Exercises in diseases of the central nervous system. Exercise therapy in various forms of mental illness. methodical methods of LG

The main tasks of medical rehabilitation are to prevent the occurrence of various diseases and injuries, accelerate recovery processes and increase their effectiveness, reduce disability, and increase the level of adaptation of a disabled person to living conditions.

One of the main sections of medical rehabilitation is physiotherapy exercises (kinesitherapy) - a natural biological method of complex functional therapy. It is based on the use of the main function of the body - movement. Movement is the main form of existence of the human body: it affects all manifestations of the body's vital activity from birth to death, all body functions and the formation of adaptive reactions to a wide variety of stimuli.

In this regard, movement can act both as a specific and non-specific stimulus, causing a reaction of both the whole organism and its individual organs or systems. The motor function of a person is extremely complex. Movements are provided by interrelated processes occurring in the internal environment of the body at the cellular, organ and system levels, with the consumption and formation of energy and contribute to the manifestation of tonic, trophic, compensatory, normalizing or destructive effects.

VIEW OF HUMAN MOTOR FUNCTION

Regular, purposeful and strictly dosed use of various motor reactions helps to strengthen the biological mechanism of protective and adaptive reactions, specific and non-specific resistance of the body to various influences.

The human body is a complex self-regulating kinematic system with many degrees of freedom in the joints when performing linear (translational) and angular (rotational) movements. When interacting with a constantly changing environment, maintaining a stable position or moving the body in space are complex processes in which the required number and combination of certain degrees of freedom are selected, carried out with the consumption and release of energy with the participation of all body systems, especially nervous, respiratory and cardiovascular . Motor activity is effective only under the condition that a person is fluent in arbitrary specialized techniques and actions that make up the arsenal of techniques for a particular type of body movement in space with minimal reversible shifts in homeostasis. Each voluntary motor act of a person is characterized by 2 interrelated components: physical and cognitive.

The physical component, in turn, can be divided into biomechanical, biochemical and functional.

The biomechanical component includes information about many factors:

• morphological parameters of the human body;
• body position (position of the center of gravity);
• movement characteristics: direction, speed, acceleration, duration (t), presence of resistance (body mass, force applied to the body, including support reaction and environmental resistance) or relief (gravity reduction, additional support);
• mechanical restriction of movement (including formed contractures, incorrectly healed fractures, amputated body parts, etc.);
• muscle strength, elasticity of connective tissue (flexibility);
• resistance to intra-abdominal pressure;
• repetition of movement, etc..

In order to obtain comprehensive information and distribute tasks to individual regions of the body, models of the human body were proposed based on mathematical modeling. One of them is Hanavan's model (1964, 1966), which divides the human body into 15 simple geometric figures of uniform density (Fig. 14-1). The advantage of this model is that it requires only a small number of simple anthropometric measurements (eg, length and circumference of the segments) to refine it and predict the position of the center of gravity as well as the moment of inertia for each body segment.

Based on the same approach, Hatze (1980) developed a more detailed model of the human body (Fig. 14-2). Hatze humanoid consists of 17 body segments, 242 anthropometric measurements are required for individualization.

A non-specific summary of the study of the physical component is the work done by the human body, a scalar value defined as the product of the displacement of the system by the projection of the force that acts in the direction of displacement and requires energy.

According to the "work-energy" approach, energy can be represented not only as a result, but also as the ability to do work. When analyzing human movements, such types of energy as potential energy are of particular importance: due to gravity, due to deformation; kinetic: translational rotation; energy released as a result of metabolic processes. When studying the relationship between work and energy, it is advisable in most cases to use the first law of thermodynamics, which characterizes the relationship between the work done and the change in the amount of energy. In biological systems, the exchange of energy during the performance of work is not an absolutely efficient process.

Only 25% of the energy released as a result of metabolic processes is used to perform work, the remaining 75% is converted into heat or used during recovery processes. The ratio of the work performed to the change in the amount of energy characterizes the efficiency (productivity) of the process. The work performed with the minimum expenditure of energy represents the most economical execution of the task and characterizes the optimal functioning.

Rice. 14-1. Hanavan's model of the human body (1964, 1966).

Rice. 14-2. Model 1 of a 7-segmented humanoid (Hatze, 1980).

Energy metabolism includes metabolic processes associated with the formation of ATP, the accumulation of energy during its synthesis and subsequent energy conversion during various types of cell activity. Depending on which biochemical process is used to supply energy for the formation of ATP molecules, there are 4 options for ATP resynthesis in tissues (biochemical component). Each option has its own metabolic and bioenergetic features. in the energy supply of muscular work, different options are used depending on the intensity and duration of the exercise (movement) performed.

ATP resynthesis can be carried out in reactions that occur without the participation of oxygen (anaerobic mechanisms) or with the participation of inhaled oxygen (aerobic mechanism). In human skeletal muscles, 3 types of anaerobic and 1 aerobic pathway of ATP resynthesis have been identified.

Anaerobic mechanisms include the following.

Creatine phosphokinase (phosphogenic, or alactate), which provides ATP resynthesis due to rephosphorylation between creatine phosphate and ADP.

Glycolytic (lactate), which provides ATP resynthesis in the process of enzymatic anaerobic breakdown of muscle glycogen or blood glucose, ending with the formation of lactic acid.

Myokinase, carrying out ATP resynthesis due to the rephosphorylation reaction between 2 ADP molecules with the participation of the enzyme myokinase (adenylate kinase).

The aerobic mechanism of ATP resynthesis mainly includes oxidative phosphorylation reactions occurring in mitochondria. The energy substrates of aerobic oxidation are glucose, fatty acids, partially amino acids, as well as intermediate metabolites of glycolysis (lactic acid) and fatty acid oxidation (ketone bodies)

The rate of oxygen delivery to tissues is one of the most important factors affecting the energy supply of muscles, since the rate of ATP resynthesis in the mitochondria of skeletal muscles, where about 90% of all the necessary energy is produced, depends to a certain extent on the concentration or tension of oxygen in the cell. At a low level of metabolism in the cell, which is detected in a resting, normally functioning muscle, changes in the rate of oxygen delivery to tissues do not affect the rate of ATP resynthesis (saturation zone). However, when the oxygen tension (pO 2 ) in the cell is below a certain critical level (fatigue, pathological process), maintaining the rate of ATP resynthesis is possible only due to adaptive shifts in intracellular metabolism, which inevitably requires an increase in the rate of O 2 delivery to the muscles and its consumption by mitochondria. The maximum rate of O 2 consumption by skeletal muscle mitochondria can be maintained only up to a certain critical value of pO 2 in the cell, which is 0.5-3.5 mm Hg. If the level of metabolic activity during muscular work exceeds the value of the maximum possible increase in aerobic ATP resynthesis, then the increased need for energy can be compensated by anaerobic ATP resynthesis. However, the range of anaerobic metabolic compensation is very narrow, and a further increase in the rate of ATP resynthesis in the working muscle, as well as the functioning of the muscles, becomes impossible. Ranges of metabolic activity within which O 2 delivery is insufficient to maintain the required level of ATP resynthesis are usually referred to as hypoxic states of varying severity. To maintain the O2 tension in mitochondria at a level above the critical value, at which the conditions for adaptive regulation of cell metabolism are still preserved, the O2 tension on the outer cell membrane should be at least 15–20 mm Hg. To maintain it and the normal functioning of the muscles, the oxygen tension in the arterioles that deliver blood directly to the working muscles should be about 40, and in the main arteries - 80-90 mm Hg. In the pulmonary alveoli, where gas exchange takes place between the blood and atmospheric air, the O 2 voltage should be approximately 110, in the inhaled air - 150 mm Hg.

The next component that determines the efficiency of oxygen delivery is hemoglobin. The ability of hemoglobin to bind oxygen is affected by the temperature of the blood and the concentration of hydrogen ions in it: the lower the temperature and the higher the pH, the more oxygen can be bound by hemoglobin. An increase in the content of CO 2 and acidic metabolic products, as well as a local increase in blood temperature in the capillaries of tissues, increase the breakdown of oxyhemoglobin and the release of oxygen.

In muscle cells, oxygen exchange is carried out with the participation of the myoglobin protein, which has a structure similar to that of hemoglobin. Myoglobin carries oxygen to the mitochondria and partially stores it. It has a greater chemical affinity for oxygen than hemoglobin, which ensures that the muscles make better use of the oxygen supplied by the blood.

When moving from a state of rest to intense muscle activity, the need for oxygen increases many times over, but it cannot be satisfied immediately, therefore, the so-called oxygen debt is formed, which is reimbursed during the recovery period. Time is needed for the activity of the respiratory and circulatory systems to increase and for the blood enriched with oxygen to reach the working muscles. As the activity of these systems increases, oxygen consumption in working muscles gradually increases.

Depending on the number of muscles involved in the processes of contraction, physical work is divided into local (involved<1/4 всех мышц тела) , региональную и глобальную (участвует >3/4 of all muscles of the body).

Local work can cause changes in the working muscle, but in general, biochemical changes in the body are insignificant.

Regional work (elements of various exercises involving medium and large muscle groups) causes much greater biochemical shifts than local muscle work, which depends on the proportion of anaerobic reactions in its energy supply.

Due to global work (walking, running, swimming), the activity of the respiratory and cardiovascular systems is significantly enhanced.

The metabolic shifts in the body are influenced by the mode of muscle activity.

Allocate static and dynamic modes of operation.

In the static version of muscular work, the cross section of the muscle increases with its length unchanged. With this type of work, the share of participation of anaerobic reactions is high.

Dynamic (isotonic) mode of operation, in which they change. both the length and the cross section of the muscle provide tissues with oxygen much better, since intermittently contracting muscles act as a kind of pump that pushes blood through the capillaries. For rest after static work, it is recommended to perform dynamic work.

Changes in biochemical processes in the body depend on the power ("dose") of the performed muscular work and its duration. At the same time, the higher the power, and, consequently, the greater the rate of ATP splitting, the less the ability to satisfy the energy demand due to respiratory oxidative processes, and the more the processes of anaerobic ATP resynthesis are connected. The power of work is inversely related to its duration, while the greater the power, the faster the biochemical changes occur, causing fatigue and prompting to stop working. Based on the power of work and energy supply mechanisms, all cyclic exercises can be divided into several types depending on the consumption of O 2. The functional equivalent of the consumption of O 2 during the performance of any work is a metabolic unit equal to 3.7 ml of oxygen consumed per 1 kg of body weight (functional component ).

An express method that allows you to set the power range of work is the definition of chess. Each range of work has a specific effect on the human body. It has been convincingly proven that the intensity threshold of training sessions increases in direct proportion to the maximum oxygen consumption before the start of training (Franklin V.A., Gordon S., Timmis G, c., 1992). For most people with significant health conditions, it is approximately 40-600/0 maximum oxygen consumption, which corresponds to 60-70% of maximum heart rate (American college of Sports Medicine, 1991).

Biochemical changes in the human body, resulting from the performance of a certain movement (exercise), are observed not only during the performance of work, but also during a significant period of rest after its completion. Such a biochemical aftereffect of exercise is referred to as "recovery". During this period, the catabolic processes that occur in the working muscles during exercise turn into anabolic ones, which contribute to the restoration of cellular structures destroyed during work, the replenishment of wasted energy resources and the restoration of the disturbed endocrine and water-electrolyte balance of the body. There are 3 phases of recovery - urgent, delayed and delayed.

The urgent recovery phase covers the first 30 minutes after the end of the exercise and is associated with the replenishment of intramuscular ATP and creatine phosphate resources, as well as with the "payment" of the alactic component of oxygen debt.

In the delayed recovery phase, which lasts from 0.5 to 6-12 hours after the end of the exercise, the wasted carbohydrate and fat reserves are replenished, the water-electrolyte balance of the body returns to its original state.

In the slow recovery phase, which lasts up to 2-3 days, the processes of protein synthesis increase, and adaptive shifts caused by the exercise are formed and consolidated in the body.

The dynamics of ongoing metabolic processes has its own characteristics in each recovery phase, which allows you to choose the right schedule for recovery activities.

