Kinesitherapy and massage in the rehabilitation of patients with acute cerebrovascular accident. Violations of cerebral circulation Indications for massage

Classical and TM massage for stroke.

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The position of the patient is lying on his back.

In this disease, special care should be taken to ensure that the head, trunk, limbs of the patient are in the most convenient physiological position.

Start massage from the lower extremities, and it is customary to start it from the affected limb and carry it from the proximal to the distal (thigh, lower leg, foot).

Then they massage the back, shoulder girdle (region of the trapezius muscle), chest, paying mainly attention to the affected side.

Determining the set of techniques and their sequence, it must be taken into account that in the paretic muscles under the influence of massage, fatigue phenomena quickly occur. That's why massage should not be long, and techniques should be performed in a gentle mode. Otherwise, the result of the course may be persistent muscle weakness, cases of increased muscle atrophy are described.

With spastic paralysis, where massage is carried out in order to reduce reflex excitability in the muscles, improve their trophism, it is recommended to start the session with exercises that restore the ability to relax the muscles, developing the ability to slow down muscle spasms during movements. Therefore, in the first sessions, you should not use kneading and shock techniques, as they increase reflex excitability. But it is not advisable to refuse them for a long time, because they are the ones that revitalize the blood and lymph circulation in inactive muscles to a greater extent, and prevent the occurrence of trophic disorders. The success of the course depends on how quickly the patient learns, at least partially, to inhibit involuntary muscle contractions at rest and during movement, and it will be possible to massage using all types of techniques and quite intensively. In any case, it is necessary to massage the patient in the recovery period of acute cerebrovascular accident with the utmost care. The following sequence of restorative massage treatment is recommended:

First four treatments- massage only the proximal parts of the limbs, without changing the position of the patient.

The next four procedures- massaging the limbs completely and the chest. If the patient's condition allows (this is not decided by the masseur, but by the attending physician), you can put him on a healthy side and massage his back and collar area.

Starting from the eighth procedure, you can change the position of the patient (lying on the back, on the stomach) and, along with the limbs and chest, completely massage the back and lower back.

Anterior thigh.

1. 
   Light planar stroking from the bottom up.
2. 
   Light wrapping stroking in the same direction.
3. 
   

1. 
   
2. 
   Embracing stroking.
3. 
   
4. 
   Surface planar stroking.
5. 
   pressure.
6. 
   Surface planar stroking.
7. 
   The stretch is longitudinal.
8. 
   Surface planar stroking.
9. 
   Stretching is transverse.
10. 
    Continuous labile vibration.
11. 
    Surface planar stroking.

On the anterior surface of the leg a more energetic complex should be recommended.

1. 
   Light flat stroking.
2. 
   Embracing stroking.
3. 
   Spiral rubbing II-V fingers.
4. 
   Surface planar stroking.
5. 
   pressure.
6. 
   Surface planar stroking.
7. 
   Hatching.
8. 
   The rubbing is comb-like.
9. 
   Surface planar stroking.
10. 
    The kneading is tongs.
11. 
    Surface planar stroking.
12. 
    Planing.
13. 
    Surface planar stroking.
14. 
    Continuous labile vibration.
15. 
    Surface planar stroking.

1. 
   Surface planar stroking.
2. 
   Embracing stroking.
3. 
   Rubbing I with fingers spirally along the intermetatarsal spaces.
4. 
   Embracing stroking.
5. 
   Rubbing is spiral-shaped with the supporting part of the brush.
6. 
   pressure.
7. 
   Surface planar stroking.
8. 
   The kneading is tongs.
9. 
   Hatching.
10. 
    Surface planar stroking.
11. 
    Continuous labile vibration.
12. 
    Surface planar stroking.

1. 
   
2. 
   Rubbing I with fingers spirally along the intermetatarsal spaces.
3. 
   pressure.
4. 
   Surface planar stroking.
5. 
   Continuous labile vibration.
6. 
   Light superficial planar stroking.

Back massage, including the latissimus dorsi, shoulder girdle with the transition to the deltoid muscle. In these areas, the muscle tone is not so high, so the massage can be performed much more vigorously, and the set of techniques should be expanded by kneading.

Massage top limbs. You can apply the same complex that is recommended for the lower limb, in relation to the parts of the hand.

Massage from the back of the shoulder , where the movements are carried out vigorously and in full set (as well as on the back of the thigh).

Anterior surface of the shoulder massaged in a sparing mode using a reduced complex (as for the anterior surface of the thigh).

Forearm massaged in a sparing mode on the front surface, vigorously - on the back.

Brush can be massaged quite vigorously on both sides, but it is better to use a gentle mode on the palmar surface.

The duration of the session is 15-20 minutes. Course 12-15 procedures.
For flaccid paralysis massage effects are carried out according to a stimulating method (vigorously, with a noticeable increase), while with spastic paralysis, sedative (inhibitory) methods are used, in which the masseur's efforts should be very moderate. This is where some vulnerability of classical massage techniques in the treatment of spasticity lies, since even the most sparing of his techniques under certain conditions or with minor errors of the massage therapist can cause an increase in muscle tone. In this regard, acupressure and linear massage are highly indicated as an effective and harmless means of relaxing spastic muscles.

However, the method of applying these types of massage in case of central (spastic) hemiparesis is not simple, since it involves a combination in one session of physiotherapy exercises with an inhibitory effect on some points and with stimulation of others.

Seems to be the most effective M. Ya. Leontieva's technique(1974), which provides for each area of ​​the body:

1. 
   Acupressure.
2. 
   Smooth, slow passive movements (3-5) together with acupressure.
3. 
   Similar active movements with the same segments of a healthy limb.
4. 
   Active (if possible) or passive movements with synchronous volitional impulses sent to the patient (idomotor movements, in the absence of voluntary muscle contractions).

This part of the session is also accompanied by acupressure.

The sequence of the session is as follows:

Upper limb - movements in the shoulder joint, in the joints of the hand and fingers, in the elbow joint.

Lower extremity: thigh - lower leg - foot. The duration of the session is 35-40 minutes.

During the session massage 8-12 TA. Course 15-20 sessions.

Upper limb.

Flexion of the shoulder to the horizontal. Before starting the movement, brake massage RP20 Zhou-zhong (BGM area), then VB21 Jian-jing (shoulder girdle) or GI15 Jian-yu (acromion).

Shoulder extension . In case of difficulty, GI14 Bi-nao is stimulated.

Full extension is facilitated by braking at the moment of movement of NW Shao-hai, P5 Chi-ze, R3 Tien-fu.

In the absence of contractions during idiomotor movement, stimulate RP20 Zhou-zhong or

C1 Chi Quan.

Shoulder abduction. Before moving, brake massage RP20 Zhou-zhong, C1 Chi-quan, IG9 Chien-zhen.

External rotation of the shoulder. Before movement, the muscles that rotate the shoulder inwards are inhibited by massage

C1 Chi-quan, IG9 Jian-zhen, or stimulate IG10 Nao-shu, IG12 Bing-feng.

Internal rotation of the shoulder. Facilitated by stimulation of C1 Chi-quan, IG9 Chien-zhen

or braking IG10 Nao-shu, IG12 Bing-feng.

Brush extension. MC7 Da-ling and TR4 Yang-chi brake at the same time

or stimulate TR5 Wai-kuan, TR6 Zhi-gou.

Bending the brush. As a rule, it turns out without difficulty.

Retraction of the brush. They slow down GI4 He-gu together with GI5 Yang-si.

Finger extension . Movement is difficult. Both before and during the movement it is necessary to brake GI4 He-gu, it is better together with IG3 Hou-si. For I-II fingers, combine with GI5 Yang-si inhibition.

opposition I finger facilitated by stimulating PI0 Yu-chi or inhibiting MC8 Lao-gong.

Supination of the forearm. In the case of a high tone of the round pronator, P5 Chi-tsze, P6 Kung-ju, P7 Le-tsue, P9 Tai-yuan slow down the square pronator.

Pronation of the forearm. As a rule, acupressure is not required, as is the case with forearm flexion.

Forearm extension. Before and during the movement, they slow down RZ Tian-fu, P5 Chi-ze, better together with NW Shao-hai, MSZ Qu-ze, GI10 Sho-san-li.

lower limb.

If the patient's condition allows, it is better to conduct a session on the side.

