Rehabilitation of spinal patients with injuries of the spine and spinal cord. Review of methods of motor rehabilitation of patients with spinal cord injury

I want to devote this article to a very serious topic, namely, rehabilitation after spinal cord injuries. As a doctor, I am often asked if a complete cure is possible after a long period of complete helplessness. Unfortunately, in most cases, no. But, probably, there is an opportunity to return at least some part of the lost functions, and this can significantly improve the patient's quality of life. That is why I recommend rehabilitation for spinal patients in Israel to both those who have become disabled for a long time, and those who have only recently been injured.
To date, in the practice of Israeli specialists, a lot of evidence has been accumulated that even with a final violation of the integrity of the spine, there is almost always the possibility of a partial return of motor functions lost after damage. The degree of possible recovery in this case depends on a combination of indicators such as

the level of injury;
the severity of the injury;
the duration of the injury;
age;
general physical condition;
timeliness of treatment.

Therefore, diagnostics is very important for rehabilitation after spinal injuries. It is she who helps to identify which parts of the brain are affected and which are not, and how severe the damage is. Thanks to accurate diagnostics, it is possible to identify promising areas of treatment even in cases where the patient's condition has not changed for several years. To obtain such data in Israel, the latest technologies are actively used. Initially, huge investments in the field of rehabilitation after spinal injuries in Israeli medicine were made because of the wars that have been going on in this country for many years, and now these developments are available to everyone.

Advanced technologies for spinal rehabilitation in Israel.

When it comes to rehabilitation after spinal injury, often the question is “where?” does not even arise because the question "how to get there?" seems insoluble. Believe me, with the current level of medical service, such issues have long faded into the background. Entrust the solution of such problems to me: I will help you and your loved ones with all the formalities and answer all questions for free. Call!

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State budgetary

professional educational institution

"Baikonur Medical College"

(GB POU "BMT")

Final qualifying work

Rehabilitation of spinal patients with injury

spine and spinal cord

Specialty 34.02.01

nursing

Full-time education

Qualification: Nurse / Nurse

Completed by: 4th year student of group 49

Kaidaulova A.S.

Head: Skits K.N.

teacher of the first qualification category

Baikonur, 2015

INTRODUCTION

Chapter 1. Introduction to Spinal Injury

1.1 Spinal injury

1.2 The structure of the spine and spinal cord

1.3 Injuries of the spine and spinal cord

1.4 Classification of injuries of the spine and spinal cord

1.5 Consequences of injuries of the spine and spinal cord

Chapter 2

2.1 Therapeutic exercise

2.2 Methodical methods of reflex therapy

2.3 Reconstruction of the pelvic organs

2.4 Regulation of urination

2.5 Trophic disorders in patients with spinal cord injury

2.6 Kinesitherapy

2.7 Contractures. Paralysis and paresis of individual muscle groups

CONCLUSION

LIST OF USED SOURCES

APPS

INTRODUCTION

spinal injury spine rehabilitation

Relevance: Interest in the problem of restoring lost functions and social and labor rehabilitation of patients with injuries of the spine and spinal cord has not decreased for many decades. At the same time, to date, there is an intensive search for reasonable methods of therapy for this severe category of patients. Measures to restore impaired functions should be carried out immediately after the patient enters the hospital, since only in this case it is possible to prevent the development of life-threatening complications. Therefore, the physical rehabilitation of patients with injuries of the spine and spinal cord is a modern and urgent task.

Object of study. The object of our study is bedridden patients, wheelchair users who have suffered trauma to the spine and spinal cord.

Subject of study. The subject of our study is the use of rehabilitation techniques for those who have suffered trauma to the spine and spinal cord.

Research hypothesis. In this work, we proceeded from the assumption that the use of rehabilitation will improve the basic principles of medical rehabilitation and will improve the health of patients who have suffered spinal cord and spinal cord injuries.

Scientific novelty. The novelty of the study lies in the fact that based on the study of the modern classification of spinal cord and spinal cord injuries and the study of medical rehabilitation methods, we have proposed methods of physical rehabilitation, taking into account the anatomical and physiological characteristics of patients.

Theoretical and practical significance. We believe that research on this issue will help families, methodologists and exercise therapy instructors in the process of conducting physical rehabilitation for patients who have suffered trauma to the spine and spinal cord.

Purpose of the study. Outline ways to improve the methods of physical rehabilitation of patients who have suffered trauma to the spine and spinal cord.

Chapter 1. Introduction to Spinal Injury

1.1 Spinal injury

spinal injury - this is an injury to the spinal cord, its membranes and nerve roots as a result of mechanical impact, which is caused by falls from a height on the buttocks and back, when the head hits the bottom when diving into the water, traffic accidents, gunshot and stab wounds, etc. .d. It happens open - with damage to the skin, soft tissues and membranes of the spinal cord and closed - without these injuries.

The spinal cord is quite well protected by the vertebral column, which protects the spinal cord from mechanical influences from the outside. Under mechanical impacts of high strength, especially fractures, the vertebrae can break, the ligaments between them can tear, causing the vertebrae themselves to shift relative to each other, deforming the spine as a whole.

More often, spinal cord injury is observed with injuries of the cervical spine, less often with injuries of the thoracic and lumbar spine. This is explained by the fact that the thoracic and lumbar spine are more resistant to damage and stronger than the cervical.

Spinal cord injuries are treated in neurosurgery departments because surgical treatment is often required. The contingent is mostly young and mature people. The duration and result of treatment depends on the severity of the injury and can stretch for months. After a spinal cord injury, especially the cervical region, the degree of disability is high.

People who find themselves in such a situation often need long-term rehabilitation, adaptation to new living conditions. After a spinal cord injury, movement in the limbs is often disturbed, accompanied by an increase in muscle tone, the so-called spasticity. With a spinal injury, a decrease in strength and the presence of spasticity can be observed in the legs (with damage to the lumbar or thoracic spine), as well as in the legs and arms - if the level of damage is located in the cervical spine.

In addition, there are violations of sensitivity in the legs or arms, as well as a violation of the functions of the pelvic organs, a person has difficulty urinating or defecation. Rehabilitation depends on the severity of the injury, with mechanical damage to the spinal cord, good recovery is possible, but it requires long and hard work of a person with a spinal cord injury. With a complete break, there is no talk of a full recovery to the previous level, in this case it is necessary to adapt a person to life in new conditions, actively use social and labor rehabilitation.

1.2 The structure of the spine and spinal cord

The spine is the main supporting structure of the human body. It provides a person with the ability to walk and stand. Another important function of the spine is to protect the spinal cord.

The spinal column is formed by 32-34 vertebrae, of which 24 vertebrae in an adult are free (7 cervical, 12 thoracic, 5 lumbar), and the rest are fused with each other and form the sacrum (5 sacral vertebrae) and the coccyx (3-5 coccygeal vertebrae) . Fig.1

Fig.1

The vertebrae are located one above the other, forming the vertebral column. Between two adjacent vertebrae there is an intervertebral disc, which is a round flat connective tissue pad with a complex morphological structure. The main function of the discs is to absorb the static and dynamic loads that inevitably occur during physical activity. Discs also serve to connect the vertebral bodies to each other.

The spinal cord (lat. Medulla spinalis) is a section of the central nervous system and is a cord consisting of millions of nerve fibers and nerve cells. The spinal cord is surrounded by three membranes (soft, arachnoid and hard) and is located in the spinal canal. The dura mater forms a sealed connective tissue sac (dural sac) in which the spinal cord and several centimeters of nerve roots are located. The spinal cord is surrounded by cerebrospinal fluid in the dural sac. Fig.2

Fig.2

In humans, as well as in other vertebrates, the segmental innervation of the body is preserved. This means that each segment of the spinal cord innervates a certain area of the body. For example, segments of the cervical spinal cord innervate the neck and arms, the thoracic region innervates the chest and abdomen, the lumbar and sacral segments innervate the legs, perineum and pelvic organs (bladder, rectum). The doctor, determining in which area of the body, disorders of sensitivity or motor function appeared, can assume at what level the damage to the spinal cord occurred

1.3 Injuries of the spine and spinal cord

Injuries to the spine and spinal cord are divided into closed - without violating the integrity of the skin and underlying soft tissues, open - with violation of the integrity of the latter (gunshot and stab wounds). Closed injuries of the spine, in turn, are divided into two groups.

*Uncomplicated spinal injuries without dysfunction of the spinal cord or its roots.

* Complicated injuries of the spine with impaired function of the spinal cord and its roots:

a) with X-ray revealed fractures, fracture-dislocations, dislocations of the vertebral bodies;

b) without radiographically detectable injuries of the spine.

Most often, spinal fractures occur in the region of the thoracic region, which is explained by the predominant transfer of kinetic forces to the area of articulation of the movable sections of the spine with relatively inactive ones. In second place in terms of frequency are fractures localized in the area of the mobile parts of the neck on the border with the inactive thoracic region.

With all types of spinal injury, all degrees of spinal cord injury can occur - from the mildest to the irreversible transverse injury syndrome. With complicated spinal injuries, the syndrome of complete transverse spinal cord injury occurs in approximately 50% of the victims.

There are the following syndromes of traumatic lesions of the spinal cord: concussion, bruise, crush. The term "concussion of the spinal cord" is understood as a reversible violation of its functions in the absence of visible damage to the structure of the brain. It is assumed that the symptoms of concussion of the spinal cord are the result of dysfunction of nerve cells with a sudden shutdown of supraspinal influences, as well as microstructural changes and parabiotic state of nerve cells and nerve fibers below the level of damage. With mild forms of concussion, the symptoms regress in the next few hours after the injury, with more severe ones - in the coming days or weeks. In clinical practice, the initial period of injury, characterized by a sudden loss of motor, sensory and reflex activity, is referred to as "spinal shock". The duration of this period in cases of reversibility of neurological symptoms is very variable and can reach several weeks and even months.

