Exercises for the stump of the lower leg. Appointment and types of exercise therapy after leg amputation. Technique and steps of the truncation procedure
prof. Kruglov Sergey Vladimirovich (left), Kryuchkova Oksana Aleksandrovna (right)
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Page editor: Kryuchkova Oksana Aleksandrovna — traumatologist-orthopedist
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Leading specialists in the field of traumatology and orthopedics
Sikilinda Vladimir Danilovich
Sikilinda Vladimir Danilovich, Professor, Doctor of Medical Sciences, Head of the Department of Traumatology and Orthopedics, Rostov State Medical University, Vice-President of the All-Russian Association of Traumatologists and Orthopedists of the Southern Federal District
Physical methods of rehabilitation of patients and disabled people with defects in the musculoskeletal system are widely used in prosthetic and orthopedic practice and are aimed at eliminating or reducing disorders and deformities that prevent prosthetics and the use of prosthetic and orthopedic products or complicate them. Rehabilitation with the help of physical methods has not only therapeutic, but also preventive value. The most effective in prosthetic and orthopedic practice are exercise therapy, occupational therapy, sports therapy, mechanotherapy, massage, electrical muscle stimulation, physiotherapeutic methods (dynamic currents, ultrasound, electrosleep, magnetic, laser and acupuncture). Physical rehabilitation methods are used at all stages of the prosthetics process - from preparation for it to learning to use prosthetic devices.
In the system of physical therapy (LFK), the leading factor affecting the patient is physical exercise. They are divided into restorative, special, sports-applied type, game.
General strengthening exercises affect the entire body, mainly on healthy areas of the body. Special (selective) exercises solve a narrower problem - the restoration of the impaired function of the musculoskeletal system. Both types of exercises are used in combination. It is very important to choose the right exercises and present them in an interesting way, which causes positive emotions in patients and distracts them from “going into the disease”. The therapeutic effect is achieved mainly through regular and prolonged exposure to physical exercise. Their correct use is determined by the clinical condition of the patient and the corresponding individual selection, methodology and dosage of exercise therapy, taking into account the characteristics of his motor abilities.
The task of exercise therapy at the first stage of prosthetics is the physical preparation of the whole body, stump or affected limb for the development of an orthosis or prosthesis.
The specific tasks of performing general strengthening and special exercises follow from the main clinical features: increasing the general tone of the body, strengthening the truncated muscles of the stumps and muscles surrounding the joints, eliminating or reducing contractures and stiffness of the joints, strengthening the muscles of the trunk and shoulder girdle, training balance and vestibular function, and also the coordination of movements of the upper and lower extremities, the supporting function of the hands, the strengthening of the muscles of the remaining limbs.
In patients who have lost limbs, another type of special gymnastics is used - phantom-pulse, that is, mental reproduction of movements in the missing limb segment. It improves blood and lymph circulation in the stump, improves tone and strengthens truncated muscles, and prevents trophic disorders. Such gymnastics is expedient not only at any stage of prosthetics, but throughout the life of the patient. With the participation of a methodologist, the disabled person sends an impulse to “flexion” or “extension” of the nearest missing joint (for example, the knee joint during hip truncation). The movement is performed slowly, muscle tension is maintained for at least 1-2 s. This is followed by a pause - rest, after which the exercise is repeated. To facilitate the ability to mentally bend the missing joint, the exercise is accompanied by a similar movement of the preserved leg. It can be combined with active hip extension, slight adduction of the stump, or internal rotation (simultaneous or sequential). Phantom-pulse gymnastics is carried out under a metronome with an average
at a rate of 24-26 beats per minute for 5-10 minutes 5-10 times a day.
In patients with flaccid paralysis of the extremities, ‘impulse gymnastics’ is also used, which causes a mental contraction of the laretic muscles. Pulse gymnastics must be strictly dosed, because excessive and frequent muscle contractions without prior preparation lead to pain and a decrease in muscle tone. In the first 3-5 days, it is recommended to perform 2 contractions twice a day. The maximum contraction of the muscles should be alternated with their maximum relaxation. After the extensors of the stump are strengthened so that during walking the patient can hold the stump of the foot in the correct position, i.e., load the heel and raise the anterior part of the stump to the level of a normal arch, they begin to learn to walk without shoes.
After articulation in the hip joint, impulse gymnastics is necessary to strengthen the gluteal muscles. After amputation of the thigh, attention is focused on strengthening the extensors of the stump and adductors. The simultaneous tension of these muscle groups facilitates the use of the prosthesis. After amputation of both hips, it is advisable to train the stump extensors, adductors and internal rotators. After amputation of the lower leg, the extensor and flexor flexors of the knee joint should be strengthened, with an emphasis on the movements necessary for walking on the prosthesis.
All patients after amputation of the lower extremities at any level need special exercises to strengthen the muscles of the trunk in order to prevent postural disorders, eliminate the pelvic tilt in the frontal plane, and strengthen the weakened muscles of the back and abdomen. For this, tilts, turns of the upper and lower half of the body towards the truncated limb are performed. Thanks to training, the patient must learn to rise with support on his hands, maintain the correct posture, and move from one position to another without assistance. At the same time, exercises are also needed to strengthen the muscles of the preserved leg.
After a unilateral amputation, conditions arise that make it difficult to relax the muscles. The supporting function of the preserved limb is enhanced, balance is difficult to maintain, the leg gets tired quickly, pains appear in the ankle and knee joints, the muscles of the leg and thigh become excessively tense. In these cases, first of all, the patient must use crutches correctly. They are selected according to his height. The transfer of the preserved leg and flexion at the knee joint should be carried out freely, without significant tension in the muscle groups. The movements of the preserved leg and stump must be coordinated. The pelvis should be kept from tilting towards the stump so that the right and left halves of it are at the same level.
When the remaining leg is carried forward, the stump must be unbent backwards with a slight adduction at the same time. This is especially important with flexion-abduction or flexion contractions.
pax. The correct position of the stump when standing and walking is a prevention of the development of limited mobility in the joints, helps to maintain balance and coordination of movements, increases stability, strengthens the muscles of the trunk and stump, creates favorable conditions for subsequent learning to walk on a prosthesis.
After amputation of the upper limb, an asymmetric position of the shoulder girdle occurs, the muscles of the truncated limb and the shoulder girdle of the same name are weakened. In this regard, scoliosis in the upper thoracic spine is possible, which can become fixed if exercise therapy is not performed.
It is important to maximize the remaining functionality of the stump and shoulder girdle. In the joints, it is necessary to restore the full range of motion and strengthen the surrounding muscle groups. Symmetrical and asymmetric exercises are used in dynamic and static modes of muscle work, as well as sports and game exercises using projectiles. Muscle tension during exercise is alternated with relaxation, and the patient must learn to relax the muscles, feeling this state. Regardless of the length of the stump, its participation in the movement is necessary. Exercises to strengthen the muscles of the shoulder girdle are of great importance in mastering the prosthesis and maintaining correct posture. They train the mobility of the shoulder girdle from the side of the truncated and preserved limb, perform exercises that contribute to the lowering of the shoulder girdle.
With congenital anomalies of the limbs, early use of exercise therapy is necessary. The exercises are aimed at developing the necessary motor abilities in children, developing mobility in the joints and muscle strength, and correcting the habitual incorrect body position. Identification and training of various movements in the limb allow using them to control the prosthesis.
Exercise therapy for patients with the consequences of poliomyelitis with flaccid paralysis of the limbs is aimed at strengthening the weakened muscle groups, eliminating deformities of the musculoskeletal system, and training the support function of the shoulder girdle and arms. At this stage, physical exercises in the unloading position are important. Exercise therapy is combined with impulse gymnastics, massage, the intensity of which increases as the active function appears.
In children with spastic cerebral palsy (CP), exercises are prescribed to help relax muscles, train voluntary movements, coordinate movements and balance. Each workout should be preceded by the alignment of the vertical posture, posture correction. Only then can you begin to master the movement. It is necessary to start walking not from the toe, but from the heel, correctly perform the front and rear pushes of the foot, in the phase of support on the entire foot, one should not bend the leg at the knee joint.
The choice of exercise therapy techniques for preparing for prosthetics in patients with paralysis of the lower extremities with spinal cord injuries depends on the level and degree of damage to it, as well as on associated complications. In these cases, it is necessary to make full use of active motor impulses traveling along the preserved pathways of the spinal cord. In patients, compensatory capabilities are identified and developed in order to maximize their use in learning to stand and walk in orthopedic devices.
In case of scoliosis, during the period of preparation and use of the corset, daily special corrective gymnastics is necessary to strengthen the weakened muscles of the back and abdomen in combination with massage. Gymnastics is carried out 2 times a day in an unloaded position (lying, on all fours). In these cases, slopes towards the convexity of the main curvature are effective. They educate and train the ability to maintain a corrected position of the spine in a sitting, standing, walking position.
MECHANOTHERAPY AND MASSAGE
Exercise therapy methods are supplemented with mechanotherapy, i.e., treatment with physical exercises using special devices (devices with blocks, pendulum). The latter are used to eliminate contractures and stiffness in the knee, ankle and elbow joints. Contractures of the hip joints are eliminated with the help of block devices. However, after amputation, and especially with short femoral stumps, the best results are achieved by manual redressing after thermal procedures (paraffin and ozocerite applications). The development of contractures by means of mechanotherapy should be carried out at least 2 times a day. After active training, patients are prescribed rest in bed in a special orthopedic styling, which fixes the position in the joint achieved by the development.
In diseases of the musculoskeletal system, manual massage is used (segmental, suction, acupressure, retraction). The method and technique of massage depend on the nature of changes in the musculoskeletal system, the localization of the pathological process, the age of the patient, etc.
Indications for the use of massage are a decrease in the functional ability of the muscles and ligamentous apparatus, their painful reflex tension, impaired peripheral circulation (edema, congestion), phantom pain, poor mobility of scar-changed skin, etc.
Massage in combination with other means contributes to the formation of a new vital organ - the stump, which can ensure the full use of the prosthetic tool. Segmental massage affects the affected part and the reflex zone, which allows it to be used in the early stages of treatment. Suction massage is used for stagnant and edematous phenomena in the tissues and starts from the upstream departments. The main techniques are various types of stroking and kneading. Acupressure is carried out taking into account nerve points, the location of which depends on the nature of the pathological process. The main techniques are rubbing and vibration. Retractive massage is used in preparation for plastic surgery on the stumps of the limbs to increase the mobility of the skin and cover them with incompetent scar tissue. The main techniques are pinch-shaped retraction of the skin, stretching stroking, displacement of the skin relative to the bone bed.
Massage is more often carried out before physical exercises, but it can be carried out after them and in the process of their implementation.
In recent years, electrical muscle stimulation (ESM) has been used in the practice of preparing patients for prosthetics.
Electrical stimulation (ES) of the stumps and weakened muscles of the lower extremities is carried out according to the Kotz method. It is carried out daily (10-15 sessions in total) using the Stimul-1 apparatus. After 2-3 sessions, patients develop a "feeling" of the muscle being trained and the ability to strain it, and after 6-7 sessions, an increase in the volume of the stump due to muscle mass can be noted. On average, during a course of electrical stimulation, muscle strength increases by 17-2 times, and their electrical activity - by 2-3 times.
Electrical stimulation allows you to cause more muscle tension than with their arbitrary contraction, and when training atrophic muscles, an increasing number of muscle fibers are gradually involved in the contraction process.
After amputation of the thigh, the gluteal muscles are stimulated in order to increase their strength and tone, actively influence the elimination of flexion contractures of the hip joints and improve the control of the prosthesis. ES of the anterior and posterior muscle groups of the femoral stump, in addition to strengthening these muscles, improving the trophism of the analgesic effect, helps patients feel these muscles and facilitates the performance of phantom-pulse gymnastics.
After amputation of the lower leg, it is advisable to perform ES of the stump and thigh (calf, quadriceps, gluteal muscles). At the same time, it is assumed that patients with a lower leg prosthesis do not extend the hip joint enough, but extend the knee joint in the stance phase, which distinguishes their walking from normal.
With congenital underdevelopment of the upper limbs, ES helps patients to feel the corresponding muscles and increase their strength in a short time. When prosthetics with bioelectric prostheses, ES allows achieving the required electrical activity of the muscles of the stumps and the separation of their contraction, which is necessary for controlling the prosthesis.
With congenital underdevelopment of the lower extremities and the use of foot movements to control movement in the knees
joints, ES of small-arm muscles is carried out in combination with manual development of foot abduction movement.
The use of ESM is especially important in teaching walking on the prob- es of the femur and tibia. The contraction of the necessary muscle groups in certain phases of the stepping movement helps the patient to feel this contraction and understand how and when the muscles should be activated when walking on a particular prosthesis. Its use in walking during primary prosthetics prevents the formation of irrational locomotor compensations and helps to correct them if they arise in the process of learning to walk.
With the stump of the thigh, electrodes are applied to the gluteal region and the back surface of the stump. In patients, stability on the prosthetic limb improves, prosthesis control skills improve, confidence appears when walking, the step of the preserved limb is more freely carried out, forward1 movement improves, and the need for additional support on a cane disappears.
In the case of the shin stump, electrodes are applied to the gluteal, quadriceps, or gastrocnemius muscles. This contributes to the strengthening of the muscles directly during the performance of step movements and the formation of the locomotor act of walking in new conditions - on the prosthesis. The use of ESM while standing and walking in prostheses also facilitates the training of sports exercises.
PHYSIOTHERAPEUTIC TREATMENT
In the process of preparing for prosthetics, physiotherapy is widely carried out. A significant effect is provided by such methods as treatment with ultrasound, laser radiation, magnetic field, diadynamic currents, electrosleep, as well as acupuncture.
Ultrasound is a mechanical vibration: particles of the medium propagating in the form of waves in the acoustic frequency range above 20 kHz, causing alternating compression and irritation of the substance. For the treatment of patients with amputation stumps of the lower extremities, high-frequency ultrasound (from 800 kHz to 3 kHz) is used. Under the influence of ultrasonic vibrations that penetrate into the tissues of the body to a depth of 5 cm, micromassage of tissue elements occurs.
Ultrasound has a local and general effect on the body. It is accompanied by tissue biostimulation phenomena: influence on biocolloids, intracellular metabolism, enzymes, membrane permeability, etc. Depending on the doses used, its effect can be damaging, depressing, stimulating-normalizing, anti-inflammatory and resolving. In small doses, ultrasound has an analgesic, anti-inflammatory, antispasmodic, vasodilating, resolving, desensitizing effect, accelerates the processes of regeneration and repair. It enhances the permeability of the skin in relation to medicinal substances and increases the absorption capacity of tissues.
In this case, ointments or solutions of drugs are used (hydrocortisone, lrednisolone, analgin, bicillin, etc.).
The therapeutic efficacy of ultrasonic effects depends on the correct selection of intensity, location, area and duration of exposure, methodological techniques or methods of conducting the procedure (labile or stable, contact or through water), mode of operation (continuous or pulsed). The duration of exposure to ultrasound on one field is 3-10 minutes. The course of treatment consists of 6-12, less often 15-20 procedures. Repeated ultrasound treatment is recommended not earlier than after 3-5 months. In case of phantom pains, trophic disorders of the stumps, vascular diseases, sometimes it is necessary to combine the local effect of ultrasound with segmental (on the paravertebral region).
In case of violations of the trophism of the stumps (scar-trophic ulcers, long-term non-healing wounds, hyperkeratosis), a continuous mode is used (mobile technique, direct contact of the vibrator). The intensity of ultrasound is 0.2-0.4 W/cm2, the duration of exposure is 3-5 minutes, and with the underwater method - 0.2-0.6 W/cm2 and 5-8 minutes, respectively. The course of treatment consists of 10-15 procedures, which are carried out every other day, less often daily. Under underwater exposure, the ulcer is lubricated with an indifferent ointment. During the epithelialization of the ulcer, the dose of ultrasound is reduced so as not to cause damage to the "young" epithelium. With post-thrombotic ulcers, ultrasound therapy is not performed.