Hip flexion. Before the start of the movement, the E35 Du-bi, E34 Liang-qiu, E32 Fu-tu are slowed down. During the movement stimulate E31 Bi-guan, E32 Fu-tu.

Hip extension. Before the start of the movement, the E32 Futu is slowed down.

During the movement stimulate VB30 Huang-tiao, V36 Cheng-fu.

Hip adduction facilitated by stimulation of R10 Yin-gu, RP10 Xu-hai.

Outward rotation of the thigh. Brake massage R10 Yin-gu, RP10 Xu-hai, stimulating VB30 Huang-tiao, E31 Bi-guan.

Internal rotation of the thigh facilitated by the opposite effect on the same points.

Flexion of the leg. Before movement, the increased tone of the quadriceps femoris muscle is neutralized by inhibition E31 Bi-guan, E32 Fu-tu.

While moving, gently stimulate V40 Wei-zhong, V56 Cheng-jin.

Leg extension relieved before starting to move by braking V36 Cheng-fu,

during movement - by stimulating V32 Fu-tu, VB34 Yang-ling-quan.

Foot extension relieved before starting to move by braking V56 Cheng-jin, V57 Cheng-shan,

and during movement - by stimulating E41 Jie-si, E44 Nei-ting.

Equinovar foot placement , to eliminate the pathological posture, they slow down V56 Cheng-jin, V57 Cheng-shan, R3 Tai-si,

and then during abduction and extension of the foot (passive or active with help) stimulate

V62 Shen Mai, V60 Kun Lun with VB40 Qiu Xu.

Foot flexion , usually does not require TA massage.

Foot abduction requires pre-braking R8 Chiao-xin, P4 Zhong-feng.

During movement, stimulate V60 Kun-lun, V62 Shen-mai, V63 Jin-men.

Foot pronation. Before moving, they slow down RP2 Da-du, RP3 Tai-bai, RP5 Shang-qiu,

during movement stimulate V60 Kun-lun, V62 Shen-mai, VB40 Qiu-hsu.

Finger extension feet. F3 Tai-chun, VB41 Zu-lin-qi slow down before moving.

During movement, stimulate E41 Jie-si and E42 Chun-yang.

apply on the upper limbs stimulating massage TA E12 Que-pen, TR14 Jian-liao, TR4 Yang-chi, IG5 Yang-gu, IG9 Chien-zhen, NW Shao-hai, MC7 Da-ling, P5 Chi-ze, GI11 Qu-chi, GI4 He -gu.

On the lower limbs: RP12 Chun-men, RP10 Xue-hai, VB34 Yang-ling-quan, VB31 Feng-shih, VB3O Huang-tiao, VB29 Ju-liao, E36 Zu-san-li, E41 Jie-si, V40 Wei-zhong, V57 Cheng-shan, V60 Kun-lun, R3 Tai-si.

The most common cause of acute disorders of cerebral circulation is ischemic (a consequence of thrombosis or vascular embolism) or hemorrhagic (hemorrhage) stroke. The residual effects of strokes are manifested by paresis (decrease in muscle strength) or paralysis (complete lack of muscle strength). Paresis and paralysis are called central. They are caused by damage to the motor centers and pathways. Paths are called pyramidal (spastic). Paresis and paralysis are characterized by increased muscle tone, high tendon reflexes, and pathological signs. The first time after a stroke, muscle tone may be reduced, but then it increases.

With pyramidal paresis, the arm is brought to the body and bent at the elbow. The hand and fingers are bent. The leg is extended at the hip and knee joints. The foot is bent and turned with the sole inward.

In paretic (weakened) limbs, synkinesis (friendly movements) occurs. They can be imitation and global. With imitation synkinesis, movement occurs on one limb when the other is moving; when the healthy limb moves, the diseased one also moves. With global synkinesis, when trying to perform isolated movements, flexion contracture (muscle tension) in the arm and extensor contracture in the leg increase: when trying to straighten the arm, the arm bends even more, in the leg it unbends. Because the points of attachment of individual muscles are brought together for a long time, these muscles shorten over time. Prolonged rest leads to stiffness of the joints. Cold, excitement, fatigue worsen movement.

The purpose of the massage- reduce the reflex excitability of spastic muscles, weaken muscle contractures, activate stretched muscles, help restore movement, trophic disorders (cold skin, swelling, discoloration).

Massage area - paretic limbs, back with lower back and chest on the side of the lesion.

tricks- stroking, spiral rubbing. For the antagonist of spastic muscles - kneading, preferably gentle longitudinal, felting and pressure. Intermittent vibration is contraindicated. If well tolerated, continuous vibration can be used.

Starting position - lying on your back, under your knees - a roller. If synkinesis appears, then the non-massaged limb is fixed with a bag of sand. The outer surface of the leg can be massaged on a healthy side, and the back surface - on the stomach. A pillow is placed under the stomach, a roller is placed under the ankle joint.

Massage Sequence. First, the front surface of the leg is massaged, then the pectoralis major muscle on the side of the lesion, the arm, the back of the leg, and the back. The limbs are massaged from the proximal sections.

Before the massage, it is necessary to relax the muscles by shaking, passive exercises at a slow pace (for example, rolling a rolling pin with the palm of your hand or sole), slight shaking of the muscles of the thigh and chest, and warming the limb. To relax the muscles of the foot, light massage and shaking of the Achilles tendon are used.

Massage technique

1. Massage of the lower limb.

a) First, an uninterrupted light superficial planar and embracing stroking, spiral rubbing of the thigh is performed, then selective massage of the muscles of the anterior, internal and posterior groups, because. muscle tone is high, then they are gently massaged.

b) Massage of the gluteal muscles.

c) Leg massage. General exposure, stroking and rubbing, then selective muscle massage. The muscles of the anterior and outer surface of the lower leg are stroked, rubbed and kneaded. The back surface of the lower leg is massaged gently by stroking and rubbing. gently massage the Achilles tendon.

d) Foot massage. Stroking, rubbing, kneading are used on the back of the foot. On the sole, the tone is high, ridge-like kneading is used, preventing extension of the first toe (Babinski's symptom).

2. Massage of the pectoralis major. A gentle massage is carried out, surface planar stroking, light rubbing and shaking can be used.

3. Massage of the upper limb.

a) Shoulder massage begins with the trapezius, latissimus dorsi, deltoid and pectoral muscles. When massaging the back, a special effect is made on the trapezius and latissimus dorsi.

A preparatory shoulder massage is performed, stroking and rubbing, and then a selective muscle massage.

b) Massage of the forearm. A general effect is made (stroking and rubbing), then a selective massage. First, the extensors are massaged (stroking, rubbing, kneading), then the flexors (stroking and rubbing).

c) Hand and fingers. First, the fingers are massaged, then the back and palmar surfaces of the hand. On the back - stroking, rubbing and kneading, on the palmar surface - stroking and light rubbing.

4. Back massage. Use all known techniques, but sparing.

Methodical instructions.

1. Each technique is repeated 3-4 times.

2. In the first three procedures in the early stages after a stroke, only massage of the proximal limbs is performed, without turning on the stomach.

3. On the 4th - 5th procedure, a massage of the chest, distal extremities (shin with foot and hand with forearm) is added with a turn to the side.

4. From the 6th - 8th procedure, a back and lower back massage is added. Later, the prone position is used.

5. After two months or more, on the first three procedures, a massage of the limbs is performed, after the third, a back and lower back massage is added.

6. During the massage of the hand, the 3rd - 5th fingers are kept unbent, and the first - retracted. During the massage, the legs lift the outer edge of the foot and set the foot at an angle of 90 degrees to the lower leg.

7. With complaints of heaviness in the head, headache. dizziness is added by massage of the head, neck and collar zone. The technique depends on blood pressure.

8. On the day of an epileptic seizure, massage is not performed.

9. Massage is combined with exercise therapy and position treatment.

Position treatment carried out from the first days of the disease to counteract the formation of contractures or to reduce them.

ü The foot is fixed at an angle of 90 degrees, penetrated, and a board, box, etc. is placed to stop the foot at the foot end of the bed.

ü An extended arm from the body to an angle of 90 degrees or as much as possible.

ü The shoulder is placed outward, the forearm is supinated, the fingers are almost straightened. A bag of sand is placed on the palm, the first finger is abducted, the hand is placed on a chair next to the bed.

