RU2834844C1 - Method for complex medical rehabilitation of patients underwent surgical ventral fixation of cervical spine segments - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to neurology, physical and rehabilitation medicine. Method involves 10-day course of a complex of physiotherapeutic effects, including a classical medical massage of the muscles of the upper extremities and the region of the scapula, shoulder and shoulder girdle; group exercises of exercise therapy, shown in diseases of cervical spine, with movements of limbs, neck and head, using a gymnastic stick, with completion of each exercise therapy session with a breathing exercise; exposure to low-intensity laser radiation (LILR) in the original mode; electrical stimulation (EST) of the extensor muscles – on the deltoid and trapezius muscles, on the right and on the left, in the original mode; exposure to low-frequency pulsed electrostatic field on the cervical spine region with the help of Hivamat 200 apparatus in the “oedema” mode. Also, general mineral chloride-sodium therapeutic baths are carried out with duration of procedure 10-15 minutes, water temperature 36-37 °C, mineralization 30 g/l daily, course of 8 baths. At the end of the day of physiotherapeutic actions, from 1st to 8th day, the daily exercises are carried out on apparatus David 140 with training of neck extension and lateral head tilting and by David 160 apparatus with training of neck rotator muscles, from day to day, the weight of the load used in the apparatus is increased and the number of repetitions in the approaches is reduced.

EFFECT: method enables to accelerate the length of rehabilitation with a significant reduction in the level of manifestations of neurological deficiency in patients with degenerative spinal diseases, having undergone surgical intervention on the cervical spine by a ventral approach, restore motor function, reduce pain syndrome and neurogenic dysfunction of lower urinary tract, reduce risk of cardiac complications with maintaining effect for at least 3 months.

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Description

The invention relates to medicine, neurology, physical and rehabilitation medicine, namely to the rehabilitation of adult patients with degenerative-dystrophic changes at the level of the cervical spine (CS) who have undergone stabilization (fixation) of damaged spinal motor segments (SMS) at the level of the CS by anterior access. The invention can be used to restore impaired functions, plan rehabilitation measures, and early social rehabilitation.

Anterior interbody spondylodesis (AIBS) in the surgical treatment of cervical spine diseases and injuries using plates has been performed for almost 50 years (N.A. Korzh, A.E. Barysh. Ventral fixation of cervical vertebrae using plates with an original contact surface topography and a bioinert ceramic coating // Chronicle of traumatology and orthopedics. 2014. No. 1-2, 233). Intervertebral disc prostheses or corporodesis are used.

The purpose of the operation is to restore the supporting function of the spine. During the surgical intervention, damaged structures are connected to each other using bone or metal structures. Most often, the operation is performed on the cervical spine, since it is most vulnerable due to the large volume of movements, load, anatomical predisposition, and often suffers under the influence of unfavorable external and internal factors.

The main indications for surgery are:

- spinal canal stenosis,

- spondylolisthesis and other degenerative diseases,

- disorders of bone growth,

- injuries and fractures,

- large herniated intervertebral discs.

Spinal fixation is used in cases of rapid progression and severe course of the disease. The operation allows to eliminate deformation, pain syndrome, and strengthen the spinal column.

Currently, a large number of modern plates are known, which differ both in their design features and in the effectiveness of clinical use. According to literature data, unsatisfactory treatment results after PMSD with plates can reach 35%.

In the postoperative period, external immobilization in all patients is performed with soft head holders. The stability of the vertebral fixation, the position of the metal structures and the signs of interbody fusion are assessed clinically and according to X-ray data. Spondylodesis is usually successful and is not accompanied by infectious complications in 100% of patients.

However, the recovery itself after the operation requires attention to the muscular function of the upper limbs, posture and a number of other functions related to the cervical spinal column. This is due to the fact that the indications for the operation to fix the ventral access at the level of the cervical spine are previous violations of the structural integrity of the spine during injuries or degenerative-destructive processes that lead to instability and immobilization, severe pain syndrome and disability. Accordingly, postoperative rehabilitation is also aimed at eliminating the consequences of these violations observed before the operation.

Spasticity of the lower extremities, decreased muscle tone of the upper girdle, upper extremities, sensory disturbances (deep and superficial sensitivity), disorders of the autonomic nervous system, movement disorders are common syndromes in patients with degenerative-dystrophic changes in the spine, complicated by the effect on neural structures. These syndromes are one of the main causes of long-term disability of patients and significantly affect their daily activities and quality of life. At the same time, the treatment of functional disorders of the nervous system with traditional medications, the use of individual methods of physical rehabilitation as monotherapy is not effective enough and prolongs the recovery period.

Given the invasiveness and volume of the operation with ventral fixation, the period of hospital stay after it is 4-7 days. It is recommended to get up on the 2nd-3rd day. Sharp and high-amplitude body movements (bending, turning) are prohibited.

Rehabilitation after ventral fixation lasts 2-3 months. Patients usually tolerate it well. It becomes possible to lead a normal life, without excruciating pain. Working capacity is restored within the same time frame. If the work is associated with heavy physical exertion, it is necessary to transfer to a light regime. It is important to remember that the less load is applied to the spinal column, the faster and better the vertebrae will fuse. Sports and active physical work are prohibited for 6-12 months.

Physical activity should be gradual. Bending the body and carrying heavy objects are prohibited for 3 months after the operation. It is necessary to use the corset recommended by the attending physician and follow a diet.

Given the complexity of postoperative recovery for such patients, specialists often consider the issue of increasing the effectiveness of medical rehabilitation, which usually includes a range of measures, including hardware physiotherapy technologies.

A method for restoring arm movements in cases of paralysis and paresis is known (RU 2475283 C2, E.Yu. Shapkova et al., 20.02.2013), which includes selective electrical stimulation (ECT) of the spinal cord through epidural or cutaneous electrodes applied in a certain way. The method is used to restore arm movements in cases of paralysis of various etiologies and levels of damage to the nervous system: caused by trauma to the cervical spine, deformations or instability of the spine, inflammatory diseases of the spine, etc., by acting on the motor neurons of the cervical enlargement of the spinal cord and the arm muscles innervated by them. However, there is no data on how effective such an effect would be after an operation to fix the cervical spine via anterior access.