In case of pain syndrome of the stump (painful neuromas, local or radiating pains, phantom pains, causalgia), ultrasound is applied to the stump area and along the projection of the neurovascular bundle. Continuous mode, direct contact, mobile technique. The intensity of ultrasound is 0.4-0.6 W / cm2, the duration of exposure is 5-7 minutes (every other day or daily). With phantom pain, it is also used paravertebral to the area of the corresponding sympathetic nodes. Continuous or pulse mode. The intensity of ultrasound is 0.2-0.4 W/cm2 for 2-3 minutes on each side. The course of treatment is 6-8 procedures.
Ultrasound therapy of the Ruots area is carried out in continuous mode, direct contact, mobile technique. Ultrasound intensity 0.4-0.8 W/cm2, 5-8 minutes (daily or every other day). The course of treatment consists of 12-15 procedures. The best contact medium (for cicatricial changes) is fish oil. With rough keloid scars, chlorpromazine phonophoresis is recommended / a 5% solution of chlorpromazine in glycerin serves as a contact medium).
With trauma, hydroadenitis, carbuncle, ultrasound is applied at the initial stage of infiltrate development. The mode is continuous, the technique is movable, the contact of the vibrator is direct or movable (for the foot and hand), the intensity of ultrasound is 0.4 0.8 W/cm2, the duration of the daily session is 3-5 minutes.
Contraindications to ultrasound treatment are diseases of the central nervous system (impaired cerebral circulation, psychoneurosis, diencephalic syndrome, arterial hypotension), pregnancy, bleeding tendency, grade III hypertension and coronary sclerosis, angina pectoris, blood diseases, cachexia, malignant neoplasms.
Indications for the appointment of laser therapy are trophic changes in the soft tissues of the stump with a violation of the processes of reparative regeneration in the form of hyperkeratosis, ulcerations, ulcers and long-term non-healing wounds, pain syndromes - phantom pain syndrome, neuralgia syndrome (in some classifications it is designated as ascending neuritis), local pain in the stump and painful neuromas; chronic inflammatory diseases of the soft tissues of the stump (namin, bursitis, trauma), degenerative-dystrophic diseases of large joints and spine, often associated with amputation stumps, osteochondrosis.
The variety of nosological forms and pathological conditions in which helium-neon laser radiation is used is explained by a wide therapeutic range of its action. The rationale for the use of helium-neon laser radiation is the active biological effect of monochromatic red light on the processes of skin regeneration, regeneration of a damaged peripheral nerve, a beneficial effect on the course of neurotrophic processes, a reduction in the formation of arterial collaterals [Rakhishev A. R., 1981], a decrease in pain impulses from the irradiated area [Tarasov O. V., 1977].
Laser therapy is prescribed in cases where other types of treatment have proven ineffective and for patients who are contraindicated in other treatments due to hypertension, coronary heart disease, atherosclerosis or diabetes mellitus. The use of helium-neon laser radiation in the TsNIIPP clinic in the treatment of the listed diseases and pathological conditions has shown its sufficient effectiveness.
With laser therapy, patients are prescribed the usual orthopedic regimen for this pathology. It is possible to combine laser therapy with exercise therapy, massage, ESM, and in wound processes - with the use of antiseptic solutions, proteolytic enzymes, and ultrasonic wound debridement. During treatment with helium-neon laser radiation, drowsiness (feeling of weakness) and a slight decrease in blood pressure may appear, which is not an indication for its termination.
For treatment, domestic lasers LG-75, LG-12, LG-36, LG-38 of continuous action based on gas (helium, neon) are used, emitting polarized monochromatic red light (wavelength 632 nm), with an output power of 15 to 50 mW. A session of laser therapy is carried out in the position of the patient lying or sitting and consists in irradiating certain areas and parts of the body
with accurate exposure. The total exposure time during one session should not exceed 20-30 minutes. The course of laser therapy is 15-20 sessions, carried out if possible daily. Laser therapy is contraindicated in oncological diseases, in the first half of pregnancy, with dysfunctional uterine bleeding, tuberculosis in the active stage, thrombophlebitis.
Clinical observations testify to the sedative, analgesic, antipruritic and anti-inflammatory effects of a constant magnetic field (PMF). When using PMP, emotional stress decreases, song normalizes, blood circulation and tissue trophism improve, and their swelling decreases.
Since there is no standard mass-produced equipment, rubber-based elastic magnetophores are used, which create a PMF with a strength of 11,940 to 160,000 A/m and more. Magnetophores are produced in the form of rectangular plates measuring 40X120x3 mm in a polyethylene sheath. Magnetophores are fixed to the body with gauze bandages. The duration of the session is from 20 minutes to 18 hours per day. The course of treatment takes from 2 to 8 weeks. Treatment is also carried out using the device "Pole-1" by exposure to a magnetic field of alternating direction. The magnetic field is effective in the following diseases of the musculoskeletal system: osteochondrosis of the spine with concomitant radiculitis, arthrosis of the joints, bursitis, phantom pain, diseases of the veins of the preserved limb after unilateral amputation, trophic ulcers and non-healing wounds of the stump.
With trophic ulcers and non-healing wounds, they are affected by a low-frequency magnetic field. The procedure can be carried out in the presence of a bandage moistened with wound discharge. In this case, the cylindrical inductor is installed on the bandage without an air gap. The current is half-wave, the magnetic field mode is pulsed. Intensity 270-350 Oe (III-IV stage). The duration of the procedures is from 10 to 20 minutes. They are carried out daily; for a course of treatment 10-20 procedures. With abundant exudation of a wound or ulcer, the tension is reduced to 175 Oe, and sometimes to 120 Oe.
In violation of the trophism of the tissues of the stump, phantom pains affect the paravertebral zones of the cervicothoracic or lumbar spine (sympathetic nodes of the autonomic nervous system, corresponding to the level of innervation of the upper or lower extremities). Rectangular inductors are installed with a gap of 5 mm. Sinusoidal current, continuous mode, intensity 190 Oe for 10 minutes. At the second stage, the stump is affected by cylindrical inductors. Sinusoidal current, continuous mode, intensity. 175-350 Oe, procedures are carried out for 10-20 minutes daily (15 procedures in total).
In diseases of the joints, osteochondrosis of the spine, epijondylitis, spurs of the calcaneus, a local effect on the affected joints is used, but not more than two joints per procedure. Cylindrical inductors are used, they are installed on the affected joint. The current is sinusoidal, the mode is continuous, the tension is 175-270 Oe (the tension is increased from the 5th procedure). The duration of the procedure is from 10 to 20 minutes. Nurs treatment is 10-15 procedures.
After surgical interventions (reamputation, excision of scars, skin plastics, etc.), magnetotherapy is used 5 days after the operation. They act on areas more distant from the operated area (for example, during surgery on the stump of the lower leg, magnetic therapy is performed in the lower third of the thigh). In this case, cylindrical inductors are used, the intensity is 270 E. The current is sinusoidal, the mode is continuous, the duration of the procedure is 10-15 minutes (5 procedures in total). After 5 days, a local effect on the operated area is carried out. Inductors are used cylindrical, their location is transverse. Sinusoidal current, continuous mode, intensity 175-270 Oe with daily use for 10-15 minutes (treatment course 15 procedures).
In chronic venous insufficiency of the lower extremities, the consequences of thrombophlebitis, the procedures are carried out on a couch with a foot end raised by 30 cm. Cylindrical inductors are placed in contact without a gap longitudinally (on the inner surface of the thigh or lower leg and on the thigh in the region of the vascular bundle) or transversely (with trophic changes or a trophic ulcer of the lower leg). Sometimes a two-stage effect is carried out, combining the longitudinal and transverse arrangement of inductors. A sinusoidal current is applied, the mode is continuous, and after the 5-7th procedure, the current is one-half-wave, the mode is intermittent, the intensity is 270 E. The duration of the procedure is 15-20 minutes (with two-stage exposure 30-40 minutes) daily; for a course of 20 procedures. With a trophic ulcer, one inductor is used, which is placed in contact on the ulcer area above the bandage. With abundant discharge of the ulcer, the magnetic field strength is 175 Oe, in other cases it is 270 Oe. A sinusoidal current is used, continuous mode, the duration of exposure is 10-20 minutes daily; for a course of 20-30 procedures. A second course is shown after 6-10 months.
Contraindications to the use of a magnetic field are pronounced hypotension, a tendency to hemorrhage, angina pectoris, post-infarction condition, pregnancy, malignant neoplasms, blood diseases, individual intolerance.
Diadynamic currents cause rhythmic muscle contraction, which contributes to increased blood circulation and stimulates trophic processes in tissues, both in the area of impact of currents and reflexively associated areas of the body and organ.
new Due to antispasmodic and vasodilating action, diadynamic currents have a positive effect on peripheral and collateral circulation. Course and single impact of these currents reduces vascular tone, improves tissue blood supply, accelerates capillary blood flow, increases the number of functioning capillaries. Diadynamic currents in tissues cause the formation of biologically active substances such as histamine, acetylcholine, etc. A full-wave continuous current has an inhibitory effect on the function of the sympathetic nervous system, increases the threshold of its excitability, resulting in a decrease in spasm of large and small vessels and improves blood circulation. The analgesic effect of the current is associated with an improvement in blood supply and the normalization of redox processes in tissues.
For treatment with diadynamic currents, domestic devices "Model-7'17", "Tonus-1", "Tonus-2" are used.
Diadynamic currents can also be used for the purpose of drug electrophoresis (diadynamophoresis). With electrophoresis with impulsive currents, medicinal substances are injected into tissues faster and much deeper than with direct current electrophoresis.
Indications for the use of diadynamic currents: 1) pain syndromes caused by diseases of the peripheral nervous system (plexitis, neuralgia, neuritis, radiculitis, painful neuromas), phantom pains; 2) pain syndromes associated with traumatic lesions (bruises of soft tissues, muscles, joints, sprains); 3) degenerative-dystrophic diseases of the joints and spine, delayed healing of wound surfaces (provided that the wound is well drained); 4) stiffness after prolonged immobilization of the joints, cicatricial and muscle contractures, keloid scars.
Treatment with diadynamic currents can be combined with inductotherapy, exercise therapy, massage, thermal, water and balneological procedures. In diadynamic therapy, the same electrodes are used as in galvanization. Electrodes in size and shape should correspond to the painful area and fit snugly to the patient's body.
In pain syndrome in the stump, the electrodes are placed on the painful areas of the stump, more often transversely. Influenced by two-phase continuous current (DN) 2 min, and then current, modulated by short periods (SP), 3-4 min 1-2 times a day. With a decrease in the intensity of pain in the course of treatment, the effect of current modulated by long periods (DP) is added, c. within 2-3 minutes. The course of treatment is 10-12 sessions.
When local pains are combined with phantom pains, the sympathetic nodes are preliminarily treated with a DN current for 2-3 minutes on each side. The electrodes are placed paravertebral - the anode is higher, the cathode is lower, and then locally act on the stump of the limb. In the postoperative period, to eliminate the pain syndrome (before removing the sutures), the electrodes are placed proximal
dressings, transversely to the axis of the limb and apply a two-phase wave current (DV) or DN for 2-3 minutes, then with a current modulated by the CP. After removing the sutures to eliminate edema, improve tissue trophism, a DN current of 2-3 minutes is used, then a modulated CP - 6 minutes (direct and reverse polarity) or calcium diadynamic electrophoresis.
In case of trophic disorders in the stumps of the extremities (ulcers, hyperkeratosis, congestion), a diadynamic current is applied to the region of the distal end of the stump, placing the electrodes transversely to the axis of the extremity. The current DN is applied for 2 minutes, then the modulated currents KP - 3-6 minutes and DP - 3-4 minutes.
For rough, immobile keloid-type scars, a double local electrode or small plate electrodes are placed longitudinally on the scar to flatten, soften and dissolve the keloid. DP current is applied for 10 min. Then they act on the area of the sympathetic node of the segment that corresponds to the localization of the keloid. With scars on the arm or face, they act on the stellate node of the affected side, with scars on the legs - paravertebral on the region of the lumbar sympathetic nodes with DN current (anode above, cathode below) daily for 3 minutes; every 5 sessions make a break for 7-10 days. A second course of treatment is carried out in a month.
With stiffness of the knee joint, two rectangular electrodes are applied first to the lateral, and then to the anterior and posterior surfaces of the knee joint. Begin exposure to the DN current (1 min), and then apply the currents of the KP and DP for 4 minutes. In the middle of exposure to the currents of the CP and DP, the polarity is reversed. The course of treatment is 6-10 daily procedures.
Contraindications to the appointment of diadynamic therapy are: individual intolerance to the current, violations of the integrity of the skin, the presence of a purulent infection, pain syndromes (due to fracture or dislocation of the bones of the joints or hemorrhage), thrombophlebitis, renal cholelithiasis, cardiovascular diseases with circulatory disorders III degree, inclination to bleeding, malignant neoplasms.
E lectr o s o n. The central nervous system is affected by a pulsed current of low frequency and low strength. To carry out the procedure for one patient, the Electrosleep-2 and Elektroeon-4T devices are used, and for the procedure to be carried out simultaneously for 4 patients, the Electrosleep-3 device is used with individual adjustment of the pulse frequency and current for each patient. During the procedure (when the electrodes are located in the region of the eye sockets and mastoid processes), the pulsed current penetrates into the cranial cavity and affects the subcortical-stem region of the Brain, where the hypothalamus, the nuclei of the optic tubercles, the reticular formation, the limbic system, etc. are located.
Based on clinical observations and the use of special
V. S. Vereshchagin, V. M. Banshchikov, E. I. Kulikova and others distinguish between two phases in the therapeutic effect of electric sleep: ; 2) the disinhibition phase associated with the activation of the functional ability of the brain, self-regulation systems and clinically manifested vigor, increased efficiency and good mood.
The impact of pulsed currents on the subcortical-stem region of the brain causes functional changes in it, leading to the restoration of emotional and vegetative-humoral balance in the body, which determines its use in diseases of amputation stumps.
Electrosleep procedures are carried out in a ventilated room isolated from noise. To the patient, electrodes with hydrophilic pads are applied and fixed on the closed eyes and the region of the mastoid processes. The eye electrodes are connected to the cathode, and the electrodes located on the mastoid processes are connected to the anode. The pulse frequency is selected individually depending on the functional state of the nervous system, on the phase and severity of the disease, the age of the patient, etc. With a sharp weakness of the main nervous processes, as well as with pronounced organic changes, a small pulse frequency (5-20 Hz) and a short duration of procedures are used. (15-20 min). As the main nervous processes normalize, the frequency of impulses (40-100 Hz) and the duration of the procedure (40-60 minutes) are increased.
With increased emotional lability, neuroses, the initial stage of hypertension, sleep disorders, itchy dermatoses, etc., a frequency of 40-120 Hz is used. The current strength is regulated depending on the sensations of the patient. During the procedure, the latter should feel a slight vibration under the electrodes in the eye area.
During the procedure, the current strength should be constant, and during subsequent procedures it is slightly increased if there are no unpleasant sensations. At the end of the procedure, the device is turned off, and the patient can sleep until he wakes up on his own. After waking up, the electrodes are removed, but the patient is warned not to look at bright light in order to avoid unpleasant sensations. The duration of the procedures is from 30 minutes to 2-3 hours (depending on the characteristics of the nervous system). Procedures are carried out daily. The course of treatment is prescribed 12-20 procedures.
Indications for the use of electrosleep are: concomitant amputations of the disease (neurosis, neurasthenia, initial forms of schizophrenia, long-term consequences of traumatic brain disease, sclerosis of cerebral vessels in the initial period), hypertension stage I and II, hypotension, obliterating diseases of the vessels of the remaining co-
values, sleep disorders, stump diseases (eczema, dermatosis, neurodermatitis).
Contraindications: current intolerance, inflammatory eye diseases, weeping dermatitis of the face, hysteria, arachnoiditis, severe circulatory disorders, severe diabetes mellitus in the stage of decompensation, cataracts and glaucoma.
Needle reflexology helps to reduce pain syndromes, improve blood circulation, normalize metabolic processes and tissue nutrition, and increase the resistance of the skin. Acupuncture is the effect on the body of various in strength and nature, intensity and duration of irritations applied to certain point areas of the body - biologically active points (BAT) located in the area of the skin surface of the head, face, torso and extremities. It is carried out by using special acupuncture metal needles, acupressure, finger pressure, electric current, radiant energy, medicines.
