Abstract: Therapeutic physical training for fractures of the lower extremities. When the leg is in a cast. Rehabilitation exercises after plaster removal

Depending on the nature of the fracture of the limb bones and the stage inpatient treatment patients, the entire course of exercise therapy after a fracture is conventionally divided into 3 periods: immobilization, post-immobilization and recovery.

The period of immobilization corresponds to bone fusion of fragments, which occurs 30–90 days after injury. The end of this stage of consolidation is an indication to stop immobilization. Exercise therapy after a fracture is prescribed from the first days of the patient’s admission to the hospital.

Contraindications to exercise therapy after a fracture

Contraindications to exercise therapy: general serious condition patient due to blood loss, shock, infection, concomitant diseases, increased body temperature (over 37.5°C), persistent pain, the presence of foreign bodies in tissues located in close proximity to large vessels, nerves, vital important organs, the danger of the appearance or resumption of bleeding due to movements.

Objectives of exercise therapy after a fracture

The objectives of exercise therapy after a fracture are: increasing the patient’s vitality, improving cardiovascular function, respiratory systems, gastrointestinal tract, metabolic processes, trophism of the immobilized limb, lymph and blood circulation in the area of ​​damage (operation) for the purpose of stimulation regenerative processes, preventing muscle wasting and joint stiffness.

How to do exercise therapy after a fracture

General developmental exercises allow you to achieve most of these tasks. Exercises are selected taking into account the ease of their implementation (starting position, sliding planes, etc.); localization of damage (for distal or proximal segments of the limbs, various parts of the spine); simplicity or complexity of movements (elementary, friendly, anti-friendly, coordination, etc.); degrees of activity (passive, active); the use of projectiles of general physiological influence; development of vital skills.

During therapeutic exercises, it is necessary to exclude the possibility of the appearance or intensification of pain, since pain, leading to reflex muscle tension, makes it difficult to perform physical exercises. Classes include static and dynamic breathing exercises, general developmental exercises covering all muscle groups. As the patient adapts to physical activity, classes are supplemented with exercises for coordination, balance (prevention of vestibular disorders), with resistance and weights, with objects. Exercises for a symmetrical limb help improve the trophism of an immobilized limb. Improved blood circulation and activation of reparative processes in the area of ​​damage (surgery) are noted when performing exercises for joints of the immobilized limb that are free from immobilization. When the joint is immobilized already in early stages disturbances in the coordination relationships of antagonist muscles and other reflex changes occur, in particular, muscle hypertonicity, which is the first stage of the development of contractures. The time factor aggravates this process. In this regard, starting from the first days of the immobilization period, patients should perform ideomotor movements in the joint. Consecutive excitation of the flexor muscles during ideomotor flexion and the extensor muscles during ideomotor extension contributes to the preservation of the motor dynamic stereotype of the processes of excitation and inhibition in the central nervous system that take place during the actual reproduction of this movement.

Isometric muscle tension helps prevent muscle atrophy and better compression of bone fragments, restore muscle sensation and other indicators of the function of the neuromuscular system. Isometric muscle tension is used in the form of rhythmic (performing tension at a rhythm of 30–50 per minute) and long-term (muscle tension is held for 3 s or more) tension.

Rhythmic muscle tension is prescribed from 2–3 days after injury. At first, patients perform the exercises as an independent methodological technique, and in the future it is recommended to include them in classes. 10–12 tensions during one session are considered optimal.

Long-term isometric muscle tension is prescribed from 3–4 days after injury, lasting 2–3 s, and subsequently increasing it to 5–7 s. When performing prolonged isometric muscle tension and ideomotor exercises, it is necessary to ensure that patients do not hold their breath.

For fractures of the lower extremities, classes include static retention of the limb (intact, damaged, immobilized with a plaster cast); exercises aimed at restoring the supporting function of the uninjured limb (grasping various small objects with the toes, simulating walking, applying basic pressure to the footrest, etc.); exercises aimed at training peripheral blood circulation (lowering and then giving an elevated position to the injured limb, immobilized with a plaster cast, etc.); dosed resistance (with the help of an instructor) in an attempt to abduct and adduct the injured limb in traction; isometric muscle tension of the thigh and lower leg, ideomotor exercises.

The listed physical exercises are used comprehensively in the form of therapeutic exercises, morning hygienic exercises and independent exercises.

Massage is prescribed from the 2nd week once a day. Patients should do therapeutic exercises 2-3 times a day. During this period, patients master the simplest self-care skills. If the upper limb is damaged, patients are offered light labor operations that involve the joints of the fingers in movement. Lighter loads are ensured not only by the selection of labor operations (weaving, knitting, etc.), but also by the combination of work of the injured and healthy hand. The post-immobilization period begins after removal of the plaster cast or skeletal traction. Clinically and radiologically, consolidation of the fracture area (primary callus) is noted at this time. At the same time, patients experience a decrease in muscle strength and endurance and range of motion in the joints of the immobilized limb.

Objectives of exercise therapy after a fracture in the post-immobilization period

The general tasks of exercise therapy after a fracture in this period are: preparing the patient to get up (subject to bed rest), training the vestibular apparatus, teaching the skills of moving on crutches and preparing the ability to support a healthy limb (in case of damage to the lower extremities).

Particular tasks of this period: restoration of the function of the damaged limb (normalization of trophism, increasing the range of motion in joints, strengthening muscles), normalization correct posture, restoration of motor skills. During this period, physical activity increases due to an increase in the number of exercises and their dosage. The classes use breathing, corrective exercises, balance exercises, static and muscle relaxation exercises, and exercises with objects.

Against the background of general developmental exercises, special ones are carried out: active movements in all joints of the limb, muscle tension lasting 5–7 s, static retention of the limb, training of axial function, etc. Initially, the exercises are performed from lightweight starting positions (sitting, lying), with sliding slides placed under the limb planes that reduce friction using roller carts, block installations, exercises in water. Movements aimed at restoring mobility in the joints are alternated with exercises that help strengthen muscles and exercises to relax muscles. Classes are supplemented with exercises at the gymnastic wall. At severe weakness muscles, muscle hypertonicity, trophic disorders, massage is recommended (10–15 procedures).

At the end of immobilization (if the upper limb is damaged), elementary labor processes are used, performed by the patient while standing, with the injured arm partially supported on the table surface (in order to relax the muscles and reduce pain in the damaged area). Patients can make envelopes, simple products, polish and grind surfaces, etc. In the future, in order to increase the endurance and strength of the muscles of the injured limb, patients are offered labor operations, during which it is necessary to hold the tool with the hand above the table surface for some time. In case of functional disorders in a joint (for example, the shoulder), patients are recommended to perform labor operations associated with active movements of the hands not only on a horizontal surface, but also with movements of the hands in a vertical surface (work on household stands, painting work, etc.). During this period, patients can be allowed to perform labor operations that require significant muscle tension.

Exercise therapy during the recovery period

IN recovery period In patients, residual effects are possible in the form of limited range of motion in the joints, decreased strength and endurance of the muscles of the injured limb, which impede the restoration of ability to work. The total physical activity during exercise is increased due to the duration and density of the procedure, the number of exercises and their repetition, and various starting positions (lying, sitting and standing). Exercise therapy after a fracture is supplemented with dosed walking, therapeutic swimming, and applied exercises. Occupational therapy is also widely used during this period. If the patient’s profession requires a full range of motion in the elbow and shoulder joints (if the upper limb is damaged), then for therapeutic purposes, occupational labor operations dosed according to the load are prescribed. Patients whose profession is not related to the assembly of small parts are offered labor operations in carpentry and plumbing workshops, in typing rooms, etc. One of the criteria for restoring the patient’s ability to work is satisfactory amplitude and coordination of movements in the joints with a positive characteristic of the muscles of the injured limb. When assessing the function of the latter, the quality of performance of basic household and work operations is also taken into account.

Evaluation of the effectiveness of exercise therapy after a fracture

The simplest methods for studying the functions of the limbs and spine make it possible not only to give objective conclusions when diagnosing injuries to the musculoskeletal system, but also to evaluate the role of physical exercise, methods of occupational and mechanical therapy in the rehabilitation of orthopedic and trauma patients. Under restoration normal function limbs are understood as the patient performing a full range of movements in the joints, restoring muscle strength, speed and coordination of movements. Angular measurements of the range of motion in joints are carried out using goniometers. Range of motion or amplitude of active and passive movement, i.e. the limit at which movements cease actively or passively is determined in degrees on the protractor scale. In addition, it is necessary to have an idea of ​​the average range of motion in the joints under study. The amplitude of movement is considered as the difference between the maximum possible extension and flexion at the joint. Using goniometry, you can measure the curvature and movement of the spine, and the angles of the pelvis. For this purpose, a Gamburtsev goniometer, a pendulum-shaped remote electrogoniometer and other devices are used. Linear measurements are carried out with a centimeter tape, the length and circumference of both the damaged and healthy limb are determined. By comparing these data, one gets an idea of ​​the degree of anatomical and functional disorders. Identification points for comparative measurement of a limb are bony protrusions.

