RU2168972C1 - Method for treating the cases of ankylosing spondyloarthritis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves mobilizing and manipulating in the area of the sacroiliac articulations by concurrently rotating iliac bones in ventrocaudal direction, ischial bones in dorsocranial direction. Then the manipulations are combined with femur extension. Vertebral column extensor muscles and vertebral column dorsal ligaments traction is relieved with their function normalized next to it. Musculoligamental contractures are withdrawn giving preference to sacroiliac muscle function repair using isometric, isotonic and postisometric techniques without increasing movement volume between the vertebral column motor segments. Flexion muscular contractures are eliminated in large joints with extensors, abductors and muscles rotating femur being strengthened. Chest excursion is enlarged and vertebral column muscles are strengthened in the ankylosis stage of two and more vertebrae without immobilization including vertebral column traction. The vertebral column is fixed with corset with head support in both phases after the mobilization and pains occurring. EFFECT: normalized body center of gravity; improved biomechanical properties of articulations and vertebral column. 3 cl

Description

 The invention relates to medicine, namely to orthopedics, vertebrology, manual medicine in the treatment of ankylosing spondylitis or ankylosing spondylitis.

 Ankylosing spondylitis is characterized by a chronic, steadily progressing course with periodic exacerbations and remissions. The outcome of the disease is ankylosis of the joints of the spine and various joints of the limbs involved in the process. Existing treatment complexes mitigate the manifestation of the disease or delay the course somewhat. To date, the etiology of the disease has not been clarified, there is no pathogenetic treatment. At the same time, the possibilities of modern manual medicine can significantly help patients, prevent the orthopedic consequences of the disease, correct or improve biomechanics, statics, and increase working capacity.

 Currently, there are three stages of the disease: The first stage, either initial or early, is characterized by a slight restriction of movements in the lumbar spine or in the joints of the limbs due to severe pain. In the sacroiliac joints, fuzziness, unevenness of the articular surfaces, expansion and uneven joint gap are determined. ESR up to 20 mm / g, test on C - reactive protein positive (+), diphenylamine test - up to 0.220 units.

 The second stage is a moderate restriction of movement in the spine, large joints due to the development of contractures. In the sacroiliac joints, a narrowing of the joint gap is revealed, X-ray changes are also revealed in the arcing joints, their selective ankylosis. ESR - 20-40 mm / g, sample C - positive reactive protein (++), diphenylamine sample - 0.230 - 260 units. The third stage is characterized by ankylosing of the sacroiliac joints, arterial, costal-vertebral joints, ossification of the sac-ligamentous apparatus of the spine.

 I.L. Tsivyan (Ankylosing spondylitis Surgery, Tashkent: Medicine, UzSSR, 1990, p. 54) recommends the prophylaxis of the orthopedic effects in the pre-ankylosis phase and, if it is impossible to prevent them, contribute to the onset of ankylosis in a functionally advantageous position. To do this, use therapeutic exercises, massage courses, breathing exercises, it is recommended to sleep on an even, hard bed.

 At the beginning of XX (Cit. According to Y. L. Tsivyan) they tried to correct the flexion deformity of the spine by the method of simultaneous bloodless redirection. Severe complications from the spinal cord forced to abandon redressions. In 1932, V.R. Vreden successfully carried out an instant correction. I.L. Tsivyan developed a dosing correction method using a halo apparatus.

 Methods of correction of flexion deformities of the spine according to M.I. Kuslik (1935) is as follows: during the preparation of the patient, they are laid on their backs on an inclined rigid plane. Traction is carried out with a Glisson loop and rods for axillary rings, the upper thighs are fixed with straps. A load in the form of sandbags is laid on the front wall of the chest, individual weight, depending on patient tolerance. Such stretching of the retracted muscles, according to the author, is carried out for 3 to 4 weeks, which eliminates contractures in the joints.

 During the period of redirections in the position on the side of the patient, they are put into a state of anesthetic sleep, after which they are laid on their back. The lower half of the body is fixed to the table with straps. In anesthesia, the upper half of the body is constantly extended to a certain limit. After that, they press on the sternum slowly slowly overcoming the spring resistance of the spine. The appearance of a light crunch, captured by the hand in the lumbar region, serves as a signal to stop pressure. The body is fixed with a plaster corset with the capture of one hip.

 V. D. Chaklin (1951) carry out a redress on a special curved frame with an extension of the Glisson loop, at the same time conduct light massage, gymnastics and drug treatment.

 The author reports on individual cases of some correction of the spine, but only one due to muscle contracture. Deformation of the spine due to joint ankylosis cannot be corrected.

