RU2800245C2 - Method of the rehabilitation of patients with chondropathy of the tibial tuberosity - Google Patents

Abstract

FIELD: medicine, orthopedics.

SUBSTANCE: invention can be used to treat patients with chondropathy of the tibial tuberosity. The method includes a set of restorative procedures consisting of autoplasma injections, combined kinesio taping and a set of exercises based on the dynamic neuromuscular stabilization (DNS) technique, instrumental soft tissue mobilization (IMMT) technique performed using the NordBlade 2.0 tool, and a procedure for activating reflex locomotion through Vojta therapy, while the IMMT technique is carried out by a combined method — first, a lymphatic drainage technique is performed, and then stabilization of the joint, courses of injections with autoplasma and kinesio taping are performed together 1 time per week for 3 weeks, IMMT is performed 7 days after the last injection of autoplasma together with the classic combined kinesio taping, the duration of an IMMT session is from 15 to 20 minutes once a week for 3–5 weeks, the procedure for activating reflex locomotion through Vojta therapy is performed on the 2nd day after the last injection of autoplasma, the duration of one session of procedures is 30–40 minutes, while each position takes 5–7 minutes, the number of repetitions is 2–3, the procedure is performed 1 time per week, for 4 weeks, the set of CNS exercises is performed after the completion of the course of injections of autoplasma by the patient independently, daily 1 time per day for 4 weeks.

EFFECT: method provides an increase in the efficiency of rehabilitation of patients with chondropathy of the tibial tuberosity.

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Description

The invention relates to medicine, namely to orthopedics, and can be used to treat patients with tibial tuberosity chondropathy - Osgood-Schlatter disease.

Osteochondropathy is a group of diseases characterized by a peculiar change in the apophyses of short and epiphyses of long bones, enchondral ossifying bones of the hand and foot, spine, less often other growing bone structures, accompanied in most cases by a successive change of necrosis, resorption or rejection of the affected areas of the bone and subsequent restoration of the bone structure. Involvement in the pathological process of the articular cartilage leads to dysfunction of the joint.

According to the literature, osteochondropathy of the tibial tuberosity - Osgood-Schlatter disease occurs in every eighth in the population and in every fourth athlete. First of all, it starts with pain in the area of the knee joints, which make the athlete refuse to train.

It is generally accepted that the disease is cured on its own and does not require special measures. But if the doctor does not intervene in the course of the disease, then this can lead to severe arthrosis, damage to the meniscus, long-term rehabilitation and disruption of the athlete's self-care.

In connection with the foregoing, the development and scientific substantiation of new methods for restoring functional disorders of the musculoskeletal system in patients with osteochondropathy of the tibial tuberosity is relevant.

From the prior art, a message is known about the use for the rehabilitation of patients after Osgood-Schlatter disease, an individual health complex, which provides for preventive and recovery programs aimed at combating osteochondropathy. Individual wellness complex includes:

- modern physiotherapy techniques;

- physical therapy exercises under the supervision of an instructor;

- pharmacopuncture;

- various types of therapeutic massage;

- professional taping for Osgood-Schlatter disease;

- recommendations for physical culture and sports during an exacerbation (see the publication: Clinical and biochemical monitoring in the preparation of a rehabilitation program for athletes with osteochondropathy of the tibial tuberosity (Osgood-Schlatter disease). https://mrtpetrograd.ru/stati/zabolevaniya/bolezn-osguda-shlattera).

According to the authors, with the help of pharmacopuncture, inflammation and pain in muscles and joints are eliminated, the work of internal organs is restored, and the body is rejuvenated.

The method of performing pharmacopuncture described in this publication is as follows: a reflexologist determines the necessary points on the patient's body, after which he injects 0.2-0.3 milliliters of the active substance into each of them to a shallow depth. It can be any one drug or a cocktail of several. Means for pharmacopuncture are selected in accordance with the patient's condition and diagnosis. These can be painkillers, vitamins, saline, hormones, drugs to improve blood circulation, a solution of sodium chloride or potassium chloride, the patient's own blood.

The number of pharmacopuncture sessions is selected according to the recommendations of the manufacturer of a particular drug. The course may include ten injections, which are carried out every other day, while in one procedure, about 2.3 milliliters of the drug is injected into the points of reflexology - about one ampoule.

According to this publication, physical therapy for Osgood-Schlatter disease is primarily aimed at pain relief without the use of drugs and an accelerated return to sports. A set of exercises is selected individually, taking into account the severity of pathological changes.

From the prior art, an attempt is known to give a scientific justification and the creation of a clinical and biochemical algorithm for the rehabilitation program for athletes with Osgood-Schlatter disease, including the use of physical rehabilitation methods, kinesio taping, local injections, and laser therapy. In the acute stage (pain, swelling, restriction of movement), plasma preparations may be administered, which relieves symptoms and helps in the fastest rehabilitation. All athletes are recommended to undergo a clinical examination by a specialist doctor (surgeon/traumatologist/rheumatologist) with an ultrasound examination of the affected joints at least once a year. It is better to do sports in the knee pads, first apply warming ointments to the joints. Kinesio taping is also recommended, both for therapeutic and prophylactic purposes (see Scientific and Sports Bulletin of the Urals and Siberia, 2019 | No. 1(21) pp. 51-57, https://uralgufk.ru/sites/default/files/page/files/2019-1_gotov.pdf).

However, the above source of information does not contain an analysis of the effectiveness of these methods when used in combination for the rehabilitation of patients with chondropathy of the tibial tuberosity. There is no gradation of the use of methods depending on the stage of the disease and the assessment of the initial status of the patient.

From the prior art revealed information selected as the closest analogue, indicating a study conducted to improve the rehabilitation program for a group of patients with Osgood-Schlatter disease. The rehabilitation program includes: a course of plasma therapy, classical kinesio taping in a combined way, a set of exercises using the Dynamic Neuromuscular Stabilization (DNS) method. In addition, athletes were prescribed a complex of magnesium, vitamin D3, omega-3 and amino acids, which was compiled individually depending on the indicators obtained as a result of a biochemical study (see the article "The content of primary, secondary and end products of lipid peroxidation in the blood serum of patients with Osgood-Schlatter disease". Collection of scientific papers of young scientists dedicated to the Day of Russian Science. Issue 19. Problems of training scientific and scientific-pedagogical personnel: experience and prospects", Chelyabinsk, 2022, pp. 133-138 https://uralgufk.ru/sites/default/files/news/files/sbornik_statey_itogovoy_konferencii_2022.pdf).