Identification points for measuring limb length are given below.

The circumference of the limb (sick and healthy) is measured in symmetrical places at a certain distance from the bone identification points. For example, if the circumference of the right thigh is measured 10 cm below the greater trochanter, then the circumference of the left thigh should be measured at the same distance. Muscle strength is assessed on a five-point scale. The five-point rating system is based on factors facilitating motor function: movements in the horizontal plane to remove the mass of the underlying segment of the limb, removal of frictional forces using suspensions, bringing together the attachment points of antagonist muscles in order to eliminate the resistance of these muscles.

Pelvis is located at the base of the spine and serves as a support not only for the spine, but also for the entire human skeleton. With the help of the pelvis, the lower limbs are connected to the body. In addition, the pelvic bones and the bone bed formed by them (pelvic ring) serve as a container for part of the internal organs, which are called pelvic. Thus, it is clear what an important role the pelvic bones play in the human body, and therefore their fractures are considered rather severe fractures, since this is associated with the possibility of damage to internal organs. Also, with a pelvic fracture, there is a large loss of blood and pain - all this, in turn, leads to shock in the victim.
According to statistics, pelvic bone fractures account for 4% to 7% of all injuries to the musculoskeletal system. The causes of a fracture can be different. But in most cases, this is compression of the pelvic bones during car accidents, collisions with pedestrians, building collapses, etc. As mentioned above, these injuries are most often accompanied by shock, which is associated with massive bleeding, as well as pain syndrome.
Diagnosis of pelvic fracture clarified as a result of x-ray examination. First you need to do overview shot in the anteroposterior direction, then - additional photographs in special projections. If there is a need, then carry out computed tomography. Also, in case of a pelvic fracture, it is necessary to conduct a digital examination of the rectum, because sometimes fragments can be felt through the wall of the rectum pelvic bones, and it is also necessary to check for intestinal ruptures. If we're talking about about a woman, then in this case she is scheduled for an examination by a gynecologist.
Depending on the nature of the fracture, various immobilizations are performed. For example, in case of injuries to the pelvis with displacement of fragments, the patient is subjected to skeletal traction, but if the pelvic fracture is bilateral, then the patient is placed on a hard bed, and cotton-gauze rolls are placed under his legs, while the knees should be apart (the so-called Volkovich position) .
The therapeutic course of rehabilitation treatment for a pelvic fracture includes 3 periods.

In the first period of treatment, it is necessary to pay attention to maintaining the general tone of the body, improving metabolism, and also not forgetting about the prevention of possible complications from the respiratory system, cardiovascular system and gastrointestinal tract.
During this period, the tasks of exercise therapy for a pelvic fracture include: improving blood circulation in the area of ​​injury in order to activate regeneration processes, preventing endurance of the muscles of the pelvic girdle and limbs, as well as preventing joint stiffness.
Some time after the injury, patients begin to be taught chest breathing. With fractures of the pelvic bones, there are often complications in the form of peritoneal hematoma, and in this case, chest breathing is gentle and prevents an increase in intra-abdominal pressure, which can increase pain and provoke bleeding.
In the first period of treatment, it is advisable to use physical exercises for a fracture of the pelvis, which contribute to the reposition of the bones of the displaced half; for this, the patient must perform the following movements: stretch the lower limb on the side of the displacement to the foot end of the bed. also in complex exercise therapy for pelvic fracture During the first period of treatment, exercises should be used that are aimed at bringing the pubic bones closer together (mowing the legs - the healthy leg rises above the immobilized one, internal rotation, etc.), among other things, these exercises help strengthen the abdominal muscles. However, therapeutic exercises for a pelvic fracture should exclude from its complex exercises that are fraught with further divergence of the symphysis pubis (leg abduction to the side, outward circular movements of the leg, etc.).
If there are no contraindications, then massage can be included in the exercise therapy complex for a pelvic fracture from 3-4 days after the injury, which is carried out to reduce swelling of the lower extremities, improve peripheral circulation and prevent thrombosis. During massage, both lower limbs should be massaged, however, for 7-10 days, massage of the immobilized limb is carried out with limited rubbing, kneading and vibration techniques. The course of treatment includes 15-20 procedures.

The second period of treatment for a pelvic fracture lasts 1-1.5 weeks. During this period, there is an improvement in the patient's general condition, adaptation to physical activity occurs, which gradually increases. At this time, as a rule, the immobilization is removed.
To tasks Exercise therapy And LH (therapeutic gymnastics) for pelvic fracture the second period includes: strengthening the muscles of the trunk, limbs, pelvic girdle, increasing the range of motion in the joints of the limbs, and training the supporting function of the lower limbs is also important. Physical activity can be increased by performing more complex exercises with both legs, as well as by performing isometric tension on the muscles of the limbs, pelvic girdle and torso, and, of course, by increasing the number of exercises and their repetitions.
During this period of treatment, early turns onto the stomach are contraindicated due to the fact that this can lead to divergence of the symphysis pubis. Now in exercise therapy (physical therapy) for fractures of the pelvic bones, you need to use exercises in the starting position, lying on your back, on your side. Before lifting the patient out of bed (several days in advance), he is taught to turn onto his stomach and a number of exercises are added in this position, such as: alternating and then simultaneous extension of the legs at the hip joints, spreading straight legs, raising the pelvis and etc.

In the third period of treatment for a fracture of the pelvic bones, much attention is paid to restoring the patient’s walking skills and ability to work.
The tasks of exercise therapy for a pelvic fracture now include: adapting all body systems to increasing physical activity, training the muscles of the limbs, torso and pelvic girdle, as well as restoring the supporting function of the lower extremities and increasing mobility in the hip and knee joints.
During this period, patients perform exercises of the first and second periods in the initial position lying on their back, on their side and on their stomach, with a large number of repetitions of each exercise. After the patient is transferred to a vertical position, half-squats, various leg movements, and bending of the torso (with obligatory support from the back of the chair) are introduced into physical therapy classes for fractures of the pelvic bones. In order to restore coordination of movements and increase physical activity, exercises with gymnastic apparatus and against the gymnastic wall are used. The patient can already move on crutches, first within the ward, and then within the hospital department, and if during 1.5-2 hours of continuous walking the patient does not experience pain in the area of ​​the injury, then he is also allowed to sit (not for long at first).

A set of therapeutic exercises for pelvic fractures .
First treatment period:
1. I.P. - lying on your back or sitting, with your knees slightly bent. Perform flexion and extension of the fingers. Repeat 8-10 times.
2. I.P. - the same. Perform dorsiflexion and plantar flexion of the foot: first healthy, then sick, then healthy and sick at the same time. Do 8-10 times in each case.
3. I.P. - the same. Place the affected leg on the knee of the healthy leg. Perform circular movements in the ankle joint: with the healthy leg, then with the sore leg, then with both the healthy and sore leg. Repeat in each case 8-10 times.
4. I.P. - the same. Grab small objects with your toes: balls, pencils, pens.
5. I.P. - the same. Turn the foot inward and outward (at the same time). Repeat 8-10 times.
6. I.P. - the same. Place your toes one on top of the other. Perform dorsiflexion and plantar flexion of the foot with resistance (at least 15-20 times).
7. I.P. - lying on your back, the sore leg is bent at the knee. Supporting your thigh with your hands, bend and straighten your leg in knee joint, while lifting the heel off the bed. Repeat 8-10 times.
8. I.P. - lying on the bed. Perform leg bending at the knee joints (8-10 times).
9. I.P. - lying on your back. From this position, move to a sitting position, then return to the starting position. Repeat 6-8 times.
10. I.P. - the same. Perform knee extensions and abductions. Repeat 6-8 times.
11. I.P. - the same. Holding the edges of the bed with your hands, alternately lift your leg, straightening the knee. Do 8-10 times.
12. I.P. - the same. Perform circular movements with your legs alternately. Repeat 6-8 times.
13. I.P. - lying on the side, with the sore leg on top of the healthy leg. Perform leg abductions. Repeat 6-8 times.
14. I.P. - lying on your back. Perform leg movements that imitate riding a bicycle ("bicycle" exercise).