 In the domestic and foreign literature, among the list of absolute contraindications for the use of manual medicine is ankylosing spondylitis (A.B.Sitel, 1993; A.A. Skromets et al., 1990; Guidelines issued for doctors by the Ministry of Health of the Ukrainian SSR, 1986; Guidelines for doctors issued by the Central Institute for Advanced Medical Studies of the Ministry of Health of the USSR together with the Ministry of Health of the Ukrainian SSR, the Kharkov Council for Resorts Management, Kharkov, 1987; V.S. Goidenko et al., 1988, A.A. Barvichenko, 1992). With caution in using manual therapy, R. MEN (1968) noted in his works, and A. Stoddart (1955), who identified five degrees of mobility that are still used by medical practitioners, considering manipulations for ankylosis and joint hypermobility to be contraindicated.

 Our experience has shown that the use of manual therapy for ankylosing spondylitis always brings improvement, even if it is small, regardless of the duration of the disease and the severity of the orthopedic consequences, and the therapy carried out from the beginning of the disease prevents the development of deformities and impaired functions. To understand the proposed method, we dwell on a number of points of the characteristics of the disease, biomechanics in the development of certain changes in the musculoskeletal system in ankylosing spondylitis.

 More often, the disease has a primary chronic course: intermittent, not entirely clear pain in the lower back and buttocks. Gradually, the pains become more persistent, constant, intensify with movements, which stimulates lumbar sciatica. Gradually, pains seize the sternum, ribs. The pain extends to the hip joints, less commonly to distal joints. Stiffness of the patient is due to the desire to reduce pain. Rest and bed rest reduce pain. There are periods of relative well-being and patients returning to their previous, normal lifestyle. Such remissions are replaced by periods of exacerbation, increased pain. Patients have a preoccupation with their health, estrangement, isolation, disbelief in the ability to recover and improve their condition.

 As the disease progresses, pain from the lumbar spine moves to the thoracic, cervical spine, to the costof vertebral joints, and superficial breathing appears, which changes to the abdominal type. All this occurs even before the ankylosing of the joints is revealed radiologically. The patient moves in small steps, mainly due to movements with bent knee joints, while the volume in the hip joints is not broken. When involved in the process of the hip joints, this peculiar gait becomes more pronounced, which first restricts movement in them, and subsequently leads to ankylosis. Patients cannot sit on the toilet, squat, spread their legs to the sides, and often there are no pains.

 Pain in the lumbar region gradually decreases, and with the onset of ankylosis in the arched joints, the attenuations completely disappear and disappear. But they appear in higher sections and goes through the same cycle.

 The chest is flattened, its anteroposterior diameter decreases.

 With the spread of the disease, pain appears in the hip or shoulder joints, and can spread to distally located joints. The pain is gradually joined by the restriction of mobility, in the final - the disappearance of movements.

 The feeling of stiffness proceeds to the progressive bending of the body. Patients cannot look straight ahead, they are bent to the ground, they see only their own feet, the ground or the floor near their feet. Such anterior bending of the body is compensated by walking on several bent at the hip and knee joints, and this in turn leads to flexion contractures in these compositions. I.L. Tsivyan (1990) concludes that flexion of the spine is not a consequence of ankylosis in the arched joints, but rather as a method of self-immobilization of the spine to reduce pain.

 Ankylosis of the cervical spine can occur in the position of strictly anterior fixation - goose or swan neck. At extreme degrees of anterior flexion, the chin rests on the upper part of the front wall of the chest, which makes it difficult to speak and chewing. Sometimes the anterior flexion is supplemented by a left or right tilt of the neck, it is not uncommon to twist the cervical region around the vertical axis to this deformation. Such deformations exacerbate the patient’s difficult situation, and correction is more difficult.

 With severe flexion, the patient's face is turned down, the trunk is bent anteriorly. Transverse, deep folds appear on the lateral abdominal wall, costal arches close to the crests of the wings of the ilium. The rectus muscles are tightened, spasmodic. The vertex of the arc of the spine falls on the XI, XII or I lumbar vertebrae. On the tops of the deformation, the interspinous spaces increase, the apexs of the spinous processes are visible under the skin. An obtuse angle is formed between the torso and thighs, open anteriorly, and an obtuse angle is open between the hips and lower legs, open anteriorly. In the shoulder joints, abduction above the horizontal line is limited.

 In the sacroiliac joints in the early stages, palpation and especially thumping causes severe pain in the joints. Soreness is detected in the arched joints, especially in the lumbar region, sometimes in the spinous processes. With the onset of ankylosis in these joints, the soreness disappears. In the hip joints, pain is first detected with rotational movements. Gradually limited rotation, abduction. Rocking movements are characteristic of the preankylosis phase.