When performing any exercise, it is possible to identify the main, most loaded links of metabolism and functions of body systems, the capabilities of which determine the ability to perform movements (exercises) at the required level of intensity, duration and complexity. These can be regulatory systems (CNS, autonomic nervous system, neurohumoral regulation), autonomic support systems (respiration, blood circulation, blood) and the executive motor system.

The motor system as a functional component of the physical component of the movement includes 3 parts.

DE (muscle fiber and the efferent nerve that innervates it), existing in the human body as slow-twitch, not susceptible to fatigue (DE S), fast-twitch, not susceptible to fatigue (DE FR) and fast-twitch, susceptible to fatigue (DE FF) .

Functional joint systems (Enoka R.M., 1998), including a rigid link (connective tissue - bone, tendon, ligament, fascia), synovial joint, muscle fiber or muscle, neuron (sensory and motor) and sensitive nerve endings (proprioreceptors - muscle spindles, tendon organs, articular receptors; exteroreceptors - receptors of the eye, ear, mechano-, thermo-, photo-, chemo- and pain receptors of the skin).

A vertically organized hierarchy of convergence of motor programs, including an idea of ​​the mechanisms of motor function control during its formation in normal conditions and in various pathological conditions.

The cognitive component of movement includes neuropsychological and psycho-emotional components. All movements can be divided into active and passive (automated, reflex). An unconscious movement, performed without the direct participation of the cerebral cortex, is either the realization of a central, genetically programmed reaction (unconditioned reflex), or an automated process, but which initially arose as a conscious action - a conditioned reflex - skill - motor skill. All actions of an integrated motor act are subject to the task of obtaining a certain adaptive result, determined by the need (motive). The formation of a need, in turn, depends not only on the organism itself, but also on the influence of the surrounding space (environment). The ability, acquired on the basis of knowledge and experience, to selectively control movements in the process of motor activity is a skill. The ability to perform a motor action is formed on the basis of certain knowledge about its technique, the presence of appropriate motor prerequisites as a result of a number of attempts to consciously build a given movement system. In the process of formation of motor skills, the search for the optimal variant of movement occurs with the leading role of consciousness. A skill is a primitive form of mastering an action, characterized by a lack of reliability, the presence of serious errors, low efficiency, high energy costs, a level of anxiety, etc. Repeated repetition of movements with the active participation of consciousness gradually leads to automation of the main elements of their coordination structure and the formation of a motor skill - automated method of motion control in a holistic motional action.

Automated motion control is the most important feature of a motor skill due to the fact that it allows you to release the mind from control over the details of the movement and switch it to achieve the main motor task in specific conditions, to select and apply the most rational methods for solving it, that is, to ensure effective functioning higher mechanisms of motion control. A feature of the skills is the unity of movements, which is manifested in an effective coordination structure, minimal energy costs, rational correction, high reliability and variability, the ability to achieve the goal of a motor action under the influence of adverse factors: excessive excitement, fatigue, changes in environmental conditions, etc.

CHANGES IN MOTOR FUNCTION IN DISEASES OF THE NERVOUS SYSTEM

At the heart of the clinical manifestations of movement disorders that occur when the nervous system is damaged, there are certain pathological mechanisms, the implementation of which covers the entire vertical system of movement regulation - muscular-tonic and phasic. Typical pathological processes that occur in the nervous system when it is damaged include the following (Kryzhanovsky G.N., 1999).

• Violation of regulatory influences from supraspinal formations.
• Violation of the principle of dual functional impulsation with a predominance of excitation over inhibition at the level of the synapse.
• Denervation syndrome, manifested by a violation of the differentiation of denervated tissues and the appearance of signs characteristic of the early stages of development (spinal shock is close to the denervation syndrome)
• Deafferentation syndrome, also characterized by an increase in the sensitivity of postsynaptic structures.

In the internal organs with vegetative innervation, there is a violation of the mechanisms of regulation of functions. Violation of the integrative activity of the nervous system is manifested in the disintegration of the proper control influences and the emergence of new pathological integrations. A change in the movement program is expressed in a complex segmental and suprasegmental influence on the processes of a complex motor act, based on a combination of an imbalance of inhibitory control influences from the higher parts of the central nervous system, disinhibition of more primitive segmental, stem, mesencephalic reflex reactions, and rigid complex programs maintaining balance and stability that retain their influence. in various positions already formed in phylogenesis, that is, there is a transition from a more perfect, but less stable form of control of functions to a less perfect, but more stable form of activity.

A motor defect develops with a combination of several pathological factors: loss or change in the functions of muscles, neurons, synapses, changes in the posture and inertial characteristics of the limbs, and the movement program. At the same time, regardless of the level of damage, the pattern of motor function disorders is subject to certain biomechanical laws: the redistribution of functions, functional copying, and ensuring the optimum.

Studies by many authors have shown that with various pathologies of the nervous system, regardless of the level of damage, almost all parts of the central and peripheral nervous system responsible for maintaining posture and controlling movement suffer.

Studies show that the trunk is the main object of regulation and maintenance of an upright posture. At the same time, it is assumed that information about the position of the body is provided by proprioreceptors of the lumbar spine and legs (primarily the ankle joint), that is, in the process of transition to a vertical position and movement in this position, a conditioned reflex, very rigid complex innervation is formed in the process of onto- and phylogenesis. a program for maintaining a stable position of the body, in which muscles function that prevent sharp fluctuations in the general center of gravity of the human body in a vertical position and when walking - muscles with the so-called power function: sacrospinous, large and middle gluteal, gastrocnemius (or extensor muscles) . According to a less rigid program, the muscles that are involved mainly in setting up movements (or flexor muscles) function: the rectus and external oblique muscles of the abdomen, flexors and partly adductors of the thigh, anterior tibial muscle. According to A.S. Vitenzon (1998), under conditions of pathology, the structure and regularity of muscle functioning are observed. According to this principle, the extensors perform mainly a power function, and the flexors perform a corrective function.

In case of damage, the lost function is replenished by a whole functional system with widely interacting central and peripheral formations that create a single complex with certain physiological properties. Under the influence of a new controlled afferentation coming from the periphery after damage, "relearning of neurons" (motor relearning) is possible, while the functions from the affected neurons are transferred to the intact ones and stimulate reparative processes in the damaged neurons. Recovery is an active process that takes place according to certain laws, with the participation of certain mechanisms and has a staged nature of development.

STAGES AND PECULIARITIES OF MOTOR REEDUCATION WHEN USING THERAPEUTIC PHYSICAL CULTURE

In the process of motor relearning, several stages can be distinguished that characterize the possible control over muscle functions.

The stage of influence on the proprioceptive apparatus, which determines the specificity of the influence on muscles, connective tissue, joints and is characterized by the simplest level of regulation: influence on the receptor - effect. At this stage, the achieved effect does not last very long and depends on the frequency and intensity of exposure. In this case, in accordance with the stages of the formation of a vertical posture of a person, the impact should be carried out first on the axial muscles in the craniocaudal direction, then on the muscles of the shoulder and hip girdle. Further - on the muscles of the limbs sequentially from the proximal to the distal joints.

The stage of attracting regulatory influences from the oculomotor muscles, rhythmic audio stimulation (counting, musical rhythmic accompaniment), stimulation of the receptors of the vestibular apparatus, depending on the position of the head in relation to the body. At this stage, complex processing of situational afferentation and reflex reactions controlled by a more complex neural system (Magnus-Klein postural reflex reactions) are stimulated.

The stage in which successive control of the shoulder and hip girdle is acquired, or the stage of changing the position of the body, When the position of the shoulder and then the pelvic girdle changes after the head.

Stage of ipsilateral control and coordination.

Stage of contralateral control and coordination.

The stage in which the area of ​​support of the body decreases, characterized by stimulation of control over the limbs successively in the distal direction - from the shoulder and hip to the wrist and ankle joints. At the same time, stability is first ensured in each new position reached, and only then mobility in this position and the possibility of changing it in the future in accordance with the stage of development of the vertical posture is ensured.

The stage of increasing the mobility of the body in a vertical (or other position achieved in the process of motor retraining): walking, running, etc. At all stages, a very important moment of rehabilitation measures is control over the state of the autonomic nervous system and the level of the patient's adaptive capabilities in order to exclude overload and reduce the efficiency of cardiorespiratory support of the movements performed. The consequence of this is a decrease in the energy potential of the neuron, followed by apoptosis or destabilization of the cardiovascular system.

Thus, the onto- and phylogenetic features of the formation of human motor skills, changes in posture and inertial characteristics of the limbs determine the starting afferentation. The biomechanical zero coordinate of the part of the movement determines the flow of proprio-, extero- and nociceptive situational afferentation for the formation of the subsequent program of actions. When solving the problem of movement (of the entire biological body or its segment), the CNS gives a complex command, which, being recoded at each of the sublevels, enters the effector neurons and causes the following changes.

Isometric contraction of muscle groups that keep segments that are not currently moving in a stable, fixed position.

Parallel dynamic concentric and eccentric muscle contractions that ensure the movement of a given body segment in a given direction and at a given speed.

Isometric and eccentric muscle tension, stabilizing the trajectory set during movement. Without the neutralization of additional contractions, the process of moving is impossible.

The process of motor skill formation can be considered two-way. On the one hand, the central nervous system "learns" to give highly differentiated commands that provide the most rational solution to a specific motor task. On the other hand, corresponding chains of muscle contractions arise in the musculoskeletal system, providing coordinated movements (purposeful, economical).

Muscular movements formed in this way represent a physiologically realized interaction between the central nervous system and the musculoskeletal system. Firstly, they are stage-by-stage in the development of the movement function, and secondly, they are basic for ensuring the improvement of motor coordination.

BASICS OF THE USE OF THERAPEUTIC PHYSICAL CULTURE

For the successful use of exercise therapy, it is necessary to correctly assess the state of the impaired function in each patient, determine the possibility of its independent recovery, the degree, nature and duration of the defect, and, on the basis of this, choose adequate ways to eliminate this disorder.

The principles of the use of exercise therapy: early onset, ontogenetic, pathophysiological and individual approach, compliance with the level of the patient's functional state, strict sequence and stages, strict dosage, regularity, gradual increase in load, duration, continuity of selected forms and methods, control over tolerability and load efficiency, maximum active participation of the patient.

Physiotherapy (kinesitherapy) involves the use of various forms aimed at restoring motor function in patients with pathology of the nervous system. Types of active and passive kinesitherapy are presented in Table. 14-1 - 14-3.

Table 14- 1 . Types of kinesitherapy (exercise therapy)

Table 14-2. Types of active kinesitherapy (exercise therapy)

Type	Variety
Physiotherapy	Respiratory
	General strengthening (cardio training)
	reflex
	Analytical
	Corrective
	Psychomuscular
	Hydrokinesitherapy
Ergotherapy	Correction of the patient's activity and participation in daily habitual activities, active interaction with environmental factors
Treatment with walking	Dosed walking, health path, walking with obstacles, dosed walks
Specialized methodological systems	Balance, Feldenkrais, Phelps, Temple Fey, Frenkel, Tardye, Kenni, Klapp, Bobath, Woitta, PNF, Br unn stg ő m and others.
exercise therapy and biofeedback	Using data from EMG, EEG, stabilography, spirography
High-tech computer programs	Computer complexes of virtual reality, biorobotics
Other teaching methods	"Non-use" of intact parts of the body, the effect of "crooked" mirrors, etc.

Table 14-3. Types of passive kinesitherapy (exercise therapy)

SCHEME OF THE USE OF THERAPEUTIC PHYSICAL CULTURE

The main components included in the program for the use of exercise therapy in patients with diseases and injuries of the nervous system are as follows.

• Comprehensive detailed topical diagnosis.
• Clarification of the nature of movement disorders (volume of active and passive movements, muscle strength and tone, manual muscle testing, EMG, stabilometry, degree of limitation of participation in effective communication with the environment).
• Determining the volume of daily or other activity and assessing the features of the motor regime.
• A thorough neuropsychological examination to clarify the nature of violations of higher mental functions and determine the strategy of interaction with the patient.
• Complex drug therapy that supports the rehabilitation process.
• Monitor monitoring of the state of the cardiovascular system (ECG. BP control), the purpose of which is to adequately assess the patient's condition, as well as dynamically manage the rehabilitation process.
• Functional testing to predict the patient's condition.