A method for restoring functions in spinal diseases is known (RU 2456034 C1, Glinyanova A.G. et al., 20.07.2012), where intravenous blood irradiation in the UV and red spectra of low-intensity laser radiation (LILI) is carried out in stages, dosed uniform traction of all sections of the spine on a traction unit without fixing devices with complete muscle relaxation. Then vacuum cupping massage is carried out paravertebrally, along the massage lines of the back, without tearing the medical cup off the skin. Then - vacuum gradient therapy along the venous outflow, hirudotherapy (HT) on the navel area, therapy on the SWING MACHINE (ST) simulator. In one day, acupressure therapy of the spinal muscular frame is performed with ebonite rollers along the massage lines of the back, manual action on its ligamentous-muscular apparatus and joints in the form of massage, yumeihotherapy, post-isometric relaxation, then ST and GT on the back area. On free days, gymnastics is performed based on the methods of Qigong, Nishi, yoga, etc. The therapeutic effect is achieved due to the influence on all pathogenesis pathways of spinal diseases: cellular, immune, humoral, neuromuscular, mechanical, reflex, at the level of the integral system, with a radical restoration of spinal health without drug treatment. However, this method is complex in terms of organization, multicomponent, which reduces the patient's compliance with rehabilitation.

Also complex is a well-known method of treating myelopathy (RU 2401092 C1, Moiseev V.V., 10.10.2010), where in addition to the introduction of drugs, they take baths, acupressure, manual therapy with ischemic compression, release phenomenon, fascia stretching, PIR of muscles involved in the pathological process. Additionally, they conduct intermittent therapeutic plasmapheresis, extracorporeal ultraviolet irradiation of blood, local cryotherapy at the level of degenerative-dystrophic altered PDS of the cervical spine and muscle attachment sites. However, the effectiveness of this method after the operation of fixing the cervical spine with anterior access is unknown.

To restore functions in degenerative-dystrophic diseases of the spine, its injuries, it is known to use massage with a pulsating electrostatic field (Khivamat-therapy), which is based on the ability of differently charged objects to be attracted to each other when an electrostatic field arises between them. Such interacting surfaces are the patient's skin and the doctor's hands in special gloves that do not conduct current.

During this procedure, the patient and the therapist are connected to a device that generates a pulsating electrostatic field with preset parameters. When the patient's skin surface is touched by the applicator or the doctor's hands in special gloves, the subcutaneous tissue is attracted to them. This creates light reciprocating movements in the patient's massaged tissues, which the patient feels as a comfortable vibration.

Electrostatic high-frequency impulses, creating small oscillations and penetrating deeply into tissues, gently affect the skin, subcutaneous tissue, connective tissue, lymphatic and venous vessels. Such oscillations have a targeted anti-inflammatory, trophic stimulating, detoxifying and drainage effect, as a result of which local metabolic and trophic processes in the skin layers are improved and accelerated; pain and swelling are significantly reduced.

Unlike classical massage, electrostatic impulses cause tissue friction, and during the intervals between impulses, the tissue elastically resists this. Thus, the tissue is “pressed” to its full depth, affecting microcirculation in the interstitial connective tissue. During the session, the patient is on a special table or in a chair, and the specialist treats problem areas with the Hivamat device. The procedure is usually painless and lasts 15-60 minutes, depending on the purpose of treatment and the patient's condition (https://ulfar.ru/stati/khivamat-terapiya-effektivnoe-lechenie-khronicheskikh-boley/). Hivamat therapy is used for:

- pain of various origins (consequences of injuries to the musculoskeletal system, reflex and radicular syndromes of osteochondrosis of the spine, migraine, etc.),

- venous circulation disorders (chronic venous insufficiency of the extremities),

- lymphatic circulation disorders, including postoperative lymphedema,

- tissue trophic disorders (deforming osteoarthritis, osteoporosis, Bechterew's disease, rheumatoid polyarthritis, trophic ulcers of the leg, bedsores),

- disorders of muscle tone and/or contractility (cerebral palsy, consequences of hemorrhagic and ischemic strokes, craniocerebral and spinal injuries, injuries to nerves and plexuses, multiple sclerosis, polyneuritis, polyneuropathy),

- respiratory diseases (bronchial asthma, COPD, chronic bronchitis, cystic fibrosis, early postoperative period after operations on the chest organs),

- violations of the integrity of the skin (burns, open wounds),

- cicatricial changes in tissues (post-traumatic, post-burn, consequences of inflammatory infiltrates), joint contractures, etc.

Khivamat therapy combines well with other methods of drug treatment, physiotherapy, helps to enhance the effect of manual therapy, classical massage (https://nczd.ru/massazh-pulsirujushhim-jelektrostaticheskim-polem-hivamat-terapija/), including in the early stages of rehabilitation in an outpatient setting. Thus, Khivamat therapy can also be used in rehabilitation after operations on the cervical spine.

Also known is the David diagnostic and treatment complex, which is a complete rehabilitation system for the lumbar, thoracic and spinal column, consisting of a number of exercise machines and software (Review of the David diagnostic and treatment complex. 09/18/2019. https://prorehabilitation.ru/blog/reabilitatsionnye-trenazhery/obzor-lechebno-diagnosticheskogo-kompleksa-david/).

The complex includes 6 simulators with personal all-in-one computers, as well as an information kiosk for patients and medical workers or administrators. The complex includes:

1) Lumbar-thoracic extension machine. Provides activation of the extensor muscles in the lumbar and thoracic spine.

2) Lumbar-thoracic rotation machine. The load during the exercises falls on the rotational and intervertebral muscles.

3) A simulator for lumbar-thoracic flexion. The load during the exercises is directed at the muscles of the thoracic and lumbar regions in the sagittal plane.

4) The trainer for extension and lateral flexion of the neck, which we use in this method. When working on it, the load is exerted on the lateral flexor muscles, extensor muscles and lateral flexors of the activating extensor of the cervical spine.