As follows from this publication, after rehabilitation, 3 weeks after its start, in patients with Osgood-Schlatter disease, the concentration of primary, secondary, end products of lipid peroxidation significantly decreased to the values of the control group. These changes in the processes of lipid peroxidation occurred against the background of an improvement in the clinical picture in the form of pain relief, an increase in the range of motion and motor activity in general. In addition, according to the ultrasound picture, there was a decrease in proliferation and fragmentation of the tibial tuberosity, a decrease in the vascularization of the own ligament of the kneecap. According to the author, the dynamics of indicators of the content of lipid peroxidation products can be used to assess the effectiveness of rehabilitation in Osgood-Schlatter disease.

However, the above source of information does not contain data on the number of injections during plasma therapy, it does not indicate which set of exercises was used according to the Dynamic Neuromuscular Stabilization (DNS) method, which does not allow a full assessment of the results of these studies.

In addition, given in a well-known source, a set of procedures is not enough to guarantee the effectiveness of the rehabilitation of patients with chondropathy of the tibial tuberosity. This is due to the fact that the use of only the above methods does not provide sufficient completeness of the effects on the patient's body to guarantee the effectiveness of rehabilitation. Thus, the absence of sessions of instrumental mobilization of soft tissues in the well-known complex does not provide proper myofascial relaxation, utilization of lactic acid from trained muscles and a corresponding correction of the balance of myofascial work.

And the absence in the well-known complex of the procedure for activating reflex locomotion through Vojta therapy does not provide correction of postural control of the body, straightening of the spine along a straight line and adequate work of the athlete's ligamentous-muscular apparatus.

Thus, the technical result, to which the claimed invention is directed, is the creation of a method that, with the complex use of such restorative procedures as the procedure for activating reflex locomotion through Vojta therapy and a set of exercises from dynamic neuromuscular stabilization, autoplasma injections (PRP), kinesio taping, instrumental soft manual techniques, guarantees highly effective rehabilitation of patients with chondropathy of the tibial tuberosity.

This technical result is achieved by the fact that in the method for the rehabilitation of patients with chondropathy of the tibial tuberosity, which is a complex of restorative procedures, including injections with autoplasma, kinesio taping by a combined method and a set of exercises according to the method of dynamic neuromuscular stabilization, according to the invention, the complex of restorative procedures additionally includes the technique of instrumental mobilization of soft tissues, carried out using the NordBlade 2.0 tool and the procedure for activating reflex locomotion through Vojta therapy, at the same time, the technique of instrumental mobilization of soft tissues is carried out by a combined method - first, a lymphatic drainage technique is performed, and then stabilization of the joint, courses of injections with autoplasma and kinesiotaping are performed together once a week for 3 weeks, instrumental mobilization of soft tissues is performed 7 days after the last injection of autoplasma, together with classical combined kinesiotaping, the duration of a session of instrumental mobilization of soft tissues is from 15 to 20 minutes once a week for 3-5 weeks, the procedure for activating reflex locomotion through Vojta therapy is performed on the 2nd day after the last injection of autoplasma, the duration of one session of procedures is 30-40 minutes, while each position takes 5-7 minutes, the number of repetitions is 2-3, the procedure is performed 1 time per week, for 4 weeks, a set of exercises for dynamic neuromuscular stabilization is performed after the completion of the course of autoplasma injections by the patient independently, once a day for 4 weeks, while the procedure for activating reflex locomotion through Vojta therapy includes a set of exercises performed as follows:

- Starting position - lying on the back, the head is turned to the side, the body is tilted in the same direction, where the face is turned, the front leg is bent, the contralateral leg is bent, the tilt of the body and the pelvic belt towards the spontaneous turn of the head, while the shoulder on the occipital side is assigned to 30 degrees, the counterattack hand is led to the torso, the forecasters are bent into the stream up to 30 degrees;

- on the front side of the body, a triggering irritation is produced by pressing in the direction of the spinal column on the surface of the chest along the nipple line in the area of the place of attachment of the diaphragm, as a result of which the head turns in the opposite direction with simultaneous stretching of the cervical spine, the upper body is extended, in the shoulder girdle, the shoulder blades are brought to the body;

- bend the lower body and legs;

- legs are held against gravity on weight above the support surface, for which, the center of gravity is shifted in the cranial direction, while the bent legs are in the position of abduction up to 30 degrees and external rotation, the feet are held along the midline in dorsal extension;

- the legs are bent, pulled up to the abduction position up to 30 degrees, the feet are placed in dorsal flexion along the midline, the toes are in the median position, the front leg is left bent, the foot is left in dorsal flexion, the toes are in the median position,

- when the pelvic girdle is in an oblique position, the legs and pelvis are unbent from the occipital side, while maintaining the external rotation of the leg,

and a set of exercises for dynamic neuromuscular stabilization includes exercises for the formation of the muscles of the body, exercises based on the leg for 8 months and squats for 12 months, while exercises for the formation of the muscles of the body are performed as follows:

- starting position - lying on the couch, the ribs are pressed to the couch, the back is straightened, the head is retracted to achieve a neutral position of the body;

- legs are bent 90 degrees at the hip joint, 90 degrees at the knee joint, 90 degrees at the ankle joint;

- perform external rotation in the hip joint;

- this position is held for 20 seconds, while maintaining straightening in the back and a neutral position in the hip and knee joint,

exercises based on the leg for 8 months are performed as follows:

- starting position - standing on 2 knees with support on the elbows with control of the position of the pelvis, in which the pelvic diaphragm is parallel to the diaphragm;

- the knee is bent 90 degrees, so that it is at the same level and parallel to the other leg;

- stand up by 10-15 cm, with control of the supporting leg;

- this position is held for 20 seconds, while maintaining straightening in the back and a neutral position in the hip and knee joints;

- a healthy leg is laid on a couch, so that there is a slight external rotation in the hip joint, flexion is performed up to 30 degrees in the knee joint;

- rotate the body around the supporting leg;

- perform 5 repetitions,

squat exercises for 12 months, perform as follows:

- starting position - feet shoulder width apart with control of the position of the pelvis;

- perform a squat up to an angle of 90 degrees in the knee joints, so that the knee is at the level of the thumb;

- this position is held for 20 seconds;

- perform a squat so that the knee does not go beyond the toe, continue squatting at the hip joint, up to 90 degrees at the knee;

- This position is held for 20 seconds.