Treatment of patients with amputation limb stumps is carried out according to the principle of joint action through points of general action, segmental acupuncture points and pain points of skin hyperalgesia zones, located in most cases: also segmentally. Acupuncture points of general action (corporally located) are localized mainly in the distal parts of the extremities. There are also points of common action on the auricle. Acupuncture points corresponding to the zones of segmental innervation of the integument of the body are located along paravertebral lines.
The general strengthening and normalizing effect on these points is explained by the peculiarities of their location and the close connections of autonomic and somatic innervation not only at the level of spinal reflexes, but also at the level of the subcortex and cerebral cortex. When exposed to them, the process of adaptation of patients to new conditions of movement is accelerated, negative psychological reactions to prosthetics are reduced, fitting of prostheses and mastering their use are facilitated. In addition, sleep and blood pressure normalize in sick and disabled people, and their general condition improves. For analgesic effects in phantom pain syndromes, except for? points of general action and segmental zones, use certain combinations of points (corporal and auricular).
Medical indications for the use of reflexology in prosthetic and orthopedic practice are phantom pain syndrome and local pain in the stump, trophic disorders (wounds, ulcers, atrophy, edema, infiltrates, venous congestion, hyperkeratosis, pyanosis), stump abrasions, negative psychological reactions associated with loss of a limb, postoperative complications (reflex urinary retention, swelling of the stump, delayed healing of postoperative wounds), concomitant radicular pain.
Contraindications to the use of reflexotherapy are tuberculosis, osteomyelitis, weakened state and exhaustion of patients, simultaneous intake of physiotherapeutic procedures or hormonal preparations.
The technique of acupuncture is generally accepted. The pose is chosen individually. For patients with stumps of the upper extremities, the sitting position is the best. A pillow is placed under the stump and the preserved limb in order to maximize the relaxation of the muscles of the stump. For patients with stumps of the lower extremities, the supine or prone position is recommended. To enhance the effect of the needle, it is possible to cauterize with wormwood cigarettes that are held over the needle (hot needle). The effect of heat on the pain points of the end part of the stump for 10 minutes and on the points of the segmental zones relieves pain and improves blood circulation in the stump. In case of insufficient effect on the same pain points, electroacupuncture is used. DC mode with polarity reversal - negative (30-50 s) and positive (3-5 s). Current strength up to 50 μA, pulse frequency 10-12 Hz.
Acupuncture of phantom pain syndrome is carried out on pain zones in combination with points of segmental level and general action. Pain zones are determined by anamnestic, palpation and with the help of indication by search devices "PEP-1", "Elite-4". These zones are located within the missing part of the limb - I or At the toe (hand). In this regard, after unilateral limb amputation, the pain zones of the preserved limb are affected, projectively associated with the pain zones of the missing limb. After bilateral amputation, they act mainly on the active points of the auricle in combination with points of general action.
Studies conducted at TsNIIPP showed that in the treatment of phantom pain syndrome, the analgesic effect is effective with the following treatment regimen:
1st procedure - impact on points of general action.
2nd procedure - impact on the points of pain zones (corporeal and auricular) in combination with points of general action.
3rd-5th procedure - impact on points of segmental zones in combination with points of general action.
6-8th procedure - impact on the points of the stump - painful and segmental located in combination with points of general action.
9th-10th procedure - impact only on points of general action (corporal and auricular).
When a phantom pain syndrome is combined with a pathological state of the stump, both the pain points (zones) of the stump and the pathological area on the stump are affected by chipping and thermal exposure with wormwood cigarettes. Painful areas on the stump often correspond to a painful scar or neuroma. In these cases, you should also act around the focus of pain. At the same time, acupuncture points are pricked on a sump
those. It is possible to influence the acupuncture and pain points on the stump only at the 6-7th procedure, when a positive result is achieved: the result of the influence on the general and segmental points (sleep and blood pressure normalized, there was a tendency to reduce pain). The painful scar of the stump is chipped with several needles, which are inserted to a depth of 2-3 cm to healthy tissues. Procedure time 45-60 min.
With a trophic ulcer on the stump, needles are inserted into the ulcer and around it, into acupuncture points located nearby, and into points of general action. Acupuncture is recommended to be combined with the thermal effect of wormwood cigarettes (30 min).
In a painful neuroma, at the beginning of treatment, the needles are inserted into distant acupuncture points, and then approach the neuroma. The needles are introduced around it under the control of tolerable sensations, not allowing them to be strengthened.
The segmental points of the stumps of the upper extremities are the acupuncture points of the first and second lateral lines of the back, corresponding to the upper and middle thoracic spine. Preferred acupuncture points of the collar zone. An important place in the treatment of phantom pain syndrome in patients with stumps of the upper extremities is occupied by the impact on the acupuncture points of the preserved limb, projectively associated with the pain zones of the missing limb (similar to the effect on the stumps of the lower extremities). On the auricle, active points are used that are projectively associated with the amputated part of the limb, and points of analgesic action.
In patients who have lost limbs due to vascular diseases (obliterating atherosclerosis, endarteritis, thromboangiitis, diabetic arteritis), pain is often observed not only in the stump, but also in the preserved limb, which are accompanied by significant trophic disorders. These diseases are known to be based on a violation of collateral circulation, a decrease in the volume and speed of blood flow, a violation of microcirculation, as a result of which tissue hypoxia develops and, as a result, pain. Phantom pain syndrome manifests itself unsharply. Pain of the ischemic type prevails (constant, aching, squeezing). There are almost no clear phantom pain sensations (“absence” of fingers of the extremities), they are of an indefinite nature. In these patients, treatment is aimed at improving the blood circulation of the stump and the preserved limb, eliminating hypoxia of the stump tissues, preventing the progression of the disease, and normalizing the functional state of the central nervous system. In this regard, acupuncture points of general and antispasmodic action, located in the reflexogenic and segmental zones, and points on the stump prevail in the treatment regimen. In patients with stumps of the lower extremities, the segmental zones are the paravertebral lines of the lumbosacral spine, and in pain
nyh with stumps of the upper extremities - paravertebral lines of the upper thoracic spine. Preference is given to deep injections (.8-10 cm). Acupuncture points of the paravertebral lines are combined with points of general action on the distal extremities. Locus points and spasmolytic points are used on the auricle. These points are well combined with points of analgesic influence.
With trophic changes in the stump and the preserved limb as a result of obliterating diseases, it is effective to warm up the changed tissue of the stump and over points located close to the focus. For electropuncture in these patients, a low current strength (20-30 μA), a small frequency of pulsed current (3-10 Hz), an unsharply pronounced polarity (from -20 to + 10-15 s), and an exposure time of 20 minutes are used.
TRAINING IN THE USE OF PROSTHETIC AND ORTHOPEDIC PRODUCTS
The general objectives of the training are to develop adaptation to the prosthesis, strengthen the muscles of the pelvis and stump, teach the correct skill of controlling the prosthetic limb, reduce contractures and stiffness in the joints, strengthen the muscles of the preserved limb, train muscle relaxation and coordination of movements of the upper and lower extremities, train balance, vestibular functions, orientation in space, development of stability on the prosthetic limb.
The main task of teaching the use of prosthetic and orthopedic products is the development of a dynamic stereotype of movements. It is developed as a result of the formation of new conditioned reflexes by training certain motor functions - walking, self-service, mastering labor processes with the help of a prosthetic limb. When teaching patients with different levels of truncation of the lower extremities, the common point is the need to restore the functions of support and movement. The complexity of the coordination control of the prosthetic limb increases depending on the level of truncation and the multiplicity of defects. Learning to walk with prostheses includes three stages.
The first stage of training, especially in primary patients, begins with the use of a therapeutic training or primary permanent prosthesis. The patient is taught to stand with uniform support on both limbs, transfer body weight to the prosthetic limb or alternately from the prosthetic limb to the remaining one, or from one prosthetic limb to another, stand on one prosthetic limb, get up from a chair, put on the prosthesis and fastening, correct alternation of tension and relaxation of muscle groups involved in the control of the prosthesis, control of the prosthetic limb in a standing position. The duration of the stage is up to 7 days. Criteria
The transition to the second stage is the ability to maintain balance while standing on a prosthetic limb for 2-3 s.
The second stage of training is transitional from standing to walking on prostheses. The skill of balance is developed in two- and one-support positions, standing on both limbs in the step position, mastering dynamic balance when relying on. prosthetic limb. Teaching the movements of the step of the prosthetic limb and its control are reduced to training - the support and transfer phases of the step of the prosthetic and preserved limb. The complexity of element-by-element learning of a step determines the use of various methods of correction and self-correction, as well as control over the quality of step movement.
At the third stage of training, rhythmic coordinated, smooth and stable walking, walking on an inclined plane and stairs, turns, overcoming obstacles, self-control techniques are developed. As a rule, shortcomings in the fitting of the prosthesis socket are identified, which must be eliminated. At the beginning of walking, stiffness of the movements of the trunk and limbs, tilt of the head forward are noted. With the development of walking, a relaxed gait is developed, coordinated - the interaction between the upper and lower limbs.
With a unilateral stump, the first step is taken with the preserved limb. This requires the patient to be able to correctly move the body while walking on the prosthesis and take the next step. First, they learn a single step, after which they move on to mastering two or more steps. The step of the prosthesis should be shorter than the step of the preserved leg, since the steps are aligned in time. It is advisable to take small steps, because in this case the center of mass moves by a smaller amount, and therefore, it is easier to maintain balance. Walking is carried out in relation to a straight line on the floor - the so-called walking guide in front of two opposite mirrors. Pay attention to the fact that the patient does not spread his legs too wide. In the process of training, uniform steps are achieved both in time and in length.
By this time, the patient is able to include the flexors and extensors of the hip joint in the control of the knee joints of the hip prosthesis: when resting on the heel of the prosthesis and in the phase of full support on the foot, the limb should be extended in the hip joint (which ensures strut resistance in the knee joints), after rolling over the toe and in the transfer phase of the prosthetic limb - bend it in the hip joint. To properly hold the trunk while resting on the prosthetic limb, a special training of the muscles of the stump and trunk is carried out.
With an abducting contracture, it is recommended to walk in a cross step, exercises in a standing position on both legs (springing inclinations towards the preserved leg), with an adductor - walking in the direction of the prosthetic limb, exercises in a standing position on both legs (springing inclinations of the torso)
tsa towards the prosthesis), with flexion - exercises in a standing position on both legs at a distance of 0.6 m from the gymnastic wall of lindens to it (spring extension of the body supported by a rail, feet in the position of maximum dorsiflexion with support on socks), with extensor - exercises in a standing position on both legs, springy flexion of the torso in the hip joints with a forward inclination.
When taking the prosthesis forward, bending should be done only in the hip joint. If there is a lock in the knee joints, then the patient is gradually taught to walk with an open lock. As a result of learning to walk on a hip prosthesis, the arrhythmia of stepping movements decreases.
After bilateral amputation of the thighs, the constant use of additional support (cane, crutches) is specific, so gymnastics is of great importance for training the support function of the arms, balance, stability, and coordination of movements. It is necessary to achieve a gradual decrease in step width and hyperlordosis of the lumbar spine. Exercises to strengthen the abdominal muscles and extensors of the hip joints are recommended.
To control the prosthesis after disarticulation in the hip joint, patients are taught to move the pelvis in the sagittal plane (push forward). This movement is performed in the preparatory period and further during the development of the prosthesis. The forward movement of the pelvis promotes the closure of the knee and hip joints when resting on the prosthesis, providing an upright posture. Walking on prostheses after bilateral hip disarticulation requires intensive and systematic training, which allows you to first replace the crutches with canes, and then use one cane for support. Such patients should work out the movements of the pelvis forward alternately to the right and left.
After amputation at the level of the lower leg, attention is paid to the thigh muscles of the truncated limb. The ability to flex and extend the knee joint, keeping it half-bent while resting on the prosthetic limb helps to develop a gait with bending in the joint in the supporting phase of the step, which approaches normal walking. Patients using deep-fitting lower leg prostheses are taught to contract the gastrocnemius muscles in the interval of transfer of the prosthetic limb (in order to better hold the prosthesis on the stump) and to relax these muscles in the interval of support on the prosthesis.
Walking training is carried out in shoes with a heel, the height of which is designed for an artificial foot. They use additional means of support: canes, crutches, walkers, parallel bars, obstacles for training in walking, a special platform with steps that imitate the landing site of urban transport.
The timing of mastering the correct walking skills is individual. After amputation of the hip, the development of walking is possible within 2 weeks,
after amputation of the lower leg - 7 days, after bilateral amputations - 3 weeks. Training in walking begins with 15-20 minutes, and after -. 3-4 days bring its duration to 1-2 hours a day with interruptions.
With anomalies in the development of the lower extremities, early learning to walk on prostheses contributes to the formation of a dynamic’ walking stereotype close to normal. In this group of patients, the lower limb, as a rule, is in the position of external rotation. The tasks of exercise therapy are to strengthen the hip flexors and extensors, achieve the maximum equinus position of the foot, strengthen the muscles that abduct and adduct the foot. In the case of placing the foot in the prosthesis socket If the ankle joint of an underdeveloped limb is located in the prosthesis at the level of the knee joint of a normally developed leg, then the patient is taught to move in the knee joint of the prosthesis due to the movements of the ankle joint of the underdeveloped limb. earlier - at the age of 1 year.
Learning to walk in orthoses is also carried out in three stages. In the preparatory period, when mastering orthoses, training is important: muscles that ensure stable standing of the gluteal, quadriceps, gastrocnemius, hip and tibia flexors, trunk muscles. support, which contributes to passive strut resistance in the knee joint. Then they are taught to roll over the foot, through the toe, and transfer the prosthetic limb.
With varying degrees of muscle paresis, the lower limb is carried forward in different ways. In this regard, when the hip flexors are weakened, they are strained during the attack on the front section of the orthosis shoe. With significant paresis of the muscles, they develop pendulum movements with the leg forward with a simultaneous deviation of the body back; while the other leg is extended at the hip joint.
With complete paralysis of the hip flexors, the removal is performed: pendulum-like or rocking movement of the leg forward while simultaneously rotating the trunk and pelvis forward. The orthoses must be worn with shoes with a heel. Training starts from 5-10 minutes and increases its duration to 1-2 hours with breaks for rest in the first 2-3 days. Walking starts with a healthy or less-affected leg. Then, when the torso is carried forward, the heel of the shoe in the orthosis easily comes off the support surface. It is better to master walking with self-control (in front of a mirror).
Daily exercise therapy, massage and walking training in lockless orthoses help to increase the rhythm of walking, improve the functions of the hip and knee joints, and develop confidence in movement. Additional support is used on one or two canes, and with widespread paralysis - on
crutches. The time of mastering walking in the apparatus (from 2 weeks to l’/g month) depends on the degree of paralysis, the age of the patient, his training, and the design of the orthosis.
It is advisable to teach patients with scoliosis to use a functional corset only in combination with exercise therapy ig. massage. Some exercises for the muscles of the trunk and limbs should be performed in a corset in an upright position of the body. If, along with a corset, a braid is assigned to shoes, then a special asymmetrical walking is taught. Its purpose is to enhance the corrective effect of the kosk on the lumbar curvature. Useful occupational therapy in a standing position with objects that require raising hands: (work on a weaving loom, on stands of electrical switches, writing and drawing on a high-hanging blackboard), skiing with an asymmetric grip of sticks.
OCCUPATIONAL THERAPY
Occupational therapy is an active method of exercise therapy using work skills and movements associated with self-care. She. carried out in combination with exercise therapy, mechanotherapy, massage, sports exercises and is a method of psychological and: physical preparation of patients for prosthetics. Its result depends on the correct choice of labor operations, as close as possible to the profession of the patient and becoming more complicated as they are mastered. Involvement of a prosthetic limb in an accessible one: the labor process leads to the development of new motor skills, which are also useful for self-care.
