RU2837137C1 - Method of treating large joint contractures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely therapy, physiotherapy, physiotherapy exercises, physical and medical rehabilitation and manual therapy, and is intended for treating limited mobility of joints in rehabilitation of patients with contractures of large joints. At the beginning, the joint zone is fixed by means of an orthosis. Further, agonist muscles and shortened muscle are electrically stimulated. Shortened agonist muscle is elongated and the orthosis is fixed in a new position. That is followed by electrical stimulation of the antagonist muscle. Rectangular bipolar current is used for stimulation for 8 s with frequency of 70 Hz and a pause period with active rest of 9 Hz for 6 s. At the end of the procedure, the orthosis is left for 2 hours of active wearing.

EFFECT: method provides recovery of muscular-articular dysfunction through recovery of range of motion.

1 cl, 2 ex

Description

The invention relates to the field of medicine, namely therapy, physiotherapy, exercise therapy, physical and medical rehabilitation and manual therapy, and is intended for the treatment of joint mobility restrictions in the rehabilitation of patients with contractures of large joints.

The problem of limiting joint mobility is acute for specialists in various fields of medicine, such as surgery, traumatology-orthopedics, neurology, physiotherapy, medical rehabilitation. The proposed method of combined action of functional electrical myostimulation, manual therapy and orthotics is intended for the treatment of patients with contractures of varying degrees of progression. This method allows accelerating the process of developing myofascial contracture, thereby expanding the capabilities of medical specialists at different stages of rehabilitation, which ultimately helps to achieve improved treatment results and quality of life for patients.

This technique has been tested on acquired contractures - this is a limitation of movement resulting from local traumatic, inflammatory, reactive and dystrophic pathological changes in the joint or in the tissues surrounding the joint (skin, subcutaneous tissue, fascia, ligaments, tendons, vessels and nerves). The frequency of contracture development in limb injuries reaches 70%, in orthopedic diseases - 20%. Also, a large percentage of contractures occur in patients after a stroke with pronounced paresis in the arm or leg due to the development of high tone and the absence or limitation of movement in the limb. A contracture in any of the joints of the limb, even a minor one, due to the formation of fascial shortenings along the muscle chain can cause changes in biomechanics in adjacent and even remote from the contracture regions with the subsequent development of pronounced functional and static disorders. Thus, with contractures in large joints of the lower limb, patients cannot move freely, a persistent change in the position of the pelvis gradually develops, functional shortening of the lower limb, as a result of which the gait stereotype changes, deformation of the spine develops and flat feet can form on the healthy leg. Expressed contractures in large joints make it completely afunctional, limiting the ability of the victim in self-care and work. Thus, the formation of contractures leads to significant restrictions on everyday and social activity, so contractures are the point of application of efforts of specialists in medical rehabilitation and require the use of targeted intensive rehabilitation measures (Guide to the rehabilitation of patients with movement disorders / Ed. A. N. Belova, O. N. Shchepetova T. 2). Many different ways of dealing with contractures are known. Since the incidence of this deformation is quite high, specialists from different fields have developed their own methods. The oldest are surgical. One such example is the work of V. I. Karptsov on a method for treating knee joint contractures, which included tendon isolation and mobilization of the heads of the quadriceps muscle (SU 1 388 013 A1 IPC A61B 17/56). Currently, similar methods can be used in the treatment of contractures in patients with cerebral palsy using the Egers method or its modifications (RU 2 392 887 C2 IPC A61B 17/56, RU 2729021C1 IPC A61B 17/56). These methods are quite effective, but radical and often cannot be used in patients with a comorbid background.

The most common methods of treating contractures include a mechanical strategy, which includes methods and techniques of exercise therapy and physiotherapy.

Therapeutic exercise is aimed at eliminating dysfunction of structures involved in the formation of myofascial contractures, both in the affected segment and in other anatomical segments involved in the formation of a pathological motor stereotype. The technique of electrical stimulation for some diseases of the neuromuscular system in trauma patients consists of the effect of sinusoidal modulated currents (SMC) directly on the antagonist muscle or through its motor nerve in order to excite the affected muscle. Thus, the mechanical strategy implies the inclusion in the concept of developing mechanisms that artificially stabilize or mobilize the damaged segment in the form of orthoses (as a stage stabilizer) and hardware and software systems that form a passive mode of work with damaged areas. Both methods, provided that they are used in monotherapy, are largely preventive and do not always give the desired result in the development of contractures. Problems of unsuccessful rehabilitation of contractures can be caused by:

1. Long periods of contracture formation due to the combined and complex nature of injuries or the impossibility of early rehabilitation as a result of the patient’s long-term serious condition due to illness or injury.