The additional inclusion in the rehabilitation complex of the technique of instrumental mobilization of soft tissues, carried out using the NordBlade 2.0 instrument and the implementation of the technique of mobilization of soft tissues by a combined method - first performing lymphatic drainage technique, and then stabilizing the joint, allows, in combination with other methods, to guarantee high effective rehabilitation of a patient with chondropathy of the tibial tuberosity (Osgood-Schlatter disease).

This is ensured due to the fact that the use of this technique allows you to influence soft tissues, accelerate physiological processes, stimulate the independent ability of tissues to regenerate, helps to relax the tendons of the 4th head of the thigh muscle and the knee’s own ligament, improves microcirculation of the vascular bed, thereby reducing the manifestations of myofascial pain syndrome. The NordBlade 2.0 instruments used in the course of therapy allow mechanical action on the skin, receptors, connective tissue and deep structures of soft tissues. Smoothing, stretching, improve tissue elasticity, restore its natural, anatomical structure. The use of NordBlade 2.0 tools allows specialists to diagnose and eliminate pain syndromes, the consequences of injuries and soft tissue dysfunction. The use of this technique allows you to influence the skin and muscle receptors, thereby increasing the flexibility and range of motion in the joints. This eliminates excess muscle tension and relieves pain caused by chondropathy of the tibial tuberosity. With instrumental mobilization of soft tissues, controlled microdamages of the affected structures are produced, in response to which a local inflammatory reaction develops in the affected areas. Inflammation triggers a cascade of regenerative processes, during which areas of fibrous or scar tissue formed as a result of the disease undergo resorption and are replaced by normal connective tissue. Under the influence of this technique at the cellular level, there is an activation and an increase in the number of fibroblasts that synthesize connective tissue. At the same time, blood microcirculation improves, adhesions in the fascia resolve. Thanks to this technique, the range of motion in the joint is expanded, muscle strength is increased, swelling is removed, pain sensitivity is reduced, and the restoration of functions lost as a result of the disease is accelerated.

The implementation of the soft tissue mobilization technique using the combined method - first, the lymphatic drainage technique, and then the stabilization of the joint, makes it possible to further guarantee the high efficiency of the rehabilitation of the claimed complex.

This is ensured by the fact that the use of lymphatic drainage technique first improves microcirculation and lymph flow in the area of plasma injection, due to which the patient does not need to use non-steroidal anti-inflammatory drugs for analgesic purposes, which level the effect of plasma. The subsequent use of joint stabilization provides a decrease in the load on the joint, immobilizes it without disturbing the functioning of the fascia and blood vessels, which makes the rehabilitation process more physiological

Used in the claimed method, the complex of the claimed exercises from dynamic neuromuscular stabilization (DNS) makes it possible to further guarantee an increase in the effectiveness of the claimed method. This is ensured by the fact that the CNS complex is based on the patient's kinesiology and spontaneous motor skills and takes into account the patient's motor capabilities and skills.

The application for the rehabilitation of patients with chondropathy of the tibial tuberosity of the declared procedures for activating reflex locomotion through Vojta therapy makes it possible to further guarantee the high efficiency of the rehabilitation of patients with chondropathy of the tibial tuberosity.

This is ensured by the fact that the use of this therapy allows you to have the following effects on:

- direct stretching of the intercostal muscles with a maximum between the 7th and 8th ribs. Proprioceptive stimulation passes through the posterior roots of the middle part of the thoracic spine;

- mediated stretching of the costotransverse muscles (mm. costotransversarii) with a maximum at the level of 6-8 ribs. The afferent proprioceptive impulse passes through the posterior roots of the vertebrae Th 6 - Th 8;

- mediated stretching of the diaphragm, possibly to a greater extent from the occipital side. Irritation passes through the phrenic nerve (n. phrenicus) to the posterior roots of the vertebrae C 1 - C 4;

- mediated compression of the lung and displacement of the mediastinum with irritation of the interoreceptors of the lungs and pleura. Irritation passes through the vagus nerve (n. vagus) to the nucleus of the vagus nerve in the medulla oblongata (medulla oblongata);

- mediated stretching of the square muscle of the lower back (m. quadratus lumborum) on the front side and the external oblique muscle of the abdomen (m. obliquus externus abdominis) on the occipital side. The impulse passes through the posterior roots at the level of the vertebrae Th 12 - L 4 or Th 5 - 12, respectively.

Together with the gluteus medius (m. glutaeus med.) and the muscle that strains the broad fascia of the thigh (m. tensor fasciae lat.), the quadriceps femoris muscle (m. quadriceps fem.), As well as the adductors of the thigh, contract. This contraction should be considered as a function of stabilizing the hip joint while extending the leg.

The use of Vojta therapy allows to achieve alignment of the position of the pelvis, straightening of the spine along the longitudinal axis, "switching on the sleeping muscles" due to the activation of motor reflexes during therapy.

The quantitative and temporal parameters of the procedures performed were determined experimentally by the applicant and also applied to 157 patients.

The claimed method is carried out as follows.

The method of rehabilitation of patients with chondropathy of the tibial tuberosity is carried out on an outpatient basis. The inclusion of a patient for rehabilitation is carried out according to the results of his preliminary examination, which includes: examination by a clinician, pain assessment according to the VAS scale, goniometry, clinical and biochemical blood tests, ultrasound and X-ray examination of the knee joints. The criteria for inclusion of a patient in rehabilitation are the presence of a diagnosis of Osgood-Schlatter disease, age 10-18 years. The laboratory determines the level of vitamin D3, the level of ionized calcium, a general clinical blood test, liver function tests, proteins, markers of autoimmune and autoinflammatory diseases.