CONTRAINDICATIONS

General contraindications to exercise therapy include the following diseases and conditions.

• Acute period of the disease or its progressive course.
• Threat of bleeding and thromboembolism.
• Severe anemia.
• Severe leukocytosis.
• ESR more than 20-25 mm/h.
• Severe somatic pathology.
• Ischemic changes on ecg.
• Heart failure (class 3 and above according to Killip).
• Significant aortic stenosis.
• Acute systemic disease.
• Uncontrolled ventricular or atrial arrhythmia, uncontrolled sinus tachycardia more than 120 per minute.
• Atrioventricular blockade of the 3rd degree without a pacemaker.
• Acute thrombophlebitis.
• Uncompensated diabetes mellitus.
• Defects of the musculoskeletal system that make it difficult to exercise.
• Gross sensory aphasia and cognitive (cognitive) disorders that prevent the active involvement of patients in rehabilitation activities.

Contraindications to the use of physical exercises in water (hydrokinesitherapy):

• violations of the integrity of the skin and skin diseases, accompanied by purulent-inflammatory changes;
• fungal and infectious skin lesions;
• diseases of the eyes and ENT organs in the acute stage;
• acute and chronic infectious diseases in the stage of bacillus carriage;
• venereal diseases;
• epilepsy;
• incontinence of urine and feces;
• copious sputum;

Contraindications for mechanotherapy

Absolute:

• spinal tumors;
• malignant neoplasms of any localization;
• pathological fragility of bones (neoplasms, genetic diseases, osteoporosis, etc.);
• acute and in the acute phase of chronic infectious diseases, including osteomyelitis of the spine, tuberculous spondylitis;
• pathological mobility in the spinal motion segment;
• fresh traumatic lesions of the skull and spine;
• condition after surgery on the skull and spine;
• acute and sub-acute inflammatory diseases of the brain and spinal cord and its membranes (myelitis, meningitis, etc.);
• thrombosis and occlusion of the vertebral artery.

Relative:

• the presence of signs of mental disorders;
• negative attitude of the patient to the method of treatment;
• progressive increase in symptoms of loss of functions of a spondylogenic nature;
• herniated disc in the cervical spine;
• diseases of internal organs in the stage of decompensation.

Risk factors when using physiotherapy exercises in patients with cerebral stroke:

• development of a hyper- or hypotonic response to restorative measures, which can lead to a decrease in the efficiency of regional cerebral blood flow;
• the appearance of shortness of breath;
• increased psychomotor arousal;
• inhibition of activity;
• increased pain in the spine and joints.

Factors that delay the recovery of motor function when using exercise therapy:

• low tolerance to physical activity;
• disbelief in the effectiveness of rehabilitation measures;
• depression;
• gross violation of deep sensitivity;
• pain syndrome;
• advanced age of the patient.

ORGANIZATION OF THERAPEUTIC PHYSICAL CULTURE

The choice of the form and method of physical exercise depends on the purpose of the lesson and the data of the initial examination of the patient. The lesson can take place individually and in a group according to a certain methodology, which contributes to a more complete realization of the patient's capabilities in the process of recovery or mastering a new motor skill. The choice of a specific physical exercise is determined by morphometric parameters and the results of a study of the nervous system. The predominance of one or another effect depends on the purpose of rehabilitation at this stage, the level of the patient's functional state and the intensity of the effect. The same movement leads to different results in different patients.

The intensity of the impact of physical exercise depends on the method of dosing:

Selection of the starting position - determines the position of the center of gravity, the axis of rotation in certain joints, the characteristics of the levers of the operating kinematic system, the nature of the isotonic contraction during the movement (concentric or eccentric);

Amplitudes and speeds of movement - indicate the prevailing nature of muscle contraction (isotony or isometry) in various muscle groups of working joints;

The multiplicity of a certain component of the movement - or the entire movement as a whole - determines the degree of automation and activation of the reactions of the cardiopulmonary system and the rate of development of fatigue;

The degree of force tension or unloading, the use of additional weights, a special device - change the length of the lever arm or the moment of force and, as a result, the ratio of the isotonic and isometric components of contraction and the nature of the reaction of the cardiovascular system;

Combinations with a certain phase of respiration - increases or decreases the efficiency of external respiration and, in turn, changes the energy costs for performing a movement;

Degrees of complexity of movement and the presence of an emotional factor - increase the energy cost of movements;

The total time of the lesson - determines the total energy costs for the implementation of a given movement.

It is fundamentally important to correctly build a lesson (procedure) and control its effectiveness. Each exercise session, regardless of form and method, should include 3 parts:

Introductory, during which the work of the cardiopulmonary system is activated (increase in heart rate and blood pressure up to 80% of the level planned for this lesson);

The main one, the role of which is to solve a special therapeutic motor task and achieve the proper values ​​of blood pressure and heart rate;

The final one, during which the indicators of the cardiopulmonary system are restored by 75-80%.

If blood pressure, heart rate do not decrease, ventilation of the lungs and muscle strength do not decrease, then this indicates that physical exercise is effective.

Only with properly regulated motor activity can we expect improvement in the functioning of body systems. Accidental and thoughtless use of physical exercises can exhaust the reserve capacity of the body, lead to the accumulation of fatigue, persistent fixation of pathological stereotypes of movement, which will certainly worsen the patient's quality of life.

To assess the adequacy and effectiveness of the load, current and staged control is carried out. Current control is carried out throughout the treatment, using the simplest methods of clinical and functional research and functional tests: control of pulse, blood pressure, respiratory rate, orthostatic test, breath holding test, assessment of well-being, degree of fatigue, etc. Staged control involves the use of more informative methods of research, such as Holter, daily monitoring of blood pressure, echocardiography at rest and with exercise, teleelectrocardiography, etc.

COMBINATION OF THERAPEUTIC PHYSICAL CULTURE WITH OTHER METHODS

Physical exercises should be given a strictly defined place in the system of activities carried out at a particular stage of recovery (rehabilitation) of a patient by medical, pedagogical and social specialists based on a multidisciplinary approach. An exercise therapy doctor needs the ability to interact with a neurologist, neurosurgeon, orthopedist, neuropsychologist, psychologist, psychiatrist, speech therapist and other specialists when discussing patient management tactics.

When using medications, nutritional supplements, and others, the issue of pharmacokinetics and pharmacodynamics of active substances and a possible change in the effect on the plasticity of the nervous system, oxygen consumption and utilization, and the excretion of metabolites during physical work should be considered. The applied natural or preformed factors of nature should have both a stimulating and restorative effect on the body, depending on the time of their use in relation to the most powerful adaptive means - movement. To facilitate and correct physical exercises, functional orthoses and unloading fixing devices (verticalizers, gravistat apparatus, dynamic parapodium) are widely used. With severe and persistent disorders of motor function in some systems (Phelps, Tardieu, etc.), in order to facilitate the restoration of motor function, a surgical method is used (for example, osteotomy, arthrotomy, sympathectomy, dissection and displacement of tendons, muscle transplantation, etc.

ENGINE MODES

The mode of human movements is determined by the position of the body, in which the patient stays for most of the day, provided that the cardiovascular and respiratory systems are stable, as well as organized forms of movement, household and professional motor activity. The motor mode determines the initial position of the patient during kinesitherapy (Table 14-4).

Table 14-4. General characteristics of motor modes

Stages of rehabilitation: d - hospital; s - sanatorium; a - outpatient clinic.

Patients in the hospital are prescribed strict bed, bed, extended bed, ward and free modes. To guarantee patients safe motor activity within aerobic limits, heart rate fluctuations during any movement should be limited to 60% of the theoretical maximum heart rate reserve (Karvonen M_L. et al., 1987): HRmax. days \u003d (HRmax - HRrest) x 60% + HRrest, where HRmax. = 145 per minute, which corresponds to a 75% level of oxygen consumption (Andersen K. L. et al., 1971) at the age of 50-59 years, regardless of gender. At the sanatorium stage of rehabilitation, patients are shown free, sparing and sparing training modes. The average daily heart rate is 60-80% of the theoretical maximum heart rate reserve. At the outpatient stage, free, sparing, sparing-training and training modes are recommended. The average daily heart rate is 60-100% of the theoretical maximum heart rate reserve. Exercise therapy techniques used for various diseases of the nervous system are presented in Table. 14-5.

Table 14-5. Differentiated application of kinesitherapy (exercise therapy) in diseases and injuries of the nervous system (Duvan S., with changes)

Estimated feature	peripheral motor neuron	Central motor neuron	Sensitive neuron	Extra-pyramidal disorders
Movement disorders	Decreased tone to atony, decreased reflexes or areflexia, reaction of nerve degeneration	Muscular hypertension, hyperreflexia, pronounced pathological concomitant movements, pathological extensor-type foot reflexes or muscle hypo- or normatonia with limitation or absence of voluntary movements, hypesthesia in the absence of a degeneration reaction of nerve trunks	No	Muscle rigidity, stiffness, stiffness in certain positions, general physical inactivity, tonic spasm, decreased tone, impaired coordination, hyperkinesis
Involuntary movements	No	Clonic spasm, athetosis, convulsive twitches, intentional trembling, adiadochokinesis	No	Positional tremor, loss of some automatic movements, involuntary movements
Localization of dysfunction	One or more muscles innervated by the affected nerve, root, plexus, etc.; all muscles below the level of the lesion, symmetrically	Hemi-, di-, or paraplegia (paresis)	Depending on the location of the lesion	Skeletal muscles
Gait	Paretic (paralytic)	Spastic, spastic-paretic, ataxic gait	Ataxic gait	Spastic, spastic-paretic, hyperkinetic
Sensory changes	No	No	Total anesthesia, sensory dissociation, cross anesthesia, pain, paresthesia, hyperesthesia	Pain from local spasms
Trophic changes	Dystrophic changes in the skin and nails, muscle atrophy, osteoporosis	No	Expressed	Change in local thermoregulation
Autonomic dysfunction	Expressed	insignificant	No	Expressed
Cognitive impairment	No	General agnosia, impaired memory, attention, speech, kinetic, spatial, regulatory (ideomotor) apraxia	Agnosia tactile, visual, auditory, kinesthetic apraxia	Apraxia kinetic, spatial, regulatory (limbic-kinetic)
Principles of kinesite-peutic treatment	Preservation and restoration of tissue trophism. Restoration of the breathing pattern. Deformation prevention. Restoration of the functional activity of DE. Consistent, staged formation of a static and dynamic stereotype. Increased endurance (tolerance to stress)	Restoration of the breathing pattern. Restoration of autonomic regulation of functions. Increased endurance (tolerance to stress). Restoration of the functional activity of DE. Consistent, staged formation of a static and dynamic stereotype (prevention of vicious positions of paretic limbs, inhibition of the development of pathological reflexes, decrease in muscle tone, restoration of gait and fine motor skills)	Preservation and restoration of tissue trophism. Formation of adequate self-control to maintain static and dynamic stereotypes (restoration of coordination of movements, especially under visual control). Restoration of walking function	Restoration of autonomic regulation of functions. Increased endurance (tolerance to stress). Restoration of the functional activity of DE. Restoration of a static stereotype. Recovery of walking function
Exercise therapy methods	Passive: massage (therapeutic and mechanical), positional treatment, mechanotherapy, manual manipulations. Active: LH (respiratory, cardio training, reflex, analytical, hydrokinesi therapy), occupational therapy, terrenterapiya, etc.	Passive: massage (reflex), positional treatment, mechanotherapy, manual manipulations (muscle-fascial). Active: LH (respiratory, cardio training, reflex, analytical, hydrokinesi therapy, psycho-muscular), occupational therapy, terrenterapiya, etc.	Passive: massage (therapeutic and mechanical), positional treatment, mechanotherapy, manual manipulations. Active: LH (respiratory, cardio training, reflex, analytical, hydrokinesi therapy), occupational therapy, terrenterapiya, etc.	Passive: massage (therapeutic and mechanical), positional treatment, mechanotherapy, manual manipulations. Active: LH (respiratory, cardio training, reflex, analytical, hydrokinesi therapy), occupational therapy, terrenterapiya, etc.
Other methods of non-drug treatment	Nursing, physiotherapy, orthotics, reflexology, psychotherapy	Nursing, physiotherapy, orthotics, reflexology, speech therapy correction, neuro-psychological correction, psychotherapy	Physiotherapy, reflexology, psychotherapy	Care, physiotherapy, orthotics, reflexology, speech therapy correction, neuro-psychological correction, psychotherapy

How often lately can one hear that someone has been diagnosed with "vegetative-vascular dystonia". What is this disease? The reason is a disorder of neuroendocrine regulation of the activity of the cardiovascular system. Unfortunately, the symptoms of the disease are diverse. Palpitations, an increase or decrease in blood pressure, pallor, sweating are disorders of the cardiovascular system. Nausea, lack of appetite, difficulty swallowing - malfunctions of the digestive system. Shortness of breath, tightness in the chest - respiratory disorders. All of these disorders are a breakdown in the interaction between the vascular and autonomic systems. But most often dystonia develops with a disorder of cardiovascular activity. And neuropsychic exhaustion, acute and chronic infectious diseases, lack of sleep and overwork contribute to this.