The term "contusion of the spinal cord" means bruising it with damage to the tissue itself. At the same time, in the final stage of the disease, residual effects of impaired brain function can be observed. Spinal cord contusion in most cases is accompanied by a picture of spinal shock, i.e. temporary paresis, paralysis, hypotension, areflexia, sensitivity disorders, dysfunction of the pelvic organs and some autonomic functions (sweating, pilomotor reflexes, false temperature, etc.).

1.4 Classification of injuries of the spine and spinal cord

Currently, the classification of injuries of the spine and spinal cord according to I.I. Babichenko, approved by the All-Union Problem Commission for Neurosurgery, is used.

According to this classification, all injuries of the spine and spinal cord are divided into open and closed. According to the nature of damage to the anatomical structures of the spine, the following types of closed injuries are distinguished:

Ligamentous apparatus injuries: distortions, ligament ruptures, isolated and multiple

v Fractures of the vertebral body:

Ш Compression;

Ш horizontal;

Ш vertical;

Ш detachable: anterior-upper and antero-inferior corners of the bodies;

Ш comminuted;

Ш compression-comminuted;

Ш explosive.

Depending on the displacement of the body or its fragments, fractures are distinguished:

W without offset;

Ш with offset in height;

Ш with displacement towards the spinal canal and compression of the spinal cord.

Spinal fracture with injury capsular-ligamentous apparatus.

Compression fracture of the body of the spine.

Compression-comminuted fracture of the body of the spine.

1.5 Consequences of injuries of the spine and spinal cord

Complications and consequences of injuries of the spinal column and spinal cord are divided as follows:

Ø infectious and inflammatory consequences;

Ø dysfunction of the pelvic organs;

Ø vascular and neurotrophic disorders;

Ø orthopedic complications.

Infectious-inflammatory complications can be both early (developing in the acute and early periods of spinal cord injury) and late.

In the acute and early stages, purulent-inflammatory complications are mainly associated with infection of the urinary and respiratory systems, as well as with pressure sores that proceed as purulent inflammation.

Late infectious and inflammatory complications include chronic arachnoiditis and epiduritis. Vascular and neurotrophic disorders occur due to impaired innervation of tissues and organs. In soft tissues in patients with spinal cord injury, bedsores and hard-healing trophic ulcers form very quickly. Ulcers and bedsores are the entrance gates of infection and the causes of septic complications, leading to death in 25-30% of cases.

Violations of the autonomic innervation of internal organs contribute to the development of purulent-necrotic ulcerative colitis, gastritis, enterocolitis, acute gastrointestinal bleeding, dysfunction of the liver, pancreas, and kidneys. There is an increase in stone formation in the biliary and urinary tract.

Violation of the sympathetic innervation of the heart (with injuries of the thoracic and cervical spinal cord) is manifested by arrhythmia, bradycardia, hypotension. Coronary heart disease may occur or worsen, and patients may not feel pain as a result of impaired afferent impulses from the heart.

On the part of the lungs, more than 60% of patients in the early period develop pneumonia, which is one of the most common causes of death in patients.

A fairly common complication of spinal cord injury is, according to various data in 15-50% of patients, dysfunction of the pelvic organs is clinically manifested by defecation and urination disorders.

In the stage of spinal shock, acute urinary retention is observed, which is associated with a deep lesion of the reflex activity of the spinal cord. As you recover from shock, the degree of neurogenic bladder dysfunction depends on the level of spinal cord injury.

2. Rehabilitation program for patients with consequencesspinal injuriesand spinal cord

Spinal injuries are among the most severe injuries of the musculoskeletal system. The tasks and sequence of therapeutic measures are determined by the prescription, degree, nature of damage and neurological disorders. In the acute period, treatment consists of eliminating the displacement of the vertebrae, compression of the membranes of the spinal cord and its roots, creating the most favorable conditions for restoring anatomical relationships, preventing relapses and secondary damage to the nerve elements, after which the main efforts should be aimed at increasing the strength and endurance of the muscles of the body and neck, and later on to increase the mobility of the spine.

medical rehabilitation

The main directions of medical rehabilitation:

Ø early diagnosis of the disease (injury);

Ø timely hospitalization;

Ø complete laboratory and instrumental examination;

Ø early complex treatment (regime, diet, medications, etc.);

Ø control over the dynamics of the disease process and the effectiveness of treatment;

Ø determination of the prognosis of the course of the disease;

III dispensary observation of patients after discharge from the hospital with the implementation of therapeutic and prophylactic and recreational activities.

Thus, timely and complete treatment is of decisive importance in the effectiveness of rehabilitation measures. Consequently, treatment and rehabilitation are inseparable parts of a single process. Medical measures (medical rehabilitation) combine therapeutic measures aimed at restoring health. They should be started immediately upon detection of the disease and carried out in a complex manner using all means that contribute to the development of compensatory processes and adaptive reactions of the body. Medical measures in most cases are carried out at all stages of rehabilitation and often remain in the plan of dispensary care for a long time.

Physical rehabilitation

The physical aspect of rehabilitation includes all issues related to the use of physical factors in the rehabilitation treatment of patients. This includes therapeutic exercises and other elements of therapeutic physical education, intensive training, spa treatment, etc. The physical aspect is part of medical rehabilitation and provides for measures to restore patients' ability to work through the use of therapeutic exercises and increasing physical training. The main purpose of the use of physical factors is the all-round increase in the physical performance of patients, the disabled, limited due to illness or disability. Unlike drugs. The use of physical factors has a wider effect on the central nervous and cardiovascular systems, metabolism and gas exchange in the lungs.

Some methodological aspects of the application of physical activity

a) Physical activity is part of medical rehabilitation, an integral part of a complex of rehabilitation measures. Physical education alone without proper nutrition, a healthy lifestyle, good rest, without giving up alcohol and smoking cannot ensure good health.

b) Physical rehabilitation should begin as early as possible. Speaking about the strategy of physical education and human development, one should remember the need for continuity of measures taken throughout all periods of a person's individual life. It is necessary to solve the problem of physical education and physical development of the population from preschool age, and then in schools, colleges, institutes, enterprises, etc.

c) Before starting physical training, it is necessary to undergo a serious medical examination using various loads. It is clear that the determination of the type and intensity of physical activity and control over its effectiveness should be undertaken by a specialist in this field - a doctor. When giving advice, a doctor should take into account not only the actual state of a person’s health, but also the degree of his physical fitness and fitness.

d) Every work must be entered gradually. You should not immediately overstrain your efforts, but it is necessary, entering the work, to develop your efforts gradually.

e) It is necessary to control the effectiveness of the use of physical activity. Evaluation of the effect or, on the contrary, a signal to cancel or change the nature and mode of physical activity.

f) The optimal choice of the type, pace, intensity and duration of physical activity, taking into account the state of health, the individual characteristics of the body and the level of its fitness. Improving physical performance with the help of therapeutic and physical factors is not an end in itself. High physical performance depends on good health and is a necessary condition for maintaining professional activity.

Thus, there is a close relationship between the medical, physical and occupational aspects of rehabilitation. The use of physical factors helps to reduce the duration of treatment, i.e. reducing the economic costs of rehabilitation. A favorable effect of physical factors on the psychological state of patients has been established. Consequently, the physical aspect of rehabilitation is connected with other rehabilitation aspects - economic and psychological.

Measures to restore impaired functions should be carried out immediately after the patient enters the hospital, since only in this case it is possible to prevent the development of life-threatening complications. These measures include means of physical (physical exercises, massage, physiotherapeutic measures, reflexology) and social and labor rehabilitation, the task of which is to increase the functionality and performance of the preserved elements of nerve cells in the early recovery period and, along with this, to promote the development of compensatory capabilities of the body, especially in the late recovery period.

At the same time, succession and stages in treatment are important (a hospital - a polyclinic - a rehabilitation center - a sanatorium stage of treatment in specialized departments).

2.1 Therapeutic exercise (LFK)

Therapeutic physical education is an independent scientific discipline. In medicine, it is a treatment method that uses physical culture for prevention, treatment, rehabilitation and supportive care. Exercise therapy forms a person's conscious attitude to physical exercises and, in this sense, has an educational value; develops strength, endurance, coordination of movements, instills hygiene skills, hardening the body with natural factors of nature. Exercise therapy is based on modern scientific data in the field of medicine, biology, physical culture. The main means of exercise therapy are physical exercises used in accordance with the objectives of treatment, taking into account the etiology, pathogenesis, clinical features, the functional state of the body, the degree of general physical performance.

Methodology treatment:

v simultaneous reposition with the imposition of a plaster corset;

v gradual staged reposition;

v functional method;

v operational methods.

In case of fracture of the bodies of the thoracic and lumbar vertebrae, the functional method is most often used, in which the patient is placed on a functional bed (a shield is placed under the mattress) with a raised head end, a cotton-gauze roller is placed under the lumbar region. At the same time, the patient is stretched by his own weight with the help of straps held behind the armpits.

I period In this period, in the treatment of traction, exercise therapy is prescribed from the 3rd-4th day. In the early days, exercises are used for small and large joints of the arms and legs (without lifting the legs from the bed) and breathing exercises. Gradually, exercises with bending of the spine are added, relying on arms bent at the elbows and feet of legs bent at the knees. During classes, the bed is placed in a horizontal position. Classes are held 3-4 times a day for 10-15 minutes. After 7-14 days after the injury, it is allowed to turn on the stomach (without bending the body). In this position, exercises are used in bending the spine with support on the hands, in the future - without support.

