Mechanical and neurogenic causes of contracture development.
Stages of rehabilitation.
I. Preparation of the stump for prosthetics
A person who has undergone an amputation of a limb, during the first year after it, will have to go through several stages of rehabilitation. It must be taken into account that each person goes through these stages at their own pace, the speed of which is influenced by many factors, such as: age, state of health, the creation of a full-fledged stump by choosing the right level and method of amputation, as well as optimal preparation for prosthetics. Someone can go through the stages of rehabilitation at an accelerated pace, for someone this period will be longer. In our Center, an individual rehabilitation plan is developed for each patient in order to guide him on this path. It is important that the disabled person remains an active participant throughout the entire recovery process. During the rehabilitation period, the patient must follow the recommendations for the care postoperative suture, the formation of the stump, maintaining the mobility of the joints and strengthening the remaining muscles.
Postoperative suture and skin care postoperative period
The postoperative suture is monitored by a doctor and a nurse. You must comply with all their instructions. This is especially true for patients with diabetes mellitus and vascular disease, as they have an increased risk of developing an infection.
After amputation, the skin of the stump is very sensitive. Using a soft brush or a massage ball, you can reduce the sensitivity by lightly massaging the stump with them. It is also effective to rub the stump with a hard towel or washcloth made of terry cloth. Massage movements always pass from the end of the stump to its base. It is recommended to massage the stump several times a day.
For daily care behind the skin of the stump, it is necessary to observe hygiene - a contrast shower of the stump is recommended, it can be washed with baby soap and wiped dry with a soft towel. Inspect the skin of the stump daily for any changes in the skin condition and, if any, immediately inform your doctor or prosthetist. It is convenient to use a small hand mirror to examine the stump.
In most cases, the wound after amputation heals within three to four weeks, then a postoperative scar forms, which must be regularly moistened. Lubricate it daily with an unscented cream.
Patients with diabetes or circulatory disorders require longer treatment and are at increased risk of infection in operating wound. For this group of patients who are prone to the development of skin complications in the future, it is advisable to use special medications for the care of the stump.
Decongestive therapy
An important problem that needs to be solved is the edema that occurs after surgery, as a natural reaction of the body to surgical intervention. Under normal conditions, the swelling subsides in one to two weeks.
Until the stitches are removed, the wound is not tightly bandaged. At first, pressure should not be exerted on the stump. To reduce swelling in the first few days after amputation, it is important to position the stump above the level of the heart. Then comes the stage of compression therapy in order to reduce swelling and prepare the stump for prosthetics. It improves blood circulation in the stump, reduces pain and accelerates the healing of the surgical suture.
To eliminate edema, it is recommended to use elastic bandage, compression stockings, silicone cover, lymphatic drainage massage, which is done by a specialist. First, all the above actions are performed by medical personnel, teaching relatives and the patient himself. Then the patient performs these procedures independently.
The bandage should not be loose or tight. Bandaging of the stump is carried out in the morning after sleep, the bandage is removed before going to bed: the pressure in the distal (lower) part of the stump should be maximum, but not painful. The bandaging is higher in the stump, the less pressure. This avoids the restriction of blood circulation in the stump.
Patients after amputation above the knee are recommended to lie down on their stomach twice a day for 30 minutes. The head must be turned to the healthy side. This provides a slight stretching of the muscles on the stump.
To determine the effectiveness of decongestant therapy, the circumference of the stump is measured in the morning and in the evening at the same measurement points. We recommend that you record your measurements to make it easier to see how the swelling subsides.
Prevention of joint contractures
Joint contracture - restriction of passive movements in the joint, caused by cicatricial deformity of the skin, muscles, tendons, joint. More often there are flexion contractures (i.e., the state of the limb when it cannot be straightened) in the hip, knee, elbow joints, which prevent prosthetics and lengthen the rehabilitation period.
Prevention methods:
- Ensuring the correct position of the limb during its immobilization. The stump should be in a straightened position as much as possible. You can not keep the stump in a bent state for a long time, because. the muscles will shorten and the mobility of the stump will decrease.
2. Timely elimination of pain and swelling. After amputation, it is recommended to use a wheelchair with a special footrest for the leg stump, which prevents deformation of the spine. From time to time, you need to change the position of the stump so that the joints do not lose mobility. The combination of correct body position and movement - essential condition to treat swelling and pain.
3. Active and passive therapeutic exercises. When exercising, avoid movements causing pain. At the first stage, gymnastics takes place under the supervision of an exercise therapy doctor, starting with breathing exercises, stretching exercises, strengthening the muscles of the spine, arms, a healthy leg, balance and coordination.
We recommend 1-2 weeks after the amputation or at the first opportunity to appear to the prosthetist and orthopedist in the department of complex and atypical prosthetics. The earlier the patient gets on the prosthesis, the less dynamic skills are lost, the more powerful the rehabilitation potential is and the adaptation to prostheses is optimized.
4. Phantom pains
Phantom pain is the sensation of pain that occurs in a lost limb. For example, a continuing sensation of tissue damage that arose at the time of the accident or itching, a feeling of numbness in the missing limb. The reduction of phantom pain is facilitated by early activation of the patient (sitting and vertical position), massage and lymphatic drainage of the stump, uniform pressure in the stump created by bandaging and compression stockings, physiotherapy, early start of physical exercises, as early as possible prosthetics.
In rare and difficult cases nerve blocks and surgery are required. In addition to the participation and support of family and relatives, the help of professional psychologists should not be neglected. In the first months after surgery, circulatory disorders in the amputated limb, prolonged immobility, infections, and sleep disturbances can lead to increased pain.
Cause of pain in more late period is mainly negligence in the care of the stump and improper wearing of prostheses. To check the correct attachment of the prosthesis, it is necessary to put on the prosthesis and take a few steps. If, despite following all the rules for its use in the stump, severe pain occurs, you should consult a doctor.
Mirror therapy is very effective. The brain integrates the signals as coming from the amputated limb. (Contraindications - paired amputation). The help of a psychotherapist is possible. In some cases, in agreement with the doctor - the use of medications.
II. Prosthetics
Prosthetics- a special type of medical care for the sick and disabled, providing for partial or complete replenishment of the form and function of an organ that has suffered as a result of an injury, disease or malformation. Prosthetics is closely related to traumatology, orthopedics and reconstructive surgery. The design of prosthetic and orthopedic products is based on the use of the achievements of physiology, biomechanics, mechanics, electronics, electromechanics, chemistry, physics, mathematics, etc.
The leading role in P.'s process belongs to the orthopedist and prosthetist. Timely and high-quality production of prostheses and orthoses of the upper or lower extremities, as well as full-fledged training in their use, allow more than 70% of patients and disabled people of orthopedic and traumatological profile to return to socially useful work.
The process of prosthetics or orthotics includes a number of stages: choosing the design of a prosthetic and orthopedic product, taking measurements, making a plaster negative and positive, assembling the product for fitting, taking into account correct location tires and hinges, finishing, issuance and training in their use. Along with these factors, the success of medical, social and professional rehabilitation depends on the quality of manufacture (weight, dimensions, control method, attachment design, cosmetics and aesthetics) and individual fitting of the product, teaching the patient to use the prosthetic and orthopedic product and the degree of development of compensatory motor skills.
The need for early therapeutic prosthetics is generally recognized. Only in this case, a rational compensatory restructuring of the motor stereotype occurs, which contributes to the restoration of motor activity and working capacity. There are primary and repeated prosthetics, or orthotics. Primary prosthetics is carried out on the 14th-21st day after amputation of the limb with primary wound healing and the absence of inflammation in the tissues of the stump. Repeated prosthetics, or orthotics, in adults are prescribed as the product wears out.
Limb prostheses
They are divided into lower limb prostheses and upper limb prostheses.
Similar information.
Contracture(lat. contractura narrowing, contraction, contraction) - limitation of normal mobility in the joint, caused by cicatricial contraction of the skin, tendons, diseases of the muscles, joints, pain reflex, etc. fibers that arise without action potentials of motoneurons. These conditions are defined as muscle contracture.
Classification of contractures
There are a large number of classification schemes for contractures. Difficulties in constructing such schemes are due to the polyetiology of these pathological conditions, a large variety structural changes in the joint and its surrounding tissues.
In addition to the above-mentioned division of contractures into passive (structural) and active (neurogenic), it is also customary to single out a group of congenital contractures, which differ in many respects from acquired contractures in clinical and structural aspects.
Classification of passive contractures is usually made taking into account the tissue that plays a predominant role in their origin. According to this principle, passive contractures are divided into arthrogenic, myogenic, dermatogenic and desmogenic. As separate forms of contractures, ischemic, immobilization are distinguished. Some authors rightly believe that contractures that develop after gunshot wounds require special consideration.