First, with the help of labor techniques, the corresponding muscles of the stump and trunk are strengthened and self-service elements are taught without prostheses and with the help of the simplest devices: (in cases of loss of the upper limb) or medical training prostheses (in case of loss of the lower limb). Then (at the final stage of prosthetics), when the patient receives permanent prostheses, occupational therapy allows you to teach the use of prostheses: both for self-service and. to perform available work processes.
Methods and means of occupational therapy should be used after amputation of the upper limbs at any level of truncation, including disarticulation of the shoulder. The tasks of labor loss are reduced to overcoming the oppressed mental state, achieving mobility in the joints, forming stumps, developing compensatory body movements, coordinating the movements of the stumps, training the muscular-articular sense and touch.
Occupational therapy of patients with stumps of the upper extremities is carried out in several stages. In the preparatory period, training is carried out without prostheses using the simplest devices for. stumps, attachments for instruments and working devices. In the course of performing labor operations, coordination of movements is developed, the muscles of the stump are strengthened, retention and retention are mastered.
46. Teaching a patient after amputation of the shoulder self-care skills using a cuff, and - before prosthetics; b, c - after prosthetics.
grasp of objects, movements in the joints of the truncated limb develop, rotational movements of the stump are developed. For the development of comprehensive movements, they give appropriate work tasks (working with paper, sculpting, polishing, cardboard work, performing installation work), offering to support and hold various objects.
With the help of the simplest self-service devices, the procedures are complicated. The patient is taught to write, eat, type on a typewriter, sew on a sewing machine (Fig. 46). Then they conduct classes with the help of working prostheses and attachments. tools. After receiving active prostheses with their help, patients are taught labor and household movements. Training is carried out on special stands for household and work operations with a set of various items. When a full range of movements is performed, the control lamp lights up. It is possible to train the movements of the prosthetic limb in all directions. The stand allows you to objectively assess the quality of prosthetics and the degree of fitness of the patient.
In prosthetics of the lower extremities, occupational therapy contributes to the development of stability, balance and coordination of movements. After amputation of the thigh, patients perform tasks to strengthen the muscles of the stump (for example, controlling the electric drive of a sewing machine with the help of a stump). At the same time, disabled people make movements associated with standing (even distribution of the load on both lower limbs) and movement (self-service, carpentry and locksmith work) on the prosthesis.
SPORT THERAPY
In the process of prosthetics, physical exercises of sports and applied type are widely used: normal walking and skiing, running, cycling, table tennis, basketball, volleyball, badminton, billiards on simulators, dance movements. Elements of sports games (sports exercises) are used in doses and under the supervision of a physician. Positive emotions that arise in the process of sports games and exercises stimulate the physical activity of the body and create a favorable psycho-emotional background for successful prosthetics. Sports exercises and games accelerate adaptation to new conditions, expand the functionality of patients, improve and restore coordination of movements, orientation in space, accelerate the development of prostheses and orthoses, educate and develop the necessary physical and moral-volitional qualities (strength, endurance, speed, agility, attention, self-confidence).
In preparation for prosthetics, sports therapy is carried out without the use of prosthetic and orthopedic products. Patients with stumps of the upper limbs should be recommended to play table tennis, basketball, volleyball, billiards. In this case, the racket is fixed with a special rubber cuff directly on the palmar or dorsal surface of the stump. To increase the contact of the racket with the stump or lengthen the lever (for short stumps), the racket handle should be longer. Attach the racket to the palmar or dorsal surface of the stump. while playing tennis and
Basketball pay attention to the combination of various positions of the truncated upper limb in relation to the direction of hitting the tennis ball, to passing and throwing the ball into the basketball basket from different starting positions.
The elements of the game of volleyball consist of hitting and receiving the ball with the stump and the preserved hand from different starting positions. Billiards is indicated for patients with one and two-sided stumps of the upper extremities with the assimilation of holding the cue with a special cuff fastening. After prosthetics, a prosthesis of the upper limb is used for sports therapy.
For patients with stumps of the lower extremities, sports games and exercises are not limited. They are carried out in the position of patients sitting on a wheelchair, chair or standing on a preserved limb (with breaks for rest). Table tennis, volleyball, badminton, billiards are available. The rules of the games are generally accepted, but also simplified depending on the conditions of the game. After the patients receive therapeutic and training or permanent prostheses, sports activities continue. At the first stage of learning to stand in prostheses, exercises are used on the “health wall” or a kayak simulator. The latter help to strengthen the muscles of the shoulder girdle, trunk, pelvis, stump of the lower limb in a standing position. Elements of sports games are also used in the standing position, which helps to speed up the adaptation of the stump to the prosthesis or orthosis.
At the second stage of learning to walk in prostheses, the same types of sports exercises are used, but not only in a standing position, but when performing individual step movements. At this stage, the use of dance movements helps to correctly perform them in various rhythms. By changing the tempo and rhythm of the musical accompaniment, during training, you can adjust the physical activity. At the third stage of learning to move in prostheses, all elements of sports games and exercises are used, but the clinical condition of the patient and the degree of functionality of the prosthetic and orthopedic product are taken into account. Sports competitions are held among the disabled, the results of which consolidate the achieved results of stump training and training in the use of prosthetic products.
Amputation of upper limbs in the early postoperative period (first period) classes exercise therapy start a few hours after the operation. The objectives of the classes are: general tonic effect on the patient, improvement of mental tone, prevention of complications. The exercises include exercises that provide stimulation of all autonomic functions, exercises that contribute to the formation of compensation for everyday movements (turns on the side, transitions to a sitting position on the bed and getting up from different positions without support with hands, eating, washing, dressing, combing with one hand). Such exercises, combined with walking, improve blood circulation and help combat physical inactivity.
The intensity and timing of activation of the motor mode are determined by clinical data. From the 3rd - 4th day, exercises are included in tension and relaxation of the muscles of the remaining segments of the amputated limb and truncated muscles (impulsive gymnastics), as well as careful movements of the shoulder girdle and movements in the free joints of the stump. From the 5-6th day, painless movements in the joints of the amputated limb can be performed with an extremely large amplitude.
After removing the sutures, they begin teaching self-care skills ( rice. 46, 47) and more complex actions with the help of working devices in the form of cuffs, hook-locks, etc.
Rice. 48. Typical exercises after splitting the forearm according to Krukenberg.
Rice. 49. Typical exercises after phalanging of the first metacarpal bone.
In the third period, i.e., from the moment of receiving a permanent prosthesis, training is made to use it. Along with this, depending on the design of the prosthesis, special exercises are used for the following purposes: strengthening muscles and improving muscle-articular sensitivity and coordination of movements that are necessary for using the prosthesis (with a traction prosthesis with a pneumatic drive); teaching isolated and dosed according to the degree of intensity of muscle tension and strengthening the muscles with the help of which the prosthesis is controlled (with prostheses with myotonic and bioelectric control); complex solution of the listed problems - with prostheses, in which more than one energy source is simultaneously used (a combination of bioelectric and myotonic, traction and pneumatically driven, etc.).
Learning to use a prosthesis begins with putting it on. In all cases, except for the disarticulation of the limbs in the shoulder joints, the patient must put on the prosthesis independently. With unilateral amputation, the prosthesis is put on with the help of a healthy hand. With bilateral amputations, the prostheses are put on first on a longer stump, then on a shorter one, or at the same time. You can remove dentures in any most convenient way. In the development of the prosthesis and the formation of motor skills, a certain sequence is observed: “opening” the hand and subsequent closing of the fingers; flexion and extension in the elbow joint (sharnige); movements along all axes in the shoulder joint; movements in the preserved joints in combination with the movement performed by the prosthesis; necessary household movements and actions (moving various objects, eating, etc.); more complex actions, including game character. The range of motion depends on the nature of the amputation, the condition of the overlying joint of the truncated limb, and the prosthesis used. So, prostheses after exarticulation and amputation of the shoulder allow the following movements:
- flexion at the elbow joint;
- fixation of the forearm in relation to the shoulder at different angles of flexion;
- opening "fingers";
- brush rotation;
- shoulder rotation.
In prostheses of the forearm, "disclosure" of the hand and its passive rotation are possible. With two prostheses, movements should be taught both separately and together. At first, it is advisable to teach the patient to take and hold objects while standing, then sitting, later to form skills in eating, writing, combing, coloring, drawing, rearranging chess pieces, tossing and catching a ball, etc. ( rice. 50, 51).
Rice. 50. Training in the use of prostheses after amputation of the upper limbs.
Rice. 51. Training in the use of prostheses after amputation of the upper limbs.
Ministry of Education of the Republic of Belarus
educational institution
"Brest State University named after A.S. Pushkin"
Faculty of Physical Education
Department of Anatomy, Physiology and Human Safety
Course work
in the academic discipline "Specialization "Physical Rehabilitation""
Physical rehabilitation for amputation of the upper limbs
Completed:
student of the 5th year of the OZO, 55 groups,
Rusavuk Stanislav Leonidovich
Scientific adviser:
Doropievich S S
Introduction
1 Definition of the concept of amputation. Indications and contraindications for amputation of the upper limbs
2 Types of amputations
3 Methods of amputation
4 Stages of amputation of the upper limbs
5 Complications after upper limb amputation
1Goal and objectives of rehabilitation
2Types of rehabilitation of disabled people after amputation of the upper limbs
3 Means of physical rehabilitation after amputation of the upper limbs
4 Prosthetics
Chapter 3
Introduction
amputation physical rehabilitation prosthetics
Amputation of limbs is considered one of the oldest operations. Hippocrates carried out amputation within dead tissues, later Celsus proposed to carry it out by capturing healthy tissues, which was more appropriate, but in the Middle Ages all this was forgotten. In the 16th century, Pare proposed ligation of vessels instead of cauterization with a red-hot iron or immersion in boiling oil, then Louis Petit began to cover the stump with skin, and in the 19th century, Pirogov proposed osteoplastic surgery.
Vascular diseases of the extremities, tumors and severe injuries are the most common indicator for amputation.
Vascular disease of the extremities is the leading cause of amputation in people aged 50 years and older, accounting for 90% of all amputations. Usually, the treatment of complicated vascular diseases consists in prescribing antibiotics, removing infected tissues, prescribing vascular drugs (eg, anticoagulants), and surgical treatment consists of such operations as angioplasty, bypass, stenting. However, when these measures fail to achieve the desired result, the surgeon has to resort to amputation as a life-saving measure.
In addition, vascular damage can also occur with severe (crushed, crushed) injuries, deep burns. As a result of this, there is also a lack of blood supply to the tissues of the limb and their necrosis. If you do not remove the necrotic tissue, then this is fraught with the spread of decay products and infection throughout the body.
One of the most important stages in the recovery of patients after amputation of the upper limbs is prosthetics. Upper limb prostheses compensate for the most important lost functions of the hand - the functions of opening and closing the hand (grabbing, holding and releasing an object), movement in the wrist, elbow and shoulder joints, as well as restoring the appearance (maximum cosmetic effect).
The object of this work is physical rehabilitation as a way to restore the disabled.
The subject of this course work is the physical rehabilitation of the amputation of the upper limbs.
The purpose of the study is to characterize the main means of physical rehabilitation after amputation of the upper limbs.
The implementation of this goal involves the solution of the following tasks:
1.To study educational and methodical and scientific literature on the topic of the course work; open the definition of "amputation";
.Identify the main goals, objectives and means of physical rehabilitation in amputation of the upper limbs;
.Collect material and prepare a multimedia presentation on the topic "Prosthetics of the upper limbs". Describe the main types of upper limb prostheses.
The practical value of the work is that the results are of interest to specialists in physical rehabilitation, medical workers who provide various areas of work with the disabled. In addition, they may be of interest to managers in the fields of medicine, education, physical culture and sports.
Chapter 1. General characteristics of amputation of the upper limbs
1Definition of the concept of amputation. Indications and contraindications for amputation of the upper limbs
amputation (lat. amputation) - truncation of the distal part of the organ as a result of trauma or surgery. Most often, the term is used in the sense of "amputation of a limb" - its truncation over a bone (or several bones), in contrast to disarticulations (disarticulation at the level of the joint).
Absolute readings:
.Complete or almost complete detachment of limb segments as a result of trauma or injury;
.Extensive damage to the limb with crushing of bones and crushing of tissues;
.Gangrene of the limb of various etiologies;
.Progressive purulent infection in the lesion of the limb;
.Malignant tumors of bones and soft tissues with the impossibility of their radical excision.
Relative readingsdetermined by the nature of the pathological process:
.Trophic ulcers that are not amenable to conservative and surgical treatment;
.Chronic osteomyelitis of bones with the threat of amyloidosis of internal organs;
.Anomalies of development and consequences of a limb injury that are not amenable to conservative and surgical correction.
Amputation contraindications:
1.Traumatic shock. It is necessary to bring the wounded out of the state of shock and only then perform the operation. However, the anti-shock period should not last more than 4 hours.
In children, relative indications should be very limited, given the great potential of the child's body for regeneration and adaptive restructuring of the musculoskeletal system. Also, it must be taken into account that amputation can adversely affect the development of the child's skeleton (curvature or shortening of the limb, deformity of the spine, chest, pelvis, etc., and this, in turn, can lead to dysfunction of internal organs.
1.2 Types of amputations
The choice of amputation level depends primarily on the location of the injury. Amputation is performed at the level that gives the greatest guarantee against the possibility of spreading infection from the area of injury. Only with truncations taken about gas gangrene or necrosis with obliterating arteritis, amputation is performed as high as possible. In addition, the level of amputation is determined by the nature of the damage and subsequent rehabilitation, medical and social.
Preliminary amputation- extended surgical debridement, which is performed when it is impossible to initially accurately determine the level of amputation.
Final amputation- treatment of the wound, carried out without subsequent reamputation, they are done in cases where there is no reason to expect dangerous inflammatory complications and the formation of a stump unsuitable for prosthetics.
Depending on the term and indications for amputation, there are primary, secondary and repeated amputations, or reamputations. Primary amputationis performed immediately after the patient is delivered to a medical institution or within 24 hours after the injury, that is, even before the development of inflammation in the area of damage.
The secondary is called amputation.produced at a later date, within 7-8 days. Primary and secondary amputations are operations performed according to early indications.
Reamputation- planned surgical intervention, which aims to complete the surgical preparation of the stump for prosthetics. Indications for this operation are vicious stumps.
Traumatic amputation- rejection of part or all of a limb (or other part of the body) as a result of mechanical violence. A specific variant of the mechanism of traumatic amputation is limb avulsion. Distinguish between complete and incomplete traumatic amputation.
According to the shape of the dissection of soft tissues, several types of amputation are distinguished, and first of all, the need to cover the bone sawdust should be taken into account. For this purpose, soft tissues are transected, taking into account their retraction below the level of bone sawing.
In practice, there are early and late amputations.
Early amputationsare performed according to urgent indications before the development of clinical signs of infection in the wound.
Late amputationslimbs are performed due to severe complications of the wound process, which are life-threatening, or in case of failures in the struggle to save a seriously injured limb
1. 3 Methods of amputation
Guillotine method- the simplest and fastest. Soft tissue is cut at the same level as the bone. It is indicated only in cases where there is a need for rapid truncation of the limb.
circular way- provides for the dissection of the skin, subcutaneous tissue and muscles in the same plane, and the bones - somewhat more proximal.
The greatest benefits are three-stage cone-circular methodaccording to Pirogov: first, the skin and subcutaneous tissue are cut with a circular incision, then all the muscles are cut along the edge of the reduced skin to the bone.
After that, the skin and muscles are retracted proximally and the muscles are re-crossed at the base of the muscle cone with a perpendicular incision.
The bone is sawn in the same plane. The resulting soft-tissue "funnel" closes the bone sawdust. Wound healing occurs with the formation of a central scar.
Indications: truncation of the limb at the level of the shoulder or hip in cases of infectious lesions of the limb, anaerobic infection and uncertainty that further development of the infection is prevented.
Patchwork way. Patchwork-circular amputation to remove the focus of intoxication during crush injuries is performed within healthy tissues and is performed 3-5 cm above the soft tissue destruction zone.
Skin-fascial flaps are cut out with a wide base.
Muscles intersect circularly. The bone is sawn along the edge of the contracted muscles.