 In case of damage to the knee joints, deformation occurs, an increase in their volume, smoothing of the natural contours, effusion in the joint, compaction and thickening of the purse-ligamentous apparatus, movement is gradually limited and then lost. Well-known morphological studies show that tissue changes in the pre-ankylosis phase are characterized by progressive lysis of the articular cartilage, its thinning, gradual destruction until the articular end of the bone disappears from certain territories. In the earlier stages, there is initially an uneven joint gap caused by thinning of the articular cartilage, in later stages the gap becomes narrow and then disappears as a result of the elimination of the articular cartilage.

 When ankylosis of the arched joints occurs, radicular pains are not observed. The size and diameters of the intervertebral foramen usually do not decrease. Ya. L. Tsivyan (1990) notes during operations the preserved normal shape of these openings, where the spinal roots, ganglia, and vessels are located.

 Subcutaneously, fatty tissue becomes thinner and somewhat denser. Fascial formations become thinner, denser, lose elasticity. Muscle tissue loses its elasticity.

 Research by V. M. Chepoy (1978) showed relatively acute inflammation or chronic inflammation of the sinoid membrane of the joints.

Diagnostic criteria
We adhere to the diagnostic criteria that were proposed in 1961 in Rome at the international conference by Forester: - pain and stiffness in the sacroiliac region for 3 months. and more and do not decrease at rest;
- pain and stiffness in the thoracic spine;
- limited mobility in the lumbar spine;
- restriction of the respiratory excursion of the chest;
- the presence of iritis, iridocyclitis in the anamnesis or their consequence;
- bilateral sacroileitis, which is detected radiologically and is the earliest sign of ankylosing spondylitis;
- atrophy of the gluteal muscles, recurrent synovitis of the knee joint, damage to the calcaneus.

New York criteria (1966) must be added to the listed criteria:
- restriction of mobility of the lumbar spine in all planes, existing or history of pain in the lumbar or lumbar regions, limitation of the respiratory excursion of the chest at least 2.5 cm at the level of the fourth intercostal space.

 To understand and justify the proposed method, a brief description of biochemical disorders in the musculoskeletal system in ankylosing spondylitis, identified by us, is necessary.

 As a result of inflammatory, degenerative-dystrophic processes and sacroiliac joints, pain occurs in the pubic joint. The pain intensifies with movements, walking. As a compensatory reaction to protect against pain, the patient, when walking, begins to bend the legs in the knee joints, and then in the hips, thereby reducing the effect of the weight of the spine - trunk, head - upper limbs on the sacrum - ilium. It turns on as if the spring function of bent limbs. Flexion in the joints of the lower limb in the presence of altered articular surfaces of the sacroiliac joints causes the pelvis to tip over dorsally, but the sacrum itself makes a nod to the ventral side. One of the axes of rotation in the sacroiliac joint, namely the horizontal, passes through the second sacral vertebra. The movement in the form of a swing of the dorsal or ventral nods of the sacrum occurs precisely around this axis. In the standing position, the sacrum is near the front border of its displacement, and in the supine position it is near the rear border. We found that in the pre-ankylosis stage, the amplitude of the displacement of the sacrum is almost 1.5 times greater than the amplitude of the movements of the sacrum in healthy people (5-6 mm according to M. Frigeiro, 1974). It was proved by other authors that the amplitude of the sacrum movements always characterizes the amplitude of the movements in the sacroiliac joint. From this we concluded that in the sacroiliac joints, the amplitude of movements also exceeds the normal by almost 3 times. While walking, we recorded the extension of the wings of the ilium within 5 - 7 mm.

 Functional radiography showed that in a standing position, when the sacrum is moved forward, bending the trunk or hips does not increase its displacement. The extension of the trunk or hips causes the sacrum to move backwards, which was determined by a change in the position of the cape or promontory.

 In this case, the center of gravity of the body, normally located anterior to the ankle joints, shifts dorsally, sometimes passing the center of the ankle joints. In this position, the patient cannot hold the body in an upright position, flexors of the trunk of the spine and then of the head begin to prevail compensatory. The more the center of gravity shifts, the more the pelvis tilts to the dorsal side, the sacrum is shifted anteriorly, the spine is bent first in the lumbar, then in the thoracic and cervical regions. To compensate for the measuring center of gravity, spinal deformities are sometimes insufficient, then a forward displacement of the head appears and a "swan neck" is formed.

 The center of gravity of the body in the pre-ankylosed phase occurs in front of the spine, an average of 2 - 2.5 cm from the center of the body 4 of the lumbar vertebra, in the stage of ankylosis of the spine moves to the ventral side and reaches tens of centimeters.

 In the sagittal plane of the body, the projection of the center of gravity in the pre-ankylosed stage is 14 - 30 mm behind the axis of rotation of the hip joint, 14 - 20 mm in front of the axis of rotation of the hip, and 20 - 30 mm from the axis of rotation of the ankle joint.

 The projection of the center of gravity on the standing area in the sagittal plane is located in the pre-ankylosed phase with some displacement from the frontal plane, depending on the magnitude of the flexion displacement of the spinal contracture.