The group of neurogenic contractures includes the following forms:
I. Psychogenic contractures: a) hysterical.
II. Central neurogenic contractures: a) cerebral, b) spinal.
III. Peripheral neurogenic contractures: a) irritative-paretic, b) pain, c) reflex, d) contractures in violation of autonomic innervation.
Depending on the restriction of one or another kind of movement in the joint, flexion, extensor, adduction, abduction, rotational (supination, pronation), etc. can be distinguished. According to the function, contractures are distinguished in a functionally advantageous and functionally disadvantageous position of the limb.
Causes of contractures
Passive contractures, which are sometimes also called local, are caused by mechanical obstacles that arise both in the joint itself and in the tissues surrounding it or located near the joint (in muscles, tendons, skin, fascia, etc.).
In patients with neurogenic contractures, there are no local mechanical causes which could explain this limitation of movement. Such patients usually have phenomena of loss or irritation from the nervous system, causing prolonged tonic tension of individual muscle groups. In this case, a violation of the normal muscular balance between the antagonists occurs, which leads to the reduction of the joints for the second time.
Initially, neurogenic contractures are unstable, can be corrected, and with the elimination of neurological disorders and the restoration of the normal function of the nervous system, they may even disappear.
Gradually, over time, neurogenic contractures acquire resistance due to the fact that components of passive contracture appear in them.
Sometimes meet combined forms contractures, in which it is difficult to differentiate the initial mechanogenesis of the developed persistent restriction of movements in the joint, that is, it is difficult to establish what was the root cause of the restriction of movements - a local process or damage to the nervous system.
The clinical significance of contractures is very high. This is the most common complication intraarticular and periarticular fractures, dislocations, bruises of the joints, gunshot injuries to the limbs, inflammatory and degenerative-dystrophic processes in the joints, injuries and diseases of the nervous system, etc. There are contractures and congenital origin.
Contracture treatment
Early and complex treatment: application therapeutic gymnastics, physiotherapy, massage, sanatorium-and-spa treatment, surgery according to indications.
Passive and active therapeutic exercises for injuries or diseases of the nervous system, for burns and the imposition of transosseous fixation devices.
Contractures are flexion and extensor. Contractures are divided into arthrogenic, myogenic and arthromyogenic. Arthroscopy allows you to solve all the problems of arthrogenic contractures. With the help of arthroscopic instruments, adhesions, intra-articular scars, which are the cause of contracture, are removed, which allows you to restore normal volume joint cavity with minimal trauma.
Arthroscopic treatment can reduce, and in some cases completely eliminate joint contracture and provides early postoperative rehabilitation.
Prevention of contracture
Prevention of contracture is the correct and timely treatment of the disease that can cause it. In case of damage to bones and joints, the limb must be fixed in the correct position, and in case of certain indications treatment of fractures during the period, immobilization should be carried out permanently skeletal traction. The latter allows you to combine the rest of the fracture site with movements in neighboring joints. After removing the plaster bandages, the subsequent treatment is vigorously carried out: therapeutic exercises, massage, baths, physiotherapy, etc. are prescribed. It is especially important to prevent arthrogenic contractures in intraarticular and periarticular fractures that require long-term immobilization for their treatment. In inflammatory and paralytic lesions, immobilization should be carried out taking into account the functionally advantageous position of the limb. So, for example, when fixing the shoulder joint, you need to move the shoulder to the 60s, for the elbow joint the most advantageous is its flexion at an angle of 90 °, for the fingers of the hand - a half-bent position and abduction of the thumb, for the knee and hip joint - straightened leg position, etc.
Dermatogenic contracture can be prevented by early skin grafting in case of extensive burns or other skin lesions. In case of tendon injuries, it is necessary to achieve timely restoration of their integrity and subsequent proper treatment. Functional contractures can be prevented by wearing orthopedic shoes(when shortening the leg), etc.
The term "contracture" (contractura - narrowing; contraho - tightening, lat.) is understood as limiting the amplitude of passive movements in the joint with the involuntary nature of this limitation. Naturally, each limitation of passive mobility in the joint is accompanied by a limitation of active movements in it. The complete absence of both passive and active movements in the joint due to bone fusion of the articular ends of the bones is called ankylosis, and the ability to perform only rocking movements is called rigidity. In addition to limiting movement in the joint, any contracture is characterized by another symptom: early onset muscle atrophy. Muscle atrophy is usually persistent. The extensor muscles atrophy earlier and to a greater extent than the flexors. On the concave side of the affected joint there are compacted tissues, connective tissue scars. Often there are signs of a tunnel lesion of the nerve trunks located in the joint area.
Contractures can be congenital (a component of many malformations of the musculoskeletal system - clubfoot, torticollis, arthrogrypposis, congenital clubhand, etc.; such contractures are often multiple and combined with other changes in the limbs) and acquired, which will be discussed in this chapter. Acquired contractures are restriction of movements resulting from local traumatic, inflammatory, reactive and dystrophic pathological changes in the joint or in the tissues surrounding the joint - skin, subcutaneous tissue, fascia, ligaments, tendons, vessels and nerves. The incidence of contractures in limb injuries reaches 70%, in orthopedic diseases - 20%. Contracture in any of the joints of the limb, no matter how small it is, can cause severe functional and static disorders. So, with contractures in the joints of the lower limb, patients cannot move freely, in advanced cases, the diseased limb lags behind in growth, spinal deformity and flat feet develop on a healthy leg. Pronounced contractures in the joints of the hand make it completely afunctional, limiting the victim's ability to self-service and work. Thus, the formation of contractures leads to significant restrictions on household and social activity, therefore contractures are the point of application of the efforts of a rehabilitation doctor and require the use of targeted intensive rehabilitation measures.
3.1.1. Types of contractures
In accordance with the position in which the limb is located as a result of restriction of movement, there are flexion (flexion restriction), extensor (extension restriction), adductor or abduction (restriction of adduction or abduction) and rotational (rotation restriction) contractures. As a rule, combined contractures are most common in the clinic. Contracture in the shoulder and hip joints is more often observed in the position of flexion and adduction, less often in abduction with rotation inward, outward or without it. AT elbow joint, joints of the fingers are usually found flexion-extension contractures. With lesions of the wrist joint, both flexion and extension, and pronation-supination movements are disturbed. Contracture in the knee joint is often accompanied by a number of additional deformities: posterior subluxation of the lower leg, curvature and outward deviation of the lower leg. In the ankle joint, contracture can be in the position of plantar flexion, dorsiflexion, adduction and abduction. It should be noted that the ankle joint, due to its significant mobility, is installed faster and easier than other joints of the lower limb in a vicious position. Finally, contracture in the hip and knee joints gives a functional shortening of the limb, and contracture in the ankle joint (for example, with a horse's foot) - a functional lengthening of it.
An indication of only the type of contracture (flexion, adductor, etc.) will not yet give an idea of the clinical significance for the patient of the existing movement restriction. It is important in what range this limitation occurred: in a functionally advantageous or in a functionally unfavorable range. So, for example, flexion-extension contracture in the elbow joint within 5° extension, 60° flexion (range of motion 55°) is unfavorable from the point of view of the function of the upper limb. A greater restriction of movements in terms of volume, but in a different range (extension 60°, flexion 100°, range of motion 40°) is more beneficial for the patient. If, for example, there is a flexion contracture in the knee joint in a functionally advantageous position, and the range of motion in the joint is 15-20°, then it is much more convenient to use such a limb than if the range of motion was twice as large, but the flexion contracture in the knee joint was under right angle. The patient would not be able to use such a limb. Consequently, a small amplitude of preserved movements with a functionally advantageous position of the limb is more valuable for the patient than a greater range of movements within the limits that are less favorable for the function.
In accordance with the predominant localization of primary contractures, they are divided into dermatogenic, desmogenic, tendogenic, myogenic and arthrogenic.
Dermatogenic contractures are the result of skin damage as a result of burns, tangential wounds, skin ulcerations. Restriction of movements occurs when sufficiently extensive scars are formed above the joint area.
Desmogenic contractures usually develop as a result of damage not only to the skin, but also to the underlying fascia, aponeurosis and ligaments with the formation of scars that prevent movement in normal volume. Such contractures can also be formed as a result of chronic inflammatory processes. Desmogenic contractures include, in particular, Dupuytren's contracture, which G. Dupuytren described in detail back in 1832.
Tendogenic and myogenic contractures are a consequence of the development of a cicatricial process around the tendons and in muscle tissue. These contractures develop after trauma, inflammation, paralysis and paresis. With paralysis, the development of contractures is associated with a violation of the coordinated work of the agonist and antagonist muscles (redistribution of muscle traction with a predominance of the function of intact muscles), and also (with spastic paralysis and paresis) with persistent spastic muscle contraction. Muscular contracture can also develop as a result of prolonged fixation of the joint in a vicious position.