Rehabilitation is carried out using a complex of restorative procedures, including:

- plasma therapy of the knee joint paraarticularly with autoplasma enriched with platelets No. 3 with an interval of 7 days, once a week for 3 weeks;

- classical kinesio taping of the knee joint by a combined method together with plasma therapy with an interval of 7 days once a week for 3 weeks;

- 7 days after the last injection of autoplasma - instrumental mobilization of soft tissues using NordBlade 2.0 instruments in conjunction with the classical kinesiotaping combined method to stabilize the knee joint, while the duration of the session of instrumental mobilization of soft tissues is from 15 to 20 minutes once a week for 3-5 weeks;

- medication correction: calcium preparations, vitamin D3;

- Vojta therapy on the 2nd day after the last injection of autoplasma, the duration of one session of the procedure is 30-40 minutes once a week for 4 weeks, while each position takes 5-7 minutes, the number of repetitions is 2-3;

- after completing the course of autoplasma, dynamic neuromuscular stabilization is performed by the patient on his own every day, 1 time per day for 4 weeks.

The process of obtaining autoplasma involves the extraction of blood from the patient, which is then centrifuged to obtain a concentrated suspension of platelets by plasmapheresis. The suspension is then subjected to a two-stage centrifugation process to separate the solid and liquid components of the anticoagulated blood. PRP is plasma from the patient's own blood with a viable platelet concentration of 1,000,000/µl. The technology for obtaining PRP is the formation and collection of BUFFY COAT, followed by its dilution with blood plasma to the desired concentration of platelets. The technology provides for layer-by-layer selection of plasma with a controlled concentration of viable platelets in each milliliter. Test tubes are not used. Blood sampling takes place in a sterile 10 or 20 ml syringe, where an anticoagulant based on sodium citrate with glucose is first added. The blood is mixed with an anticoagulant and dispensed into one or two syringe tubes. The latter are placed in a centrifuge. A specially designed centrifuge with a gentle (soft) centrifugation mode (620g, 12 minutes) is used. Then, with a 5 ml or 3 ml syringe, a layer-by-layer plasma sampling is carried out from syringe test tubes and “Buffy Coat” with the surface part of the erythrocyte layer, which contains the young, most active platelets and monocytes. When centrifuging 10 ml of blood, we get the first layer - normoplasm - this is about 3 milliliters of the upper plasma. The remaining 2 ml with "Buffy Coat" contains about 1,000,000 platelets in 1 µl - this is PRP.

Plasma therapy is carried out by a course of 3 injections of autoplasma enriched with platelets periarticularly into the area of interest and at the points of maximum pain. Immediately after the injection, classical kinesio tapes are applied using a combined method.

The method of applying classic kinesio tapes using a combined method: after treating the skin of the knee joint area with an alcohol solution, kinesio tapes are applied, cut in the form of "lanterns" in the amount of 3-4, depending on the injection area, the base is applied towards the nearest lymph nodes, the anchor is attached to the opposite side. I-shaped tapes are applied on top in the amount of three pieces with muscle technique to stabilize the kneecap and the knee joint as a whole. The application is removed after 4-5 days. The interval between procedures is 7 days, the course is 21 days. At the time of injection, physical activity is limited, training is canceled and NSAIDs are prohibited, which neutralize the effect of plasma.

Then, 4 weeks after the first injection of autoplasma, instrumental soft tissue mobilization is performed using the NordBlade 2.0 method. The method of instrumental mobilization of soft tissues - an ultrasonic gel is applied to the skin, then scanning, warming up, and stabilization of the muscles of both thighs using NordBlade-2.0.

If the athlete continues training, then it is necessary to exclude dynamic loads on the knee joints, namely the following speed-strength exercises: jumping over barriers, jumping off a hill, squatting and jumping on one leg, falling on your knees.

Vojta therapy classes include a set of exercises performed as follows:

- starting position - lying on the back, the head is turned to the side, the body is slightly bent and tilted in the same direction as the face is turned; the front leg is extended, the contralateral leg is bent, the torso and pelvic girdle are tilted towards the spontaneous turn of the head, while the shoulder is slightly abducted from the occipital side, the contralateral arm is adducted, the forearms are slightly bent at the elbow joints, or the elbow joint is slightly extended on the front side;

- on the front side of the body, a triggering irritation is produced by pressing in the direction of the spinal column on the surface of the chest along the nipple (mamillary) line in the area of the place of attachment of the diaphragm, as a result of which the head turns in the opposite direction with simultaneous stretching of the cervical spine, the upper body is extended, in the shoulder girdle adduction of the shoulder blades occurs;

- bend the lower body and legs;

- the legs are held against gravity on weight above the support surface, for which, the center of gravity is shifted in the cranial direction, while the bent legs are in a position of easy abduction and external rotation, the feet are held along the midline in dorsiflexion;

- the legs are bent, pulled up to the position of easy abduction, the feet are placed in dorsal flexion along the midline, the toes are in the median position, the front leg is left bent, the foot is left in dorsal flexion, the toes are in the median position,

- when the pelvic girdle is in an oblique position, the legs and the pelvis are unbent from the occipital side, while maintaining the external rotation of the leg.

A set of exercises for dynamic neuromuscular stabilization (DNS) includes exercises for the formation of the muscles of the body, exercises based on the leg for 8 months and squats for 12 months, while exercises for the formation of the muscles of the body are performed as follows:

- starting position - lying on the couch, the ribs are pressed to the couch, the back is straightened, the head is retracted to achieve a neutral position of the body;

- legs are bent 90 degrees at the hip joint, 90 degrees at the knee joint, 90 degrees at the ankle joint;

- perform external rotation in the hip joint;

- this position is held for 20 seconds, while maintaining straightening in the back and a neutral position in the hip and knee joint,

exercises based on the leg for 8 months are performed as follows:

- starting position - standing on 2 knees with support on the elbows with control of the position of the pelvis, in which the pelvic diaphragm is parallel to the diaphragm;

- the knee is bent 90 degrees, so that it is at the same level and parallel to the other leg;

- stand up by 10-15 cm, with control of the supporting leg;

- this position is held for 20 seconds, while maintaining straightening in the back and a neutral position in the hip and knee joints;

- a healthy leg is laid on a couch, so that there is a slight external rotation in the hip joint, slight flexion in the knee joint is performed;

- rotate the body around the supporting leg;

- perform 5 repetitions;

squat exercises for 12 months, perform as follows:

- starting position - feet shoulder width apart with control of the position of the pelvis;

- perform a slight squat, so that the knee is at the level of the thumb;

- this position is held for 20 seconds;

- perform a squat so that the knee does not go beyond the toe, continue squatting at the hip joint, up to 90 degrees at the knee;

- this position is held for 20 seconds;

The complex is performed independently daily 1 time per day for 1 month.

