RU2806494C1 - Method of rehabilitation of patients after hip replacement surgery for coxarthrosis - Google Patents

Abstract

FIELD: medicine; orthopedics; medical; physical rehabilitation.

SUBSTANCE: invention relates to therapeutic physical effects for recovery after endoprosthetics (EP) operations on the hip joint (HJ) for coxarthrosis. The method includes basic therapy with a complex of physical effects, therapeutic exercises, training on a touch treadmill, exposure to infrared laser low-intensity radiation. Additionally, the complex includes classes using virtual reality (VR) technology and robotic mechanotherapy with biofeedback (RMT BFB). Classes using VR technology are carried out in the form of training exercises on the rehabilitation interactive markerless VR system NIRVANA, 25 minutes a day. The NIRVANA VR systems for these exercises are used as games, selected according to the patient’s preferences from the following group: "Independent Graphic Object", "Hunting", "Games", "Movement", "Follow Me". RMT BFB is carried out using the CON-TREX complex, for which the patient is placed in a chair of the CON-TREX complex in a sitting position with a flexion angle at the knee and hip joint up to 90 degrees. As part of one RMT BFB session, 3 cycles of alternating leg presses are performed in the isokinetic mode of the CON-TREX complex, 10 repetitions in each cycle, movement speed is 0.1 m/sec, with a total duration of exercises in the isokinetic mode of 20 minutes. The rest between cycles of alternating leg presses is 60 seconds in the operating mode of the SRM complex, which is performing of the same movements with the lower limbs in a passive mode. During the day, the physical complex is performed in the following sequence: therapeutic exercises, RMT biofeedback using the CON-TREX complex, exercise using NIRVANA rehabilitation interactive markerless VR system, exercise using a touch treadmill, exposure to infrared laser low-intensity radiation. The course includes 10 sessions of each physical impact as part of their complex, 5 days a week for 2 weeks.

EFFECT: method provides improvement in walking parameters, range of active movements, psycho-emotional state of patients, reduction in pain syndrome, compared to the prototype, through the use of a certain sequence and a more individualized mode of carrying out activities for the rehabilitation complex of physical influences after EP hip joint with an individualized choice by the patient of preferred exercises in VR conditions as part of a standardized set of influences.

1 cl, 1 tbl, 1 ex

Description

The invention relates to medicine, orthopedics, medical and physical rehabilitation, therapeutic physical effects for recovery after endoprosthetics (EP) operations on the hip joint (HJ) for coxarthrosis, and can be used in specialized clinics or sanatorium-resort institutions of the corresponding profile, in the late , namely, the residual period after surgery (from 3 months to 1 year after EP hip surgery), at the 2nd stage of medical rehabilitation (N.V. Zagorodniy, M.A. Eremushkin. Methodological manual on hip replacement with rehabilitation. M. 2019. 40 p.).

Osteoarthritis is the most common form of joint damage and one of the leading causes of disability, causing a deterioration in quality of life, especially in older people. Among patients with osteoarthritis of the hip joint (coxarthrosis), men predominate at a young age, and women predominate among older patients. Osteoarthritis affects approximately 7% of the population, reaching a third of the population in old age (Rebecca J., 2007).

In patients with severe forms of coxarthrosis (stage 4 according to the Kellgren J.H., Lawrence J.S. classification) or aseptic necrosis of the femoral head, conservative treatment methods are ineffective and can increase pain and functional limitations. The main method of treating coxarthrosis at this stage is to replace the affected hip joint by installing an endoprosthesis.

Rehabilitation measures for patients after EP surgery improve their motor and coordination abilities, quality of life, helping to restore joint function and reduce pain. Physical therapy is necessary to prevent postoperative complications, prevent long-term disability and disability, which is largely caused by a lack of motor activity with impaired mobility.

Severe forms of coxarthrosis occur not only in the elderly, but often also in able-bodied individuals. Therefore, the question arises about the possibility of returning them to the fullest possible life, increasing physical and social activity.

In recent decades, EP surgery has become the main method of anatomical and functional correction of severe coxarthrosis (Bruyere O. et al., 2019; Vasilkin A.K. et al., 2016). However, frequent complications (persistence of motor and functional disorders, pain, contracture of limb joints), often associated with the lack of adequate rehabilitation, can completely neutralize the effect of treatment (Vasilkin A.K. et al., 2016; Gomi M. et al., 2018; Moyer R. et al., 2018: Wada O. Et al., 2019; Bruyere O. et al., 2019).

For full rehabilitation, active recovery is necessary using new techniques to prevent such complications, improve the quality of life and physical functioning (Pogonchenkova I.V. et al., 2018; Moyer R. Et al., 2018).

It is known that physical therapy methods improve the motor activity of patients after EP hip replacement (Eichler S. et al., 2017; Pogonchenkova I.V. et al., 2018; Svinоy O.E. et al., 2019; Papalia R. et al., 2020 ). The existing clinical guidelines “Rehabilitation for hip arthroplasty in a special hospital department” (2014), “Coxarthrosis” (2021, http://disuria.ru/_ld/10/1086_kr21M16MZ.pdf) describe rehabilitation methods after EP of the hip joint.

Scientific work has been carried out to prove the positive effect of various types of physical therapy after EP of the hip joint, including physical therapy (physical therapy), postural training, mechanotherapy on the quality of life and physical activity. However, there is no consensus on the advantages of individual methods and recommendations for management of such patients.

Certain treatment methods were used with good effect, including those confirmed by clinical studies on traumatological and rheumatological patients (Rud I.M. et al., 2018; Vasilkin A.K. et al., 2016; Ageenko A.M. et al. , 2017; Makarova M.R. et al., 2016; Moyer R. Et al., 2018; Eichler S. et al., 2017; Papalia R. Et al. 2020; Svinøy O.E. et al., 2019).

