RU2695721C1 - Method of restoration of hand function in patients with paralysis and paresis of upper limbs - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to restorative medicine, and can be used for restoration of hand function in patients with paralysis and paresis of upper extremities. Proposed method involves massage and self-massage of an affected extremity, performance of physical exercises, manipulations with a brush with objects of different weight and shape. Lesson involves three stages. Each lesson consists of three parts: introductory, main and final. Introductory part involves performing an affected limb by a massage assistant, which is performed equally at all stages. In the main part of all three stages, a complex of physical exercises is performed, at that, in the proximal radioulnar and radial-wrist joints, movements for the hand, then – flexion and extension in joints of fingers, then – opposition of thumb and little finger, their removal and bringing. At the third stage, exercises requiring coordinated activity of all muscle groups of the upper limb and shoulder girdle are added to form plucked, ball-like, cylindrical grips. Final part of the exercises is the same for all stages and includes manipulation of objects, massage and self-massage.

EFFECT: method enables forming in patients all types of active grip: planar, cylindrical, ball, interdigital, gable, master manipulation of objects, which widens their motor abilities, opens prospects of domestic and labor rehabilitation, expands patient's independence.

1 cl, 2 ex

Description

The invention relates to medicine, namely to reconstructive medicine, can be used to treat patients with severe neurological pathology of the upper limbs.

Restoring the function of the hands and fingers - an important indicator of the effectiveness of the treatment of patients with paralysis and paresis of the upper limb - involves restoring the ability to capture objects of various shapes and sizes and manipulating them.

The following types of seizure are distinguished: planar, interdigital, cylindrical, spherical, forceps [Occupational therapy in traumatology and orthopedics / A.F. Kaptelin, L.A. Lasskaya. M .: "Medicine", 1979. - S. 12]. For the normal functioning of the brush, all types of grip are necessary. Plane is used when capturing large objects, for example, a large ball with two hands. Cylindrical is required to capture medium-sized objects, such as a ski pole, glass. The ball is used to capture small rounded objects: a tennis ball. Nippers are used to capture small items: needles, pens, buttons.

There are a number of ways to restore the function of the hands and fingers. In particular, the method of restoring the motor function of the hand [Alexandrov N.M., Yakovlev N.M., Petrov S.V. Copyright certificate SU No. 1703132, IPC A61N 1/32, publ. Bull. N 1, 01/07/92]. The authors conduct a clinical and neurophysiological examination and identify closely lying muscles that can perform the function of the absent. Then electrodes are implanted in them and selective electrical stimulation is carried out, followed by active directed muscle contraction using biofeedback through an electromyograph.

The disadvantage is the need for healthy muscles on the hand, the function of which is restored. In patients with pathology of the central nervous system, as a rule, there are no healthy muscles with preserved innervation on the affected hand.

S.V. Prokopenko and E.Yu. Mozheiko suggest using a sensory glove to restore fine brush motility in patients after a stroke [RF Patent No. 2494670, Method for correcting fine motor skills using a sensory glove. IPC A61B 5/00, A61B 5/04, A61B 5/11, G09B 9/00, G09B 19/00, publ. 10/10/2013, Bull. No. 28]. The touch glove contains 5 flexible sensors that respond to flexion and extension of the fingers connected to a personal computer. In the process of implementing the method, the patient puts a glove on a paretic hand and uses finger movements to control a computer game.

The disadvantage of this method is the focus of rehabilitation treatment only on flexion and extension of the fingers, while the function of the hand is much more diverse, includes various grips and two-handed manipulation.

Closest to the proposed is a rehabilitation method for self-study at home of patients with flaccid peripheral paralysis of the limbs [Physical rehabilitation of patients with flaccid peripheral paralysis of the limbs using massage techniques and rational movement techniques / B.C. Shtolok, G.A. Yamaletdinova // Health, education and security, 2016. - No. 4 (8). - S. 57-62]. Physical rehabilitation is based on the joint activities of the instructor and the patient, including self-massage of the affected limb and the corresponding parts of the spine and physical exercises. At the first stages, passive, isometric and breathing exercises are used, then, as the patient's motor abilities expand, movements on a sliding surface and movements with flexion of the limb are added.

Complete the course of the exercise to include limbs in the general motor

stereotypes on the example of walking and two-handed manipulation on the example of modeling, throwing the ball with a gradual decrease in its size.

The disadvantages of the method

1. The method does not include stretching the soft tissues of the fingers and hands, which is important to reduce the resistance to movement from the soft tissues of the hand.

2. The method does not include work in a closed kinematic chain, which does not allow full use of the rehabilitation potential in the first stages of rehabilitation treatment

3. The method does not include active-passive exercises, when the assistant creates the conditions for the patient to implement the active movement of a paralyzed limb.

4. The method does not include focused training of movements as part of synergies, which facilitates the execution of active movements.

5. The method does not include focused training of isolated movements, which is very important for restoring the function of the hand, given the abundance of degrees of freedom of the terminal phalanges relative to the trunk.

6. The method does not provide for the formation of movements from larger joints to small ones, from phylogenetically old to young, which corresponds to the natural path of formation of movements.

The purpose of the invention is the restoration of hand function in patients with paralysis and paresis of the upper extremities by conducting therapeutic exercises.

The purpose of the invention is achieved by the method of restoring the function of the brush in patients with paralysis and paresis of the upper extremities, including massage and self-massage of the affected limb, performing physical exercises, manipulating the brush with objects of different weights and shapes.