The reason for the development of arthrogenic contractures are pathological changes in the articular surfaces or in the ligamentous-capsular apparatus in acute or chronic diseases of the joint, after intra- and periarticular injuries. The main cause of contractures is a long-term limitation of joint function. This leads to the fact that the joint capsule shrinks and thickens. Adhesions develop between the sheets of the synovial membrane, synovial fluid thickens, organized, inversions are partially or completely obliterated. Due to prolonged inactivity, the articular cartilage loses its elasticity and strength, and foci of necrosis appear in it. Subsequently, scars appear, soldering it with the capsule. At the same time, the process of wrinkling of the fascia and the growth of intermuscular connective tissue occurs, which partially replaces muscle tissue. The development of scar tissue outside the joint is facilitated by the presence of soft tissues traumatic hematomas and their subsequent organization, inflammatory purulent processes, both specific and nonspecific. Scars solder tendons and other soft tissues to bones. There are so-called "third points of fixation", which are a persistent obstacle to movements in the joints.
Since the pathological process rarely affects one tissue, mixed forms are often observed in the clinic: dermatodesmogenic, tendomyogenic, arthromyogenic. So, arthromyogenic contractures include Bonnet's contracture, which occurs with some infectious lesions of the joints with simultaneously acute muscle atrophy.
The mechanogenesis of limited joint mobility to a certain extent depends on the etiology of the lesion. For example, contractures that develop after trauma and osteomyelitis are mainly due to cicatricial changes that develop outside the joint. With contractures after the tuberculous process, cicatricial changes in the surrounding tissues and in the joint itself are of primary importance in the origin of the contracture. In case of injuries of the joints between the articular surfaces, foreign body, which causes restriction of movement. Dystrophic changes in the joints (osteoarthritis) also often lead to the development of arthrogenic contractures. However, there is no strict delimitation of the localization of the development of the pathological process in certain tissues depending on the etiology. We can only talk about the prevalence of changes in certain tissues.
According to the etiological basis, post-traumatic, post-burn, neurogenic, reflex, immobilization, ischemic, professional contractures are conventionally distinguished (the conditionality of such a division is due to the fact that often several factors play a role in the origin of contractures - for example, trauma, and immobilization, and ischemia).
The most complex contractures result from severe mechanical injuries, gunshot wounds. At gunshot wounds contractures can occur as a result of the combined action of several pathogenetic factors: rough scarring of extensive and deep wounds of different localization, as a result of wrinkling of the fascia and the occurrence of adhesions between the tendons and their sheaths; violations of muscle synergy; injuries of the central and peripheral nervous system and limb vessels; prolonged pain and reflex muscle tension; prolonged fixation of the limb in a functionally disadvantageous position.
Neurogenic contractures are usually called contractures that occur in diseases or damage to the nervous system due to changes that have occurred. nervous regulation: disruptions of reflex processes, violations of the connections of the cortex with the subcortical and underlying parts of the nervous system. An example is contractures in patients with a predominant lesion of the extrapyramidal system (spastic torticollis, torsion dystonia), in patients with spastic hemiplegia, which developed as a result of pathological processes in the cerebral hemispheres (cerebral stroke, traumatic brain injury, tumor), in patients with various diseases and injuries spinal cord. With spastic hemiplegia in patients who have had a cerebral stroke, early and late contractures are distinguished. Early hemiplegic contracture develops during the acute period of cerebral stroke with massive lesions of the brain (bleeding into the ventricles, etc.), characterized by attacks of particularly strong tonic spasm. These attacks can develop under the influence of various stimuli and be accompanied by changes in pulse, respiration and pupil size. In favorable cases defensive reflexes begin to regress further, which is the reason for the disappearance of symptoms of early contracture. Late hemiplegic contracture appears 3 weeks to several months after a stroke. Its manifestations are usually reduced to flexion of the forearm, pronation and flexion of the hand, flexion of the fingers and extension of the thigh and lower leg - the Wernicke-Mann posture. In addition to the most common posture in which the limbs freeze in late hemiplegic contracture, there are a number of individual variants of it. Such are contractures with a predominance of excessive convulsive pronation or supination of the hand, or with rotation of the foot inward or outward, as well as with a flexion setting on the side of paralysis, not only of the arm, but also of the leg. These flexion postures in late hemiplegic contracture are associated with simultaneous pain sensations.
At various diseases Contractures of the spinal cord can manifest themselves as an extensor setting of the legs (tonic extension of the hips, legs and flexion of the feet - the so-called extensor contracture) or in the form of a flexion of the legs (tonic flexion of the hips and legs and extension of the feet - flexor contracture). extensor contracture more typical for the predominant defeat of the pyramidal tracts of the spinal cord, accompanied by an increase in tendon reflexes and the appearance of clonus of the patella and feet. Flexion contracture often indicates damage to both the pyramidal and extrapyramidal pathways, and is characterized by the presence of pronounced protective reflexes.
Neurogenic contractures can also be a manifestation of disinhibition of the motor neurons of the spinal cord and trunk due to a toxic-infectious process: for example, convulsive muscle contractions during tetanus, which can be expressed not only in individual paroxysms, but also be in the nature of persistent contractures of the muscles of the face, trunk and limbs; tonic convulsions in strychnine poisoning. Persistent contractures can also be observed in hysteria. At the same time, the distribution of contracted muscles always reproduces some kind of voluntary movement or expressive action, and the entire syndrome is clearly associated with some kind of mental experience; simultaneous removal of contracture after psychotherapy confirms its hysterical origin.
Neurogenic contractures are most often myogenic, associated with a violation of the normal muscle balance and, as a result, with a prolonged forced position of the joints.
Special place occupied by reflex contractures. They occur with lesions of the peripheral nerves as a result of chronic irritation of various parts of the reflex arc; with severe pain caused by wounds, ulcers and poor fixation of bone fragments during a fracture. Reflex contractures are characteristic of wartime, and are rare in peacetime. Reflex contracture is characterized by peculiar signs of rigidity and paralysis, but there are no objective signs of contracture (limitation of passive movements) and paralysis (changes in muscle tone and reflexes, muscle atrophy). According to I.I. Rusetsky, these patients do not have a "real" contracture, there is no "real" paralysis, or, as it is said about the features of reflex contracture, "paralysis is not paralysis, contracture is not contracture." The hand with reflex contracture takes an almost motionless, frozen position, the fingers are usually straightened, elongated, the hand takes the position of the "obstetrician's hand". There may be other positions of the fingers: they are often bent in the main phalanx, occupy a cross position with respect to the rest of the fingers. The hand takes the form of scissors or the position of "taking tobacco". A slight flexion in the wrist, and sometimes in the elbow joints, often joins the contracture of the hand. The hand can be brought to the body. The lower limb in patients with reflex contracture is usually shortened: the leg is bent at the knee joint, and the foot takes the form of a horse foot. In other patients, the foot may be a concavity with bent fingers such as a neck or with unbent fingers, be in a position of increased supination and adduction. This position of the limb is preserved when the patient lies on his stomach. With some effort, the doctor will be able to straighten the affected leg, but then it bends again and takes its previous position.
The nature of reflex contractures is associated with direct irritation of the peripheral nerve fibers, with ischemia of the nerve trunks, with impaired autonomic innervation, as well as with the psychopathological characteristics of the patient's personality.
Immobilization contractures can be an integral part of post-traumatic, post-burn and other types of contractures. They develop during prolonged immobilization, most often in the affected joint, but are also possible in the absence of damage to the joint formations. When the affected joint is immobilized in a vicious position, contracture develops much more often and faster. In this case, the myogenic component also plays a role in the pathogenesis of contracture.
Ischemic contractures occur as a result of circulatory disorders in muscles, nerves and other tissues, followed by their cicatricial change. These contractures develop after injuries of large arterial trunks, when they are compressed by a plaster cast, hemostatic tourniquet, bone fragments, due to tissue edema, and from many other reasons. In the origin of ischemic contracture, ischemic damage to the nerve trunks and perivascular nerve plexuses also plays a role. Volkmann's contracture is the most typical ischemic contracture. It develops as a result of acute arterial insufficiency - ischemia of the nerves and muscles of the forearm with prolonged compression of the neurovascular bundle with a tourniquet, with large hemorrhages in the elbow bend, squeezing blood vessels, nerves and muscles, with large swelling of soft tissues after severe injuries or operations; with edema under circular plaster bandages (especially in children); after stretching, compression, bending of blood vessels when they are injured. This contracture often occurs after supracondylar fractures of the humerus and fractures of the bones of the forearm.
In the development of professional contractures, constant or prolonged overwork and tension of certain muscle groups (in cutters, shoemakers, dentists, etc.) and chronic microtraumas with tendon damage (in athletes, ballet dancers, loaders) play a role. Most often, these are neuromyogenic reflex contractures.