Systemic vegetative-vascular dystonias proceed according to the hyper- and hypotensive type. The first type is characterized by small and infrequent rises in blood pressure within 140/90 mm Hg. Art., fatigue, sweating, increased heart rate, etc.

The second type is hypotensive. Arterial pressure is characterized by a pressure of 100/60 mm Hg. Art., and in this case dizziness, weakness, increased fatigue, drowsiness, a tendency to fainting are noted.

Since vegetative-vascular dystonia can be observed in adolescence and youth, the prevention of this disease must begin at an early stage. This concerns the organization of a rational mode of work and rest.

Have you been diagnosed with "vegetative-vascular dystonia"? That's not fatal. Compliance with all doctor's prescriptions, regimen, avoidance of traumatic factors have a beneficial effect on the treatment process. On a par with the drug treatment of this disease are non-drug treatments: hardening procedures, physiotherapy, balneotherapy, certain sports, as well as physical education.

A very good effect is achieved by exercising in the pool. But dosed physiotherapy exercises have no less effect, since it increases the activity of the most important organs and systems that are involved in the pathological process. Therapeutic physical training perfectly increases working capacity, balances the processes of excitation and inhibition in the central nervous system.

An approximate set of general developmental exercises for vegetative-vascular dystonia

Exercise 1. Starting position - lying on your back. Arms out to the sides, tennis ball in right hand. Pass the ball to your left hand. Return to starting position. Look at the ball. Repeat 10-12 times.

Exercise 2. Starting position - lying on your back. Hands to the side. Perform cross movements with straight arms in front of you. Repeat for 15-20 s. Follow hand movements. arbitrary.

Exercise 3. Starting position - lying down. Hands forward. Swing with the right foot to the left hand. Return to starting position. Do the same with the left foot. Repeat 6-8 times. Look at the toe of the foot. The move is fast.

Exercise 4. Starting position - lying on your back. Basketball in hand. Leg swing - get the ball. Repeat with each leg 6 times.

Exercise 5. Starting position - lying on your back. In the raised right hand is a tennis ball. Make circles clockwise, then counterclockwise. Return to starting position. Repeat with the left hand. Look at the ball. Run 10-15 seconds.

Exercise 6. Starting position - sitting on the floor. Hands on the back. Straight legs are raised slightly above the floor. Make cross movements with your legs, right on top, then change legs. Don't hold your breath. Look at the toe of the foot. Run 10-15 seconds.

Exercise 7. Starting position - sitting on the floor. Hands on the back. Mahi with straight legs alternately. The amplitude is high. Run 10-15 seconds.

Exercise 8. Starting position - sitting on the floor. Swing your legs to the sides. Alternately repeat 6-8 times with each leg.

Exercise 9. Starting position - sitting on the floor. Hands on the back. Take the right leg to the right until it stops. Return to starting position. Do the same with your left foot. Make movements slowly. Repeat 6-8 times.

Exercise 10. Starting position - sitting on the floor. Hands on the back. Slightly raise the right leg and draw a circle in the air clockwise, then against. Initial position. Repeat the same with the left leg. Repeat 6-8 times with each leg.

Exercise 11. Starting position - sitting on the floor. Emphasis with hands - raise both legs above the floor and make circular movements in one direction, then in the other. Run 10-15 seconds.

Exercise 12. Starting position - standing. In the hands of a gymnastic stick. Raise the stick above your head - bend in the lower back - inhale, return to the starting position - exhale. Repeat 8-10 times.

Exercise 13. Starting position - standing. Hands lowered, in the hands of a gymnastic stick. Sit down, raise the stick up above your head - inhale. Return to the starting position - exhale. Repeat 6-8 times.

Exercise 14. Starting position - standing. Dumbbells in lowered hands. Hands to the sides - inhale, lower - exhale. Repeat 8-10 times.

Exercise 15. Starting position - the same. Raise your arms at shoulder level, to the sides. Make circular motions with your hands. The pace is slow. Repeat 4-6 times.

Exercise 16. Starting position - standing. Dumbbells in lowered hands. Raise hands alternately. Repeat 6-8 times.

Special exercises (performed in pairs)

Exercise 1. Passing the ball from the chest to a partner standing at a distance of 5-7 m. Repeat 12-15 times.

Exercise 2. Passing the ball to a partner from behind from behind the head. Repeat 10-12 times.

Exercise 3. Passing the ball to a partner with one hand from the shoulder. Repeat with each hand 7-8 times.

Exercise 4. Throw the ball up with one hand, catch it with the other. Repeat 7-8 times.

Exercise 5. Hit the ball with force on the floor. Let him bounce and try to catch with one hand, then the other. Repeat 6-8 times.

Exercise 6. Throwing a tennis ball into the wall from 5-8 m. Repeat 10-15 times.

Exercise 7. Throwing the ball into the basketball hoop with one hand from a distance of 3-5 m, then with two. Repeat 10-12 times.

Exercise 8. Throwing a tennis ball at a target. Repeat 10-12 times.

Exercise 9. Starting position - sitting on a chair. Lower your head (assuming the fetal position) and take a calm, deep breath.

Exercise therapy for paresis and paralysis

Paralysis and paresis are a consequence of damage to the spinal cord that occurs with spinal injuries. The most common cause of spinal injuries are compression fractures of the vertebral bodies. In this case, the posterior surface of the vertebral bodies is wedged into the anterior spinal cord, which leads to its compression without destruction of the medulla or with destruction, up to a complete anatomical break as a result of the introduction of bone fragments into the substance of the brain. Depending on the area of ​​damage to the spinal cord, either the upper limbs are affected, or both upper and lower at the same time, with paralysis of the respiratory muscles and anesthesia of the whole body. With timely elimination of compression, in contrast to the anatomical break, these phenomena are reversible.

We do not set ourselves the task of telling about all stages of the treatment of paralysis and paresis, since the book is not a manual for doctors. One of the stages of treatment and restoration of the health of such patients is therapeutic exercises, which are quite effective in preventing atrophy, strengthening and developing the muscular apparatus. The approach to therapeutic exercises for this category of patients should be differentiated and focused directly on the degree of compensation of the patient, the type of paralysis and the timing of the injury. Depending on the severity of the case, this happens on the 3-5-12th day after the injury. The first gymnastics lessons in a patient with a fracture of the spine of the lumbar or thoracic region consist of light movements of the head, arms and legs and in teaching proper breathing. All movements should be carried out without sharp muscular tension.

When performing exercises in paralyzed limbs, some relief positions should be used, as well as various devices.

We would like to note that in the early period of illness, classes should be conducted only with an instructor, since such patients need constant help from a health worker. Then, in the chronic and residual stages, the patient must work on his own. Mobilizing gymnastics contributes to the improvement of all general physiological processes, therefore, we do not see any contraindications for its implementation. This gymnastics is necessary for the patient at all stages of rehabilitation.

A set of exercises for patients with spastic paresis and paralysis (acute stage of the early period of traumatic disease of the spinal cord)

All exercises are performed lying on your back.

Exercise 1. Strong inhalation of air with expansion of the chest. Long deep breath. On exhalation, retract the stomach, on inhalation - protrude.

Exercise 2. Take a deep breath, bring the shoulder blades together, relax the shoulder blades - exhale.

Exercise 3. Hands along the body. Slide your palms along the body up - inhale, down - exhale.

Exercise 4. Inhale - bend your arms at the elbow joints, exhale - unbend.

Exercise 5. Move your legs apart - inhale, return to the starting position - exhale.

Exercise 6. Raise the straight right leg - inhale, return to the starting position - exhale, repeat the same with the left leg.

Exercise 7. Bend the right leg at the knee and pull it towards the chest - inhale, return to the starting position - exhale. Repeat the same with the left leg.

Exercise 8. Spread your arms to the sides - inhale, return to the starting position - exhale.

Exercise 9. Raise your hands up, take them behind your head - inhale, return to the starting position - exhale.

Exercise 10. Bend the right arm at the elbow, pull it to the shoulder, the left straight arm - inhale, bend the left arm, pull it to the shoulder, straighten the right arm - exhale.

Exercise 11. Raise your right leg and draw a circle in the air with your foot - inhale, return to the starting position, repeat everything with your left foot.

Exercise 12. We count the fingers. Use your thumb to touch your fingers and count. Perform the exercise first with the right hand, then with the left.

Exercise 13. Fingering as if playing the piano or working on a typewriter.

Exercise 14. Rest on the forearms and raise the pelvis - inhale, return to the starting position - exhale.

A set of exercises for patients with flaccid paresis and paralysis (acute stage of the early period)

Exercise 1. Raise your hands up - inhale, lower - exhale.

Exercise 2. Take dumbbells. Bend and unbend your arms while holding dumbbells. The exercise is done with effort.

Exercise 3. Raise the dumbbells, on outstretched arms - inhale, return to the starting position - exhale.

Exercise 4. Lean on the shoulder joints and raise the pelvis - inhale, return to the starting position - exhale.

Exercise 5. Raise and lower your legs with the help of a block and traction. Raise your legs - inhale. Return to the starting position - exhale.

Exercise 6. Bending the legs at the knee and hip joints with the help of a block and traction.

Exercise 7. Turning the body to the right side with throwing the leg over the left leg. Then turn the body to the left with throwing the left leg over the right.

Exercise 8. Relying on the forearms. Bend in the thoracic region ("bridge").

Exercise 9. Hand movements. Imitate the movements of the breaststroke style of swimming.

Exercise 10. Hand movement - boxing imitation.

Exercise 11. Leg movements - imitation of swimming on the back.

Exercise 12. Raise your leg and in the air draw a circle with your toe. Change the position of the legs.

Exercise 13. Put one hand on the chest, the other on the stomach. Inhale - inflate the stomach, exhale - retract.

Exercise 14. In the hands of an expander. Stretch in front of the chest. Stretch - inhale, return to the starting position - exhale.

Exercise 15. Extend and bring the elbows of the hands behind the head. Bring your elbows together - inhale, spread - exhale.

Exercise 16. Stretch the expander with arms extended forward.

Exercise 17. Stretch the expander over your head.

Exercises are performed at a slow pace. If you feel unwell, you should not cancel classes, you just need to reduce the dosage. To perform passive exercises, blocks, hammocks, loops are used, for strength exercises - dumbbells, expanders. The duration of classes should not exceed 15-20 minutes, in debilitated patients 10-12. Repeat exercises from 3-4 times to 5-7 times.

Exercise therapy after a stroke

A stroke is an acute violation of the coronary circulation. This disease is the third leading cause of death. Unfortunately, a stroke is a very severe and extremely dangerous vascular lesion of the central nervous system. It is caused by a violation of cerebral circulation. More often than others, the elderly suffer from this disease, although recently this disease has begun to overtake the young. Jumps in blood pressure, overweight, atherosclerosis, overwork, alcohol and smoking - all these factors can cause spasm of cerebral vessels.

Conventionally, a stroke is divided into cerebral infarction and cerebral hemorrhage. So, young people most often have a cerebral infarction, that is, a hemorrhagic stroke. The elderly are overtaken by the so-called ischemic stroke, which is caused by a violation of the oxygen supply to nerve cells. This disease is characterized by a much more severe course and more serious complications.