5) A simulator for lumbar-thoracic lateral flexion. It is used to perform bends in the frontal plane. This exercise involves the lateral flexors in the lumbar and thoracic spine.

6) A cervical rotation trainer, also used by us in this method. The work of the rotational muscles of the cervical spine and head is often neglected, although they are important for the health of both the spine and cerebral circulation. Directed load on the cervical spine in the transverse plane ensures the most physiological movements.

The simulator also includes an information kiosk for managing the training session and an autonomous central station - on the same computer as the information kiosk - for storing and processing training results.

Even patients with severe back pain, low isometric muscle strength, and poor coordination can use David exercise machines. Exercises are performed in isolation: only those muscles that need to be activated are included in the work.

The exercise machines provide the most precise adjustment of the body position and smooth amplitude of movements. A small step of increasing the load makes it possible for them to be used by patients with different levels of physical fitness and pain sensations.

All exercise machines are equipped with modern EVE software, which significantly simplifies the work of selecting exercises, allows patients to independently monitor the effectiveness of training, and automatically maintains records for each patient and for the work of the entire institution.

The setting eliminates the possibility of incorrect exercise performance, so the training session is completely safe and pain is minimized.

The David medical and diagnostic complex is used for diagnostics, treatment and prevention of functional and degenerative-dystrophic diseases of the musculoskeletal system, such as: osteochondrosis, spondylosis, myositis, protrusions and herniated discs, instability of the cervical spine, scoliosis and other posture disorders, chronic pain syndrome, for rehabilitation after injuries and illnesses, spinal surgeries, for the formation and maintenance of a muscular corset, and the elimination of headaches.

A treatment complex is known that includes the combined use of a physical factor (pulsed electrostatic field - IPEF), balneotherapy (general hydrogalvanic baths) and therapeutic exercise (LFK): exercises on a simulator with biofeedback for chronic cerebral ischemia (Vygovskaya S.N., Rachin A.P., Konchugova T.V., Tarasova L.Yu., Nuvakhova M.B., Razvalyaeva D.V., Borodulina I.V., Romanenko D.N. Treatment of chronic cerebral ischemia and prevention of strokes based on a complex of physiobalneotherapy. // Medicine: practice and science: collection of scientific papers. - M .: OJSC "Medicine", 2019. - 135 p., pp. 110-114). The complex provides simultaneous correction of various mechanisms of ischemia development, including normalization of blood pressure, blood circulation in the main vessels of the head, vascular reactions of the sympathoadrenal system, restoration of the motor stereotype in the cervical PDS, relief of pain syndrome and its components (phenomena of reactive inflammation, muscle rigidity, etc.). Thus, the progression of the vascular process against the background of degenerative-dystrophic changes in the spine leads to the formation of microfocal neurological deficit with predominant damage to the stem structures of the brain, cerebellum, vestibulopathies and disorders in the psychoemotional sphere.

In this case, in the process of exposure to INCHEP in combination with hydrogalvanic baths and exercise therapy, the effect occurs already in the first days: improvement of general well-being, mood, appearance of cheerfulness, reduction of pain intensity in the neck area, their area and depth, increase in the range of motion in the cervical spine. Whereas when receiving a therapeutic complex of INCHEP and exercise therapy without hydrogalvanic baths, sympathalgia not only does not decrease from the first procedure, but on the contrary, can cause an exacerbation of the disease from the 3-4th procedure.

Against the background of the course of complex treatment, positive changes in cerebral hemodynamics are noted: activation of collateral and venous circulation against the background of normalization of the tone of intracerebral arteries.

Thus, this well-known complex of effects is effective for non-invasive neuromodulation in rehabilitation of patients with a neurological profile with a stable myorelaxant, venotonic, antispasmodic and analgesic therapeutic effect and is pathogenetically substantiated. This therapeutic complex promotes a more rapid and complete restoration of the functional state of the cervical spine, normalizes central and cerebral hemodynamics, blood hemorheology.

To summarize, we note that the most effective in the rehabilitation of various neurological problems, with a combined therapeutic and restorative effect, are certain complexes of effects that cover, if possible, the greatest number of links in the pathogenesis of a certain condition.

In patients after surgery for anterior fixation of the cervical spine, the most important factors in determining the maximum possible level of recovery, compensation for impaired body functions and limitations of life activities are the assessment of the amplitude and strength of the cervical spine muscles during extension in the sagittal plane, flexion/extension in the frontal plane with testing of rotational abilities on the David 140 and David 160 simulators, assessment of impulse conduction along the nerves in response to its stimulation with electric current (simulation ENMG), neuroimaging data (MRI of the cervical spine). In this case, it is necessary to take into account the individual reserves of the body and the compensatory capabilities of a specific patient, risk factors for complications and the environment that limit or facilitate rehabilitation, as well as determined in accordance with assessment scales (10-point Visual Analogue Scale of Pain - VAS, Pain-detect scale, Roland-Morris scale, comprehensive pain questionnaire, Spielberger-Hanin scale, Beck scale, DASH questionnaire - Disabilities of the Arm, Shoulder and Hand). To assess the patient's functions, the scale of impairment of the function of the arm, shoulder and hand, the Penn Shoulder Assessment questionnaire, the scale of pain, function and subjective sensations of use of the upper limb, the shoulder assessment scale of the University of California, Los Angeles (UCLA), the Constant scale - Constant-Murey Shoulder Score are also used.

It is recommended to start the active rehabilitation process from the 4th week of the postoperative period, and the program usually includes methods aimed at reducing the intensity of the pain syndrome: low-intensity laser therapy, electrotherapy with diadynamic or sinusoidal modulated currents, general hydrogalvanic baths combining the effects of fresh water of an indifferent temperature and electric current, relaxing gentle massage. A specific method for treating neuropathic pain is transcranial magnetic stimulation (TMS) - rhythmic action on certain areas of the brain with a high-intensity magnetic field with a given frequency and duration. The mechanism of action is based on the suppression of the pain dominant in the regulatory centers of the brain and a decrease in the excitability of the central analyzer in response to ascending afferent influences.