According to the available clinical recommendations for the management of patients with coxarthrosis (2021, Electronic resource: https://cr.minzdrav.gov.ru/schema/666; clause 4. Medical rehabilitation, medical indications and contraindications for the use of rehabilitation methods), all The course of postoperative rehabilitation treatment after hip joint EP surgery consists of 2 periods - early and late postoperative periods.

The early postoperative period continues during the first 1-2 weeks from the moment of surgery, when acute postoperative reactive inflammation and healing of the postoperative wound occurs. Its objectives are to prevent postoperative complications from the cardiovascular and respiratory systems, gastrointestinal tract, prevent trophic disorders (bedsores), reduce swelling and create optimal anatomical and physiological conditions for the healing of tissues injured during surgery. This is the first stage of rehabilitation, which takes place in a specialized surgical department.

The late postoperative period begins from the 7-15th day after surgery and lasts for 4-8 weeks (up to 10-12 weeks from the date of surgery). This period is conventionally divided into two: early recovery period, which corresponds to the second stage of rehabilitation and is carried out, as a rule, in the inpatient rehabilitation department, and late recovery period, which corresponds to the third stage of rehabilitation and lasts from the 6th to the 10-12th week. moment of the operation. The main tasks of the late postoperative period are restoration of support function, movement, self-care skills, professional and social activity.

So, the patient is allowed to get out of bed and is prescribed gymnastics from the starting position while standing. The muscles (extensors, abductors and flexors) of the operated hip are strengthened and stretched in the “standing with bilateral support” position.

Standing on the toes, the patient balances with tension in the hip extensor muscles. Hands are placed on a support, legs are shoulder-width apart. The patient raises his heels and simultaneously strains his gluteal muscles, holding the position for 3-5 seconds; 5-15 exercises are performed 5-10 times a day.

Strengthening the hip extensors is done from the starting position: the operated leg is behind, the other leg is bent. By lifting the heel of the operated leg, the patient strains the extensors of the operated joint. It is recommended to hold the position for 3-5 seconds; 5-15 exercises are performed 5-10 times a day.

The abductor muscles of the thigh are well strengthened when performing the “rumba” exercise (feet shoulder-width apart, the patient transfers the weight of the body from one leg to the other). There is a simultaneous stretching of the adductor muscles of the thigh; 10-15 exercises are performed 5-10 times a day.

To strengthen the abductor and stretch the adductor muscles of the thigh, exercises using a footrest are prescribed. In the “healthy leg on a support” position (arms on a support), the abductor muscles of the operated leg are strained. The tension should be maintained for 3-5 seconds; 5-10 exercises are performed 5-10 times a day.

In the “operated leg on a support” position (arms on a support), tension is exerted on the adductor muscles of the operated hip. The tension should be maintained for 1-3 seconds; 3-5 exercises are performed 3-5 times a day.

When resting on the support of the operated leg bent in the hip joint (arms on the support), tension is produced in the flexor muscles of the operated hip. Perform 5-10 exercises 5-10 times a day. The height of the stand when performing this exercise is gradually increased.

In addition to static exercises, active movements in the operated hip joint (flexion, extension, abduction) are prescribed with the patient standing. When performing them, the patient stands on his healthy leg on a stand 5-8 cm high, his arms are on a support, his back is straight. Each exercise is performed 5-10 times, repeating up to 10 times a day.

Depending on the specific rehabilitation period, the age of the patient, the characteristics of the initial pathology of the hip joint, individually selected exercises are carried out (Abeltsev V.P. et al. Rehabilitation of patients after hip replacement with various systems. // Kremlin Medicine, Clinical Bulletin. 2012, 2, p. 36-42; RU 2725245 C1, 06/30/2020, PJSC Prokopyevsky Sanatorium).

In publication: N.V. Zagorodniy, M.A. Eremushkin. Methodological manual on hip replacement with rehabilitation. M. 2019. 40 p., see p. 24-36, - a slightly different classification of postoperative rehabilitation periods is given in terms of timing and content of therapeutic physical effects. In particular, the second stage of medical rehabilitation includes the late postoperative period (up to 3 months after surgery) and the residual period (up to 1 year after surgery), which includes the use of the method we propose.

From other scientific publications, certain effective treatment methods and complexes of methods are known and used within the framework of rehabilitation in the late postoperative period after hip replacement surgery.

The use of the C-Mill biofeedback complex is known (Koneva E.S. Efficiency of restoring the walking stereotype in patients after hip replacement using the method of hardware biofeedback - video reconstruction. // Issues of balneology, physiotherapy and therapeutic physical culture. 2015, 6, p. 23 -29) to train a physiologically correct walking pattern. The design of the complex makes it possible to study the patient’s walking parameters with the subsequent selection of individual training programs by setting video markers and conducting game trainings.

The software allows training in an active motor mode, provided that the correct dynamic stereotype is imposed on the patient by placing video marks on the track surface. At the same time, the exercise therapy instructor, after testing the patient and analyzing the personal characteristics of walking, selects the parameters for training the dynamic stereotype for a particular patient.

Monitoring the effectiveness of training is carried out by conducting diagnostic testing of all patients at the beginning and at the end of the course on the C-Mill complex, with the assessment of a number of walking parameters: distance traveled (in m); average walking speed (in km/h). Characteristics of one walking cycle: speed (in km/h); cycle duration (in sec); step frequency (in steps/min); step width (in mm); independent assessment for the left and right limb (in absolute units and % asymmetry) for the parameters of step length (in mm) and contact time (in sec). The graph of the integral load of the center of pressure (CP) of the lower extremities is analyzed by assessing the symmetry of the distribution of the center of pressure between them and the range of the graph of the pressure of the center of mass for the right and left lower extremities.