Second treatment period:
1. I.P. - standing, holding the chair with his hands. Rise onto your toes, then move onto your heels and lower onto your entire foot. Perform 8-10 times.
2. I.P. - the same. The toes are slightly turned inward. Raise the inner arch of the foot, while transferring the entire weight of the body to the outer arch. Repeat 8-10 times.
3. I.P. - sitting on the bed. The legs are bent (the sore leg is supported by the hand). Perform flexion and extension of the leg at the knee joint; at the moment of bending, place the leg on the bed. Do 6-8 times.
4. I.P. - sitting on the edge of the bed. Perform active alternating flexion and extension of the legs at the knee joint. Repeat 8-10 times.
5. I.P. - standing with support on the headboard. Raise the affected leg forward, bend it at the knee joint, then straighten and lower it. Perform 6-8 times.
6. I.P. - standing, hands on waist. Take your healthy leg back and place it on your toes. Bend the affected leg at the knee. Repeat 8-10 times.
7. I.P. - standing, legs apart. Shift your body weight alternately to the right and to the left leg. Then bend the leg at the knee joint. Perform 8-10 times.
8. I.P. - lying on your back, arms along the body. Go to a sitting position without using your hands: quickly, then slowly, then in the “hands on the waist” position, return to the starting position. Repeat 6-8 times.

Third treatment period:
1. I.P. - standing, the sore leg is on the back of the toe (gradually increase the distance). Perform a springing movement, trying to reach the floor with your heel. Repeat 8-10 times.
2. I.P. - standing facing or sideways to the gymnastics wall, leaning your hand on the wall at shoulder level. Place the affected leg on the 3-4th rail, then squat down on the healthy leg as deeply as possible. Perform 6-8 times.
3. I.P. - standing facing the gymnastic wall. Climb the wall on your toes, performing additional spring squats on the toe of the sore leg (in order to increase the range of motion in the ankle joint). Do it 2-3 times.
4. I.P. - the same. Climb the wall, moving your foot over 2-3 slats. Do 5-6 times.
5. I.P. - standing sideways to the gymnastics wall. Place the straight sore leg on the 2-3 rail, hands on the belt. Bend towards your leg, performing springy swings. Do 8-10 times.
6. I. P. - standing on the 2-3 rail of the gymnastic wall. Hands rest on the wall at chest level. Then perform the following steps (sequentially):
a) squat down until your arms are fully extended
b) straighten your legs at the knee joints, without bending your arms
c) pull yourself up with your arms. Repeat all movements 16-20 times.
7. I.P. - hanging with his back to the gymnastics wall. Perform the following movements:
a) alternately and simultaneously raise your legs bent at the knees
b) alternately raise straight legs
c) simultaneously raise straight legs. Repeat each movement 6-8 times.
8. Walking with changing step length.
9. Walk, while pushing the medicine ball in front of you with the dorsum of the foot of the affected leg. Perform 80-100 movements.
10. Walking on the rail of a gymnastic bench.

Regular performance of exercises included in the exercise therapy complex (physical therapy) for a pelvic fracture contributes to a beneficial effect not only on the area of ​​damage, but also on the entire body as a whole, as well as rapid rehabilitation after a fracture.

Absolutely necessary for bone fractures. Mechanical influences - pressure, stretching and friction - have a significant impact on the development of callus. The mutual pressure of bone fragments when they are in close contact accelerates the formation of callus. Uneven pressure can lead to the development of secondary deformation. Constant friction and mutual displacement of loosely adjacent fragments contributes to the appearance of cartilaginous callus. The lack of mutual pressure, the presence of diastasis between the fragments and their mobility in relation to each other lead to the formation of a cicatricial adhesive.

Why do you need exercise therapy for bone fractures?

Traction, used for the purpose of repositioning a fracture and eliminating the resulting deformity (corrective traction), is characterized by the use of traction of significant intensity; it impairs the blood supply to the fracture area and stimulates the formation of connective tissue adhesions between the fragments - you cannot do without exercise therapy.

Traction used to hold reduced fragments in the correct position or to eliminate mutual pressure articular surfaces and the creation of diastasis between them after on the joints and in case of their damage, allows it to be combined (with appropriate clinical data) with a dosed axial load. It also provides the possibility of movement in all joints and tension of all muscles of the damaged segment of the musculoskeletal system and has a less adverse effect on blood circulation in the damaged limb. To improve blood circulation, exercise therapy after bone fractures is the best remedy.

The objectives of the therapeutic use of exercise therapy for injuries of bones and joints after surgical interventions on them are:

• stimulation of regeneration processes;
• reducing the degree of manifestation of secondary changes in the musculoskeletal system;
• promoting rapid elimination pathological changes and dysfunction of damaged segments of the musculoskeletal system;
• assistance in the rapid elimination of common manifestations of traumatic disease;
• restoration of the patient’s general adaptability to industrial and household stress.

The purpose of exercise therapy for bone fractures is to maintain adequate blood supply and tone of the muscles surrounding the fracture site, promoting regeneration. Severe muscle atrophy or crushing of the muscle sheath sharply slows down regeneration and is often the cause of pseudarthrosis.

Exercise therapy complex after fractures

Gymnastic, applied and everyday movements are mainly used. Therapeutic and hygienic gymnastics, tasks (including both gymnastic and applied movements), games are carried out, and in sanatorium-resort institutions, in addition, sports entertainment, training and even competitions.

Intra-articular fractures and surgical interventions on joints. The leading task in the first period is to maintain their mobility. Mostly movements performed under the influence of gravity are used, and passive movements are used very carefully. Exercises begin as soon as it is possible according to clinical data (in the absence of large, with good standing or fixation of fragments, or when movement can help improve this standing).

For joint resections or fractures in which the best outcome is ankylosis of the joint, the technique used for diaphyseal fractures is fully applied.

In the second period, the leading one is the restoration of mobility in the joint. Gymnastic exercise therapy movements are used after bone fractures with increasing load, and a limited number of passive movements. The damaged bone is included in the movements of household self-care.

The main requirements for the method of exercise therapy after bone fractures are to ensure a careful increasing mutual pressure of the articular ends while maintaining the maximum range of motion, to ensure a slow recovery of the muscles that produce movement in the joint.

In the third period, the exercise therapy complex after bone fractures should provide stimulation of tissue adaptation (callus, articular cartilage, menisci) to load requirements, restoration of muscle strength, and restoration of motor skills performed using the damaged joint.

Why is recovery delayed without exercise therapy?

Regenerative processes during surgical interventions on bones after fractures can differ significantly from regeneration processes during fractures, but both types slow down significantly without exercise and there is a physiological explanation for this. When a metal nail is inserted into the medullary canal, delayed development of myelogenous and endosteal callus is observed. At open method When inserting a nail, the periosteum is additionally injured: the resulting hyperplastic, coarse, spongy-type periosteal callus is not strong enough. The process of final functional reconstruction of the callus is delayed, since the presence of a nail changes the nature of the load in the fracture zone. In more late dates Resorption of the bone around the nail may occur: it ceases to fix from breaking and may even contribute to the softening of the callus. Exercise therapy after bone fractures can prevent resorption.

A bone graft introduced into the medullary canal has a similar effect to a metal graft, but fixes the fracture much less firmly. The bone used for osteosynthesis is easily resorbed. When the graft is located near the wall, it is implanted (in case of autotransplantation), providing fixation of the ends of the fracture for some time, and subsequently undergoes functional transformation or is absorbed.
When resection of individual sections of bone along with the periosteum, the bone defect is difficult to replace on its own. If the resection is performed subperiosteally, then a callus replacing it is easily formed at the site of the removed bone.

In intra-articular fractures, the formation of callus is possible only due to myelogenous and endosteal callus. Availability synovial fluid delays the formation of a blood clot between fragments. Since the blood supply is provided only through the proximal fragment, capillary ingrowth into blood clot It only goes on one side. Poor blood supply to the callus leads to the fact that it easily acquires a pronounced fibrous character. An already formed callus is not very resistant to axial load. Excessively early and inadequate load for the course of regeneration processes can contribute to the transformation of a callus into a scar. The formation of a callus is impossible when the distal fragment is rotated with its cartilaginous surface towards the fracture plane. All these factors can be corrected with the help of exercise therapy.

Damaged articular cartilage, representing avascular tissue, does not regenerate, but is replaced by fibrous cartilage. Gradually, under the influence of function, it becomes hyalinized, without, however, acquiring all the mechanical properties of hyaline cartilage. With a partial defect of the cartilage, the unhindered sliding of the articular surfaces in relation to each other is disrupted. Subsequently, without exercise therapy, degenerative changes arthrosis develops in the cartilage.

In cases where one of the articular surfaces is skeletonized, the articular cartilage on the undamaged surface undergoes fiber disintegration during movements and partially dies. On damaged menisci, marginal scars form at the site of tears. When the menisci are removed, they are first replaced by protrusion of the synovial membrane. Under the influence of movements and axial load during exercise therapy after fractures, the synovial membrane is transformed into a connective tissue meniscus. Functionally, it is quite complete.

With arthroplasty, tissue transformation occurs and a multi-chamber joint is formed, equipped with an articular capsule, synovial membrane, and articular cartilage of a fibrous structure.

In accordance with the nature of the fractures and the stages of treatment, the entire course of therapeutic physical education for bone fractures is divided into three periods: immobilization, restoration of function and training of function.