Rehabilitation of patients with residual/persistent neurological deficit after this surgical intervention has the following goals:

- formation of the correct motor stereotype (everyday skills, daily activities);

- restoration of the spinal support capacity - adequate biomechanics of the spinal column;

- prevention/minimization of delayed complications;

- regression of neurological deficit;

- correction of somatic disorders (pelvic organ dysfunction).

The timeframes for activation and the beginning of motor rehabilitation do not differ from those described earlier. However, in patients of this category, residual or newly developed - as a complication - neurological deficit in the form of sensory (loss of sensitivity, hypoesthesia, hyperalgesia, etc.), motor disorders (paresis of the limbs) and neurogenic dysfunction of the pelvic organs comes to the fore. The rehabilitation strategy should be adjusted taking into account the degree of dysfunction.

The physical rehabilitation program also recommends including strength exercises to train the muscles of the limbs and mobilize the joints. Occupational therapy is indicated for the development of limited or lost everyday skills and fine motor skills. These methods are usually used in patients who have undergone surgery for degenerative stenosis of the cervical spine and have a clinical picture of myelopathic syndrome.

Physiotherapeutic and balneotherapeutic procedures are recommended to be started early after the compression effect on the nerve structures has been eliminated (approximately 5-7 days after surgery). They use electrical and magnetic stimulation of paretic limbs, low-intensity laser therapy at the exit points of the peripheral nerve fiber, local (hand or foot) hydrogalvanic baths, hydrogen sulphide baths, mud applications on the affected limb.

The types of neurogenic urination disorder vary depending on the level of damage. Thus, in myelopathic syndrome due to degenerative stenosis of the cervical spine, the clinical picture shows increased frequency of urination and an increase in its strength (imperativeness). Such a disorder is corrected by taking anticholinergic drugs, it is favorable in terms of prognosis, but requires dynamic observation, since a change in the form of the disorder is possible in the long term.

As auxiliary physiotherapeutic methods, the patient is prescribed intravaginal or intrarectal electrical stimulation, peripheral sacral magnetic stimulation, biofeedback therapy for training the muscles of the pelvic diaphragm. There is also a method of chronic sacral neuromodulation - electrical stimulation of the third sacral roots using an implantable electrode. However, at the moment, it is incorrect to draw a conclusion about the effectiveness of this method in patients with degenerative spinal lesions and neurogenic dysfunction of urination in the postoperative period due to the lack of clinical data in studies.

The technical task of the proposed invention was to develop such a medical rehabilitation complex that, despite the numerous physical effects in its composition, would not reduce the patient's compliance and was capable of providing an integral therapeutic, restorative effect - on the maximum possible links in the pathogenesis of disorders that arose even before the operation with ventral fixation of the cervical spine (musculoskeletal, muscular systems, respiratory, cardiovascular and urinary systems, autonomic nervous system).

The technical result of the method is the acceleration of rehabilitation periods with a significant reduction in the level of manifestations of neurological deficit in patients with degenerative diseases of the spine who have undergone surgery on the cervical spine by anterior access, and who usually have a significant limitation of motor function, pain syndrome, neurogenic dysfunction of the lower urinary tract, cardiac complications. As a result of this rehabilitation complex, all the listed functions are restored, improved, with the effect maintained for at least 3 months.

The technical result is achieved by implementing a method for complex medical rehabilitation of patients who have undergone surgical ventral fixation of the cervical spine segments, including a set of physiotherapeutic interventions.

The complex consists of:

- classical medical massage of the muscles of the upper limbs and the area of the scapula, shoulder and supraspinatus, the duration of the procedure is 20 minutes, per course - 10 massage procedures;

- group exercise therapy sessions indicated for diseases of the cervical spine - with movements of the limbs, neck and head, using a gymnastic stick, with each exercise therapy session ending with a breathing exercise, per course - 10 daily sessions;

- exposure to low-intensity laser radiation (LILR) with a wavelength of 0.89 µm, a frequency of 80 Hz, a pulse power of 40 W, an exposure of 5 min, a contact method on the cervical spine area, a frequency of 80 Hz, a course of 10 daily exposure procedures;

- electrical stimulation (ECT) of the extensor muscles - on the deltoid and trapezius muscles, on the right and left, in a rhythmically changing frequency mode, with a carrier frequency of 2000 Hz, a frequency range of 15 Hz, a pulse-pause ratio of 3:5, with an increase in current strength from 0 mA to a current strength level that causes the appearance of a visible painless contraction of the muscle, the duration of the procedure at this current strength level is 10 minutes per area;

- exposure to a low-frequency pulsed electrostatic field on the cervical spine area using the Khivamat 200 device in the “edema” mode: electrostatic field frequency of 180 Hz for 4 minutes, frequency of 30 Hz for 4 minutes and 85 Hz for 2 minutes, per course - 10 daily procedures;

- general mineral sodium chloride therapeutic baths with a procedure duration of 10-15 minutes, water temperature of 36-37°C, mineralization of 30 g/l, daily, in a course of 8 baths.

At the end of the day of physiotherapy interventions from the 1st to the 8th day, daily sessions are conducted on the David 140 apparatus with training of neck extension and lateral head tilts and the David 160 with training of the rotator muscles of the neck, and from session to session, the weight of the load used in the apparatus is increased and the number of repetitions in the approaches is reduced.

Thus, the proposed method includes a set of measures based on hardware physiotherapy technologies, balneotherapy and mechanotherapy using David 140 and 160 spine trainers in combination with a basic rehabilitation program that includes the described effects.

The method is carried out as follows.

A classic medical massage of the upper limb is performed, affecting the shoulder, scapula and shoulder girdle area, to improve muscle tone and optimize it. The patient is in a sitting position. The procedure is performed using stroking, rubbing, kneading and squeezing techniques. The duration of the procedure is 20 minutes. The procedures are performed daily for 10 days.

Group exercise therapy classes in the complex are aimed at increasing the volume of active movements and muscle endurance to loads. Upper limb movements are performed smoothly, without sudden movements, with a comfortable amplitude, the pace of the exercises is slow and medium - comfortable for the subjective feeling of the patient. During the classes, the rule of alternating muscle groups involved in the work is taken into account, special exercises are alternated with distracting ones, and a breathing exercise is performed at the end of the class. Classes are held in a gym under the supervision of an exercise therapy instructor. The duration of the procedure (class) is usually 30 minutes. The procedures are carried out daily for 10 days.