 The main purpose of the ligaments of the spine is to limit the bending and twisting of the spine. In the initial state, the ligaments connecting the vertebrae are stretched. Ligaments slow down the mutual movement of the vertebrae. Ligaments before muscles react to the movement of the spine. Our data coincide with the results of Silver (1954), which showed that when the spine is bent, tensile stresses in the supraspinous and interspinous ligaments occur earlier than back rectifiers are included in the work.

 The equilibrium position of the body is supported not only by the efforts of the muscles, but by the elastic forces of the ligaments. This explains the inclusion in the treatment plan of measures to establish the function of the ligaments, especially the dorsal surface of the spine.

 Gyroscopes allow you to determine at any time a step the angle of inclination of the pelvis and segment of the spine to the side, forward or backward and their rotation around the vertical axis.

 The lumbar as a hinge, on the one hand, allows the pelvis to make the necessary movements for walking, and on the other hand, provides the upper spine with the ability to maintain an upright position.

 The forward inclination of the lumbar and thoracic spine is compensated by an increase in cervical lordosis. That is why with an exacerbation of the process in the lumbar-thoracic regions, to reduce the cervical lordosis, it is necessary to appoint a corset with a head holder.

 The horizontal rotation curve of the pelvis resembles a sinusoid. When resting on the right leg, the pelvis rotates clockwise, on the left - counterclockwise. Together with the pelvis, lumbar vertebrae rotate for almost the entire step. The pelvis and upper thoracic vertebrae rotate in opposite directions. This means (A.I. Kazmin, Scoliosis, M., M., 1981) the lower thoracic segment is the border zone, which, when walking, remains in a neutral position. This ensures damage to the lumbar, and not the thoracic spine, which we took into account when carrying out certain activities, giving preference to the effects on the lumbar.

 According to the laws of mechanics, the total load at each level of the spine can be depicted as a resultant passing through the pulpous nucleus of the intervertebral disc. The direction of the resultant depends on the horizontal components of the muscle forces involved in maintaining the balance of the body. In the upper thoracic region, the traction of the paravertebral muscles that perform the anti-gravity function is directed down and back, in the lower thoracic muscle - almost only downward, and in the lumbar, thanks to the participation of the iliopsoas muscles - down and forward.

 In accordance with the direction of traction of muscular effort, the position of the resultant also changes: first, it is directed slightly backward, then downward, and then deviates anteriorly. That is why, with the slightest violation of the function of the flexors and extensors of the spine, the latter, due to the action of the resultant, leans forward in the lumbar region, lordosis is lost, followed by the formation of a single kyphosis with the thoracic region. The lumbo-iliac muscles act as a disco-coordinator here, which is why we include normalization of the function of this muscle in the action plan.

 Gravitational spinal deformities occur in ankylosing spondylitis from the appearance of deforming forces as a result of the displacement of the partial centers of gravity of the body from the mid-sagittal plane during pelvic distortion, muscle contractures. In ankylosing spondylitis, gravitational deformations develop in the form of the disappearance of lumbar lordosis, total kyphosis. Therefore, pelvic alignment, manipulations, special exercises that extend the flexors of the spine, lead to the elimination of deformation. The most effective exercises in the abdomen.

 Our experience shows that it is much easier to reduce spinal deformity than to maintain the achieved correction. Therefore, in addition to the appointment of a corset at certain time intervals, it is important to carry out active mobilization by assigning exercises that are more appropriate than passive exercises, such as stretching, hanging on the gymnastic stairs.

 Our anthropometric studies have shown that in stage I of the disease, when the process is localized in the sacroiliac joints, and pain occurs in the lumbar region, the iliopsoas muscle is in a spasmodic, shortened state. The steam muscle, located to the left and right of the spine, is reduced symmetrically and at first plays a compensatory role in eliminating or reducing pain. There is a chain of compensation processes: flexion of the hips, in the knees, bending of the body and all this to reduce pain. When the center of gravity of the head and trunk is moved ventrally from the frontal plane and the pelvis is tipped to the dorsal side, the state of the iliopsoas muscles changes: the attachment points approach each other, the muscle from an increased tone goes into a paretic state.

 The paretic state of the flexors and extensors of the lumbar-thoracic region with the continued action of the body mass on the lumbar spine and sacrum leads to the disappearance of lumbar lordosis and the formation of lumbar kyphosis. The dysfunction of the flexors and extensors is more dependent on the condition of the iliopsoas muscle. Under normal conditions, with the vertical position of the body, both iliopsoas muscles are lengthened, the action of the body mass acting in the mid-sagittal plane is balanced by the efforts of the paravertebral muscles and ligaments.