Plastic amputation methods:
Tendoplasticoperations are indicated for truncation of the upper limb in the distal part of the shoulder or forearm, for disarticulation in the elbow or wrist joint, for vascular diseases or diabetic gangrene. The tendons of the antagonist muscles are sutured together.
fascioplastica method of amputation, in which the bone sawdust is closed with skin-fascial flaps. The method of high fasciocutaneous amputation was developed to preserve the knee joint during limb amputation due to vascular diseases.
myoplasticThe method of amputation has become widespread in recent years.
The main technical point of the stump muscle plasty is the suturing of the ends of the truncated antagonist muscles over the bone sawdust to create distal muscle attachment points. Bone processing. The most common method of treating a bone stump is the Petit periostoplastic method. When amputating from the removed area of the bone, before sawing it, a periosteal flap is formed, which closes the sawdust of the bone, and after amputation of the lower leg, both tibia bones.
4Stages of amputation of the upper limbs
A patient who is about to have a limb amputated must be prepared not only physically but also psychologically. He must realize that after amputation he will be able to take an active part in work and social life.
Amputation is usually performed under anesthesia, but in some cases the use of local anesthesia is acceptable. Spinal anesthesia for amputations in the condition of injury is unacceptable. Before the amputation operation, as a rule, Esmarch's tourniquet is applied 10-15 cm above the level of amputation of the limb. The exception is amputations due to damage to the main vessels or due to anaerobic infection, in which the operation is performed without a tourniquet.
The main stages of amputation:
1. Dissection of the skin, subcutaneous tissue and fascia;
2. Dissection of muscles;
3. Ligation of blood vessels and treatment of nerve trunks;
4. Dissection of the periosteum and sawing of the bones
Stump formation
The muscles are crossed to the bone in a plane perpendicular to the long axis of the segment, taking into account their contractility from 3 to 6 cm distal to the bone filing.
Important for amputation processing of nerve trunks. At present, it is customary to cross the nerves with a razor or a sharp scalpel while moving the soft tissues in the proximal direction by 5-6 cm; it is recommended not to stretch the nerve. Cutting the nerve with scissors is not allowed.
Bone processing is important for favorable outcomes of amputation and subsequent prosthetics. After a circular dissection of the periosteum, it is recommended to push the periosteum distally with a raspator. The sawing of the bone should be done as slowly as possible, constantly irrigating the place where the saw was cut with a solution of novocaine and sodium chloride. After sawing the bone, the outer edge of the entire bone sawdust is cleaned with a file with a round notch.
The most common method of treating a bone stump is the Petit periostoplastic method. When amputating from the removed area of the bone, before sawing it, a periosteal flap is formed, which closes the sawdust of the bone, and after amputation of the forearm, both of its bones.
Hemostasis is considered the responsible moment of amputation. Before ligation, large vessels are freed from soft tissues. Ligation of large arteries along with muscles can lead to eruption and slippage of the ligatures, followed by bleeding.
Vessels are tied up with catgut. Ligation with catgut is the prevention of ligature fistulas. After ligation of large vessels, the tourniquet or bandage is removed. Appeared bleeding is stitched with catgut. Less tissue should be taken into the ligature so that there are fewer necrotic tissues in the wound.
After amputation, in order to avoid contracture in a straightened position, the limb is immobilized with plaster casts or splints. The splint should be removed after the wound has completely healed.
After amputation of the fingers, hand or forearm in the lower or middle third, reconstructive operations are used. When the fingers are amputated, an operation is performed to phalange the metacarpal bones, as a result of which partial compensation of the function of the fingers is possible. When amputating the hand and forearm, the forearm is split according to Krukenberg with the formation of two "fingers": the radial and ulnar. As a result of these operations, an active grasping organ is created, which, unlike a prosthesis, has tactile sensitivity, due to which the patient's household and professional working capacity is significantly expanded.
5Complications after amputation of the upper limbs
When performing amputation, the development of the same complications as with other types of surgical intervention is possible. The most frequent and dangerous complication, for example, in traumatic amputation, is traumatic shock. It is the harder, the more proximal the level of traumatic amputation. The most severe, often irreversible shock occurs when both limbs are amputated. The severity of shock is also influenced by frequent (in 80% of victims with traumatic amputation) other injuries of the limbs and internal organs. Damage to the latter can dominate the clinical picture and determine the prognosis. Other general complications (acute renal failure, fat embolism, thromboembolism) are closely related to the severity of shock, the usefulness of its treatment, and the severity of injury.
The most frequent purulent-septic complications: purulent-necrotic process in the wound of the stump, osteomyelitis, rarely sepsis, anaerobic infection in the stump, tetanus.
Specific complications that occur after amputation include contracture (deformity of the limb due to improper fusion of the tendon and muscle contraction), soft tissue hematomas (accumulation of blood due to injury to the vessel), necrosis of the skin in the amputation area (necrosis), impaired wound healing and infection. In rare cases, a second surgical intervention is required.
Amputation pain deserves special attention.
Amputation pains do not occur immediately after surgery or injury, but after a certain time, sometimes they are a continuation of postoperative ones.
The most intense pain occurs after high shoulder amputations.
Types of amputation pain:
1 typical phantom pain (illusory);
2 actually amputation pains, localized mainly at the root of the stump and accompanied by vascular and trophic disorders in the stump. They are aggravated by bright light and loud noise, by changes in barometric pressure and by the influence of mood;
3 pain in the stump, characterized by increased widespread hyperesthesia and stubborn constancy.
phantom pains.Phantom sensations or pain are observed in almost all patients after limb amputation as a vicious perception of the lost limb in their minds.
Illusory-pain symptom complexcharacterized by a sensation of an amputated limb, in which burning, aching pain persists for a long time. Often these pains take on a pulsating, shooting character or resemble the range of pain that the patient experienced at the time of the injury.
Illusory pains are most intensely expressed on the upper limb, especially in the fingertips and palms. These pain sensations do not change their localization and intensity. A relapse, or exacerbation, often occurs at night or during the day under the influence of unrest or external stimuli.
Treatment with novocaine blockade of the neuromas of the stump and sympathetic nodes gives a long-term antalgic effect, the absence of which is an indication for surgical treatment. Reconstructive surgeries are performed on the neurovascular elements of the limb stump: scars and neuromas are excised, and the stumps of nerves and blood vessels are freed from adhesions and blocked with novocaine solution.
If the reconstructive operation does not bring the expected result, they resort to sympathectomy at the appropriate level: for the upper limb - the stellate node and the first two thoracic nodes.
Chapter 2. Rehabilitation of patients after amputation of the upper limbs
2.1Purpose and objectives of rehabilitation
Rehabilitation is a socially necessary, functional, social and labor recovery of sick and disabled people, carried out by the complex implementation of state, public, medical, psychological, pedagogical, professional, legal and other activities.
The concept of rehabilitation includes:
Functional recovery:
a) full recovery;
b) compensation for limited or no recovery;
Adaptation to everyday life;
Joining the labor process;
Dispensary observation of the rehabilitated.
Rehabilitation provides for two main points;
) the return of the victim to work;
) creation of optimal conditions for active participation in the life of society.
Rehabilitation of the disabled is a social problem, the solution of which is within the competence of medicine.
The purpose of rehabilitation is as follows: adaptation at the previous workplace or readaptation - work at a new workplace with changed conditions, but at the same enterprise. If it is impossible to implement the listed items, an appropriate retraining at the same enterprise is necessary; in case of failure or obvious impossibility of recovery - retraining in a rehabilitation center with subsequent job search in a new specialty.
The tasks of motor rehabilitation in amputation of the upper limbs are determined by many factors. The changed conditions of statics and dynamics of the body after amputation of limbs impose new requirements on the musculoskeletal system and the body as a whole.
Mastering prostheses and using them is carried out according to the mechanism of compensatory adaptability, the limits of which are individual and depend mainly on the psychophysical state of the victim. In this regard, in the process of physical therapy, the mechanisms of the tonic and trophic effects of physical exercises are primarily used, which create a favorable background for the successful development of new motor skills that most fully implement the functional capabilities inherent in one or another prosthesis design.
Particular tasks of therapeutic physical culture after limb amputation are diverse:
1.improvement of blood circulation in the stump in order to quickly eliminate postoperative edema, infiltrate;
.prevention of contractures and muscle atrophy;
3.development of muscle strength, especially those that will carry out the movements of artificial limbs;
.development of strength in general with the aim of increasing compensatory functions;
.increased mobility in all joints;
.development of endurance, muscular-articular sensitivity, coordination, separate and combined movements;
.development of self-service skills, training in the use of working devices, temporary and permanent prostheses.
Thus, one of the distinguishing features of rehabilitation after amputation of the upper limbs is a wide variety of particular tasks and methods used, aimed mainly at normalizing the activity of various body systems in new conditions, at developing motor qualities, developing compensation and developing skills in using artificial limbs.
It should be noted that the formation of the skill of using the prosthesis, as well as other motor skills, goes through three stages:
1.the first - is characterized by insufficient coordination and stiffness of movements, which is due to the irradiation of nervous processes;
.in the second - as a result of repeated repetitions, the movements become coordinated, less constrained - the skill stabilizes;
3.in the third - movements are automated.
The first stage requires special attention, since it is during this period that many superfluous, unnecessary movements are observed, which are fixed in the stabilization stage and subsequently corrected with great difficulty.
2.2Types of rehabilitation of disabled people after amputation of the upper limbs
There are three main types of rehabilitation:
1.Medical rehabilitation.
Includes therapeutic measures aimed at restoring the health of the patient. During this period, the psychological preparation of the victim for the necessary adaptation, re-adaptation or retraining is carried out. Medical rehabilitation begins from the moment the patient goes to the doctor, so the psychological preparation of the victim is within the competence of the doctor.
2.Social rehabilitation.
Social rehabilitation is one of its most important types and sets the main goal of developing the victim's skills for self-service. The main task of the doctor in this case is to teach the disabled person to use the simplest, mostly household appliances.
3.Professional rehabilitation.
Occupational or industrial rehabilitation sets the main goal of preparing a disabled person for work. The time elapsed from medical rehabilitation to professional rehabilitation should be minimal.
Industrial rehabilitation combines the successes of medical and social rehabilitation. It has now been established that rational work improves cardiovascular activity and blood circulation, as well as metabolism. While prolonged immobility will lead to muscle atrophy and premature aging. Therefore, occupational therapy is extremely important in the treatment process.
The main objectives of occupational therapy are:
1. Restoration of physical functions: a) increase in joint mobility, muscle strengthening, restoration of movement coordination, increase and maintenance of the ability to master working skills; b) training in everyday activities (eating, dressing, etc.); c) homework training (child care, home care, cooking, etc.); d) training in the use of prostheses and orthoses, as well as their care.
2. Production in the department of occupational therapy of simplified devices that allow a disabled person to engage in everyday types of work and household activities.
3. Determining the degree of professional ability to work in order to optimally select the type of work that is suitable in a particular case.
Basic principles of rehabilitation:
1. Perhaps an early start of rehabilitation measures, which should organically flow into therapeutic measures and complement them.
2. Continuity of rehabilitation as the basis of its effectiveness.
3. Comprehensive nature of rehabilitation measures. Not only medical workers, but also other specialists should participate in the rehabilitation of disabled people: a psychologist, a sociologist, representatives of the social security organization and trade union, lawyers, etc. Rehabilitation measures must be carried out under the guidance of a doctor.
4. Individuality of the system of rehabilitation measures. The course of the disease process, the nature of people in various conditions of their activity and life are taken into account, which requires a strictly individual compilation of rehabilitation programs for each patient or disabled person.
5. Implementation of rehabilitation in the society of patients (disabled people). This is due to the fact that the goal of rehabilitation is the return of the victim to the team.
6. Return of the disabled to active socially useful work.
2.3 Means of physical rehabilitation after amputation of the upper limbs
Of great importance in the social adaptation of patients after amputation of the upper limbs is physical rehabilitation, which makes it possible to prepare the patient well for prosthetics, and in the future to avoid complications associated with the use of the prosthesis. After the operation, which is performed under general anesthesia, typical postoperative complications are possible: congestion in the lungs; impaired activity of the cardiovascular system; thrombosis and thromboembolism. There is atrophy of the muscles of the stump, caused by the fact that the muscles lose their points of distal attachment, as well as the transection of blood vessels and nerves.
After the operation, due to the pain syndrome, the mobility of the remaining joints of the limb is limited, further interfering with prosthetics. Amputation of the forearms causes contracture in the elbow and shoulder joints, atrophy of the muscles of the forearm. In the upper thoracic spine, a curvature is observed, which is associated with an upward displacement of the shoulder girdle on the side of the amputation.
Exercise therapy after amputation of the upper limbs.
After amputation of limbs in the exercise therapy technique, three main periods are distinguished :
· early postoperative (from the day of surgery to the removal of sutures);
· the period of preparation for prosthetics (from the moment the sutures are removed to the receipt of a permanent prosthesis);
· the period of mastering the prosthesis.
Early postoperative period. During this period, the following tasks of exercise therapy are solved.
· prevention of postoperative complications (congestive pneumonia, intestinal atony, thrombosis, embolism);
· improvement of blood circulation in the stump;
· prevention of muscle atrophy of the stump;
· stimulation of regeneration processes.
Contraindications to the appointment of exercise therapy: acute inflammatory process in the stump; the general serious condition of the patient; height body temperature; danger of bleeding. LH classes should be started on the first day after surgery. They include breathing exercises, exercises for healthy limbs. From the 2-3rd day, isometric tensions are performed for the preserved segments of the amputated limb and truncated muscles; facilitated movements in the joints of the stump free from immobilization; apply phantom gymnastics (mental execution of movements in the absent joint), which is very important for the prevention of contracture, reducing pain and atrophy of the muscles of the stump. After amputation of the upper limb, the patient can sit down, stand up, walk. After the removal of the sutures, the 2nd period begins - the period of preparation for prosthetics. In this case, the main attention is paid to the formation of the stump: it must be of the correct (cylindrical) shape, painless, supportive, strong, resistant to stress. First, mobility is restored in the remaining joints of the amputated limb. As pain decreases and mobility in these joints increases, exercises for the muscles of the stump are included in the classes. Carry out a uniform strengthening of the muscles that determine the correct shape of the stump, necessary for a snug fit of the prosthesis sleeve. LH includes active movements in the distal joint, performed by the patient at first with the support of the stump, and then independently and with the resistance of the instructor's hands. Training of the stump for support consists in pressing its end first on a soft pillow, and then on pillows of various densities (stuffed with cotton, hair, felt) and in exercises with the support of the stump on a special soft stand. Start such a workout with 2 minutes and bring its duration to 15 minutes or more. For the development of muscular-articular feeling and coordination of movements, exercises should be used in the exact reproduction of a given amplitude of movements without visual control.
After amputation of the upper limb (and especially both), much attention is paid to the development of self-care skills for the stump - with the help of such simple devices as a rubber cuff worn on the stump, under which a pencil, spoon, fork, etc. are inserted. Amputation of extremities leads to posture disorders, therefore corrective exercises should be included in the CG complex. When amputating the upper limb - due to the displacement of the shoulder girdle on the side of the amputation up and forward, as well as the development of "pterygoid shoulder blades" - against the background of general developmental exercises for the shoulder girdle, movements are used aimed at lowering the shoulder girdle and bringing the shoulder blades together. Compensatory can develop scoliotic curvature in the opposite direction in the thoracic and cervical spine.
At the final stage of rehabilitation treatment after amputation of a limb, therapeutic exercises are aimed at developing skills in using prostheses. Training depends on the type of prosthesis. For fine work (for example, writing), a prosthesis with a passive grip is used, for more rough physical work, a prosthesis with an active finger grip is used due to the traction of the muscles of the shoulder girdle. Recently, bioelectric prostheses with active finger grip, based on the use of currents that occur at moments of muscle tension, have been widely used.