Performing exercises from dynamic neuromuscular stabilization provides stabilization of the muscles of the body and the knee joint, due to the formation of the muscles of the body, as happens in a child in the first year of life.

The formation of the muscles of the body - as in a child in the first year of life, occurs as follows.

The patient should press the ribs to the couch, straighten the back, retract the head (there is a neutral position of the whole body), then flex the legs 90 degrees at the hip joint, 90 degrees at the knee joint, 90 degrees at the ankle joint and, very importantly, a small external rotation at the hip joint. This is the neutral position on the back for the knee joint of 90 degrees of flexion (the final position of the legs in the first phase of the turn in reflex crawl). The patient should hold this position for 20 seconds, keeping the back straight and the hip and knee in a neutral position. If the patient cannot bring the neutral position or hold the leg, help him by periodically releasing the limb so that the patient himself tries to maintain this position.

Add leg exercises.

Leg support exercises are exercises for 8 months standing up with support.

The patient should get on 2 knees and give support on the elbows. Next, the position of the pelvis is controlled (the diaphragm of the pelvis should be parallel with the diaphragm), then it is necessary to bend the knee (90 degrees), so that the bent knee is at the same level and parallel to the other leg.

Then you need to get up 10-15 cm, at this time the supporting leg is controlled so that there is no bending (more than 90 degrees) and the foot does not fall into a valgus or varus).

The patient should hold this position for 20 seconds, keeping the back straight and the hip and knee in a neutral position.

Then, the patient puts the healthy leg on the couch so that there is a slight external rotation in the hip joint, slight flexion in the knee joint. Then the patient rotates the body around the supporting leg.

It is necessary to monitor the foot so that it does not fall into a valgus position, and behind the knee, thigh, so that it does not go into internal rotation.

5 repetitions are performed.

IV. Squat exercise for 12 months.

The patient sets the legs shoulder-width apart, controls the position of the pelvis (the diaphragm of the pelvis should be parallel to the diaphragm).

A squat is performed so that the knee is at the level of the thumb (no more, does not go forward).

The position is held for 20 seconds. During the exercise, it is necessary to monitor the foot so that it does not fall into a valgus position, and behind the knee, thigh, so that they do not go into internal rotation.

Continue squatting so that the knee does not go past the toe, up to 90 degrees at the knee. The position is held for 20 seconds. It is necessary to monitor the foot so that it does not fall into a valgus position, and behind the knee, thigh, so that it does not go into internal rotation.

The athlete performs this complex at home on his own every day for 1 month.

In addition, once a week for 4 weeks, the patient visits the Vojta-therapist. Vojta therapy classes include the first phase of the reflex reversal. The initial position of the patient - lying on his back, spontaneously occupies an asymmetric position. The head is turned to the side, the body is slightly bent and tilted in the same direction as the face. The front leg is extended, the contralateral leg is bent, the torso and pelvic girdle are tilted in the direction of spontaneous head rotation. The shoulder is slightly abducted from the occipital side, the contralateral arm is adducted. The forearms are either slightly bent at the elbow joints. Triggering irritation is performed on the front side by pressing on the surface of the chest along the mammillary line in the area of the attachment of the diaphragm. This pressing is made in depth in the direction of the spinal column and has the following effect:

1. Direct stretching of the intercostal muscles with a maximum between the 7th and 8th ribs. Proprioceptive stimulation passes through the posterior roots of the middle part of the thoracic spine.

2. Indirect stretching of the costotransverse muscles (mm. costotransversarii) with a maximum at the level of 6-8 ribs. The afferent proprioceptive impulse passes through the posterior roots of the vertebrae Th 6 - Th 8.

3. Indirect stretching of the diaphragm, possibly to a greater extent from the occipital side. The irritation passes through the phrenic nerve (n. phrenicus) to the posterior roots of the vertebrae C 1 - C 4.

4. Mediated compression of the lung and displacement of the mediastinum with irritation of the interoreceptors of the lungs and pleura. Irritation passes through the vagus nerve (n. vagus) to the nucleus of the vagus nerve in the medulla oblongata (medulla oblongata).

5. Indirect stretching of the square muscle of the lower back (m. quadratus lumborum) on the front side and the external oblique muscle of the abdomen (m. obliquus externus abdominis) on the occipital side. The impulse passes through the posterior roots at the level of the vertebrae Th 12 - L 4 or Th 5 - 12, respectively.

When pressing on the chest area, the head turns to the other side with simultaneous stretching of the cervical spine. The upper body is stretched. In the shoulder girdle, the shoulder blades are adducted.

The lower body and legs are bent. The legs are held against gravity in weight above the support surface. To do this, the center of gravity shifts in the cranial direction. The bent legs are in a position of easy abduction and external rotation, the feet are held in the midline in dorsiflexion.

As the lower body bends, the legs also bend. They are pulled up in the position of easy abduction, the feet are in dorsal flexion along the midline. Toes in the middle position. The front leg remains bent. She participates in the rotation of the pelvis, while remaining in a position of easy abduction. In addition to the proportional contraction of the muscle groups of the abductors and adductors, the external rotators of the thigh are also actively involved in holding this posture. During rotation, flexion at the hip joint and contraction of the adductor muscles increase slightly. The foot remains in dorsal flexion, the toes are in the median position.

On the occipital leg, when the pelvic girdle is in an oblique position, the flexion of the leg weakens, and this leads to extension of the leg and pelvis from the occipital side. External rotation of the leg is maintained. Together with the gluteus medius (m. glutaeus med.) and the muscle that strains the broad fascia of the thigh (m. tensor fasciae lat.), the quadriceps femoris muscle (m. quadriceps fem.), As well as the adductors of the thigh, contract. This contraction should be considered as a function of stabilizing the hip joint while extending the leg.

The procedure for activating reflex locomotion through Vojta therapy is performed on the 2nd day after the last injection of autoplasma.

The duration of the procedure for activating reflex locomotion through Vojta therapy is 30-40 minutes once a week for 4 weeks, while each position takes 5-7 minutes, the number of repetitions is 2-3.