Treatment with the position is carried out 3-4 times a day for 10-40 minutes, depending on the patient's condition. In a state of sleep, positional treatment is not carried out.

10. Passive movements include in the early stages of the disease.

Between the masseur's hands there should be only one exercised joint. Before passive movements, active movements are carried out on a healthy limb, the same as subsequent passive ones. In the future, active movement on a healthy limb is performed simultaneously with a passive movement of a diseased limb. Subsequently, these movements are performed alternately: with active movement, the healthy limb is bent, the diseased limb is passively unbent.

11. It is better to start active movements with movement in a horizontal plane, when you do not need to overcome gravity. Bend-unbend the leg better on the side.

One should strive for flexion and external rotation of the shoulder, for extension and supination of the forearm, for extension of the hand and all five fingers, for abduction and adduction of the bent hip, for flexion of the hip in the hip joint during its internal rotation, for flexion of the lower leg, for dorsiflexion of the foot with while raising its outer edge.

12. When it is allowed to sit, passive movements are carried out for the belt of the upper extremities - raising and lowering the scapula, adduction and abduction of the scapula to the spine. The forearm and hand are extended.

13. When walking, pay attention to the position of the foot, do not take it to the side, do not touch the floor with your toe. Correct foot placement. It is enough to bend the leg at the hip and knee joint.

14. The duration of the procedure is from 5-10 to 15-20 minutes (according to Mashkov - up to 25 minutes). Course - 20-30 procedures. Break between courses - 14 days.

Cerebrovascular accidents occur for various reasons. It can be thrombosis, skull trauma, cerebral embolism. This happens due to a dynamic violation of cerebral circulation, hemorrhage in the brain.

There are characteristic symptoms that characterize the acute period of circulatory disorders in the brain. Such symptoms are paralysis of the muscles of the trunk and limbs on the opposite side of the lesion. First, there is a decrease, and then an increase in muscle tone. There are violations of the functions of blood circulation, metabolism, respiration. At this point, there is a general flaccid paralysis with areflexia, that is, tendon reflexes disappear. This process can be explained by the development of inhibition in the spinal cord. The decrease in muscle tone and areflexia in the area of ​​paralysis lasts longer than on the side not affected. When the cerebral phenomena end, muscle tone rises, tendon reflexes appear. During this period, there are symptoms of focal lesions of the brain, the spinal cord is disinhibited.

Approximately a few weeks after the period of acute cerebrovascular accident, instead of atonic phenomena, spastic ones appear due to the fact that there is no inhibitory effect of the cerebral cortex and the reflex activity of the spinal cord is manifested.

On the affected limbs, spastic phenomena increase, which eventually turn into contracture with a peculiar type of its distribution. In this situation, with spastic paralysis, all the muscles of the diseased limb are affected. During the transition from hypotension to spasticity, developed and strong muscles prevail over their own antagonists. So, the antagonists become stretched, the limb freezes in a specific position. In connection with the violation of lymph and blood circulation, cyanosis and edema appear in the diseased limb. Due to long forced inactivity, muscle atrophy and scoliosis develop. Increased reflex excitability can be observed in the muscles of paralyzed limbs. Tendon reflexes suddenly increase, this should be taken into account by the massage therapist during the massage procedures.

For about two weeks, it is necessary to prescribe rest. When the patient's condition improves, selective massage should be used on the affected limbs. In order to be able to quickly restore the functions of diseased limbs, it is necessary to prescribe a massage in a timely manner.

Before massage, the goal is to treat patients with spastic (central) paralysis and paresis: reduce reflex excitability, increase the tone of shortened muscles, strengthen weakened and stretched muscles, improve joint function, prevent their stiffness, improve lymph and blood circulation in diseased limbs, and prevent contractures . On tense and shortened muscles, light stroking and rubbing should first be applied, then, as the functional state of these muscles improves, light, gentle kneading should be used. Intermittent manual vibration should not be used because it can increase muscle hypertonicity. Before massaging stretched muscles, it is necessary to apply muscle massage with increased tone.

On stretched muscles, you must first apply rubbing and light stroking. Subsequently, over time, the massage therapist must increase the pressure force of the hands when applying these massage techniques, you also need to include felting, then longitudinal, semicircular, transverse kneading. But you should not use very energetic and strong massage techniques, as they can provoke overwork of stretched muscles.

It is necessary to massage every day, first for ten minutes on each limb, then for twenty minutes. Affected muscles tend to tire quickly, therefore, at the end of therapeutic exercises, it is necessary to carry out a light short-term massage for recovery, which consists of stroking techniques.
It is necessary to massage not only the muscles, but also the joints of the affected limbs in order to prevent and eliminate stiffness. In this situation, joint massage should be carried out based on the general plan of joint massage, anatomical and topographic features should be taken into account and mainly rubbing techniques should be used, combining them with passive gymnastics. In order to have a reflex effect on the affected limb, it is recommended to massage a healthy limb, based on the general plan using all massage techniques.
Before starting the massage of the upper limb, it is necessary to massage the pectoralis major muscle, the scapula zone, and the shoulder girdle. Before starting the massage of the lower limb, you need to massage the buttocks and the lumbosacral part. First, when the patient is on bed rest and it is forbidden to lie on his stomach, you should limit yourself to massaging the limbs for a while.
Before the massage, the limb must be warmed up, the massage should be performed exclusively with warm hands.
The course of massage for paralysis should include from fifteen to twenty procedures. The course must be repeated every few months until the affected limb is fully restored.

Paralysis and spastic paresis often develop with injuries and diseases of the spinal cord. If the upper cervical segments of the spinal cord are affected, diaphragmatic paralysis may occur. Hiccups, shortness of breath, spastic paralysis of the muscles of the arms and legs appear, below the level of the lesion there is a complete loss of sensitivity. There is a disorder of urination. There are radicular pains that radiate to the back of the head.

If the cervical thickening of the spinal cord at the level of the C5-D2 segments is affected, spastic paralysis of the lower extremities and flaccid paralysis of the upper extremities often develop. Sensitivity is completely lost, urination is upset. There may be radicular pain radiating to the upper limb.

If the thoracic segments D3-D12 are affected, then spastic paralysis of the lower extremities may develop, urination disorder occurs, loss of sensitivity occurs below the level of the lesion. There are radicular pains of girdle character. With the development of a patient with spastic paralysis of the lower extremities and flaccid upper limbs, a massage technique is used on the upper limbs, as in flaccid paralysis.

03.09.2015 2133/7153

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A stroke is an acute cerebrovascular accident. This is a dangerous, disabling pathology that can lead to death.

The rehabilitation period after acute cerebrovascular accident lasts, on average, from six months to two years. All this time, the patient is shown: taking angioprotectors, exercise therapy and massage.

You can massage the affected areas of the body at home. It's important to know how to do it right.

Tasks

During an ischemic or hemorrhagic stroke, certain parts of the brain are destroyed. As a result, the body loses those functions for which this or that cerebral structure is responsible. After a stroke, massage is indicated to solve the following problems:

• Removal of muscle hypertonicity. As a result of spasm, so-called. hyperkinesis: areas of spasmodic muscles. Rehabilitation massage is designed to relieve a pathological symptom.
• Normalization of blood circulation in tissues. This is vital for bedridden patients, as it prevents the development of bedsores.
• Optimization of the work of internal organs. As a result of damage to the brain, the whole body comes into dissonance. Massage allows you to improve the work of all body systems.
• The described treatment process is necessary to restore the functions of paralyzed limbs (arms and legs).
• Massage treatments reduce pain.

The procedure is prescribed to restore the general condition of the body.

Advantages and benefits of massage treatments

Restorative massage after a stroke has pronounced beneficial properties:

• It improves the outflow of lymph from the hands and feet, reducing swelling of the extremities.
• Rehabilitation massage makes it possible to normalize the work of the digestive organs, the cardiovascular system, the body as a whole, as it eliminates congestion.
• It reduces the risk of developing pneumonia (a common occurrence in bedridden patients).
• Normalizes the psycho-emotional state of the patient. This is important, given that stress during the recovery period is contraindicated.
• Improves nutrition of affected tissues.

The usefulness of this technique resonates with its objectives.

