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«physical rehabilitation in surgery, traumatology and orthopedics.»




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Lecture №5: «PHYSICAL REHABILITATION IN SURGERY, TRAUMATOLOGY AND ORTHOPEDICS. »

In surgery - at operations on internal organs for access to them it is necessary to open a chest and an abdominal cavity. By preparation and carrying out of cavitary operations to an occasion of chronic diseases treatment is subdivided into the preoperative and postoperative periods.

Operations on thoracic cavity - in the preoperative period operations on lungs with the purpose of a reserve of functionalities MPC is included.

The primary tasks:

  • Reduction of intoxication.

- Improvement of function of cardiovascular system and external breath.

- Strengthening of physical strengths of a patient and psychological status.

- Mastering by the exercises necessary for the patient in the early postoperative period.

Contra-indications:

Pulmonary bleeding, cardiovascular insufficiency (III stage), myocardial or lung infarction in an acute period, high temperature (38-39° С).

The technique of physical rehabilitation is made in view of localization and prevalence of pathological process, a condition of external breath, age of the patient, character of disease and a kind of intervention, a degree of physical readiness of the patient.


^ The early postoperative period:

Tasks:

- Prophylaxis of pulmonary complications by improvement of ventilation of lungs, drainage of bronchus’s, straightening of the remained part of a lung.

- Prophylaxis of phlebothrambosies.

Prophylaxis of disturbances from the side of gastro-intestinal tract (paresis’s of a stomach and an intestine, a delay of a stool, meteorism.

- Improvement of function of breath and cardiac activity.

- Prophylaxis of restriction of mobility in a humeral joint on the operated party.

- Preparation of patients for expansion of a motor regimen.

- Increase of a tone of nervous system.

Contra-indications have temporary character:

The general severe condition of patients caused by complications during operation is (a shock, cardiac arrest, loss of blood, etc.), a secondary bleeding, frequent small pulse.

The medical gymnastics is appointed in 1-2 hours on 3-5 times a day and includes: diaphragmal breath, exercises on an exhalation, turns on the healthy side, dynamic respiratory exercises for 2nd day. Massage, a postural drainage, since the 2nd-3rd weeks getting up, walking on stairs, on a corridor. In 2 months after it is possible to appoint medical swimming.

Operations on an abdominal cavity. Operations on organs of abdominal cavity are made to an occasion of peptic ulcer of a stomach and duodenum, cholecystitis, hernia, appendicitis, wounds of an abdominal cavity, etc.

^ Tasks of the preoperative period are:

  • To increase the general tone of an organism (emotional and nervous-muscular).

- To improve a functional-condition of cardiovascular and respiratory systems.

- Improvement of motor function of a stomach and intestine.

- Strengthening of muscles of pleura abdominal.

Technique of MPC includes: training of chest type of breath, with the formed, extended exhalation, general-developing and special exercises in various starting positions (lying on a back, on a right and a left side, standing on all four / with highly lifted pelvis).

Independent employments up to 5-6 times in a day should include the exercises promoting removing of sputum, activization of blood circulation in distal departments, increase in mobility of a diaphragm, extremities, reductions and expansions of muscles of a pleura abdominal.

Contra-indications:

The general severe condition, increase of a temperature, danger of a bleeding, perforation of vermiform process, suspicion on an ulcer, appendicle infiltrate, peritonitis and so forth.


^ In the postoperative period:

In the early postoperative period a technique of the medical gymnastics is made in view of features of operative intervention, current of the postoperative period, a condition of the patient before operation and after it, age of the patient.

Respiratory exercises with the subsequent expectoration are used. The medical gymnastics after appendectomy can be begun at the first 3-5 o'clock, for the 2nd-3rd day is getting up both walking on a corridor and stairs. For the 4th-5th day in a group, for the 6th-7th day the patient is discharged from hospital.

Medical gymnastics after operation of peptic ulcer of a duodenum and a stomach: in the 1st day - chest type of breath (respiratory exercises) and exercises on distal departments of extremities, N 5-6 on 5-10 minutes.

