RU2236210C1 - Method for training invalid persons suffering from paraplegia and deep paraparesis, to stand - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves teaching patient standing with support or external fixation of lower extremities and performing physical training exercises. Orthostatic tonic vibration reflex activation is additionally carried out in addition by applying lower extremity vibrostimulation in patient in standing position with an additional support or fixed on orthopedic table at an angle of 60-80° to horizontal plane. After orthostatic tonic vibration reflex extinction taking place, therapeutic physical training exercises are done 20-30 s later daily during 10 days on postactivation effect of orthostatic reflex taking place. The treatment is repeated when needed. Patients standing in vertical position, therapeutic physical training exercises starts with exercises aimed at stretching posterior crural muscle group and then exercises are done with feedback via vision analyzer being applied with minimum support on the part of arms and maximum on the part of legs, transferring the center of gravity in frontal plane and next to it in sagittal plane. Exercises with no feedback on keeping equilibrium when twisting are done for coordinating muscle work of torso, pelvic girdle and shoulder girdle. Exercises with transferring load from one leg to the other one bending non-supporting leg are also done. Patients fixed on orthopedic table do exercises with feedback via vision analyzer transferring projection of the center of gravity in frontal plane and next to it in sagittal plane bending non-supporting leg.

EFFECT: enhanced effectiveness of treatment.

6 dwg

Description

The invention relates to medicine, namely to physiotherapy and physiotherapy, can be used to restore motor functions of people with disabilities with paraplegia, deep paraparesis.

The postural type of activity is a separate class of involuntary motor activation of the muscle. Due to its involuntary nature, it is difficult to correct even in people with minimal pathology, as evidenced by the widespread prevalence of posture disturbance, despite all the efforts made by society to correct it (Kuraev G.A., Sergeev S.K., Shlenov Yu. B. Valeological system of preserving the health of the population of Russia Valeology. No. 1. 1996. S.7-17). Restoring the standing of people with disabilities with lower flaccid and spastic paraplegia syndromes is a serious problem.

Another type of activity is known, caused artificially and in many ways similar to the cognitive one. These are post-activation effects, which are involuntary reactions of the tonic type, characterized by a considerable duration - from seconds to a minute or more. They can appear as a result of voluntary effort or be the result of muscle tension caused by vibrational effects on the muscle.

Both in maintaining the posture and during the post-activation effect, muscle activity has the character of involuntary tonic type tension, easily modulated by voluntary and reflex interventions. This makes them interested in studying the mechanisms of postural activity. Postactivation effects are most pronounced on the proximal muscles of the extremities: deltoid, biceps, quadriceps, and glutes. The phenomenon of switching the post-activation effect from distal to proximal muscles is described. It manifests itself in the fact that when distal muscles are activated, the near post-activation effect, as a rule, does not develop in them, but switches to the muscles of the proximal joints.

The influence of the posture on the manifestation of post-activation effects in the muscles of the trunk (Gurfinkel V.S., Levik Yu.S., Lebedev M.A. Near and long-term post-activation effects in the human motor system. Neurophysiology. 1989. 21, No. 3. P.343- 351) also indicates a close relationship between these two types of muscle activity.

The property of post-activation effects to create a long-lasting background of activity of tonic structures is used by neurophysiologists to study the basic mechanisms of organization of posture in humans (Gurfinkel V.S., Levik Yu.S., Lebedev M.A. Near and long-term post-activation effects in the human motor system. Neurophysiology. -1989. 21. No. 3. P.343-351), but it is not used for medicinal purposes to correct posture, restore posture.

Closest to the claimed is a method of learning the function of standing. It allows you to restore the vertical position of people with disabilities with deep paraparesis. paraplegia (Potekhin L.D. Kinesitherapy of patients with spinal paraplegia. A manual for doctors, methodologists and instructors of physiotherapy exercises; physiotherapists. Novokuznetsk. 2001. 36-42 p.).

To restore the standing of disabled people with syndromes of lower flaccid and spastic paraplegia, a set of rehabilitation measures is used. including physiotherapy exercises, physiotherapy and training in standing function (Potekhin L.D. Spinal cord injury at the chest level, complicated by gross motor disorders, and principles of adequate rehabilitation. Author. Cand. Cand. dis. Novokuznetsk. 1989 C.9-11). Carrying out such a complex of rehabilitation measures requires time and equipment and highly qualified personnel. Even in these conditions, not every disabled person can master standing and walking without external locking devices. The most difficult thing is to give the pelvic girdle and hip joints such a position that would make it possible to keep the knee joints closed.

The prototype has several disadvantages.