 Based on the studies, we came to the conclusion: the ileo-lumbar muscles, both in the state of compensatory contracture and in the paretic state, are subject to normalization of the function. Our studies showed that strength exercises are not tolerated by patients because of pain, only exercises in isotonic and isometric modes are possible. Technique for training the iliopsoas muscle: starting position on the back, flexion of the thigh of the lower leg at an angle at which there is no pain. From the position of painless hip flexion, the hip flexion is passively performed, leading to the abdomen, symmetrically, at the same time, starting from 10 to 15 movements, bringing in 1 to 2 months to double or triple the value.

 The isotonic regimen is indicated for the atanic state of the muscles; the isometric regimen is advisable to be performed with increased tone. It recommends overcoming resistance from 2 - 3 kg to 5 kg. In the same period, it is advisable to carry out postisometric relaxation. It is necessary to educate the patient at the end of the subsidence of an exacerbation of autobilization aimed at normalizing the function of the lumbar iliac muscles.

 To improve trophism of the abdominal muscles, relieve hypertonicity, increase the distance of attachment points, it is necessary to massage. Massage, wrapping warming with compresses, mud therapy is advisable for both the abdominal muscles and the back. Normalization of the tone of the muscles of the abdomen and back should be carried out both with their increase, and with the paretic state, as one of the measures for creating a muscle corset. The patient must firmly understand that the appearance of pain in the spine is a signal for putting on a corset with a head holder. As well as the disappearance of pain should be a signal to remove the corset and take measures to strengthen muscle, i.e. biological corset. Where possible, it is advisable to carry out exposure by the method of electrical stimulation, from which one can expect a much larger and faster increase in muscle diameter than with arbitrary training. In addition, individual muscles and muscle groups can be strengthened by electrical stimulation.

 It should be noted that in a corset without a head holder, the activity of the back muscles decreases, with a head holder it increases, which delays the flexion of the spine and the progression of other orthopedic changes. The main purpose of the corset is to preserve the correction achieved before its use.

 At the first stage of the disease, we manage to maintain joint function and prevent the development of muscle hypotrophy.

 In the second stage, it is possible to maintain the existing range of motion in the joint and, developing compensatory mechanisms, stabilize the range of motion. Restore joint function in full is no longer possible.

 At any stage, the effect should be aimed primarily at stabilizing and unloading the joint by strengthening and training the muscle groups surrounding it.

 During an exacerbation with a pronounced pain syndrome, the main objective of the treatment is to reduce the pain syndrome, relax the muscle groups surrounding the joint, and prevent stiffness in adjacent joints. All procedures must be carried out under the condition of unloading the affected joint, i.e. mostly in supine position.

 Exercise is performed at a slow pace, without causing increased pain. The average duration of the procedure is 10 to 15 minutes. During the period of exacerbation, it is necessary to relax the adductor muscles and hip flexors. This applies to the rectus femoris muscle, the iliopsoas, the sartorius muscle, which strains the wide fascia, the adductors of the thigh, and the soft and semi-tendonous muscle. It is necessary to improve blood circulation in the limbs and joints. During an exacerbation, bed rest is prescribed. It is necessary to perform free dynamic exercises in the ankle joint, short-term isometric tension of the gluteal muscle group, active relaxation, methods of post-isometric relaxation of the hip flexors. At the same time, segmental massage is performed with relaxing techniques for hip flexors. Joint massage is not performed.

 In the subacute period, measures are taken to improve blood circulation in the limb, in the joint, normalize muscle tone, and restore range of motion.

 In the subacute period, as pain decreases, the effect is on the restoration of the possible range of motion in stages I - II of the disease. Isometric training of weakened muscle groups is carried out with a series of exercises of 5-10 stresses with an exposure of 5-7 s and relaxation of contracted muscle groups.

 During remission, muscle groups are strengthened with the aim of unloading and stabilizing the affected joint, correcting the revealed violations, developing and training compensatory skills. Strengthening muscle groups helps maintain joint function in the initial stages of the disease and create compensatory mechanisms. During the period of remission, conditions are created for the hip joint, which would slow down the progression of the process by strengthening the periarticular muscle groups, and massage the joint. The emphasis is on extensors and abducting muscles of the thigh, mainly on the gluteus maximus muscle, biceps, middle, gluteus maximus muscle, straining the broad fascia of the thigh.

 Hip extension is best performed lying on the stomach on the couch, without burdening, holding the limb in an unbent position for 7 to 10 seconds.

 In the ankylosis stage, any attempt to rock the joint is unsuccessful. In the absence of movements in the joint, isometric muscle training can be performed. You can not use a rough correction of the spine, it is necessary to carry out measures to increase the strength and endurance of the back muscles, abdominals in the supine position. To maintain the state of the muscular system, three times a week are enough, at least a month, during the year 3-4 times.