Conduct a course of studies, which includes three stages, the criterion for the transition from stage to stage is the development of the exercises of the previous stage. Each lesson consists of three parts: introductory, main and final. The patient is in a sitting position, limb on the table, at the first stage, the patient performs some exercises with the help of an assistant, while the patient makes part of the movement, the assistant helps to complete the movement in full, creates a biokinematic chain configuration that facilitates the movement.

In the lesson of the first stage, the introductory part of the exercises includes:

massage of the affected limb by point pressing to the centers of the terminal, middle and main phalanges of each finger in the palmar-dorsal and lateral directions, repeat the procedure three times;

the assistant performs all of the following point presses once: pressure in the region of the lower and middle third of the forearm;

further - stretching of the soft tissues of the hand and fingers, for which the assistant grabs the hand in the area of the tenar and hypotenar, straightens the patient's fingers and keeping them straight; stretches a brush; performs back, then palmar bending of the patient’s hand with straight fingers;

passive bending of fingers and hands, followed by extension;

alternating flexion and extension of each finger.

In the lesson of the first stage, the main part of the exercises includes: active-passive exercises, first movements in the radial-elbow and radial-wrist joints (LZS), then flexion and extension in the joints of the fingers, then the opposition of the thumb and little finger:

carry out the abduction and bringing the brush from the position when the forearm and the hand lie on the table with the palm surface down, the kinematic chain is closed;

then they perform palm flexion of the hand, the forearm with the palm surface rests on the table, the brush with straight fingers in the back flexion position is held by the assistant, the kinematic chain is closed, the flexors are pre-stretched, gravity contributes to the flexion of the hand;

alternately raising fingers with subsequent lowering, while the patient makes part of the upward movement himself, the assistant helps to complete the upward movement in full, provides resistance when moving downward;

alternate abduction and adduction of all fingers simultaneously with flexion and extension in the metacarpophalangeal joints, the assistant helps to abduct by moving the thumb, and holds the LSS;

flexion of the fingers in the pronation position, while the forearm and hand lie on the table with the palm surface, the assistant fixes the area of the LSS, the kinematic chain is closed;

bending of the fingers in a neutral position, while the forearm and hand rest on the table with an ulnar surface, the assistant fixes the LSA region, the kinematic chain is closed;

flexion of the fingers in the supination position, the palm rests on the table, palm up, the movement is active and passive: the patient initiates the movement, the assistant helps to complete it;

form pinch grip, forearm and hand on the table palm down, thumb in opposition, under the palm, the kinematic chain is closed, pinch grip is realized due to the opposition of the thumb, supination of the hand and flexion of the fingers, for which the patient initiates the movement of finger flexion, the assistant helps to complete motion;

then the forceps capture is realized due to the opposition of the thumb and flexion of the remaining fingers, the patient initiates the movement of the flexion of the fingers, the assistant helps to complete the movement;

fingers are extended in a closed kinematic chain, the hand on the table, palm down, fingers are bent, the assistant holds the LPS and fingers that are not involved in the movement, the patient alternately extends the fingers;

then they perform the abduction of the thumb, the forearm and the hand on the table with the palm surface down, the thumb is brought down, located

under the palm, the patient takes his thumb away, the assistant holds the remaining fingers and LPS;

then they bring the thumb, the brush on the ulnar edge, the patient brings the thumb, the assistant returns it to the abduction position;

then they perform abduction and adduction of the little finger, the palm rests on the table, the assistant fixes the LSS, holds three fingers of the patient together except the thumb and little finger, the patient takes and brings the little finger;

then they bring and bring the thumb and little finger, the brush on the table in the palm of the hand, the assistant fixes the three middle fingers, the patient takes and brings the thumb and little finger.

In the lesson of the first stage, the final part of the exercises includes:

the inclusion of acquired opportunities in everyday activities by shifting from hand to hand objects of different weights and shapes, lacing, laying out mosaics;

then they perform relaxation of the working muscles, the hand rests on the table with the palm surface, the assistant strokes the first intercarpal gap with increasing force, in the absence of spasticity - pinching;

next, the patient performs self-massage, palm on a spiky rug, tapping fingers on the rug one by one, stroking the rug with his palm, tapping the rug with the ulnar edge of the palm;

when mastering the exercises of the first stage, they proceed to the second stage, which includes performing exercises in the classroom under light conditions in a closed kinematic chain.

In the lesson of the second stage, the introductory part of the exercises includes the repetition of the exercises in the first stage of the introductory part.

In the lesson of the second stage, the main part of the exercises includes performing the movement as part of synergies, first the movement in the radial-elbow joint and the LSS, then flexion and extension in the joints of the fingers, then the opposition of the thumb and little finger:

abduction and adduction of the hand is performed with an open kinematic chain, support on the elbow, LPS in the neutral position, the forearm is shifted in the direction of movement of the hand;

then perform palm flexion of the hand, the forearm and hand lie with the palm surface down, the patient presses the palm of the hand to the table and holds the position for 5 seconds, the forearm can be raised, the brush with straight fingers in the back flexion position is held by the assistant, the palm of the hand with straight fingers is flexed, kinematic the circuit is closed;

then alternately raising fingers with a brush, followed by lowering;

further, alternate abduction and adduction of all fingers simultaneously with slight flexion and extension in the metacarpophalangeal joints, the LSS on the roller, the terminal phalanges of the fingers rest on the table surface, the patient turns his fingers away with slight supination and returns to the place with pronation;