Hemorrhagic stroke is a complication of hypertension. It usually occurs after a busy day at work. Nausea, vomiting and severe headache are the first signs of a hemorrhagic stroke. Symptoms come on suddenly and escalate rapidly. Speech, sensitivity and coordination of movements change, the pulse is rare and intense, fever is possible. The person turns red, sweat comes out and there is a kind of blow in the head. Loss of consciousness is already a stroke. From a ruptured vessel, blood enters the brain tissue, which is fraught with a fatal outcome.

External signs of hemorrhagic stroke: increased pulsation of blood vessels in the neck, hoarse and loud breathing. Sometimes vomiting may occur. Eyeballs sometimes begin to deviate to the affected side. Possible paralysis of the upper and lower extremities on the opposite side of the affected area.

Ischemic stroke does not develop so rapidly. The ailments that can be observed during this period in a patient can last for several days. The blow most often happens either at night or in the morning. And if ischemia is not caused by a thrombus or atherosclerotic plaque (embolus), which can be brought with the blood flow, then the onset of the disease is quite calm. The patient may not lose consciousness and, feeling a deterioration in health, consult a doctor. Signs of "strike": the face is pale, the pulse is soft and moderately rapid. However, paralysis of the limbs on either side may soon occur, depending on the area of ​​brain damage.

Despite such calmness, the consequences are quite severe. The part of the brain deprived of blood dies and cannot perform its functions. And this, depending on which part of the brain is affected, leads to impaired speech and memory, coordination of movements and paralysis, recognition and even dumbness. The patient either speaks in separate words and phrases, or becomes completely dumb.

An experienced doctor can tell exactly which part of the brain is affected by a stroke based on certain symptoms, which makes it possible to predetermine the course of the disease and a possible prognosis. It includes three options: favorable, average and unfavorable. Lost functions and abilities are restored - this is the first case. The course of the disease is complicated by chronic diseases that have joined, which worsens and prolongs the course of the disease - this is the second option. The third option, as a rule, does not bode well. A large area of ​​the brain is affected or the patient experiences repeated strokes. The probability of repeated strikes is very high and reaches 70%. The most critical days after the first strike are the 3rd, 7th and 10th.

Urgent hospitalization in a specialized neurological department is an indispensable condition for a stroke, since with a hemorrhagic stroke it is urgent to lower blood pressure and reduce cerebral edema, and in ischemic stroke it is necessary to take control of blood clotting.

Timely provision of medical care, attention associated with the general care of the patient, classes in therapeutic and regenerative gymnastics - these are the possibilities to bring the patient back to life. Not the last role in the victory of a stroke is played by the patient's awareness of his current condition. Negative emotions will not do you any good and can lead to a second hit, so focus on restoring health. Your goal is to restore mobility to the limbs. All together will help you restore health.

It is an important effective method of rehabilitation, since it affects various body systems: cardiovascular, respiratory, musculoskeletal, nervous. It is also an effective method in the recovery period.

Therapeutic exercises for stroke are, in fact, physical exercises that affect motor and sensory functions. Not the last place in rehabilitation is occupied by breathing exercises. Its tasks are to improve pulmonary ventilation and train external respiration.

Breathing exercises are carried out for 3-6 minutes 8-12 times a day. Breathe deeply and evenly. If there is sputum, it must be coughed up. Breathing exercises are used with an extended inhalation and exhalation (diaphragmatic breathing).

The motor complex of exercises includes exercises for small and medium muscle groups of the arms and legs, as well as movements in the shoulder girdle. In case of severe disorders of the cardiovascular system and unstable blood pressure, as well as arrhythmias accompanied by heart failure, active breathing exercises are not recommended.

In the early stages of the disease and with insufficient activity of the patient, passive breathing exercises are used, which are carried out by an instructor of physiotherapy exercises.

The instructor stands on the side of the patient. His hands are located on the patient's chest, during the exhalation of the patient, he begins to squeeze his chest with a vibrating movement and adjusts to the patient's breathing, thereby activating exhalation. The degree of impact on the chest increases with each exhalation. Every 2-3 respiratory movements, the position of the health worker's hands on the patient's body changes. This allows you to increase the irritation of the respiratory apparatus. Hands are alternately located on different parts of the chest and abdomen. The number of forced breathing exercises is 6-7, then the patient performs 4-5 normal cycles. Then the breathing exercise is repeated again. To achieve a greater effect from respiratory gymnastics, it is advisable to carry it out 5-6 times a day. The duration is 10-15 minutes.

In a later period, the patient takes an active part in breathing exercises with a combination of semi-passive and active movements of the upper and lower extremities. In order to do breathing exercises correctly, it must be controlled. Hands should be placed one on the chest, the other on the stomach. We inhale calmly and smoothly.

Respiratory gymnastics complex for stroke survivors

Exercise 1. Inhale to do so, to feel how the stomach rises. The hand on the chest should remain motionless. This indicates that there is no chest breathing. Exhale more fully, so that the stomach seems to be drawn in.

Exercise 2. Inhale - the chest has risen, along with it the arm. The stomach does not rise. This indicates that there is no abdominal breathing. The exercise is performed calmly and slowly.

Exercise 3. Inhale with abdominal breathing, and then continue to breathe with your chest. Fill the chest as if to failure. Exhalation begins with the stomach, then chest exhalation follows. This exercise is called "full breathing".

Exercise 4. Inhale with significant tension of all respiratory muscles. Then take 2 calm breaths and exhalations.

Exercise 5. Repeat exercise 4.

Having mastered breathing exercises, you will help yourself and your body by doing a kind of ventilation of the lungs. This reduces the likelihood of pneumonia, congestion in the lungs and bronchi.

With a motor deficit - paresis - it is necessary to start with exercises, first of all, to overcome the resistance to movement. Through regular exercise, the affected limbs will gain greater mobility. At the same time, you will not only restore mobility to the limbs, but also strengthen them. Of great psychological importance for the patient is the ability to see how, with the help of simple, but purposeful and deliberate methods, the desired effect is achieved with little effort.

An approximate set of exercises to overcome resistance

Exercise 1. With a healthy hand - thumb and forefinger - squeeze the other hand. At the instructor’s command, make stepwise efforts “weak, a little stronger, still, very strong, maximum.”

Exercise 2. Then gradually teach the patient to hold a slice of bread, a comb and other small household items.

Exercise 3. Rotating the telephone dial, whipping soap suds, stirring with a spoon in a glass bring the patient closer to performing familiar and important skills.

In addition to such exercises, it is advisable to perform motor exercises under the supervision and with the help of an instructor.

Approximate set of motor exercises

All exercises are performed from a prone position.

Exercise 1. Movement with the hands without taking your hands off the bed. Raise the brush, lower the brush. If it is impossible to perform movements with a sore hand, then the help of an instructor is required. Repeat 4-6 times.

Exercise 2. Circular movements with brushes. The exercise is performed at a slow pace.

Exercise 3. Lying down, bend and unbend your toes. Try to do this consistently, i.e. start bending from the little finger. When unbending, try to spread your fingers (the help of an instructor or relatives is useful).

Exercise 4. Pull the feet towards you. Return to starting position. Repeat 4-6 times.

Exercise 5. Turn the feet to the sides: to the left - return to the starting position, then to the right, and vice versa.

Exercise 6. Without taking your head off the pillow, turn it to the right and left. The amplitude of movement depends on the degree of damage.

Exercise 7. Lying on the bed, put your hands with your palms up. Bend your fingers, trying to make a fist. Squeeze, squeeze.

Exercise 8. Hands lie on the bed. The fingers are closed. Spread your fingers, close your fingers.

Exercise 9. Hands lie on the bed. Bring the fingers into the cam of one hand, the second lies quietly. Then change hands (the instructor or relatives help to do the movement on the diseased limb).

Exercise 10. Flexion and extension of the legs at the knee joint. The pace is slow.

Exercise 11. Give a tennis ball to the patient's hand. Squeeze the ball. With a healthy hand, do more repetitions, with a sick hand - if possible.

Simple and familiar to us everyday activities are quite difficult for the patient. The most difficult period is the early stages of recovery. But in order for the patient to learn, he needs the help of not only medical personnel, but also the active help of relatives.

Since the coordination of movements is impaired, among the exercises to increase the coordination of actions between two or more muscle groups, there should be exercises for training balance in a standing position and when walking. With small and medium lesions, patients are transferred to a vertical position from the 5-7th day.

As soon as the patient has been put on his feet, you need to start learning how to walk correctly. To do this, he is taught to bend his lower leg. The methodologist sits next to the patient on a bench and helps him fix the thigh, creates an emphasis for him. As soon as the patient has mastered this, he is taught to bring the hip forward with simultaneous extension of the lower leg with the back flexion of the foot.

In the same period, the patient is taught accuracy and coordination of actions with his hands.

An approximate set of exercises for the development of fine motor skills of the hand

Exercise 1. Prick with a needle. Repeat 6-8 times with one hand, then with the other (if the patient is not able to grab the needle with the affected hand, the help of an instructor or relatives is necessary).

Exercise 2. Give the patient scissors. On command, he must shift them from hand to hand. The pace is slow.

Exercise 3. The patient has a pen in his hands. At the instructor's command, he should try to fix the position of the pen, as for writing.

Exercise 4. The patient folds his palms like a boat. The instructor lightly tosses him a tennis ball. The patient tries to pass the ball to the instructor with a bad hand (if it doesn't work, the ball is passed with a healthy one).

Exercise 5. Starting position - sitting on the bed. Bend one leg at the knee, then the other.

Exercise 6. Starting position - sitting on the bed. Do not take your feet off the floor, raise your socks, lower them. Repeat 4-6 times.

Exercise 7. Starting position - sitting on the bed. Bend your arms at the elbows, straighten. Repeat 4-6 times.

Exercise 8. Starting position - lying on the bed. Bend your arms at the elbows (with the elbows resting on the bed). Turning the closed hands towards you with your palm, away from you. Repeat 3-4 times.

Exercise 9. Starting position - lying on the bed. Hands in the same position as in the previous exercise. We make a cam with one hand, then with the other. Repeat 3-4 times.

Exercise 10. Starting position - lying on the bed. Hands in the position of exercise 8. Bend the hands (depict a "duck"). Turn your hands away from you, towards you. Repeat 4-6 times.

Exercise 11. Starting position - lying down. Hands in exercise position 8. Make circular movements with your hands. Elbows are motionless, rest against the bed.

Exercise 12. Starting position - lying down. Bend your legs at the knees. Hands along the body. Place one leg on the bent knee of the other leg. Bend and unbend the lower leg of the "hanging" leg. Repeat 3-4 times. Then change the position of the legs.

Exercise 13. Starting position - standing by the bed and leaning on it. The instructor rolls the ball to the patient's leg. He must push him away.

Exercise 14. Starting position - standing by the bed and leaning on it. The instructor places a matchbox on the floor in front of the patient. Raise your leg just above the box and, as it were, step over it. Perform with one foot, then change the position of the legs.

Exercise 9. Starting position - sitting on the bed. The patient rolls the round block with the foot of the foot.

Self-service motor skills are one of the most important tasks in rehabilitation. Therefore, they need to teach the patient with the help of exercises of a special nature. Efficiency is achieved by a sequence of exercises, moving from simple to complex and gradually increasing the load.

Very effective in the rehabilitation of the patient are children's games with the ball, where there are exercises with the ball rebounding from the wall, from the floor, throws up and elements of football. All of these exercises help restore joint movement and muscle strength.

Approximate set of exercises

Exercise 1. Starting position - sitting on a chair or bed. Hands on knees. Head tilts forward and backward. Movements are indistinct. Repeat 3-4 times.

Exercise 2. Starting position - the same. Head tilts to the side. Repeat 3-4 times.

Exercise 3. Starting position - the same. Raise your arms in front of you and shake your hands. Then bend your elbows and shake them.

Exercise 4. Starting position - the same. Hands are extended in front of you. Fists clench, unclench. Spread your fingers as wide as possible. Repeat 3-4 times.

Exercise 5. Starting position - sitting on a chair. Grab your leg under your knee and lift it up with your hands. Repeat the same with the other leg. Repeat 3-4 times.

