds to passive movements.

It is optimal to perform stimulation and reduction for 5 min for each muscle for mild and moderate severity of lesions and 3 min for severe forms of lesion.

Analytical Systems

Assessing the analytical systems of exercise therapy in the treatment of patients with diseases and injuries of the nervous system, it is necessary to note the following. The analytical approach allows the isolation of individual muscle groups and avoiding substitutions and complex combinations. However, these systems do not take into account the general patterns of development of motor functions in a child (neurology of childhood) or an adult patient (optimal motor stereotype).

The low efficiency of the analytical systems of exercise therapy, especially in the late recovery period of diseases of the nervous system, made it necessary to abandon the principle of feasible step physical exercise in conditions of facilitated movement. In LFK there was another direction that uses "complex movements" to activate the affected muscles in conditions of proprioceptive relief. This trend took shape in a system known as the Cabot method (Kabot, 1950), or the system of "proprioceptive relief", or "Propriozeptive Neuromuskulare Fazilitation" (PNF).

According to Voss and Knott (1956), for the first time this LFK method was used in the complex therapy of patients with military trauma. Later it was used to treat various diseases with gross disorders of movement.

Numerous techniques offered by the Cabot system are based on the following principles:

• leading and coordinating incentives for muscle contraction are proprioceptive stimuli;
• There are adjacent types of movement, where some predispose to other specific types of motion;
• motor behavior is determined by volitional (arbitrary) movements.

Cabot system provides:

• refusal of gradual increase of loads;
• maximum possible resistance to movement of the segment or the entire limb, or trunk from the very beginning of therapy;
• Excludes analytical work with the affected muscle; instead of isolated motion of the affected muscle, a complex movement is proposed, embracing simultaneously and consistently many muscle groups;
• one of the factors facilitating the reduction of the paretic (affected) muscle is its preliminary stretching;
• It is necessary to neglect fatigue and engage in an intensive program of maximum activity.

The author warns that not all methods are effective for the patient. First, simpler, then sequentially more complex or combined methods should be tested, until the intended result is achieved.

"Proprioceptive relief" is achieved by the following methods:

• maximum resistance to movement;
• reversion of muscle-antagonists;
• preliminary stretching of the affected muscles;
• alternation of muscle-antagonists;
• complex motor acts.

A) The  maximum resistance to movement can be practically used in the following methods:

• resistance provided by the hands of a methodologist. Resistance is unstable and varies throughout the volume during muscle contraction. In the resistance, the instructor forces the patient's muscles to work throughout the movement with the same force, i. E. In isotonic mode;
• alternation of muscular work. Overcoming the "maximum resistance, the practiced limb section (for example, the shoulder) moves to a certain point of motion. Then the methodologist, increasing the resistance, prevents further movement. The patient is asked to hold this section of the limb in the specified position and, increasing the resistance, achieve the greatest activity of the muscles in the isometric mode of operation (2-3 seconds exposure). After that, reducing resistance, they ask the patient to continue moving. Thus, the isometric operation becomes isotonic;
• repetition of muscle contractions; an arbitrary contraction of the muscles continues until the onset of fatigue. Alternation of types of muscular work, is carried out several times throughout the movement.

B) Rapid change in the direction of movement, called reversal, can be carried out in different versions, both with the full amplitude of movements in the joint, and in its individual parts. With a slow reversion of the antagonist muscles, movement with resistance towards their contraction is slow, with a subsequent transition to movements with resistance of the paretic muscles. In this case, the effect of the stimulating proprioceptive effect is used, since the excitability of the motor cells of the spinal cord, the innervating and paretic muscles, is increased due to the tension of the antagonists. It can be suggested to the patient at the end of the movement to hold the distal limb section (exposure 1-2 s) and without pause to move to the opposite movement. There is also a slow reversal of antagonists with isometric retention and subsequent relaxation, or slow reversion of antagonists, followed by relaxation.

Rapid execution of movements towards the paretic muscles after a slow maximum resistance of the antagonist muscles is called a rapid reversal of the antagonists. Increase the rate of contraction of the paretic muscles can be due to a weakening of the resistance or helping the patient. To finish fast movement it is necessary for static deduction of a limb, rendering, thus the maximum resistance.