The dynamics and evaluation of the results of rehabilitation is carried out under the control of ultrasound scanning. Ultrasound assessment is performed before and after the course of rehabilitation - for the first time at the time of the patient's initial visit, then after the course of plasma therapy, one month after the course of plasma therapy during rehabilitation, after 3 and 6 months from the start of dynamic neuromuscular stabilization. Monitoring the dynamics and evaluating the ongoing fascial manipulations using ultrasound scanning makes it possible to monitor the dynamics of rehabilitation in real time, justify the need and duration of the application of the proposed procedures, which significantly contributes to the effectiveness of rehabilitation.

Example 1 Osgood-Schlatter disease is an acute stage, severe pain syndrome. Patient K., 14 years old, came with acute pain in the area of the right knee joint. The pain is aggravated by movement and sports. The patient has been doing gymnastics since the age of 6. Pain disturbed periodically for 3 years, appeared suddenly during training and also suddenly disappeared on its own. The patient was examined by a rheumatologist, laboratory and instrumental studies were carried out, as a result of which a diagnosis was made - Chondropathy of the tibial tuberosity on the right, acute period (Osgood-Schlatter disease, acute stage).

On examination, the patient limps on the right leg, functional flexion contracture in the right knee joint, swelling and pain on palpation in the area of the tibial tuberosity on the right, the joint is not externally changed, there are no signs of arthritis. YOUR 9 points. According to goniometry, flexion in the right knee joint was 90º, in the left 100º.

Instrumental and laboratory data:

– Ultrasound of the knee joints: thickening of the own ligament of the kneecap, fragmentation of the tuberosity of the tibial tuberosity on the right, pronounced proliferation and vascularization in the area of the tuberosity of the tibia. Conclusion - Tendopathy of the right ligament of the kneecap on the right, the growth zones are open. Osgood-Schlatter disease, the stage of fragmentation of the tibial tuberosity.

X-ray of the knee joints: signs of chondropathy of the tibial tuberosity on the right, acute stage.

Laboratory: vitamin D3 deficiency (12 ng / ml at a rate of 50 ng / ml), a decrease in the level of ionized calcium (1.01 mmol / l at a rate of 1.15 mmol / l). Other indicators of the general clinical blood test, liver function tests, proteins of the detuned phase are within the age norm. Markers of autoimmune and autoinflammatory diseases were not found.

Conclusion: Osgood-Schlatter disease on the right, acute period, stage of fragmentation of the tibial tuberosity. Tendopathy of the own ligament of the kneecap. Myofascial pain syndrome of the adductor muscles of the right thigh. Overloading the tendons of the 4th head of the muscle of both thighs. Vitamin D deficiency. Hypocalcemia.

Rehabilitation plan:

1. Plasma therapy of the right knee joint with paraarticular autoplasma enriched with platelets No. 3 with an interval of 7 days, once a week.

2. Classical kinesio taping of the right knee joint by a combined method together with plasma therapy once a week with an interval of 7 days for 3 weeks.

3. 7 days after the last injection of autoplasma - instrumental soft manual techniques (IMMT) NordBlade 2.0 for stabilization of the knee joints, performed in conjunction with the classical kinesio taping combined method. The duration of the session is 20 minutes once a week for 3 weeks.

4. Drug correction: calcium preparations 500 mg/day, vitamin D3 5000 IU per day daily for 1 month.

5. Vojta therapy - on the 2nd day after the last injection of autoplasma once a week for 4 weeks, the duration of the procedure is 30 minutes, each position takes 5 minutes, the number of repetitions is 3.

Vojta therapy classes included a set of exercises performed as follows:

- Starting position - lying on the back, the head is turned to the side, the body is tilted in the same direction, where the face is turned, the front leg is bent, the contralateral leg is bent, the tilt of the body and the pelvic belt towards the spontaneous turn of the head, while the shoulder on the occipital side is assigned to 30 degrees, the contralatter hand is led to the torso, the forecasters are bent into the stream up to 30 degrees;

- triggering stimulation was performed on the front side of the body by pressing in the direction of the spinal column on the surface of the chest along the nipple line in the area of the attachment of the diaphragm, as a result of which the head turned in the opposite direction with simultaneous stretching of the cervical spine, the upper body was extended, in the shoulder girdle the shoulder blades were brought to the body;

- bent lower body and legs;

- the legs were held against gravity in weight above the support surface, for which, the center of gravity was shifted in the cranial direction, while the bent legs were in the position of abduction up to 30 degrees and external rotation, the feet were held along the midline in dorsiflexion;

- the legs were bent, pulled up to the abduction position up to 30 degrees, the feet were located in dorsal flexion along the midline, the toes were in the median position, the front leg was left bent, the foot was left in dorsal flexion, the toes were in the median position;

- when the pelvic girdle was in an oblique position, the legs and pelvis were unbent from the occipital side, maintaining the external rotation of the leg,

6. A set of exercises for dynamic neuromuscular stabilization was performed by the patient independently after completion of the course of injections of autoplasma, daily 1 time per day for 4 weeks.

A set of exercises for dynamic neuromuscular stabilization included exercises for the formation of the muscles of the body, exercises with support on the leg for 8 months and exercises for squats for 12 months, while exercises for the formation of the muscles of the body were performed as follows:

- starting position - lying on the couch, the ribs are pressed to the couch, the back is straightened, the head was retracted to achieve a neutral position of the body;

- the legs were bent 90 degrees at the hip joint, 90 degrees at the knee joint, 90 degrees at the ankle joint;

- performed external rotation in the hip joint;

- this position was held for 20 seconds, keeping the back straight and the neutral position in the hip and knee joint,

leg-supporting exercises for 8 months were performed as follows:

- starting position - standing on 2 knees with support on the elbows with control of the position of the pelvis, in which the pelvic diaphragm is parallel to the diaphragm;

- the knee was bent 90 degrees, so that it was at the same level and parallel to the other leg;

- got up by 10-15 cm, with the control of the supporting leg;

- this position was held for 20 seconds, keeping the back straight and the neutral position in the hip and knee joints;

- a healthy leg was laid on the couch, so that there was a slight external rotation in the hip joint, flexion was performed up to 30 degrees in the knee joint;

- performed rotation of the body around the supporting leg;

- performed 5 repetitions;

squat exercises for 12 months, performed as follows:

- starting position - feet shoulder width apart with control of the position of the pelvis;

- squats were performed up to an angle of 90 degrees in the knee joints, so that the knee was at the level of the thumb;

- this position was held for 20 seconds;

- squats were performed so that the knee did not go beyond the toe, squats in the hip joint continued, up to 90 degrees in the knee;

- This position was held for 20 seconds.