The leading problem in the impairment of locomotion in patients after EP of the hip joint is “lameness,” which occurs as a result of a shift in the center of mass pressure (CMP). Getting rid of the patient from this disorder of the walking stereotype is associated with a complex of problems: a fixed pathological stereotype of walking due to a long preoperative history, fear of axial load on the operated joint, etc.

However, the described well-known effective biofeedback technique is only one of the methods of influence in the complex of rehabilitation of patients after hip replacement surgery.

There is a known method for the rehabilitation of patients with EP of the hip joint (RU 2309721 C1, 11/10/2007, S.M. Bubnovsky), which includes a gradual increase in the amplitude of movement in all axes by performing exercises. During the period of walking in walkers and on crutches, exercises are performed daily without compression loads on narrow-local simulators, when the operated limb is fixed along the entire axis of movement. During the period of walking on crutches, additional exercises are performed on the MTB 1 simulator - bench press with weights with two legs forward or upward, lying on your back with support on the entire surface of the back. The method allows you to prevent muscle wasting in the operated leg and reduce the risk of pain in the lower back. However, such training is narrowly local and does not allow obtaining complex effects.

Complex methods of rehabilitation after EP hip joint (Smirnova N.G. et al. Technology of medical rehabilitation of patients who have undergone high-tech operations on the joints and spine. // Russian Journal of Geriatric Medicine. 2022, No. 03, pp. 168-175) include, in addition to drug treatment, diet therapy (high-protein diet), also physiotherapy, massage, exercise therapy, mechanotherapy, balneotherapy. The treatment course includes therapy for the underlying disease and posthemorrhagic anemia, concomitant diseases, angioprotective, analgesic and anti-inflammatory therapy, prevention of thromboembolic syndrome (anticoagulants, elastic compression of the lower extremities, breathing exercises, coagulogram monitoring), correction of the psycho-emotional state. The scope of physical rehabilitation measures for patients who have undergone EP of the hip joint, according to the mentioned well-known set of measures, includes individual and group exercise therapy, massage, laser, acupuncture, phototherapy, etc. This course lasts 12 days and, in terms of the number of treatment methods, is quite stressful for the patient.

There is a well-known complex of rehabilitation after EP of the hip joint, including early ultraviolet irradiation of the operated area, massage, exercise therapy against the background of anti-inflammatory and anticoagulant therapy, pulsed electrical and magnetic stimulation of the muscles of the lower extremities, ozokerite therapy and underwater shower massage (Yamshchikov O.N. et al. Physiotherapeutic provision of patients with dysplastic coxarthrosis after total hip replacement // Medicine and physical culture: science and practice. 2020, vol. 2, no. 3 (7), pp. 7-16).

Abeltsev V.P. etc. (Rehabilitation treatment after hip replacement for dysplastic coxarthrosis. // Kremlin Medicine. Clinical Bulletin. 2012, 2, p. 61-65) is carried out at different periods after surgery to relieve pain, improve tissue trophism, reduce contracture, expanding the range of motion, strengthening muscles, restoring walking, a complex of effects: pulsed currents on the segmental zone and hip joint, magnetic and laser therapy, massage of segmental zones and limbs, electrical stimulation of muscles, breathing exercises, exercise therapy, going up and down stairs, teaching household skills, light therapy during dressings, vibration massage of the chest, pneumomassage from the Lymphopress apparatus on the contralateral leg, exercises with resistance and weights, exercises on cyclic trainers, exercises in the pool, including for practicing the elements of walking, ozokerite applications, therapeutic baths (pearl baths with bischofite, jet baths) and underwater shower-massage, pulsed currents on pain points, electrophoresis using the longitudinal method, elements of post-isometric muscle relaxation, etc. Such a wide range of influences is also stressful for patients.

Each of the above known methods of rehabilitation is effective in its own way. However, as a rule, such methods do not take into account the individual characteristics of patients, their emotional and psychological preferences and motivation. It seems relevant to develop a standardized complex of rehabilitation after hip replacement surgery, which also has an individual focus, taking into account the characteristics of a particular patient, while maintaining the overall effectiveness of the complex.

More individually targeted can be considered complex methods, including training on devices with biofeedback, biofeedback (Vasilkin A.S. et al. Method of biofeedback in the complex of rehabilitation after hip replacement. // Traumatology and Orthopedics of Russia. 2016, vol. 22, No. 4, pp. 35-44), in particular, in the early postoperative period, when, along with therapeutic exercises, additional procedures (training) were carried out taking into account the individual physical capabilities of the patients. They use BOS devices “Myotonic-02” produced by JSC “Biosvyaz” and “Amblyokor-01D” produced by “IN VITRO” (St. Petersburg). As a rule, treatment procedures began with training the quadriceps muscle, first the healthy and then the operated limb, using the threshold method of presenting biofeedback signals. The duration of each session was determined by the total contraction of the muscle and was at least 10 minutes on the healthy limb and at least 5-10 minutes on the operated limb. An alternating mode of work was carried out (4-12 contractions, alternating with rest, per minute). The chosen mode was optimal, as it allowed training for a long time without tiring the patient. Periods of functional muscle activity alternated with periods of rest. The general course of treatment using biofeedback devices consisted of at least 10-12 procedures. The criterion for effectiveness, along with the patient’s subjective feelings, was objective EMG and stabilometry data obtained during biofeedback therapy at the end of each session.

There is also a known method for the treatment and prevention of back pain using the method of isometric biofeedback training of patients after EP of the joints of the lower extremities (RU 2758631 C1, 01.11.2021, Somov D.A. et al.), which is carried out on the Tergumed 3D simulator Proxomed, Gmbh, sequentially asking the patient to apply pressure to the sensor of the simulator while trying to bend the torso forward (flexion), then back (extension), then lateral bend to the left, then to the right, then turn to the left and turn to the right. Positioning the patient on the simulator and exercising on it prevents flexion in the hip joint at an angle greater than 90 degrees, which ensures safety and is necessary to prevent dislocation of the endoprosthesis. Each exercise is performed for 10 repetitions, in two approaches, with a pause between approaches of 10 seconds. Each repetition lasts 4 seconds, training time is 20-30 minutes, 6-10 procedures per course. Correction of postural balance during isometric training of the back muscles with biofeedback improves the isometric tension of the muscles involved, reduces the severity of pain, improves gait, and increases the motivation and involvement of the patient.