As a rule, contracture is only one of many symptoms of the underlying disease or pathological condition of the joint or the whole organism. The time of occurrence of contracture varies widely and depends on the etiology. So, after an injury or an inflammatory process, the deformity as a result of a slowly developing cicatricial process can progress within several months, while Volkmann's ischemic contracture develops within a few hours.
Primary contractures are also distinguished - limitation of mobility in the affected joint and secondary - limitation of mobility in the joints adjacent to the affected. The contracture of one of the joints of the limb can cause the development of a vicious installation in adjacent joints, functionally compensating for the primary deformity. Such an installation is functionally adaptive (compensatory). Initially, this contracture is reflex myogenic in nature, but subsequently all tissues within the joint are subject to change. An example of a functional-adaptive contracture is a contracture in the knee joint, which often occurs with contracture of the hip joint with polyarthritis, tuberculous coxitis. Another example is a persistent equinus position in case of shortening of the lower limb.
3.1.2. Examination of a patient with contracture
Appointment restoration measures should be preceded by a thorough examination of the patient. It is recommended to adhere to the following examination plan [Korolev S.B., 1991]:
1. A detailed clarification of the history of the disease: an analysis of the mechanism of injury, the timing, nature and results of emergency care, and then all subsequent stages and methods of treatment. The result of the first stage of the examination should be the formulation of a preliminary (working) hypothesis of the pathogenesis of a specific limitation of movement in the joint.
2. Comparative examination of the limbs. Pay attention to trophic changes in tissues (color, turgor, shine, excessive dryness or moisture of the skin, localization of edema and its density), general degree muscle atrophy, mobility not only in the affected, but also in neighboring joints.
3. Manual examination, assessment of range of motion, muscle strength, muscle tone.
Careful palpation of the joint area evaluates the size, configuration, relative position and displacement of bone anatomical formations, possible ossifications and bone protrusions. At the same time, the degree of elasticity and mobility of soft tissue structures of paraarticular tissues, lateral ligaments, and accessibility for palpation of the joint space are determined. Zones of local pain and hyperthermia are revealed.
The amplitude of movements is assessed using a goniometer (goniometer): they measure both active movements in the joints performed by the patient himself, and passive ones made by the doctor.
Muscle strength in the simplest version is assessed by inviting the patient to overcome the resistance provided by the doctor when the patient performs the appropriate movement. More accurate, quantitative characteristics can be obtained using dynamometers of various designs. It should be noted that a comparative study of muscle strength on the right and left limbs must be carried out with the same mutual arrangement of them. The study of strength helps to clarify the origin of muscle atrophy. So, with a general uniform decrease in force various groups muscles, the reason for this should be sought either in damage and scarring of these muscles during trauma, previous interventions, forced redressing, or in a violation of the biomechanical ratio of the muscles shoulders (chronic dislocations, improperly healed fractures), or, finally, in the pain syndrome associated with the presence of a false joint, ununited fracture.
The study of muscle tone is carried out by palpation of the muscle (assessment of its mechanical and elastic properties) and by assessing the resistance that occurs during passive flexion or extension of the limb or its segment (reflex muscle contractility). During palpation, the muscles determine its elasticity, indentation, while the limb should be in the most comfortable position, favorable for muscle relaxation. Palpation is carried out by repeatedly squeezing the muscle or muscles from the lateral surfaces with the doctor's fingers or by pressing the hand on the muscle's abdomen from above. When assessing muscle tone by the method of passive movements, the doctor performs passive movements of extension and flexion in the joint at an average pace, approximately in time with the clock pendulum, and determines the resistance felt by him.
Attention is also paid to the presence of sensory disturbances from the peripheral nerves. The results of the examination and manual examination are compared with the data of instrumental research methods. 4. Instrumental Methods Key words: radiography, electromyography, thermal imaging.
X-ray examination of the joint in contractures is of decisive importance in the presence of arthrogenic changes (assessment of changes in the articular ends. In other types of contractures, this study helps in differential diagnosis. It must be remembered that the prolonged existence of dermatodesmogenic or myogenic contractures leads to secondary changes in the joint such as osteoarthrosis, which also visible in the picture.
A standard thermal imaging study using thermal and drug tests allows not only to identify, but also to quantitatively characterize trophic and inflammatory manifestations.
Interference and stimulation electromyography, electrodiagnostics are used to assess the degree of violation of muscle innervation. Based on the results of the survey, an idea is formed about the specific mechanisms of the pathogenesis of this contracture or ankylosis, the role of biomechanical, pain and psychological factors in its development is assessed, which is necessary to develop an optimal plan rehabilitation treatment, solving the issue of choosing a radical and at the same time sparing surgical intervention.
Clinical diagnosis in case of contracture, it includes an indication of the type (or types) of contracture and its etiology, for example, flexion-extension arthrogenic contracture of the knee joint due to an improperly fused fracture of the femoral condyles.
3.1.3. Prevention and treatment of contractures
3.1.3.1. Preventive actions
It is much easier to prevent the occurrence of contracture than to cure it.
The main methods of prevention include:
- ensuring the correct position of the limb in case of muscle paralysis or in case of immobilization of the limb with a plaster cast (in case of injury);
- early provision of movements in the joints of the affected limb;
- timely appointment of restorative measures aimed at eliminating pain, edema, tissue ischemia.
To the top priority preventive measure refers to the application of plaster casts (in trauma patients) in the correct position - i.e. in a position corresponding to the average physiological and at the same time contributing to the prevention of edema and ischemia of the limb. This position prevents the tension of the capsule and ligaments of the joint, promotes maximum relaxation of the muscles. The average physiological position is achieved with the following installation of the limb:
- shoulder joint: abduction 45°, flexion 40°, internal rotation of the shoulder 40°;
- elbow joint: 80° flexion, midway between pronation and supination (palm facing chest);
- wrist joint: extension 10°, ulnar abduction 15°;
- fingers of the hand: their slightly bent position in all joints and slight abduction of the thumb;
- hip joint: 40° flexion;
- knee joint: 40° flexion;
- ankle joint: plantar flexion of the foot 10°.
In case of injuries, immobilization of the segment in the physiological position achieves a significant decrease or even complete elimination of hypertension of muscle groups and a decrease in intra-articular pressure. Relaxation of the muscles, the creation of complete rest of the injured limb, first of all, eliminate the source of pain in the area of the focus of irritation. However, proper immobilization includes not only giving an average physiological position, but also, as an obligatory component, an elevated position of the limb, since edema aggravates the course of the inflammatory process and contributes to the development of contractures. Timely longitudinal dissection of circular plaster casts in severe injuries avoids tissue ischemia due to their edema and compression in the plaster cast. The same goal is pursued by the use of local hypothermia and oxybarotherapy according to indications. In severe open injuries, early surgical treatment is of great importance, according to indications, dissection of the fascia without subsequent suturing, primary skin grafting for skin defects. An important point is the relief of pain syndrome, since pain contributes to the emergence of protective pain contractures. For this, analgesics, physiotherapy (electrophoresis of analgesics, ultrasound) are prescribed.
Holding a limb in an average physiological position is also very important for paralysis (flaccid, spastic), when active movements are impossible. To do this, use orthoses, special styling (Chapter 1).
The methods of prevention of contractures also include the early appointment of passive and active exercises of therapeutic exercises. Active contraction of muscles and movements in the joints enhance tissue nutrition and metabolism, accelerate the resorption of pathological products, thereby preventing the occurrence of contractures. In cases of limb injuries, movements are carried out in joints free from immobilization, provided that these movements are painless and complete immobility of the reduced fragments is ensured. Optimal for conducting therapeutic exercises in this case is the imposition in early dates after an injury instead of plaster casts of external fixation devices (Ilizarov, Gudushauri, Volkov Oganesyan, etc.). Patients remain mobile for the duration of treatment. In cases of already formed contractures, these devices allow for slow and measured stretching of the soft tissues of the flexion surfaces of the limb, applying efforts directly to the bones.
Prevention of contractures is also a competent, dosed conduction of motor therapy. Rough violent passive movements that cause pain and reflex muscle spasm should be avoided, especially when treating patients with intra-articular fractures.
3.1.3.2. Treatment of contractures
Treatment of contractures requires a lot of time and labor, strict individualization of treatment and, despite this, will not always give satisfactory results.
Rehabilitation of patients with contractures begins, as a rule, with conservative measures. Their nature largely depends on the underlying disease, localization and type of contractures. However, there are general principles of treatment, which include:
- very gradual stretching of contracted tissues, carried out after preliminary relaxation of the muscles;
- strengthening of muscles stretched due to contracture (muscles-antagonists to contracted muscles);
- ensuring painless impacts.
It is important to achieve a conscious attitude of the patient to the applied therapeutic measures.
The basis of the complex treatment of contractures is positional treatment and kinesitherapy (active and passive therapeutic exercises, hydrocolonotherapy, mechano- and occupational therapy).