II period In the II period include exercises with significant muscle tension, but with the obligatory condition of painlessness during movements. During the first month of this period, exercises with legs off the bed are carried out only alternately. The use of exercise therapy is aimed at strengthening the muscles of the back, abdominals, pelvis, arms, legs. At the beginning of the 2nd month apply torso to the sides and slight turns in positions on the back, and subsequently on the stomach. The duration of the lesson is up to 40-45 minutes several times a day with an emphasis on special exercises that strengthen the muscles of the body.

The main objectives of therapeutic gymnastics are:

v stimulation of the normalization of blood circulation in the lumbosacral region and the affected limb;

v restoration of normal range of motion;

v strengthening the weakened muscles of the gluteal region and legs, restoring their normal tone, relaxing the tense muscles of the lumbosacral region;

v improvement and strengthening of the whole body of the patient.

2.2 Methodical methods of reflex therapy

Its purpose is to develop passive movements in individual segments of the limbs, to develop active relaxation and receptor contractions of antagonist muscles. Describing the methodological techniques of analytic therapy, it should be noted that they all include the following four components:

1) techniques aimed at relaxing individual muscle groups;

2) techniques that improve mobility in the joints;

3) training in active tension of certain muscles;

4) the formation of the correct coordinating relationships between antagonist muscles and integral motor acts.

Techniques aimed at relaxing individual muscle groups are massage and learning to voluntarily relax individual muscle groups. Stroking, shaking, rolling and vibration are used as relaxing types of massage. Recently, acupressure has become widespread, in which acupressure is applied to small areas of the skin in the area of the tendons of the most tense muscles.

In recent years, interest in hardware types of massage has increased.

Vibration- rhythmic fluctuations of the elastic medium - has a wide therapeutic range. For vibration and vibration-impact massage, low-frequency vibration from 30-50 to 150-170 Hz is mainly used.

Water massage(hydromassage) is carried out in manual and hardware versions. Manual underwater massage is a classic massage performed under special conditions.

There are several types of hydromassage with the help of devices:

Water jet massage. The procedures are carried out with a jet of water (or several jets at the same time) in the air. An example is the Charcot shower, circular shower. For the treatment of patients with traumatic disease of the spinal cord, you can use a hinged douche-massage (by the type of circular). Water jet massage under water. Procedures are released in special baths using the apparatus. A jet of water is ejected through a flexible hose at a pressure of 2-3 atm. To change the power of the jet, various nozzles can be put on the hose. The mechanical force of the jet can also be adjusted by changing the distance to the body area and the angle of impact. Underwater pneumomassage carried out by a jet of compressed air under water. The method is extremely simple and can be applied in any hospital.

Exercises for active, voluntary muscle relaxation are aimed at teaching the conscious regulation of the degree of muscle tension. Then the patient is taught to dose both the degree of relaxation and tension of certain muscle groups.

To improve mobility in the joints, passive exercises are used, which are best combined with thermal procedures, which contributes to the maximum stretching of the muscles. The effect of passive movements can be fixed by subsequent posture correction.

Elements of the development of movement coordination are contained in the methods of teaching active relaxation and tension (according to indications) of certain muscle groups. The basis of the technique aimed at cultivating the correct rhythmic coordinated movement in the joint is the use of additional afferentation. In some cases, the patient is asked to carefully observe the correct alternation of flexion-extensor, adductor, abduction or rotational movements in the joint. In other cases, streak stimuli are applied to the skin at a certain point in the movement, which stimulates the function of the affected agonist or antagonist. The techniques of the Kebot system (slow or fast reversion of antagonists) are effective.

The success of therapy largely depends on the ability to find such stimuli for muscle activity that would overcome functional disorders and compensate for the death of part of the motor neurons. From this point of view, it is of particular importance to improve exercises that make it possible to activate the affected segments as much as possible. Such exercises include exercises of the repercussive effect, postural tonic reflexes and complex-type movements that activate the affected muscles due to reflex connections.

The Kabat system provides for the rejection of a gradual increase in loads. Maximum resistance is given from the start of therapy. Analytical work with the affected muscle is completely excluded. Instead of an isolated movement of the affected muscle, a complex movement is proposed, covering many muscle groups simultaneously and sequentially. One of the factors facilitating the contraction of the paretic muscle is its preliminary stretching. " Proprioceptive facilitation is achieved through the following techniques:

Ш maximum resistance to movement;

Ø reversion of antagonists;

Ш preliminary stretching of the affected muscles:

III complex motor acts.

Physical exercises and massage in patients with flaccid paralysis should be considered as a biological factor in stimulating recovery processes and developing adaptive replacement mechanisms. The upbringing of the motor function should proceed along the path of using the preserved active movements, which are revealed in various ways: with an attempt to perform the necessary movement in different initial positions, with various assistance, in the aquatic environment, etc.

Long-term forced stay of patients on bed rest leads to a sharp violation of the functions of the cardiovascular, respiratory systems and vestibular apparatus, therefore, exercises that prepare the body for significant physical exertion, which are created only in the upright position of the patient, should occupy a significant place in the training methodology.

Important for the development of the ability of independent movement is apparatus treatment, which provides an increase in the motor activity of patients. During the period of learning to move, gypsum splints and splints were most widely used. In recent years, lightweight gypsum-gelatin, gypsum-nitro-lacquer and plastic splints have been used. Proposed for use during the period of learning to walk educational and training fixing devices, which are comfortable and can easily be adjusted to the lower limbs of various sizes. Mmm See annex 2

2.3 Reconstruction of the pelvic organs. Defecation.

Since the start of intensive rehabilitation, the patient begins to recover intestinal peristalsis. In the first days at the time of classes, an involuntary discharge of feces is possible. After the toilet, classes continue. Atonic constipation will alternate with spastic. Then the peristalsis is normalized, and the act of defecation will not cause any special problems. Gases will begin to leave on their own. It is possible that the first months will have to periodically use laxatives or special candles. As soon as the patient begins to sit confidently in a chair (not in a chair), we suggest that the patient make a special toilet chair (with a hole in the seat).

On the second month from the start of rehabilitation, every day at the same time, the patient should insert a candle, sit on this chair and empty the intestines. You can use Regulax 8 hours before a bowel movement. Over time, the patient will develop a conditioned reflex to the time and place, and he will be able to perform the act of defecation on his own.

2.4 Regulation of urination

As soon as the patient begins to drink a lot, he will produce a large amount of urine. Try to keep the patient focused on their feelings. Usually, at the time of passage of urine through the urethra, patients feel "goosebumps".

1. Teach the patient to distinguish "crawling" on the skin when urinating from other types of sensitivity.

2. Many spinal patients have a catheter. In the first months, you can not bandage it. During classes, urination intensifies, stones, pus, rejected cells of the urinary tract, sometimes even an admixture of blood, begin to depart intensively. Attach the catheter to a urinal or a plastic bag. After class, looking at the contents of the package, you can see how much urine and various impurities have been released. If pus, stones, blood appear, then within a week the patient should take chloramphenicol 0.5 g 6 times a day or other antibiotics. Over time, the urine will begin to lighten and become the usual yellow color. All patients who have been immobile for a long time develop urolithiasis and concomitant urinary tract infection. When performing speed rehabilitation exercises, all patients begin to intensively remove stones. The temperature rises, profuse sweat is released, the color of the urine changes from red to fine white. Since there is no sensitivity below the lesion of the spinal cord, these symptoms mislead doctors due to the absence of pain. Urinalysis will help establish the diagnosis. Cessation of activities leads to a decrease in symptoms, the resumption of activities will lead to the manifestation of these symptoms again. It is necessary to reduce the load, but not stop exercising. Assign no-shpu, baralgin, levomycetin, bearberry, dill, washing the bladder with furacillin, drinking plenty of water. Over time, against the background of rehabilitation classes, all the stones will move away, the kidneys and urinary tract will be cleansed, and these symptoms will no longer bother the patient. Then you need to remove the catheter and learn to do without it.

3. Now focus the patient's attention on the sensations that occur before urination. The patient begins to analyze his feelings, which he did not pay attention to before. Now the main thing is to substitute the vessel or the vessel replacing it in time.

4. When the urinary tract is cleared of stones and other impurities, the process of urination will acquire a reflex character (with an interval of 45 minutes to 3 hours).

5. When the patient learns to feel the urge to urinate, they begin to train the bladder. At the moment of the urge, a vessel is substituted, and the patient tries to distract himself from this feeling, counting first to 10, and then to 100 or more. Control how long the patient can hold urine. The patient may be distracted in other ways: draw, sing songs, etc. Soon he will find that the urge to urinate does not last long, and control of the bladder becomes easier and easier. The volume of urine released will gradually increase and reach 250-300 ml.

Yes, there will be breakdowns: both involuntary defecation and urination, especially in the first months. Everything is like in small children, who develop a conditioned reflex to these problems. This will gradually restore control of the pelvic organs.

2.5 Trophic disorders in bol with vertebral-spinaloh injury

Decubitus (lat. Decubitus) - necrosis (necrosis) of soft tissues as a result of constant pressure, accompanied by local circulatory disorders and nervous trophism.

Damage to the spinal cord in many patients leads to the development of a severe neurodystrophic process in all tissues and organs. Pressure sores appear in almost all patients with severe spinal cord injury. This is due to the fact that the neurodystrophic process is combined with neurological disorders: a violation or lack of sensitivity and movement, as well as a loss of control over the function of the pelvic organs. Accession of an infection, especially nosocomial forms of Pseudomonas aeruginosa, Staphylococcus aureus and Proteus mirabilis, causes a severe purulent process, often leading to the death of patients. According to A. Pansky, bedsores during the First World War in 83% of cases became the cause of deaths. During the Great Patriotic War, bedsores were a source of sepsis and led to death in 20% of cases. In peacetime, according to various authors, from 3 to 9% of patients die from bedsores.