Features of the

Principles of

• Massage should be done in the morning, before lunch.
• The first sessions should last no more than five minutes. Over time, you can increase the time to ten to thirty minutes.
• The position of the patient - lying on his back or stomach. All muscles are as relaxed as possible. It is important that the upper torso is above the legs.
• Therapeutic massage after a stroke should begin with the upper body (from the head and neck to the lower extremities).
• In case of a stroke on the right side, the procedure should be carried out on the entire right side of the body, and vice versa, massage in case of a stroke on the left side affects this half of the body.
• The process begins with exposure to the collar region of the spine. Hand movements are smooth, unhurried. It is not necessary to squeeze the muscles with all your strength.
• An exception to the previous rule is with hyperkinesis and muscle hypertonicity. In this case, strong rubbing movements are shown, but only at 7-10 sessions, not earlier.
• These rules are also valid for individual limbs. So, a foot massage starts from the hip, a process for a paralyzed arm - from the shoulder, etc.
• It is necessary to exclude sudden movements.
• The massage therapist's passes should be rubbing to improve tissue nutrition. It is not necessary to push through the deep layers of the skin and muscles immediately.

Preparatory activities

It is necessary to create comfortable conditions for the session. In the room where the massage will be done, it is necessary to create a comfortable temperature regime, an atmosphere of silence, peace, since the main task of the massage process is to relax the patient.

The masseur offers the patient to lie on his back. The head should be on a high pillow. The knees are bent, a roller is placed under them. The process begins with the relaxation of healthy parts of the body, and only then they move on to the affected ones.

Features of the procedure

If massage is performed after a stroke at home, relatives can be given some important advice:

• Hands during the procedure must be inseparably touching the patient's body.
• It is necessary to observe the massage technique and take into account that all the muscles of the patient are in a different state. Even before the start of the process, it is important to determine which muscles are in good shape, which are in a normal state, which are in hypertonicity.
• Both healthy and affected tissues should be massaged.
• If the right side is affected, start with the left, and vice versa.
• The same goes for limb massage.
• The process should begin with light stroking movements, only then make efforts. It is not worth forcing the course of massaging.
• The above is true for the definition of proper differentiation. The stronger the muscles are tense, the more delicate the approach to massaging should be: they start with stroking.

So the sessions will be most effective. Especially if the massage is carried out at home by the patient's family members themselves.

When should you start

A natural question arises, is it possible to do massage and when to start doing massage after a stroke? It is not only possible, but necessary. It should be started from the first day after the onset of symptoms of acute cerebral ischemia. In a hospital setting, sessions begin immediately; at home, relatives should deal with massage. This is important, and seriously affects the prognosis: the earlier massage procedures begin, the more favorable the outcome.

It is important to note. It is best to clarify the technique of conducting sessions with the masseur from the hospital himself, do not be shy to ask questions. Information on the massage technique should be exhaustive. So errors will be excluded.

The full course lasts 30 days, then the patient rests for 5-10 days and the procedure is repeated. In no case should you intensively work on the muscles from the very first days, this is dangerous, because it will provoke an increase in blood pressure. This is fraught with the development of a second stroke. Also, massage is important for maintaining the functions of healthy limbs, which, under conditions of prolonged physical inactivity, will certainly undergo dystrophic changes.

Precaution

• In the early stages, sessions are carried out only by an experienced massage therapist, since there is a high risk of developing gross violations of body functions, swelling of the limbs after a stroke, etc. Massage after a stroke at home is acceptable, but only at a late rehabilitation stage (after a month and a half).
• The procedure takes place in the supine position or lying on its side. It is not worth laying on the patient's stomach, only if there are no interruptions in the work of the internal organs and the heart.
• The movements are gentle, stroking. It is impossible to force the massaging process. This is fraught with spasms and muscle cramps. As already mentioned, there is a time for everything.
• To achieve a greater effect, it is recommended to use special massagers on a rigid basis, etc.
• Do not over-massage the affected areas, this is fraught with the development of pain.

Compliance with precautionary measures will reduce the risk of formation of undesirable "side" effects.

Types of massage activities and methods of conducting

Logopedic massage

Allows you to reduce salivation, improve the functioning of the speech apparatus and facial muscles. To achieve these goals, acupressure of the face and tongue is shown.

Arms

Hand massage after a stroke makes it possible to relieve pathological muscle tension and restore the functional activity of the affected upper limbs.

Hand massage after a stroke is carried out according to the following technology:

• The patient assumes a supine position. The arm is straight, the palm is open. It is important to fix the limb in this position with a bandage. The impact should begin with the pectoralis major muscle. With ischemic stroke and its hemorrhagic form, it is always in hypertonicity. It is necessary to carry out light stroking movements on the chest, vibrating, oscillatory movements are acceptable, but not rough rubbing.

Principles of influence on individual parts of the hand:

Hand massage after a stroke should be done carefully. Strong pressure on the structures of the shoulder is excluded, since there is a high risk of damaging the main vessels!

Legs

How to do a foot massage? Foot massage after a stroke is designed to increase the motor activity of the lower extremities, improve blood flow and relieve muscle spasm.

The patient should be covered with a blanket, outside only warmed feet. The recommended position is lying on your stomach. This will provide access to the calf muscles. The study should begin with large muscles, only then moving on to small ones.

Methodology:

Relatives bear a huge responsibility for the fate of a loved one. It is important to decide whether to entrust the patient to a professional massage therapist or continue to conduct sessions on your own. Anyone can understand how to do a massage correctly. It is important to know the correct session sequence.

In what order are the massage procedures performed:

Massage first:

• Legs from the front surface (buttock, thigh, lower leg, foot).
• Pectoral muscles.
• Arms (shoulder, forearm, hands, fingers).
• Back surfaces of the leg.
• back.

A few more tips:

• You need to start with healthy structures, then move on to the affected ones.
• From small muscles to larger ones.
• From light massaging movements to more intense ones.

What movements are carried out during massage after a stroke:

Trituration- light movements affecting the outer layers of the skin and subcutaneous tissue.

Stroking- the brush glides over the surface of the skin without touching deep structures.

kneading- a strong massaging effect on the deep structures of the area.

Vibration- oscillatory movements of the hands located on the surface of the massaged area.

Massage contraindications: hyperthermia (high temperature); respiratory failure; high blood pressure, heart problems.

exercise therapy and physiotherapy

At the end of the acute period, the patient is shown exercise therapy (after a stroke) and physiotherapy. The basis of physiotherapy is electrophoresis, magnetotherapy, ultrasound treatment. Physiotherapy allows you to fix a favorable result of treatment.

Exercise therapy exercises should be gentle and are selected by the patient and his relatives in tandem with a specialist.

After a stroke, you can and should live a full life. Massage plays an important role in rehabilitation. It will not replace medical support, but such massage procedures do not pursue the goals either. Their task is to normalize the vegetative processes of the body by non-invasive methods.

In competent hands, this is a powerful recovery tool, the main thing is to use it correctly.

Massage tasks: improve blood and lymph circulation, promote the restoration of function, counteract the formation of contractures, help reduce increased muscle tone, reduce friendly movements, as well as trophic disorders in the limbs, promote general recovery, strengthen the body, reduce pain.

Methodology. Perform a classic massage. It is more rational to start the massage in the position of the patient on the back (under the knee - a roller, if necessary, then on the foot - a fixing bag of sand, with the appearance of synkinesis on a non-massaged limb). They start with stroking, light rubbing and labile continuous vibration on the front surface of the thigh (for relaxation), then the same relaxation techniques on the inner surface of the thigh. On the back of the thigh, techniques can be carried out more vigorously, with kneading, pressing, spiral rubbing.

The massage of the affected lower limb is carried out from the proximal to the distal parts, that is, after massaging the thigh, then the lower leg area is massaged, all sparing techniques are used on the back surface of it: stroking, rubbing, continuous labile vibrations, on the front surface all techniques can be carried out more vigorously (comb-shaped stroking, spiral-shaped, comb-shaped rubbing, tong-shaped kneading, pressure, vibration, hatching, planing). When massaging the foot on the rear, all techniques can be carried out more vigorously than on the sole, where light stroking, rubbing, pressure, and labile vibration are uninterrupted. Gently massage the heel tendon. Avoid causing Babinsky's symptom (sharp dorsal extension of the first toe).