2. The complexity of using the correct movement pattern and the process of adaptation to it - “correct biomechanics of the movement process”.

3. Unstable dynamics with a lack of compliance with the patient’s recommendation sheet “violation of the regime and sequence.”

4. The seesaw effect within the required volume of work of local zones and the resource inability of structures (shortening of the agonist) to perform the volume of functional work in the zone of interest.

When studying the literature, a method close to the proposed method is a combined method of rehabilitation of patients with knee joint contractures, including therapeutic exercise, exercises with objects, mechanotherapy and treatment by position under the control of goniometric indicators. Exercises of therapeutic gymnastics are used by performing inertial movements in the knee joint in combination with movements in other joints using a medicine ball or a roller cart (rolling the foot on the medicine ball, simultaneously inertially rolling the ball to perform flexion and extension in the knee joint). Treatment by position is carried out lying on the stomach by fixing the thigh with a cuff attached to the foot and by means of a fishing line connected through a block to a support for the load, with gradual flexion in the knee joint due to an increase in the load. Before the sessions of physiotherapy exercises, 2-3 times at intervals of 10 days, a femoral nerve block is performed on the side of the injured limb - 20 ml of a 1% lidocaine solution and 0.3 ml of a 0.1% adrenaline solution are administered. The block is performed for a course of 30 days of physiotherapy exercises, and physical education classes begin 1 hour after the block. Mechanotherapy is performed by performing exercises on the passive ARTHROMOT device on days when there are no blockades. Additionally, post-isometric relaxation is performed taking into account the applied resistance against the course of contraction of the shortened muscles. The entire rehabilitation process is performed under the control of rheovasography and Dopplerography (RU 2 338 503 C1 IPC A61H 1/00). The disadvantages of this method are the presence of invasive procedures and a long period of time.

The author's method "20 to 80" is known - this is a variant of combined exercise therapy and physiotherapy - the closest prototype of our invention. It contains only two consecutive stages "20 and 80", corresponding to the percentage redistribution of time when performing the method.

Stage 1: 20% of the total therapy time “Manual Therapy”

Stage 2: 80% of the total therapy time “Therapeutic and physical education”.

The principle used in this method allows to change the direct (stage 1) "aggressive" technique of impact on the shortened muscle using the basis described in manual therapy by the classical "Muscle-Energy Technique" by Samorukov A.E., also known as (P.I.R.), also known as (Hold - Relax), to the indirect (stage 2) technique of concentric low-amplitude actions up to 5 degrees, described in classical exercise therapy in the section on developing physical strength in the structures of myofascial tissues. To enhance and eliminate the undesirable consequences of stage 1 of therapy.

But this technique has negative consequences, namely the "swing effect", when most of the effectiveness disappears during the patient's absence between procedures. Initially, specialists blamed the incorrectly selected periodization for this manipulation and played up the variability, based on the available information on tissue reactivity to the elongation process, coming to the conclusion about expanding the permissible time limits for therapy in the amount of 48-72 hours depending on the age and condition of the myofascial apparatus. Even after the introduction of attempts to maintain the effect achieved with the help of the "Muscle-Energy Technique" in the form of orthopedic immobilization with tutors, orthoses, plaster, the success was partial.

Due to the inability to withstand a pause with limb fixation without intensive sedation. Even 2 hours of maintaining the effect of therapy were an unattainable result due to increasing discomfort and pain in the area of elongation of the shortened muscle, which leads to an average loss of 30% of the effect of therapy by the next manipulation.

Thus, the conceptual direction of the treatment algorithm:

PIR - Immobilization - Sedation gave way to the strategy of using physiotherapy and therapeutic and physical culture, so in a short period of time other options for the treatment algorithm appeared:

Paraffin (heat therapy) - PIR - Massage;

Massage - PIR - exercise therapy.

The structure of the latter revealed positive results due to the effect of post-elongation loading on antagonists of high-amplitude concentric nature - what is called "PUMP training" in the "FITNESS" industry. Multi-repetition action allowed to remove the state of excessive tension of the agonist muscles that underwent the PIR procedure and to withstand the time interval without losing the quality of the first procedure.