Treatment by position is carried out with the aim of stretching the contracted tissues. For this, orthoses and splints are used. It is important to remember that the corrective force must be small in magnitude. When correcting contracture, it is necessary to renounce the use of brute force. It is not necessary to perform corrective manipulations under anesthesia and in one step. Forced stretching often causes serious damage to the muscle, causing a condition in it called pseudoparalysis. In addition, such stretching can be extremely detrimental to the peripheral nerve, causing paresis and paralysis of the muscles of the limb. With simultaneous corrections of flexion contractures, circulatory disorders are also possible, manifested by venous congestion and edema, or difficulty in arterial blood flow due to a decrease in the lumen of the stretched vessels. These complications can only be avoided with the use of low force. In addition, the use of low force eliminates the risk of pain due to tissue trauma. Pain, as you know, causes reflex muscle tension, which not only serves as a serious obstacle to the elimination of contracture, but often helps to strengthen it.
At the same time, the corrective force must act as continuously as possible. The forces that fix the joint in a vicious position are very small, but their action is constant and long-lasting. The same should be the force that removes the joint from a vicious position. It is necessary to use a continuous force that lies below the "pain threshold of irritation", built up gradually, "drip" way, and therefore, to certain limits, almost imperceptible to the patient. An increase in tensile strength is achieved by changing the angles between the shoulders of orthoses or splints. If it is not possible to eliminate the contracture with the help of orthoses, then treatment with stage plaster bandages is used.
For example, with flexion contracture of the knee joint, a circular plaster bandage is applied from the head of the metatarsal bones to the inguinal fold. After the dressing dries, it is dissected at the level of the joint, the joint is carefully unbent by 5-10° and in this position is quickly fixed with a plaster bandage. To eliminate contracture, it is necessary to repeat this manipulation several times. After complete elimination of the contracture, the limb remains fixed for another two weeks [Gaidar B.V., 1997].
Kinesiotherapy is carried out in the form of passive and active therapeutic exercises. Applying passive physical exercises, they try to stretch the contracted muscles and periarticular tissues. Wherein Special attention pay for activities to relax the muscles. For this purpose, exercises are carried out in warm water, special muscle relaxation techniques are used, and the starting position is correctly chosen when performing physical exercises.
The purpose of active exercises is to increase the muscle strength of the stretched muscles, i.e. muscles, the function of which counteracts contracture. So, with flexion contractures, it is necessary to achieve strengthening of the extensor muscles. This is essential not only in the treatment of contracture, but also to prevent its recurrence.
To strengthen the muscles, active exercises with resistance are used, exercises on mechano-therapeutic devices, mainly on block installations. When exercising on any mechanotherapeutic apparatus, it is necessary to monitor the correct initial position and fixation of the moving limb segment on the apparatus, the position of the free parts of the exercising limb outside the apparatus, as well as the correct dosing of the load. Gradually increase the range of motion in the affected joint, the magnitude and duration of the load, while reducing the duration of pauses for rest. Thermal procedures are used as introductory before classes of movement therapy: applications of paraffin, ozocerite, heat packs.
Treatment has its own characteristics depending on the type of contractures. When eliminating post-traumatic contractures, there are three stages:
1) with the least persistent (myogenic) contracture at an early stage after the injury, active light physical exercises are used against the background of relaxation of painfully tense muscles;
2) with desmogenic changes that occur in connection with the cicatricial adhesive process, more intense active physical exercises are used to stretch the periarticular tissues and shortened muscles;
3) at a late stage of contracture development with a predominance of articular changes, along with active exercises, passive exercises on mechanotherapy devices are used. The therapeutic effect achieved by physical exercises fixes the treatment with a position. Kinesiotherapy is carried out 2-3 times a day for 30-40 minutes in close combination with agents that have a direct effect on changes in the musculo-articular apparatus and the process of tissue scarring: muscle electrical stimulation, electro- and phonophoresis of absorbable substances, heat and hydrotherapy, massage . These procedures improve impaired blood and lymph circulation, reduce pain, and prevent the progression of muscle atrophy. With dermatogenic and desmogenic contractures, it is possible to introduce lidase into the area of scar tissue (64 IU in 3-5 ml of 0.5% novocaine), followed by galvanization of this area. Also shown is the local application of dressings with Ronidase on the scar area for 10-14 days.
Less often, one-stage or staged redressing is shown, followed by the imposition of fixing bandages.
With neurogenic contractures, the basis of treatment is to give the correct position of the patient's limb and the organization of a full-fledged functional treatment. Stretching of contracted muscles and secondarily altered periarticular tissues is achieved by applying passive movements in the joints. Passive movements are repeated many times (4-5 times) throughout the day, preferably after a preliminary thermal effect(hot wrap, paraffin therapy, mud therapy. In parallel, active physical exercises are used to restore muscle balance, helping to strengthen weakened muscles. Improving the function of these muscles is also achieved by massage, light thermal influences, performance of physical exercises in warm water. After exercise, with the help of splints or plaster bandages, the joint is fixed in the position of the achieved correction.
Ischemic contracture requires especially early treatment. In the first hours after its occurrence, it is necessary to create conditions that improve the blood circulation of the affected limb: immediately remove the plaster cast, give the limb an elevated position, carry out constant hypothermia, use vasodilators, antispasmodics and anticoagulant drugs. Also shown are periarterial novocaine blockades or blockade of the cervical sympathetic ganglion.
Treatment of reflex contractures is especially difficult. The goal of therapy is to eliminate or, in any case, reduce the irritation existing on the periphery: excision by the nerve, release of the nerve trunk from scars, etc. are carried out. Apply various ways sending kinesthetic stimuli from the muscles of the contracted parts of the limb. Produce slow passive movements in the hand and fingers (or foot). You can combine passive movements with oral orders: “unbend”, “bend”. It is possible to reinforce these movements with similar active movements of the opposite limb. Much attention is paid to psychotherapy. It is recommended, having studied the characteristics of the patient, his attitude to the disease and social attitudes, to achieve at least minimal voluntary movements in the limb through suggestive therapy. The results achieved by psychotherapy are consolidated and developed by passive and active exercises, massage, local warm baths, applications of paraffin, ozocerite or mud.
In the treatment of patients with hysterical contractures, the main role belongs to psychotherapy. The doctor must carefully examine the patient, learn his features, be aware of the events that preceded the development of contracture. It is necessary to strictly individualize treatment. In some patients, contracture is relatively easy to psychotherapeutic effects, supported by simple therapeutic measures: passive extension of the limb and holding it in this position. The same can be achieved by applying electrical procedures that cause contraction of antagonist muscles. In other patients, the contracture will respond very poorly to treatment, especially with a longer duration of the existence of contractures. In these cases, one has to resort to hypnosis, drug therapy.
In case of ineffectiveness of conservative therapy for contractures, surgical treatment is used, which consists in various plastic surgeries on soft tissues and bones: types of skin plasty, myotenolysis, tenotomy, capsulotomy, arthrolysis, mobilization of the joint with the help of articulated distraction devices, etc.
The prognosis in the treatment of contractures depends on its nature and type, the time elapsed since its occurrence, the age and condition of the patient, the start date of treatment and its usefulness. Early initiation of treatment using modern conservative and surgical methods usually allows to achieve significant positive results.
Contracture- congenital or acquired limitation of joint mobility. An example of congenital contractures can serve as clubfoot. Acquired contracture as a result of damage to the joint itself or a past disease. So the most persistent contractures arise as a result of fractures and dislocations of the limbs, when the patient is forced to stay in a cast for a long time. Causes of occurrence contractures can also be called: diseases of the central nervous system, for example, a stroke, as a result of which muscle paralysis occurs, as well as the patient's persistent unwillingness to regularly change the position of the limbs.
Contracture treatment which is delayed, leads to a partial or even complete loss of joint mobility, which, in turn, means a loss of the ability to serve itself independently. So, if the patient's elbow practically does not bend, he is not able to fasten buttons or bring a spoon to his mouth.
Currently, medical practice provides for a comprehensive contracture treatment. It includes massage, physiotherapy, therapeutic exercises and is carried out by an orthopedic doctor. During contracture treatment various orthopedic devices are used, plaster bandages, corrective tires. In severe cases resort to surgical intervention.
The appearance of the rack contractures can be prevented by a number of preventive procedures. One of the main conditions is - timely started manipulations. Prevention of contracture consists, for the most part, in the conduct of therapeutic exercises. A set of exercises is prescribed by a doctor after an examination and is performed, first under the guidance of a doctor, then with the help of a nurse who monitors the quantity and quality of classes, motivates the patient to perform them.
In order to be effective, it is very important to ensure a comfortable and correct position of the limbs. For example, a long stay of a patient in a supine position, when the blanket presses on the feet, often leads to the fact that his foot falls forward and a contracture occurs, called the "horse foot". The patient appears to be standing on tiptoe. For contracture prevention it is good to use a stand that will not allow the blanket to press on the foot. Or you need to give the foot a position at an angle of 90 0 and putpillow under the leg.