After the massage of the lower limb, they proceed to the massage of the upper limb on the side of the lesion. Begin the procedure with the pectoralis major muscle area; most often, its tone is increased, so all techniques are carried out according to a sparing technique - light stroking, rubbing, vibration of a relaxing effect. Then they massage the area of ​​the shoulder girdle, back, trapezius muscles, deltoid - here the tone is low and manipulations can be carried out more vigorously, using stroking, comb-like spiral rubbing, forceps kneading, pressure, vibration using hatching "alternating them with other varieties of techniques. After that, they move on to shoulder massage, on the front surface of which all techniques are carried out in a gentle way, and on the back surface more energetic effects can be used. Massage begins from the back of the shoulder - stroking, rubbing, kneading, vibration. Specially affect the shoulder joint. Then they massage the forearm, where they gently affect the inner surface, and on the outer side of the forearm and on the hand, all techniques can be carried out more energetically.

When massaging the brush, painful points should be identified (usually on the palmar surface), trying to influence them in a relaxing, relaxing way. When the patient has the opportunity to lie on his side or on his stomach, then massage the back, lumbar, pelvis. All receptions are carried out sparingly.

Guidelines.

1. In each procedure, massage techniques are repeated 3-4 times.
2. On the 1st-2nd procedures, the area of ​​influence is insignificant (only the proximal parts of the limbs, do not turn the patient on his back).
3. From the 4-5th procedure, with a good response of the patient to manipulations, expand the area of ​​​​impact to the distal extremities, chest, with a turn to the healthy side - massage of the back, collar area.
4. From the 6-8th procedure, the back and lumbar region are completely massaged (the patient lies on his stomach). Combine massage with other types of influence (treatment by position, balneotherapy, electroprocedures, air ionization, etc.). Massage can be prescribed both before and after these procedures, in consultation with your doctor.

Timely treatment with the use of various therapeutic methods has a beneficial effect on the patient's condition. There are 3 stages of treatment: early recovery (up to 3 months), late recovery (up to 1 year) and the stage of compensation for residual motor function disorders (over 1 year).

The most beneficial effect is exerted by therapeutic exercises in combination with acupressure.

Dot.

Acupressure contributes to the regulation of the processes of excitation and inhibition in the cerebral cortex, as well as the normalization of the reciprocal relationships of antagonist muscles.

The initial position of the patient during acupressure is lying on his back. Massage always begins with the upper limbs, preferably in combination with passive movements in the corresponding joints of the massaged limb.

Methodology, sequence of exposure (Fig. 128). To relax or stimulate the muscles of the shoulder girdle, they act on the points:

1. jian-jing - on the line corresponding to the middle of the shoulder girdle, in the center of the supraspinous fossa;
2. jian-yu - on the shoulder between the acromion and the greater tubercle of the humerus (below and anterior to the acromion);
3. zhou-zhong - in the second intercostal space, along the 3rd line of the chest, on the pectoralis major muscle;
4. nao-shu - posterior to the fossa of the shoulder joint on a vertical line with the armpit (well defined when raising the arm);

Rice. 128. Topography of "points of influence" for acupressure in the rehabilitation of post-stroke patients.

a - on the chest, on the back; b - on the upper limbs; c - on the lower limbs.

1. fu-fen - between the II and III thoracic vertebrae on the 2nd line of the back, at the inner upper edge of the scapula (D 2-3/2);
2. gao-huang - at the level between the IV and V thoracic vertebrae on the 2nd line of the back, at the inner edge of the scapula (D 4-5/2);
3. bi-nao - on the outer side of the humerus at the posterior edge of the deltoid muscle and at the outer edge of the triceps muscle of the shoulder:
4. chiquan - on the shoulder at the level of the axillary fold, directly at the lower edge of the pectoralis major muscle:
5. pjian-zhen - from top to bottom and behind the shoulder joint along the posterior axillary line, between the humerus and scapula.

To relax the flexors and pronators of the upper limb, they act on the points:

1. qu-chi - in the area of ​​the elbow joint at the end of the fold formed during flexion in the elbow joint, on the side of the first finger;

Rice. 128. in (continued)

1. chi-jie - in the fold of the elbow at the outer edge of the tendon of the biceps muscle of the shoulder;
2. shao-hai - in front of the internal condyle of the ulna in the cavity, here, with deep pressure, the ulnar nerve is palpated;
3. nei guan - 2 cun above the middle of the wrist fold towards the elbow joint;
4. da-lin - in the center between the wrist folds on the inner surface of the wrist joint;
5. lao-gun - in the middle of the palm, when the fingers of the hand are bent between the III and IV fingers (terminal phalanges);
6. shi-hsuan - tips of all 10 fingers (their distal phalanges);
7. show-san-li - on the back of the forearm 2 cun below the elbow crease, towards the first finger;
8. he-gu - at the top of the mound formed by squeezing the 1st and 2nd fingers of the hand together, on its back.

To stimulate the abductor and other muscles, the hands act on the points:

1. xiao-le - in the middle of the back surface of the triceps muscle of the shoulder, 5 cun above the elbow joint, in the direction of the shoulder joint;
2. yang-chi - on the back surface of the wrist joint, in the center of the wrist fold;
3. wai-guan - 2 cun above the yang-chi point, between the tendon of the common extensor of the fingers and the extensor of the fifth finger;
4. e-men - on the back surface of the hand between the metacarpophalangeal joints of the IV and V fingers, at their base;
5. shi-hsuan - on the tips of all 10 fingers of the hand;
6. yang-si - between the tendons of the long and short extensor of the first finger, in an anatomical snuffbox;
7. yang-gu - in the hollow between the styloid process of the ulna and the trihedral bone of the wrist;
8. tian-jing - above the olecranon, in the cavity of the cubital fossa.

To relax the muscles that extend the thigh and lower leg, they act on the points:

1. bi-guan - on the front surface of the thigh, in the middle of the inguinal fold below it by 1 cun towards the knee joint;
2. huan-tiao - in the cavity in the middle of the gluteal muscle, when the leg is bent at the knee joint, the heel is pressed against the area of ​​the point;
3. fu-tu - on the front surface of the thigh 6 cun above the upper edge of the patella;
4. du-bi - in the hollow outward from the patella, at the level of its lower edge;
5. he-din - in the middle of the upper edge of the patella, where it is clearly defined with the leg bent at the knee joint;
6. cheng-jin - below the middle of the popliteal fossa, 5 cun folds, between the abdomens of the gastrocnemius muscle;
7. cheng-shan 3 cun below the cheng-jin point, or in the center of the back surface of the lower leg, in the cavity at the junction of both abdomens of the gastrocnemius muscle;
8. kun-lun - behind and below between the outer ankle and the calcaneal tendon.

To stimulate active contractions of the lower leg flexors, the following points are acted upon:

1. cheng-fu - in the center of the subgluteal fold;
2. yin-men - in the middle of the back of the thigh between the biceps and semi-suture genus muscles, below the infragluteal fold by 6 cun.

For stimulation (and more often for relaxation, depending on the condition of the patient), the points on the inner surface of the thigh are affected:

1. yin-bao - in the middle of the lateral surface of the thigh, its inner side, 5 cun above the knee joint;
2. chi-men - on the inner surface of the thigh, in the hollow at the inner edge of the quadriceps muscle, in the middle of the distance, 6 cun above the upper edge of the patella.

To stimulate the muscles that extensor the foot and fingers, they act on the points:

1. yin-ling-quan - on the inner surface of the lower leg, at the posterior edge of the inner condyle of the tibia;
2. yang-ling-quan - at the anterior lower edge of the head of the fibula, on the same line with the point of yin-ling-quan, on the sides of the knee joint;
3. zu-san-li (point of longevity) 3 cun below the lower edge of the patella and 1 cun outward from the midline of the leg, under the joint of the fibula and tibia;
4. jie-si - in the middle of the back surface of the ankle joint, in the center of the fossa formed when the foot is bent towards itself;
5. shan-qiu - on the inner surface of the foot, in front and below the inner ankle;
6. qiu-hsu - on the back surface of the foot in front and below on the outer side of the ankle;
7. pu-shen a series of points (5-6) along the outer edge of the foot, starting from the toes;
8. yongquan - in the center of the plantar surface between the II and III toes of the foot, when the fingers are compressed, a fold is formed on the sole, in the center of which there is a point.