1. In case of damage to the spinal cord at the lumbar level, flexion lends itself to arbitrary control, as opposed to extension, since the innervation of the flexor of the hip joint, the iliopsoas muscle, occurs from the level of the lower pectoral segments (Th ₁₁ ). and the extensor, the gluteus maximus muscle, is significantly lower (L ₅ -S ₂ ) (Arseni K., Simonescu M. Neurosurgical vertebro-medullary pathology. Bucharest: Medical Publishing House. 1973. - P.39-42).

2. Cognitive activity is automatically regulated and difficult to arbitrarily control. This creates additional obstacles for the mutual understanding of the instructor and the patient during the restoration of the vertical posture.

3. Many patients have a fear of holding a vertical posture without external fixation of the joints, which creates a psychological barrier and inhibits the recovery of standing function.

4. Patients with lower spastic paraplegia syndrome have involuntary motor activity, which often has a flexion character.

The objective of the invention is the creation of an effective and affordable way to teach patients with paraplegia, deep paraparesis by forming extensor motor activity against the background of the post-activation effect of the orthostatic tonic vibration reflex.

The task is achieved by the following sequence of actions.

The patient is established with support or external fixation of the lower extremities and the procedure of therapeutic exercises is performed. Additionally, an orthostatic tonic vibration reflex is activated by vibration stimulation of the lower extremities. In patients standing with additional support or fixed on the orthostol at an angle of 60-80 ° to the horizontal, after the extinction of the orthostatic tonic vibration reflex, after 20-30 seconds when the post-activation effect of the orthostatic reflex appears, therapeutic exercises are performed daily for 10 days. If necessary, repeat the course. For patients standing in an upright position, physiotherapy exercises begin with exercises to stretch the back of the leg muscles, then perform exercises using feedback through the visual analyzer with minimal support on the arms and maximum on the legs with the projection of the common center of mass in the front, then in the sagittal plane of the exercise without feedback on maintaining balance during twisting to form the coordinated work of the muscles of the trunk, pelvic and shoulder girdles, exercises on load transfer from one leg to another with bending of the unsupported leg. Patients mounted on an orthostol perform exercises using feedback through the visual analyzer, transferring the projection of the common center of mass in the frontal plane, then in the sagittal plane of the exercise without feedback on transferring the load from one leg to the other with bending of the support leg.

The novelty of the method:

- Additionally, an orthostatic tonic vibration reflex is activated by vibration stimulation of the lower extremities in patients standing upright with a support or mounted on an orthostol at an angle of 60-80 ° to the horizontal.

- After the extinction of the orthostatic tonic vibration reflex after 20-30 seconds when a post-activation effect appears, therapeutic exercises are performed.

- The course of treatment daily for 10 days, if necessary, repeat the course.

- For patients in an upright position, physiotherapy exercises begin with exercises to stretch the back of the leg muscles, then perform exercises using feedback through the visual analyzer with minimal support on the arms and maximum on the legs with the projection of the common center of mass in the frontal plane , then in the sagittal plane exercises without feedback on maintaining equilibrium during twisting to form coordination of the muscles of the trunk, pelvic and shoulder girdles, exercises on p load transfer from one leg to another with bending of the unsupported leg.

- Patients mounted on the orthostolum perform exercises using feedback through the visual analyzer with transfer of the projection of the common center of mass in the frontal plane, then in the sagittal plane of the exercise without feedback on the transfer of load from one leg to another with bending of the support leg.

The post-activation effects by origin and manifestation are close to postural activity, therefore, in the present method, it is proposed to use the post-activation effect of the orthostatic reflex to restore the vertical posture. Post-activation effects occur after vibration reflexes and arbitrary tonic effort. In the contingent under consideration, arbitrary effort cannot be developed, since there is no arbitrary control of the lower extremities. Therefore, it is proposed to use a tonic vibration reflex to form a post-activation effect. To restore the vertical posture, it is proposed to stimulate the orthostatic reflex, since it is he who forms the vertical posture.

During the post-activation effect of the orthostatic reflex, it was proposed to carry out physical therapy exercises, which is learning to stand, because against the background of increased tonus of the musculature of the trunk and extensors of the lower extremities, which takes place during the post-activation effect of the orthostatic reflex, patients are easier to complete tasks and restore the vertical posture more quickly. On the other hand, classes contribute to increasing the duration of the post-activation effect from 1-1.5 minutes to 10-20 minutes.