 With the closure of two or more vertebrae, it is necessary to strengthen the muscles without increasing the amplitude of the movements of the spine. Mobilization of the spine, increasing the range of motion, violates the compensation that has arisen, increases pain. Therefore, traction events are not shown. Strengthen the muscular system of the spine is necessary in the initial positions of the reduced load on the spine. It is necessary to carry out measures to increase the mobility of the ribs, the expansion of the chest, to correct posture, straightening the spine. Such exercises include extension of the torso, circular movements of the arms, extension in the cervical region with the resistance of the patient's arms brought to the back of the head while lying on his stomach, standing exercise with a gymnastic stick in his hands, breathing exercises.

 The movement of the upper and lower extremities stabilize the spine by strengthening the muscles of the back, abdominal wall without increasing the mobility of the spine.

 The result achieved by the short-term use of passive manual exposure in manual therapy is fixed in the subsequent long-term active medical gymnastics, auto-mobilization.

 Our pathophysiological, biomechanical studies on biomanicenes formed the basis of treatment methods.

 1. It is necessary to completely exclude active flexion movements for the spine, lower extremities, since any flexion leads to the displacement of the sacrum to the ventral side.

 2. Only extension movements in the spine, lower extremities should be used, since such movements contribute to the displacement of the sacrum back, ie to the dorsal side.

 3. Reception of the anterior rotation of the iliac wings and posterior of the ischium. This manipulation can be carried out in a supine position. The lower leg and thigh are in the position that was formed as a result of contractures. The doctor shifts the iliac wing anteriorly or ventrally with one hand, and presses dorsally and posteriorly on the ischium with the other hand. Such mobilization in the sacroiliac joint contributes to the displacement of the sacrum from the anterior installation to normal. The same mobilization is carried out on the opposite side. Before the described mobilization, compression and stretching of the ilium wings is carried out without pain.

 4. The combination of anterior rotation of the ilium wings with simultaneous extension in the hip joints.

 The mobilization is carried out in the position of the patient on the abdomen. A roller is placed under the front surface of the thigh, the size of which creates excessive extension, with one hand they press on the thigh in the region of the roller, with the other hand they act on the iliac wing alternately, rotating them anteriorly, i.e., ventrally. It is advisable to combine excessive extension in the hip joint, anterior rotation of the wings of the ilium with distraction of the straightened limb along its axis, along the axis of the femoral neck.

 We believe that indications and contraindications for manual therapy determines the degree of mobility in the joint. According to the classification of A. Stoddart (1959), zero degree of mobility (ankylosis) is an absolute contraindication to manual therapy. With limited mobility in the joint caused by muscular reflex reactions, which occurs with Ankylosing spondylitis during the remission of the process, we use gentle mobilization methods for muscle relaxation and preparation for painless manipulations.

 Relaxation, as a method of manual therapy, is performed as a relaxation of spasmodic muscles and includes both general and regional. A feature of regional relaxation is the provision of fixation of that posture of the trunk and limbs for 25-30 minutes, with which the doctor met at the next session.

 The patient himself fits in the position that provides him with comfort. Due to the existing relaxation contractures, inflatable rollers, pillows, filling the gaps between the couch and the back surface of the head, neck, lower back, limbs, are brought under the head, neck, lower back, and popliteal region. Regional relaxation aimed at eliminating functional blocks is performed only from the position of the styling described above.

 To relax the muscles, improve their traffic and ligaments, we use the classic techniques of manual or hardware massage (stroking, rubbing, kneading, vibration).

A feature of mobilization in ankylosing spondylitis is that traction is performed with minimal load, without pain, without breaking elastic structures, without bringing the stretch to the physiological limits of stretching. When mobilizing by passive movements, repetitive movements are reproduced in the direction of limiting movements with a constant increase in volume by no more than 0.5 - 1 ^o . This makes it possible to prevent pain and creasing of the articular surfaces of degeneratively altered ones.

 Receptions are performed slowly, in the exhalation phase 5 to 10 times. A feature of mobilization in ankylosing spondylitis is the unfocused nature of the impact, i.e. the impact is not on one joint, but on several joints. This corresponds to the pathoganism of the disease, especially in the spine, where dysfunction of the spinal motor segment in the lumbar region leads to compensatory deformation of the cervical, cervicothoracic regions.

 In ankylosing spondylitis, manipulation is purposeful, but should not exceed the range of movements available at the time of manipulation.

 When the hip joint is affected, pain is determined upon palpation of the posterolateral surface of the greater trochanter, at the site of attachment of the rectus abdominis to the symphysis, in the projection of the intertrochanteric crest, at the site of attachment of the adductors in the upper and middle third of the inner thigh.