then flexion of the fingers, while the patient’s forearm lies on the table, the hand hangs down, the fingers are straight, the assistant fixes the area of the LSS, the kinematic chain is open;

further flexion of the fingers in a neutral position, while the forearm and hand rest on the table with an ulnar surface;

then bending the fingers in the supination position, the palm on the table with the palm up, the movement is active, the assistant fixes the wrist;

then a pinch grip, forearm and hand are formed on the table, palm down, thumb in opposition, under the palm, the kinematic chain is closed, pinch capture is achieved by alternately connecting the terminal phalanx of the thumb, with the terminal phalanges of the remaining fingers with a slight supination;

further, the forceps capture is realized due to the opposition of the thumb and flexion of the remaining fingers, the kinematic chain is closed, the patient alternately connects the terminal phalanx of the thumb and the terminal phalanges of the remaining fingers with a slight back flexion of the hand;

followed by extension of the fingers: the hand on the elbow, palm to the patient, extension of the fingers simultaneously with extension in the LSS and the radial joint (LS), is performed from the neutral position and the position of the palm flexion;

then carry out the abduction of the thumb, the brush on the ulnar edge, the patient takes the thumb away, the assistant fixes the LSS;

then they bring and bring the thumb, the palm on the table with the palm down, the thumb in the abduction position, the assistant fixes the LSS, holds four fingers except the thumb, the patient takes and brings the thumb;

then they perform abduction and adduction of the little finger, the palm rests on the table, the assistant holds the fingers of the patient together except the little finger, the patient takes away and brings the little finger;

then they bring and bring the thumb and little finger, the brush on the table in the palm of the hand, the patient takes and brings the thumb and little finger.

In the lesson of the second stage, the final part of the exercises includes repeating the exercises of the lessons of the first stage, the final part.

When mastering the exercises of the second stage, they move on to the third stage, in the lesson of the third stage, the introductory part of the exercises includes repeating the exercises of the first stage of the introduction.

In the lesson of the third stage, the bulk of the exercises involves the patient performing the movement independently in an open kinematic chain, at the end they perform exercises that coordinate the work of all muscle groups of the upper limb and shoulder girdle:

first, the patient performs abduction and adduction of the hand, the forearm rests on the elbow;

then the patient performs exercises in the forearm position and the palm of the hand with the palm surface on the table: palm flexion of the hand: the patient presses the palm of the hand on the table and holds the position for 5 seconds without lifting the forearm;

then the patient performs a successive lifting of the fingers, followed by lowering without brush movements;

then the patient performs the alternate abduction and adduction of all fingers without brush movements;

then the patient alternately bends his fingers in the neutral position of the hand, pronation, supination;

followed by the formation of pinch grip: the elbow rests on the table, the hand hangs, the patient connects the terminal phalanges of the thumb and other fingers in turn;

after that, the patient performs extension of the fingers without movement in the LSS and LS;

followed by flexion of the hand into a fist and extension with overcoming the resistance that the assistant provides;

then follows the abduction of the thumb from the position: the elbow rests on the table, the brush hangs;

next - bringing the thumb without external fixation of the joints of the hand from the same position;

then the patient performs the abduction and bringing the little finger from the same position;

after which it brings and leads the thumb and little finger from the same position;

next is the retention of the spherical grip in the position of support on the elbow, in the hand the ball, the patient bends and extends the arm in the LSS, performs pronation and supination, holding the ball;

then comes the retention of the cylindrical grip from the position: forearm

leans on a roller with a ulnar surface, a cylinder is clamped in the hand, the patient raises and lowers the brush, holding the cylinder, the assistant controls the absence of back and hand flexion in the LSS;

the exercises follow from the position: the arm is stretched forward, the ball in the hand, the patient pronates and supines the forearm, holding the ball, in the process of mastering the exercise, the assistant controls the drugs, gradually reducing external support;

then the patient performs palmar and dorsiflexion in the LSS, the assistant controls the immobility in the LS, the exercise is performed in two versions: in supination and pronation;

the patient holds a soft expander in his hand, bending his arm in the drug, and squeezes the expander, unbending, reduces the compression force of the expander.

In the lesson of the third stage, the final part of the exercises includes repeating the exercises of the lessons of the first stage, the final part. The novelty of the method:

• The method includes stretching the soft tissues of the fingers and hands, which is important to reduce the resistance to movement from the soft tissues of the hand.

• The method includes performing exercises in a closed kinematic chain and as part of synergies, which allows the patient to make maximum use of the mass-inertial characteristics of the limb and the available neuromotor and resources.

• The method involves two options for assistance in the framework of active-passive exercises: a) the patient initiates the movement, the assistant helps to complete it in full; b) the assistant gives the brush a configuration that maximally facilitates the execution of the required movement.

This is especially true when working with the hand and fingers, given that the flexor and extensor muscles of the fingers begin from the bones of the forearm, their tendons pass the wrist-joint, wrist, metacarpal, metacarpophalangeal and proximal interphalangeal joints (extensor and deep flexor) and attached to the terminal phalanges of the fingers. Therefore, in order to shorten these muscles with the necessary movement, the coordinated work of many other muscles as agonists, antagonists, fixatives and stabilizers is necessary. In the initial stages of the work of these muscles, an assistant helps in the process of performing active-passive exercises.

• The method is aimed at the formation of movements of the hand and fingers as part of phylogenetically determined synergies: flexor and extensor. These synergies are quite stable, so getting an active movement of the hand and fingers in their composition is much easier than creating an isolated movement right away.