I period – immobilization (general tonic). It clinically coincides with the formation of primary callus. Rehabilitation means are: segmental massage, massage of healthy tissues, massage of an uninjured limb; electrophoresis, electrical stimulation; Exercise therapy. Therapeutic exercise is prescribed immediately after the plaster cast has completely dried or pain has been reduced after applying a traction. The early timing of the appointment of exercise therapy is explained by the need to eliminate the manifestations of a traumatic disease, prevent the occurrence of physical inactivity, and facilitate the body’s adaptation to immobilization.

General tasks of exercise therapy during immobilization: improvement of the course of basic nervous processes; normalization of the patient’s emotional tone; improving the functioning of internal organs; activation of general metabolic processes.

Special tasks of the 1st period: a) improvement of trophism of the immobilized limb and prevention muscle atrophy; b) prevention of dysfunction of the joints of the immobilized limb, the formation of stiffness and contractures, development of the necessary temporary compensations.

General treatment problems are solved with the help of general developmental exercises. They are performed from all possible starting positions during immobilization and should cover all muscle groups. Exercise therapy classes include breathing exercises (static and dynamic), attention, coordination of movements, stretching and relaxation of muscles, and corrective exercises. The pace of exercise is slow.

To solve special problems of the first period, the following exercises are included:

1. Exercises for a symmetrical limb (help improve blood supply and trophism in an immobilized limb).

2. Exercises in joints of the affected limb that are free from immobilization (performed first with help and then independently).

3. Ideomotor exercises for the immobilized limb (focus on performing movements in the affected part).

4. Exercises in static tension of the muscles of the immobilized limb (promote the convergence of bone fragments, stimulate regeneration processes at the fracture site, improve blood supply and trophism).

5. Exercises that promote the formation of compensation: strengthening a healthy leg and arms to prepare for walking with a lower limb injury; improving the quality of movement of a healthy arm in case of injury to the upper extremities, etc.

6. Exercises to apply pressure along the axis of the limb (for fractures of the femur and tibia): on a box, a special stand or headboard.

7. Exercises in lowering an immobilized limb below bed level.

II period – period of restoration of function. Clinically, during this period, the final formation of callus occurs and the function of the affected limb can normalize. It is characterized by: atrophy of the immobilized limb; limited movement in joints; insufficient strength of the callus.

General treatment tasks are the same as in the first period. The range and dosage of general educational exercises is significantly expanded, and outdoor games are added. The pace of exercise is average.

The special tasks of the II period include: a) final formation of callus; b) elimination of muscle atrophy; c) restoration of movements in the joints of the affected limb; d) restoration and normalization of the function of the affected limb; e) elimination of unnecessary temporary compensation; f) restoration of posture, normalization of motor skills, improvement of their quality.

Special exercises of the II period:

1. Active gymnastic exercises for the affected limb from facilitating initial positions (such initial positions ensure movement in the joints of the affected limb with minimal muscle tension).

2. Exercises in lighter conditions, where body weight becomes lighter and muscle tension is relieved (exercises in warm water).

3. Exercises using a healthy limb, exercises in swing movements to increase the range of motion in the joints while relaxing the muscles.

4. Resistance exercises (to restore muscle strength).

5. Walking exercises (for fractures of the lower extremities).

6. Passive exercises (prescribed when the fragments are well consolidated). The limb should be completely relaxed.

III period – period of function training. During this period, possible residual effects are eliminated. Rehabilitation means: segmental reflex massage; training on simulators; ice massage (cryomassage); special exercises; sauna (bath); electrical stimulation.

Special tasks of the III period are: a) complete rehabilitation of the patient’s body; b) restoration of motor skills; c) achieving perfection of the function of the injured limb; d) formation of the most profitable permanent compensation (if the usefulness of the function cannot be ensured).

Means of exercise therapy of the third period:

1. General developmental exercises, the overall physical load in classes increases, expanding the capabilities of the body.

2. Applied exercises that include the affected limb in work: various walking options for fractures of the lower extremities, grips for lesions of the hand, etc.

3. Exercises to develop and consolidate the skills of correct posture.

4. Gymnastic exercises for coordination, balance, attention, exercises with objects and simple apparatus.

5. Outdoor games appropriate to the age and capabilities of the patient.

Ministry of Education of the Russian Federation

Department of “physical culture”

On the topic “Therapeutic physical education for fractures of the lower extremities”

Supervisor:

Khabarovsk 2004

1. Introduction………………………………………….………………..3

2. History of the development of exercise therapy………………………………………..….4

3. General basics of physical therapy…………………….……7

3.1. Classification of physical exercises…………………8

4. Forms and methods of physical therapy……………….……...13

5. Therapeutic exercise for injuries and some diseases of the movement apparatus……………………………….16

6. Exercise therapy for fractures of the lower extremities…………………..…19

6.1. Approximate complexes of therapeutic exercises……………...22

6.1.1. Exercises for ankle joint and foot joints…………………………………………...22

6.1.2. Exercises for the knee joint……………………23

6.1.3. Exercise for all joints of the lower extremities...24

6.1.4. Some exercises in plaster immobilizing bandages; exercises preparing for walking…………………………….24

6.2. Mechanotherapy………………………………………………………...…25

7. References……………………………………………………………...…..30

1. Introduction.

Physiotherapy - an independent scientific discipline. In medicine, this is a treatment method that uses physical education for prevention, treatment, rehabilitation and supportive care. Exercise therapy forms a person’s conscious attitude towards exercise physical exercise and in this sense, it has educational value; develops strength, endurance, coordination of movements, instills hygiene skills, hardening the body with natural factors. Exercise therapy is based on modern scientific data in the field of medicine, biology, and physical education.

Main means of physical therapy are physical exercises used in accordance with the objectives of treatment, taking into account the etiology, pathogenesis, clinical features, functional state organism, degree of general physical performance.

Physiotherapy:

1. a natural biological method, as it uses the body’s inherent function of movement;

2. method nonspecific therapy, but at the same time, certain types of exercise can affect certain body functions;

3. method pathogenetic therapy, due to the ability of physical exercise to influence the reactivity of the body;

4. a method of active functional therapy, as it adapts the patient’s body to increasing physical activity;

5. method of maintenance therapy at stages medical rehabilitation in elderly people;

6. method of restorative therapy in complex treatment of patients.

7. A characteristic feature of exercise therapy is the process of training patients with physical exercises.

There are general and special training:

1. general training is aimed at improving health and strengthening the patient’s body with the help of general strengthening exercises;

2. special training is carried out with exercises that specifically target the affected organ, the area of ​​injury.

Massage - a method of treatment, prevention, rehabilitation after illnesses and recovery, which is a set of techniques of mechanical, dosed influence on various areas surface of the human body, produced by the hands of a massage therapist or special devices. To achieve a positive result when using massage, it is necessary to differentiate its technique depending on the etiology, pathogenesis, clinical features, functional state of the central and nervous system(CNS), nature of influence various techniques on the body.

Exercise therapy and massage are widely used in combination with other methods for diseases and injuries, and can also be independent methods of treating many chronic diseases and consequences of injuries: for paralysis, paresis, curvature of the spine, emphysema, consequences of bone fractures, etc.

Exercise therapy is used in the pre- and postpartum periods. Massage etc. physical exercise promotes better performance psychophysical development healthy children and are used in nurseries, kindergartens, and at home.

2. History of the development of exercise therapy.

Physical exercises for the purpose of treatment and prevention were used in ancient times, 2 thousand years BC in China and India. In Ancient Rome and Ancient Greece, physical exercise and massage were integral in everyday life, military affairs, and treatment. Hippocrates (460-370 BC) described the use of physical exercises and massage for diseases of the heart, lungs, metabolic disorders, etc. Ibn Sina (Avicenna, 980-1037) highlighted in his works the method of using physical exercises for sick and healthy, dividing loads into small and large, strong and weak, fast and slow. During the Renaissance (XIV-XVI centuries), physical exercise was promoted as a means to achieve harmonious development.

In Russia, outstanding clinicians such as M. Ya. Mudrov (1776-1831), N. I. Pirogov (1810-1881), S. P. Botkin (1831-1889), G. A. Zakharyin (1829-1897 ), A. A. Ostroumov. (1844-1908), attached great importance to the use of physical exercises in treatment practice.

The works of P. F. Lesgaft (1837-1909), V. V. Gorinevsky (1857-1937) contributed to the understanding of the unity of mental and physical education for more perfect human development.

The discoveries of great physiologists - I. M. Sechenov (1829-1922), Nobel Prize laureate I. P. Pavlov (1849-1936), N. E. Vvedensky (1852-1922), who substantiated the importance of the central nervous system for the life of the body - influenced development of a new approach to a comprehensive assessment of a sick person. Treatment of diseases gives way to treatment of the patient. In this regard, the ideas of functional therapy and exercise therapy are beginning to spread more widely in the clinic, being such a method, it has found recognition and wide application.