Exercise 6. Starting position - sitting on a chair. Stretch your arms out in front of you and lean forward slightly. Repeat 3-4 times.

Exercise 7. Starting position - sitting on a chair. Bend your arms at the elbows, put your hands on your shoulders. Pull your elbows towards each other.

Exercise 8. Starting position - lying on the bed. Bend your arms at the elbows. The palms are turned towards the patient's face. Lower your arms, turn your palms away from you. Repeat 4-6 times.

Exercise 9. Starting position - lying down. Hands along the body. Bend one arm at the elbow and reach the shoulder with the hands. Change the position of the hands. Repeat 4-6 times.

Exercise 10. Starting position - sitting on a chair. Raise your legs off the floor and cross your legs. Repeat 3-4 times.

Exercise 12. Starting position - lying on the bed. Pull the foot of one leg towards you, pull the other away from you. Repeat with a change of legs 3-4 times.

Exercise 13. Starting position - sitting on a chair. Hands on knees. Tilt your body to the right, then to the left. When changing positions, return to the starting position. Repeat 4-6 times.

Exercise 14. Starting position - sitting. Hands on the belt. Turn your body to the left, return to the starting position, then turn to the right. Repeat 4-6 times.

The pace of execution is slow. If you experience discomfort during execution, do not perform the exercise or perform it with a smaller range of motion.

Of primary importance in the functional therapy of injuries and disorders of the peripheral nervous system is the course of the nerve fibers that make up the pyramidal motor pathway. It is from it that the impulse along the nerve fibers is directed to the motor cells of the anterior horns of the spinal cord, from where it is directed to the muscles through the fibers of the peripheral neuron, which form the motor roots. Therefore, any pathological influences on any of the sections of this path cause disorders of the motor apparatus, expressed in paralysis, paresis, and also manifested by a decrease in the strength of the corresponding muscles. Such influences include injuries, hemorrhages, intoxications, infections, compression of the nerve roots by bone growths, etc. A characteristic feature of movement disorders in lesions of a peripheral neuron is flaccid paralysis and paresis with a decrease or complete absence of tendon reflexes, often with impaired skin sensitivity. With traumatic neuritis, in addition to local damage to the nerve trunk, there are also disorders in the nerve roots, in the elements of the spinal cord, and functional disorders in the somatic and autonomic centers of the brain.

With neuritis, the lesion is localized in the peripheral nerve trunks of usually mixed nerves, as a result of which the main symptoms in them are paralysis or paresis of the peripheral type, corresponding to the muscular innervation of this nerve. Paralysis is flaccid, most often accompanied by muscle atrophy with a decrease or disappearance of tendon reflexes, with a decrease in muscle tone. Along with a violation of muscle function, disorders of skin sensitivity can be observed, pain appears with pressure on the affected trunks and muscles when they are stretched.

Neuritis is of different origin. Traumatic neuritis is the most common. They occur with bruises in areas of the body through which the nerve trunks pass, with fractures of the bones, next to which motor nerve fibers are located.

With neuritis, it is most often necessary to use complex treatment, an integral part of which are exercise therapy and massage. The forms of application of exercises and their ratio in the medical complex are determined by the causes of the disease, its stage, the form and characteristics of the course, as well as the individual characteristics of the patient.

IN tasks Exercise therapy for damage to a peripheral motor neuron includes:

• 1) restoration of the functions of the nerve elements of the damaged neuron;
• 2) normalization of the activity of the muscles innervated by the damaged neuron;
• 3) general strengthening effect.

Afferent stimuli that arise at the moment of performing a passive or active movement serve as factors that cut through the nerve pathways, support their function, and coordinate the combined functioning of all nervous elements that have come into disorder. In addition, these impulses stimulate the regeneration of nerve conductors disturbed by illness or injury. The fact is that due to the degeneration of the axon and the breakdown of myelin, the conductivity of the nerve pathways is impaired. The performance of physical exercises contributes to the enhancement of metabolic (and ionic) processes in the fiber, thereby increasing its conductivity. Such influences are especially effective in the first periods of illness or injury. In cases where a significant period of time has already passed, and connective scar tissue begins to form at the site of the lesion, and the regeneration of neuron elements becomes difficult, although physical exercises still contribute to the partial resorption of this tissue and an increase in its elasticity.

The use of exercise therapy for traumatic neuritis is divided into two periods. In the early stages of the wound process, it is used to stimulate wound healing, improve circulation in the innervated tissue areas, prevent complications, and develop a rough scar at the wound site. Among the preventive measures against complications affecting the functional state of the nerve and the muscles and other tissues innervated by it, one can include a light massage of parts of the limb after its preliminary heating, which creates moderate hyperemia of the tissues surrounding the wound. This improves circulation in the injured limb, reduces swelling and maintains tissue nutrition, and reduces irritation of nerve conductors. Where the condition of the wound and pain disorders do not prevent movement, it is possible to start therapeutic exercises from the very first days after the injury or operation: passive, and where possible, active exercises, ideomotor efforts and sending impulses. When immobilizing the affected limb, physical exercises should be carried out for a healthy limb, based on their reflex effect on the processes of blood circulation and nervous excitability in the diseased limb.

To restore the functional ability of the injured nerve, stimulate the growth of the nerve fiber, to bring the central nerve formations associated with the affected nerve to a normal functional state, it is of paramount importance to ensure that a sufficient number of afferent impulses flow along the affected nerve from the periphery of the organ.

In cases where paralysis phenomena prevail, and pain does not occur, or from the moment when they no longer interfere with movements, it is necessary to start active and passive gymnastics, paying attention to those exercises that correspond to the function of the affected muscle groups. The signs of fatigue or increased pain that occur in some cases after performing gymnastic exercises most often disappear under the influence of a subsequent, even a short thermal procedure.

In the treatment of reflex contractures, the issue of removing the peripheral focus of irritation is primarily addressed, which is usually carried out by surgical and conservative methods. The physical exercises used in this case actively contribute to a decrease in the excitability of the central reflex devices and a decrease in the tone of the muscles that are in a state of spasm. Depending on the timing of spasm development, movement treatment is combined with various orthopedic measures (fixing bandages, corrective operations, heat therapy, massage, etc.), the features of which should be taken into account in the construction of exercise therapy.

The effectiveness of exercise therapy for neuritis is determined not only by the correct selection and implementation of physical exercises, but also by the mode of their implementation. It must fully correspond to the relationship between the duration and intensity of exercises, it requires the achievement of fatigue during the performance of each complex and a gradual increase in load. Therefore, in the first period, with a complex duration of 10-15 minutes, it should be repeated at least 6-8 times during the day. In between exercise therapy complexes, massage (self-massage) of tissues in the area of ​​innervation of the damaged neuron is performed for 10-12 minutes.

The second period of functional therapy of traumatic neuritis corresponds to the stage after wound healing. It is characterized by the presence of late residual clinical phenomena, the development of scar tissue at the site of the wound, circulatory and trophic disorders here, paralysis, contractures, and pain symptoms. As a result of rationally constructed and long-term exercise therapy, all these phenomena are eliminated (or at least facilitated) due to the normalization of the nutrition of tissues innervated by the affected nerve, the restoration of blood circulation in them with the active removal of residual inflammatory products from the affected nerves themselves and surrounding tissues. A favorable circumstance in this case is that physical exercises help strengthen the paretic muscles, articular bags and ligamentous apparatus, maintain joint mobility and their functional readiness by the time the nervous apparatus is restored.

In the second period, the duration of the exercise therapy complex gradually increases to 30-40 minutes, and the repetition of its implementation - 2-3 during the day. The duration of massage (self-massage) can reach 20-30 minutes.

As an example of the use of exercise therapy for neuritis, consider the relatively common neuritis of the facial and sciatic nerves.

Neuritis of the facial nerve is manifested mainly by paralysis of the mimic muscles of the affected side of the face: the eye does not close or does not completely close, the blinking of the eyelids is disturbed, the mouth is drawn to the healthy side, the nasolabial fold is smoothed, there is no movement of the lips in the direction of the neuritis, the corner of the mouth is lowered, wrinkling of the forehead is impossible, the patient cannot raise his eyebrows. Depending on the severity of neuritis, it lasts from two weeks to many months and does not always end in complete recovery.

The cause of neuritis is various nerve lesions during its passage through the canal of the pyramidal part of the temporal bone, inflammatory processes in the middle ear, intoxication, infection, postoperative and surgical complications. The course of neuritis of the facial nerve is accompanied by such a complication as contracture of the facial muscles of the affected side, when the corner of the mouth is already drawn to the diseased side, the nasolabial fold becomes deeper, the palpebral fissure narrows, remaining half-closed, the asymmetry of the face becomes more pronounced. Both contracture and friendly movements interfere with mimic movements, exacerbate the severity of paralysis.

The treatment complex for neuritis of the facial nerve is of a combined nature and includes drug therapy, exercise therapy with massage and physiotherapy.

Physiotherapy. At the onset of the disease, it is of particular importance to ensure adequate afferent impulses from the periphery, due to which the conduction of nerve fibers is maintained and the preservation of motor skills of the facial muscles is stimulated. To do this, it is recommended to use passive exercises and a special massage of the entire face and neck using light stroking, light rubbing and, finally, vibration along the nerve branches with your fingertips. The complex of physical exercises includes special exercises in wrinkling the forehead by raising the eyebrows, moving them (frown), blinking the eyelids, baring the teeth and folding the lips for a whistle, puffing out the sore cheek, etc.

The regimen of exercise therapy requires repeated use of physical exercises during the day, in particular, independently performed by the patient. However, at the same time, there is a danger that independent exercises in mimic gymnastics in front of a mirror are not always performed correctly (for example, when exercising in closing the eyes in the presence of paralysis of the lower eyelid, the patient tries to close it by propping up the eyelid by pulling up the corner of the mouth). At the same time, as a result of repeated exercises, a stable perverted conditioned reflex connection is organized to perform a friendly movement. Therefore, it is extremely important to teach the patient to independently correctly perform corrective exercises.

When independent mimic movements appear (or at least manifestations of minimal contractile activity) in any mimic muscle, the main emphasis should be shifted from passive exercises to repeatedly repeated active efforts from this particular muscle.

The causes of sciatic nerve neuritis can be very diverse - infections, metabolic disorders (gout, diabetes), trauma, cooling, spinal disease, etc.

With lesions of the sciatic nerve, sensitivity disorders occur, paresis and muscle paralysis appear. With a high localization of damage to the nerve trunk, the function of turning the thigh outward suffers, as well as flexion of the lower leg to the thigh, walking is very difficult. With a complete lesion of the entire diameter of the nerve, the loss of movement of the foot and fingers is added.

Already during the period of bed keeping of the patient, it is necessary to take care of preventing the sagging of the foot. In addition to passive correction (in particular, with the help of a splint that holds the foot in the middle physiological position) and giving half-bent position in the knee and ankle joints while lying on the side, passive exercises are used. With the advent of active movements, special exercises are applied in bending the lower leg to the thigh, turning it outward, in unbending the foot and fingers, moving it to the side and inward, and extending the thumb.

The effectiveness of therapeutic exercises increases when using a warming massage and a number of physiotherapeutic effects, mainly of a thermal nature, before exercises. In addition to increasing the elasticity of soft tissues and the articular-ligamentous apparatus, allowing for movements with a greater amplitude, this measure reduces pain. For the same purpose, thermal exposure can be used after performing gymnastic exercises.

Given these circumstances, in the selection of means and methods of exercise therapy for lesions of the tibial nerve, one should proceed from the need to increase the tone of the muscles that are in a state of its loss, and reduce the tone of spasmodic muscles.

As with other types of lesions of the peripheral nervous system, in exercise therapy it is necessary to adhere to a dense repeated and repeated exercise regimen. At the same time, one should carefully monitor the state of tone and activity of the affected muscles, and at the first signs of improvement in their condition, transfer an increasing part of the load to them, increasingly preferring active exercises over passive ones.