• The method provides the simplest, biomechanical and evolutionarily justified order of mastering movements from large joints to small ones, from phylogenetically old movements to young ones.

The proposed method allows to obtain a new technical result: to form all types of active gripping in patients: flat, cylindrical, spherical, interdigital, forceps, to master manipulation of objects, which expands their motor capabilities, opens up prospects for domestic and labor rehabilitation. This is achieved through training to use the existing rehabilitation potential: mass-inertial properties of the limbs and phylogenetically determined synergies; the formation of voluntary movements through the targeted use of fragments of synergies; formation of active voluntary movements; increase in strength and strength endurance of the muscles of the upper limb, primarily, controlling the work of the hand and fingers.

The method involves the development by the patient of the performance of isolated movements, which is in demand in labor and household activities.

The method includes mastering by the patient the implementation of such activities as: writing, domestic, labor operations, as a result of which the patient expands adaptive activity.

The method is as follows.

Conduct a course of studies, which includes three stages, the criterion for the transition from stage to stage is the development of the exercises of the previous stage. Each lesson consists of three parts: introductory, main and final, the patient is in a sitting position, limb on the table, at the first stage, the patient performs some exercises with the help of an assistant, while the patient makes part of the movement, the assistant helps to complete the movement in full, creates biokinematic chain configuration facilitating movement.

The introductory part includes massage, passive and active-passive exercises, aimed at equalizing the tone of the flexors and extensors of the fingers, reducing the resistance of viscoelastic forces to movement, updating the fingers in the outline of the patient’s body.

In the lesson of the first stage, the introductory part of the exercises includes:

1. The assistant massages the affected limb by means of point pressing in the centers of the terminal, middle and main phalanges of each finger in the palmar-dorsal and lateral directions, repeats the reception three times.

2. The assistant performs once slowly: pressure in the lower and middle third of the forearm.

3. Next - stretching the soft tissues of the hand and fingers, for which the assistant grabs the hand in the area of the tenar and hypotenar, straightens the fingers of the patient and keeping them straight; stretches a brush; performs back, then palmar bending of the patient’s hand with straight fingers. Reception is performed once, slowly.

4. Passive bending of fingers and hands, followed by extension. Once, slowly.

5. Alternate flexion and extension of each finger. Once, slowly.

In the first stage lesson, the main part of the exercises includes performing active-passive exercises, first moving in the elbow-ray and wrist-joint (LPS), then flexion and extension in the joints of the fingers, then the opposition of the thumb and little finger. As the patient develops the complex of exercises, the number of repetitions of each exercise increases, starting from three, gradually increasing to eight.

6. Perform the abduction and adduction of the hand from the position when the forearm and hand lie on the table with the palm surface down, the kinematic chain is closed.

7. Then perform palm flexion of the hand, the forearm with the palm surface lying on the table, the brush with straight fingers in the position of the back flexion is held by the assistant, the kinematic chain is closed, the flexors are pre-stretched, the force of gravity contributes to the flexion of the hand.

8. Alternately raising the fingers with subsequent lowering, while the patient makes part of the upward movement himself, the assistant helps to complete the upward movement in full, provides resistance when moving downward.

9. Alternate abduction and adduction of all fingers simultaneously with flexion and extension in the metacarpophalangeal joints, the assistant helps to abduct by moving the thumb, and holds the LSS.

10. Flexion of the fingers in the pronation position, while the forearm and the hand lie on the table with the palm surface, the assistant fixes the area of the LSS, the kinematic chain is closed.

Flexion of the fingers in a neutral position, while the forearm and hand rest on the table with the ulnar surface, the assistant fixes the area of the LSS, the kinematic chain is closed.

The fingers are flexed in the supination position, the palm rests on the table, palm up, the movement is active and passive: the patient initiates the movement, the assistant helps to complete it.

11. Form the grip, forearm and hand on the table, palm down, thumb in opposition, under the palm, the kinematic chain is closed, the grip is realized due to the opposition of the thumb, supination of the hand and flexion of the fingers, for which the patient initiates the movement of the finger flexion, assistant helps complete the move.

Next, the forceps capture is realized due to the opposition of the thumb and flexion of the remaining fingers, the patient initiates the movement of the flexion of the fingers, the assistant helps to complete the movement.

12. The fingers are extended in a closed kinematic chain, the hand on the table, palm down, fingers bent, the assistant holds the LPS and fingers that are not involved in the movement, the patient alternately extends the fingers;

13. Next, lead the thumb, forearm and hand on the table with the palm surface down, the thumb is brought down, located under the palm of the hand, the patient takes the thumb away, the assistant holds the remaining fingers and the LSS.

14. Then the cast of the thumb is performed, the brush on the ulnar margin, the patient brings the thumb, the assistant returns it to the abduction position.

15. Next, lead and bring the little finger, the palm rests on the table, the assistant fixes the LSS, holds together three fingers of the patient except the thumb and little finger, the patient takes and brings the little finger.

16. Then bring and bring the thumb and little finger, the brush on the table in the palm of the hand, the assistant fixes the three middle fingers, the patient takes and brings the thumb and little finger.

In the lesson of the first stage, the final part of the exercises includes:

17. Inclusion of acquired opportunities in everyday activities by transferring objects of different weights and shapes from hand to hand, lacing, laying out mosaics.

18. Next, the working muscles are relaxed, the hand rests on the table with the palm surface, the assistant strokes the first intercarpal gap, first lightly, then with increasing force, in the absence of spasticity - tingling.