Elimination of extensor contracture is performed in the patient’s position on the back, with one hand the doctor fixes the patient’s pelvis, the other region of the ankle joint, bend the joint to the extent possible, but without pain, increasing the range of movements by no more than 0.5 - 1 ^o per session. Extension is performed while lying on the stomach. The sciatic tubercle is fixed with one hand, while holding the lower third of the thigh with the other hand, raise it upward by no more than 0.5 - 1 ^o per session.

 Internal rotation in the hip joint is not performed, since hip rotation in patients with ankylosing spondylitis in the acute stage always causes pain. The cause of pain during internal rotation is the load on the sacroiliac and pubic joints. External rotation of the thigh does not cause pain, it should be done in the supine position, in the position of the flexion contracture in the hip and knee joints that was present at the time of mobilization.

 Eliminate the leading contracture of the thigh while lying on the back, one leg is straightened, the foot of the other leg is located on the knee joint of the other leg. The ilium is fixed with one hand, and the thigh is pulled out with the other. If the abduction is limited due to blockage in the hip joint, pain appears in the projection of the acetabulum. After elimination of the blockade, the pain disappears. Mobilization along the axis of the femoral neck is important, it is carried out by hand or with the help of fixing straps by traction. With traction along the axis of the femoral neck, all methods of mobilizing the joint begin, but only in the absence of pain.

Re-extension in the hip, knee, and other joints used in the treatment of contractures of the lower extremity is unacceptable for ankylosing spondylitis, as it leads to severe trauma to soft tissues (ligaments, muscles) and articular surfaces (crushing of subchondral tissue). Therefore, we must remember that in the hip joint normal extension is possible up to 10 - 15 ^o , flexion 120 - 130 ^o , lead 40 - 45 ^o , cast 25 - 30 ^o , rotation out 45 ^° , rotation inward 40 ^o .

 Mobilization of the sacroiliac joints: the patient's position on the back, leg muscles are relaxed. The doctor covers the area of the ankle joints with his hands, slowly spreads his legs to the sides and brings them closer. The technique is used when there is pain during movements in the hip joint and there is no pain in the sacroiliac joint to eliminate pelvic distortion, as a preparatory stage for eliminating the relative inequality of the lower extremities. This inequality occurs when one half of the pelvis is omitted due to a compensatory reaction to the predominance of the active process in the joint between the ilium and the sacrum. The above technique can be replaced by rhythmic active rapprochement and dilution of the wings of the ilium. With the predominance of the active process in one of the joints, one wing of the ilium and the symphysis region can be used as a support for approaching and breeding of the jointed surfaces.

 A technique aimed at eliminating contracture of the flexors of the spine, mainly in the cervical spine, of the hip flexors.

 The patient is laid on the couch, the shoulder girdle, the other region of the forehead are fixed with one hand, pressure is first applied to the shoulder girdle first, then to the frontal part, trying to bring the area of the shoulder blades and the back of the head to the couch. Then, the pelvic ring is fixed with one hand, the second hand is laid on the front surface of the knee joints or the lower third of the hips, and with straightened legs, pressure is applied until the heels approach the couch.

 Reception aimed at increasing movements in the lumbar and thoracic regions.

 When sitting or standing, measure the distance from the V lumbar vertebra to the VII cervical vertebra. The patient bends the spine to the maximum size, but without pain, 1 time after 5 - 6 breaths - exhalations for 5-6 minutes. The movement ends when registering an increase in this distance in one session by 0.5 - 1 cm, with course treatment by 4 - 5 cm. Such an increase indicates the elimination of the Schober sign.

 A technique aimed at increasing chest excursion, which can be controlled spirometrically.

 In the patient's position, the doctor stands with the tips of the fingers of his straightened palms, laid on the crests of the wings of the ilium, deepens into the gap under the ribs. Overcoming the rigidity of the muscles, the fingers deepen towards the spine and spread the fingers to the lateral side. In one session, the ribs are mobilized synchronously with the breath, 10-15 times. During the course of treatment, the scope of the rib cage is increased to 2.0 - 2.5 cm.

 Thus, our studies have shown that a key point in the development of biomechanical disorders is dysfunction in the sacroiliac joint.

 Pain in the sacroiliac joint is, as it were, a trigger for successively occurring changes in the musculoskeletal system. Pain leads to restriction of internal rotation, abduction of the thigh, contracture of the adductors, rotators, and hip flexors. Muscular imbalance helps to limit movement in the joint, hypertrophy, muscle hypotension gradually develops. This is facilitated by the approximation of the attachment points of the flexor muscles.

 Prolonged flexion in the hip, knee joints leads to tension of the triceps muscles of the legs, flexion contracture in the ankle joint. Moving the center of gravity under these conditions leads to additional overloads in the joints.

 Strengthening the abducting muscles and extensors of the thigh, relaxing the group of flexors, it is possible to fight the development of flexion contracture in the hip, knee and ankle joints.