Very pIt is useful to use orthoses - special orthopedic devices that fix the joint in the rightflax position. The choice of an orthosis is made by a doctor and depends on its purpose, function.and, design and material.
In a number of medical institutions there is a tendency to lay the patient with paraplegia, especially in an unconscious state or with limited consciousness, on the affected side. Until the restoration of active consciousness, this is not recommended for the following reasons: a) damage to the skeletal mice of one half of the body reduces the activity of the "muscle pump", worsening the peripheral circulation; b) the mechanical pressure of body weight on the affected muscles increases the risk of trophic disorders (in particular, bedsores); c) the danger of restriction of movement, mainly abduction in the shoulder and hip joints \Beucc A/. et al.. 1986], If consciousness is not fully preserved, it is recommended to lay the patient in positions on the back or on a healthy side. Treatment with the position lasts up to 2-3 hours.
It is known that focal lesions of the nervous system of various origins cause significant changes in many internal organs. In addition, forced inactivity disrupts the normal functioning of the most important systems of the body, affecting mainly their adaptive properties. Treatment with a position on a "rotating table" allows to some extent to prevent or compensate for these disorders (Fig. Ya. /). Careful orthostatic loading contributes to positive changes in the patient's body (B.J1. Naidin):
Adequate load of the heart muscle, vascular tone is normalized in the center and on the periphery;
gradual increase loads (as you move to a vertical position, the effect of body weight on the lower limbs and spine increases their readiness for the upcoming activity - getting up and walking);
The changing rate of lifting of the table plane improves the adaptive properties vestibular apparatus;
Gradual training in the transition to a vertical position has a positive effect on the CSF circulation system.
Regular, long-term use of corrective positions of the affected limbs adapts them to new conditions (stretching or shortening) and helps to reduce their excitability and rigidity.
Attention! Positional treatment should be used not only during bed rest, but also later, during the period of restoration of the function of movement, when the patient can already move independently.
In the complex of restorative measures, the corrective position of the patient in bed allows not only to limit and prevent the development of contractures and deformities, but also helps to reduce the reflex excitability of the muscles, the best manifestation of active movements.
4. Restoration of the disturbed motor act.
Passive movements are used to stimulate the recovery of movements and prevent contractures in paresis and paralysis. local action exercise in passive movements manifests itself mainly in a slight activation of tissue nutrition, maintaining, improving or restoring mobility in the joints. Passive movements in the joints of the extremities provide a slight general tonic effect and a slight activation of local blood circulation, preventing thrombus formation when local blood flow slows down. At the same time, with the help of passive movements, disturbed patterns of normal movements are preserved or restored ”in cases of spastic paresis, side accompanying movements (pathological synkinesis) are excluded - thus the general scheme of a normal voluntary motor act lost by the patient is restored. In this case, the patient's visual control (an additional afferent channel) should be used, which is based on a conscious sensation of a deep articular-mental feeling. Passive exercises are a preparatory phase for better reproduction of gradually developing active movements.
With the help of active exercises, one can not only influence muscle tone, restore their strength, performance and range of motion in the joints, but also “re-educate” the neuromuscular apparatus, contributing to the improvement of movements. It should be borne in mind that a patient with hemiparesis performs active movements with great effort. With inadequate exercise, heart rate and breathing become more frequent, blood pressure rises. Active exercises should not cause pain; they are performed at a slow, calm pace without forcing the range of motion. The extensor muscles of the upper limb, the flexors of the lower leg, and the flexors (dorsiflexion) of the foot should be predominantly trained to prevent the formation of hemiplegic contracture.
5. Massage. Massage techniques are performed superficially (light strokes) on the affected muscles of the limbs (flexors and pronators of the arm, extensors and adductors of the leg), in which an increase in tone usually occurs. For the rest of the muscles of the limbs, the massage can be deeper; in addition to stroking, rubbing and gentle kneading are used. Massage is combined with passive movements.
When determining the set of techniques and their sequence, it should be borne in mind that in the paretic muscles under the influence of massage, fatigue quickly sets in, so the massage should not be long, and the movements are performed at a calm pace - otherwise the result of the massage course may be persistent muscle weakness, increased muscle hypotrophy. However, even the mildest classic massage can help improve muscle tone. Acupressure is an effective means of relaxing spastic muscles, and selective stimulation of weakened muscle groups allows you to simultaneously activate the patient's motor activity, reducing the severity of paresis.
6. Preparing the patient for learning to walk. As neurological symptoms decrease, the patient should be gradually prepared to stand up using the following techniques.
Changing the position of the patient in bed: turns on his side with a return to the supine position, transfer to a sitting position.
Attention! The transfer of the patient to a sitting position on the bed should begin from the moment when voluntary movements appear in the hip joint (taking into account the general condition of the patient).
sitting with legs down, you can transfer the patient to a vertical position (with self-insurance or with the help of an exercise therapy methodologist).
An important place in the complex of rehabilitation treatment is occupied by training in standing and walking. Carrying out medical training sessions on a special “rotating table” is the first stage in restoring the function of statics and gait. Immediately after these classes, the patient begins to learn how to get up and move around. The biomechanical model of standing up is restored - torso tilt forward with simultaneous tension of the quadriceps muscles of the thigh, extension of the legs in the hip and knee joints, simultaneous movement of the arms forward, etc. In the standing position, the patient learns uniform distribution body weight on both legs, then transferring the body from one leg to the other.
By transferring the patient to a vertical position with simultaneous training in independent movements in bed, dressing and eating, a certain stage of rehabilitation treatment is completed.
Attention! The effect of training largely depends on the correct step-by-step selection of exercises that are strictly specific for the clinical motor picture that is determined in a particular patient.
With hemiparesis, the function of the deltoid muscle is also affected, this reduces its role in strengthening the joint; when the patient is transferred to a sitting and standing position, there is a danger of stretching the joint capsule under the weight of the hanging limb and the exit of the head of the humerus from the articular cavity (subluxation of the joint). This may be accompanied by pain in the joint area, tension of the periarticular muscles, which makes it difficult to move. In order to prevent possible joint subluxation, patients are advised to fix the affected arm with a special bandage (Fig. 8.3).
8.2.2. Rehabilitation treatment
in early rehabilitation wards
Regression of neurological deficit (motor disorders, musculo-articular sense, coordination and speech) and mental disorders depends on the location and volume of the pathological focus, the intensity of therapy in acute period stroke. In patients during these periods, there is an increase in muscle tone.
The position of the limbs in spastic paralysis is typical: the upper limbs are pressed to the body, bent at the elbow joints, the forearms are pronated, the hands are in the position of palmar flexion and ulnar abduction. The fingers of the hand are usually unbent with parapleshes, bent with hemilegia, and the thumb often lies under the index finger. The lower limbs with paraplegia are given, bent at the hip and knee joints, the feet are in the position of plantar flexion, as a result of which the support is limited only to the anterior sections of the soles. Deformities are observed in the feet, more often of the varus type, less often - valgus. With extreme degrees of spasticity of the gastrocnemius muscles and simultaneous tension of the extensor muscles of the foot, the heel and its anterior section are pulled up, forming a severe deformity. phylogenetically stronger and more stable flexor and adductor muscles compared to their antagonists.In paraparesis, this position of the limbs is observed on both sides, in hemiparesis - on one side.
The degree of spasticity is usually distributed unevenly: with the greatest frequency it is observed in the adductor muscles of the shoulder, flexor muscles and pronators of the upper limb and extensor muscles of the thigh and lower leg, less often in the flexor muscles of the lower leg and gastrocnemius muscle, in some cases - in the adductor muscles and internal rotators of the thigh, supinators and adductors of the foot. Along with the muscle tone a number of other muscle groups (extensors and supinators of the upper limb, a group of peroneal muscles, pronators and foot abductors - on the lower) remains normal or markedly reduced. Such an uneven change in muscle tone in most patients with central paralysis is manifested by the characteristic Wernicke-Mann posture.
Tasks of physical rehabilitation:
Restoration of the correct system of triggering afferentation and reflex activity;
Normalization of muscle tone by disinhibition and active stimulation of temporarily inactivated nerve centers;
Improvement of vegetative and sensory provision of motor acts;
Prevention of persistent movement disorders, contractures and joint pain;
Identification and stimulation of isolated contraction of paralyzed limb muscles;
Combining and integrating individual links and elements of the kinematic chain into an integral movement;
Teaching the patient to move within the ward (with the help of staff, special devices), then the department;
Increasing the volume of self-service.
To achieve the effectiveness of rehabilitation treatment, one should adhere to a certain sequence and rational distribution of rehabilitation means during the day: drug therapy - physical factors- physical exercises with massage and position correction - occupational therapy. Rehabilitation treatment of patients with spastic hemiparesis should be carried out against the background of psychotherapy and drug therapy.