For the first time in the period 1923-1924. Exercise therapy. was introduced in sanatoriums and resorts. In 1926, I. M. Sarkizov-Serazini (1887-1964) headed the first department of exercise therapy at the Moscow Institute of Physical Culture, where the future first doctors and candidates of science (V. N. Moshkov, V. K. Dobrovolsky, D. A. Vinokurov, K. N. Pribylov, etc.).

Textbooks on physical therapy by I. M. Sarkizov-Serazini went through a number of editions. The first People's Commissar of Health N.A. Semashko (1874-1949) attached great importance to physical therapy. On his initiative, in the early 1930s, departments were opened in a number of research institutes, departments of physical therapy were created in institutes for advanced training of doctors and some medical universities. A major role in the organization of medical and physical education services belongs to B.A. Ivanovsky (1890-1941), since 1931, head of the department of medical supervision and physical therapy at the Central Institute for Advanced Medical Training.

In the 30s and 40s, monographs, manuals, and manuals on physical therapy were published (V.V. Gorinevskaya, E.F. Dreving, M.A. Minkevich, etc.).

During the Great Patriotic War physical therapy was widely used in hospitals.

In the 50s, medical and physical training clinics were created to provide medical support to those involved in physical education and sports, organizational and methodological guidance on physical therapy. Departments of physical therapy and medical supervision are organized in all medical universities, and classes in physical therapy and massage are held in medical schools.

In 1941, the department of therapeutic exercise and medical supervision at the Central Institute of Advanced Medical Training and the department of therapeutic exercise at the Institute of Physiotherapy - later at the Central Institute of Balneology and Physiotherapy of the USSR Ministry of Health - was headed by Corresponding Member of the USSR Academy of Medical Sciences V. N. Moshkov. The fruitful pedagogical and scientific activities of V.N. Moshkov have found wide recognition in the country and abroad; he is the founder of the modern school of physical therapy; he has written monographs on all main areas of physical therapy, prepared big number doctors and candidates of science who headed departments, departments in universities and research institutes of the country.

In the 60-90s, the number of highly qualified specialists who defended doctoral and candidate dissertations increased significantly (E. F. Andreev, N. M. Badridze, I. B. Geroeva, N. A. Gukasova, S. A. Gusarova, V. A. Egairanov, O. F. Kuznetsov, B. A. Polyaev, S. D. Polyakov, N. N. Prokopyev, V. A. Siluyanova, Z. V. Sokova, O. V. Tokareva, N. V. Fokeeva, S. V. Khrushchev, A. V. Chogovadze and many others).

Currently, Moscow is successfully training specialists and scientific work departments at the Russian State medical university(head of department B. A. Polyaev), Moscow State Medical and Dental University (head of department V. A. Epifanov), Russian Medical Academy postgraduate education(Head of the department K. P. Levchenko) and other medical higher education institutions educational institutions Russia.

In a number of European countries, the term kinesitherapy has been adopted, rather than physical therapy. In connection with international conferences, scientific contacts with foreign specialists, and joint research, the Association of Kinesitherapy and Sports Medicine Specialists (president S.V. Khrushchev) is successfully functioning in Russia. The Association annually holds international conferences on current problems specialties.

3. General principles of physical therapy.

Exercise therapy classes provide healing effect only with proper, regular, long-term use of physical exercise. For these purposes, a methodology for conducting classes, indications and contraindications for their use, accounting for effectiveness, hygienic requirements to places of study.

There are general and specific methods of exercise therapy. General technique Exercise therapy provides rules for conducting classes (procedures), classification of physical exercises, dosage of physical activity, a scheme for conducting classes at different periods of the course of treatment, rules for constructing a separate lesson (procedure), forms of application of exercise therapy, and diagrams of movement modes. Private exercise therapy techniques are intended for a specific nosological form of the disease, injury and are individualized taking into account the etiology, pathogenesis, clinical characteristics, age, physical fitness sick. Special exercises to influence the affected systems and organs must be combined with general strengthening exercises, which provides general and special training .

Physical exercise should not increase pain, since pain reflexively causes vasospasm and stiffness of movement. Exercises, causing pain, should be carried out after preliminary relaxation of the muscles, at the moment of exhalation, in optimal starting positions. From the first days of classes, the patient should be taught proper breathing and the ability to relax muscles. Relaxation is more easily achieved after vigorous muscle tension. With unilateral lesions of the limbs, relaxation training begins with a healthy limb. Musical accompaniment of classes increases their effectiveness.

3.1. Classification of physical exercises

Physical exercises in exercise therapy are divided into three groups: gymnastics, applied sports and games.

Gymnastic exercises.

Consist of combined movements. With their help you can influence various systems the body and into individual muscle groups, joints, developing and restoring muscle strength, speed, coordination, etc. All exercises are divided into general developmental (general strengthening), special and breathing (static and dynamic).

1. General strengthening exercises

Used to heal and strengthen the body, increase physical performance and psycho-emotional tone, activate blood circulation and breathing. These exercises facilitate the therapeutic effect of special ones.

2. Special exercises

Selectively act on musculoskeletal system. For example, on the spine - with its curvature, on the foot - with flat feet and injury. For a healthy person, exercises for the torso are general strengthening; for osteochondrosis and scoliosis, they are classified as special, since their action is aimed at solving treatment problems - increasing the mobility of the spine, correcting the spine, strengthening the muscles surrounding it. Leg exercises are general strengthening for healthy people, and after surgery on the lower extremities, trauma, paresis, joint diseases, these same exercises are classified as special. The same exercises, depending on the method of their application, can solve different problems. For example, extension and flexion in the knee or other joint in some cases is aimed at developing mobility, in others - to strengthen the muscles surrounding the joint (exercises with weights, resistance), in order to develop muscle-joint sense (accurate reproduction of movement without visual control) . Typically, special exercises are used in combination with general developmental exercises.

Gymnastic exercises are divided into groups:

· according to anatomical characteristics;

· by the nature of the exercise;

· by species;

based on activity;

· based on the objects and projectiles used.

Based on anatomical characteristics, the following exercises are distinguished:

· for small muscle groups (hands, feet, face);

· for medium muscle groups (neck, forearms, shoulder, lower leg, thigh);

· for large muscle groups (upper and lower limbs, torso),

· combined.

Based on the nature of muscle contraction, exercises are divided into two groups:

· dynamic (isotonic);

· static (isometric).

A muscle contraction in which it develops tension but does not change its length is called isometric (static). For example, when actively lifting a leg up from the starting position while lying on his back, the patient performs dynamic work (lifting); when holding the leg raised up for some time, the muscles work in an isometric mode (static work). Isometric exercises are effective for injuries during immobilization.

Dynamic exercises are most often used. In this case, periods of contraction alternate with periods of relaxation.

Other groups of exercises are also distinguished by their nature. For example, stretching exercises are used to treat joint stiffness.

Based on type, exercises are divided into exercises:

· in throwing,

· for coordination,

· for balance,

· in resistance,

· hangs and supports,

· climbing,

· corrective,

· respiratory,

· preparatory

· ordinal.

Balance exercises are used to improve coordination of movements, improve posture, as well as to restore this function in diseases of the central nervous system and vestibular apparatus. Corrective exercises are aimed at recovery correct position spine, chest and lower extremities. Coordination exercises restore overall coordination of movements or individual body segments. They are used from different IPs with various combinations movements of arms and legs in different planes. Necessary for diseases and injuries of the central nervous system and after prolonged bed rest.

Based on activity, dynamic exercises are divided into the following:

· active,

· passive,

· for relaxation.

To facilitate the work of the flexor and extensor muscles of the arms and legs, exercises are performed in the IP lying on the side opposite to the limb being exercised. To facilitate the work of the foot muscles, exercises are performed in the IP on the side on the side of the limb being exercised. To facilitate the work of the adductor and abductor muscles of the arms and legs, exercises are performed in the IP on the back and abdomen.

To complicate the work of the flexor and extensor muscles of the arms and legs, exercises are performed in the IP lying on the back or stomach. To complicate the work of the adductor and abductor muscles of the arms and legs, exercises are performed in the IP lying on the side opposite to the limb being exercised.

To perform exercises with effort, resistance is applied by the instructor or a healthy limb.

Mentally imaginary (phantom), ideomotor exercises or exercises “sending impulses to contraction” are performed mentally and are used for injuries during immobilization, peripheral paralysis, and paresis.

Reflex exercises involve influencing muscles distant from those being trained. For example, to strengthen the muscles of the pelvic girdle and hips, exercises that strengthen the muscles of the shoulder girdle are used.

Passive exercises are those performed with the help of an instructor, without the patient’s volitional effort, in the absence of active muscle contraction. Passive exercises are used when the patient cannot perform active movement, to prevent stiffness in the joints, to recreate the correct motor act (for paresis or paralysis of the limbs).

Relaxation exercises reduce muscle tone and create conditions for relaxation. Patients are taught “volitional” muscle relaxation using swinging movements and shaking. Relaxation is alternated with dynamic and statistical exercises.