Over time, it became clear that the main problem with this strategy is the insufficient potential of the antagonist muscles in the injured area and its marked decrease at the end of the amplitude of concentric movement. Thus, the "swing effect" affects the process of effective development of myofascial contracture - on average, up to 20% of the loss of the effect of the 1st stage of therapy. Muscle strength was required in the antagonists while maintaining the position of maximum elongation of the agonists, and its development in exercise therapy took a lot of time, which reduced the potential for direct impact on the shortened muscle group by PIR, while exercise therapy consistently reduced discomfort and pain in the stretched structures.

The objective of the present invention is to create a two-stage method that combines the capabilities of physiotherapy, manual therapy and exercise therapy to combat joint contractures, which would ensure maximum effectiveness in treating joint mobility restrictions in the rehabilitation of patients with contractures, while avoiding the main inhibitory factors.

The task at hand is solved due to the fact that the proposed method, “20 to 80” (the name of the method is formed by the ratio of the duration of the treatment methods), differs from other methods of treating contractures by combining and optimizing previously invented methods in rehabilitation, as well as expanding the range and sequence of application of the techniques used, allowing for an accelerated, stable, positive treatment result.

The essence of the proposed method is to carry out two consecutive stages of therapy (stage 1: 20% of the total therapy time, stage 2: 80%, respectively), the duration of the technique is a maximum of 30 minutes and the frequency of use is once every 72 hours.

Stage I – manual therapy and physiotherapy (direct technique).

Therapy is carried out only on AGONISTS: the “shortened muscle”. Electrotherapeutic manipulation is in the nature of the concept of functional electrical stimulation and leads to an increase in the elongation properties of muscle tissue.

The current shape is rectangular bipolar.

The operating frequency of the contraction phase is 70 Hz.

The working frequency of the relaxation phase is 9 Hz.

The maximum permissible intensity for the APC is 140 mA with a working step of 1 mA.

Electrical stimulation of the agonist muscle that has undergone shortening (a variant of the post-isometric relaxation technique). 20% of the time (6 minutes) is allocated for this stage; a direct method of influencing the shortened muscle is used (in case of flexion contracture - on the flexor, in case of extension contracture - on the extensor), in combination with fixation of the joint area using an orthosis (such as ORLETT HKS-303, registration certificate dated 12.04.2011 FSZ 2011/09552 or similar). The electrical stimulation session is carried out using electrical stimulators with self-adhesive electrodes (for example, APK Compex, registration certificate dated 30.06.2011 No. FSZ 2011/0996 or similar, using the Resictance 3 program). Electrodes are placed longitudinally at the attachment sites of the agonist muscles that have been shortened. Current parameters: rectangular current for 8 seconds with a frequency of 70 Hz and a pause period with active rest of 9 Hz for 6 seconds. During the stimulation period, the patient is given a verbal command to perform work (contraction) with the shortened muscle, during the pause period - the command to "relax", elongation of the shortened agonist muscle is performed and the orthosis is fixed in a new position. On average, 8-10 manipulation cycles are performed at the 1st stage. The result of the 1st stage is fixed with the orthosis to the maximum fixation capabilities of the orthosis.

The advantage of this stage is that high productivity is formed in the injured area with the help of "Functional Electrical Stimulation", which has a direct effect on the shortened muscle (agonist), avoiding complications such as muscle weakness, sensorimotor format disorder and inability to create a directed contraction, due to the presence of fear syndrome (due to pain) before this kind of movement. In the 20% phase of therapy, the electric current leveled the first half of the shortcomings of the muscle-energy technique "PIR". A high degree of participation of structures in the work on elongation is also noted, which leads to an increase in the effectiveness of the 1st stage by an average of 15% compared to the original version of the manual PIR technique alone.

Stage II - indirect technique of working with the agonist due to concentric contractions of the antagonist muscle.

The therapy is carried out only on ANTAGONISTS. Electrotherapeutic manipulation has the character of a myofascial concept and leads to an increase in the volume of muscle tissue (muscle strength) in the area of influence.

The current shape is rectangular bipolar.

The operating frequency of the contraction phase is 70 Hz.

The working frequency of the relaxation phase is 9 Hz.

The maximum permissible intensity for the APC is 140 mA with a working step of 1 mA.