19. Next, the patient performs self-massage, palm on a thorny rug, tapping fingers on the rug one by one, stroking the rug with his palm, tapping the rug with the ulnar edge of the palm of the hand.

When mastering the exercises of the first stage, they proceed to the second stage, which includes performing exercises in the classroom under light conditions: in a closed kinematic chain.

In the lesson of the second stage, the introductory part of the exercises includes the repetition of exercises 1-5 of the lessons of the first stage of the introductory part.

In the lesson of the second stage, the bulk of the exercises involves performing movements in synergy, first movements in the elbow joint and LSS, then flexion and extension in the joints of the fingers, then the opposition of the thumb and little finger.

20. The abduction and adduction of the hand is performed with an open kinematic chain, support on the elbow, LPS in the neutral position, the forearm is shifted in the direction of movement of the hand.

21. Then perform palm flexion of the hand, the forearm and hand lie with the palm surface down, the patient presses the palm of the hand on the table and holds the position for 5 seconds, the forearm can be raised, the brush with straight fingers in the back flexion position is held by the assistant, the palm of the hand is bent with straight fingers , the kinematic chain is closed.

22. Then alternately raise the fingers with the brush, followed by lowering;

then alternate abduction and adduction of all fingers simultaneously with slight flexion and extension in the metacarpophalangeal joints, the LSS on the roller, the terminal phalanges of the fingers rest on the table surface, the patient turns his fingers away with slight supination and returns to the place with pronation.

23. Then the fingers are bent, while the patient’s forearm lies on the table, the hand hangs down, the fingers are straight, the assistant fixes the area of the LSS, the kinematic chain is open.

Further, the bending of the fingers in a neutral position, while the forearm and hand rest on the table with an ulnar surface.

Further, the bending of the fingers in the supination position, the palm on the table with the palm up, the movement is active, the assistant fixes the wrist.

24. Then the pinch grip, forearm and hand are formed, palm down, thumb in opposition, under the palm, the kinematic chain is closed, pinch grip is realized by alternately connecting the terminal phalanx of the thumb, with the terminal phalanges of the remaining fingers with a small supination.

Further, the forceps capture is realized due to the opposition of the thumb and flexion of the remaining fingers, the kinematic chain is closed, the patient alternately connects the terminal phalanx of the thumb and the terminal phalanges of the remaining fingers with a slight back flexion of the hand.

25. Following the extension of the fingers: the hand on the elbow, palm to the patient, extension of the fingers simultaneously with extension in the LSS and the radial joint (LS), perform from the neutral position and the position of the palm flexion.

26. Then carry out the abduction of the thumb, the brush on the ulnar margin, the patient removes the thumb, the assistant fixes the LPS.

27. Next, the thumb is brought down and abducted, the hand on the table is palm down, the thumb is in the abduction position, the assistant fixes the LSS, holds four fingers in addition to the thumb, the patient takes away and brings the thumb.

28. Then the abduction and adduction of the little finger is carried out, the palm rests on the table, the assistant holds the fingers of the patient together except the little finger, the patient takes away and brings the little finger.

29. Next, the adduction and abduction of the thumb and little finger are performed, the brush on the table in the palm of the hand, the patient takes and brings the thumb and little finger.

In the lessons of the second stage, the final part is repeated exercises 17-19 exercises of the classes of the first stage, the final part.

When mastering the exercises of the second stage, they proceed to the third stage. In the lesson of the third stage, the introductory part of the exercises includes the repetition of exercises 1-5 of the lessons of the first stage of the introductory part.

In the lesson of the third stage, the main part of the exercises includes: Performing the patient’s movement independently in an open kinematic chain, at the end perform exercises that coordinate the work of all muscle groups of the upper limb and shoulder girdle.

30. First, the patient performs abduction and adduction of the hand, the forearm rests on the elbow.

31. Then the patient performs exercises in the forearm position and the palm of the hand with the palm surface on the table: palmar flexion of the hand: the patient presses the palm of the hand to the table and holds the position for 5 seconds without lifting the forearm.

32. Next, the patient performs a successive lifting of the fingers, followed by lowering without moving the brush.

33. Next, the patient performs the alternate abduction and adduction of all fingers without brush movements.

34. Next, the patient alternately bends his fingers in the neutral position of the hand, pronation, supination.

35. The formation of pinch grip follows: the elbow rests on the table, the hand hangs, the patient connects the terminal phalanges of the thumb and other fingers in turn.

36. After that, the patient performs extension of the fingers without movement in the LSS and the LS.

37. Next is the flexion of the hand into a fist and extension with overcoming the small resistance that the assistant has.

38. The following is the abduction of the thumb from the position: the elbow rests on the table, the brush hangs.

39. Following is the adduction of the thumb without external fixation of the joints of the hand from the same position.

40. Then the patient performs the abduction and bringing the little finger from the same position: the elbow rests on the table, the brush hangs.

41. Then it performs the reduction and abduction of the thumb and little finger from the same position.

42. Holding the spherical grip in the position of resting on the elbow, in the hand the ball, the patient bends and extends the arm in the LSS, performs pronation and supination, holding the ball;

43. Holding the cylindrical grip from the position: the forearm rests on the roller with the ulnar surface, the cylinder is clamped in the brush, the patient raises and lowers the brush while holding the cylinder, the assistant controls the absence of back and palmar flexion in the LSS.

44. The exercises follow from the position: the arm is stretched forward, the ball in the hand. The patient performs pronation and supination of the forearm, holding the ball. In the process of mastering the exercise, the assistant controls the drugs, gradually reducing external support.