A comprehensive rehabilitation method using a telemedicine system for patients to perform exercises is also known (Eichler S. et al. ReMove-It study group. Effectiveness of an interactive telerehabilitation system with home-based exercise training in patients after total hip or knee replacement: study protocol for a multicenter, superiority, no-blinded randomized controlled trial. Trials. 2017; 18 (1): 438). This is a 3-month interactive telerehabilitation with home exercises, based on the MyRehab® system, after discharge from hospital. An individually tailored workout with a choice of exercises (38 different exercises for strength and balance) and methods (number of repetitions and approaches, rest duration) is developed and monitored by a responsible physiotherapist in the rehabilitation center. The patient is instructed to exercise 3-4 times a week. The physical therapist and patient communicate via text or voice messages, and video conferences take place weekly. The exercises are visible on the screen, the patient performs them simultaneously with the system. The training is recorded on a video camera. By tracking the nature of movements, the patient receives automatic biofeedback about movement in real time in the form of green and red coloring of individual body segments, respectively, for correct and incorrect movements. After each exercise, the patient receives an assessment of this exercise and the workout as a whole. It can also be seen and interpreted by a physical therapist for further adjustments. Patients are allowed to use additional, voluntary aftercare programs such as group exercise training, personal training or physical therapy, or self-study. All completed options, including frequency and duration, are recorded in a personal diary.

Koneva E.S. and others (Personalized approach to prescribing hardware methods for restoring the walking stereotype in patients after total hip replacement. // Issues of balneology, physiotherapy and therapeutic physical culture. 2018, vol. 95, 1, pp. 26-34) indicate the need for more an individualized approach in patients after hip replacement surgery through the use of hardware techniques, in particular, depending on the age and body weight of the patients: patients with average parameters of age and body weight, obese patients and the elderly. All patients received a basic program of early rehabilitation; in the main groups, they were additionally prescribed hardware training to restore the walking stereotype using 3 types of devices (body weight unloading; video reconstruction associated with biofeedback; robotic therapy). A comparative analysis of the effectiveness of these techniques showed that in patients with average physical parameters, the results are comparable when using any hardware technique. In elderly patients, significantly higher rates of gait reconstruction efficiency were noted when using biofeedback training. Robotic training is more effective in obese patients.

Thus, individualization of rehabilitation after EP biofeedback, with the need to develop and comply with standards for such rehabilitation, is important to increase the efficiency of recovery of such patients.

As the closest analogue (prototype ) of the complex method we propose, we can consider the one we developed earlier: L.A. Marchenkova, O.V. Yurova, A.D. Fesyun. A method of rehabilitation using virtual reality technology and robotic mechanotherapy in patients with coxarthrosis after hip replacement surgery. // Doctor. 2023; 34(2). pp. 57-59. https://doi.org/10.29296/25877305-2023-02-12

In this known method, the effect of a rehabilitation method involving virtual reality (VR) technology and robotic mechanotherapy with biofeedback (RMT) on the speed and biomechanics of walking in patients with coxarthrosis after EP hip replacement was assessed. The sample consisted of 40 patients aged 40-80 years after this operation. For 14 days, patients in the main group (n=20) received a new complex of physical therapy, including RMT and training on a system with VR technology. In the control group (n=20), only a standard rehabilitation complex was performed. In the main group, a decrease in the level of pain according to VAS was detected by 41.7% (p = 0.023 - compared to the baseline; p = 0.047 - compared to the control group), as well as an increase in walking speed (by 20.5%; p = 0.028) and a decrease in step width (by 8.2%; p=0.048). Also in the main group there was a decrease in the time to complete the “Get up and Walk” test (by 15.4%; p = 0.043) and an increase in walking speed according to the ten-meter test (by 23.9%; p = 0.039). There were no significant changes in the data in the control group (p>0.05). Based on these results, it is recommended to include RMT methods with biofeedback and virtual reality in the complex of rehabilitation of patients with coxarthrosis after hip joint surgery.

However, this complex is also more standardized than an individually targeted method, since the training program for different patients is the same.

The goal of our further developments was to increase the individual focus of hardware rehabilitation of patients after EP hip replacement, taking into account both their physical and psycho-emotional state.

The technical result of the proposed method was a significant improvement in walking parameters, range of active movements, psycho-emotional state of patients, reduction in pain syndrome, compared with the prototype, due to the use of a certain sequence and a more individualized mode of carrying out activities for the rehabilitation complex of physical influences after EP hip replacement with an individualized choice by the patient of the preferred ones exercises in VR conditions as part of a standardized set of influences.

To achieve this technical result, a method has been proposed for the rehabilitation of patients in the residual period (the second stage of rehabilitation, from 3 months to 1 year) after hip joint surgery for coxarthrosis, including basic therapy with a complex of physical influences - therapeutic exercises, exercises on a touch treadmill, exposure to low-intensity infrared laser radiation.

Additionally, the complex includes classes using VR technology and RMT biofeedback. Classes using VR technology are carried out in the form of training exercises on the rehabilitation interactive markerless VR system NIRVANA, lasting 25 minutes.

Moreover, in the first three lessons, training exercises are carried out only for the muscles of the upper limbs and body, using games of the NIRVANA VR system with a projection onto a vertical surface - a wall.

In the next 7 lessons, these training exercises for the muscles of the upper limbs and core are supplemented with training exercises for the muscles of the lower limbs, using games of the NIRVANA VR system with a projection onto a horizontal surface - the floor.