Depending on the gymnastic apparatus and equipment used, exercises are divided into the following:

· exercises without objects and equipment;

· exercises with objects and equipment (gymnastic sticks, dumbbells, clubs, medicine balls, jump ropes, expanders, etc.);

· exercises on apparatus, simulators, mechanical devices.

Sports and applied exercises.

Applied sports exercises include walking, running, crawling and climbing, throwing and catching a ball, rowing, skiing, skating, cycling, health path (metered climbing), hiking. Walking is the most widely used - for a wide variety of diseases and almost all types and forms of exercise. The amount of physical activity when walking depends on the length of the path, the size of the steps, the pace of walking, the terrain and difficulty. Walking is used before starting classes as a preparatory and organizing exercise. Walking can be complicated - on toes, on heels, walking in a cross step, in a half-squat, with high knees. Special walking - on crutches, with a stick, on prostheses - is used when the lower extremities are affected. Walking speed is divided into: slow - 60-80 steps per minute, medium - 80-100 steps per minute, fast - 100-120 steps per minute and very fast - 120-140 steps per minute.

Games.

Games are divided into four groups of increasing load:

· on site;

· sedentary;

· movable;

· sports.

4. Forms and methods of physical therapy.

A system of certain physical exercises is a form of exercise therapy; These are therapeutic exercises, morning hygienic exercises, independent exercises for patients on the recommendation of a doctor or instructor; dosed walking, health path, physical exercises in water and swimming, skiing, rowing, training on exercise machines, mechanical equipment, games (volleyball, badminton, tennis), small towns. In addition to physical exercise, exercise therapy includes massage, air and water hardening, occupational therapy, and physical therapy (horseback riding).

Hygienic gymnastics intended for sick and healthy. Carrying it out in the morning after a night's sleep is called morning hygienic gymnastics; it helps relieve inhibition processes and promote vigor.

Physiotherapy - the most common form of using physical exercises for treatment and rehabilitation purposes. The ability, through a variety of exercises, to purposefully influence the restoration of damaged organs and systems determines the role of this form in the exercise therapy system. Classes (procedures) are carried out individually for seriously ill patients, in small group (3-5 people) and group (8-15 people) methods. Patients are grouped into groups according to nosology, i.e. with the same disease; according to the location of the injury. It is wrong to group patients with different diseases into one group.

Each lesson is built according to a specific plan and consists of three sections: preparatory (introductory), main and final. The introductory section provides preparation for performing special exercises and gradually includes them in the load. The duration of the section takes 10-20% of the time of the entire lesson.

In the main section, classes solve problems of treatment and rehabilitation and use special exercises in alternation with general strengthening exercises. Duration of the section: - 60-80% of the total class time.

In the final section, the load is gradually reduced.

Physical activity is monitored and regulated by observing the body's responses. Pulse monitoring is simple and accessible. A graphical representation of the change in its frequency during an exercise is called a physiological load curve. The greatest increase in heart rate and maximum load is usually achieved in the middle of the session - this is a single-peak curve. For a number of diseases it is necessary after increased load apply a decrease in it, and then increase it again; in these cases the curve may have several vertices. You should also count your pulse 3-5 minutes after exercise.

The density of classes is very important, i.e. time of actual execution of exercises, expressed as a percentage of the total time of the lesson. In inpatients, the density gradually increases from 20-25 to 50%. At spa treatment in the training mode in general physical training groups, the density of classes is 80-90%. Individual independent exercises complement the therapeutic exercises conducted by the instructor, and can subsequently be carried out only independently with periodic visits to the instructor to receive instructions.

Gymnastic method , carried out in therapeutic exercises, has become most widespread. The game method complements it when working with children.

Sports method used to a limited extent and mainly in sanatorium and resort practice.

When using exercise therapy, you should follow the principles of training, taking into account the therapeutic and educational objectives of the method.

· Individualization in methodology and dosage, taking into account the characteristics of the disease and the general condition of the patient.

· Systematic and consistent use of physical exercises. They start with simple ones and move on to complex exercises, including 2 simple and 1 complex new exercise in each lesson.

· Regularity of exposure.

· Duration of classes ensures the effectiveness of treatment.

· Gradual increase in physical activity during the treatment process to ensure a training effect.

· Diversity and novelty in the selection of exercises - are achieved by updating them by 10-15% with repeating 85-90% of the previous ones to consolidate the results of treatment.

· Moderate, prolonged or fractional loads are more appropriate to use than increased loads.

· Maintain a cyclic pattern of alternating exercises with rest.

· The principle of comprehensiveness - provides for an impact not only on the affected organ or system, but also on the entire body.

· Visualization and accessibility of exercises - especially necessary in exercises with lesions of the central nervous system, with children and the elderly.

· Conscious and active participation of the patient is achieved by skillful explanation and selection of exercises.

5. Therapeutic exercise for injuries and some diseases of the movement apparatus.

Injuries to the musculoskeletal system cause disturbances in the anatomical integrity of tissues and their functions, accompanied by both local and general reactions from various body systems.

When treating fractures, fragments are repositioned to restore the length and shape of the limbs and fixed until bone fusion occurs. Immobility in the damaged area is achieved by fixation, traction, or surgery.

More often than others, in 70-75% of patients with fractures, the fixation method is used by applying fixing bandages made of plaster and polymer materials.

When using traction (extension method), the limb is stretched using weights to compare fragments for from several hours to several days (the first repositioning phase). Then, in the second retention phase, the fragments are held until they are completely consolidated and relapses of their displacement are prevented.

At operative method comparison of fragments is achieved by fastening them with screws or metal clamps, bone grafts (open and closed comparison of fragments is used).

Physiotherapy - required component complex treatment, as it helps restore the functions of the musculoskeletal system, has a beneficial effect on various body systems based on the principle of motor-visceral reflexes.

It is customary to divide the entire course of exercise therapy into three periods: immobilization, post-immobilization and recovery.

Exercise therapy begins on the first day of injury when severe pain disappears.

Contraindications to prescribe exercise therapy: shock, large blood loss, danger of bleeding or its appearance during movements, persistent pain.

Throughout the entire course of treatment, general and special problems are solved when using exercise therapy.

I period (immobilization).

In the first period, fusion of fragments occurs (formation of primary bone callus) after 60-90 days. Special objectives of exercise therapy: improve trophism in the area of ​​injury, accelerate fracture consolidation, help prevent muscle atrophy, joint stiffness, and develop the necessary temporary compensation.

To solve these problems, exercises are used for a symmetrical limb, for joints free from immobilization, ideomotor exercises and static muscle tension (isometric), exercises for an immobilized limb. All intact segments and non-immobilized joints on the injured limb are included in the movement process. Static muscle tension in the area of ​​injury and movement in immobilized joints (under a plaster cast) is used when the fragments are in good condition and are completely fixed. The risk of displacement is less when connecting fragments with metal structures, bone pins, or plates; when treating fractures with the help of Ilizarov, Volkov-Oganesyan and others, it is possible to more early dates include active muscle contractions and movements in adjacent joints.

The solution of general problems is facilitated by general developmental exercises, breathing exercises of a static and dynamic nature, exercises for coordination, balance, with resistance and weights. Lightweight IP and exercises on sliding planes are used first. Exercise should not cause or increase pain. For open fractures, exercises are selected taking into account the degree of wound healing.

Massage for diaphyseal fractures in patients with a plaster cast is prescribed from the 2nd week. They start with a healthy limb, and then act on segments of the damaged limb, free from immobilization, starting the effect above the site of injury. In patients on skeletal traction, massage of a healthy limb and extrafocal massage on the damaged one begin on the 2-3rd day. All massage techniques are used, especially those that help relax the muscles on the affected side.

Contraindications : purulent processes, thrombophlebitis.

II period (post-immobilization).

The second period begins after removal of the plaster cast or traction. The patients developed the usual callus, but in most cases the muscle strength was reduced and the range of motion in the joints was limited. During this period, exercise therapy is aimed at further normalizing trophism in the area of ​​injury for the final formation of callus, eliminating muscle atrophy and achieving a normal range of motion in the joints, eliminating temporary compensation, and restoring posture.

When applying physical exercises, it should be taken into account that the primary callus is not yet strong enough. During this period, the dosage of general strengthening exercises is increased, a variety of IPs are used; prepare for standing up (for those who were on bed rest), train vestibular apparatus, teach movement on: crutches, train the sports function of a healthy leg (in case of a leg injury), restore normal posture.

For the affected limb, active gymnastic exercises are used in light, IP, which alternate with relaxation exercises for muscles with increased tone. To restore muscle strength, exercises with resistance, objects, or against a gymnastic wall are used.

Massage is prescribed for muscle weakness, hypertonicity and is carried out using a suction technique, starting above the site of injury. Massage techniques are alternated with elementary gymnastic exercises.

III period (recovery).