Exercise therapy for reconstructive operations on the stumps of the upper limbs is used in the pre- and postoperative period and contributes to the speedy formation and improvement of motor compensation. Preoperative preparation of the forearm stump consists of massaging the muscles of the stump, retraction of the skin (due to its lack in local plasticity at the time of finger formation), restoration with the help of passive and active movements of pronation and supination of the forearm. After the operation, the goal of therapeutic exercises is to develop a grip due to the reduction and dilution of the newly formed fingers of the forearm stump. This movement is absent under normal conditions. In the future, the patient is taught to write, and first with a specially adapted pen (thicker, with recesses for the ulnar and radial fingers). After splitting the forearm for cosmetic purposes, patients are provided with a prosthetic arm.
Massage after amputation of the upper limbs.
Massage technique .
In the early postoperative period, segmental reflex effects are applied in the area of the corresponding paravertebral zones.
Massage of the stump can be started after the removal of surgical sutures. Healing by secondary intention, the presence of a granulating wound surface, even the presence of fistulas at normal temperature, the absence of a local inflammatory reaction, and also pathological changes in the blood are not a contraindication for massage. Of the massage techniques, various types of stroking, rubbing and light kneading (spiral in the longitudinal direction) are used.
In the first week, massaging near the postoperative suture should be avoided until it gets stronger. In the presence of scar formations soldered to the underlying tissues of the stump, massage is an excellent tool for removing these adhesions. In such cases, first of all, various kneading techniques are used (shifting the scar, etc.). To develop the support ability of the stump in the area of the distal end, vibration is used in the form of tapping, chopping, and quilting.
When massaging an amputated limb, special attention should be paid to the muscles that have survived after the operation and should contribute to the restoration of normal movements. So, after amputation in the area of the middle third of the thigh, it is recommended to strengthen the adductors and extensors of the thigh as much as possible.
After amputation below the knee joint, special attention should be paid to strengthening the quadriceps muscle. After amputation in the middle third of the shoulder, the abductors and muscles that perform external rotation of the shoulder should be selectively strengthened. Abduction exercises (abducting the limb to the side) of the shoulder prevent atrophy of the deltoid and supraspinatus muscles (strengthening the muscles that abduct the shoulder) and atrophy of the infraspinatus and small round muscles (muscles that rotate the shoulder outward).
Massage of the amputation stump at first should not last more than 5-10 minutes; gradually the duration of the massage procedure is adjusted to 15 - 20 minutes. For the development of the function of the stump, the mobility of the nearest joints is very important. During the massage, it is recommended to perform physical exercises, which should be started as early as possible.
These include, first of all, the sending of motor impulses aimed at performing movements of the stump in various directions. Such exercises help to strengthen the crossed muscles, mobilize the scars soldered to the bone and increase the trophism of the stump tissues. Exercises are performed daily 3-5 times a day. Exercises for a healthy limb in all joints are also recommended; such exercises greatly contribute to the recovery process in the stump.
Further, exercises aimed at developing its endurance are used: pressing the end of the stump onto special pads of various hardness (cotton wool, sand, felt, wooden stand), tapping the stump with a wooden mallet lined with felt, etc. In order to develop coordination skills when standing and walking with a prosthesis, as well as restoring tactile, muscular and joint sensations in the remaining part of the limb, it is recommended to combine massage with exercises to develop balance: torso tilts, half-squats and squats on one leg with open and closed eyes. Skin care of the stump in the early postoperative period is also very important.
Physiotherapy after upper limb amputation.
Phantom pain is a postoperative complication that manifests itself as a sensation of pain in the amputated limb, which can be combined with pain in the stump itself. UVR of the stump area is applied in 5-8 biodoses (8-10 exposures in total); diadynamic currents in the stump area (10-12 procedures); darsonvalization; electrophoresis of novocaine and iodine; applications of paraffin, ozocerite; dirt on the stump area; general baths: pearl, radon, coniferous, hydrogen sulfide.
After amputation, as with other types of surgical interventions, an infiltrate may form in the area of the postoperative suture. In the treatment of infiltration in the acute stage, cold is used to limit its development and ultraviolet irradiation. Apply UHF for 10-12 minutes daily, CMW, ultrasound, inductotherapy, ozocerite and paraffin applications on the infiltrate area, UVI. After 2-3 days after the subsidence of acute inflammatory phenomena, they switch to thermal procedures.
General contraindications to physiotherapy procedures also remain unchanged:
state of extreme exhaustion
tendency to bleed
blood diseases
malignant neoplasms
pronounced manifestations of systemic organ failure (cardiovascular failure, respiratory failure, impaired renal function).
In the absence of contraindications, physiotherapy is prescribed as soon as possible and is carried out for a long time, until the start of prosthetics.
Chapter 3
The task of the surgeon during amputation is by no means limited to surgical intervention. An equally important task is the "education" of the stump, preparing it for prosthetics. The amputation stump must meet the following requirements:
) it must have a regular, even outline (not have a conical shape);
) be painless;
- stump tissues should be minimally edematous and maximally reduced in volume;
- the skin of the stump should be well stretched, with difficulty to be captured in the fold, should not have protrusions;
- the end of the stump should be covered with a more or less thick (but without excess) layer of soft tissues;
- the scar on the stump should be narrow, smooth, located away from points subjected to pressure;
) the stump must be hardy, supportable;
) the function of the stump must be fully preserved in terms of muscle strength and range of motion. The foundations of all these conditions are laid on the operating table, but each of the conditions can be lost or increased depending on the mode of the amputation stump, as well as the quality of the subsequent treatment. Thus, the incorrect position of the stump after surgery, insufficient attention to the preservation of its function can lead to the development of contracture and cause a vicious position of the stump. The stump can become sensitive, the end of it can take on a flask shape as a result of improper bandaging or improper massaging. As you know, the process of forming an amputation stump in order to prepare it for prosthetics.
3.1 General characteristics of upper limb prostheses
Upper limb prostheses
Upper limb prostheses should replace the most important lost functions of the hand - the functions of opening and closing the hand, i.e. grabbing, holding and releasing an object, as well as restoring the appearance.
Two types of upper limb prostheses are offered: passive and active.
· The passive ones are cosmetic prostheses, which serve only to restore the natural appearance.
· Active prostheses are mechanical and bioelectric.
Bioelectric upper limb prostheses
Modern upper limb prostheses are designed not only to restore the natural appearance, but also to make up for the most important lost functions of the human hand, such as opening and closing the hand, that is, grasping, holding and releasing various objects.
One of the latest developments in this area is the so-called bioelectric prostheses of the upper limbs, which are actuated by means of electrodes that read the electric current generated by the muscles of the stump at the moment of their contraction. Then the information is transmitted to the microprocessor, and as a result, the prosthesis comes into action. Thanks to the latest technology, artificial hands allow rotational movements in the hand, grasping and holding objects. Bioelectric prostheses make it possible to successfully use such things as a spoon, fork, ballpoint pen, etc. It should be noted that this system is designed not only for adult users, but also for children and adolescents.
The essence of biomechanical prostheses is that after amputation of the stump of the hand, it retains the remnants of the previously existing grasping muscle. When they contract, an electrical impulse of alternating current is received, which is perceived by the control electrodes of the biomechanical prosthesis located on the skin. The electronic amplifying system available in these electrodes, even with a slight contraction of muscle tissue, allows you to turn on / off a small but powerful electric motor that moves the thumb and forefinger.
The latest modifications of the bioelectric brushes of the Otto Bock trademark, produced by the world famous orthopedic concern Otto Bock (Germany), are equipped with special touch sensors that control the force of gripping the object. These sensors are localized in the finger zone. Thanks to them, the user has the ability to take various items, including such fragile things as a glass of thin glass or, say, an ordinary chicken egg, without fear of breaking or crushing them.
The latest models of biomechanical hand prostheses combine an aesthetically flawless appearance with a significant grip force and speed of its implementation, as well as many additional features or combinations of expanding functions. When using microelectronic technology, such artificial hands are even more effective.
By the way, in relation to the above-mentioned company Otto Bock, it should be noted that it was founded back in 1919 by the German orthopedic technician Otto Bock, after whom it was named. The parent company of the concern is located in the city of Duderstadt (Lower Saxony), subsidiaries are located in more than thirty countries of the world, including Russia (since 1989). Over the past years, the Otto Bock company has taken a stable position in the Russian market and has become one of the leading suppliers of modern technical means of rehabilitation, as well as orthopedic products, materials, components and equipment necessary for prosthetic and orthopedic production.
Mechanical upper limb prostheses
Mechanical prostheses are active prostheses that simultaneously solve two tasks: social and work. The hand of a mechanical prosthesis recreates, as far as possible, the natural appearance of the hand, which allows a person to feel confident and comfortable in the company of people, and performs the functions of capturing and holding an object. The hand is actuated by means of a bandage fixed on the shoulder girdle. If a person needs to provide a wider range of activities, for example, when working in production, on a personal plot, etc., then the brush can be easily replaced with working nozzles, selected depending on the type of activity.
Cosmetic (passive) upper limb prostheses
Cosmetic or passive prostheses are designed purely to recreate the natural appearance and are used, respectively, in cases where the shape, weight, wearing comfort and ease of use of the artificial hand are of paramount importance, and the patient does not seek to compensate for the motor functions of the lost upper limb.
Such prostheses are absolutely suitable for any level of arm amputation, but they are of particular importance for high amputations, when functional prostheses cannot be used or it is not possible to restore the missing functions. The possibilities of such a hand are limited to simply holding objects, but it looks quite natural, and fully satisfies the desires of those individuals who gave preference to it.
Classical cosmetic prostheses consist of a stump, a hand frame, and a cosmetic glove. To meet the aesthetic and functional needs of patients, there are currently so-called systemic prostheses of the upper limbs, also consisting of a stump receiver, a frame and a cosmetic shell, but in addition, having a special body with a mechanical assembly. The capture function directly depends on the design of the latter. Thus, they provide a natural look of the upper limb, and have a fairly wide functionality.
Now the color, shape and structure of the outer surface of the latest cosmetic gloves fully reproduce the external features of a natural brush. For example, OTTO Bock (Germany) prostheses offer forty-three models of men's and women's gloves for individual selection, each of them in eighteen color shades. At the same time, cleaning and replacement of cosmetic gloves, if necessary, is carried out without any problems.
The molded foam frame of the hand, with its minimum weight, gives it high stability and thus increases wearing comfort. In addition, thanks to various mounting options, this frame has an almost universal application. In case of partial loss of the brush, it is made individually. For traditional cosmetic prostheses, passive systemic hands are used, which open with the help of a saved hand, and close independently.
In a word, modern cosmetic upper limb prostheses are easy to use, optimal in weight and easy to maintain. The problem of contamination has already been solved by 100%, so the care of products is no longer a problem.
Over time, dentures should be changed. It is unacceptable when the prostheses become too large for the patient, they dangle, which leads to scuffs and reflex contractures.
Sensitive prosthetic arm SmartHand
The bioadaptive SmartHand prosthesis is an artificial upper limb that the patient can feel like their real hand. The invention belongs to a group of developers from the engineering department of Tel Aviv University (Israel) led by Professor Yossi Shacham-Diamand (Yosi Shacham-Diamand). In collaboration with their colleagues from the European Union, they brought to life a technique for creating an upper limb prosthesis, which uses the preserved nerve endings left in the stump of an amputated hand.
The device, called "SmartHand", not only looks like the hand of an ordinary person, it allows the patient to return after amputation what until recently was considered impossible - sensitivity in his upper limb.
In Sweden, clinical trials of prototypes of this invention have already been carried out, which have shown very encouraging results. The first patient to receive such a prosthesis was a man who needed only a few training sessions to get used to the artificial limb and learn how to use it, not only for manipulating the type of food intake, but also for writing.
The development of SmartHand was originally aimed not only at restoring the function of a lost limb, but also at creating feedback with the prosthesis by stimulating peripheral nerve endings. In fact, we are talking about making the artificial hand sensitive to the user and not only partially return the functions of the hand, but also eliminate such a problem as phantom pain. After all, for people who have lost their upper limbs, the consequences can turn into a disaster: in addition to the fact that they had to lose a very complex and important motor mechanism of their body - their hands, their psyche often suffers - self-esteem decreases and self-consciousness is distorted. In addition, sometimes they have exhausting phantom pains. All this significantly worsens the quality of life.
Thanks to the SmartHand prosthesis, it was possible to achieve that the human brain began to process the signals received from the artificial hand and perceive them as natural afferent impulses. This is achieved through a special neural interface in which four dozen sensors perceive information coming from the prosthesis and transmit it further to the remaining intact nerve endings located on the forearm, shoulder, shoulder girdle or chest, and from there to a certain somatosensory area in the cerebral cortex. Thus, the artificial hand actually restores sensitivity in the lost upper limb.
In fact, the SmartHand project should not only solve medical issues by raising the process of rehabilitation of people with lost upper limbs to a completely new level, it also has a huge social significance. After all, a person's hands in a sense determine his essence, thanks to their anatomical and functional features, people can write, draw, play the piano, etc.
1.I have studied educational and methodical and scientific literature on the topic of course work. Based on the material studied, amputation can be defined as a truncation of a limb along a bone (or several bones). The term amputation is also used to truncate the peripheral part or even the whole organ, for example, the rectum, the mammary gland.
.The purpose of the physical rehabilitation of disabled people after amputation of the upper limbs is their recovery and adaptation in society. In this regard, the tasks of physical rehabilitation can be distinguished, such as:
· functional recovery;
· adaptation to everyday life;
· participation in the labor process.
To solve the tasks, the following tools are used:
· Healing Fitness;
·massage;
· physiotherapy procedures.
3. After analyzing modern upper limb prosthetics, we can conclude that modern upper limb prostheses differ in their functional features. Depending on the level of amputation, various prostheses are made: fingers, forearm, shoulder and the entire arm (after disarticulation in the shoulder joint). To date, there are two types of upper limb prostheses: therapeutic and training and permanent. Therapeutic and training prostheses are designed to prepare the patient for prosthetics. If we talk about permanent prostheses, then modern medicine distinguishes two types of them: active and passive. Passive are cosmetic hand prostheses. They are intended only to give the lost limb a natural appearance. As for active prostheses, they can be called mechanical. Mechanical prostheses are designed to perform two functions: social and work.
List of sources used
1. Azolov V.V. Rehabilitation of patients with certain diseases and injuries of the hand: Sat. scientific works of the Gorky Research Institute of Traumatology and Orthopedics / ed. V.V. Azolova. - Gorky, 1987. - 207 p.
Belousov P. I. Corrective and preventive exercises after amputation of the upper extremities. L., 1954. Belousov P. I. Orthopedist, traumatol., 1963.
Starting position - lying on your back
1. Flexion and extension in the ankle joint of a healthy leg (10-12 times).
2. Bending the legs with the help of the hands until the hips touch the stomach (3-5 times).
3. Transition to a sitting position with subsequent leaning forward until the hands touch the toes (3-4 times).
4. Imitation of kicking cycling.
Starting position - sitting on the floor
5. Turn and tilt of the body towards the stump with support on the hands (3-6 times).
6. Raise the stump and unbend the lower leg with the help of hands (6-8 times).
7. Retraction of the stump in the hip joint (5-8 times).
8. Raising the body with support on the arm (4-6 times).
9. Raising the legs.
Starting position - lying on the stomach
10. Bending the legs in the knee joints (6-8 times).
11. Alternate extension of the legs in the hip joints (4-8 times).
12. Hands to the sides (forward) - extension of the body (4-6 times). Starting position - standing (holding on to a chair or headboard).
13. Squat (4-6 times).
14. Rise on the toe and roll on the heel (6-8 times).
15. Retraction of the stump back (6-8 times).
16. Fixing the balance while standing on the leg with a different position of the hands.
The period of mastering the prosthesis. At the final stage of rehabilitation treatment after amputation of a limb, the patient is taught to use the prosthesis. Before teaching the patient to walk, it is necessary to check the correct fit of the prosthesis to the stump and the correct fit. The technique of walking and the method of teaching it are determined by the design of the prosthesis, the characteristics of the amputation and the condition of the patient. When conducting classes with patients after amputation of the lower extremities due to obliterating endarteritis, diabetes, atherosclerosis, as well as in the elderly, it is necessary to especially carefully and consistently increase the load, controlling the reaction from the cardiovascular system. Training to walk on prostheses consists of three stages. At the first stage, they teach standing with uniform support on both limbs, transferring body weight in the frontal plane. On the second stage, they carry out the transfer of body weight in the sagittal plane, train the support and transfer phases of the step of the prosthetic and preserved limb. At the third stage, uniform step movements are developed. In the future, the patient masters walking on an inclined plane, turns, walking up stairs and rough terrain. Activities with young and middle-aged patients include elements of volleyball, basketball, badminton, table tennis, etc.