Treatment and rehabilitation of patients with various diseases and injuries of the central and peripheral nervous system is one of the urgent problems of modern medicine, requiring an integrated approach using a wide range of therapeutic agents, including therapeutic physical culture. Diseases and injuries of the nervous system are manifested in the form of motor, sensory, coordination disorders and trophic disorders. In diseases of the nervous system, the following movement disorders can be observed: paralysis, paresis, and hyperkinesis. Paralysis, or plegia, is a complete loss of muscle contraction, paresis is a partial loss of motor function. Paralysis or paresis of one limb is called monoplegia or monoparesis, respectively, two limbs on one side of the body - hemiplegia or hemiparesis, three limbs - triplegia or triparesis, four limbs - tetraplegia or tetraparesis.

Paralysis and paresis are of two types: spastic and flaccid. Spastic paralysis is characterized by the absence of only voluntary movements, an increase in muscle tone and all tendon reflexes. It occurs when the cortex of the anterior central gyrus or pyramidal tract is damaged. Flaccid paralysis is manifested by the absence of both voluntary and involuntary movements, tendon reflexes, low tone and muscle atrophy. Flaccid paralysis occurs when the peripheral nerves, roots of the spinal cord, or the gray matter of the spinal cord (anterior horns) are affected.

Hyperkinesias are called altered movements, devoid of physiological significance, arising involuntarily. These include convulsions, athetosis, trembling.

Seizures can be of two types: clonic, which are rapidly alternating muscle contractions and relaxations, and tonic, which are prolonged muscle contractions. Seizures occur as a result of irritation of the cortex or brain stem.

Athetosis - slow worm-like movements of the fingers, hand, torso, as a result of which it twists in a corkscrew shape when walking. Athetosis is observed when the subcortical nodes are affected.
Trembling - involuntary rhythmic vibrations of the limbs or head. It is observed with damage to the cerebellum and subcortical formations.

The lack of coordination is called ataxia. Distinguish between static ataxia - imbalance when standing and dynamic ataxia, manifested in impaired coordination of movements, disproportionate motor acts. Ataxia most often occurs with damage to the cerebellum and the vestibular apparatus.

With a disease of the nervous system, sensitivity disorders often occur. There is a complete loss of sensitivity - anesthesia, a decrease in sensitivity - hyposthesia and an increase in sensitivity - hyperesthesia. with violations of superficial sensitivity, the patient does not distinguish between heat and cold, does not feel pricks; with a disorder of deep sensitivity, he loses an idea of ​​​​the position of the limbs in space, as a result of which his movements become uncontrollable. Sensitivity disorders occur when peripheral nerves, roots, pathways and spinal cord, pathways and the parietal lobe of the cerebral cortex are damaged.

In many diseases of the nervous system, trophic disorders occur: the skin becomes dry, cracks easily appear on it, bedsores form, exciting and underlying tissues; bones become brittle. Especially severe bedsores occur when the spinal cord is damaged.

Mechanisms of the therapeutic effect of physical exercises

The mechanisms of the therapeutic effect of physical exercises in traumatic injuries and diseases of the peripheral nerves are diverse. The use of various forms of therapeutic physical culture: morning hygienic gymnastics, therapeutic exercises, gymnastics in water, walks, some sports exercises and sports games - helps to restore nerve conduction, lost movements and develop compensatory motor skills, stimulates regeneration processes, improves trophism, prevents complications ( contractures and deformities), improves the mental state of the patient, has a general health-improving and restorative effect on the body.

General principles of the methodology of therapeutic physical culture

Therapeutic physical culture for lesions of peripheral nerves is carried out according to three established periods.

I period - the period of acute and subacute condition - lasts 30-45 days from the moment of injury. The tasks of therapeutic physical culture in this period: 1) removing the patient from a serious condition, increasing mental tone, general strengthening effect on the body; 2) improvement of lymph and blood circulation, metabolism and trophism in the affected area, resorption of the inflammatory process, prevention of adhesion formation, formation of a soft, elastic scar (in case of nerve injury); 3) strengthening of peripheral muscles, ligamentous apparatus, fight against muscle atrophy, prevention of contractures, vicious positions and deformities; 4) sending impulses to restore lost movements; 5) improving the functioning of the respiratory system, blood circulation, excretion and metabolism in the body.

Classes of therapeutic physical culture in the I period are held 1-2 times a day with an instructor and 6-8 times a day on their own (a set of exercises is selected individually). Duration of classes with an instructor - 20-30 minutes, self-study - 10-20 minutes.
II period begins from the 30-45th day and lasts 6-8 months from the moment of injury or damage to the peripheral nerve. The tasks of therapeutic physical culture in this period are: 1) strengthening the paretic muscles and ligamentous apparatus, combating atrophy and flabbiness of the muscles of the affected area, as well as training the muscles of the entire limb; 2) restoration of full volume, coordination, dexterity, speed of performing active movements in the affected area, and if it is impossible, the maximum development of compensatory motor skills; 3) prevention of the development of the vicious position of the affected area and related related disorders in the body (disturbances in posture, gait, torticollis, etc.).

Classes of therapeutic physical culture in the II period are held 1-2 times a day with an instructor and 4-6 times on their own (individual complex). The duration of classes with an instructor is 40-60 minutes, self-study - 25-30 minutes.

III period - training - the period of the final restoration of all functions of the affected area and the body as a whole. It lasts up to 12-15 months from the moment of injury. The tasks of therapeutic physical culture of this period are: 1) the final restoration of all motor functions of the affected area and the body as a whole; 2) training of highly differentiated movements in complex coordination, speed, strength, agility, endurance; 3) restoration of complex labor processes and general working capacity.

Therapeutic physical culture classes are held in the III period once with an instructor and 4-5 times on their own (a set of exercises prescribed by a doctor or an instructor of therapeutic physical culture is performed). The duration of classes with an instructor is 60-90 minutes, self-study - 50-60 minutes.

Therapeutic gymnastics in water is carried out in all periods of treatment. Water temperature 36-37°. In case of damage to the peripheral nerves of the upper limb, the duration of the lesson in
I period - 8-10 minutes, in II - 15 minutes, in III - 20 minutes. To generate impulses for active movements in the paretic muscles, all kinds of finger movements are performed in a friendly manner with both hands (breeding, bending, matching all fingers with the first finger, “claws”, clicks, etc.), grasping large rubber and plastic objects with fingers: ball, sponge, and etc.; all kinds of exercises for the wrist joint, including pronation and supination. By the end of the 1st period and in the 2nd period, active exercises with the paretic hand are supplemented, guided by the healthy hand of the patient. In the III period, exercises are performed in the water to develop the grip (for example, with a paretic hand to hold and try to hold a towel, and with a healthy hand to tear it out, etc.), to capture small objects and hold them, that is, to overcome resistance. With damage to the peripheral nerves of the lower limb, the duration of the lesson in the I period is 10 minutes, in the II - 15 minutes, in the III - 25 minutes. If possible, it is desirable to perform physical exercises in the pool. In the first period, much attention is paid to sending impulses to the development of active movements in the paretic muscles in combination with friendly movements of the healthy leg, as well as with the help of the patient's hands. Exercises are performed in the bath or in the pool in the initial position of sitting, standing and walking. Exercises for the fingers and ankle joint are carried out on weight, relying on the heel and on the entire foot. A lot of time is devoted to movements in the ankle joint in all directions. In the II and III periods, these movements are supplemented by exercises with objects, on the ball (rolling the ball, circular movements), on a gymnastic stick, in flippers, in different walking options (on the entire foot, on toes, on the heels, on the outer and inner edges of the foot ), with a rubber bandage (it is held by the patient himself or by the methodologist), swimming with the participation of the legs. During surgical interventions, therapeutic physical culture in water is prescribed after the removal of sutures.

With any damage to the peripheral nerves, active movements (especially at their first manifestations) are performed in the minimum dosage: 1-2 times in the I period, 2-4 times in the II and 4-6 times in the III. If the muscle is overstressed, it will lose the ability to actively contract for several days, and the recovery of active movements will be slow. Therefore, active movements are performed in such a dosage, but repeated several times during the session.
In case of any damage to the peripheral nerves, to prevent contractures, vicious positions and deformities, a fixing bandage is necessarily applied, which is removed during classes. The instructor of therapeutic physical culture at each lesson passively works out all the joints of the paretic limb in all possible directions.

If, with damage to the peripheral nerves of the lower limb, drooping of the foot is noted, much attention is paid to teaching the patient the correct support on the leg and walking. The hanging foot must be fixed with elastic traction to ordinary shoes or a special orthopedic boot (Fig. 46). Before teaching a patient to walk, it is necessary to teach him to stand correctly, leaning on a sore leg, using an additional point of support: the back of a chair, crutches, a stick; then teach walking on the spot, walking with two crutches or sticks, with one stick, and only then without support.

Treatment of lesions of peripheral nerves is carried out in a hospital, on an outpatient basis, in sanatoriums, resorts and is complex. At all stages, the complex of medical procedures includes therapeutic physical culture, massage, electrical stimulation of paretic muscles, therapeutic exercises in water, physiotherapy and drug therapy.

Neuritis is a disease of peripheral nerves that occurs as a result of traumatic injury, infectious, inflammatory diseases (diphtheria, influenza, etc.), beriberi (lack of B vitamins), intoxication (alcohol, lead) and metabolic disorders (diabetes).

The most common neuritis of the facial nerve, neuritis of the radial, median, ulnar, sciatic, femoral and tibial nerves.

The nature of functional disorders in injuries of the peripheral nerves of the upper and lower extremities is determined by their localization and the degree of damage. The clinical picture in neuritis is manifested by sensitivity disorders (pain, temperature, tactile), motor and vegetotrophic disorders.

Motor disorders in neuritis are manifested in the development of paresis or paralysis.

Peripheral (flaccid) paralysis is accompanied by muscle atrophy, decrease or disappearance of tendon reflexes, muscle tone, trophic changes, skin sensitivity disorders, pain when stretching muscles.

Exercise therapy, massage and physiotherapy occupy an important place in complex rehabilitation treatment.

Tasks of complex rehabilitation treatment for peripheral paralysis:

Stimulation of the processes of regeneration and disinhibition of nerve sections that are in a state of oppression;

Improving blood supply and trophic processes in the lesion in order to prevent the formation of adhesions and cicatricial changes;

Strengthening paretic muscles and ligaments;

Prevention of contractures and stiffness in the joint;

Recovery of working capacity by normalizing motor functions and developing compensatory adaptations.

Exercise therapy is contraindicated in severe pain and severe general condition of the patient. The methodology and nature of rehabilitation measures are determined by the nature of movement disorders, their localization and the stage of the disease.

The following periods are distinguished: early recovery (2-20th day), late recovery, or main (20-60th day), and residual (more than 2 months).

With surgical interventions on the nerves, the time limits of all periods are fuzzy: for example, the early recovery period can last up to 30-40 days, the late one - 3-4 months, and the residual one - 2-3 years.

early recovery period. With the development of paralysis, optimal conditions are created for the restoration of a damaged limb - treatment with position, massage and physiotherapy procedures are used.

Positional treatment is prescribed to prevent overstretching of weakened muscles; for this, splints are used that support the limb, special “laying”, corrective positions. Treatment by position is carried out throughout the entire period - with the exception of therapeutic exercises.

A feature of massage in peripheral paralysis is the differentiation of its effects on muscles, a strict dosage of intensity, the segmental-reflex nature of the effect (massage of the collar, lumbosacral regions). A beneficial effect is exerted by hardware massage (vibration), carried out at the "motor points" and along the paretic muscles; vortex and jet underwater massage, combining the positive temperature effect of warm water and its mechanical effect on tissues.

In the absence of motor functions, physiotherapy (electrophoresis with calcium ions) is used to improve nerve conduction.

After physiotherapeutic procedures, therapeutic exercises are carried out; with complete paralysis, they mainly consist of passive and ideomotor exercises. It is advisable to combine passive exercises with active movements in the same joints of a symmetrical limb.

During classes, it is especially necessary to monitor the appearance of voluntary movements, choosing the optimal starting positions, and strive to support the development of active movements.

In the late recovery period, positional treatment, massage, therapeutic exercises and physiotherapy are also used.

Treatment with the position has a dosed character and is determined by the depth of the paresis: the deeper the lesion, the longer the duration of treatment with the position (from 2-3 minutes to 1.5 hours).

Massage is carried out differentially, in accordance with the localization of muscle damage. Weakened muscles are massaged more intensively; using the techniques of stroking and surface rubbing, their antagonists relax.