IN III period Exercise therapy is aimed at restoring the full range of motion in the joints and further strengthening the muscles. General developmental gymnastic exercises are used with greater load, supplemented with walking, swimming, physical exercise in water, and mechanotherapy.

6. Exercise therapy for fractures of the lower extremities.

For fractures of the femoral neck, therapeutic exercises begin on the 1st day, using breathing exercises. On the 2-3rd day include exercises for abdominals. In the first period, when treating with traction, special exercises should be used for the joints of the lower leg, foot, and fingers. The procedure begins with exercises for all segments of the healthy limb. In patients with a plaster cast, static muscle exercises are used on the 8-10th day hip joint. In the second period, it is necessary to prepare for walking and, when the fragments heal, to restore walking. Exercises are prescribed to restore muscle strength. First, with the help, and then actively, the patient performs abduction and adduction, raising and lowering the leg. They teach walking with crutches and then without them. In the third period, the restoration of muscle strength and full joint mobility continues.

At surgical treatment- osteosynthesis - the length of time the patient remains on bed rest is significantly reduced. 2-4 weeks after surgery, you are allowed to walk with the help of crutches. To walk the patient in bed, exercises are used for the hip joint, asking him to sit down with the help of various devices (straps, “reins”, fixed bars above the bed).

For fractures of the diaphysis and distal femur in the first period, special exercises are used for joints free from immobilization. For the damaged segment, ideomotor and isometric exercises are used. For fractures of the femur and tibia in the first period, pressure can be applied along the axis of the limb, lowering the immobilized leg below the level of the bed; at the end of the period, walking in a plaster cast with crutches is allowed, but the degree of support is strictly measured. In the second period, the volume of exercises is expanded, taking into account the strength of the callus and the state of reposition. In the third period, with good fusion, walking is trained, gradually increasing the load.

In case of periarticular and intra-articular fractures of the distal femur, it is necessary to strive for an earlier restoration of movements in the knee joint. With correct reposition and impending fusion, first use isometric exercises, then active ones - flexion and extension of the leg, raising the leg (with a short-term switch off of the load traction (with skeletal traction). The load is increased very gradually, slowly. During exercises for the knee joint, the area of ​​​​the femur fracture fixed with hands and cuffs.

After osteosynthesis, the method of physical therapy is similar to that used with a plaster cast, but all loads begin earlier than with conservative treatment. During treatment with Ilizarov and other apparatuses, in the first days, isometric exercises are used in the area of ​​the operated segment and exercises for all non-immobilized joints.

At open injuries knee joint and after operations on the joint, therapeutic exercises are used from the 8-10th day, exercises for the joint from the 3rd week after surgery. At closed injuries Therapeutic gymnastics is included from the 2-6th day. In the first period of immobilization, isometric exercises are used in the area of ​​injury, as well as exercises for uninjured joints and the healthy leg. In patients without immobilization, exercises with a small amplitude are used for the knee joint using the healthy leg in the IP lying on its side. For the ankle and hip joints, use active exercises, supporting the thigh with your hands. In the second period, mainly active exercises are used with caution in the area of ​​the knee joint with axial load to restore walking. In the third period, supporting function and walking are restored.

For fractures of the shin bones, when treated with traction in the first period, exercises for the toes are used. Exercises for the knee joint should be included very carefully. This can be done by moving the hip as you raise and lower your pelvis. In patients after osteosynthesis, walking with crutches is allowed early, stepping on the affected leg and the load on it is gradually increased (axial load). In the second period, exercises are continued for full support and restoration of the range of motion in the ankle joint. Exercises are used to eliminate foot deformities. Period III exercises are aimed at restoring the normal range of motion in the joints, strengthening muscle strength, eliminating contractures, and preventing flattening of the arches of the feet. In case of fractures of the tibial condyles, very carefully, only after 6 weeks do they allow the weight of the body to be loaded on the knee joint. With osteosynthesis, exercises for the knee and ankle joint are prescribed in the 1st week, and axial loads are prescribed after 3-4 weeks.

For fractures in the ankle area, with any immobilization, exercises are used for the muscles of the lower leg and foot in order to prevent contractures and flat feet.

For fractures of the bones of the foot in the first period, ideomotor and isometric exercises are used for the muscles of the lower leg and foot; in IP lying with a raised leg, movements are used in the ankle joint, active movements in the knee and hip joints, in the absence of contraindications, exercises with pressure on the plantar surface. Supporting the foot when walking with crutches is allowed if correct positioning feet. In the second period, exercises are used to strengthen the muscles of the arch of the foot. In the third period, correct walking is restored.

For all injuries, water exercises, massage, and physiobalneotherapy are widely used.

6.1 Approximate complexes of therapeutic exercises.

6.1.1. Exercises for the ankle and foot joints.

IP - lying on your back or sitting with your legs slightly bent at the knee joints. Flexion and extension of the toes (actively passive). Flexion and extension of the foot of the healthy leg and the patient leg alternately and simultaneously. Circular movements in the ankle joints of the healthy leg and the diseased leg alternately and simultaneously. Rotation of the foot inward and outward. Extension of the foot with increasing range of motion using a band with a loop. The pace of exercise is slow, medium or varying (20-30 times).

IP - the same. The toes are placed one on top of the other. Flexion and extension of the foot with resistance provided by one leg while the other moves. Slow pace (15-20 times).

IP - sitting with legs slightly bent at the knee joints. Grasping small objects (balls, pencils, etc.) with your toes.

IP - sitting: a) feet of both legs on a rocking chair. Active flexion and extension for the healthy and passive for the patient. The pace is slow and medium (60-80 times), b) the foot of the sore leg on a rocking chair. Active flexion and extension of the foot. The pace is slow and medium (60-80 times).

IP - standing, holding the bar of the gymnastic wall, or standing with your hands on your belt. Raising on the toes and lowering the entire foot Raising the toes and lowering the entire foot. The pace is slow (20-30 times).

IP - standing on the 2-3rd rail of the gymnastic wall, grip with your hands at chest level. Spring movements on the toes, try to lower the heel as low as possible. The pace is average (40-60 times).

6.1.2. Exercises for the knee joint.

IP - sitting in bed. The leg muscles are relaxed. Grasping the patella with your hand. Passive displacements to the sides, up, down The pace is slow (18-20 times).

IP - lying on your back, the sore leg is bent, supported by your hands on your thigh or resting on a bolster. Flexion and extension of the EG knee joint with the heel lifted off the bed. The pace is slow (12-16 times).

IP - sitting on the edge of the bed, legs down: a) flexion and extension of the sore leg at the knee joint with the help of the healthy one. The pace is slow (10-20 times); b) active alternating flexion and extension of the legs at the knee joints. The pace is average (24-30 times).

IP - lying on your stomach. Bending the affected leg at the knee joint while gradually overcoming the resistance of a load weighing from 1 to 4 kg. The pace is slow (20-30 times).

IP - standing with support on the headboard. Raise the sore leg bent at the knee joint forward, straighten it, and lower it. The pace is slow and medium (8-10 times).

6.1.3. Exercises for all joints of the lower limb.

IP - lying on your back, the patient’s foot resting on a medicine ball. Rolling the ball towards the body and into the IP. The pace is slow (5-6 times).

IP - lying on your back, holding the edges of the bed with your hands. "Bike". The pace is medium to fast (30-40 times).

IP - standing facing the headboard with support from your hands: a) alternately raising your legs forward, bending them at the knee and hip joints. The tempo is slow (8-10 times); b) half squat. The tempo is slow (8-10 times); c) deep squat. The pace is slow (12-16 times).

IP - standing, sore leg one step forward. Bend the affected leg at the knee and tilt the torso forward to a “lunge” position. The pace is slow (10-25 times).

IP - standing facing the gymnastics wall. Wall climbing on toes with additional spring squats on the toe of the sore leg. The pace is slow (2-3 times).

IP - hanging with your back to the gymnastic wall: a) alternate and simultaneous raising of the legs bent at the knee joints; b) alternate and simultaneous raising of straight legs. The pace is slow (6-8 times).

6.1.4. Some exercises in plaster immobilizing bandages; exercises that prepare you for walking.

IP - lying on your back (high plaster hip cast). Tension and relaxation of the quadriceps femoris (“patella play”). The pace is slow (8-20 times).

IP - the same, holding the edges of the bed with his hands. Foot pressure on the instructor's hand, board or box. The pace is slow (8-10 times).

IP - lying on your back (high cast). With the help of an instructor, turn onto your stomach and back. The pace is slow (2-3 times).

IP - the same, arms bent in elbow joints, the healthy leg is bent at the knee joint with support on the foot. Raising the sore leg. The pace is slow (2-5 times).

IP - lying on your back, on the edge of the bed (high plaster hip cast). Leaning on your hands and lowering your sore leg over the edge of the bed, sit down. The pace is slow (5-6 times).