A set of special physical exercises for the cervical and thoracic spine may include, for example, the following set of exercises from different starting positions.

Starting position (SP) - sitting on a chair :

1. Raise your arms up through the sides - inhale, lower - exhale. Above the head, turn the palms inward. Repeat 4 times.

2. Hands lie on knees. Squeeze and unclench fingers and toes simultaneously. Repeat 10 times.

3. Hands lie on knees. Raise fingers and toes up simultaneously. Repeat 8 times.

4. Shake your limbs, relax. Legs resting on your heels - rotate your hands and feet in a circle 8 times in each direction.

5. Raise the shoulder blade - inhale, lower - exhale. Repeat 4 times for each side.

6. Interlock your fingers. Straighten your arms forward, unfolding the "lock". Repeat 8 times. Then shake your hands to relax.

7. Raise your leg up onto your toes, lifting your heel off the floor one by one. Repeat 12 times for each leg.

8. Raise your straight arms up through the sides - inhale, lower - exhale. Above the head, turn the palms outward. Repeat 3 times.

9. Straighten the suspended (raised) leg one by one, pulling the toe towards you. 6 times for each leg.

10. Bend and straighten your arms at the elbows, touching the same shoulder with your hands. 8 times for each arm.

11. Raise both shoulder blades to the ears at the same time - inhale, lower - exhale. Repeat 4 times.

12. Palms lie on knees, lift leg up, performing successive "steps" while sitting - right and left leg. Repeat 8 "steps" for each leg.

13. Spread your arms to the sides - inhale. Grasp your leg by the knee with your hands and pull it to your stomach - exhale. Repeat 4 times for each leg.

14. Arms are bent, hands are located at the shoulder joints. Perform movements of the arms forward and backward for 16 counts.

15. Relax your hands and shake them.

16. Sitting on the edge of a chair, move your leg to the side, bending it at the knee as much as possible. 6 times for each leg.

17. Raise straight arms up through the sides - inhale. Bend forward, clasping your hands from below your knees - exhale. Repeat 5 times.

IP - sitting on a chair with a gymnastic stick :

18. Place the stick on the hips across the longitudinal axis of the body. Roll the stick back and forth along the hip with the palm, side and back of the hand, then the forearm. Repeat 4 times on each side.

19. The stick lies on the floor across the longitudinal axis of the body, near the feet. Roll the stick with the feet back and forth 8 times with the outer, inner and plantar surfaces of the foot.

20. Hands forward, take the stick by the middle with both hands, elbows straight. Turn the stick with your hands to the right and left 8 times in each direction. Lower your hands, shaking, relaxing.

21. Place the stick on the floor in the sagittal plane of the body. Move both legs, connected at the feet, over the stick from side to side - to the right of the stick, to the left of the stick. Repeat 5 times in each direction.

22. Hold the stick with your hands by the ends in front of your chest. Straighten your elbows alternately, stretching your arm with the stick horizontally in the appropriate direction ("lezginka"). 8 times in each direction.

23. Hold the stick with your hands by the ends in front of your chest. Raise your hands with the stick up - inhale, while exhaling lower the stick behind your head, repeat 4 times.

24. Hold the stick with your hands by the ends in front of your chest. Make circular movements with your hands holding the stick towards you and away from you - 8 times in each direction.

25. Hold the stick with your hands by the ends in front of your chest. Perform canoe-type movements to the right and left, slightly turning your body. 6-8 times ("strokes") on each side.

27. Place the stick on your hips, across, legs wider than shoulder-width apart. As you exhale, bend your arms at the elbows, arching your lower back and chest. Raise your chin up, trying to touch the stick with your chest. Repeat 8 times.

IP - sitting on a chair, putting the stick aside :

28. Hands rest on knees. Move straight arm to side with torso rotation - inhale. Touch same knee with elbow of this arm, then - with palm, then - stretch hand to heel of other leg. Repeat 4 times with each hand.

29. The hands are on the knees. Raise the hand through the side while inhaling and touch the opposite ear. Repeat 4 times for each hand.

30. Hands on the waist. Tilt the head to the right and left 4-6 times in each direction.

31. Turn your head left and right slowly 4-6 times in each direction.

32. Try to touch your chest with your chin, 4-6 times.

33. Pull your chin up, 4-6 times.

34. Hands on the waist. Rest your palms on your pelvis, trying to push yourself up from it. Reach up with the crown of your head. Repeat 4 times.

35. Raise your arms up - inhale, and as you exhale, gradually relax your muscles, from the top, starting from the fingertips to the muscles of the back and legs, lowering your arms to the starting position.

IP - standing with a gymnastic stick in your hands:

36. Feet wider than shoulders, hands on the stick in front of you at shoulder width. Raise your hands with the stick up while inhaling, rising on your toes. Lower onto your full foot and lower your hands - exhale. Repeat 6 times.

37. Hands - in the middle of the stick in front of you. The body is slightly tilted forward. Swing your arms with the stick from side to side with a comfortable amplitude. 12 times.

38. The stick is behind the buttocks, across the body, the hands of the lowered straight arms hold it - at shoulder width. Without leaning forward, raise the straight arms up as much as possible. Repeat 8 times.

39. IP is the same: the stick is behind the buttocks, across the body, the hands of the lowered straight arms hold it at shoulder width. Bend the elbows and lead the stick along the back to the shoulder blades while inhaling. On exhalation - return to IP. Repeat 8 times.

40. Stick - behind the buttocks, across the body, the hands of the lowered straight arms hold it by the ends. The body is slightly tilted forward. The arms with the stick are swung from side to side with an amplitude comfortable for the patient. Repeat 4 times in each direction.

41. Feet wider than shoulders, hands on the stick at shoulder width in front. Raise straight arms with the stick up while inhaling, simultaneously moving one leg back (alternate). Lower arms - exhale. Repeat 6 times for each leg.