Places of bedsore formation

Causes

v Poor nursing care.

v Too much or too little patient weight.

v Dry skin.

v Urinary or fecal incontinence.

v Diseases that lead to disruption of tissue trophism (nutrition).

v Limited mobility.

v Increase or decrease in body temperature.

v Insufficient protein nutrition.

Stages of bedsores

Grade I: the skin is not broken. Persistent hyperemia that does not go away after the cessation of pressure.

Grade II: superficial (shallow) violation of the integrity of the skin with spread to the subcutaneous tissue. Persistent hyperemia. Detachment of the epidermis.

Grade III: destruction of the skin up to the muscle layer with penetration into the muscle. A bedsore looks like a wound. There may be liquid discharge.

Grade IV: damage to all soft tissues. The presence of a cavity exposing the underlying tissues (tendons, up to the bone).

With pressure sores of III-IV degree, the main method of treatment is surgical .

Prevention

Treatment and prevention of bedsores are inextricably linked with a whole range of measures to care for a sick person. Material costs for the prevention of bedsores are always less than for their treatment.

The organization of care and observation of the patient should be carried out by one person. He may have assistants - specialists with whom you can consult; but the one who organizes the care and has the most opportunity to observe the sick person should make the final decision.

Patients using a wheelchair, bedridden patients, patients suffering from partial immobility (of body parts), urinary and / or fecal incontinence, malnourished patients, obese patients suffering from diabetes mellitus, etc. need preventive measures.

In order to avoid bedsores, their prevention should be carried out correctly, for which it is necessary to do the following:

Ø change the position of the patient's body several times a day, if his condition allows;

Shake sheets daily several times a day so that there are no crumbs on them;

Ш monitor the absence of folds on the bed and underwear;

Ø to put seriously ill patients who have been in bed on their backs for a long time, an inflatable rubber circle nested in a pillowcase, so that the sacrum is above its opening

Ø when hyperemia (redness) appears, rub the skin with a dry towel or quartz it to improve local blood circulation;

Wash the skin in the affected areas with cold water and soap, wipe with alcohol, followed by powdering;

Wipe the skin daily with disinfectant solutions.

As a rule, disinfectant solutions of the following composition are used:

Ш camphor alcohol (before use it is heated under a stream of warm water);

W warm water - 1/2 l and vinegar, cologne or alcohol - 2 tbsp. l.

In the absence of a disinfectant solution, the skin can be wiped with warm water. The back of the head, shoulder blades, elbows, sacrum, knees, heels, buttocks - these are the areas of the body that the caregiver should pay special attention to in order to protect him from bedsores.

Skin rubbing technique

Ш Moisten one end of the towel with a disinfectant solution, squeeze lightly.

Ш Wipe the neck, behind the ears, back, front surface of the chest, armpits.

Ø Particular attention should be paid to the folds under the mammary glands, where diaper rash can form in obese and sweating women.

Wipe the skin dry in the same order.

2.6 Kinesiotherapy

Kinesiotherapy, or movement therapy, plays a leading role in the rehabilitation of patients with movement disorders. The role of kinesitherapy is both in the correction of particular motor disorders, and in reducing the adverse effects of physical inactivity in general. Forced physical inactivity, being an inevitable consequence of damage to the musculoskeletal system, in turn, leads to a significant decrease in proprioceptive impulses, turning off motor-visceral reflexes, which contributes to the deterioration of the function of the cardiovascular system, and a decrease in the overall adaptive ability of the body.

The mechanisms of the therapeutic effect of physical exercises are associated with a variety of complex mental, physiological and biochemical processes occurring in the body during exercise therapy. Dosed muscle loads have a general tonic effect, since the motor zone of the cerebral cortex, sending impulses to the motor apparatus, simultaneously excites the centers of the autonomic nervous system, which leads to the activation of the adrenal glands and other endocrine glands, stimulation of the cardiovascular and respiratory systems, increase metabolism. Trophic processes and regeneration processes improve in the muscles involved in movements, since as a result of proprioceptive impulses, blood flow to them increases, oxidative processes are activated, the flow of plastic protein fractions and their assimilation increase, and neurogenic regulation of tissue trophism is restored. The processes of bone tissue remodeling are also normalized, the functions of the tendon-ligamentous apparatus are restored.

The influence of kinesitherapy on the psyche is characterized by an increase in mood, distraction of thoughts from the disease, which is also very important. Physiotherapy exercises are indicated for almost all patients with motor disorders, since correctly selected (by nature, intensity, duration) exercises necessarily give a positive effect. Contraindications to its appointment can only be temporary: an acute period of the disease or an acute infectious disease, the general serious condition of the patient, high fever, severe pain, the risk of massive bleeding.

2.7 Contractures. Paralysis and paresis of individual muscle groups

Spinal patients often develop multiple contractures. Sometimes these are artificial contractures that have arisen due to forced fixation of the feet in the position of flexion (adduction) with rollers, plaster casts, or surgery. In combined injuries, in the case of intra-articular fractures, contractures of the elbow and ankle joints are often encountered, usually flexion, due to the consolidation of fractures under a plaster cast that fixes the limb in the elbow or ankle joint. More often, muscle contractures occur as a result of continuous irritation of the motor portion of the roots of the spinal cord both at the fracture site and above and below the fracture site of the spine.

PRINCIPLES OF INTENSIVE LIQUIDATION OF CONTRACTURES

In the first days of rehabilitation, swaying in the affected joints is allowed within acceptable limits.

v Only after 2-3 weeks from the start of rehabilitation, when the mobility of the segments of the spinal column has become optimal and the spinal cord roots have been decompressed as far as possible, they begin to eliminate contractures.

v It is desirable, and sometimes necessary, to remove the plates used for spinal fusion, as they can cause compression of motor fibers and cause contractures.

v By the time contractures develop in the limbs, trophism should be normalized and blood flow should be restored. They should be warm to the touch. The presence of wounds and trophic ulcers on the limbs is not a contraindication for the development of contractures.

v The development of contractures in the limbs necessarily goes from larger joints to smaller ones: from the hip to the ankle. Then the joints of the foot and fingers are developed.

A. In case of flexion contracture, a movement must first be made that continues flexion, and only then extension is performed (photo 1, 2).

B. With extensor contracture, extension is first performed and only then flexion.

v In the hip and shoulder joints, all possible degrees of freedom of movement are worked out, achieving the maximum possible amplitude, and only then they begin to eliminate contractures in the elbow and knee joints.

v In the elbow and knee joints, during the development of contractures, movements are carried out not only in flexion and extension, but also to the sides. Movement to the sides along the frontal plane in these joints is also normal in the form of play. The same movements to the sides are carried out in the ankle and metacarpal joints, in the joints of the hand, foot and fingers.

v Development of contractures is carried out with moderate force swinging movements, gradually, day after day.

v You can not hang a load from the limbs for the passive elimination of contractures - this always leads to trauma to the ligamentous apparatus, and sometimes to fractures.

With extensor contracture of the knee joint, lowering of the limb after exercise is allowed. Under the influence of the own weight of the limb, the contracture will also decrease. In this case, it is necessary to control the blood flow in the distal limbs. When the skin turns blue, the limb should be raised, laid on a chair. After normalization of skin coloring, the limb is lowered again.

CONCLUSION

Based on my research, we have come to the following conclusions:

Restoring lost functions after injury to the spine and spinal cord is a very difficult task. The difficulty lies, first of all, in the fact that the material basis for recovery should be the connection of damaged conductors and the formation of new cell formations, that is, the morphological structure of the tissue, which ensures its normal functioning. However, the reparative-regenerative process is difficult due to the growth of glial tissue (auxiliary tissue of the nervous system) in the area of the rupture of the spinal cord and the formation of cavities in the damaged area. One of the reasons that impede regeneration is hemodynamic disturbance in the area of damage as a result of breaks, thrombosis and hemodynamic disturbances in the capillary network, which leads to the shutdown of a part of the vascular collector, hypoxia, and delays the growth and myelination of regenerating axons.

The use of physical rehabilitation after an injury to the spine and spinal cord in patients should be carried out in the widest possible way in order to have a general effect on the entire body of the victim. Physiotherapy exercises are indicated for both conservative and surgical treatment starting from the second or third day, and, above all, for the prevention of possible complications associated with prolonged immobilization.

The choice of the method of physical therapy and the mode of movement is strictly individualized depending on the general condition of the victim, the state of his nervous and cardiovascular systems and the stage of the traumatic disease. Physical exercises are prescribed in order to achieve positive changes in the state of health, and, in particular, to improve and compensate for lost motor functions, prevent muscle atrophy, restore correct posture and walking skills, and increase the body's resistance to adverse external influences.

Significant progress has been made in the treatment of spinal cord injuries. At the moment, many rehabilitation centers for spinal patients have been opened that meet all the requirements of modern medicine (Bubnovsky Center, Burdenko Center, Dikul Center, Talsuat Center, etc.) We hope that modern medicine and technology will help many spinal patients find a full life.

LIST OF USED LITERATURE

1. http://aupam.ru/pages/fizkult/lfk_i_fizioterapiya_posle_travmih_pozvonochnika/oglavlenie.html

2. http://aupam.ru/pages/fizkult/lfk_i_fizioterapiya_posle_travmih_pozvonochnika/oglavlenie.html

3. Bersenev V.A. Cervical spinal nodes. - M.: Medicine, 1980.

4. Weiss M., Zembatiy A. Physiotherapy / Per. from Polish - M.: Medicine, 1986.

5. http://aupam.narod.ru/pages/invasport/kompleksnaya_profilaktika_zabolevaniyj_reabilitaciya_boljnihkh_invalidov/page_09.htm

6. http://vlanamed.com/prolezhni/ Encyclopedia of Diseases ©

7. Skoblin A.P., Moskin V.Ya. Care of trauma and orthopedic patients. - Leningrad: "Medicine", 1985.

8. Sumin S.A. Urgent conditions. - Moscow: Mia, 2002.

9. Popov S.N., Physical rehabilitation: textbook, M.: Phoenix, 2008. - 603 p.

10. Medical rehabilitation: a practical guide edited by Academician V.M. Bogolyubov, - M .: IPK Zvezda, Volume 2, 1998.- 648 p.