IP - standing (high plaster hip cast), holding the headboard of the bed with one hand or hands on the belt. Bend the torso forward, placing the sore leg back on the toe and bending the healthy one. The pace is slow (3-4 times).

IP - standing on a gymnastic bench or on the 2nd rail of a gymnastic wall on a healthy leg, the patient is freely lowered: a) rocking the affected leg (12-16 movements); b) copying the figure eight with the sore leg (4-6 times).

IP - walking with the help of crutches (without leaning on the sore leg, stepping lightly on the sore leg, loading the sore leg). Options: walking with one crutch and a stick, with one crutch, with one stick.

6.2 Mechanotherapy.

It is advisable to use pendulum-type devices with loads of various weights.

According to the degree of the patient’s volitional participation in the implementation of movements on mechanotherapy devices, they are divided into three groups: passive, passive-active and active.

The main tasks of mechanotherapy:

Increased range of motion in affected joints;

· strengthening weakened hypotrophied muscles and improving their tone;

· improvement of the function of the neuromuscular system of the exercised limb;

· increased blood and lymph circulation, as well as tissue metabolism of the affected limb.

Before starting procedures on mechanotherapeutic devices, the patient must be examined. It is necessary to check the range of motion in the joint using a protractor, determine the degree of muscle wasting of the limb visually and by measuring it with a centimeter, as well as the severity of pain at rest and during movement.

Methodology mechanotherapy is strictly differentiated depending on the characteristics clinical forms defeats. One should strictly take into account the severity of the exudative component of inflammation in the joint, the activity of the rheumatoid process, the stage and duration of the disease, the degree functional failure joints, features of the process.

Indications for the use of mechanotherapy:

· restriction of movements in joints of any degree;

· wasting of the muscles of the limbs;

· contractures.

Contraindications:

presence of ankylosis.

In accordance with the systematization of exercises on mechanotherapeutic devices, passive-active movements with a large element of activity should be used.

The course of mechanotherapy consists of three periods: introductory, main and final.

In the introductory period, exercises on mechanotherapeutic devices are gentle and training; mainly of a training nature; in the final stage, elements of training are added to continue independent exercises at home.

Mechanotherapy is prescribed simultaneously with therapeutic gymnastics procedures. It can be used in the subacute and chronic stages of the disease, with severe, moderate and mild disease. The exudative component of inflammation in the joint, the presence of an accelerated erythrocyte sedimentation rate (ESR), leukocytosis, and low-grade fever are not contraindications for mechanotherapy. With a pronounced exudative component in the joint with hyperemia and an increase in the temperature of the skin above it, with pronounced activity of the rheumatoid process, mechanotherapy procedures are added with great caution, only after 4-6 procedures of therapeutic exercises at a minimum dosage and with its gradual increase. The same conditions should be observed in case of significant limitation of mobility in the joint.

In case of ankylosis of the joints, mechanotherapy for these joints is not advisable, but nearby non-ankylotic joints should be trained on devices as early as possible for preventive purposes.

When using mechanotherapy, you should adhere to the principle of sparing the affected organ and gradually implementing the training.

Before the procedure, the patient must be explained the importance of mechanotherapy. It must be carried out in the presence of medical personnel, which can simultaneously monitor several patients exercising on different devices. The mechanotherapy room should have either an hourglass or a special signal clock.

The mechanotherapy procedure is carried out with the patient sitting near the apparatus (with the exception of procedures for shoulder joint which are carried out with the patient standing and for the hip joint, which are carried out in a lying position).

The patient's position on the chair should be comfortable, with support on his back, all muscles should be relaxed, breathing should be voluntary.

In order to maximize the sparing of the affected joint, exercises begin with the use of a minimum load: at a slow pace that does not cause increased pain, with a small range of motion with inclusion frequent pauses for relax. The duration of the first procedure is no more than 5 minutes, and in the presence of significantly severe pain - no more than 2-3 minutes. In severely ill patients, the first mechanotherapy procedures can be carried out without a load in order to make it easier for the patient to take them. First, the load during the procedure is increased according to its duration, and subsequently - according to the mass of the load on the pendulum.

If movements in the joint are limited due to the exudative component of inflammation and pain, mechanotherapy is used after the therapeutic exercises procedure. Gradually exercise all affected joints.

In the first days, the mechanotherapy procedure is carried out once a day, exercising all affected joints, subsequently - twice and in trained patients - up to three times a day (no more). The load is increased very carefully, both in terms of the number of procedures per day, and the duration of the procedure and the weight of the load used. The degree of hypotrophy of the muscles being exercised, the severity of the pain syndrome, the tolerability of the procedure should be taken into account, and for those patients in whom these symptoms are less pronounced, the load can be increased more actively.

While observing the general principles of mechanotherapy procedures, it should be individualized for different joints.

Knee-joint . Using the device, the flexors and extensors of this joint are affected. The patient's IP is sitting. It is necessary that the chair and thigh support are at the same level. The thigh and lower leg are secured with straps on a moving bracket with a stand. With the leg extended, the patient does active flexion, and with the leg bent, active extension. The duration of the procedure is from 5 to 25 minutes, the weight of the load is immediately large - 4 kg, in the future it can be increased to 5 kg, but no more.

Ankle joint . When using the device for this joint, the flexors, extensors, abductors and adductors of the foot are affected. The patient's IP is sitting on a high chair. The exercised foot is fixed on the footrest bed using straps, the second leg is on a stand 25-30 cm high. The patient sits, the knee is bent - active flexion of the foot, with the knee joint straightened - active extension. In the same IP, abduction and adduction of the foot are performed. The duration of the procedure is from 5 to 15 minutes, the weight of the load is from 2 to 3 kg. When exercising the ankle joint, fatigue of the lower leg muscles occurs faster, and therefore increasing the duration of the procedure and the weight of the load above those indicated is undesirable.

During mechanotherapy procedures, an increase in load can be achieved by changing the position of the load on the pendulum, lengthening or shortening the pendulum itself, changing the angle of the stand to support the exercised segment, which is secured using a gear coupling.

Therapeutic gymnastics is carried out in a fresh water pool for deforming osteoarthritis, water temperature 30-32°C. Objectives of the introductory section of the procedure - adaptation to aquatic environment, identifying the degree of pain and limitation of movement, swimming ability, duration 3-6 minutes. In the main section (10-30 min) the training tasks are carried out. The final section of the procedure - it lasts 5-7 minutes - is characterized by a gradual decrease in physical activity.

It is preferable to perform exercises from the IP: sitting on a hanging chair, lying on the chest, on the stomach, on the side, simulating “clean hangs”; the volume of general physical and special load during the procedure is changed due to different depths of the patient’s immersion in water, the pace of exercises, changes in the specific gravity of exercises for small, medium and large muscle groups with varying degrees of effort. They also change the ratio of active and passive exercises, with elements of relief and relaxation of muscles, with inflatable, foam floating objects and equipment, exercises on a hanging chair, with fins-gloves and fins for feet, with water dumbbells, exercises of a static nature, simulating “clean” hangs "and mixed, isometric stresses, breathing exercises, pauses for rest, imitation of elements of swimming in sports styles (crawl, breaststroke), subject to the principle of load dissipation. Passive exercises are carried out with the help of an instructor or using floating objects (rafts, inflatable rings, “frogs”, etc.), exercises without support on the bottom of the pool. Active movements prevail in water. The range of movements at the beginning of the procedure is limited to the point of pain; sudden jerking movements are excluded. As a result of the procedure, increased pain, paresthesia, and convulsions should not be allowed. The course of treatment consists of 10-17 procedures, the duration of the procedure is 15-20 minutes.

Contraindicated therapeutic exercises in the pool:

· patients with severe pain syndrome with symptoms of reactive secondary synovitis;

· the first 3 days after joint puncture.

Bibliography.

1. Big medical encyclopedia. / Ed. B.V. Petrovsky - M.: “Sov. Encyclopedia", 1980 – vol. 13.

2. V. A. Epifanova “Therapeutic physical culture. Directory". – M.: “Medicine”, 1988.

3. Vydrin V. M., Zykov B. K., Lotonenko A. V. Physical culture of university students. – M.: 1996.

4. Demin D.F. Medical supervision during physical exercise classes. – St. Petersburg: 1999.

5. Kots Ya.M., Sports physiology. – M.: Physical culture and sport, 1986.

6. I. L. Krupko. Guide to traumatology and orthopedics - Leningrad: “Medicine”, 1976.

7. G. S. Yumashev. Traumatology and orthopedics. – M.: “Medicine”, 1977.

8. A. N. Bakulev, F. F. Petrov “Popular medical encyclopedia.” – St. Petersburg: 1998.

9. Petrovsky B.V. “Popular medical encyclopedia.” – Tashkent, 1993.

10. Encyclopedia of health. / Ed. V.I. Belova. – M.: 1993.

11. N. M. Amosov, Y. A. Bendet. Human health - M.: 1984.