45. Then the patient performs palmar and dorsiflexion in the LSS, the assistant controls the immobility in the LS, the exercise is performed in two versions: in supination and pronation.

46. The patient holds a soft expander in his hand, bending his arm in the drug, and compresses the expander, unbending, reduces the compression force of the expander.

In the lesson of the third stage, the final part of the exercises includes the repetition of exercises 17-19 of the lessons of the first stage of the final part.

Example 1. Patient G-ko N.S., born in 1970, diagnosis: late period of traumatic disease of the spinal cord (trauma in 2014) as a result of a C ₆ vertebra fracture. Partial conduction disturbance syndrome in the spinal cord from level C of ₇ segments. Type B ASIA, upper flaccid spastic paraparesis, lower spastic paraplegia.

Upon admission, the patient had active movements in the shoulder and elbow joints with a strength of 2-3 points, extension in the wrist joints with a strength of 4 points. There were no other active movements in the joints of the hand and fingers.

The patient was engaged in therapeutic exercises according to the above method. In the lesson of the first stage, the introductory part of the exercises included massage, passive and active-passive exercises. The assistant performed point clicks in the centers of the terminal, middle and main phalanges of each finger in the palmar-dorsal and lateral directions 3 times, pressed in the lower and middle third of the forearm. Then the assistant grabbed the brush by the area of the tenar and hypotenar, straightening the patient's fingers and keeping them straight; stretched a brush; slowly performed the back, then palmar bending of the patient’s hand with straight fingers, passive bending of the fingers and hands, followed by extension and alternately bending and unbending each finger.

In the lessons of the first stage, the main part included active-passive exercises, in the second stage - movements as part of synergies, in the third stage - isolated movements and movements requiring coordinated work of all muscle groups of the upper limb and shoulder girdle. First, movements were performed in the elbow and wrist joints, then flexion and extension in the joints of the fingers, then the opposition of the thumb and little finger. At the third stage, the main part was completed by exercises requiring the coordinated activity of several muscle groups. As you master the complex, the number of repetitions of each exercise is increased, starting from 3, gradually increasing to 8.

In the lessons of the first stage, the final part included manipulations with objects of different weights and shapes: shifting from hand to hand, lacing, laying out mosaics. Massage of the first intercarpal gap, then - tingling. Self-massage of a brush on a massage mat completed the procedure.

In the lessons of the first stage in the final part of the exercises, the patient shifted plastic disposable glasses from hand to hand, worked with large lacing, laid out the mosaic, moving the elements along the plane. In the second stage, he shifted the plastic cubes, worked with medium-sized lacing, a mosaic with volumetric elements. In the lessons of the third stage, the patient worked with corrugated plastic balls, medium-sized lacing, mosaics with medium-sized elements.

In the classes of the first stage, they studied with the patient for 6 days, in the second stage - 8 days, 4 days the patient performed exercises in the classes of the third stage.

As a result of the course, the strength of active movements in the shoulder and elbow joints increased to a confident 3 points, there was an active flexion in the wrist joints, movements in the joints of the fingers with a force of 1-2 points. The patient managed to form a planar, cylindrical, spherical, interdigital grasp. The patient has mastered two-handed manipulation of large and medium objects of small weight (plastic cubes, disposable containers, glasses).

Example 2. S-in A.S., born in 1969, diagnosis: cerebrovascular disease, ischemic stroke in the vertebrobasilar pool in November 2017. Spastic right-sided hemiparesis. Hypertension III, AH 1, risk IV.

Upon admission, the patient had active movements in the shoulder, elbow and wrist joints of the right upper limb with a force of 2-3 points. In the joints of the thumb and forefinger there were active movements of 2 points. There were no active movements in the joints of the remaining fingers. Spastic syndrome limited the volume of active and passive movements. The patient did not use his right hand for self-care.

The patient was engaged in therapeutic exercises according to the above method. The prologue included massage, passive and active-passive exercises. In the lesson of the first stage, the introductory part of the exercises included performing assistant point pressure in the centers of the terminal, middle and main phalanges of each finger in the palmar-dorsal and lateral directions 3 times, pressed in the lower and middle third of the forearm. Then the assistant grabbed the brush by the area of the tenar and hypotenar, straightening the patient's fingers and keeping them straight; slightly stretched the brush; performed back, then palmar flexion of the patient’s hand with straight fingers, passive bending of fingers and hands, followed by extension and alternately bending and unbending each finger.

In the lessons of the first stage, the main part included active-passive exercises, in the second stage - movements as part of synergies, in the third stage - isolated movements and movements requiring coordinated work of all muscle groups of the upper limb and shoulder girdle. First, movements were performed in the elbow and wrist joints, then flexion and extension in the joints of the fingers, then the opposition of the thumb and little finger. In the lesson of the third stage of the main part, exercises were completed that required the coordinated activity of several muscle groups. As the complex was mastered, the number of repetitions of each exercise increased, starting from 3, gradually increasing to 8.

In the lessons of the first stage, the final part of the exercises included manipulations with objects of different weights and shapes: shifting from hand to hand, lacing, laying out mosaics. Massage of the first intercarpal gap. Self-massage of a brush on a massage mat completed the procedure.

As you master the execution of movements, the size of objects decreased, the weight increased, the surface became smoother. At first they used balls made of foam rubber, a very large lacing, a mosaic with large, convex elements. Then they switched to embossed plastic balls, medium-sized lacing, mosaics with medium-sized elements. Finished the course using walnuts, tennis balls, lacing household sizes, small children's mosaics.