42. Feet wider than shoulder-width apart, stick behind buttocks. Straight arms are on the ends of the stick. The body is slightly tilted back. Swing your arms with the stick from side to side with a comfortable amplitude. Repeat 6 times in each direction.

43. Put the stick down. Raise your arms up and gradually relax your muscles as you exhale, starting from the top, from the fingertips to the muscles of the back and legs.

Breathing exercises are performed at the end of the exercise complex. One breathing exercise is performed at one's choice - with the purpose of activating the blood flow to the internal organs, the spine, and including the whole body in the systemic work. Breathing exercises eliminate the compression of the vertebral arteries that supply blood to the spinal cord, the sympathetic nerve trunks that go along with the vessels, as a result the pain symptom and swelling in the area of inflammation of the spinal nerve roots are reduced.

The patient is offered the following breathing exercises to choose from.

1. “Hug your shoulders” - inhale while squeezing your chest:

IP: standing, arms bent at the elbows and raised to shoulder level. Direct the movement of the arms towards each other until they stop, as if hugging themselves by the shoulders. And at the same time with each "embrace" sharply "sniff" the nose. The arms at the moment of the "embrace" go parallel to each other (and not crosswise), in no case do they change them, but it does not matter which hand is on top - the right or the left; do not spread them wide apart and do not strain.

Having mastered this exercise, you can slightly tilt your head back at the moment of the oncoming movement of your hands - "inhalation from the ceiling". Normally, you can do this exercise 12 times with 8 inhalations-movements.

2. "Palms":

IP: basic stance, arms bent at the elbows, palms at the shoulders, directed away from you - forward. When clenching your palms into fists, take a short noisy breath in through the nose, exhale passively through the mouth, without noise. Repeat this cycle 4 times. Then rest for 4-5 seconds. And repeat this 3 more times.

3. "Shoulder straps":

IP: basic stance, hands at waist level, pressed to the stomach in front and clenched into fists. When inhaling, the fists are energetically lowered down with straightening of the arms, the shoulders are tense. Return to IP, the shoulders are relaxed - exhale. Perform 4 such inhale-exhale cycles. Then rest for 3-5 seconds. Then repeat the exercise one more time.

The effect of NILI with the parameters specified in the invention formula is carried out using the AZOR-2K device, with the imposition of two matrix emitters in the projection of the operated cervical spine paravertebrally.

The ECT procedures for the extensor muscles (on the deltoid and trapezius muscles) in the modes specified in the invention formula are carried out using the appropriate devices from Physiomed-Expert, BTL.

The effect of a low-frequency pulsed electrostatic field on the cervical spine area is carried out using the Khivamat 200 device in the "edema" mode: an electrostatic field frequency of 180 Hz for 4 minutes, a frequency of 30 Hz - 4 minutes and 85 Hz - 2 minutes, per course - 10 daily procedures. Electrostatic impulses that create small vibrations and deeply penetrate into the tissues gently affect the skin, subcutaneous fat, connective tissue, lymphatic and venous vessels. Such vibrations have a targeted anti-inflammatory, trophic stimulating, detoxifying and drainage effect, as a result, local metabolic and trophic processes in the skin layers improve and accelerate; pain and swelling are significantly reduced. In our case, such an effect is carried out on the cervical spine to improve trophism, reduce pain and myofascial syndrome. The course consists of 10 procedures carried out daily for 20-25 minutes.

General mineral sodium chloride therapeutic baths with a procedure duration of 10-15 minutes are carried out at a water temperature of 36-37°C. Mineralization is 30 g/l, the procedures are carried out daily, in a course of 8 baths.

All of the listed effects are carried out in a random sequence throughout the day.

At the end of the day of physiotherapy treatments from the 1st to the 8th day, daily sessions are conducted on the David 140 apparatus with training of neck extension and lateral head tilts and the David 160 with training of the rotator muscles of the neck, and from session to session, the weight of the load used in the apparatus and the duration of the approaches are increased.

The duration of such a procedure is 10-15 minutes. The procedures are carried out daily, in a course of 8 training sessions.

The first part of the BFB training is testing the isometric strength of tilting the head forward and backward, then 1 circle of exercises with the minimum weight for the patient. The second part begins only on the 4th day of training - with testing the isometric strength level with lateral tilts of the head and one circle of neck turns. The load is increased gradually - with a step of 1-2 kg per training. The number of repetitions in the approach is gradually reduced.

Before the 8th lesson, the limits of flexibility and strength of the muscles of the cervical spine are tested. The results of the initial, intermediate and final tests are compared. The following muscles are involved in the training: mm. Superior trapezius, Splenius capitis, Splenius cervicis, Semispinalis capitis, Longissimus capitis, Longissimus cervicis, Interspinales cervicis, Semispinalis cervicis, Sternocleidomastoideus, Scalene anterior, Scalene middle, Scalene posterior and others.

The David 140 simulator directs the load on the extensor muscles and lateral flexors of the activating extensor of the cervical spine and on the lateral flexor muscles (m. splenius, cervicaler m. erector spinae, m. levator scapulae, m. trapezius pars descendens, thoracaler m. erector spinae, m. scalenus anterior, m. longus capitis, m. sternocleidomastoideus).

The David 160 trainer directs the load on the cervical spine in the transverse plane, activating the rotational muscles of the head and neck (m. sternocleidomastoideus, m. splenius capitis, m. splenius cervicis, m. rectus capitis posterior major, m. obliquus capitis inferior, m. scalene anterior, m. scalene middle, m. scalene posterior, m. multifidus, m. semispinalis cervicis). These trainers with biofeedback provide isolated movement similar to real movement in everyday life.

The actual training on the exercise machines is carried out for 8 days daily in the first half of the day after the rest of the physiotherapy methods of the rehabilitation course have been completed.

On the first day of the training course, patients undergo testing to assess the capabilities of the extensor and lateral flexor muscles of the cervical spine on the David 140 device. Based on the data obtained, a trial session is conducted. The addition of additional weight during training is only 1 kg (minimum weight), the number of repetitions in one approach is 35.

The 2nd day of training already includes three sets of 35 repetitions, the additional weight during training is 2 kg for the first two sets and 3 kg for the third, final set.