The second stage takes about 80% of the procedure time (24 min). Electrical stimulation is used in the same parameters on the unaffected antagonist muscle, but for a longer period of time. Conducting the 2nd stage creates discomfort for the patient in the area of the shortened agonist, so the patient is given a command to participate in the antagonist contraction phase, since additional work in the stimulation phase in the opposing muscle (antagonist) will minimize discomfort in the agonist muscle obtained in the 1st stage during the elongation period. The second stage is based on the principle of reciprocal innervation - reflex excitation in a group of nerve cells innervating, in this case, the antagonist, is accompanied by coupled inhibition of the activity of nerve cells functionally associated with agonists, which leads to its relaxation. Interneurons of the nervous system act as relay switches. Retraining of the nervous system and restoration of the coupled agonist-antagonist work occurs. If there is no significant discomfort in the agonist, the 2nd stage can be carried out in a state of rest.

Upon completion of the 1st and 2nd stages of the technique, as a rule, an increase in the mobility (play) of the limb in the orthosis is observed, additional fixation in the new position is not performed. The orthosis must be left for 2 hours of active wear after the completion of the technique. The next procedure can be carried out no earlier than 72 hours later, with an average of 5 procedures per course. With the possibility of prolongation if necessary. Upon completion of the procedure, a mandatory recommendation of exercises to maintain the achieved result.

At the same time, positive dynamics are observed in the form of:

1. Increasing the angle of extension of the joint affected by myofascial contracture.

2. Restoration of the “muscle balance” of tone and strength of the agonist and antagonist muscles.

Advantages of the method

This method has mutual potentiation of effects due to the simultaneous use of several techniques.

This method reduces the time of work (frequency 72 hours) and minimizes the physical load of the specialist in solving the problem of combating contracture.

Minimal "swing effect" (return to the original state).

The procedure allows you to form a motor stereotype adapted to the rehabilitation program.

This method has the ability to work during the period of joint immobilization (working with the muscle with the above-described current parameters while creating additional stretching), which helps prevent the formation of secondary myofascial changes.

The technical result is expressed in the restoration of muscle-joint dysfunction through the restoration of the range of motion.

Description of a clinical case.

Example 1. Patient D., 40 years old, was admitted to the Main Clinical Hospital of the Ministry of Internal Affairs of the Russian Federation with a clinical diagnosis: Flexion contracture of the left elbow joint. Admitted six months after the injury and 8 months after the removal of immobilization. Elbow flexion 90 degrees.

The patient underwent a rehabilitation course, including physiotherapy, massage, hardware mechanotherapy, and a course of individual exercise therapy using post-isometric relaxation.

The course of treatment consisted of 10-15 procedures, increasing flexion from 120 to 90 degrees. A rehabilitation course was conducted for 10 days: exercise therapy (individually, soft manual techniques), massage, physiotherapy, hardware mechanotherapy, the effect was insignificant, a "swing effect" was observed.

On the 11th day of treatment, the 1st procedure was performed according to the proposed method, in the form of increasing flexion by 7 degrees, a course of 5 procedures. At the end of the course of 5 procedures, flexion is 45 degrees (the norm is 40).

Description of the method:

Working with muscle contracture is divided into 2 stages. The first is the "reactive stage", which takes up 20% of the working time of the 10-minute protocol.

First action: 2 or 4 electrodes are applied to the shortened muscle or muscles "agonists" in a "longitudinal version" in the places of its or their attachment. Their "antagonists" are applied in the same way. In the first stage, electrotherapy is carried out with agonists, and in the second stage - with antagonists.

The second action: the shortened myofascial structure "agonist" is positioned in the position of maximum permissible tension (the only limitation for strong tension will be the patient's personal sensitivity and the zone of maximum tissue shortening, which should be stretched) manually by a specialist through manipulations with the attachment sites or through transverse "pulling" of the myofascial tissue on both sides. Also acceptable are options for fixation in functional orthoses "with the function of changing the angle by degrees" or the use of the APC robotic mechanotherapy according to the class of decontractive therapy "with the function of changing the angle by degrees" (example of the APC Orthorent K).

Third action: the essence of the stage and his direct participation in supporting the treatment process (if the patient is communicative) are explained to the patient, namely: to strengthen, combining the potential with his own “moderate” contraction in the phase of electrical contraction (within the framework of this action, the specialist will give the verbal command “Attention contraction”), and to relax in the phase of electrical relaxation, without interfering with the further actions of the specialist described below (within the framework of this action, the specialist will give the verbal command “Attention relaxation”).