LH classes begin with movements in large joints, first on the healthy, and then on the affected side. All patients are shown exercises for the symmetrical muscles of a healthy limb. THEM. Sechenov proved that the work of the muscles of one hand increases the efficiency of the other. Due to the close anatomical and physiological connection between the two halves of the sleeping brain, trophic metameric reactions also manifest themselves in symmetrical areas of the opposite half of the body. Training of muscles that are symmetrical to the affected, through the central nervous system, has an effect on the corresponding paretic muscles of the other limb, causing their involuntary contraction. During the exercise with symmetrical muscles of a healthy limb, the methodologist should massage the paretic muscles (mainly stroking and light rubbing techniques).
Attention! All exercises are carried out at a slow pace in order to avoid an increase in blood pressure.
For the functional recovery of the affected limbs, it is necessary to use the LH in classes:
Optimal starting positions for obtaining the maximum range of motion for both healthy and paretic limbs;
■ passive movements in order to preserve the function of the joints with the involvement of the paretic muscles (they contribute to the shortening of the paretic muscles and the lengthening of their antagonists, which is important for preventing contractures);
Active movements of healthy and affected limbs; if it is impossible to make active movements, a volitional sending of impulses to contraction of the paretic muscles (ideomotor exercises) or muscle tension of healthy limbs is used for a reflex increase in the tone of the paretic muscles;
■ exercises for the development of replacement functions due to vicariously working muscles or re-education of the function of certain muscle groups after surgical interventions.
The main task of L G: with flaccid forms of paresis or paralysis - strengthening the muscles, with spastic - establishing their control, therefore, with different forms movement disorders, the selection of exercises varies significantly.
It is expedient to introduce passive counter-friendly movements into CG exercises: this is a combination of elements of flexion and extension synergies. Such exercises allow you to significantly stretch several spastically tense muscle groups at once (raise or abduct the arm, simultaneously supinating and unbending the forearm, hand and fingers). This type of exercise is recommended only if it does not increase muscle stiffness.
With spastic hemiparesis, special attention is paid to the following passive movements (V.L. Naidin): a) flexion and external rotation of the shoulder; b) extension and supination of the forearm; c) extension of the hand and fingers; d) abduction and opposition of the thumb; e) hip flexion and rotation; e) flexion of the lower leg (with the hip extended); g) dorsiflexion and pronation of the foot. These exercises are carried out in the initial positions lying on the back, on the stomach (especially flexion of the lower leg while fixing the pelvis), on the side (extension of the hip, rotation of the shoulder, etc.). Later, when the patient is allowed to sit, passive movements for the shoulder girdle can be carried out: raising the shoulder blades and shoulder girdle, lowering them completely, abducting-bringing the shoulder blades to the spine.
Vnmavne! When performing passive movements in two or more joints of the paretic limb, if possible, it is necessary to prevent unwanted synkinesis, which, during the period of further activation of the patient, can significantly impede the restoration of normal movements.
Conducting passive movements should end with treatment (correction) position, then move on to active with help and active exercises.
Active exercises basically repeat passive ones. The purpose of their application is a differentiated "education" of the contraction of paretic mice (both with increased and decreased tone). Initially, active exercises for the limbs involved in the pathological process are performed with the help of a physiotherapist in light conditions. In the future, it is recommended to include the muscles of the paretic limbs in various modes (overcoming, static, yielding, with varying degrees of muscle tension).
To facilitate active movements, the patient is taught active relaxation, starting with static breathing (for example, a deep exhalation reduces the tone of the entire muscles of the body), selection of initial positions, relaxation of the muscles of the affected limb.
The ability of patients with spastic paralysis to move is largely impaired by the pathological manifestation of friendly movements - synkinesis. They are based on insufficient concentration of the process of excitation, radiating to areas of the cortex that should not take part in this motor act.
The weakening of muscle tension occurs under the influence of local exposure to cold (cryotherapy) with the help of ice bags or special packages. The effect is achieved by a combination of cryotherapy, exercise and acupressure. For local reduction of synkinesis, the inhibitory method of acupressure is used. With high muscle tone, acupressure is indicated; with a slight increase - selective massage: acupressure - for spastic muscles and superficial stroking of their hypotonic antagonists.
There is a certain sequence of exercises. First, movements are carried out in the proximal section of the upper limbs (in the shoulder joint), then the hands and fingers, then in the elbow joint. After that, movements are realized in the lower extremities - in the proximal joints, then in the distal sections. Before and during the exercise, acupressure.
With spastic paralysis, it is necessary to massage (therapeutic massage) all the muscles of the weakened limbs, not excluding the most rigid ones, dosing the strength of the massage in accordance with the reaction of the patient's muscles and not allowing their tension to increase. Massage should be superficial, cause a decrease in muscle tone. The procedures use stroking, rubbing, kneading (limited!), shaking and stretching techniques. All these techniques are used in combination with passive movements.
Muscle strengthening exercises should be used carefully. Failure to comply with this principle often leads to hypertonicity. It is not advisable to use resistance exercises: they usually cause significant stress, and this negatively affects the coordination of movements. When there are signs of increased tone in spastic muscle groups, it is necessary to reduce the number of repetitions of exercises and the degree of muscle tension. In this period of rehabilitation treatment, it is not recommended to use exercises with expanders, rubber bands, etc., since they increase the tone of the flexor muscles of the hand and fingers, sharply aggravating the disorders and making it difficult to further functional recovery.
upper limbs that have slightly lost their function, it is necessary to train to perform more complex movements that are useful in everyday life: opening and closing doors, locks, locks, using tableware (plates, spoons, forks, cups, etc.).
Great importance in rehabilitation treatment is given to directed enhancement of proprioception, which is carried out at all stages of rehabilitation mainly in two ways.
Application of the method of dosed resistance to the movement being made (Y. Rabat method, or PNF - proprioceptive peygot uscu la g fac Hi tat ion).
The use of reflexes emanating from receptors on the periphery [Stary O. et al., 1960; Bobath V., K.].
The method developed by L, Rabat is aimed mainly at restoring motor function in diseases and disorders of the central and peripheral nervous systems. In this case, certain schemes and types of exercises are used, approaching natural movements (Fig. 8.4). The method is based on the premise that by amplifying the signals from the proprioreceptors it is possible to improve the functional state of the motor centers.
 Rice. 8.4. Scheme of basic movements. |
Droprioceptive signals are called excitation of deep receptors located in the muscles, on the surface of the joints or receptors of the corresponding fields of the cerebral cortex, subcortical nuclei and cerebellar cortex, as a result of which the excitation is transmitted along the afferent nerve fibers to the corresponding level of the central nervous system. From here, after the reflected analysis, “an order is sent » along afferent nerve fibers to the periphery in order to perform a certain arbitrary function or reflex reaction. For example, movement in a joint with measured resistance activates all functional reserves in the area of this joint due to the maximum excitation of the motor centers.
*Proprioceptive neuromuscular relief” is achieved using the following methodological techniques: a) maximum resistance to movement; b) reversion of antagonists; c) preliminary stretching of the affected muscles; d) complex motor acts.
The use of reflex mechanisms of movement in LG exercises causes sufficient tension in certain muscle groups, strengthening them and increasing the accuracy of controlling these muscles during many movements. When performing such exercises, they stimulate the reflex and strive to perform the movement in the same group of muscles that contract under the influence of the reflex (O. Stary et al., V., K. Bobath).
The method of the spouses K. and B. Bobath consists in inhibiting abnormal tonic reflexes, in an effort to achieve higher coordinated postural reactions in a certain sequence with a constant transition to voluntary movements and regulation of reciprocal muscle activity. Postural reflex activity starts predominantly from the head, neck, and shoulder girdle. The position of these parts of the body significantly affects the distribution of abnormal muscle tone in the limbs. Any change in the position of the head causes typical synergies, this explains the impossibility of maintaining a normal position, balance and movement. Inhibition of pathological postures and movements in patients with spastic paralysis can be caused by selecting certain positions of the ready, neck or shoulder girdle, therefore, in this technique, much attention is paid to the correct use of tonic reflexes.
Basic tonic reflexes
Labyrinth-tonic reflex: increased tone of the extensor muscles in the supine position and increased tension of the flexor muscles when turning over on the stomach. In the supine position, the tone of the extensor muscles can increase to varying degrees - from a slight straightening of the legs to a sharp tilting of the head back and extension of the back in the form of an arc. Without overcoming the increased extension, the patient cannot sit down. Depending on which muscle tone is increased, one or another pose is taken. Fixing the posture can lead to contractures of these joints.
Asymmetric tonic neck reflex: rotation of the head to the side causes an increase in the tone of the muscles of the limbs on the half of the body corresponding to the rotation, and on the opposite side, the tone of the muscles of the limbs decreases.