The sequence of exercises is built from simple to more complex. The first exercise: standing on triangular braids is aimed at stretching the muscles of the back group of the lower leg, full extension of the knee joints. It facilitates the patient's upright position. The second exercise: standing on the floor scales allows the patient to see what percentage of the weight falls on the legs, to control how much he increased the load on the legs during the exercise. The following exercises are more complex, they are aimed at separately controlling the operation of each leg: standing on a pair of floor scales and transferring body weight from one leg to another. During the exercise, the patient learns to maintain balance in the conditions of migration of the projection of the common center of mass in the frontal plane. Reflexively, this stimulates the work of the muscles of the pelvic girdle and hip joints (V.S. Vetrile, I.S. Kosov, A.K. Orletsky Stabilometry as a method for evaluating proprioception in injuries of the cannula-ligamentous apparatus of the knee joint. N. Traumatology and Orthopedics Journal. N. Priorova. 2002, No. 2. - P.34-37). In the next exercise, the patient learns to maintain balance when moving the common center of mass in the sagittal plane, which stimulates the work of the muscles that control the ankle joint, and is a more difficult task for the contingent under consideration. The following exercises are performed in even more difficult conditions, since there is no feedback through the visual analyzer, and proprioception below the level of damage in the contingent under consideration is practically absent. Standing on the turntable, teaching to maintain balance during twisting, forms the coordinated work of the muscles of the trunk, shoulder and pelvic girdle, linking the muscles above and below the lesion level in a single coordination without the use of distant analyzers. Standing with each foot on a separate rotary disk is aimed at teaching the patient separate control of the lower limbs and maintaining balance in a more complex biomechanical situation. Recent exercises on a swinging platform allow the patient to master not only the transfer of load from one leg to another, but also the coordinated bending of the unsupported leg and are preparatory to walking.

Patients receiving standing procedures perform the entire range of exercises. Less trained patients with unstable hemodynamics, gross contractures in the joints of the lower extremities, pronounced involuntary activity of the muscles of the flexors of the lower extremities, etc., receive the procedure by being fixed on the orthostol. They perform a simpler set of exercises. They exclude standing on triangular braids, since the muscles of the posterior tibia group are not ready for significant stretching. Exclude standing on the same floor scales. This exercise does not make sense, since patients do not rest on their hands, body weight is distributed between the feet and back. The back load is determined by the angle of inclination of the orthostol. Exclude standing on one and a pair of rotary disks. This task is coordinately difficult for such patients, and technically it is not feasible, since the body partially rests on the table.

The invention is illustrated by the following schemes: figure 1. Standing on triangular braids; figure 2. Standing on the scales with visual control of the load on the legs; figure 3. Standing on a pair of floor scales, transferring body weight from one leg to another with visual control; figure 4. Standing on the turntable; figure 5. Standing on a swinging platform with a longitudinal axis; Fig.6. Standing on a swinging platform with a transverse axis.

The proposed method is as follows.

A patient with paraplegia undergoes the procedure of stimulation of the orthostatic tonic vibration reflex. For this, vibration parameters are set on the biomechanical stimulator simulator, the patient is set with soles on the vibrotode of the biomechanical stimulator simulator, previously fixing the ankle joints at right angles with the help of “wrestlers”. The instructor holds the knee joints in a straightened position, while palpating the quadriceps muscles of the patient. Turn on the device. 5-20 seconds after the start of vibration, the instructor feels that the tone of the quadriceps muscles has increased, the knee joints have straightened reflexively. Visually, straightening in the hip joints, a decrease in the bends of the spine and the fragility of the pelvic angle are determined. At this time, the instructor stops fixing the patient's knee joints. After 60-90 seconds, the device is turned off. Tonic muscle contraction fades from 30 to 60 seconds. After the termination of tonic muscle contraction, the patient moves from the biomechanical stimulator simulator to the floor to a stable additional support. After 20-30 seconds, when the post-activation effect of the orthostatic reflex appears, the patient receives a standing training procedure, performing the following exercises in the prescribed manner.

1. Standing on triangular braids (figure 1), which creates additional stretching of the posterior muscle group of the lower leg, promotes passive extension of the knee joint and facilitates the preservation of the vertical posture.

2. Standing on the scales with minimal support on the hands and maximum on the legs (figure 2). This is a more difficult exercise, since the element of kinematic closure in the joints of the lower extremities created by the braids is absent here. In the exercise, there is a feedback: the patient sees with what force he relies on his legs.

3. Standing on a pair of floor scales: with each foot on separate scales (Fig. 3) with minimal support on the arms, transferring body weight from one leg to another in the frontal plane. The exercise uses feedback through the visual analyzer and allows you to learn how to transfer the projection of the common center of mass in the frontal plane.