ATTACHMENT 1

APPENDIX 2

Gypsum splints

APPENDIX 3

Splinters (fr. tuteur) --a fixing orthopedic apparatus for immobilizing joints, consisting of sleeves (sometimes a shoe) connected by tires without hinges.

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medical rehabilitation

The main directions of medical rehabilitation:

Ø early diagnosis of the disease (injury);
Ø timely hospitalization;
Ø complete laboratory and instrumental examination;
Ø early complex treatment (regime, diet, medications, etc.);
Ø control over the dynamics of the disease process and the effectiveness of treatment;
Ø determination of the prognosis of the course of the disease;
III dispensary observation of patients after discharge from the hospital with the implementation of therapeutic and prophylactic and recreational activities.

Physical rehabilitation

Some methodological aspects of the application of physical activity

a) Physical activity is part of medical rehabilitation, an integral part of a complex of rehabilitation measures. Physical education alone without proper nutrition, a healthy lifestyle, good rest, without giving up alcohol and smoking cannot ensure good health.
b) Physical rehabilitation should begin as early as possible. Speaking about the strategy of physical education and human development, one should remember the need for continuity of measures taken throughout all periods of a person's individual life. It is necessary to solve the problem of physical education and physical development of the population from preschool age, and then in schools, colleges, institutes, enterprises, etc.
c) Before starting physical training, it is necessary to undergo a serious medical examination using various loads. It is clear that the determination of the type and intensity of physical activity and control over its effectiveness should be undertaken by a specialist in this field - a doctor. When giving advice, a doctor should take into account not only the actual state of a person’s health, but also the degree of his physical fitness and fitness.
d) Every work must be entered gradually. You should not immediately overstrain your efforts, but it is necessary, entering the work, to develop your efforts gradually.
e) It is necessary to control the effectiveness of the use of physical activity. Evaluation of the effect or, on the contrary, a signal to cancel or change the nature and mode of physical activity.
f) The optimal choice of the type, pace, intensity and duration of physical activity, taking into account the state of health, the individual characteristics of the body and the level of its fitness. Improving physical performance with the help of therapeutic and physical factors is not an end in itself. High physical performance depends on good health and is a necessary condition for maintaining professional activity.

At the same time, succession and stages in treatment are important (a hospital - a polyclinic - a rehabilitation center - a sanatorium stage of treatment in specialized departments).

Considering the special significance of motor disorders, the main attention should be paid to the restoration of motor functions. The means of motor rehabilitation (DR) - physical exercises come to the fore here. There are 4 main mechanisms of action of physical exercises: 1) tonic; 2) trophic; 3) formation of functional compensations; 4) normalization of functions and holistic activity of the body.

Since DR increases the viability of the body in adverse conditions, all patients with spinal cord injury need a set of general strengthening and mobilizing measures that remove the negative effects of physical inactivity. Rational styling is just as necessary. The functional and physiological position, taking into account the cordance of muscle lesions and deformities, provides optimal conditions for treatment. When spinocortical connections are damaged, the flow of impulses from proprioreceptors located caudal to the injury decreases. At the same time, it sharply increases from the damaged zone, forming a pathological dominant in the cerebral cortex, which suppresses the activity of cortical structures. These circumstances lead to a weakening of the regulatory influence of the cortex on the functions of the body. Tonic physical exercises can reduce this inhibition. Regular systematic repetition of exercises excites the corresponding motor cells of the cortex and keeps them in a state of functional activity. Physical exercises bring metabolic and energy processes in the muscles to a new level, contribute to increased blood circulation.

Thus, the tasks of DR in the clinic of spinal cord injuries are general strengthening measures, the provision of functional and physiological positions, the activation of the motor centers of the cortex, and the improvement of blood circulation in the area with impaired innervation.

Based on the clinic of movement disorders in patients with spinal cord injury, obviously, special attention should be paid to breathing exercises, orthostatic training, and coordination exercises. Special exercises are important to improve intestinal motility, with reflux and urolithiasis, to increase blood supply to the spinal cord. When drawing up a treatment plan, specific plasticity is taken into account, as well as the ability of the musculoskeletal system to realize the functions of grasping, standing and walking in pathological conditions.

DR techniques are multidirectional depending on the type of flaccid or spastic paralysis. With flaccid paralysis, the selection of exercises is carried out in such a way that the flow of impulses from the proprioreceptors of the paretic limbs increases. In spastic paralysis, efforts are directed at relaxing and stretching the muscles. In both cases, the object for training is defective muscles. In case of gross injuries (unresolved compression, crushing of structures, anatomical break), when recovery is impossible, DR solves the problems of substitution of functions (compensation), neuromotor re-education of muscles that are not normally involved in this motor act, and adaptation to the defect. In each period of traumatic disease of the spinal cord, DR has its own characteristics. They concern both the goal and the choice of a set of movements, their pace, volume and strength, as well as the amount of private and general load.

There is an opinion that DR should not be performed in the early period of spinal injury, it is even considered contraindicated. Meanwhile, the start of DR classes immediately after the complex of urgent life-saving measures is advisable. At the same time, classes have a preventive focus and are focused on early warning of bedsores, contractures and congestion in the lungs. The patient is provided with physiologically rational laying, breathing exercises are performed (if he is not intubated), passive movements in the joints of the limbs. The use of DR in a critical period for patients can significantly reduce postoperative complications and mortality. DR during the debut period has a positive effect on the manifestation of the main syndromes of the emerging traumatic spinal cord disease, and on the functional prognosis. Of course, we are talking about physical exercises that are adequate to the condition of patients. Overloads generally cause asynchronization of the rhythms of different body systems. It is known that intense exhausting excitation leads to a change in protein metabolism towards catabolism, causes structural changes in protein molecules, a decrease in glycogen in brain tissues, deposition of ammonia in nervous tissue, and a decrease in ATP in brain structures, which leads to a decrease in excitability and increased inhibition. Therefore, it is important to carry out mobilizing measures, static and passive exercises, breathing exercises in the acute stage of injury, limiting motor activity in terms of volume and loads.

In the subacute stage of the early period of traumatic illness, DR is focused on functional restitution. Classes become more complicated, parametric indicators increase - strength, amplitude and speed of exercises. Strengthening of afferent signaling from the periphery contributes to the restructuring of the integrative activity of the spinal cord. An increase in the activity of centers of various modalities in the process of reintegration leads to an increase in the flow of efferent impulses.

The chronic stage of the late period of traumatic disease of the spinal cord requires a complex correction of stimulating, restructuring and normalizing afferent impulses aimed at vicarious replacement. The most adequate therapeutic measures in this case will be those that increase the flow of excitatory impulses and block inhibitory ones. In spastic paralysis and paresis, the first priority are techniques that eliminate or reduce the imbalance of antagonist muscles. With flaccid paresis, increased afferentation from proprioceptors, stimulating exercises, and posture regulation will play a leading role.

It has been established that when movements are used as a therapeutic factor in muscles, glycogen resynthesis and utilization of protein-free nitrogen increase, protein synthesis and oxygen consumption increase. This circumstance is of fundamental importance. Under conditions of reduced motor activity, the metabolism of RNA and proteins is disturbed, while muscle atrophy outstrips the atrophy of the corresponding motor neurons. In the denervated muscles, an even deeper restructuring is noted. Therefore, the normalization of metabolic processes in the muscles plays an important role in the recovery process. Under the influence of DR, pronounced humoral shifts occur, accompanied by the activation of hormones, enzymes, potassium and calcium ions. The main difficulty in the rehabilitation therapy of patients with the consequences of spinal cord injury is the transfer of excitation from the proximal segment of the spinal cord to the distal one. Training with passive and active movements, accompanied by afferent and efferent impulses, contributes to tissue regeneration in the lesion, disinhibition of morphologically preserved, but functionally inactive neurons in the zone of functional asynapsia, and the development of new pathways of impulse transmission. The afferent discharge is multi-segmented, the issue of “multisensory convergence on afferent neurons” is widely discussed by physiologists, which is considered one of the main factors in the activity of sensory systems in pathological conditions.

With partial injuries of the spinal cord, when some conductors are preserved, the inclusion of additional interneurons in the formation of new reflex reactions to replace the lost ones ensures the development of movements in a volume sufficient for functional recovery. When the cord is ruptured, impulse transmission from the center to the periphery is carried out along extramedullary connectives, which leads to the activation of adaptive mechanisms and compensation of the formed defect, “to the development of motor functions even in conditions of anatomical interruption of the spinal cord” .

In the residual stage of a traumatic disease, therapeutic physical culture (exercise therapy) is aimed at consolidating the achieved level of motor activity and adapting the patient to the existing defect. However, even at this stage, cases of functional recovery are noted in the literature.

After a spinal cord injury, the ability to move independently is lost or walking is specifically disfigured: arrhythmic, accompanied by a violation of the support function, temporal and spatial asymmetry, a change in the structure of movement, vertical or lateral swaying of the body, tension, a change in the postural characteristics of the legs, and most often by handy means. Walking is a movement with the transfer of the general center of gravity of the body, while alternately and sequentially the limbs perform support and transfer of the leg. The stance phase is formed by such components as the front push, foot roll and back push. In the swing phase, the leading moment will be the extension moment and the vertical moment. The displacement of the general center of gravity of the body occurs when walking in the vertical, forward and lateral directions, causing certain deviations (oscillations) of the body.