Moreover, in the 4-5th lessons, training exercises for the muscles of the upper limbs and core are carried out for 10 minutes of the lesson time, and then 15 minutes - training exercises for the muscles of the lower limbs.

At the 8-10th lessons, training exercises for the muscles of the upper limbs and core are carried out for 5 minutes of class time, and then 20 minutes - training exercises for the muscles of the lower limbs,

As games for these exercises, the NIRVANA VR system is used, selected according to the patient’s preferences from the group: “Independent graphic object”, “Hunting”, “Games”, “Movement”, “Follow me”,

RMT BFB is carried out using the CON-TREX complex, for which the patient is placed in a chair of the CON-TREX complex in a sitting position with a flexion angle at the knee and hip joint up to 90 degrees. As part of one RMT BFB session, 3 cycles of alternating leg presses are performed in the isokinetic mode of the CON-TREX complex, 10 repetitions in each cycle, movement speed is 0.1 m/sec, with a total duration of exercises in the isokinetic mode of 20 minutes.

In this case, rest between cycles of alternating leg presses is carried out for 60 seconds in the operating mode of the SRM complex - passive mode. This operating mode involves performing the same movements with the lower limbs and in the same range as in the isokinetic mode, but in the form of passive movements.

During the day, the physical effects of the complex are carried out in the following sequence:

physiotherapy,

RMT BOS on the CON-TREX complex,

lesson on the rehabilitation interactive markerless VR system NIRVANA,

exercise on a touch treadmill,

exposure to infrared laser low-intensity radiation.

The course includes 10 sessions of each physical impact as part of their complex, 5 days a week for 2 weeks.

The complex method we have developed for the rehabilitation of patients with coxarthrosis after hip joint surgery includes five sequential methods, of which three are components of the basic rehabilitation program (therapeutic gymnastics, exercises on an interactive touch treadmill and laser exposure), and two are methods proposed in the method -prototype (classes on the VR and RMT system on a simulator with biofeedback for targeted training of the muscles of the lower extremities).

In the process of rehabilitation work with patients according to the program of the prototype method, it was revealed that those of them who received the entire complex of techniques in the sequence and modes proposed by us in the present invention had a number of indicators of the functions of the operated hip joint, walking, quality of life, degree of pain and psycho-emotional states turned out to be significantly better than in patients who received the same effects in other modes and in a random sequence (see below).

Our proposed sequence of physical effects of the complex during the day of the rehabilitation course is as follows:

-therapeutic gymnastics in a group, ensuring the preparation of the interested muscles for a subsequent increase in physical activity,

- RMT biofeedback on the CON-TREX complex, which allows not only to perform active movements, but also to carry out active rest during the passive mode of operation of this robotic complex (CPM mode), which is more productive for obtaining therapeutic results;

- training on the rehabilitation interactive marker-free VR system NIRVANA, which ensures increased motivation of patients, a smoother, personalized entry of the patient into activities characteristic of ordinary, everyday life, due to the patient’s choice of the most subjectively attractive games of this VR system for him;

- exercise on a touch treadmill, to consolidate the obtained motor effects, with an emphasis on the walking function, with the provision of biofeedback,

-short pulsed exposure to low-intensity infrared laser radiation to achieve physiologically determined therapeutic effects at a deeper tissue (muscle) level of the body in the postoperative area of the hip joint.

The rehabilitation complex we have developed allows us to specifically train the muscles of the lower extremities, including the deep muscles of the thigh, form the correct motor stereotype, restore healthy gait biomechanics lost due to severe osteoarthritis and replacement of the hip joint with an endoprosthesis, reduce pain, improve coordination, increase motor activity, and overall endurance the body and quality of life, help restore labor potential and reduce the incidence of disability.

All used simulators are equipped with biofeedback, which allows you to adequately dose the load. Classes are conducted by a physical therapy instructor, which also ensures the rationality of the load and the safety of patients.

The rehabilitation course includes the following methods in the proposed sequence to be performed daily, 5 days a week, for 2 weeks.

1) Therapeutic gymnastics in the hall (10 lessons of 30 minutes each). The training is conducted by a physical therapy instructor in a group. The set of exercises includes general developmental, breathing and special exercises. Special exercises: strengthening and stretching the muscles (extensors, abductors and flexors) of the operated hip, stretching the adductor muscles of the hip in the form of static exercises, in addition, active movements are used in the operated hip joint (flexion, extension, abduction). In this case, the following conditions must be met: do not bend the leg at the hip joint more than 90°, avoid simultaneous flexion, adduction and internal rotation in the operated hip joint.

The exercises themselves are directly selected individually, based on the patient’s medical history, the presence of other somatic indications and contraindications. Thus, the sets of exercises performed during therapeutic gymnastics may be different. Groups of patients can be selected accordingly so that the exercises carried out in the group are adequate for all its participants (5-7 people).

The exercises can be used, for example, those given in the study: Ilyas M. Dauletin et al. The use of exercises with countertraction during rehabilitation after hip replacement. // Science and Healthcare, 2020, 6 (Vol. 22) Original research. Received: October 14, 2020 / Accepted: November 09, 2020 / Published online: December 08, 2020. DOI 10.34689/SH.2020.22.6.010, p. 71-79.

Most often we used in our work the exercises shown in the Federal Clinical Guidelines “Rehabilitation for Hip Replacement in a Specialized Department of a Hospital,” 2014, pp. 15-28; and also – exercises at the second stage of medical rehabilitation in the above-mentioned publication: N.V. Zagorodniy, M.A. Eremushkin. Methodological manual on hip replacement with rehabilitation. M. 2019. P.24-33.

2) RMT on a simulator with biofeedback (CON-TREX) for targeted training of the muscles of the lower extremities, including the deep muscles of the thigh (10 sessions of 25 minutes).