4. Standing on a pair of floor scales: with the front sections of the feet on one and the rear on others with weight transfer from the heels to the central sections of the feet and back in the sagittal plane. The exercise uses feedback through the visual analyzer and allows you to learn how to transfer the projection of the common center of mass in the sagittal plane.

5. Standing on the rotary disk (figure 4) is a more complex exercise, performed without feedback. It allows you to train the balance when twisting. The muscles of the trunk, pelvic and shoulder girdles work.

6. Standing on a pair of rotary disks: separate under each leg. It forms the coordinated work of the muscles of the pelvic girdle in a complex biomechanical situation.

7. Standing on a swinging platform with a longitudinal (figure 5) and transverse (figure 6) axis arrangement allows the patient to master the transfer of load from one leg to another, standing next to or slightly in front and bending of the unsupported leg. Exercise is preparatory to walking.

Each exercise is performed for 3-5 minutes. The total duration of the lesson is 25-40 minutes.

If the patient cannot receive the procedure for stimulating the vibrotonic reflex while standing, he will undergo the procedure on the orthostol. Orthostol is installed at an angle of 60-80 ° to the horizontal. In this position, to stimulate the reflex, you can use a pair of portable vibratory massagers such as “Kharkov”, “Cheerfulness”. Vibrodes of vibratory massagers are installed on the region of the patient's own patellar ligaments. The vibration frequency is 50 Hz, the amplitude is selected sufficient to form an orthostatic tonic vibration reflex. The duration of the vibration is 60-90 seconds.

After stimulation of the reflex, the patient is left on the orthostol and in this position they carry out a training procedure for standing after the post-activation effect. Use the following exercises. Standing on a pair of floor scales: with each foot on separate scales, transferring body weight from one leg to another. The exercise uses feedback through the visual analyzer and allows you to learn how to transfer the projection of the common center of mass in the frontal plane.

Standing on a pair of floor scales: the front of the feet on one, and the back on the other with the transfer of weight from the heels to the central departments of the feet and back. The exercise uses feedback through the visual analyzer and allows you to learn how to transfer the load in the sagittal plane.

Standing on a swinging platform with a longitudinal and transverse axis allows the patient to master the transfer of load from one leg to another, standing next to or slightly in front and bending of the unsupported leg. Exercise is preparatory to walking.

The proposed method allows to obtain a new technical effect, namely, it makes it possible to perform therapeutic physical exercises for patients who cannot perform these exercises in other conditions.

The proposed method is effective for restoring the vertical posture of patients with syndromes of lower flaccid and spastic paraplegia, deep paraparesis. Its use promotes faster recovery of the vertical posture, helps to overcome the fear of holding the vertical posture without external fixation of the joints and remove the psychological barrier that inhibits the process of restoring standing function.

In patients with lower spastic paraplegia syndrome, the use of the method contributes to the formation of extensor motor activity and training the patient to manage it.

Example 1. Patient G. Born in 1952 Diagnosis: traumatic disease of the spinal cord, late period. Partial conduction disturbance syndrome from level L ₁ . Lower flaccid paraparesis to plegia in the feet.

At admission, the patient could not hold a vertical posture without external fixation of the knee joints, he moved with a wheelchair. Attempts to master holding a vertical posture without fixing the knee joints led to flexion of the lower extremities, since the most preserved of all the muscles of the lower extremities - the ileo-lumbar - were included in any exercise and led to flexion in the hip joints. The patient was confident in the impossibility of holding a vertical posture without external fixation of the knee joints. Stimulation of the tonic vibrational orthostatic reflex was carried out in a standing position on the biomechanical stimulator-simulator, holding hands on a stable motionless additional support. The vibration frequency is 20 Hz, the amplitude is 5 mm, the duration of the vibration is 90 seconds. A tonic vibration reflex appeared 20 seconds after the start of vibration and persisted for 20-30 seconds after its termination. After 20-30 seconds after the cessation of the reflex, tonic tension of the muscles of the trunk and extensors of the extremities reappeared, which was used to conduct the lesson.

1. Standing on triangular braids for 2-3 minutes. At the beginning of this exercise, the post-activation effect of the orthostatic tonic vibration reflex was formed, which manifested itself in the tonic tension of the muscles of the trunk and extensors of the lower extremities.

2. Standing on the floor scales with minimal support on the hands and maximum - on the feet for 2-3 minutes. Performing this exercise, the patient increased the load on the legs by 3-6 kg.

3. Standing with each foot on separate scales with minimal support on the hands. transfer of body weight from one leg to another for 3-4 minutes. At the beginning of the course, the pressure on the scales varied within 1-2 kg; by the end of the course, the change in pressure on the scales amounted to 10 kg.