Treatment effectiveness:

A week after the first injection and kinesio taping, the VAS score was 5 points (before treatment, 9 points), according to the results of goniometry, flexion in the right knee joint was 100º.

After 4 weeks from the start of rehabilitation - VAS 2 points due to myofascial pain syndrome in the thigh area, according to ultrasound data - a slight thickening of the right ligament of the kneecap on the right, there are no signs of proliferation and vascularization in the area of the tibial tuberosity. Clinically, the overload of the tendons of the quadriceps muscle of both thighs is preserved.

After 2 months from the first injection of autoplasma and BMI - VAS 0 points. According to the ultrasound of the knee joints - tendinopathy of the own ligament of the minimum degree of activity. Clinical relief of myofascial pain syndrome. Goniometry - flexion in both knee joints 110º.

Example 2 Osgood-Schlatter disease, subacute stage, pain syndrome.

A 12-year-old patient complained of discomfort in the area of the knee joints during training. The patient has been playing water polo since she was 10 years old. Pain disturbed periodically for 1 year, appeared suddenly during training and also suddenly disappeared on its own. The patient was examined by a rheumatologist, laboratory and instrumental studies were carried out, as a result of which a diagnosis was made - Chondropathy of the tibial tuberosity bilateral subacute course, period of fragmentation (Osgood-Schlatter disease subacute course).

On examination, the patient's position is normal, activity is preserved, pain on palpation in the area of the tibial tuberosity on both sides, the external joint is not changed, there are no signs of arthritis. YOUR 5 points. According to goniometry, flexion in the right knee joint was 100º, in the left 100º.

Instrumental and laboratory data

– Ultrasound of the knee joints: thickening of the own ligament of the kneecap, fragmentation of the tuberosity of the tibial tuberosity on the right, slight proliferation and vascularization in the area of the tuberosity of the tibia. Conclusion - Tendopathy of the right ligament of the kneecap on the right, the growth zones are open. Osgood-Schlatter disease, the stage of fragmentation of the tibial tuberosity.

X-ray of the knee joints: signs of chondropathy of the tibial tuberosity on the right, acute stage.

Laboratory: vitamin D3 deficiency (22 ng / ml at a rate of 50 ng / ml), a decrease in the level of ionized calcium (1.00 mmol / l at a rate of 1.15 mmol / l). Other indicators of the general clinical blood test, liver function tests, proteins of the detuned phase are within the age norm. Markers of autoimmune and autoinflammatory diseases were not found.

Conclusion: Osgood-Schlatter disease on the right, subacute course, stage of fragmentation of the tibial tuberosity. Tendopathy of the own ligament of the kneecap. Myofascial pain syndrome of the adductor muscles of the right thigh. Overloading the tendons of the 4th head of the muscle of both thighs. Vitamin D deficiency. Hypocalcemia.

Rehabilitation plan:

1. Plasma therapy of the right knee joint with paraarticular autoplasma enriched with platelets No. 3 with an interval of 7 days, once a week.

2. Classical kinesio taping of the right knee joint by a combined method together with plasma therapy with an interval of 7 days, once a week for 3 weeks.

3. 7 days after the last injection of autoplasma - IMMT NordBlade 2.0 together with the classical kinesio taping combined method to stabilize the knee joints, the duration of the session of instrumental soft tissue mobilization is 15 minutes once a week for 3 weeks;

4. Drug correction: calcium preparations 500 mg/day, vitamin D3 5000 IU per day daily for 1 month.

5. Vojta therapy on the 2nd day after the last injection of autoplasma, once a week for 4 weeks, the duration of the procedure is 30 minutes, it took 5 minutes to complete the first position, 7 minutes each for the remaining positions, the number of repetitions is 3. The sequence of exercises performed, see Example No. 1.

6. Dynamic neuromuscular stabilization was performed 7 days after the last injection of autoplasma, independently daily 1 time per day for 4 weeks. The sequence of exercises performed, see Example No. 1.

Treatment effectiveness:

A week after the first injection and kinesio taping, the VAS score was 2 points (before treatment, 5 points), according to the results of goniometry, flexion in the right knee joint was 100º.

After 4 weeks from the start of rehabilitation - VAS 1 point due to myofascial pain syndrome in the thigh area, according to ultrasound data - a slight thickening of the right ligament of the kneecap on the right, there are no signs of proliferation and vascularization in the area of the tibial tuberosity. Clinically, the overload of the tendons of the quadriceps muscle of both thighs is preserved.

After 2 months from the first injection of autoplasma and BMI - VAS 0 points. According to the ultrasound of the knee joints - tendinopathy of the own ligament of the minimum degree of activity. Clinical relief of myofascial pain syndrome. Goniometry - flexion in both knee joints 110º.

Example 3 Osgood-Schlatter disease is a subacute, very early stage.

A 12-year-old patient complained of recurrent pain in the area of the right knee joint. The pain appears when playing sports. The patient has been involved in athletics since the age of 5. Pain disturbed periodically for 3 years, appeared suddenly during training and also suddenly disappeared on its own. The patient was examined by a rheumatologist, laboratory and instrumental studies were carried out, as a result of which a diagnosis was made - Chondropathy of the tibial tuberosity on the right (Osgood-Schlatter disease, acute stage).

On examination, there was pain on palpation in the area of the tibial tuberosity on the right, the joint was not changed externally, there were no signs of arthritis. YOUR 6 points. According to goniometry, flexion in the right knee joint was 100º, in the left 100º.

Instrumental and laboratory data - ultrasound of the knee joints: thickening of the own ligament of the kneecap, the structure of the tuberosity of the tibial tuberosity is not changed, slight proliferation and vascularization in the area of the tuberosity of the tibia. Conclusion - Tendopathy of the right ligament of the kneecap on the right, the growth zones are open. Osgood-Schlatter disease, a very early stage of chondropathy of the tibial tuberosity. Radiography of the knee joints: knee joints without pathology.