For the 2nd-3rd day - supporting a postoperative wound the patient carries out the medical gymnastics including respiratory exercises and exercises on small and average muscular groups, small and average joints, turns of a trunk sideways, massage of muscles of a spine, preventive maintenance of developments of stagnation in lungs (postural drainage), transition in position sitting in beds (for the 4th-5th day), then to getting up for the 6th-9th day.

From the 9th-10th day of employment by morning hygienic gymnastics, the medical gymnastics including respiratory general-developing exercises, exercises on strengthening of muscles of a pleura abdominal), massage of a spine.

^ At cholecistectomy - the same principle, as in the previous material, only to sit with the lowered legs on the 6th day, to get up on the 10th-12th day, thus on postoperative cicatrix the bandage is imposed. Within 6-12 months heavy work with a pressure of muscles of a pleura abdominal is not recommended. MPC in conditions of a polyclinic the medical gymnastics, morning hygienic gymnastics, massage of a backbone, terrencur) is appointed.


^ PHYSICAL REHABILITATION AFTER HERNIOTOMY HAS PECULIARITIES:

In the first 7-10 days after operation as much as possible reduce load on the abdominoanterior wall, pressure of muscles of a stomach is excluded, to sit on the 5th -6th day, to go on the 8-10th with a supporting bandage. At the strangulated hernias - exercises on strengthening of muscles of a stomach only in 2-3 weeks, to sit on the 6th -8th day, to get up on the 12-14th day. For 14th day MPC includes morning hygienic gymnastics, medical gymnastics, walking, stay on fresh air, adaptation to household load. Only in 3-4 months after herniotomy it is shown the complex of medical gymnastics promoting strengthening of muscles of a pleura abdominal, from starting positions lying, sitting and standing.


^ PHYSICAL REHABILITATION IN TRAUMATOLOGY AND ORTHOPEDICS

Use of physical exercises at diseases and traumas of locomotors system promote to healing of wounds, improvement of blood supply and to elimination of developments of congestion in the injured parts of a body, to the prevention of complications - contractures, muscular dystrophies, commeasures, etc. Physical exercises render normalizing influence on a level of the basic ' nervous processes, increase a tone of a cortex of cerebral big hemispheres, work psycho-therapeutic, and restore forces of the patient more quickly. Physical exercises are appointed in the first days after patient's reception in a hospital in view of a patient's condition and his specific features.

All course of physical rehabilitation is conditionally divided into 3 periods: immobilization; post-immobilization; recovery.

^ I. The period of immobilization corresponds to bone adhesion of breaks, which comes in 30-90 days after a trauma.


Tasks:

- Increase of a vitality of the patient;

- Improvement of function of cardiovascular, respiratory systems, gastro-intestinal tract, metabolic processes, immobilized extremities.

- Improvement of blood- and lympho-circulation in a zone of damage.

- Stimulation of regenerative processes.

- The prevention of muscles hypotrophy and rigidity of joints.

Contra-indications:

- The general severe condition caused by loss of blood, a shock, an infection, accompanying diseases, increase of a temperature higher than 37,5° С, a proof painful syndrome, danger of a bleeding, presence of the foreign bodies located near from large joints, nerves, vitally-important organs.

- From forms of MPC are used: MGG, medical gymnastics (1-3 times a day), including static and dynamic respiratory exercises, general developing exercises covering all muscular groups, exercises on coordination, balance. Exercises for symmetric of extremities, ideomotor and isometric exercises on immobilized muscular groups, for prophylaxis of contractures and hypotrophy of muscles in the form of independent individual employment. Massage is appointed from the 2nd week once a day. Mastering by the elementary skills of self-service.

^ II. Post immobilization period: is begun after removal of a plaster bandage or skeletal extension. Clinically and roentgenologically in these terms consolidation of area of fracture and reduction of force and endurance of muscles, amplitudes of movements in joints is marked.

Tasks:

- Preparation of the patient to getting up, training of the vestibular apparatus, training to skills of movement on crutches.

- Restoration of function of the injured extremities.

- Normalization of a correct posture.

- Recovery of motor skills.

In this period are used: MG, medical gymnastics, load increases due to increase of a number of exercises and their dosage, massage of 10-15 procedures, independent individual employment, mechanotherapy, hydrokinezotherapy, and work therapy.

^ III. Recovery period.