4. Standing by the front sections of the feet on one scale, and the rear on others, with the transfer of weight from the heels to the central sections of the feet and back for 3-4 minutes. From the fifth session, the balance began to record the load under the front sections of the feet.

5. Standing on the rotary disk for 2-3 minutes. From the fourth session, the patient was able to gradually turn his head and body to the sides.

6. Standing on a pair of rotary disks for 4-5 minutes. From the sixth session, the patient was able to turn his head and body to the sides.

7. Standing on a swinging platform with a longitudinal and transverse axis for 3-4 minutes with the transfer of load from one leg to another and bending of the unsupported leg.

The course of treatment daily for 10 days. In addition to the purely therapeutic effect associated with the formation of the standing function, the treatment had a pronounced psychotherapeutic effect on the patient: against the background of increased muscle tone of the extensors of the lower extremities and trunk, the patient noted successes every day during the session, this strengthened his faith in his own strength. As a result of a ten-day course of treatment, the patient mastered the retention of a vertical posture without external fixation of the knee and hip joints and was able to begin to master walking with a stable fixed additional support.

Example 2. Patient M. Born 1962 Diagnosis: traumatic disease of the spinal cord, late period. Partial Conductivity Disorder Syndrome with Th ₁₁ Level Lower spastic paraparesis.

At admission, the patient had a slight restriction of extension in the knee, hip joints, restriction of the back flexion in the ankle joints of muscle origin, could not maintain an upright posture. The stimulation of the tonic vibrational orthostatic reflex was carried out in a standing position on the orthostol using a pair of portable “Vivacity” vibratory massagers, the vibration methods of which were installed in the region of the patient’s own patellar ligaments. Vibration frequency 50 Hz, amplitude 1 mm. The tonic vibration reflex appeared 10 seconds after the start of vibration and persisted for 30-40 seconds after its termination. After 20-30 seconds after the cessation of the reflex, tonic tension of the muscles of the trunk and extensors of the extremities reappeared. which was used to conduct classes on the orthostol. Orthostolum was set at an angle of 80 ° to the horizontal. The patient performed the following exercises.

1. Standing on a pair of floor scales: with each foot on separate scales, transferring body weight from one leg to another for 5 minutes

2. Standing on a pair of floor scales: the front sections of the feet on one, and the rear on the others, transferring weight from the heels to the central sections of the feet and back for 5 minutes.

3. Standing on a swinging platform with a longitudinal and transverse axis for 5 minutes.

The course of treatment included daily classes for 10 days. As a result of the course of treatment, the patient mastered the retention of a vertical posture without external fixation of the knee and hip joints and was able to start mastering walking with a stable fixed additional support. The method allows faster and more efficient to generate postural activity, extensor motor activity and contributes to the more rapid acquisition of skills to maintain a vertical posture for patients with syndromes of lower flaccid and spastic paraplegia, deep paraparesis.

The proposed method was used on the basis of the Federal State Institution Novokuznetsk Scientific and Practical Center for Medical and Social Expertise and Rehabilitation of Persons with Disabilities. This method treated more than 40 patients with syndromes of lower flaccid and spastic paraplegia, deep paraparesis. As a result of treatment, all patients mastered the retention of a vertical posture without external fixation of the knee joints.

Claims (1)

A method of teaching the disabled to stand with paraplegia, deep paraparesis, including standing training with support or external fixation of the lower limbs of the patient, conducting therapeutic exercises, characterized in that they additionally activate the orthostatic tonic vibration reflex by vibration stimulation of the lower limbs in patients standing upright with an additional support or fixed on the orthostol at an angle of 60-80 ° to the horizontal, after the extinction of the orthostatic tonic vibration reflex ksa after 20-30 s when the post-activation effect of the orthostatic reflex appears, conduct therapeutic exercises daily for 10 days, if necessary, repeat the course, for patients standing upright, physiotherapy exercises begin with exercises to stretch the back of the leg muscles, then perform exercises using feedback through the visual analyzer with minimal support on the hands and maximum on the legs with the transfer of the projection of the common center of mass in the frontal, then in the sagittal plane STI, exercises without feedback to maintain balance during twisting to form coordinated work of the muscles of the trunk, pelvic and shoulder girdles, exercises to transfer the load from one leg to another with flexion of the unsupported leg, patients fixed on the orthostol perform exercises using feedback through visual analyzer with transfer of the projection of the common center of mass in the frontal plane, then in the sagittal plane, exercises without feedback on the transfer of load from one leg to another from the bend lower leg.

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