The fourth action: the CEFAR COMPAX myofascial electrotherapy system, model 600, is used with a program selection called RESISTANCE, modification 3 (TAKING INTO ACCOUNT THE MANUALLY DISCONNECTED WARM-UP AND COOL-DOWN PHASES). Thus, electric discharges of different frequencies and strengths are supplied to the shortened, but at the same time maximally stretched structure in two preset modes, CONTRACTION - RELAXATION, with the following time intervals: 9 seconds of active contraction, cyclically replaced by 7 seconds of passive relaxation, which in the volume of 20% of the working time will be equal to 7.5 cycles of action.

The fifth action: occurs simultaneously with the fourth action and is the main part of this stage. At the moment of the "contraction phase" the specialist manually or by means of special means ("functional orthosis; APC decontracting therapy) fixes the position of the shortened muscle in the maximum permissible tension for the entire period of the contraction phase, after its completion the "relaxation phase" begins, at this very moment the specialist increases the pressure on the shortened muscle in order to stretch it, the pressure should not exceed the permissible sensitivity limit of "a feeling of discomfort, but not severe pain" up to 8 points on the VAS scale. Also taken into account is the average amplitude of stretching up to 2-5 degrees, and as soon as a new contraction phase begins, the position of the muscle is again fixed at new tension limits, waiting for the relaxation phase.

Sixth step: after all 7.5 cycles are completed, the best tension result is fixed manually or with the help of functional orthoses or APC decontracting therapy in order to proceed to the second stage. To improve the achieved results, the tension fixation is not removed until the very end of the working session.

The second stage of “reverse distraction”, which takes up 80% of the working time of the 10-minute protocol .

First step: the application made in stage 1 in a “longitudinal version” is used in the places where the “antagonists” are attached to conduct electrotherapy.

Second action: the myofascial structure “antagonist” is already positioned in the position of maximum permissible shortening for therapy.

Third step: the patient is explained the essence of the stage and his direct participation in supporting the treatment process (if the patient is communicative), namely maintaining the body position without displacement in the area of electrotherapy.

The fourth action: the main part of this stage, where the application of the APC for myofascial electrotherapy "CEFAR COMPAX" model "600" continues with the selection of a program called "RESISTANCE" modification "3" (TAKING INTO ACCOUNT THE MANUALLY DISCONNECTED WARM-UP AND COOL-DOWN PHASES). Thus, electrical discharges of different frequencies and strengths are supplied to the structure of antagonists in two preset modes "CONTRACTION" - "RELAXATION". It is also permissible to periodically increase the current strength after adaptation to the load in the amount of 80% of the working time from the 10-minute protocol, such increases can be about two times.

Fifth action: after completing only 80% of the working time of the stage, the specialist in no case tries to improve the position of the fixation orthosis, in order to avoid discomfort in the stretching zone. Even if the fixation orthosis is mobile, it is recommended to leave it without tightening for up to two hours after the procedure.

Clinical example 2.

Patient M., 41 years old, was admitted for rehabilitation of shoulder joint contracture three months after a shoulder injury; rehabilitation was not performed in the early period (outpatient rehabilitation experience).

Severe limitation of abduction (up to 30 degrees), flexion (up to 80 degrees), external and internal rotation.

After 3 weeks of treatment according to the above protocol (outpatient 2-3 times a week, with an individual protocol of independent exercise therapy sessions, the number of sessions according to the proposed method is 6 sessions), the full range of passive movements was restored. Training to restore muscle strength and endurance was continued.

Claims (1)

The method for treating contractures of large joints consists of sequentially conducting two stages of therapy, where the first stage involves electrical stimulation of the agonist muscle in combination with fixation of the joint area using an orthosis using electrical stimulators with self-adhesive electrodes, which are placed longitudinally at the attachment sites of the agonist muscles that have undergone shortening, rectangular bipolar current is applied for 8 s with a frequency of 70 Hz and a pause period with active rest of 9 Hz for 6 s; during the stimulation period, the patient is given a verbal command to contract the shortened muscle, during the pause period, a command is given to relax and elongation of the shortened agonist muscle is performed and the orthosis is fixed in a new position; the duration of the first stage is 6 min; at the second stage, electrical stimulation of the antagonist muscle is performed using electrical stimulators with self-adhesive electrodes, which are placed longitudinally at the attachment sites of the antagonist muscles, a rectangular bipolar current is applied for 8 s with a frequency of 70 Hz and a pause period with active rest of 9 Hz for 6 s; during the stimulation period, the patient is given a verbal command to perform a contraction of the antagonist muscle; the duration of the second stage is 24 minutes; after the procedure, the orthosis is left for 2 hours of active wear, the number of procedures per course of treatment is 5 with a time interval of 72 hours between procedures.