During this period the residual phenomena in the form of restriction of amplitude of movements in joints, decrease of force and endurance of muscles of the injured extremities leading to reduction of working capacity are possible.

In this period MGG, medical gymnastics, the independent individual employment, the dosed out walking, mechanotherapy, hydrokinezotherapy are appointed.

^ Estimation, efficacy of treatment:

Under recovery is understood as performance by patients of full volume of movements in joints, recovery of muscular force, speed and coordination of movements.

Measurements are spent:

1. Angular measurements of amplitude of movement in a joint by means of goniometers (a limit the act. and pass, movements).

2. Goniometry - measurement of curvature and movement in a spine, corners of an inclination of a pelvis, (Gamburtsev's goniometer).

3. Linear measurements by a centimeter tape (length, a circle of the injured and healthy extremity in comparison).

4. A circle of extremity.

5. Muscular force (dynamometer).

6. Endurance of muscles in static (dynamograph) and dynamic (ergograph) work.

7. A tone of muscles.

8. Applied purposeful movements.

Traumas of a spine: These are the severest injuries; the sequence of medical actions is determined by prescription, a degree, character of injury and neurological disorders.

Tasks in the period of immobilization:

- Elimination of displacement of vertebrae.

- Elimination of a compression of a spinal cord and it roots.

- The prevention of relapses and secondary injuries of nervous elements.

- Increase of force and endurance of muscles of a trunk and neck.

- Increase in mobility of a spine. At injury of a cervical department (С5-С6) it is appointed:

  • Treatment by position, (the patient stack on a rigid bed, extension by means of Glisson's loop) the head end is raised on 50 cm (at flexion fracture). At extension fracture under a head the small pillow keeps within and extension is imposed, the medical gymnastics is appointed on 2-3 day (general-developing exercises for distal departments of extremities and respiratory exercises in the ratio I:2, in the certain rate with pauses, with recurrences 4-6 times, 2-3 times a day.

  • In 15-30 days after extension pass during - 8-10 days in position sitting with expansion of motor regimen (to sit, move). The medical gymnastics, the dosed out walking, independent individual employment (a pressure of muscles of a neck).

Contra-indications: movements of a trunk forward;

In post immobilized period in 8-10 weeks remove fixing plaster bandage. The medical gymnastics is directed to this period on strengthening of muscles of a neck, a shoulder girdle and the upper extremities, recovery of movements in a cervical department of a spine. Medical gymnastics spend in a starting position laying, then sitting and standing. Widely use exercises on coordination of movements, balance, normalization of a posture and gait. Alongside with gymnastics is appointed massage of portal zones of muscles of a spine and the upper extremities, hydrokinezotherapy in pool, work therapy.

^ Injury of bodies chest and lumbar vertebra.

More often compression fracture is met. At small compression (no more than 1/3 of heights of a body vertebra), accepts the functional method of treatment developed by V.V. Gorinevskaya and E.F. Dreving), which essence consists in longitudinal extension for axillary’s spaces on rigid bed with an inclination 40-60 cm, and bolsters under area of injury.

The Medical physical cultures divided for 4 periods:

1. The period (7-10 days): the medical gymnastics is directed on increase of vitality, maintenance of cardiovascular, respiratory and digestive systems, the prevention of decrease in force and endurance of muscles.

Respiratory exercises (static and dynamic), general-developing for the small and average muscles, the facilitated sliding movements in micro-extremities, raising a little of a pelvis, during 10-15 minutes, lying on a spine, individually are used.

2. The period (up to 30 days): Alongside with the previous tasks strengthening of trunks muscles, a shoulder girdle and pelvis fundus, development of "a muscular corset", employment by medical gymnastics during 20 minutes are appointed, turns on a stomach, extensive exercises, caving in a chest department, the bolsters under a breast in a starting position lying, in a combination with isometric (a pressure \ a relaxation of muscles of a spine, active movements of the lower extremities) are already resolved.

3. The period (till 45-60 days) - strengthening of trunk muscles and pelvis fundus, extremities, coordination of movements and mobility of a spine.

Basis - is an axial gradual load on a spine (being on all fours, in a knee) lying on a spine. Deduction of a trunk in a pose «swallows" (lying on a stomach) - during 2-3 minutes and direct legs under a corner 45°- 23 minutes.