Day 3 - three sets of 35 repetitions, additional weight during training - 3 kg for the first two sets and 4 kg during the final set. The exercise execution time from day 1 to day 3 is 7 sec (extension in the sagittal plane, bending to the right and left in the frontal plane) to obtain an isometric effect for the purpose of more detailed, isolated training of the neck muscles.

On the 4th day, testing is carried out to assess the rotational capabilities of the CSP using the David 160, 3 training sets of 30 repetitions, the additional weight used is 5 kg for the first two repetitions and 6 kg for the final set on the David 140 and one test training set on the David 160.

The starting position (IP) when performing rotational movements is an angle of 30°, opposite to the direction of the planned movement.

Day 5 - The workout included 3 sets of 30 reps, an additional weight of 6 kg for two sets and 7 kg for the third, final set on David 140, as well as 2 sets with an additional weight at the time of training of 2 kg on David 160.

The exercise execution time on the 4th and 5th days of training was reduced to 4 seconds. Increasing the additional weight during training and reducing the exercise execution time allows for the formation of a motor stereotype, since 2-4 seconds are usually required for the patient to perform a movement in the spinal column when performing everyday tasks.

Since dynamic stereotypes can be considered as a basic structural unit of the entire system of movements, implemented through elements of the musculoskeletal system, it is worth paying special attention to their formation. Additional weight during training is increased daily by 1 kg before performing the third, final approach, for better adaptation of the patient as a whole to the load.

Day 6 - the workout consists of 3 sets of 25 reps, additional weight - 8 and 9 (for the 3rd set) kg, respectively, on David 140, and 2 sets on David 160, additional weight -3 kg.

Day 7 - 3 sets of 25 reps, additional weight 9 and 10 kg (for the 3rd set) on David 140, and 2 sets on David 160, additional weight -4 kg.

Day 8 - training includes 3 sets of 20 reps with additional weight of 11 and 12 (for the 3rd set) kg on David 140, and 2 sets on David 160, additional weight - 5 kg.

The time for performing exercises in the period from the 5th to the 8th day increases and is 7 seconds due to the patient’s achieved adaptation, as well as to improve his strength qualities.

On the last, 8th day of the training course on David simulators, in addition to training approaches, repeated testing is carried out on both simulators - David 140 and David 160, to assess the effectiveness of the training process (assessment of the amplitude and strength of the muscles of the cervical spine during extension in the sagittal plane, flexion/extension in the frontal plane and testing of rotational abilities).

The proposed method provides a comprehensive approach to the restoration of lost functions, a favorable motivational background for the patient, prevention of postoperative complications, an increase in the range of motion in the affected limbs, an improvement in the sensory component, a reduction in pain syndrome and muscle dystonia; with the preservation of the achieved effects for 3 months or more.

Treatment of lost neurological functions was performed in 10 adult patients with degenerative-dystrophic changes in the spine at the level of the cervical spine, with stabilization of damaged VDS at the level of the cervical spine by anterior access with the presence of pain syndrome, sensory disorders, impaired control of the lower urinary tract, impaired motor activity according to the rehabilitation routing scale 4 (5 men, 5 women, average age 35.89 ± 9.33). All patients, along with drug therapy (Clinical guidelines - Degenerative diseases of the spine - 2021-2022-2023 (04.03.2022) - Approved by the Ministry of Health of the Russian Federation), underwent neurorehabilitation treatment in the form of the proposed set of procedures, including hardware physiotherapy, mechanotherapy using the David spine simulator, and general mineral baths.

For clinical assessment of the severity of patients' condition, the following scales were used: VAS (10-point), Pain-detect scale, Roland-Morris scale (https://sudact.ru/law/klinicheskie-rekomendatsii-skeletno-myshechnye-nespetsificheskie-boli-v-nizhnei/prilozhenie-g1-gn/prilozhenie-g3/), comprehensive pain questionnaire, Spielberger-Khanin scale, Beck scale, DASH questionnaire (Disabilities of the Arm, Shoulder and Hand), Arm, Shoulder and Hand Disability Scale, Penn Shoulder Assessment questionnaire, pain, function and subjective sensations scale of upper limb use, UCLA Shoulder Assessment Scale, Constant-Murey Shoulder Score, assessment of the amplitude and strength of the cervical spine muscles during extension in sagittal plane, flexion/extension in the frontal plane and testing of rotational abilities on the David 140 and David 160 simulators.

Against the background of the individual rehabilitation program conducted within the framework of the study, a decrease in spasticity of the muscles of the lower extremities, torsional tension, a decrease in the intensity of pain in the area of surgical intervention were noted, more than 55% of the studied patients noted the restoration of superficial sensitivity in the hand, an improvement in fine motor skills of the hand of the previously affected hand, positive effects on the neurogenic bladder, an improvement in the quality of life were noted. Two out of 10 patients completely returned to the previous standard of living (before the disease). Three out of 10 patients noted slightly positive dynamics. During control examinations 3 months after the end of the rehabilitation course, the achieved improvements are preserved. In the process of receiving the rehabilitation course, all patients noted good tolerance of the physical effects, good compliance.

To demonstrate the achievement of the technical result of the invention, we also present a clinical example of the use of the claimed method.

Example 1

Patient P., 45 years old. Diagnosis: Failure to undergo back surgery syndrome. Surgery on June 19, 2023: Anterior microsurgical decompression of the spinal cord at the level of the C5-C6 vertebrae, anterior stabilization of the spine (Anchor-C cage, Stryker) at the level of the C5-C6 vertebrae under fluoroscopic image intensifier control (radiation load - 0.75 m3v).

Background diseases: Degenerative-dystrophic disease of the cervical spine, combined degenerative stenosis of the spinal canal at the level of C5-C6 vertebrae, bilateral compression-ischemic radiculopathy C6.M48.0.