The first stage was occupied with the patient for 4 days, the second stage for 8 days, 9 days the patient performed the third stage exercises.

As a result of the course, the patient began to confidently perform active movements in the shoulder, elbow and wrist joints with a strength of 3 points. Movements in the joints of the thumb and forefinger remained 2 points in strength, there were active movements in the joints of the remaining fingers with a strength of 1-2 points. It was possible to form planar, cylindrical, spherical, interdigital and pinch grips. The patient mastered two-handed manipulation of medium and small objects: plastic cubes, massage balls, walnuts, details of a children's plastic mosaic; He began to use the right hand for self-service: to hold objects in it, transfer it to the left hand, hold the fabric while fastening buttons, buttons.

This method is used in the Federal State Budgetary Institution "Novokuznetsk Scientific and Practical Center for Medical and Social Expertise and Rehabilitation of Persons with Disabilities" of the Ministry of Labor and Social Protection of the Russian Federation since 2017. 16 patients with consequences of acute cerebrovascular accident, hemiparesis and 12 patients with traumatic disease were treated spinal cord, spinal cord conduction disorder syndrome from the cervical level.

Claims (65)

A method of restoring the function of the brush in patients with paralysis and paresis of the upper extremities, including massage and self-massage of the affected limb, performing physical exercises, manipulating the brush with objects of different weights and shapes, characterized in that the course includes three stages, the criterion for the transition from stage to stage mastering the exercises of the previous stage serves, each lesson consists of three parts: introductory, main and final, the patient is in a sitting position, limb on the table, at the first stage some razhneniya patient performs with the help of an assistant, the part of the movement the patient makes, assistant guides you through the motion in its entirety, creates configuration biokinematic chain, facilitating the execution of the movement, In the lesson of the first stage, the introductory part of the exercises includes: massage of the affected limb by point pressing to the centers of the terminal, middle and main phalanges of each finger in the palmar-dorsal and lateral directions, repeat the procedure three times; the assistant performs all of the following point presses once: pressure in the region of the lower and middle third of the forearm; further - stretching of the soft tissues of the hand and fingers, for which the assistant grabs the hand in the area of the tenar and hypotenar, straightens the patient's fingers and keeping them straight; stretches a brush; performs the back, then - palmar bending of the patient’s hand with straight fingers; passive bending of fingers and hands, followed by extension; alternating flexion and extension of each finger; In the first stage lesson, the main part of the exercises includes: active-passive exercises, first movements in the elbow-ray and wrist-joint (LZS), then flexion and extension in the joints of the fingers, then the opposition of the thumb and little finger: carry out the abduction and bringing the brush from the position when the forearm and the hand lie on the table with the palm surface down, the kinematic chain is closed; then they perform palm flexion of the hand, the forearm with the palm surface rests on the table, the brush with straight fingers in the back flexion position is held by the assistant, the kinematic chain is closed, the flexors are pre-stretched, gravity contributes to the flexion of the hand; alternately raising fingers with subsequent lowering, while the patient makes part of the upward movement himself, the assistant helps to complete the upward movement in full, provides resistance when moving downward; alternate abduction and adduction of all fingers simultaneously with flexion and extension in the metacarpophalangeal joints, the assistant helps to abduct by moving the thumb, and holds the wrist joint (LSS); flexion of the fingers in the pronation position, while the forearm and hand lie on the table with the palm surface, the assistant fixes the area of the LSS, the kinematic chain is closed; bending of the fingers in a neutral position, while the forearm and hand rest on the table with the ulnar surface, the assistant fixes the area of the LSS, the kinematic chain is closed; flexion of the fingers in the supination position, the palm rests on the table, palm up, the movement is active and passive: the patient initiates the movement, the assistant helps to complete it; form pinch grip, forearm and hand on the table palm down, thumb in opposition, under the palm, the kinematic chain is closed, pinch grip is realized due to the opposition of the thumb, supination of the hand and flexion of the fingers, for which the patient initiates the movement of finger flexion, the assistant helps to complete motion; then the forceps capture is realized due to the opposition of the thumb and flexion of the remaining fingers, the patient initiates the movement of the flexion of the fingers, the assistant helps to complete the movement; fingers are extended in a closed kinematic chain, the hand on the table, palm down, fingers are bent, the assistant holds the LPS and fingers that are not involved in the movement, the patient alternately extends the fingers; then the thumb is retracted, the forearm and the hand on the table with the palm surface down, the thumb is brought down, is located under the palm of the hand, the patient takes the thumb away, the assistant holds the remaining fingers and the LSS; then they bring the thumb, the brush on the ulnar edge, the patient brings the thumb, the assistant returns it to the abduction position; then they perform abduction and adduction of the little finger, the palm rests on the table, the assistant fixes the LSS, holds three fingers of the patient together except the thumb and little finger, the patient takes and brings the little finger; then they bring and bring the thumb and little finger, the brush on the table in the palm of the hand, the assistant fixes the three middle fingers, the patient takes and brings the thumb and little finger; in the lesson of the first stage, the final part of the exercises includes: the inclusion of acquired opportunities in everyday activities by shifting from hand to hand objects of different weights and shapes, lacing, laying out mosaics; then they perform relaxation of the working muscles, the hand rests on the table with the palm surface, the assistant strokes the first intercarpal gap with increasing force, in the absence of spasticity - pinching; next, the patient performs self-massage, palm on a spiky rug, tapping fingers on the rug one by one, stroking the rug with his palm, tapping the rug with the ulnar