Guidelines. The starting position of the patient is lying on his back. The masseur is always on the side of the paretic limbs. From the proposed points on this area, choose the most effective for this procedure. Strive to achieve the desired effect (relaxation or stimulation), while using the appropriate technique of acupressure - when stimulated - tonic, when relaxed - soothing, relaxing. Use a combination of some points to increase the effectiveness of the impact: on the shoulder joint of nao-shu and zhou-rong, on the elbow joint of shao-hai and qu-chi, on the wrist joint of he-gu and lao-gong, or yang-chi and da-lin , yang-si and yang-gu, wai-guan and nei-guan, on the lower limbs - kun-lun and tse-si, yang-ling-quan and yin-ling-quan. In combination with passive movements, the effectiveness of acupressure is much higher; rehabilitation time is shortened.

In some conditions, it is more rational to start massage not with classical techniques, but with point effects and passive movements. The technique of acupressure compares favorably with the fact that this method in practice, if performed correctly, has no contraindications.

Acupressure can compete with acupuncture in terms of speed of relaxation, which gives it an advantage during various gymnastic exercises.

It should be remembered that it is not always possible to achieve complete relaxation in the first procedure, especially in patients with a relatively long history of stroke, therefore, one should not increase the intensity of exposure and especially often change selected points. One course consists of 20 procedures for 25-30 minutes. Courses are repeated with intervals of 15-30 days or more.

Massage for the consequences of acute cerebrovascular accident

The purpose of the massage

tricks

Massage Sequence

1. Massage of the lower limb.

b) Massage of the gluteal muscles.

2

4. Back massage.

Position treatment

Massage for the consequences of acute cerebrovascular accident

The most common cause of acute disorders of cerebral circulation is ischemic (a consequence of thrombosis or vascular embolism) or hemorrhagic (hemorrhage) stroke. The residual effects of strokes are manifested by paresis (decrease in muscle strength) or paralysis (complete lack of muscle strength). Paresis and paralysis are called central. They are caused by damage to the motor centers and pathways. Paths are called pyramidal (spastic). Paresis and paralysis are characterized by increased muscle tone, high tendon reflexes, and pathological signs. The first time after a stroke, muscle tone may be reduced, but then it increases.

With pyramidal paresis, the arm is brought to the body and bent at the elbow. The hand and fingers are bent. The leg is extended at the hip and knee joints. The foot is bent and turned with the sole inward.

In paretic (weakened) limbs, synkinesis (friendly movements) occurs. They can be imitation and global. With imitation synkinesis, movement occurs on one limb when the other is moving; when the healthy limb moves, the diseased one also moves. With global synkinesis, when trying to perform isolated movements, flexion contracture (muscle tension) in the arm and extensor contracture in the leg increase: when trying to straighten the arm, the arm bends even more, in the leg it unbends. Because the points of attachment of individual muscles are brought together for a long time, these muscles shorten over time. Prolonged rest leads to stiffness of the joints. Cold, excitement, fatigue worsen movement.

The purpose of the massage- reduce the reflex excitability of spastic muscles, weaken muscle contractures, activate stretched muscles, help restore movement, trophic disorders (cold skin, swelling, discoloration).

Massage area - paretic limbs, back with lower back and chest on the side of the lesion.

tricks- stroking, spiral rubbing. For the antagonist of spastic muscles - kneading, preferably gentle longitudinal, felting and pressure. Intermittent vibration is contraindicated. If well tolerated, continuous vibration can be used.

Starting position - lying on your back, under your knees - a roller. If synkinesis appears, then the non-massaged limb is fixed with a bag of sand. The outer surface of the leg can be massaged on a healthy side, and the back surface - on the stomach. A pillow is placed under the stomach, a roller is placed under the ankle joint.

Massage Sequence. First, the front surface of the leg is massaged, then the pectoralis major muscle on the side of the lesion, the arm, the back of the leg, and the back. The limbs are massaged from the proximal sections.

Before the massage, it is necessary to relax the muscles by shaking, passive exercises at a slow pace (for example, rolling a rolling pin with the palm of your hand or sole), slight shaking of the muscles of the thigh and chest, and warming the limb. To relax the muscles of the foot, light massage and shaking of the Achilles tendon are used.

1. Massage of the lower limb.

a) First, an uninterrupted light superficial planar and embracing stroking, spiral rubbing of the thigh is performed, then selective massage of the muscles of the anterior, internal and posterior groups, because. muscle tone is high, then they are gently massaged.

b) Massage of the gluteal muscles.

c) Leg massage. General exposure, stroking and rubbing, then selective muscle massage. The muscles of the anterior and outer surface of the lower leg are stroked, rubbed and kneaded. The back surface of the lower leg is massaged gently by stroking and rubbing. gently massage the Achilles tendon.

d) Foot massage. Stroking, rubbing, kneading are used on the back of the foot. On the sole, the tone is high, ridge-like kneading is used, preventing extension of the first toe (Babinski's symptom).

2. Massage of the pectoralis major. A gentle massage is carried out, surface planar stroking, light rubbing and shaking can be used.

3. Massage of the upper limb.

a) Shoulder massage begins with the trapezius, latissimus dorsi, deltoid and pectoral muscles. When massaging the back, a special effect is made on the trapezius and latissimus dorsi.

A preparatory shoulder massage is performed, stroking and rubbing, and then a selective muscle massage.

b) Massage of the forearm. A general effect is made (stroking and rubbing), then a selective massage. First, the extensors are massaged (stroking, rubbing, kneading), then the flexors (stroking and rubbing).

c) Hand and fingers. First, the fingers are massaged, then the back and palmar surfaces of the hand. On the back - stroking, rubbing and kneading, on the palmar surface - stroking and light rubbing.

4. Back massage. Use all known techniques, but sparing.

1. Each technique is repeated 3-4 times.

2. In the first three procedures in the early stages after a stroke, only massage of the proximal limbs is performed, without turning on the stomach.

3. On the 4th - 5th procedure, a massage of the chest, distal extremities (shin with foot and hand with forearm) is added with a turn to the side.

4. From the 6th - 8th procedure, a back and lower back massage is added. Later, the prone position is used.

5. After two months or more, on the first three procedures, a massage of the limbs is performed, after the third, a back and lower back massage is added.

6. During the massage of the hand, the 3rd - 5th fingers are kept unbent, and the first - retracted. During the massage, the legs lift the outer edge of the foot and set the foot at an angle of 90 degrees to the lower leg.

7. With complaints of heaviness in the head, headache. dizziness is added by massage of the head, neck and collar zone. The technique depends on blood pressure.

8. On the day of an epileptic seizure, massage is not performed.

9. Massage is combined with exercise therapy and position treatment.

Position treatment carried out from the first days of the disease to counteract the formation of contractures or to reduce them.

ü The foot is fixed at an angle of 90 degrees, penetrated, and a board, box, etc. is placed to stop the foot at the foot end of the bed.

ü An extended arm from the body to an angle of 90 degrees or as much as possible.

ü The shoulder is placed outward, the forearm is supinated, the fingers are almost straightened. A bag of sand is placed on the palm, the first finger is abducted, the hand is placed on a chair next to the bed.

Treatment with the position is carried out 3-4 times a day, depending on the condition of the patient. In a state of sleep, positional treatment is not carried out.

10. Passive movements include in the early stages of the disease.

Between the masseur's hands there should be only one exercised joint. Before passive movements, active movements are carried out on a healthy limb, the same as subsequent passive ones. In the future, active movement on a healthy limb is performed simultaneously with a passive movement of a diseased limb. Subsequently, these movements are performed alternately: with active movement, the healthy limb is bent, the diseased limb is passively unbent.

11. It is better to start active movements with movement in a horizontal plane, when you do not need to overcome gravity. Bend-unbend the leg better on the side.

One should strive for flexion and external rotation of the shoulder, for extension and supination of the forearm, for extension of the hand and all five fingers, for abduction and adduction of the bent hip, for flexion of the hip in the hip joint during its internal rotation, for flexion of the lower leg, for dorsiflexion of the foot with while raising its outer edge.

12. When it is allowed to sit, passive movements are carried out for the belt of the upper extremities - raising and lowering the scapula, adduction and abduction of the scapula to the spine. The forearm and hand are extended.