C) The preliminary stretching of the affected muscles can be carried out in the form of:

• passive stretching of muscles. The extremities give such a position, in which the stretching of the paretic muscles is performed due to flexion or extension in several joints. For example, to train the straight muscle of the hip, the lower limb is preliminarily unbent in the hip and bent at the knee joint. This technique stretches and prepares to contract the straight muscle of the thigh. Then exercise this muscle with extension at the knee joint;
• rapid stretching from a fixed position of the limb. By resisting antagonists, the instructor asks the patient to fix the limb in the given position, maximizing the work of unaffected muscles. Then the resistance force decreases and the movement of the limb of the patient is caused. Do not move to the full volume, change the direction of motion to the opposite, i.e. Include weakened muscles in the work. Consequently, the contraction of the paretic muscles occurs after their preliminary rapid stretching;
• rapid stretching of the muscles, which immediately follows the active movement. Overcoming the maximum resistance, the patient performs a slow movement. Suddenly, the instructor reduces the resistance force, which leads to rapid movement. Without bringing the movement to full volume, change the direction of movement to the opposite by including affected muscular groups.

D) Alternation of antagonists:

1. Slow alternations of isotonic contractions of antagonists within the framework of the movement (limb segment). Movement: maximum reduction in agonist. With the dosed resistance, after which the antagonist contractions (also with resistance) follow.

ATTENTION! The stronger the reduction of the agonist, the greater the relief (assistance) of the antagonist. It is important from the outset to achieve maximum resistance in reducing antagonists, before resistance is given to a weaker agonist.

Reduction should be done slowly to create the possibility of optimal excitation.

1. A slow alternation with a static force is an isotonic contraction, followed by either an isometric contraction or an eccentric contraction that interests a limited volume of the same muscle group. This method is used immediately afterwards, using antagonistic muscle groups. For example, when the arm is bent at the elbow joint (isotonic mode), the doctor stops the movement at an angle of 25 ° and asks the patient to continue contracting the flexor muscles with the maximum possible force (isometric mode of operation), with their hand resistance to movement. After this, the doctor asks the patient to perform extension and blocks this movement, giving resistance, at the maximum amplitude level or at the end of it.
2. Rhythmic stabilization is the blocking of movement (resistance by the hand of the doctor) at a certain amplitude, followed by blocking the movement in the opposite direction. Thus, for example, we block, for example, one of the diagonal schemes: the flexion and rotation of the thigh, increasing the resistance, while at the same time making the muscles contract isometrically; then immediately the doctor asks the patient to perform the extension of the thigh and turn it in the opposite direction, the movement, which is also blocked.
3. Slow alternation - relaxation is carried out by applying the procedure specified in the first paragraph, after which each contraction is followed by relaxation, before coming to a new isotonic contraction.
4. A slow alternation with static effort and relaxation consists of applying the procedure of the second point, followed by the greatest possible relaxation of the muscles.
5. Combination of the procedures of the 4th and 5th points in the sense of applying slow alternation with relaxation (after isotonic contraction) for the antagonist and slow alternation with static effort and relaxation (after isometric contraction) for a weaker agonist.

ATTENTION! The last three procedures are used to relax tense muscles. With these procedures, the moment of relaxation is important. The relaxation time should be long enough for the patient to feel this effect and the doctor will be sure that the greatest possible relaxation is achieved.

E) Complex motor acts are carried out by joint reduction of paratrices and retained or less affected muscles. In this case, not individual contracting muscles (or muscle) are trained, but significant muscle regions involved in significant and complex motor acts that are most characteristic of the patient.

The author notes that the pattern of the movements of a person's daily normal activity, which requires some effort at work and during classes, for example, physical fitness, is performed along a diagonal trajectory relative to the vertical axis of the body. The movements used in this way are more effective and correspond to the possibilities of applying the maximum possible force, as:

1) allows to correctly anatomically distribute certain groups of muscles and influence them;

2) these schemes involve a large number of muscle groups in the movement, the treatment covers at once a large number of interested muscles and leads, therefore, to more rapid results.

Exercises are performed with resistance provided by blocks (with load), dumbbells, expanders, etc. It is possible to use simpler schemes, where resistance is a series of actions, such as crawling forward, backward, and so on. These exercises are performed sequentially - from simple to complex and more complex (IP - lying, standing on all fours, on the knees, in the semicircle, etc.).

Complex movements are performed on all three axes: flexion and extension, reduction and retraction, internal and external rotation in various combinations along two basic diagonal planes. Movements to the head are considered as bending (by the nature of movements in the shoulder and hip joint), movement down and back from the head - extension, towards the middle line - by reduction, from the midline - by the lead.