The training is carried out on a robotic mechanotherapy complex with biofeedback - CON-TREX (Phisyomed, Germany, 11-461-710, (https://www.keleanz.ru/catalog/39/186/), which is a robotic biomechanical diagnostic training complex with biofeedback. Its tasks include diagnostics and objective assessment of the functions of the patient’s musculoskeletal and neuromuscular systems based on the volume of movements performed, the patient’s recorded effort, determination of his speed-strength characteristics. The complex allows you to actively compensate for gravity and train patients whose applied effort can be even less than the force of gravity acting on the limb (ballistic mode).This is especially important for patients with pathologies of the lower extremities, whose physical functions are weakened.

The complex has a number of modules and provides diagnostics and training with biofeedback for all major joints of the upper and lower extremities in isolated and mixed movements; complex movements of the lower extremities in unilateral, bilateral or alternate modes; body movements; small everyday movements. The modules can be connected in different ways and provide both isolated and complex effects on muscles and joints.

In the proposed method, a linear module (leg press) CON-TREX LP is used to influence the lower limbs. It allows you to influence both one limb and two limbs in independent, synchronous or alternate modes.

In the initial stages of rehabilitation, patients often do not have sufficient strength to perform active movements on traditional modern isokinetic computer-controlled training systems. Physiologically expected movement speeds can only be realized to a certain level.

Possible types of loads provided by the CON-TREX complex program (modes):

-isokinetic in classical and ballistic modes,

-isotonic in classical and ballistic modes,

-isometric (fixed position),

-CPM (Continuous Passive Motion) – constant passive movement.

In each of these modes, in addition to CPM, a combined load is also possible: concentric/CPM, CPM/concentric, concentric/concentric, eccentric/CPM, CPM/eccentric movement.

In the proposed method, we use the classical isokinetic load mode with the application of force in the direction of movement and the CPM mode.

The required muscle group (from the muscle groups of the thigh and pelvic girdle) is trained in the isokinetic classical load mode at the speed set for the complex - 0.1 m/sec. As part of one RMT BFB session, 3 cycles of alternating leg presses are performed in the isokinetic mode of the CON-TREX complex, 10 repetitions in each cycle, with a total duration of exercises in the isokinetic mode of 20 minutes, 10 sessions. In this case, rest between cycles of alternating leg presses is carried out for 60 seconds in the operating mode of the CPM complex (constant passive movement) - in the form of performing the same movements with the lower extremities in a passive mode, in the same range as in the isokinetic mode; in the CPM mode, movements are also performed at a speed of 0.1 m/sec. When conducting classes, visual biofeedback is used.

In real time, CON-TREX determines the current state and parameters of the movement and automatically adjusts the load and/or gain, allowing the movement to be performed correctly even with limitations in the amplitude and capabilities of the patient. Before and after the course of treatment, an objective functional assessment of the condition of the musculoskeletal and neuromuscular system of the practicing patient is performed.

3) Training on the marker-free interactive VR system NIRVANA ® (https://www.keleanz.ru/catalog/65/195/), which offers special exercises aimed at overcoming cognitive and motor deficits in the form of a set of preset tasks for the upper, lower extremities and the patient's core, as well as tools for creating customized tasks according to the individual needs of patients. The effectiveness of the NIRVANA system is based on a motivating approach: goal orientation and game form, as well as the possibility of biofeedback at the sensory level, which stimulates the patient’s activity.

NIRVANA® is the world's first markerless (non-invasive) system that provides full sensory immersion (acoustic and visual) in VR. It reproduces scenarios that can be projected onto horizontal and vertical surfaces using an optoelectronic infrared system: the patient can interact with the VR in a natural way, moving against the background of the projected images. In addition to multiple modes and increasing levels of difficulty, each task is defined by multiple sensory feedbacks: compared to a traditional therapeutic approach, the patient receives cognitive and motor stimuli, which increases his motivation to perform more complex and complex exercises. Exercises can be of various types: perceptive, aimed at perceiving the environment, aimed at achieving a goal (follow an animal or walk along a line, etc.), motor (an event occurs when the patient crosses an object) or gaming (football, balloons, etc.).

NIRVANA® is applicable for any therapeutic treatment of patients with cognitive and motor deficits of the lower, upper extremities and trunk. For any exercise, measurable parameters are provided so that the doctor can assess the patient’s performance and promptly change the difficulty level of the exercise.

Evaluation of results with visualization for the patient is an important motivational factor. Quantitative parameters calculated based on data after each exercise can be supplemented with a video report. The information is recorded in a database using an RFID ID card as a tool for assessing the patient's progress during rehabilitation and as a source of information about the dynamics of rehabilitation. After each test, a report is automatically generated with a list of exercises and results for each task.

The system is capable of programming a sequence of scenes, has 30 controllable training scenes and effects, as well as an unlimited library of effects, replenished via the Internet, which best allows for the most individualized selection of the games offered.

The system includes a set of exercises for the upper and lower limbs and body when projecting scenarios on both a vertical surface and a horizontal one (floor). In the proposed method, for a smoother introduction of the patient into the features of the games provided by this system, first we propose to conduct games to train the muscles of the upper limbs and body, and only then - for the lower limbs, the motor functions of which are impaired after EP of the hip joint.

4) Classes on an interactive touch treadmill - C-mill ergometer to form the correct gait stereotype and balance training (10 lessons of 20 minutes each). A multifunctional system with biofeedback is used for biomechanical diagnostics and correction of walking skills. This treadmill, with additional sensors and software, and with biofeedback based on audiovisual monitoring of the patient’s correct movement performance, allows not only to diagnose the individual characteristics of movement disorders when walking, but also to develop a personalized algorithm for restoring the patient’s coordination of movements. The system is equipped with built-in force platforms and a system of light projection of indicator markings on the moving surface of the track, which in real time allows you to obtain and compare operational data on movement characteristics: step length, step frequency, time between feet touching the surface, foot repulsion force, gait symmetry.