13. When walking, pay attention to the position of the foot, do not take it to the side, do not touch the floor with your toe. Correct foot placement. It is enough to bend the leg at the hip and knee joint.

14. The duration of the procedure is from 5-10 dominoes (according to Mashkov - up to 25 minutes). The course is a procedure. Break between courses - 14 days.

Kinesitherapy and massage in the rehabilitation of patients with acute cerebrovascular accident

Acute cerebrovascular accident (ACV) should be considered as a common disease, as a result of which many patients become disabled.

The lack of specialized rehabilitation centers for this category of patients leads to the fact that in almost all neurological and therapeutic hospitals one can meet patients with the consequences of a stroke.

brain stroke

The increase in the number of cardiovascular diseases, as well as vascular lesions of the brain, makes the problem of cerebrovascular pathology one of the most urgent neurological, general medical and social problems (N.V. Vereshchagin, 1996).

Cerebral stroke is one of the main causes of disability and mortality in people.

Every year, 3 out of 1000 people are affected by a stroke. In Western Europe alone, a stroke occurs in 1 million people every year. At the same time, 25% of patients with acute cerebrovascular accident die on the first day, 40% - within two to three weeks. About 50% of survivors die in the next 4-5 years. Only about 18% continue to work after recovery (A.M. Gurlenya, G.E. Bagel, 1989).

In the CIS countries, cerebral strokes account for more than two cases per 1000 healthy population. Mortality from them is 12% in the overall structure of mortality. There is a tendency to a significant "rejuvenation" of cerebral stroke. So, in one third of people it occurs before the age of 50 years. 70% of survivors become disabled (L. A. Shevchenko et al., 1996). In recent years, the incidence of cerebral stroke has been on the rise in the Republic of Belarus. According to statistical data, in 1995 the incidence of this nosology in the republic was at the level of 261.9, and in 1996 - 302.9. At least 30% of patients in the acute stage of stroke die (E. I. Gusev et al., 1996).

In recent years, an increase in mortality from cerebrovascular accidents has been observed in Belarus: in 1995, the mortality rate was 171, and in 1996 it increased to 174.5. In the structure of mortality, patients with cerebral stroke rank third in the country. Among the surviving patients, most cannot return to work and need constant care (E.I. Gusev et al., 1995). Disability from disorders of cerebral circulation in Belarus in 1995 amounted to 4.32 of the population (L. S. Gitkina, 1995).

Ischemic stroke is the most common form of acute persistent disorders of cerebral circulation, accounting for 60% to 90% of all strokes (VE Smirnov, 1991).

Based on the above, it is necessary to pay special attention to the rehabilitation of patients who have suffered a cerebral stroke.

Rehabilitation of patients who have had a stroke includes preventing the development of contractures, conducting active and passive gymnastics, prescribing CT in combination with muscle relaxants and anticholinesterase drugs, followed by occupational therapy, speech therapy classes, psychological and physical preparation of patients for a further lifestyle (A. E. Semak , E. N. Ponomareva et al., 1993).

As a result of an acute violation of cerebral circulation caused by hemorrhage, thrombosis of the cerebral arteries or embolism of the cerebral vessels, severe motor disorders come to the fore: hemiparesis or hemiplegia, muscle hypertonicity on the side of the lesion or muscle atony, an increased level of tendon reflexes; there may be a speech disorder or spatial orientation, mental lability, etc.

CT plays an important role in the rehabilitation of patients with the consequences of a cerebral stroke. Therapeutic gymnastics procedures, in addition to restoring the function of the pyramidal tract and directly affecting the paretic limbs, have a general health effect, strengthen the cardiovascular system and respiratory apparatus, and prevent pulmonary complications associated with prolonged bed rest.

Special physical exercises in post-stroke hemiparesis are aimed primarily at maintaining the motor acts of the healthy side, reducing the pathological muscle tone of the affected limbs, increasing muscle strength, training the combined work of synergists and antagonists, eliminating vicious friendly movements, expanding adaptation to muscle loads, recreating and the formation of the most important motor skills necessary in daily activities.

CT in the rehabilitation of patients with stroke is prescribed in the acute period in order to prevent complications associated with hypokinesia or akinesia of the limbs of the affected half of the body. The most serious complications in this period include peripheral vascular thrombosis and embolism, disorders of the respiratory and cardiovascular systems, hypostatic pneumonia, atony of the intestines and bladder, bedsores, joint contractures.

Position treatment

Important prophylactic value in the first days of stroke is treatment with position. For this, rollers, folded blankets, pillows are used.

In the supine position, laying is applied with the abduction of the affected upper limb to an angle °. When changing the position of the hand, it is necessary to alternately place it in the position of external and internal rotation. The elbow joint is periodically bent at an angle of 90 °, while the hand is fixed to the ball - the position "big fist, the 1st finger should be in opposition and opposed to the rest." The lower limb is placed in mid-hip flexion and slight abduction (5°), while avoiding external rotation of the leg is important. The foot should be in the extension position (dorsiflexion), this is achieved by substituting a box between the foot and the headboard.

In the supine position, the head is placed on a high pillow parallel to the bed, the upper healthy limb is positioned so as to ensure balance while lying on the healthy side, the upper affected limb is slightly bent at the elbow joint, the hand is in the “big fist” position. The lower healthy limb is bent at an angle of 90°. It is not recommended for hemiplegia, especially in an unconscious state or with limited consciousness, the position on the affected side, because this significantly impairs blood circulation, and the mechanical pressure of body weight contributes to the development of bedsores.

With severe contracture, it is necessary to fix the limbs in a corrective position (using special splints or light splints) around the clock.

In the early period, along with position treatment, passive exercises are used for the affected limbs from the initial position lying on the back and healthy side, as well as static breathing exercises of the chest and diaphragm type to prevent hypostatic pneumonia from the same position. Patients should be advised to repeat passive exercises several times a day.

When the cerebral phenomena are smoothed out and motor disorders, depending on the localization of the pathological process, come to the fore, active gymnastic exercises for healthy limbs are prescribed in combination with passive exercises for paretic limbs, therapeutic styling and breathing exercises. During this period, it is very important to begin the vertical installation of the patient by actively moving to a sitting position, legs dangling. The transition to a sitting position is carried out from a lying position on a healthy side, leaning on the bed with a hand. Further, the motor mode is expanded by including exercises in the therapeutic gymnastics procedure from the initial position sitting on the bed, and then on a chair. In the sitting position, the functional capabilities of the lower extremities, the ability to lean on the affected limb and perform a supporting function are evaluated.

If the patient cannot load the affected leg, then before transferring the patient to a standing position, it is recommended to fix the knee and ankle joint. This improves proprioceptive prototyping and contributes to the correct pattern of walking. The next stages are related to learning to walk, restoring the function of the upper limb, improving the general condition and mastering everyday skills to achieve independence. Assistive devices are used for learning to move independently: crutches, walkers, canes. The goal of learning to move is to make the patient as independent as possible (in the toilet, in the bathroom).

In the late recovery period, along with special physical exercises aimed at restoring motor functions, general strengthening exercises are used, from the simplest to more complex and stressful, games are included, some types of daily activities (climbing stairs, carrying various things, rearranging books on high shelves ), exercises with elastic bands and isometric exercises.

It is very important to teach family members how to help the patient with the exercises, since for a long period after discharge from the hospital, he needs to do therapeutic exercises.

General strengthening exercises should maximally cover all muscle groups of the upper limbs, trunk, lower limbs.

For a long time, for post-stroke patients, the generally accepted complex of therapeutic exercises was used, excluding any significant physical exertion. At the same time, the commonality of pathogenetic mechanisms leading to damage to the heart and brain, the relationship between central and cerebral hemodynamics, especially in violation of the physiological mechanisms of autoregulation of cerebral blood flow, is well known.

In general, the most favorable in terms of training effect on the cardiovascular system and activation of cerebral hemodynamics for post-stroke patients are loads involving large muscle groups of the lower extremities. The duration of the development of a stroke within the recovery and residual periods does not have a direct effect on tolerance to physical activity; the decisive factors are the severity of movement disorders and concomitant pathology of the heart (A. N. Belova, S. A. Afoshin, 1993).