4. The period in 60 days after a trauma - goes adaptation to vertical position and in employment exercises in a starting position "standing" (inclinations, removal and reduction of legs, half squatting) are included, skill of a correct posture, with gymnastic subjects, at a gymnastic wall is got.

At treatment of fractures with a significant forward compression for 4-6 months is imposed an extensive plaster corset and medical gymnastics from the first days after a trauma is appointed. In 4-6 months the medical gymnastics is directed on strengthening of a trunk muscles, extremities, massage, hydrokinezotherapy is recommended.

^ At fractures of pelvis bones methodical principles of MPC are the same as at a fracture of spinal column. The patient without complicated fracture stack on a mattress with the wooden board enclosed under it, for relaxation of muscles of a pelvis and legs under half-bent both slightly dissolved hips and knees ("position a frog") bring the bolster. Employment by medical gymnastics in 3-5 days after crisis is begun.

In the I the period various exercises of hands and partially to a trunk, very cautious movements on the bolster by legs without tearing off heels from a bed are applied at support of the methodologist.

In the 2 period exercises for legs, pelvis girdle, muscles of a spine, in a starting position lying on a stomach are entered.

In the 3 period to the patient allow to rise, observe of functions of pelvis muscles, walking and a poster.


^ PHYSICAL REHABILITATION IN ORTHOPEDICS AT AN OSTEOCHONDROSIS

OF A CERVICAL DEPARTMENT OF A SPINE.

The osteochondrosis of a spine represents a disease in which basis the degeneration of an intervertebral disk with the subsequent involving in process of a body of adjacent vertebrae, and also changes in intervertebral joints and the ligamentous apparatus. Increase of degenerative changes in an intervertebral disk has corresponding morphological, a substratum and characteristic clinical displays. But the variety of clinical forms of osteochondrosis entails also variety of ways of physical rehabilitation, which develops from various orthopedic, medicamentous and physiotherapeutic, and also MPC.

MPC is effective not only at an exacerbation of disease, but also is a basis of prophylaxis of exacerbations and progressing of degenerative process. The medical gymnastics at osteochondrosis in the methodological plan should be uniform, but with the obligatory account of specific peculiarities of an organism, localization of process and a stage of disease.

At carrying out of medical gymnastics it is necessary to observe following principles:

- The medical gymnastics is spent in a cotton-gauze collar of Shvants's type. Constant carrying it during of a course. Thus rest for a cervical department is created, microtraumas are prevented, and pathological impulsation is decreased.

- In the initial and basic period of course of treatment active movements are completely excluded, they are supposed for 15-20 day.

- All gymnastic exercises alternate with exercises on a relaxation.

- From the first procedures of medical gymnastics exercises for strengthening of a neck muscles, isometric, respiratory exercises are entered.

- Occurrence of pains testifies about necessity to reduce a load.

Tasks:

- Strengthening of an organism.

- Decrease of pathological proprioceptive impulsation from a cervical department.

Improvement of blood circulation in the injured segment, reduction of a hypostasis in tissues.

- At humeroscapular periarthritis - reduction of pain in a humeral joint, and the upper extremity, prophylaxis of neurogenic contracture of a humeral joint, recovery of movements amplitude.

- At a back local sympathetic syndrome - prophylaxis of vestibular disturbances.

- At discogenic ischemic myelopathy - strengthening of the weakened muscles and struggle against spastic displays of diseases.

- Means and forms of MPC: medical gymnastics up to 30 procedures, massage of collar zone, muscles of hands (15 proc.), treatment by position (a dream on a rigid bed with a small pillow), hydrokinezotherapy.

^ Technique of medical gymnastics: in the acute period of disease (a relaxation of muscles of a shoulder girdle, exercise on small both average muscular groups and joints. In subacute period the medical gymnastics is directed on strengthening of muscles of a neck and a shoulder girdle, general-developing, respiratory, isometric exercises are used. Active movements in a cervical department - in the final period of MPC are used.

^ Osteochondrosis of a lumbosacral department of a spine.

Treatment is consisted of medicamentous therapy, traction of a spine for reduction of volume of prolabial parts of a disk and decompression of a nervous vertebra; MPC and physiotherapy is appointed.