In the process of phased exercises to teach patients to walk, efforts should be focused on improving the kinematic characteristics - straightening the legs during the reference period of the step, increasing the amplitude of movements in the transfer phase. This ensures the development of the correct dynamic stereotype of movement. At the same time, the time indicators of the step improve, the posture of the leg normalizes, and the pattern of walking improves.

The phasing of classes provides for a sequence of power and temporary loads, dynamic complications and the inclusion of different muscle groups in arbitrary motor activity. All this ultimately leads to the release of the patient from improvised means of support. Practicing a vertical posture and movement is also important because it contributes to the restoration of the function of the pelvic organs, improves the activity of all vital systems of the body. Therefore, training in movement is also necessary in the residual stage, even with gross and functionally irreversible changes. In these cases, efforts are directed to the elimination of pathological relationships between the muscles of the extremities, discordant contractures, restoration of support ability, inclusion in the movement of muscles that are not normally involved in it, and ensuring the possibility of orthograde movement. A new walking stereotype is being created, requiring additional muscle work.

During training and retraining of the patient, orthopedic means - prosthetic devices and supporting devices are widely used. Rational prosthetics improves the conditions of limb support, helps to reduce asymmetry in all respects. Additional reliance on auxiliary handy devices reduces the frontal component, lateral torso sway and foot turn, and makes it easier to keep the body in balance. Thus, the use of DR as a differentiated system for the use of movements for therapeutic purposes, used in appropriate combinations and in a certain sequence, makes it possible to selectively influence denervated and altered muscles. The effect is provided by the restoration or reconstruction of lost functions, their replacement by others or the formation of new ones with the help of orthotics.

Our analysis of the scientific and methodological literature made it possible to identify a number of the most effective methods of motor rehabilitation.

Restorative therapeutic gymnastics. The main purpose of this type of exercise is a general stimulating effect. Such exercises are included in all gymnastic complexes in alternation with targeted activities. General strengthening gymnastics in the form of non-specific elementary gymnastic exercises of a general nature is aimed at activating the cardiovascular system, respiration, improving metabolic, elementary and autonomic functions. Gradually, in the course of classes, general strengthening exercises are obscured by special ones. However, such a replacement in medical complexes should not be complete: subsequently, the exercises alternate with more or less frequency. Techniques for performing general strengthening exercises are described above, when considering exercises of mobilizing gymnastics. It should be noted that targeted gymnastic activities on motor-visceral reflexes stimulate the activity of internal organs. And yet, in some cases, there is a need for special organ-functional stimulations, which can be facilitated by specially selected exercises.

Breathing exercises. Its goal is to help reduce congestion in the lungs by freeing the bronchi from the accumulated secret and increasing pulmonary ventilation. Congestive lungs often complicate the course of traumatic spinal cord disease. Hypodynamia, a decrease in lung excursion due to weakness of the intercostal muscles, a decrease in diaphragm mobility create conditions for obturation of the bronchial tree with mucus, the breathing rhythm is upset, and hypoxia occurs. Respiratory disorders are especially common in patients with injuries of the cervical spine and spinal cord. Therefore, respiratory gymnastics should be included in medical complexes in all patients with high localization of damage.

Based on the task, as well as methodological techniques, for people who have suffered a spinal injury, it is most expedient to combine elementary gymnastic exercises (dynamic exercises) with special starting positions (static exercises). These exercises can be strengthened by the methodologist's hand - tapping, vibration, compression. Providing a local impact on the upper or lower part of the chest alternately, the methodologist can include one or another segment of the lung in vigorous activity. Additional techniques are breathing through a tube, inflating rubber chambers, breathing through a closed mouth, etc. This increases the depth of breathing and stimulates the respiratory muscles and additional resistance. In the course of the lesson, frequent changes in drainage positions should be practiced. Breathing exercises are carried out 3-4 times a day for 15-20 minutes, before that it is advisable to perform several general strengthening exercises (Appendix B).

In patients with spinal cord injury, physical activity causes an excessive increase in the minute volume of breathing, which impairs gas exchange and significantly reduces physical performance. Special trainings are carried out aimed at restoring the optimal level of minute breathing volume. Exercises consist in an extended (from 5-8 to 15-20 s) inhalation through the nose with an involuntary duration of exhalation through the mouth. This enhances the exhalation power of the ability to exhale large volumes of air, improves gas exchange and creates favorable conditions for reducing the pathological intensity of inhalation. The minute volume of breathing at the same time is increasingly approaching the proper value. Exercises will be more effective if they are combined with movements - torso tilts to the sides (if classes are held in a sitting position) or with squeezing and unclenching the hands (if classes are held in a prone position).

Therapeutic exercises for neurogenic disorders of urination. The main goal of gymnastic exercises for spinal urination disorders is the ability to normalize the functions of the sphincter apparatus of the bladder. The treatment complex includes exercises for the abdominal muscles, back, perineum, as well as exercises with abdominal breathing, tension in the abdominal muscles, various movements of the legs (abduction and adduction, flexion and extension) and the pelvis. Under the influence of these exercises, an alternating drop in intra-abdominal pressure occurs, and the hemodynamics of the pelvic organs will also improve. In the acute stage of the early period of traumatic disease of the spinal cord, when the passage of urine, as a rule, is difficult, the treatment complex includes exercises for tension of the abdominal muscles, abdominal breathing, efforts to tighten the perineum. Gradually, the load is increased, passive movements of the legs, turns on the side are additionally introduced. By the end of this period, bending of the legs, movements of the pelvis, careful deflections of the spine in the lumbar region can be carried out. Free urination is facilitated by the transfer to a vertical position. This is allowed for a short time and only with reliable immobilization of the spinal column. In a standing position with fixation behind the knee support, bends, deflections, point-like tensions of the abdominal wall are recommended (Appendix B).

At vesicoureteral reflux applied postural treatment. To do this, the head end of the bed is raised by 40-50 cm. Passive leg movements are performed in the form of adduction-abduction, internal and external rotation of the feet. The patient can be given an elevated position for 30-40 minutes on an orthostand (or Gracchus table) set at an angle of 45-60°. An even greater effect is noted when the patient is transferred to a standing position. This is complemented by lateral deviations. The patient at this time should be transferred to chest breathing, all exercises with tension in the abdominal muscles should be excluded. Shaking gives good results.

At urolithiasis(in such patients, as a rule, it proceeds without a characteristic pain syndrome, unless obturation of the stone has occurred) gymnastics is performed, as with reflux. In some cases, with small stones, this contributes to their discharge. For large calculi and staghorn stones, these exercises and postural treatment promote urine flow.

Mobilizing gymnastics. Mobilizing exercises are usually carried out in the form of morning hygienic gymnastics with elements of breathing exercises and strength exercises. They have a preventive focus, have a general strengthening and tonic effect, improve blood circulation, respiration, and contribute to the normalization of metabolic processes and tissue metabolism. They seem to prepare the patient for the main activities during the day. The exercises are simple, of the same type, accessible, cover various muscle groups, that is, they correspond to the principle of load dispersion. In this case, the main physical efforts fall on healthy muscles, denervated muscles are passively included in the work - by the patient himself or with the help of an instructor.

In the early period of a traumatic illness, classes are conducted by an instructor; in the chronic and residual stages, the patient must work on his own. Patients with damage to the cervical level of the spinal cord need the constant help of an instructor. Since mobilizing gymnastics improves general physiological processes, we believe that patients with spinal cord injury should have no contraindications for it. Mobilizing gymnastics is necessary at all stages of rehabilitation. Classes should begin already in the acute stage, on the 2-3rd day after the injury, and be carried out regularly, regardless of changes in the general condition of the patient. In case of poor health, fever, etc. it is only necessary to reduce the procedural dosage. During classes, light positions can be used. To perform passive exercises, the patient can use blocks, hammocks, loops. Strength exercises are performed using dumbbells, expander, mace. Exercises are performed at a slow pace. The duration of classes is 15-20 minutes. In weakened patients, the time of classes is reduced to 10-12 minutes. (Appendix D).

Analytical gymnastics. The basis of analytical gymnastics is the development of voluntary movements in individual joints of the limb by educating active regulation of muscle tension, relaxation and reciprocal contractions of the muscles - antagonists of this segment of the limb. Therefore, it is also called segmental gymnastics. Analytical gymnastics faces local tasks - to increase the volume and strength in a certain muscle or muscle group, to stimulate the recovery of movements in them. However, the formation of isolated reciprocal movements in individual joints subsequently ensures the development of complex motor acts. Such regulation of muscles can be static and dynamic.

Analytical gymnastics. The basis of analytical gymnastics is the development of voluntary movements in individual joints of the limb by educating active regulation of muscle tension, relaxation and reciprocal contractions of the antagonist muscles of this segment of the limb. Therefore, it is also called segmental gymnastics. Analytical gymnastics faces local tasks - to increase the volume and strength in a certain muscle or muscle group, to stimulate the recovery of movements in them. However, the formation of isolated reciprocal movements in individual joints subsequently ensures the development of complex motor acts. Such regulation of muscles can be static and dynamic.

Static gymnastics. The general name "static gymnastics" means two concepts: 1) mental imagination of any movement - an ideomotor exercise; 2) rhythmic isometric muscle tension.