The correct gait pattern was practiced on the sensory track. The gait cycle was displayed on the monitor. We varied the symmetry, length and width of the step by setting marks-traces. The display showed the current results of the gait analysis in real time. The physical therapy instructor-methodologist controlled the correctness of walking, teaching the patient to take a shorter step with the operated leg and a longer one with the “healthy” one in order to ultimately achieve uniformity of the step. The patient was also taught not to lift the heel and keep it as close to the ground as possible during the last part of the stance phase.

On the sensory path, walking was performed at a pace that was subjectively slow for the patient.

5) Laser therapy with infrared low-intensity laser radiation on the area of the operated hip joint in pulsed mode, pulse power 20 W/pulse, pulse repetition rate 80 Hz, from a matrix emitter, procedure duration 5 minutes for the purpose of pain relief, improvement of trophism and tissue regeneration. The exposure is carried out using the AZOR-2K-02 device (azormed.ru), however, other devices suitable for laser therapy can be used.

The operation of the device used is based on the MH-1 30 mT ring magnet it contains. Pulsed infrared emitters are used in reflexology, for diseases of the joints and internal organs, when it is necessary to deliver radiation to deep-lying inflammatory foci.

The matrix of pulsed lasers (ML) of the device is used for the treatment of the musculoskeletal system, diseases of internal organs (area 40 cm2, power up to 90 W per pulse). The device allows you to automatically calculate the dose and adjust the power.

At the same time, the proposed comprehensive method of rehabilitation after hip joint surgery is used against the background of basic drug therapy, which the patient constantly receives for existing comorbid diseases.

Modern RMT devices and VR systems allow targeted work with weakened muscle groups, preventing atrophy and restoring their strength. After EP of the hip joint, almost all patients have problems maintaining balance and require walking aids due to pain, limited mobility and functionality of the joint.

The complex we offer is aimed at strengthening the muscles of the thigh, pelvis, and gluteal muscles, restoring coordination and forming the correct gait pattern, as well as increasing flexibility, endurance and overall physical functioning. A pre-training examination, including video analysis of gait, strain dynamometry, stabilometry, assessment of hip joint functions, allows you to calculate a load commensurate with the capabilities of even weakened patients, and biofeedback allows you to timely adjust these loads already in the process of rehabilitation itself for the most productive training regimen (choice of amplitude, intensity, tempo , directions for performing various movements).

A clinical study conducted at the Federal State Budgetary Institution "National Medical Research Center of the Republic of Kazakhstan" of the Ministry of Health of Russia showed that patients who received the proposed complex method of rehabilitation, compared with the prototype method, had more effective results both in terms of improving motor function (in particular, walking parameters), and in regarding psycho-emotional state. All 20 patients (age 40-80 years) were included in the main group described in the prototype method. At the same time, it subsequently differentially assessed the results of patients (n=10) who received basic rehabilitation and exercises on a VR system and a robotic simulator with biofeedback in their random sequence, and patients (n=10) who received the same effects, however, in a certain sequence proposed by the method under consideration. Comparative data are shown in Table 1.

Table 1. Comparison of the results obtained from the use of rehabilitation complexes using the prototype method and the proposed method.

Indicators Results obtained by implementing the prototype method
(without following the sequence of rehabilitation interventions)* Results of the proposed method
(subject to a certain sequence of influences)* Number of patients in the group 10 10 Reduced pain level (VAS) By 38.3% (p=0.08) By 42.9% (p=0.1) Increasing walking speed By 16.2% (p=-0.03) By 22.3% (p=-0.02) Reducing stride width By 6.4% (p=0.05) By 9.2% (p=0.03) Time reduction
performing the “Get up and walk” test By 12.3% (p=0.09) By 17.4% (p=0.01) Increasing walking speed according to the ten-meter test By 20.1% (p=0.03) By 23.4% (p=0.045) Improving quality of life
(SF-36 questionnaire):
-Physical component of health
-Mental health component -By 35% (p=0.02)
-By 9.3% (p=0.04) -By 44% (p=0.01)
-By 32.6% (p=0.02) Improvement of psycho-emotional state (SAN questionnaire - “well-being, activity, mood”) By 10.5% (p=0.09) By 38.2% (p=0.05)

Note: * – compared to the initial level.

Thus, from Table 1 it follows that the use of rehabilitation methods of the complex according to the program of the proposed method is more effective both for the physical indicators of patients, in particular for improving walking parameters, and for their psycho-emotional state, which may indicate a greater individual orientation of the complex .

Clinical example.

Patient T., born in 1957 Diagnosis: right-sided coxarthrosis since 2010. She was treated conservatively for a long time, without noticeable effects.

Complaints: pain in the hip joint and lumbar area. At the beginning of 2022, she underwent total EP of the right hip joint. She received therapeutic effects at the first stage of medical rehabilitation, after surgery (breathing exercises, exercises for the distal parts of the lower extremities, isometric muscle tension, etc.). In September 2022, she entered the second stage of rehabilitation.

In the department she received the stated complex of rehabilitation effects in the proposed sequence and modes. Course – 10 days, 5 days a week.

The patient's walking function, muscle strength parameters and stabilometric parameters, as well as her psycho-emotional state according to the above-mentioned questionnaires, improved. There is practically no pain syndrome observed.

Thus, a comprehensive method of rehabilitation of patients with coxarthrosis who underwent hip joint surgery is justified and effective, and therefore can be recommended for use in rehabilitation centers, and also proposed as an addition to clinical recommendations for this nosology. If actively implemented in practice, this complex can improve the quality of medical care for patients with coxarthrosis who have undergone EP hip surgery, contribute to the formation of standards for the provision of medical care to such patients at the second stage of medical rehabilitation, while simultaneously ensuring its individualized focus.