At selection of exercises it is necessary to consider following anatomo-biochemical peculiarities of a lumbosacral department of a spine.

Intradisk pressure in the injured disk is decreased in horizontal position (on 0,5-1 kg/cm2) and in vertical is increased. Therefore the dream on a board is appointed, and physical exercises are executed in a starting position, lying on a spine, a stomach, a side, on all fours.

As hernias of an intervertebral disk enters more often "conflict" to the nervous endings that is shown in a pressure, and it is possible and contracture of long muscles of a spine it is necessary to include exercises in employment of medical gymnastics on a relaxation.

Already in subacute stage in employment are included:

a) Physical exercises on bending of a spine;

b) A starting position lying on a stomach with leading under a stomach of the small sizes of cotton-gauze blotters;

It is unnecessary to include in medical gymnastics physical exercises on unbending of a lumbar department of a spine (especially in acute and subacute stages).

It is necessary to use physical exercises on "extension" of a lumbar department already in acute and subacute stages, i.e. they promote to decompression.

Active movements in a lumbar department it is shown only outside of a stage of exacerbation and for stimulation of the injured department of a spine and strengthening of trunk muscles, pelvis fundus static exercises (on 2-3-5 sec.) are used.

At employment by medical gymnastics it is necessary to fix a lumbar department by a belt of weight-lifter or an orthopedic corset.

Except for medical gymnastics massage of muscles of a spine, a waist, receptions of manipulation, skeletal extension, in a chronic stage of hydrokinezotherapy, swimming, terrain cure, the dosed out walking is used.

Surgical treatment is shown at absence of effect from conservative therapy within 6-9 months.

^ PHYSICAL REHABILITATION FOR CHILDREN WITH AN ORTHOPEDIC PATHOLOGY.

Platypodia.

Tasks:

Strengthening of all organism and the muscular apparatus of feet, improvement of local blood circulation of feet, increase of the general and force endurance of muscles of the lower extremities.

The basic place in MPC is occupied with the special tasks directed on correction of feet deformation, education and fastening of a habit of correct position. A basis of rehabilitation is the general training of an organism.

In the beginning of a course special physical exercises for muscles of a crus and the feet directed on restoration of deformation of feet, reduction of the pronation and supernited contracture of a forward department of feet are appointed, which are alternated with general-developing and exercises on relaxation. For strengthening of muscles walking on sand, a pebble is used. To fix correction it is necessary by means of special kinds of walking: on tiptoe, heels, an external surface of feet, and for corregated effect ridge boards, slanting surfaces are used. Except for medical gymnastics massage after warm feet baths is necessary used. On a course is 12-15 procedures necessary. Orthopedic methods - carrying of special footwear on a thick sole with a low heel. Addition to treatment swimming by style "crawl", walking on skis, driving on a bicycle, game in volleyball is.

Scoliosis

General tasks: improvement of a functional condition of cardiovascular system, organs of breath, the nervous-muscular apparatus. Increase of physical working capacity by the general training of an organism.

^ Special tasks: unload of a spine, correction of scoliotic deformation, formation of well developed muscular corset for stabilization of a spine and the prevention of progressing of scoliosis, training and fastening of a habit of a correct posture.

Patients with the 1st and the 2nd degree of scoliosis MGG, MG with inclusion of general-developing, respiratory and special exercises for muscles of a spine, breast, a stomach and extremities is appointed. For correction of scoliosis symmetric and dissymmetric corregated and distortion exercises in position of the least static pressure (laying on a stomach and a spine) are used.

Congenital muscular torticollis.

Tasks:

Improvement of blood- lympho-circulation in the injured muscle, the prevention of rough scarring. Reduction of muscular contracture, increase in mobility and reduction of an inclination of a head, compensator increase in a muscular tone at the healthy side. The prevention of a face asymmetry.

Treatment should begin in early terms from 2 weeks till 3 months, stroking massage of extremities, massage of muscles of a neck is appointed. On the injured side - light grinding, stroking from time to time and vibration. Except for these methods treatment by position, a corregated cap is used. In the age of 7-8 months - Shants's cotton-paste collar, ionophoresis with potassium iodide, solux.

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