edge of the palm; when mastering the exercises of the first stage, they proceed to the second stage, which includes performing exercises in the classroom under light conditions: in a closed kinematic chain, in the lesson of the second stage, the introductory part of the exercises includes repeating the exercises of the lessons of the first stage of the introductory part; In the lesson of the second stage, the main part of the exercises includes performing the movement as part of synergies, first moving in the radial-elbow joint and LSS, then flexion and extension in the joints of the fingers, then the opposition of the thumb and little finger: abduction and adduction of the hand is performed with an open kinematic chain, support on the elbow, LPS in the neutral position, the forearm is shifted in the direction of movement of the hand; then perform palm flexion of the hand, the forearm and hand lie with the palm surface down, the patient presses the palm of the hand to the table and holds the position for 5 seconds, the forearm can be raised, the brush with straight fingers in the back flexion position is held by the assistant, the palm of the hand with straight fingers is flexed, kinematic the circuit is closed; then alternately raising fingers with a brush, followed by lowering; then alternate abduction and adduction of all fingers simultaneously with flexion and extension in the metacarpophalangeal joints, the LSS on the roller, the terminal phalanges of the fingers rest on the table surface, the patient turns his fingers away with supination and returns to the place with pronation; then flexion of the fingers, while the patient’s forearm lies on the table, the hand hangs down, the fingers are straight, the assistant fixes the area of the LSS, the kinematic chain is open; further flexion of the fingers in a neutral position, while the forearm and hand rest on the table with an ulnar surface; then bending the fingers in the supination position, the palm on the table with the palm up, the movement is active, the assistant fixes the wrist; then the pinch grip, forearm and hand are formed on the table, palm down, thumb in opposition, under the palm, the kinematic chain is closed, pinch grip is realized by alternately connecting the terminal phalanx of the thumb with the terminal phalanges of the remaining fingers with supination; Further, the forceps capture is realized due to the opposition of the thumb and flexion of the remaining fingers, the kinematic chain is closed, the patient alternately connects the terminal phalanx of the thumb and the terminal phalanges of the remaining fingers with the back flexion of the hand; followed by extension of the fingers: the hand on the elbow, palm to the patient, extension of the fingers simultaneously with extension in the LSS and the elbow joint (LS), perform from the neutral position and the position of the palm flexion; then carry out the abduction of the thumb, the brush on the ulnar edge, the patient takes the thumb away, the assistant fixes the LSS; then they bring and bring the thumb, the palm on the table with the palm down, the thumb in the abduction position, the assistant fixes the LSS, holds four fingers except the thumb, the patient takes and brings the thumb; then they perform abduction and adduction of the little finger, the palm rests on the table, the assistant holds the fingers of the patient together except the little finger, the patient takes away and brings the little finger; then they bring and bring the thumb and little finger, the brush on the table in the palm of the hand, the patient takes and brings the thumb and little finger; in the lesson of the second stage, the final part of the exercises includes repeating the exercises of the lessons of the first stage of the final part; when mastering the exercises of the second stage go to the third stage, in the lesson of the third stage, the introductory part of the exercises includes repeating the exercises of the first stage of the introductory part; in the lesson of the third stage, the bulk of the exercises involves the patient performing the movement independently in an open kinematic chain, at the end they perform exercises that coordinate the work of all muscle groups of the upper limb and shoulder girdle: first, the patient performs abduction and adduction of the hand, the forearm rests on the elbow; then the patient performs exercises in position: the forearm and hand with the palm surface on the table, palm flexion of the hand, the patient presses the palm of the hand to the table and holds the position for 5 seconds, without raising the forearm; then the patient performs a successive lifting of the fingers, followed by lowering without brush movements; then the patient performs the alternate abduction and adduction of all fingers without brush movements; then the patient alternately bends his fingers in the neutral position of the hand, pronation, supination; followed by the formation of pinch grip: the elbow rests on the table, the hand hangs, the patient connects the terminal phalanges of the thumb and other fingers in turn; after that, the patient performs extension of the fingers without movement in the LSS and LS; followed by flexion of the hand into a fist and extension with overcoming the resistance that the assistant provides; then follows the abduction of the thumb from the position: the elbow rests on the table, the brush hangs; next - bringing the thumb without external fixation of the joints of the hand from the same position; then the patient performs the abduction and bringing the little finger from the same position; after which it brings and leads the thumb and little finger from the same position; next is the retention of the spherical grip in position: resting on the elbow, the ball in the hand, the patient bends and extends the arm in the LSS, performs pronation and supination, holding the ball; then comes the retention of the cylindrical grip from the position: the forearm rests on the roller with the ulnar surface, the cylinder is clamped in the hand, the patient raises and lowers the brush, holding the cylinder, the assistant controls the absence of back and hand flexion in the LSS; the exercises follow from the position: the arm is stretched forward, the ball in the hand, the patient pronates and supines the forearm, holding the ball, in the process of mastering the exercise, the assistant controls the drugs, gradually reducing external support; then the patient performs palmar and dorsiflexion in the LSS, the assistant controls the immobility in the LS, the exercise is performed in two versions: in supination and pronation; the patient holds a soft expander in his hand, bending his arm in the drug, and squeezes the expander, unbending, reduces the compression force of the expander; in the lesson of the third stage, the final part of the exercises includes repeating the exercises of the lessons of the first stage of the final part.