 Strengthening the back muscles, relaxing the abdominal muscles, you can compensate for static disorders in the spine.

 Strengthening the muscles of the limbs, stabilizing the position of the pelvis and spine, you can restore the normal center of gravity.

 Therefore, the prevention, elimination or compensation of changes in the musculoskeletal system with manual therapy should be given the main attention at the stages of treatment of the pre-cancerous stage of the disease.

 The treatment results were evaluated by reducing pain, the amplitude of movement in the joint, by the functional state of the muscle groups surrounding the joint, by the results of dynamometry, tonometry, electromyography, podography.

Patient G., 31 years old, complained of periodically occurring pain in the lumbar region, hip joints, general stiffness. For several years he was treated for radiculitis. In 1996, after an examination at CITO, ankylosing spondylitis was diagnosed. He refused spinal surgery. When handling revealed restrictions on movements in the lumbar spine in the direction of flexion by 7 - 9 ^o , extension to 5 ^o , ankylosis of the arched joints between 1 - 2, 3 and 4 and 4 - 5 lumbar vertebrae. The joint gap of the sacroiliac joint is narrowed on the left, on the right - a fuzzy and uneven articular surface, an uneven joint gap. The x-ray picture of the changes on the left indicates the initial stage of the lesion, while on the right the changes are pre-ankylosed in nature with a sharp restriction of mobility in the joint.

When handling it, it has on its hands a week ago tests: ESR 22 mm / h, test for C-reactive protein (+), diphenylamine test - 0.218 units. A positive symptom of Schober in the lumbar region, a symptom of Zatsepin, the symptoms of Kushelevsky and Mennel are positive. In the lumbar region of lordosis as such, there is no. Flexion contracture in the hip joint up to 45 ^o , in the knee up to 30 ^o , abduction of the thigh is reduced by half possible. The chest is flattened in the anteroposterior direction, the abdominal type of breathing. An additional x-ray revealed a typical pattern of "tram rails" in the thoracic region, pronounced osteoporosis. Walks in small steps. The torso is not involved in movement when walking. Due to the existing deformations, he cannot work in his profession - a teacher of RU. Twice a year, starting in 1966, the patient was treated in the described manner, taking into account the fact that there is ankylosis in three lumbar vertebrae, i.e. when strengthening the muscles of the spine, mobilization of the spine with traction was not used. After mobilization and manipulations aimed at rotating the ilium at the end of the third week, the patient had half-flexion contracture in the hip joint, after 1.5 months he began to walk in steps of 40 cm. The back and abdominal muscles, the ileo-lumbar muscles were strengthened by the described isotonic , isometric techniques. Over a three-year period, there were twice exacerbations of the disease with a rise in temperature, the appearance of pain in the spine. After agreeing by phone, the patient during this period used a corset with a headband. Conducted manual therapy not only prevented the development of orthopedic deformities, but also led to the elimination of contractures in the hip and knee joints, pelvic rollover decreased, flexion contracture of the spine decreased, and stiffness in the morning disappeared. Morphological changes in the spine do not progress. Excursion of the chest, measured at the level of 4 thoracic vertebra increased by 3.2 cm, there are no blockages in the costal vertebral joints. The patient is satisfied with his physical condition, works in his profession, meticulously performs exercises on muscle self-mobilization according to a certain scheme aimed at strengthening the muscles of the antagonists of the limbs and spine.

 According to our technique, 18 patients with good stabilizing results were treated. All of them prevented the development of orthopedic consequences, corrected and improved the biomechanics of their condition, walking, and increased their ability to work at home and at work.

Claims (3)

 1. A method of treating ankylosing spondylitis with first mobilization and manipulation in the sacroiliac joints by simultaneously rotating the iliac bones in the ventrocaudal direction and the sciatic bones in the dorsocranial direction, then acting on the spine, depending on the stage of the disease, eliminate flexion muscle contractures in t joints with strengthening of the extensor, abducting and rotating thigh muscles, increase chest excursion due to the mobilization of the costal-vertebral joints, after exposure to the spine, sacroiliac joints and during an exacerbation of the disease, the spine is fixed with a corset with a head holder.  2. The method according to claim 1, characterized in that in the pre-ankylosed stage of the disease, the spine is affected by eliminating the stretching of the muscles of the extensor spine and ligaments of the dorsal region of the spine with the subsequent normalization of their function, eliminating the flexion musculo-ligamentous contractures of the spine, preferring to restore the function of the ileum lumbar muscles, isometric, isotonic and post-isometric methods without increasing the range of motion between the vertebral motor segments.  3. The method according to claim 1, characterized in that when ankylosed stage, when two or more vertebrae are closed, the spinal muscles are strengthened without mobilization, including its traction, due to movements of the upper and lower extremities.