Physiotherapy treatment is complemented by electrical muscle stimulation.

The following method of therapeutic exercises gives a positive effect: active movements in the symmetrical joints of a healthy limb, passive movements in the joints of the affected limb, friendly active, lightweight exercises involving weakened muscles. Relief of the functional load is achieved by selecting the appropriate initial positions for performing exercises that reduce the inhibitory effect of the weight of the limb segment. To reduce friction, the limb segment is supported by a soft strap (on weight). Facilitate the work of paretic muscles and exercise in warm water. In the residual period, they continue to do therapeutic exercises; the number of applied exercises for training everyday and professional skills is significantly increased; game and sports-applied elements are introduced; optimal compensatory adaptations are formed.

The patient is prescribed a massage (15-20 procedures). The massage course is repeated after 2-3 months.

Positional treatment is determined by orthopedic tasks (sagging of the foot or hand) and is carried out with the help of orthopedic and prosthetic products (devices, splints, special shoes).

In this period, contractures and stiffness in the joints are of particular difficulty in treatment. The alternation of passive movements with active exercises of a different nature and massage of unaffected areas, thermal procedures allow you to restore the necessary range of motion.

With the persistence of secondary changes in tissues, mechanotherapy is used, which is effectively used in water.

Neuritis of the facial nerve

The most common causes of lesions of the facial nerve are infection, hypothermia, trauma, inflammatory diseases of the ear.

clinical picture. It is mainly characterized by the acute development of paralysis or paresis of the facial muscles. The affected side becomes flabby, lethargic; blinking of the eyelids is disturbed, the eye does not completely close; the nasolabial fold is smoothed; the face is asymmetrical, drawn to the healthy side; speech is slurred; the patient cannot wrinkle his forehead, frown his eyebrows; loss of taste, lacrimation are noted.

Rehabilitation activities include positional therapy, massage, therapeutic exercises and physiotherapy.

Rehabilitation tasks:

Improving blood circulation in the face (especially on the side of the lesion), neck and the entire collar zone;

Restoration of the function of facial muscles, impaired speech;

Prevention of the development of contractures and friendly movements.

In the early period (1-10 days of illness), positional treatment, massage and therapeutic exercises are used. Treatment by position includes the following recommendations:

Sleep on your side (on the affected side);

For 10-15 minutes (3-4 times a day), sit with your head bowed in the direction of the lesion, supporting it with the back of the hand (supported by the elbow); pull the muscles from the healthy side to the side of the lesion (from bottom to top) with a handkerchief, while trying to restore the symmetry of the face.

To eliminate the asymmetry, adhesive plaster tension is applied from the healthy side to the patient, directed against the traction of the muscles of the healthy side. It is carried out by firmly fixing the free end of the patch to a special helmet-mask, made individually for each patient (Fig. 36).

Treatment position is carried out in the daytime. On the first day - 30-60 minutes (2-3 times a day), mainly during active facial actions (eating, talking). Then its duration is increased to 2-3 hours a day.

Massage begins with the collar area and neck. This is followed by a facial massage. The patient sits down with a mirror in his hands, and the massage therapist is located opposite the patient in order to be sure to see his entire face. The patient performs the exercises recommended during the procedure, observing the accuracy of their execution with the help of a mirror. Massage techniques - stroking, rubbing, light kneading, vibration - are carried out according to a gentle technique. In the first days, the massage lasts 5-7 minutes; then its duration increases to 15-17 minutes.

Massage of the muscles of the face is mainly of a point nature, so that the skin displacements are insignificant and do not stretch the skin of the affected half of the face. The main massage is carried out from the inside of the mouth, and all massage movements are combined with therapeutic exercises.

Therapeutic gymnastics is mainly addressed to the muscles of the healthy side - this is an isolated tension of the facial muscles and muscles surrounding the oral fissure. The duration of the lesson is 10-12 minutes (2 times a day).

In the main period (from the 10-12th day from the onset of the disease to 2-3 months), along with the use of massage and positional treatment, special physical exercises are performed.

Position treatment. Its duration increases to 4-6 hours a day; it alternates with LH and massage. The degree of tension of the adhesive plaster also increases, reaching hypercorrection, with a significant shift to the diseased side, in order to achieve stretching and, as a result, weakening of the muscle strength on the healthy side of the face.

In some cases, adhesive plaster tension is carried out within 8-10 hours.

Exemplary special exercises for training mimic muscles

1. Raise your eyebrows up.

2. Wrinkle your eyebrows (frown).

3. Look down; then close your eyes, holding the eyelid on the side of the lesion with your fingers, and keep them closed for 1 minute; open and close your eyes 3 times in a row.

4. Smile with your mouth closed.

5. Squint.

6. Lower your head down, take a breath and, at the moment of exhalation, “snort” (vibrate your lips).

7. Whistle.

8. Flare the nostrils.

9. Raise the upper lip, exposing the upper teeth.

10. Lower the lower lip, exposing the lower teeth.

11. Smile with your mouth open.

12. Blow on a lit match.

13. Take water in your mouth, close your mouth and rinse, trying not to pour out the water.

14. Puff out your cheeks.

15. Move air from one half of the mouth to the other alternately.

16. Lower the corners of the mouth down (with the mouth closed).

17. Stick out the tongue and make it narrow.

18. Opening your mouth, move your tongue back and forth.

19. Opening your mouth, move your tongue left and right.

20. Pull out the lips with a "tube".

21. Follow with your eyes a finger moving in a circle.

22. Draw in the cheeks (with the mouth closed).

23. Lower the upper lip to the lower.

24. With the tip of the tongue, drive along the gums alternately to the right and left (with the mouth closed), pressing the tongue against them with different efforts.

Exercises to improve articulation

1. Pronounce the sounds "o", "and", "y".

2. Pronounce the sounds “p”, “f”, “v”, bringing the lower lip under the upper teeth.

3. Pronounce sound combinations: “oh”, “fu”, “fi”, etc.

4. Pronounce words containing these sound combinations in syllables (o-kosh-ko, Fek-la, i-zyum, pu-fik, Var-fo-lo-mei, i-vol-ga, etc.).

The listed exercises are performed in front of a mirror, with the participation of an exercise therapy instructor, and are necessarily repeated by the patient on their own 2-3 times a day.

In the residual period (after 3 months), massage, positional treatment and therapeutic exercises are used, which are used in the main period. The proportion of therapeutic exercises, the task of which is the maximum possible restoration of facial symmetry, is significantly increasing. During this period, the training of facial muscles increases. Exercises for mimic muscles should be alternated with restorative and breathing exercises.

Brachial plexus neuritis

The most common causes of brachial plexus neuritis (plexitis) are: injury from dislocation of the humerus; wound; highly applied tourniquet for a long time. With the defeat of the entire brachial plexus, peripheral paralysis or paresis occurs and a sharp decrease in sensitivity in the arm.

Paralysis and atrophy of the following muscles develop: deltoid, biceps, internal shoulder, flexors of the hand and fingers (the arm hangs like a whip). In complex treatment, the leading method is position treatment: the hands are placed in a half-bent position and placed on a splint with a roller placed in the area of ​​the metacarpophalangeal joint.

The forearm and hand (in a splint) are hung on a scarf. Special exercises for the shoulder girdle, muscles of the shoulder, forearm and hand are recommended, as well as general developmental and breathing exercises.

A set of special exercises for plexitis (according to A. N. Tranquillitati, 1992)

1. I. p. - sitting or standing, hands on the belt. Raise your shoulders up - lower. Repeat 8-10 times.

2. I. p. - the same. Squeeze your shoulder blades, then return to the starting position. Repeat 8-10 times.

3. I.p. - the same, hands down. Raise your arms up (hands to your shoulders), spread your elbows to the sides, then press them back to your body. Circular movements of the arm bent at the elbow (movements in the shoulder joint) clockwise and against it. Repeat 6-8 times. The movements of the affected hand are performed with the help of an exercise therapy methodologist.

4. I.p. - Same. Bend the injured arm, then straighten; take it to the side (straight or bent at the elbow), then return to the sp. Repeat 6-8 times. The exercise is performed with the help of a methodologist or a healthy hand.

5. I.p. - standing, leaning towards the injured arm (the other hand on the belt). Circular movements with a straight arm clockwise and against it. Repeat 6-8 times.

6. I.p. - Same. Swing movements with both hands back and forth and crosswise in front of you. Repeat 6-8 times.

7. I.p. - standing or sitting. Leaning forward, bend the sore arm at the elbow and straighten it with the help of a healthy arm. Repeat 5-6 times.

8. I.p. - Same. Turn the forearm and hand with the palm towards you and away from you. Repeat 6-8 times.

If necessary, movements are also performed in the wrist joint and finger joints.

Gradually, when the injured hand can already hold objects, exercises with a stick and a ball are included in the LG complex.

In parallel with therapeutic exercises, hydrocolonotherapy, massage and physiotherapy are prescribed.

Neuritis of the ulnar nerve

Most often, ulnar nerve neuritis develops as a result of nerve compression in the area of ​​the elbow joint, which occurs in people whose work is associated with elbow support (on a machine, table, workbench), or when sitting for a long time, putting their hands on the armrests of a chair.

clinical picture. The brush hangs down; no supination of the forearm; the function of the interosseous muscles of the hand is disturbed, in connection with which the fingers are claw-like bent ("clawed brush"); the patient cannot pick up and hold objects. There comes a rapid atrophy of the interosseous muscles of the fingers and the muscles of the palm from the side of the little finger; hyperextension of the main phalanges of the fingers, flexion of the middle and nail phalanges is noted; it is impossible to spread and adduct the fingers. In this position, the muscles that extensor the forearm are stretched, and contracture of the muscles that flex the hand occurs. Therefore, from the first hours of damage to the ulnar nerve, a special splint is applied to the hand and forearm. The hand is given a position of possible extension in the wrist joint, and the fingers are in a half-bent position; the forearm and hand are suspended on a scarf in the position of flexion at the elbow joint (at an angle of 80°), i.e. in the middle position.

Exercise therapy is prescribed on the 2nd day after the imposition of a fixing bandage. From the first days (due to the lack of active movements), passive gymnastics, gymnastics in water begin; doing a massage. As active movements appear, active gymnastics classes begin.

A.N. Tranquillitati proposes to include the following exercises in the complex of therapeutic exercises.

1. I.p. - sitting at the table; the arm, bent at the elbow, rests on it, the forearm is perpendicular to the table. Lowering the thumb down, raise the index finger up, then vice versa. Repeat 8-10 times.

2. I.p. - Same. With a healthy hand, grab the main phalanges of the 2-5 fingers of the injured hand so that the thumb of the healthy hand is located on the side of the palm, and the others on the back of the hand. Bend and unbend the main phalanges of the fingers. Then, moving a healthy hand, also bend and unbend the middle phalanges.

Along with LH, electrical stimulation of the muscles innervated by the ulnar nerve is performed. When active movements appear, elements of occupational therapy (modeling from plasticine, clay), as well as learning to grasp small objects (matches, nails, peas, etc.) are included in the classes.

Neuritis of the femoral nerve

With neuritis of the femoral nerve, the quadriceps and tailor muscles are paralyzed. The movements of the patient with this disease are sharply limited: it is impossible to unbend the leg bent at the knee; (running and jumping are impossible; standing and climbing stairs are difficult, moving from a lying position to a sitting position. With neuritis of the femoral nerve, loss of sensitivity and acute pain are possible.

When muscle paralysis occurs, passive movements, massage are used. As the recovery progresses, active movements are used: leg extension, bringing the hip to the pelvis, moving from a lying position to a sitting position, exercises to overcome resistance (with blocks, springs, on simulators).

Along with therapeutic exercises, massage, electrical stimulation of paretic muscles, etc. are used.

Control questions and tasks

1. What symptoms are typical for the clinical picture of neuritis?

2. Tasks of complex restorative treatment of peripheral paralysis and characteristics of its periods.

3. Clinical picture of neuritis of the facial nerve and methods of rehabilitation in different periods.

4. Clinical picture of brachial plexus neuritis (plexitis). Special exercises for this disease.

5. Clinical picture of ulnar nerve neuritis. The method of exercise therapy for this disease.