A set of rehabilitation measures was carried out in accordance with the effects specified in the invention formula:

- classic medical massage of the upper limb and shoulder girdle, with a choice of massage movements taking into account the existing tone of the corresponding muscles, 10 procedures;

- group exercise therapy with a set of exercises for diseases of the spine and cervical spine, using a gymnastic stick and a breathing exercise at the end of each session, the patient chose one of the breathing exercises we offered, 10 sessions;

- exposure to LILI in the specified mode and parameters in order to improve microcirculation, regenerative and anti-edematous effects, to achieve anti-inflammatory, analgesic effects and improve the mobility of the cervical spine joints;

- ECT of the extensor muscles - on the deltoid and trapezius muscles, on the right and left, in the rhythmically changing frequency mode, with a carrier frequency of 2000 Hz, a frequency range of 15 Hz, a burst-pause ratio of 3:5, with an increase in current strength from 0 mA to a current strength level causing the appearance of a visible painless contraction of the muscle (changed from session to session), the duration of the procedure at the achieved current strength level for contraction of muscle fibers was 10 minutes per muscle area;

- exposure to a low-frequency pulsed electrostatic field on the cervical spine area using the Khivamat 200 device in the “edema” mode: an electrostatic field frequency of 180 Hz was applied for 4 minutes, a frequency of 30 Hz for 4 minutes, and then 85 Hz for 2 minutes, per course - 10 daily procedures;

- general mineral sodium chloride therapeutic baths lasting 10-15 minutes (the time varied from procedure to procedure), water temperature 36-37°C (the water temperature fluctuated within this range during each procedure), mineralization 30 g/l, daily, in a course of 8 baths.

At the end of the day of physiotherapy interventions, from the 1st to the 8th day of the entire 10-day course, daily sessions were conducted on the David 140 apparatus with training of neck extension and lateral head tilts and the David 160 with training of the rotator cuff muscles, with the weight of the load used in the apparatus being increased from session to session and the number of repetitions in the approaches being reduced, as shown above.

Against the background of the conducted complex, dynamics were noted on a number of assessment scales and criteria:

1) Evaluation on the David hardware complex:

- range of motion in the cervical spine , increase after the rehabilitation course, compared with the data obtained upon admission of the patient:

extension +21.8%, flexion +47.1%,

lateral tilt to the right +0.6%, lateral tilt to the left +8.7%,

right rotation +13.2%, left rotation +7.2%;

- the strength of movements in the cervical spine, an increase after the rehabilitation course, compared with the data obtained upon admission of the patient:

extension +19.9%,

right flexion +17.4%,

lateral flexion to the left +26.6%,

right rotation +117.1%,

left rotation +65.5%.

2) YOUR score upon admission - 6 points, upon discharge - 3 points.

3) Pain-detect scale data: upon admission - 13 points (undefined neuropathic component), upon discharge - 10 points (negative neuropathic component).

4) Data from the Roland-Morris scale (consists of 24 items that the patient answers; the total number of items marked by the patient is calculated, the possible result is from 0 to 24; the greater the number of items marked, the more pronounced the impairment of vital functions): upon admission - 3, upon discharge - 2.

5) Assessment of the patient’s emotional and personal sphere.

In the patient's current condition at the time of discharge from the hospital, no signs of anxiety and depression were detected according to the HADS scale. The mood background is stable.

The patient assesses his condition as satisfactory (the level of subjective comfort is somewhat reduced). The condition index is 46 points (initially upon admission - 40 points), with the norm being 48 points. Psychophysical tone, sleep functions are reduced (wakes up at night, then cannot fall asleep for a long time).

A quantitative assessment of the emotional-personal sphere and attitude towards the disease is presented in Table 1.

Table 1

Indicators/date of assessment 11.09.23 22.09.23 HADS Anxiety Level 7 5 HADS Depression Level 7 4 Level of situational anxiety according to the Spielberger-Hanin scale 37 33 Level of personal anxiety according to the Spielberger-Hanin scale 37 32 Physical Health SF-36 31.09 33,00 Mental Health SF-36 57.64 66.97

The patient subjectively notes good tolerance of the effects used, increased faith in the success of rehabilitation, treatment and complete restoration of functions.

At the control examination after 3 months - improvements were maintained, muscle tone of the limbs, neck, shoulder and pelvic girdle was not affected, there was no pain syndrome. Movements were in full range.

Claims (9)

A method of comprehensive medical rehabilitation of patients who have undergone surgical ventral fixation of segments of the cervical spine (CS), including a range of physiotherapeutic interventions, characterized in that the complex consists of: - classical medical massage of the muscles of the upper limbs and the area of the scapula, shoulder and supraspinatus, the procedure duration is 20 minutes, per course - 10 massage procedures; - group exercise therapy sessions indicated for diseases of the cervical spine - with movements of the limbs, neck and head, using a gymnastic stick, with each exercise therapy session ending with a breathing exercise, per course - 10 daily sessions; - exposure to low-intensity laser radiation (LILR) with a wavelength of 0.89 µm, a frequency of 80 Hz, a pulse power of 40 W, a 5-minute exposure using the contact method on the cervical spine area, a frequency of 80 Hz, a course of 10 daily exposure procedures; - electrical stimulation (ECT) of the extensor muscles - on the deltoid and trapezius muscles, on the right and left, in a rhythmically changing frequency mode, with a carrier frequency of 2000 Hz, a frequency range of 15 Hz, a pulse-pause ratio of 3:5, with an increase in current strength from 0 mA to a current strength level that causes the appearance of a visible painless contraction of the muscle, the duration of the procedure at this current strength level is 10 minutes per area; - exposure to a low-frequency pulsed electrostatic field on the cervical spine area using the Khivamat 200 device in the “edema” mode: electrostatic field frequency of 180 Hz for 4 minutes, frequency of 30 Hz for 4 minutes and 85 Hz for 2 minutes, per course - 10 daily procedures; - general mineral sodium chloride therapeutic baths with a procedure duration of 10-15 minutes, water temperature of 36-37°C, mineralization of 30 g/l, daily, in a course of 8 baths; At the end of the day of physiotherapy treatments from the 1st to the 8th day, daily sessions are conducted on the David 140 apparatus with training of neck extension and lateral head tilts and the David 160 with training of the rotator cuff muscles, and from session to session, the weight of the load used in the apparatus is increased and the number of repetitions in the approaches is reduced.