In the first diagonal plane, the limb moves to the head (up) and to the midline (flexion-reduction), and in the opposite direction - down and out (extension-retraction). In the second diagonal plane, the limb is directed upwards and outwards (flexion-retraction), in the opposite direction - down and inside (extension-reduction).

Flexion-reduction is combined with external rotation and supination, extension-retraction - with internal rotation and pronation. Apply symmetrical and asymmetric exercises, which should be performed from the distal parts of the limbs, using overcoming, inferior and retaining muscle forces. Motions (in two opposite directions) in two joints (for example, in the shoulder and elbow, hip and knee) are permissible. Head turns are permitted in the direction of movement.

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

Unconditional tonic reflexes in the formation of arbitrary movements

Congenital motor reflexes ensure the preservation of normal posture, balance, coordinate the posture with the position of the head in relation to the trunk.

In accordance with the existing classification, congenital motor reflexes are subdivided:

• on reflexes, which determine the position of the body at rest (reflexes of position);
• Reflexes that ensure the return to the initial position (adjusting reflexes).

Reflexes occur when the head tilts and turns due to irritation of the nerve endings of the neck muscles (cervical-tonic reflexes) and labyrinths of the inner ear (labyrinth reflexes). Raising or lowering the head causes a reflex change in the tone of the muscles of the trunk and extremities, ensuring the preservation of normal posture.

Means of physical rehabilitation in the therapy of osteochondrosis of the spine

The adjusting reflexes ensure the preservation of the posture when it deviates from its normal position (for example, straightening the trunk). The chain of rectifying reflexes begins with the raising of the head and the subsequent change in the position of the trunk, which ends with the restoration of the normal posture. Vestibular and visual apparatus, proprioceptors of muscles, skin receptors participate in the implementation of rectifying reflexes.

The productive and household activities of a person are connected with continuous changes in the interaction of the organism and the environment. Mastering complex physical exercises with changing external conditions (for example, in a game environment, coordination exercises, etc.) is an example of such interaction. The development of the finest differentiations that allow one to exercise this exercise rationally is the result of the analytic-synthetic activity of the brain. On the basis of this activity, a system for managing arbitrary movements is formed.

In France, a method of sequential training of motor functions based on the developed static poses and equilibrium reactions is proposed . The authors propose a number of physical exercises aimed at activating the muscles of the extensors of the trunk. The balance is trained on the basis of the use of a cervical tonic asymmetric reflex. From the same standpoint, the technique of the spouses K. And B. Bobath (Bobath Karela et Berta) deserves attention, which consists in inhibition of abnormal tonic reflexes, in the protraction of higher coordinated postural reactions in a certain sequence with a constant transition to arbitrary movements and regulation of reciprocal muscular activity. The inhibition of pathological postures and movements in patients with spastic paralysis of the head, neck or shoulder girdle. Therefore, in the method of K. And B. Bobath, great attention is paid to the correct use of tonic reflexes.

The main tonic reflexes are:

• tonic labyrinth reflex, depending on the position of the head in space. In the supine position on the back, hypertension of the extensor muscles of the back is caused. The patient can not lift his head, push his shoulders forward, turn on his side. In the position - lying on the abdomen, the tone of the flexor muscles of the back increases. The trunk and head are bent, hands in a bent position are pressed to the chest, legs are bent in all joints;
• asymmetric tonic reflex (cervical). Rotation to the side of the head causes an increase in the tone of the muscles of the limbs, on the corresponding turn of the half of the body, and on the opposite side the tonus of the muscles of the extremities decreases;
• symmetrical tonic cervical reflex. When lifting the head, the tonus of the arms extensions and flexors of the legs intensifies, while lowering it, on the contrary, increases the tone of the flexors of the arms and extensors of the legs;
• the reaction is associated with tonic reflexes that begin in one limb and strengthen the tonus of the muscles of the other limb, which, with frequent repetition, contribute to the development of contractures. The main pathology of motility is the violation of the normal mechanism of automatic preservation of balance and normal position of the head. Perverted muscle tone causes pathological conditions that impede movement. Depending on the position of the head in space and its relationship with the neck and body changes the tone of different muscle groups.

All the tonic reflexes act together, harmoniously amplifying or weakening each other.

Features of the methodology:

• selection of initial positions, inhibitory reflexes. For example, in IP. - lying on the back (the spasticity of the extensor muscles is increased), the head is moved to the middle position and bends forward. Arms bend in the shoulder and elbow joints and are placed on the chest. Legs bend and, if necessary, are diverted. This creates a pose that allows you to stretch all spasmodically contracted muscles.