Ideomotor gymnastics. In the literature, one can find recommendations for “volitional tensions”, “impulse gymnastics” for muscles in an inactive state, “sending impulses to move” an immobilized or denervated limb, that imaginary movements are accompanied by minimal muscle contractions that can be objectively recorded. Since there is no visible shortening of the muscle during the ideomotor exercise, such a movement should be classified as postural, and the training itself as static. As 3.M. Ataev (1973), "... imaginary movements are also essentially isometric" . However, the physiological mechanisms of the ideomotor act differ significantly from the mechanisms underlying the isometric ones. When mentally reproducing the movement, the bioelectrical characteristics of the muscles are identical to those during real movement, they are only reduced in amplitude and frequency of oscillations, which gives reason to consider the imaginary movement as a true motor act with a sharply reduced intensity of excitation processes in the muscles. When mentally reproducing movements, an increase in fatigue and vegetative reactions was noted. 3M. Ataev found that this was due to the patients holding their breath at the time of training and proposed a system of exercises with controlled breathing.

Isometric gymnastics. Volitional excitation of impulses of active movement, in which the muscle tone increases, but without its shortening, is usually referred to as isometric tension. The idea of using isometric spinal cord disease is tempting in that this type of training results in an increase in muscle mass and strength. Z.M. Ataev found that with isometric tension, the efferent discharge is amplified against the usual one due to the impulsation of muscle spindles, which is not suppressed by muscle fibers, since there is no moment of muscle contraction. Such amplification contributes to the distribution of the bioelectrical influence of the activity fields of the involved motoneurons to neighboring, initially unexcited, cells and recruits them. And since the contracting muscle fiber, in addition to the force of tension, will simultaneously act in the opposite direction of the stretching force, the contractile proteins are rearranged, and plastic processes in the muscle are stimulated. Hypertrophy of the same muscle provides its strength indicators. The method of isometric gymnastics is suitable both in the early and late periods of traumatic spinal cord disease. It can be used for flaccid, spastic paresis, and plegia (Appendix E).

If during ideomotor gymnastics the patient mentally constructs a movement and reproduces it in his imagination, then an isometric exercise is a actually performed motor act, reproduced in a static voltage mode. With spastic paresis and paralysis, isometric gymnastics contributes to the development of conscious regulation of the degree of muscle tension, active relaxation and repiprocal contractions of the antagonist muscles. The development of the patient's ability to voluntary relaxation of spastic muscles is possible only after cultivating the ability to maximize their tension. The emerging muscle hypertrophies contribute to an increase in the performance of muscles in overcoming, holding and fixing work. Overcoming hypertonicity makes the movement freer, more voluminous, and the muscles more plastic. In the case of flaccid paralysis and paresis, isometric training is an effective means of combating muscle atrophy, and the strength gain in the muscles helps to overcome the motor defect. The method of using additional afferentation in patients with spinal cord injury is simple and easy to implement.

Such exercises are complicated by using blocks with balancing resistance. In this way, any muscle can be trained. During classes, it is very important to avoid holding the patient's breath. According to the studies of Z.M. Ataev, temporary loads for 5-7 s are the optimal mode. Large exposures, without providing the effect of the development of muscle strength, lead to pronounced and persistent vegetative shifts. Training should be performed 2 times a day, classes are held during all periods of traumatic spinal cord disease.

Kinetic gymnastics. This includes dynamic training of individual muscles in isotonic mode. The purpose of training is to strengthen the muscular system, improve plasticity and tone, increase joint mobility, nurture and stimulate voluntary movements, and prepare the patient to perform complex complex movements. According to their purpose, these are special exercises, since they are specifically aimed at the isolated inclusion of certain muscles, avoiding substitutions and complex combinations. According to the method of performing exercises of this type of gymnastics, they can be passive, passive - active and active. In general, they are aimed at developing simple motor acts (flexion, extension, abduction, adduction, rotation). Classes begin with exercises for the preservation of muscle groups in order to repercussively affect the paretic muscles. Particular attention is paid to exercises to strengthen the muscles that provide grasping function and stability when walking. Training programs for patients with various forms of movement disorders should be built differently. Selective training methods for flaccid forms of paresis are stimulating in nature and are aimed at increasing muscle tone and maximizing the inclusion of idle and weakened muscles in voluntary motor activity. Methods of stimulation of non-working and strengthening of weakened muscles consist in the activation of synergists, the use of facilitating positions; exercises for spastic paresis are relaxing in nature with training in the management of spastic. Relaxation methods include the use of such stimuli for muscle activity that would overcome the functional impairment and compensate for it: elongation, the inclusion of antagonists in counteracting the spasmodic muscle and their reversion; the load should be dispersed with alternating activity of the affected and intact segments. Muscle load in the process of training is increased gradually due to the starting position, resistance, number of repetitions; Classes are held individually 2 times a day every day. Training begins with the proximal joints, exercises in the distal limbs are repeated 20-25 times, in the proximal - 10-15 times. With flaccid paralysis and paresis, exercises are performed rhythmically at a fast pace, with spastic - in a calm, slow; at first, exercises are carried out under visual control 3-4 times, then with closed eyes (as if internal experience of movement) 5-6 times, then again under visual control (Appendix E).

Mechanotherapy. By mechanotherapy is meant the performance of gymnastic exercises for the development of movement in individual joints with the help of various devices. It has been proven that local effects of mechanotherapy devices through the excitation of proprioceptors and the central zones of the motor analyzer have a wide impact on the body as a whole. Activation of proprioceptors causes reflex shifts in the autonomic nervous system. According to the mechanism of motor-visceral and motor-skin reflexes, blood circulation in the trained limb is enhanced. Mobility in the joint increases under the influence of inertial forces produced by the movement of the pendulum. Weak rhythmic stimuli in total provide a concentration of excitation in the nerve centers, which, through irradiation and induction, leads to the appearance or intensification of reflex motor discharges. The cyclicity of muscle activity during exercise improves the voluntary regulation of muscle contraction and relaxation, and changes muscle strength.

In the rehabilitation treatment of patients with spinal cord injury, where long-term repeated repetition of the same type of movements is required, mechanotherapy is necessary as an obligatory component. Mechanotherapeutic training provides the possibility of mechanical stretching of soft tissues in case of muscle spasticity. Hardware gymnastics contributes to the development of articular contractures, increases proprioception, which is pleasant to consider the most promising direction in therapeutic exercises. Mechanotherapy allows you to limit the dispersion of force orientation and apply training in the desired direction. Improving local and general hemodynamics and tissue trophism, increasing muscle strength make mechanotherapy an indispensable method for the functional restoration of the hand and fingers. The locality of the impact, the ability to dose resistance, a certain rhythm - all this makes hardware training a particularly valuable therapeutic tool.

There are several main types of mechanotherapeutic devices that differ in the principles of using the laws of mechanics:

Lever devices. These designs include Zander apparatuses. Their work is based on the principle of a two-arm lever.

pendulum devices. These include the devices of Karo, Krukenberg, Stepanov, working on the principle of a pendulum.

Block devices. Tilo's block installations can serve as an example.

Apparatuses with overcoming elastic or spring resistance, similar to Hertz apparatuses.

Tasks of mechanotherapy: 1) to actively influence contractile and plastic muscle tone; 2) increase the strength and endurance of hypotrophic muscles; 3) influence the mobility of the joints; 4) increase afferent impulses in defective muscles. Classes should be programmed according to the phases of generalization, concentration and automatism of movements. Exercises are carried out in a certain sequence - first dynamic, cyclic and strength, then exercises with strict detail. With spastic paresis and contractures, procedural techniques are built with stretching exercises, with flaccid paresis, strengthening exercises are prescribed. A number of designs allow you to install the apparatus for preferential extension or flexion of the joint. When prescribing mechanotherapy to patients with flaccid paresis, special care should be taken not to aggravate the looseness of the joints. This is facilitated by a gradual increase in amplitude in alternation with strength exercises.

The effectiveness of mechanotherapy is ensured by the system and sequence of classes. Hardware training should begin as soon as the patient can sit up on his own. In people who have suffered a spinal injury, many authors consider the most rational use of mechanotherapy before therapeutic exercises. Classes begin with minimal dosages. Loads on the joint and muscle groups are dosed by changing the mass of the load, the length and angle of the pendulum, the frequency of its oscillations and the duration of the session.

MODERN ASPECTS OF REHABILITATION OF PATIENTS WITH SPINAL CORD INJURIES

Selivanov Evgeny Vladimirovich,

Karaganda State Medical University,

student of the Faculty of General Medicine,

Karaganda, Kazakhstan

ANNOTATION:

The development of modern methods of anesthesia and rehabilitation programs for patients with spinal cord injuries remains one of the most urgent problems of modern medicine. The relevance is due to the high pain syndrome and the large number of annual injuries of patients, as well as the lack of universal approaches to solving this problem.

Keywords: spinal cord injury, approach to problem solving.

Inga Boldt, Inge Eriks-Hoogland et all found that many people living with spinal cord injury (SCI) have chronic pain. In addition to painkillers, other treatment options are often offered. For one type of treatment, transcranial direct current stimulation (TSCT), the results of the two studies could be combined. The pooled results suggest that TSPT reduces pain in the short to medium term. Also, the use of exercise programs for chronic shoulder pain provided pain relief.

Jan Mehrholz et all, in a study of spinal cord injury patients, argue that locomotor gait learning is used in rehabilitation after spinal cord injury and can help improve a person's ability to walk. None of the locomotor interventions had a beneficial or detrimental effect on the people who took part. There is insufficient evidence that a locomotor training strategy is most effective in improving walking in people with spinal cord injury.

Berlowitz DJ, Tamplin J in the study of patients with spinal cord injuries indicate that after an injury to the cervical spinal cord, the muscles responsible for breathing are paralyzed or weakened. This weakness reduces lung capacity (lung capacity), the ability to take a deep breath and cough, and puts them at increased risk of lung infection. Any kind of respiratory muscle training was compared with standard care or sham treatment. For people with cervical spinal cord injury, there is a small positive effect of respiratory muscle training on lung capacity and strength of the muscles used for breathing. No side effects of respiratory muscle training have been found in people with cervical spinal cord injury.