When supplying upper limb prostheses therapeutic gymnastics is aimed at developing skills in using prostheses. Training depends on the type of prosthesis. For fine work (for example, writing), a prosthesis with a passive grip is used, for more rough physical work, a prosthesis with an active finger grip is used due to the traction of the muscles of the shoulder girdle. Recently, bioelectric prostheses with active finger grip, based on the use of currents that occur at moments of muscle tension, have been more widely used.
After amputation of fingers, hands or forearms in the lower or middle third, reconstructive operations. At amputation of fingers an operation is performed to phalangize the metacarpal bones, as a result of which partial compensation of the function of the fingers is possible. At amputations of the hand and forearm split the forearm according to Krukenberg with the formation of two "fingers": radial and ulnar. As a result of these operations, an active grasping organ is created, which, unlike a prosthesis, has tactile sensitivity, due to which the patient's household and professional working capacity is significantly expanded.
Exercise therapy for reconstructive operations on the stumps of the upper limbs is used in the pre- and postoperative period and contributes to the speedy formation and improvement of motor compensation. Postoperative preparation of the forearm stump consists of massaging the muscles of the stump, retracting the skin (due to its lack in local plasticity at the time of finger formation), restoring with the help of passive and active movements of pronation and supination of the forearm. After the operation, the goal of therapeutic exercises is to develop capture due to the reduction and dilution of the newly formed fingers of the stump of the forearm. This movement is absent under normal conditions. In the future, the patient is taught to write, and first with a specially adapted pen (thicker, with recesses for the ulnar and radial fingers). After splitting the forearm for cosmetic purposes, patients are provided with a prosthetic arm.
Massage for limb amputation. To eliminate edema, prevent contractures and atrophy of the stump in complex treatment, it is recommended to apply massage as soon as possible. With a general good condition and a favorable course of wound healing, massage is prescribed on the 7-10th day after the operation.
Massage technique. In the early postoperative period, segmental reflex effects are applied in the area of the corresponding paravertebral zones. To reduce the tone of the muscles covered by reflex contractures, the techniques of planar and enveloping stroking, rubbing with the ends of the fingers, shading, and sawing are used. The joints are massaged with stroking and rubbing techniques. After the wound has healed and the surgical sutures have been removed, the stump is massaged to prepare its supporting function for prosthetics. Differentiation, using deep kneading and vibration techniques, strengthens those remaining after amputation in the thigh area - adductor muscles and hip extensors; with amputation in the shin area - the calf muscle; when amputated in the shoulder area - the deltoid muscle, etc. The stump is massaged with the techniques of planar circular and encircling stroking, rubbing, forceps-like kneading. To develop the support ability of the stump in the area of the distal cone, vibration is used - tapping, chopping, quilting.
With persistent myogenic contractures, strong short-term, repeatedly repeated manual or mechanical vibrations are used. The duration of the procedure is 10-20 minutes, daily or every other day (course - 20-25 procedures). With a strengthened postoperative scar, an underwater shower is indicated - massage and mechanomassage. With the constant use of the prosthesis, patients during the period of sanatorium treatment are prescribed massage in combination with balneo-physiotherapeutic procedures and bathing: segmental-reflex effects are used, massage of all remaining segments of the limb and stump with stroking, rubbing, kneading, vibration techniques.
Physiotherapy for amputation of limbs. Phantom pain is a postoperative complication that manifests itself as a sensation of pain in the amputated limb, which can be combined with pain in the stump itself. UVR of the stump area is applied in 5-8 biodoses (8-10 exposures in total); diadynamic currents in the stump area (10-12 procedures); darsonvalization; electrophoresis of novocaine and iodine, applications of paraffin, ozocerite, mud on the stump area; general baths: pearl, radon, coniferous, hydrogen sulfide.
After amputation, as with other types of surgical interventions, an infiltrate may form in the area of the postoperative suture. In the treatment of infiltration in the acute stage, cold is used to limit its development and ultraviolet irradiation. Apply UHF for 10-12 minutes daily, CMW, ultrasound, inductotherapy, ozocerite and paraffin applications on the infiltrate area, UVI. After 2-3 days after the subsidence of acute inflammatory phenomena, they switch to thermal procedures.
The tasks of physiotherapy exercises in this period are: a psychotherapeutic effect on the patient, aimed at building confidence in the practical possibility of walking, being a useful member of society and the family, strengthening an intact limb, accelerating wound healing, reducing swelling of the stump.
For the prevention of postoperative complications, dysfunctions of the main vital systems of the body from the first day after amputation, general strengthening exercises are used. In the first two days, mainly breathing exercises of a general tonic nature are used, without movements of the stumps. It is only recommended to send impulses to movement in the knee and hip joints (depending on the level of limb amputation). In order to prevent contractures in the knee joint, a plaster splint or plastic splint is applied along the back surface of the stump of the lower leg and thigh. After amputation of the thigh, in order to prevent flexion contracture in the hip joint, the patient is placed on the shield, and to prevent abduction contracture, sandbags are placed on the outside of the stump.
A few days after the amputation, the patient's condition improves and exercises performed by the stump are added to the general strengthening exercises. In essence, from this period, the implementation of one of the main tasks of therapeutic exercises begins - the preparation of the stump for prosthetics. The method of therapeutic exercises should provide for the requirements for the stump for prosthetics: 1) the stump must be supporting; 2) the stump should not have movement restrictions; 3) the muscles of the stump must be able to contract, and the force of their contractions must be extremely large. At first, the exercises are performed lying on your back and as soon as the patient feels better, lying on a healthy side, on his stomach and sitting.
In order for the patient to be able to walk in the future, the muscles of the stump of the thigh and lower leg must be strong enough. For this, additional isometric tensions of the muscles of the thigh and lower leg, flexion and extension of the stump with resistance, and exercises in the hip and knee joints are used. Training the muscles of the stump presents certain difficulties due to the lack of a lower leg or foot. Given this, exercises are applied in the imaginary performance of various movements with the missing lower leg and foot. In this case, the muscles of the stump are brought into a state of active contractions, corresponding to the nature of the “performed movement”. Imaginary movements are an obligatory means of developing the strength of the muscles of the stump and they must be performed during the day every 2 hours for a duration of 10-15 minutes. This phantom-pulse gymnastics should be performed throughout the life of the amputee.
Venue - hospital ward
1.1. Starting position (ip): lying on your back, one hand on your stomach, the other on your chest. Thoracic and abdominal breathing. 6-8 minutes at a slow pace.
1.2. I. p .: lying on your back, arms down along the body. Alternately raising the arms up - inhale, return to the starting position - exhale. 20 times at a moderate pace.
1.3. I. p .: the same. Simultaneous spreading of the arms to the sides (inhale), return to and. p. - exhale. 20 times at a slow pace.
1.4. I. p .: the same, hands in the castle. Raise your hands up behind your head. 20 times at a moderate pace.
1.5. I. p .: the same, reliance on arms bent at the elbows. Raising the upper body. 20 times at a moderate pace.
1.6. I. p .: the same, resting on the elbows, the back of the head and the heel of the remaining healthy leg. Raising the pelvis up to the maximum. 20 times at a slow pace.
1.7. I. p .: the same, hands to the sides. Turns the body to the right and left, connect the palms. 20 times in each direction at a moderate pace.
1.8. I. p .: the same, the arms are bent at the elbow joints, the fingers are clenched into a fist. Alternate extension of the arms forward (boxing). 20 times with each hand at a fast pace.
1.9. I. p .: the same, arms along the body, a healthy leg is bent at the knee joint, resting on the foot. Fulfillment: lifting the pelvis up. 20 times at a slow pace.
1.10. I. p .: the same, hands in front of the chest, palms down. Raise your arms to the sides, palms up. 25 - 30 times at a moderate pace.
1.11. I. p .: the same, hands behind the head, elbows up. Deployment of the elbows to the sides. 25 - 30 times at a moderate pace.
1.12. I. p .: the same, arms along the body. Flexion of the preserved leg with adduction to the chest. 20 times at an arbitrary pace.
1.13. I. p .: the same, hands hold on to the headboard. Raising the straightened healthy leg up. 20 times at a slow pace.
1.14. I. p .: the same, hands behind the headboard, leg raised up. Circular movements of the leg along a small radius clockwise and counterclockwise. 20 movements in both directions at a moderate pace.
1.15. I. p .: the same, hands behind the head. Simultaneous bending of the stump to the stomach and raising the arms up vertically. 20 times at a slow pace.
1.16. I. p .: lying on a healthy side, grab the bedpost with your hands. Retraction of the stump back. 20 times at a slow pace.
1.7. I. p .: the same, hands behind the headboard. Lifting the stump up to the limit, lowering to the mattress. 25 times at a slow pace.
1.18. I. p .: also, the hand on the side of the stump is laid back. Circular movements of the stumps clockwise and counterclockwise. 15 times in both directions at a slow pace.
1.19. I. p .: lying on your back, hands behind the “holder” (towel, rope behind the headboard). Raising the body to a sitting position. 25 times at a moderate pace.
1.20. I. p .: the same, arms along the body. Raising the body to a sitting position with support on the hands. 20 times at a slow pace.
COMPLEX OF THERAPEUTIC PHYSICAL
EXERCISES TO DEVELOP BALANCE AFTER
LOWER LIMB AMPUTS
After amputation of the lower limb, the usual conditions for maintaining balance are always violated, which is the result of a halving of the area of support. The center of gravity moves to the remaining leg. In maintaining the vertical position of the body, the proprio receptors of the lower extremities, as well as receptors located on the sole, play an important role. Therefore, after amputation of the lower limb, the conditions for maintaining balance inevitably change dramatically. In this regard, the use of exercises to develop balance is necessary for every patient, especially in the early post-amputation period. And although when performing almost all exercises in the “standing” position, balance and coordination of movements are simultaneously trained, nevertheless, these exercises should be separated into a separate group and repeated more often throughout the day. Exercises performed in the "standing" position can be attributed to exercises that develop mainly statistical balance, and performed during movement as developing dynamic balance. For amputees equipped with temporary or permanent prostheses, the very act of standing (without moving any part of the body) is difficult at first. It is clear that the development of compensatory adaptability when the body is poorly maintained in balance is very limited and difficult. Without proper training, walking on prostheses is impossible. Therefore, when learning to walk on prostheses, first of all, exercises are necessary to develop balance. In cases of amputation of one lower limb, they should be used in preparation for prosthetics.
Physical exercises for the development of balance after amputation of the lower limb are performed in the ward or gym
2.1. I. p .: standing on all fours with support on the knee of the preserved leg, alternately raising the arms forward and upward. 1 about
20 times. When raising the arm, inhale; when lowering, exhale. The pace is fast.
2.2. I. p .: standing on the knee of the preserved leg, hands on the belt. Tilt the torso and arms forward - exhale, straighten the torso - inhale. 10-12 times at a slow pace.
2.3. I. p .: kneeling, arms along the body. Half turn left and right, touch the heel of the remaining leg with your hand. 10 times in each direction at a slow pace.
2.4. I. p .: standing on the knee of the remaining leg, hands on the belt. Tilt the body forward, arms to the sides. When leaning forward - exhale, when straightening - inhale. 10-15 times at a slow pace.
2.5. I. p .: standing on the knee of the preserved leg, hands down. Bring your hands up behind your head - inhale, hands down - exhale. 10-15 times at a slow pace.
2.6. I. p .: standing on the knee of the preserved leg, arms bent at the elbows. Raise your arms up with your eyes closed (inhale), lower your arms (exhale). 10-15 times at a moderate pace.
2.7. I. p .: sitting on a chair (bed), hands behind your back. Tilts of the head forward-backward, right-left. 10-15 times at a moderate pace.
2.8. I. p .: sitting on a chair, hands in support behind. Rotation of the head around the vertical axis clockwise and counterclockwise. 10-15 rotations at a slow pace.
2.9. I. p .: sitting on a chair, hands on the belt. Tilt the torso forward and to the sides with closed eyes (exhale), straighten the torso (inhale). 10 times to the right and left sides at a slow pace.
2.10. I. p .: standing at the head of the bed, arms to the sides. Raising your hands up. 10-15 times at a moderate pace.
2.11. I. p .: the same. Tilts of the body to the sides alternately. 20 times at a slow pace.
2.12. I. p .: standing by the bed, hands behind the head. Tilts of the body to the sides alternately. 20 times at a slow pace.
2.13. I. p .: standing by the bed, hands on the belt. Torso forward. 20 times at a slow pace.
2.14. I. p .: standing, hands down. Tilt the body forward, take the stump back, arms to the sides. 15 times at a slow pace.
2.15. I. p .: standing at the hanging ball, hands on the belt. Beating the ball with a stump. 2 minutes at your own pace.
2.16. I. p .: standing, arms along the body. Squat on the remaining leg, arms forward. 10 times at an average pace.
2.17. I. p .: standing, ball in hand. Throwing the ball up and catching it. 2-3 minutes at your own pace.
2.18. I. p .: the same. Hitting the floor with a rubber ball. 2-3 minutes at your own pace.
2.19. I. p .: standing, arms along the body. Raising the remaining leg on the toe, arms up. 15-20 times at a slow pace.
COMPLEX OF THERAPEUTIC PHYSICAL
EXERCISES WITH UNILATERAL
AMPUTION STUD OF THE SHIN
3.1. Starting position (I. p.): lying on your back, arms along the body. Raising the arms to the sides 25 times.
3.2. I. p .: the same, arms along the body. Raise your arms up and throw back behind your head, return to and. n. 20 movements at a moderate pace.
3.3. I. p .: the same, palms behind the back of the head. Raising the elbows to the sides and bringing them together 20 times.
3.4. I. p .: the same, hands on the chest. Lifting the stump up 30 times.
3.5. I. p .: the same, arms along the body. Lifting up a healthy leg to the vertical 20 times.
3.6. I. p .: the same, simultaneous lifting of the stump and healthy leg up to the vertical. 20 times at an arbitrary pace.
3.7. I. p .: the same, hands are divorced. Abduction of the stump of the lower leg along the horizontal plane to the limit, 20 times, then abduction of the healthy leg to the side 10 times.
3.8. I. p .: too, arms along the body. Cross movements on the weight of the stumps and a healthy leg. 20 times at a moderate pace.
3.9. I. p .: the same, the stump is raised vertically. Circular movements of the stump clockwise and counterclockwise 10 times at a moderate pace.
3.10. I. p .: the same, the emphasis of the stumps on the mattress with the knee joint bent at a right angle. Raising the pelvis and back up 25 times at a slow pace.
3.11. I. p .: the same, emphasis on the mattress with hands. Sitting down (raising the body to the vertical) 20 times.
3.12. I. p .: the same, the legs are raised up. Imitation of cycling movements, 20 rotations.
3.13. I. p .: the same, but 20 movements in the opposite direction.
3.14. I. p .: lying on his stomach. Lifting the stump up back with the knee joint extended, 20 times at a slow pace.
3.15. I. p .: the same. Retraction to the side of the stump from the middle
body lines to the stop, return to and. n. 20 times at a slow pace.
3.16. I. p .: lying on the stomach, arms along the body. Raising the stump and healthy leg at the same time 10 times at a slow pace.
3.17. I. p .: standing on all fours. Raising the alternately extended stump, then legs up and back 20 times with each leg.
3.18. I. p .: the same. Lifting up and back the stump of the lower leg and the opposite arm up 10 times, then lifting the healthy leg up back and the opposite arm up. 10 times at a slow pace.
3.19. I. p .: lying on a healthy side, emphasis on the palm of your head. Raising (abducting) the stump up and lowering it to the mattress 25 times at a slow pace.
3.20. I. p .: lying on a healthy side, palm under the head. Circular movements of the stump clockwise and counterclockwise 20 times at a moderate pace.