Bibliography:

1. Belyaev A.F., Kantur T.A., Khmeleva E.V., Fotina O.N., Kudryavikh A.V., Litvinova I.I., Kolesnikova Yu.B., Shevchuk E.Yu. Rehabilitation of patients after hip replacement. // Bulletin of restorative medicine. 2018. No. 4 (86). pp. 2-6.

2. Vasilkin A.K., Shaparyuk S.I., Shevchenko S.B., Denisov A.O. Biofeedback method in the complex of rehabilitation after hip replacement // Traumatology and Orthopedics of Russia. 2016. T. 22. No. 4. pp. 35-44. DOI: 10.21823/2311-2905-2016-22-4-35-44.

3. Ageenko A.M., Sadovaya M.A., Shelyakina O.V., Ovtin M.A. Technology of accelerated rehabilitation after hip and knee replacement (literature review) // Traumatology and Orthopedics of Russia. 2017. T. 23. No. 4. pp. 146-155. DOI: 10.21823/2311-2905-2017-23-4-146-155.

4. Zaitsev K.S. Modern approaches to physical rehabilitation of patients after total hip replacement // Modern issues of biomedicine. 2018. Vol. 2. No. 2 (3). P. 9.

5. Nikolaev N.S., Efimov A.V., Petrova R.V., Kovalev D.V., Ivanov M.I. Management of patients in the postoperative period after minimally invasive hip arthroplasty. // Physical and rehabilitation medicine, medical rehabilitation. 2019. Vol. 4. No. 4. pp. 32-38. DOI: 10.36425/2658-6843-2019-4-32-38.

6. Khozyainova S.S., Kovlen D.V., Ponomarenko G.N., Abuseva G.R., Adkhamov B.M., Ishchuk V.N., Karpova T.N., Kondrina E.F., Konoplyankin I.V., Podberezkina L.A., Tolmachev S.V. Physical therapy in the rehabilitation of patients after endoprosthetics of large joints of the lower extremities: scientometric analysis of evidence-based research // Issues of balneology, physiotherapy and physical therapy. 2019. T. 96. No. 6. P. 22-31. DOI: 10.17116/kurort20199606122.

7. Moyer R, Lanting B, Marsh J, Al-Jurayyan A, Churchill L, Howard J, Somerville L. Postoperative Gait Mechanics After Total Hip Arthroplasty: A Systematic Review and Meta-Analysis. // JBJS Rev. 2018 Nov;6(11): e1. doi: 10.2106/JBJS.RVW.17.00133.

8. Eichler S, Rabe S, Salzwedel A, Müller S, Stoll J, Tilgner N, John M, Wegscheider K, Mayer F, Völler H; ReMove-It study group. Effectiveness of an interactive telerehabilitation system with home-based exercise training in patients after total hip or knee replacement: study protocol for a multicenter, superiority, no-blinded randomized controlled trial. // Trials. 2017 Sep 21;18(1):438. doi:10.1186/s13063-017-2173-3.

9. Wada O, Asai T, Hiyama Y, Nitta S, Mizuno K. Gait Variability in Women With Hip Osteoarthritis Before and After Total Hip Replacement: A Prospective Cohort Study. // Am J Phys Med Rehabil. 2019 Oct;98(10):866-871. doi: 10.1097/PHM.0000000000001206.

10. Gomi M, Maezawa K, Nozawa M, Yuasa T, Sugimoto M, Hayashi A, Mikawa S, Kaneko K. Early clinical evaluation of total hip arthroplasty by three-dimensional gait analysis and muscle strength testing. // Gait Posture. Oct 2018; 66: 214-220. doi: 10.1016/j.gaitpost.2018.08.037.

Claims (19)

A method of rehabilitation of patients in the residual period after hip arthroplasty (HJ) surgery for coxarthrosis, including basic therapy with a complex of physical effects - therapeutic exercises, exercises on a touch treadmill, exposure to infrared laser low-intensity radiation, characterized in that the complex additionally includes classes using virtual reality (VR) technology and robotic mechanotherapy with biofeedback (RMT BFB), Moreover, classes using VR technology are carried out in the form of training exercises on the rehabilitation interactive markerless VR system NIRVANA, 25 minutes a day, Moreover, in the first three lessons, training exercises are carried out only for the muscles of the upper limbs and body, using games of the NIRVANA VR system with a projection onto a vertical surface - a wall, and in the next seven sessions, these training exercises for the muscles of the upper limbs and core are supplemented with training exercises for the muscles of the lower limbs, using games of the NIRVANA VR system with a projection onto a horizontal surface - the floor, as games for these exercises, the NIRVANA VR system is used, selected according to the patient’s preferences from the group: “Independent graphic object”, “Hunting”, “Games”, “Movement”, “Follow me”; RMT biofeedback is carried out using the CON-TREX complex, for which the patient is placed in a chair of the CON-TREX complex in a sitting position with a flexion angle at the knee and hip joint up to 90 degrees, within one RMT BFB session, 3 cycles of alternating leg presses are carried out in the isokinetic mode of operation of the CON-TREX complex, 10 repetitions in each cycle, movement speed – 0.1 m/sec, with a total duration of exercises in isokinetic mode of 20 minutes, in this case, rest between cycles of alternating leg presses is carried out for 60 seconds in the CRM mode of the complex - in the form of performing the same movements with the lower limbs in a passive mode; exposure to low-intensity infrared laser radiation is carried out on the area of the operated hip joint in a pulsed mode, pulse power 20 W/pulse, pulse repetition rate 80 Hz, procedure duration 5 minutes; during the day, the physical effects of the complex are carried out in the following sequences: physiotherapy, RMT BOS on the CON-TREX complex, lesson on the rehabilitation interactive markerless VR system NIRVANA, exercise on a touch treadmill, exposure to infrared laser low-intensity radiation, per course – 10 classes of each physical impact as part of their complex, 5 days a week for 2 weeks.