Laboratory: indicators of a general clinical blood test, liver function tests, proteins of the rebuilt phase within the age norm. Markers of autoimmune and autoinflammatory diseases were not found.

Conclusion: Osgood-Schlatter disease on the right, subacute course, stage of fragmentation of the tibial tuberosity. Tendopathy of the own ligament of the kneecap. Lateroposition of the kneecaps.

Rehabilitation plan:

1. Plasma therapy of the right knee joint with paraarticular autoplasma enriched with platelets No. 3 with an interval of 7 days, once a week.

2. Classical kinesio taping of the right knee joint by a combined method together with plasma therapy once a week with an interval of 7 days for 3 weeks.

3. 7 days after the last injection of autoplasma - IMMT NordBlade 2.0 together with the classic kinesio taping combined method to stabilize the knee joints. The duration of the IMMT session is 20 minutes once a week. Number of procedures 5.

4. Vojta-therapy on the 2nd day after the last injection of autoplasma once a week for 4 weeks. The duration of the procedures is 30 minutes, 5 minutes are spent on each position. Number of repetitions 2.

For the sequence of exercises, see Example No. 1.

5. Dynamic neuromuscular stabilization was performed by the patient independently after completing the course of injections of autoplasma daily 1 time per day for 4 weeks. For the sequence of exercises, see Example No. 1.

Treatment effectiveness:

A week after the first injection and kinesio taping, the VAS score was 2 points (before treatment, 6 points), according to the results of goniometry, flexion in the right knee joint was 110º.

After 4 weeks from the start of rehabilitation - VAS score 0, according to ultrasound data - a slight thickening of the right ligament of the kneecap on the right, there are no signs of proliferation and vascularization in the area of the tibial tuberosity. Clinically - overload of the tendons of the quadriceps muscle of both thighs.

After 2 months from the first injection of autoplasma and BMI - VAS 0 points. According to the ultrasound of the knee joints - tendinopathy of the own ligament of the minimum degree of activity. Clinical relief of myofascial pain syndrome. Goniometry - flexion in both knee joints 110º.

Claims (32)

A method for the rehabilitation of patients with chondropathy of the tibial tuberosity, including injections of autoplasma, combined kinesio taping and a set of exercises according to the method of dynamic neuromuscular stabilization, characterized in that that courses of injections of autoplasma into the knee joint are performed paraarticularly once a week for 3 weeks with a platelet concentration in autoplasma of 1,000,000/µl, together with combined kinesiotaping, which is performed as follows: after treating the skin of the knee joint area with an alcohol solution, kinesiotapes are applied, cut in the form of "flashlights" in the amount of 3-4, while the base is applied in the side of the nearest lymph nodes, then I-shaped tapes are applied on top in the amount of 3 pieces, the application is removed after 4-5 days; after completing the course of injections of autoplasma, a set of exercises for dynamic neuromuscular stabilization is performed daily once a day for 4 weeks; on the 2nd day after the last injection of autoplasma, Vojta therapy is additionally performed, the duration of one session of procedures is 30-40 minutes, while holding each position takes 5-7 minutes, the number of repetitions per session is 2-3, the procedure is performed once a week, for 4 weeks; 7 days after the last injection of autoplasma, together with combined kinesio taping, instrumental mobilization of the soft tissues of the thighs with the NordBlade 2.0 instrument is additionally performed, performed as follows: - after applying the ultrasonic gel to the skin, the muscles of both thighs are scanned, warmed up and stabilized, while the duration of the session is from 15 to 20 minutes once a week for 3-5 weeks; at the same time, a set of exercises for dynamic neuromuscular stabilization includes exercises for the formation of the muscles of the body, exercises relying on the leg and squatting exercises; while exercises for the formation of the muscles of the body are performed as follows: - starting position - lying on the couch, the ribs are pressed to the couch, the back is straightened, the head is retracted; - legs are bent 90 degrees at the hip joint, 90 degrees at the knee joint, 90 degrees at the ankle joint; - perform external rotation in the hip joint; - this position is held for 20 seconds, keeping the back straight and keeping the position in the hip and knee joint; exercises with support on the leg, which are repeated 5 times, are performed as follows: - starting position - standing on 2 knees with support on the elbows with control of the position of the pelvis, in which the pelvic diaphragm is parallel to the diaphragm; - the knee is bent 90 degrees; - stand up by 10-15 cm; - this position is held for 20 seconds, keeping the back straight and keeping the position in the hip and knee joint; - a healthy leg is laid on a couch so that there is external rotation in the hip joint, flexion is performed up to 30 degrees in the knee joint; - rotate the body around the supporting leg; squat exercises are performed as follows: - starting position - feet shoulder-width apart with control of the position of the pelvis, in which the pelvic diaphragm is parallel to the diaphragm; - perform a squat up to an angle of 90 degrees in the knee joints so that the knee is at the level of the thumb; - this position is held for 20 seconds; - perform a squat so that the knee does not go beyond the toe, continue squatting at the hip joint, up to 90 degrees at the knee; - this position is held for 20 seconds; At the same time, Vojta therapy classes include a set of exercises performed as follows: - starting position - lying on the back, the head is turned to the side, the body is tilted in the same direction as the face is turned, one of the legs is extended, the contralateral leg is bent, the torso and pelvic girdle are tilted towards spontaneous head rotation, while the shoulder is abducted up to 30 degrees, the contralateral arm is brought to the body, the forearms are bent at the elbow joints up to 30 degrees; - press in the direction of the spinal column on the surface of the chest along the nipple line in the area of the place of attachment of the diaphragm, ensuring that the head is turned in the opposite direction with simultaneous stretching of the cervical spine and upper body, in the shoulder girdle the shoulder blades are brought to the body; - bend the lower body and legs; - the legs are held in weight above the support surface, for which the center of gravity is shifted in the cranial direction, while the bent legs are in the position of abduction up to 30 degrees and external rotation, the feet are held along the midline in dorsiflexion; - bend the legs, pull them up to the abduction position up to 30 degrees, place the feet in dorsal flexion along the midline, toes in the median position, keep the leg bent, foot in dorsal flexion, toes in the median position, - when the pelvic girdle is in an oblique position, the legs and pelvis are unbent, while maintaining the external rotation of the leg; - the knee is bent 90 degrees so that it is at the same level and parallel to the other leg.