Symmetrical tonic neck reflex: when the head is raised, the tone of the extensors of the arms and flexors of the legs increases, while lowering it, on the contrary, the tone of the flexor muscles of the arms and the extensor muscles of the legs increases.
Associated reactions - tonic reflexes: begin in one limb and increase muscle tone in the other, with frequent repetition, this contributes to the development of contractures.
Attention! All tonic reflexes act together, harmoniously strengthening or weakening each other.
To correct pathological postural reflexes, when performing certain movements, the limbs are given a position opposite to that which occurs under the influence of cervical and labyrinth-tonic reflexes. For example, when trying to sit down, in some cases, the patient experiences rotation of the hips, lower legs inward, extension of the feet. In this case, when trying to sit down, help him keep the limb in the position of external rotation of the hips, lower legs, dorsiflexion of the feet.
Attention! Pathological increase in muscle tone may decrease or increase depending on the change in posture.
The use of congenital cervico-tonic reflexes (K. Bobath et al) with the use of dosed turns and tilts of the head not only improves the quality of the action of one paretic limb, but also normalizes its synergistic connections with the other limb, increasing the degree of coordination of their actions. This improves the quality of movement. The use of reflex exercises combined with overcoming various degrees of resistance, as well as a strict choice of the direction of movement, taking into account the points of attachment of the exercised and relaxed muscles, make it possible to restore the normal pattern of complex motor movements. For example, in I.P. lying on his stomach, the patient is invited to unbend the right thigh, overcoming the resistance of the hand of the exercise therapy methodologist and turning his head to the left. This leads to reflex tension of the external rotators of the shoulder and the extensor muscles of the forearm of the left hand.
Reflex exercises are effective when they are aimed at obtaining initial tension in deeply paretic muscles and are used as a "trigger" mechanism. They are also shown as an addition to ideomotor exercises in cases where the joints of the affected limb are fixed with splints (treatment by position).
Attention! The treatment is not based on "muscle training" but on the re-education of "ways of movement".
With further training of the patient in proper movement, motor disorders should be taken into account:
“the gait is somewhat slow;
■ the affected limb is straightened at the knee joint (functional lengthening);
■ when moving forward, the affected leg performs circular movements;
The affected leg is practically not involved in movement.
It is also necessary to pay attention to the position of the foot, first pulling up the toe with a fixing bandage (elastic band) attached to the knee joint (Fig. 8.5).
The patient moves with small steps. It is necessary to control its stability, monitor the balance and achieve independent and rational movement of the affected leg: it must bend it sufficiently in the hip and knee joints, do not take it to the side, do not touch the toe of the floor, correctly place the foot on the floor surface (with the entire sole) . Overcoming the distance, patients move with support (with one hand) on a crutch or cane. Further improvement of walking consists in the use of less and less stable supporting orthopedic devices and the single overcoming of increasing distances without rest. An important component of physical activity is walking up the stairs, which is taught when the patient has learned to move within the ward, department, and courtyard of the hospital.
Component rehabilitation treatment - occupational therapy, which is built taking into account the severity of hemiparesis and its structure, the distribution of paresis and tone in various muscle groups:
With a mild type of hemiparesis, labor operations are prescribed that directly affect impaired functions;
With moderate and deep types of hemiparesis, labor operations are used, gradually involving the most affected parts of the limbs in motor activity;
With the distal type of paresis, labor operations are first prescribed, performed at the expense of the proximal limbs; the most affected muscles of the distal sections are gradually connected;
With the proximal type of paresis, reverse tactics are used: as elementary motor functions are restored, more complex motor movements are trained by mastering labor actions that require performing fine hand and finger operations;
With hemiparesis without a tendency to recovery, a complete replacement compensation for the function of the affected limb is developed (L. G. Stolyarova et al. T.D. Demidenko).
Labor operations of a facilitated nature (cardboard
works, production of gauze bandages, etc.); in the types of work aimed at restoring muscle strength
(modeling from plasticine, etc.); ■ labor operations that develop fine coordination of the fingers and increase their sensitivity (weaving, knitting, etc.).
When performing a labor operation, movements occur in several joints simultaneously with the participation of a number of muscle groups. At the same time, in the labor process, it is possible to achieve a differentiated effect on a certain segment of the locomotor apparatus. For example, technological process making an envelope consists of a blank pattern on a stencil, folding and gluing the envelope. To do this, you need to use a pencil, scissors, fold and iron the paper. In this case, the following movements develop: flexion of the fingers, adduction and opposition of one finger, pronation and supination of the forearm, the so-called forceps grip is formed.
The selection of labor operations is carried out on the basis of a detailed analysis of the function of the muscles, movements performed in the joints of the fingers, joints of the upper and lower extremities, and the foot. Of great importance when performing work is the correct initial position of the affected hand, achieved by leaning on the plane of the table, hanging it on a special strap, etc.
With persistent loss of motor function during the performance of various labor operations, the patient develops useful compensatory devices that replace the functional defect.
All of the listed methods of rehabilitation treatment are closely related and complement each other, are used in different combinations depending on the individual treatment program of the patient.
Before discharge from the hospital, not only the achieved degree of recovery is assessed, but also the possibility of further normalization of functions is predicted, and the prospects for post-stroke recovery are determined. Patients with a positive rehabilitation potential and a willingness to learn are referred for repeated courses of rehabilitation therapy in specialized centers (polyclinics), sanatoriums.
8.2.3. Rehabilitation of patients at the stage of the clinic-sanatorium
Patients are admitted to the neurological department of a polyclinic or sanatorium for a full rehabilitation course or for its continuation when transferred from a hospital.
Mandatory conditions for admission to treatment (T.D. Demidenko):
The presence of a certain level of compensation for lost functions and adaptation to the real life environment;
The ability of active movement and elementary self-service.
Rehabilitation measures at this stage are shown no earlier than 4-8 weeks after acute lesion brain vessels. The timing of the transfer of the patient is determined not only by the underlying vascular disease, but also by the depth of cerebrovascular accident, as well as the localization of the cerebrovascular disorder depending on the vascular pool (carotid, vertebrobasilar), somatic burden of the patient, his compensatory capabilities and safety. mental functions. At the same time, a rehabilitation specialist should assess the period required to restore impaired functions, which depends on the following reasons;
The nature and course of the pathological process that caused the disorder of cerebral circulation;
The degree of circulatory disorders in the brain;
The state of cerebral circulation, the dynamics of vascular disorders in the focus of brain damage, the state of collateral circulation;
The primary or recurrence of cerebrovascular accidents;
The state of the cardiovascular system and respiratory organs.
The main tasks of physical rehabilitation means:
Consolidation of positive changes achieved at the stationary stage of rehabilitation in the treatment of the underlying vascular disease of the brain, as well as concomitant diseases;
Elimination of the consequences of the disease (paresis, paralysis, speech disorders, etc.) and prevention of repeated cerebrovascular accidents;
Further increase in the patient's psychological and physical activity to the level necessary to perform professional duties or other types of labor and social activities, as well as domestic services.
As the general condition of the patient improves, there are opportunities to use various means of physical rehabilitation more widely and actively (kineso-, ergo-, physio-, psychotherapy, etc.). However, at this stage, the patient may develop stable pathological conditions (spastic muscle tone, contractures, pain syndrome, epileptic seizures, etc.), which requires additional efforts on the part of the rehabilitation team. In addition, the more time has passed since the stroke, the less chance there is for spontaneous recovery of functions and the more emphasis is placed on teaching the patient to adapt to the existing defect through the use of preserved functions and assistive devices.
At this stage of rehabilitation treatment, the efforts of rehabilitation therapists are more focused on teaching the patient to achieve the greatest possible independence and resolving questions about the need for aids, as well as helping to solve social problems. These tasks are solved with the help of various means of physical rehabilitation against the background of drug therapy.
The purpose of psychotherapeutic measures at this stage of treatment is to overcome the patient's depressing life circumstances, the adoption of a new line of behavior in life, taking into account the presence of painful manifestations and the need for active involvement in the treatment process.
Autogenic training is one of the methods medical rehabilitation, including therapeutic self-hypnosis, self-knowledge, neurosomatic training, sedative and activating psycho-treatment, carried out in conditions of muscle relaxation and leading to self-education and mental self-regulation of the body.
Psychological aspects of autogenic training:
Educating the patient's skills of "figurative representations";
Autogenic meditation (meditation - reflection, contemplation), autogenic immersion;
Development of the skill of mobilization of the psycho-physiological state, etc.
Autogenic training is built in accordance with the stages of exercise therapy Tsemidenko T.D. et al., 1979].
I period (main) - teaching patients to actively relax the muscles.
II period - the use of ideomotor exercises for the purpose of localized impact on isolated muscle groups against the background of their general relaxation.
III period - the use of ideomotor exercises to activate patients, mastering skills correct walking and self-service.
Forms of psychotherapy
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