Anne-Marie Bagnall, Lisa Jones et all, working with spinal cord injury patients, concluded that the benefits and harms of spinal fixation surgery in people with spinal cord injury are currently unknown. The quality of the existing evidence is too low to be included in the review as it is likely to be unreliable. Good quality controlled trials are needed to answer this question. Early decompression surgery may be beneficial, but no convincing evidence has been found for the effectiveness of surgical treatment for spinal cord injuries.

Foulon BL, Ginis KA when analyzing patients with spinal cord injuries revealed that the analysis did not reveal a significant effect of vignette on social cognition. An informational portrait vignette describing a physically active person with SCI and targeting multiple social cognitions is not recommended as a physical activity promotion strategy for people with SCI.

Jorge A Gutiérrez et all, in a study of patients with spinal cord injuries, argue that there are several types of interventions that could theoretically be effective in preventing fractures. The most common are: standing and walking endurance (eg, walking on a treadmill using long leg braces, weight transfer on a folding table, and a rehabilitation program using orthoses); exercise therapy (eg paraplegic athletes, wheelchair athletes, muscle stretching and resistance training); exercise methods (eg yoga and tai chi); electrical stimulation (eg, transcutaneous electrical nerve stimulation (TSET), vagus nerve stimulation, cyclic functional electrical stimulation, functional electrical stimulation to the quadriceps femoris and tibialis anterior muscles, electrical stimulation of the plantar muscle, and electrical acupuncture); manipulation of the musculoskeletal system (eg, spinal manipulation, acupressure, movement therapy, and massage); and other physical interventions (eg, low-intensity pulsed ultrasound, shock vibration, hydrotherapy, hyperthermia, ammotherapy, diathermy, steam bath, and myofunctional therapy).

Constanza Montenegro et all, in a study of patients with spinal cord injury, found that antiresorptive therapies comprise five major classes of agents: bisphosphonates, estrogens, selective estrogen receptor modulators (SERMs), calcitonin, and monoclonal antibodies. Combinations of antiresorptive agents may provide additional benefits over monotherapy. For example, one study found that hormone replacement therapy added to bisphosphonates or calcitonin provided an additional benefit. Antiresorptive agents reduce bone resorption through a variety of mechanisms, including physicochemical, cellular, and biochemical processes to reduce or stop bone loss.

Rice LA, Smith I et all in a study of spinal cord injury patients concluded that for participants who perform assisted or dependent movements, the use of a sound structured educational program during acute inpatient rehabilitation has the potential to significantly improve movement quality.

Patzer D, Vu P et all in a study of patients with spinal cord injury found that changes in gait appear to be more pronounced in patients with moderate to tonic spasticity in the lower extremity compared to subjects with milder spasticity. The results so far suggest that whole-body vibration as a preliminary intervention may be beneficial for patients with high levels of spasticity in the lower extremity.

Zewdie ET , Roy FD in the study of patients with spinal cord injuries conducted the following: two groups of participants were trained for 2 months by the method of endurance or precision training. Then 2 months of rest before moving on to another type of training. Both forms of training increased maximum motor-evoked potential. Although gait function was improved by both forms of training, a positive correlation on clinical gait scores was only achieved after endurance training.

Han ZA, Song DH et all, working with patients with spinal cord injuries, have found that botulinum toxin type A can reduce intractable chronic neuropathic pain in patients with spinal cord injury. The correlation coefficient has a high level of evidence.

From the American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, I have concluded that virtual walking for the treatment of neuropathic pain associated with spinal cord injury (SCI-NB) can be beneficial. Experimental results indicate that SCM-NB responded to treatment regardless of the site of pain, with the trend towards the greatest decrease in SCI-NB levels.

Yang JF, Musselman KE et all, when working with patients with spinal cord injuries, described the following: participants for 7 months were randomly assigned to start accuracy or endurance training. Both forms of training resulted in significant improvement in walking, and endurance training produced greater improvements in walking distance than precision training, especially for highly functional walkers who had an initial walking speed of >0.5 m/s. Intensive walking in the chronic phase after spinal cord injury is effective in improving ground walking.

Klose KJ, Schmidt et all, in a study of patients with spinal cord injuries, subjects received either 1) controlled physical therapy (PET), 2) neuromuscular stimulation (NMS), or 3) electromyographic (EMG) biofeedback. Significant improvement over time was found in all dependent measures, with the exception of voluntary EMG.

Fu G, Wu J, Cong et all conducted a study in patients with spinal cord injury comparing two doses of botulinum toxin-A. A regimen of Botulinum-A 200 U toxin injection including bladder trigonus can achieve a short-term effect comparable to that of a standard 300 U injection excluding trigonus. It may be an effective and safe treatment for neurogenic incontinence in patients with spinal cord injury. After the injection, no toxic or side effects were observed in both groups.

Knikou M and Mummidisetty CK, while studying patients with spinal cord injuries, made the following conclusions that locomotor training changed the amplitude of EMG excitability in the locomotor, promoted the coordination of intracranial and interlympic movements, and had a different effect on cocontraction between the antagonistic muscles of the knee and ankle joint in the injured leg. compared to the weakened leg. The results provide strong evidence that locomotor training improves premotor neuronal control after SCI in humans at rest and while walking.

Tai Q, Kirshblum S et all found the following in their work with patients with spinal cord injuries: Gabapentin has a beneficial effect on some types of neuropathic pain. There was a significant reduction in "discomfort" and a downward trend in both "pain intensity" and "burning".

Groah SL, Lichy AM et all in a study of patients with injuries of the dorsal spine made the following conclusions: the loss of bone mineral density (BMD) of the lower extremities increases with distance from the spine. An intensive lower extremity ES program may attenuate BMD localization after acute motor UTI, although it is not known if these benefits are maintained in the long term.

Harness E T et all, in a study of patients with spinal cord injuries, concluded that after 6 months, subjects with intense physical activity had a significantly greater increase in motor activity than subjects with control intervention. Multimodal intense physical activity can significantly improve motor function in patients with chronic SCI.

Arija-Blázquez A, Ceruelo-Abajo S et all found the following when working with spinal cord injury patients: The intervention group showed a significant increase in quadriceps femoris size compared to the control group. The loss of bone mineralization was the same in both groups. Basal levels of bone biomarkers did not change over time. Glucose and insulin peaks moved forward after exercise in the intervention group.

This study shows that the skeletal muscle of patients with complete SCI retains the ability to grow in response to longitudinal EMS training, while the bone does not respond to such external stimuli.

Hoffman L, Field-Fote E when studying patients with spinal cord injuries revealed the following: the results were evaluated before and after the control and the intervention period. Compared to the control/delayed intervention, the intervention group had greater changes in transient function and corticomotor area, regardless of whether the practice was combined with functional electrical stimulation or with somatosensory stimulation. Regardless of stimulation type, bimanual subgroups improved more than single-gene subgroups on bimanual manual testing.

Shuai L, Yu GH, Feng Z et all in a study of patients with spinal cord injuries found that a gait orthotic helped patients with paraplegia to stand up and walk independently, although this method could not be individualized for patients with various spinal cord injuries and functional recovery lower limbs. There is a great need to develop a custom gait orthotic to improve the overall quality of life of patients with paraplegia.

Nygren-Bonnier M, Werner J. when working with patients with spinal cord injuries revealed that people with spinal cord injury of the cervical spine have dysfunction of the respiratory muscles, which leads to a decrease in ventilation. Glossopharyngeal insufflation was seen as a life-changing opportunity by improving respiratory function, both immediately and over time, and thereby making daily activities easier. Increasing autonomy can lead to increased self-esteem and increased well-being.

Gassaway J, Jones ML et all in a study of spinal cord injury patients found that individuals who receive intensive peer mentoring during and after rehabilitation for spinal cord injury patients demonstrate higher self-efficacy outcomes over time and have fewer days of unplanned readmission to hospital. the first 180 days after discharge.

Hoffman H, Sierro T. in working with patients with spinal cord injuries found the following results: A weekly activity-based therapy program based on hand-to-hand combat is feasible and effective in increasing manual task performance in subjects with spinal cord injuries.

Anna Z, Katarzyna JW. in a study of patients with spinal cord injuries found that mesenchymal stem cells, as well as olfactory cells, seem to have a therapeutic effect on the injured spinal cord and may be useful in neuroregeneration. Recent studies in animal models and the first human trials give spinal cord injury patients hope for recovery.

Scandola M, Aglioti SM. in a study of patients with spinal cord injuries, types of misconceptions about the body have been studied. Six different types of bodily illusions were identified: feelings of loss of the body; Wrong body parts; Somatoparafenia; Feeling disappointed; Illusory movement and misoplegia. All of these types (with the exception of misoplegia) are modulated by clinical variables such as pain, completeness of the lesion, level of the lesion, and length of time since the onset of the lesion.

Shulga A, Lioumis P. in the study of patients with brain injuries came to the following conclusion that one session of paired associative stimulation can induce transient plasticity in patients with spinal cord injury. A paraplegic patient, previously paralyzed below the knee, recovered the plantar reflex and the dorsal musculature of both legs. The tetraplegic patient regained grasping ability. New acquired voluntary movements can be performed by patients in the absence of stimulation and for at least 1 month after the last stimulation session.

Conclusion. At the moment, a full-scale search for ways to solve this problem is underway. Against the background of the above methods of anesthesia and rehabilitation of patients with spinal cord injuries, one can judge a significant improvement in the quality of life of patients with an increase in physical and social adaptation.

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