3.21. I. p .: lying on your back, grab the headboard with your hand, move to the edge of the bed. Lowering the thigh with the stump over the edge of the bed to the limit, then returning to and. n. 20 times of movements at a slow pace.
3.22. I. p .: lying on your back on the edge of the bed, grabbing the back of the bed with your hand. Swing movements of the stump up and down to the stop, 20 times at a slow pace.
3.23. I. p .: sitting on the bed. Tilts of the body forward at an average pace of 20 times.
3.24. I. p .: the same. Extension of the stump in the knee joint with resistance to extension by the hands.
3.25. I. p .: kneeling, hands hold on to the headboard, the body is tilted to the healthy side. Swing movements of the stump back and forth 20 times at a fast pace.
3.26. I. p .: standing on your knees, resting your hand on a wall or crutch. Kneeling forward and backward on the bed, 20 steps in each direction at a slow pace.
3.27. I. p .: standing on your knees, hold onto the wall or crutch with your hands. Walking sideways to the right and left for 20 steps in each direction at a slow pace.
3.28. I. p .: standing on your knees, grasping the back of the bed with your hands. Deep squats to the stop and return to and. P.
20 times at a slow pace.
3.29. I. p .: kneeling, grasping the back of the bed with your hands, the body is tilted to the healthy side. Circular movements of the stump clockwise and counterclockwise, 10 movements in each direction.
3.30. I. p .: the same, the stump is unbent at the knee joint. Standing at the end of the stump for a few seconds until a slight pain occurs.
3.31. I. p .: standing on the floor on a healthy leg, facing the headboard. Grab the back of the bed with your hands. Balance training by raising arms to the sides and up, 20 times at an average pace.
3.32. I. p .: the same. Squats on a healthy leg, 20 times at a moderate pace.
3.33. I. p .: standing on the floor on a healthy leg, hold on to the back of the bed with your hands. Standing up on the toe of a healthy leg, 15 times at an average pace.
3.34. I. p .: the same. Lateral inclinations of the body towards the stump and a healthy leg 20 times at a moderate pace.
3.35. I. p .: sitting on a stool (chair), in the hands of a dumbbell. Lateral torso in both directions 15 times at a moderate pace.
COMPLEX OF THERAPEUTIC PHYSICAL
EXERCISES WITH BILATERAL
amputation stumps
SHIN
Venue - ward
4.1. Starting position (I. p.): lying on your back, arms along the body. Bringing (pressing) the thigh to the stomach and chest due to flexion in the hip joint, alternately with the right and left thigh 20 times.
4.2. I. p .: the same. Abduction to the side of the thigh to the limit along the plane of the bed with an elongated stump of the lower leg, alternately with the right and left thigh 20 times.
4.3. I. p .: the same, the thigh is raised up. Abduction of the hip to the side outward to the limit, alternately with the right and left hips in 20 phases.
4.4. I. p .: the same. Circular movements of the right thigh 10 times clockwise and counterclockwise, then also the same movements of the left thigh in the same directions.
4.5. I. p .: the same, the legs are extended. Cross movements of both hips raised simultaneously with the stumps straightened in the knee joints (“scissors”). 20 movements at a fast pace. Pause 1 min.
4.6. I. p .: on the back, just move to the edge of the bed, the hand holds on to the headboard. Lowering the hip downward (extension of the hip in the hip joint) to the limit, then return to and. n. Alternately with each thigh for 20 movements.
4.7. I. p .: on the back, move to the edge of the bed, grab the headboard with your hand. Swing movements with each hip 10 times at a fast pace. Pause 1 min.
4.8. I. p .: lying first on the left, then on the right side. Raising (abducting) the hip up (outward) as much as possible, then lowering to the surface of the bed. 20 movements with the right and left hips.
4.9. I. p .: lying on your back, arms along the body. Raising (lifting) the pelvis upward while resting on the stumps of both legs, bent at a right angle at the knee joints with an emphasis on the mattress. 20 movements at a moderate pace.
4.10. I. p .: lying first on the right side, then on the left. Swing movements of the hip - maximum flexion and extension in the hip joint in the horizontal plane. 20 movements of the right and left hips at a moderate pace.
4.11. I. p .: lying on your back, arms along the body. Raising the pelvis upward while resting on one stump bent at a right angle at the knee joint. The second leg is straightened and lies on the bed. 20 movements while relying on one, then on the other stump alternately at a slow pace.
4.12. I. p .: lying on the stomach, arms along the body. Lifting the thigh up with a straightened stump. 20 movements with the right and left hips at a slow pace.
4.13. I. p .: the same. Abduction in an arc towards the outside alternately of the right and left hips 20 times at a moderate pace.
4.14. I. p .: lying on your back. Bending (pressing) the hip to the stomach with weighting with a rubber band or tourniquet in the form of a ring attached to the back of the bed and the area of the knee joint. 20 movements of the right and left hip alternately at a moderate pace.
4.15. I. p .: standing on your knees, the torso is vertical, grasping the back of the bed with your hands. Swing movements with the right and left thigh alternately 20 times at a moderate pace.
4.16. I. p .: the same, support with hands on a wall or crutch. Walking on your knees back and forth on the bed. Only 40 steps at an average pace.
4.17. I. p .: the same, stick with your hand to the wall or crutch. Walking sideways to the right and left on the bed. Only 40 steps at a slow pace.
4.18. I. p .: the same, grasping the back of the bed with hands. Deep squats to the stop (to the mattress) and return to and. n. 20 movements at an average pace.
4.19. I. p .: kneeling on the edge of the bed, grasping the back of the bed with your hands. Outward abduction alternately of the right and left thigh 20 times, at a slow pace.
4.20. I. p .: the same, hands hold on to the headboard. Circular movements with the right thigh clockwise and counterclockwise 10 times, then the same with the left thigh. The pace of execution is moderate.
4.21. I. p .: the same. Cautious rising to the end
stump, unbent at the knee joint for a few seconds alternately (without causing pain).
4.22. I. p .: lying on the stomach, arms along the body. Raising up both hips at the same time. 10 times at a moderate pace.
Physical exercises should never be performed through force. Their volume and intensity are determined primarily by the patient's well-being.
COMPLEX OF THERAPEUTIC PHYSICAL
EXERCISES WITH UNILATERAL
IMPUTE AMPUTATION
HIPS CULT
Location - ward, apartment, gym
5.1. I. p .: lying on your back, arms along the body. Raise the stump up and down. 20 - 30 times at an arbitrary pace.
5.2. I. p .: the same. Raise the remaining leg up and down. 15-20 times at a slow pace.
5.3. I. p .: the same. Tilts of the torso towards the stump of the thigh (exhale), while straightening the torso - inhale. 15-20 times at a slow pace.
5.4. I. p .: the same, arms to the sides, the stump is raised up. Circular movements of the stump clockwise and counterclockwise. 15 times in different directions at a moderate pace.
5.5. I. p .: the same, arms along the body. Pulse-phantom gymnastics for truncated thigh muscles, combine muscle tension on the posterior surface of the stump with pressing the stump to the support plane. 15-20 times at an arbitrary pace.
5.6. I. p .: the same, raise the remaining leg up vertically. Circular movements of the leg clockwise and counterclockwise. 10-15 times in both directions at a moderate pace.
5.7. I. p .: the same, arms along the body. Sitting down on the plane of support. 10-15 times at a slow pace.
5.8. I. p .: the same, arms to the sides on the support plane. Breeding to the sides of the stump and the preserved leg, then bringing them together. 15 times at a moderate pace.
5.9. I. p .: the same, arms along the body. Cross movements of the preserved leg and femoral stump. 15-20 times at a moderate pace.
5.10. I. p .: the same, resting on the shoulders and heel of the preserved leg. Raise the pelvis up (bend) and lower it. When bending - inhale, when lowering - exhale. 15-20 times at a slow pace.
5.11. I. p .: the same, the legs are raised up. Simulation of driving
bicycle. 20 leg rotations at a fast pace.
5.12. I. p .: the same, 20 movements in the opposite direction.
5.13. I. p .: lying on your back on the edge of the bed, the femoral stump outside the edge. Vigorous lowering of the stump down (extension in the hip joint). 20 times at a moderate pace.
5.14. I. p .: lying on your back, arms along the body. Raising the straightened remaining leg to 40 - 509 and at the same time vigorously pressing the stump to the support plane is an imitation of a step. 15-20 times at a moderate pace.
5.15. I. p .: lying on his stomach, arms bent at the elbows, palms on the support plane. Raising the upper torso ("push-ups"), keeping the torso straight. 15-20 times at a slow pace.
5.16. I. p .: the same. Retraction of the stump back-up (extension in the hip joint). 15-20 times at a moderate pace.
5.17. I. p .: the same, hands up behind the head. Alternately lifting up the right arm and left leg, then the left arm and right leg. 10-15 times at a slow pace.
5.18. I. p .: the same, arms along the body. Simultaneous lifting up of the stump and the remaining leg. 10-15 times at a slow pace, do not hold your breath.
5.19. I. p .: the same, hands to the sides. Raising arms, torso, legs up. 10-15 times at a moderate pace.
5.20. I. p .: lying on your side on the side of the preserved leg. Retraction of the stump of the thigh back to the limit. 20 times at a moderate pace.,
5.21. I. p .: the same. Lifting the stump up and lowering it to the plane of support. 20 times at a slow pace.
5.22. I. p .: standing on all fours with support on the knee of the preserved leg. Simultaneous abduction of the stump back-up and the opposite hand forward-up. 15-20 times at a slow pace.
5.23. I. p .: reliance on the hands and knee of the remaining leg. Vigorous swing movements of the stumps back and forth. 15-20 times at a fast pace.
5.24. I. p .: sitting on the bed, hands on the support plane. Raising half of the pelvis on the side of the stump for a few seconds. Repeat 10-15 times at a slow pace.
5.25. I. p .: sitting on a chair, hands on the inner surfaces
hips. Try to bring the legs together with the maximum resistance of the hands. 20 repetitions at an arbitrary pace.
5.26. I. p .: sitting on a chair (on the edge of the bed). Throwing the stump of the thigh from one hand to the other. 20 - 30 times at a fast pace.
5.27. I. p .: the same, hands on hips. Torso rotation to the right and left alternately. 20 rotations in each direction at a moderate pace.
5.28. I. p .: standing on the preserved leg facing the headboard, holding it with his hands. Torso to the right and left. 15 times in each direction at a moderate pace.
5.29. I. p .: standing on the remaining leg, resting your hands on the back of the bed. Squatting on the leg with simultaneous retraction of the stump towards the outside. 15-20 times at a slow pace.
5.30. I. p .: the same. Lateral swing movements of the femoral stump with maximum abduction and adduction. 20 times at a fast pace.
5.31. I. p .: the same. Toe lift. 10-15 times at a slow pace.
5.32. I. p .: the same. Circular movements of the stump clockwise and counterclockwise. 15 movements in both directions at a fast pace.
5.33. I. p .: the same. Flexion of the trunk and stump back. 15-20 times at a moderate pace.
COMPLEX OF THERAPEUTIC PHYSICAL
EXERCISES WITH BILATERAL
amputation stumps
HIPS WITHOUT PROSTHESES
Location - ward
6.1. I. p .: lying on your back, arms along the body. Alternately lifting the stumps up. 20 times each stump at a moderate pace.
6.2. I. p .: the same. Alternate maximum bending of the legs with the help of hands. 20 times at a moderate pace.
6.3. I. p .: the same. Simultaneous bending of the legs with raising the pelvis to the chest with the help of the hands. 25 times at an average pace.
6.4. I. p .: the same. Raising the legs and torso up above the head. 20 times at a moderate pace.
6.5. I. p .: the same. Sitting down from a prone position without support on the hands. 15 times at a moderate pace.
6.6. I. p .: the same. Breeding to the sides and crossing the legs ("scissors"). 20 times at an average pace.
6.7. I. p .: the same. Circular movements of each stump alternately clockwise and against it. 20 movements in each direction at a moderate pace.
6.8. I. p .: lying on his stomach. Alternately lifting the stump up and back 20 times at a moderate pace.
6.9. I. p .: the same. Imitation of crawl and breaststroke swimming movements. 2 min. at a fast pace.
6.10. I. p .: the same. Stretching the arms up and forward with support on the pelvis. 20 movements at a slow pace.
6.11. I. p .: on the stomach, arms along the body. Taking the hands to the sides. 20 times at a moderate pace.
6.12. I. p .: the same. Lifting the stump up and back with a load on the stump. 15 times with each leg at a moderate pace.
6.13. I. p .: the same. Putting hands behind the head with a slight lifting of the torso. 20 times at a moderate pace.
6.14. I. p .: lying on his stomach, arms bent at the elbows. Raising the head, torso and shoulders up. 20 times at a moderate pace.
6.15. I. p .: the same. Bringing the arms back, raising the arms, torso and legs back and up. 10 times at a moderate pace.
6.16. I. p .: the same, hands under the head. Lifting the stump up with resistance (rubber tourniquet, tape). Alternately each stump 20 times at a moderate pace.
6.17. I. p .: sitting in bed or on a stool. Maximum torso forward, arms extended. 20 times at a moderate pace.
6.18. I. p .: sitting, hands on the back of the head. Torso twists, left elbow to right leg and vice versa. 20 times in both directions.
6.19. I. p .: sitting, arms and legs to the sides. Turns of the body with an inclination to the opposite leg. 15 times at a moderate pace.
6.20. I. p .: sitting, arms to the sides. Pressing the elbows to the body. 25 times at an arbitrary pace.
6.21. I. p .: the same. Putting the hands behind the head. 20 times at a moderate pace.
6.22. I. p .: sitting. Raising arms up, lowering down bent at the elbows. 20 times at a moderate pace.
6.23. I. p .: sitting, hands raised up. The establishment of the hands behind the back of the head. 25 times at a fast pace.
6.24. I. p .: sitting, arms to the sides. Circular movements of the hands clockwise and against it. 20 times in each direction at an arbitrary pace.
6.25. I. p .: sitting, hands behind at an emphasis. Circular movements of each stump clockwise and against it. 20 times at a moderate pace.
6.26. I. p .: sitting, emphasis with hands behind. Lifting the pelvis forward and upward with support on the ends of the stumps of the thighs.
6.27. I. p .: sitting, stick in straightened hands. Raise the stick up. 25 times at a moderate pace.
6.28. I. p .: sitting, a stick in his hands behind his head. Raise the stick up. 25 times at a fast pace.
6.29. I. p .: sitting, stick in arms extended above the head. Lowering the stick in front of the chest. 20 times at a moderate pace.
6.30. I. p .: the same. Lateral torso to the right and left. 20 times in both directions at a moderate pace.
COMPLEX OF THERAPEUTIC PHYSICAL
EXERCISES FOR THE DEVELOPMENT OF SUPPORT
amputation stumps
SHIN AND THIGH
The end support of the stumps plays an important role in the development of compensatory adaptability. The support on the end of the stump in the prosthesis creates conditions under which patients feel confident, firmer on prostheses, a “feeling of the ground” is created, which leads to an improvement in gait. And since the coordination and development of motor skills depend on the amount of impulses received from the skin, ligaments, tendons, muscles, joints, it can be assumed that the use of end support should ensure the receipt of certain impulses and thereby contribute to the improvement of motor acts associated with walking ( statistical and dynamic balance, coordination). Support when wearing the prosthesis is provided by the contact of the end of the stump with the support pad. It is possible to increase the support of the stumps not only by surgical, but also by conservative methods - through special training. It is advisable to develop the support of the stump even when the prosthesis is supposed to be without emphasis on the end of the stump. The prescription of amputation (reamputation) does not significantly affect the result of training. Under the influence of training, along with an increase in support, the endurance of the stump to dynamic and static loads increases. Support can be improved successfully by training many years after the amputation. The support of the shin stumps will increase most rapidly. To develop support, exercises are used with pressure on the end of the stump or the emphasis of the end of the stump on an object of different hardness (foam rubber of different elasticity, rubber of different elasticity, mattress, sandbags, boards, etc.). The training of the end support of the stump is started by the end of the third week after amputation.