One of the most effective methods of motor rehabilitation of patients with the consequences of cerebrovascular accident is currently considered to be the method of neuromotor retraining, developed by K. and V. Bobat. The method is aimed at activating the normal neurophysiological mechanisms of motor acts and at suppressing the pathological mechanisms that have arisen as a result of a stroke (primarily, this is the disinhibition of the tonic reflexes of the brain stem).

Basic Principles of Neuromotor Relearning (Bobat)

The first principle is postural adaptation. Normal voluntary movement can be formed only on the basis of normal muscle tone, which creates favorable conditions for the development of purposeful active movements. To suppress the increased tone and pathological motor stereotypes, reflex-inhibitory postures are used. As a rule, this position is opposite to that which the patient seeks to occupy. The patient is taught to independently take these postures and maintain them for quite a long time.

The second principle is based on reflex-inhibiting postures, the gradual restoration of first normal automatic, then isolated volitional movements.

At the same time, retraining in voluntary movements should be carried out in accordance with the ontogenetic sequence of human motor development:

• in the cranio-caudal direction;
• from the center to the periphery (from the proximal to the distal);
• flexion and adduction is restored to extension and abduction;
• first, movements are restored in large joints (gross motor skills), and then in small ones (fine motor skills);
• the restoration of reflex movements precedes the restoration of voluntary ones.

The development of a stable motor stereotype is achieved by repeated repetitions of voluntary movements. It must be remembered that the desire to layer a normal movement on a pathological one will lead to the formation of a pathological motor stereotype. Movements that increase pathological reflex activity should be avoided, as they increase muscle tone.

The third principle is the association of voluntary isolated movements with normal sensory perception. The restoration of motor activity goes in parallel with the restoration of sensitivity and largely depends on it. For a faster and more complete recovery of motor skills, the patient needs to learn to feel his limbs, their position in relation to the body, the direction of movements, etc. This is achieved with the help of tactile stimulation, pressure, movements directed against gravity, and the use of key points.

The method of neuromotor retraining is used for all types of central paresis and paralysis, however, the choice of specific exercises depends on the motor, sensory, and intellectual disorders that each patient has. Balance exercises should be included in the complex, since this gradually reduces the role of reflex-inhibitory postures, allowing the patient to independently control muscle tone and correct balance. It is not necessary to achieve complete recovery of one motor function before moving on to training the next one.

The method of neuromotor retraining (Bobat therapy) is most effective with the so-called 24-hour activating care, when the work of all specialists (doctors, nurses, physical rehabilitation instructors, massage therapists, etc.) is built on the same principles and approaches.

Bobath position treatment

The patient should be placed in the correct position as early as possible. This must be done before the first signs of increased muscle tone appear.

In the prone position, 3 main types of styling are used: on the affected side, on the healthy side, on the back. The position changes every 2 hours.

1. Lying position on the affected side:

• the patient's back is parallel to the edge of the bed and rests on a pillow to prevent rolling onto his back;
• the head is on the pillow in a neutral position (avoid excessive bending forward);
• the scapula on the affected side is pushed forward;
• the diseased shoulder is abducted 90 degrees (because a smaller angle contributes to the development of spasticity);
• sore arm in supination position;
• the hand should lie on the bed (or stand), a slight drooping of the supinated hand stimulates the extension of the wrist joint;
• the pelvis is slightly turned forward;
• the affected hip is straightened;
• the affected knee is slightly bent;
• a healthy leg is bent 135 degrees at the hip, knee, ankle joints and lies on a folded blanket or pillow.

2. Lying on the back:

• the head is supported by pillows in the midline (symmetrically);
• the body is laid symmetrically to prevent shortening of the affected side in the future;
• a pillow is placed under the sore shoulder so that the shoulders are at the same level;
• the affected arm is lying on the bed or slightly raised on the pillow, the elbow is extended, the forearm is supinated;
• a small pad or rolled towel placed under the buttock on the affected side prevents the leg from turning outward;
• do not put a pillow (roller) under the knees and emphasis under the feet, because this leads to flexion contracture in the knee joint and contributes to the formation of extensor synergy in the lower limb.

3. Lying position on the healthy side:

• the back is parallel to the edge of the bed;
• the head on the pillow in the midline is slightly bent forward;
• the scapula on the diseased side is pushed forward;
• the affected arm is raised and straightened on the pillow;
• the sore shoulder is at an angle of 90 degrees to the body;
• the affected hand is supported (to avoid flexion at the wrist joint);
• the affected leg, bent at the hip and knee joints (135 degrees), lies on a pillow (or a folded blanket);
• the foot is on the pillow in a neutral position to avoid its incorrect installation (inversion).

4. In the sitting position, the patient moves if he is conscious and able to maintain this posture.

It is necessary to ensure that the torso is symmetrical and has sufficient support at the back (up to shoulder level). In the sitting position on the bed - the hip joints are bent, the knees are unbent, a folded towel or pillow is placed on the outside of the affected knee to prevent the leg from turning outward. A table is placed in front of the patient, on which the hands rest. In a sitting position on a chair - the arms are pushed forward, brought to the midline and lean on the table from the level of the elbow joints. Hip, knee and ankle joints are bent at an angle of 90 degrees. Feet symmetrically rest on the floor or other support.

Motor rehabilitation of post-stroke patients, in accordance with the principles of Bobath therapy, successively goes through a number of stages.

1. Motor activity (mobility) within the bed includes teaching the technique of lifting the head and pelvis (“bridge” and “half-bridge”) and turns to the diseased and healthy side. Such training inhibits the influence of cervical tonic reflexes, stabilizes the supporting function of the body and facilitates bringing the arms to the midline.

2. Active transition to a sitting position from a lying position. At the beginning, they train the transition to a sitting position through turning on their side to the sore side. The patient should sit down as follows:

• starting position - lying on your back, the diseased side is facing the free edge of the bed;
• raise the sore leg and lower it over the edge of the bed;
• raise the head and a healthy shoulder;
• turn the healthy shoulder to the affected side, at the same time bring the healthy arm forward obliquely to the body and lean on the palm in front of you;
• lower your healthy leg off the bed and sit down, leaning on the palm of your healthy hand.

First, the patient is helped, gradually he learns to sit down on his own, without relying on a healthy hand. Similarly, the transition to a sitting position through the healthy side is trained. The patient can then be taught to sit straight from the supine position, without turning to the side.

1. Transition to a standing position from a sitting position. Standing is a complex posture that requires the interaction of the abdominal muscles, gluteal muscles and hip extensors. They alternately train support on the left and right feet, even distribution of body weight on both legs, isolated flexion and extension in all joints of the limbs, control of the vertical position of the body. Particular attention should be paid to the training of balance reactions, without which free walking is impossible.

2. Teaching (or retraining) functionally correct walking. Start with walking with support (parallel bars, crutches, poles, walkers, instructor's hands). Normal walking is symmetrical in time and space, so the time of support on each leg should be the same, as well as the length of the step. Walking training includes direction of movement (forward, backward, sideways), stride length, rhythm, movement speed, walking up and down stairs. Additional stability to the affected side can be given with special shoes, an elastic bandage, or a peroneal splint.

Rehabilitation of patients with aphasia is based on the general principles of medical rehabilitation, but has specific features:

1. Early start as soon as the patient's condition allows.

2. Complexity - in the process of rehabilitation, a single medical, psychological and speech therapy chain is established, speech therapy is an integral part of the rehabilitation program and is carried out only in combination with other methods.

3. Phasism - the acute phase of aphasia, the stabilization phase and the chronic phase of aphasia are distinguished, the rehabilitation program in different phases includes different approaches and methods.

4. Individuality - taking into account the type, severity of speech disorders, the presence of other consequences of a stroke.

5. Duration - from several months to 2 years, on average 6 months (lack of effect after daily classes for 6 months is an indication to stop speech therapy).

At present, a new original and highly effective method for the rehabilitation of this group of patients has been proposed using the Adeli-92 medical suit, created on the basis of the Penguin load suit, which protects cosmonauts from the adverse effects of weightlessness. Due to the system of built-in elastic rods, it allows you to influence the implementation of locomotor acts, create new motor stereotypes (S. B. Shvarkov et al., 1996).

Despite the large number of methods for the rehabilitation of patients with the consequences of cerebrovascular accident, kinesitherapy and massage remain the main methods.

The purpose of massage in these patients is to normalize the muscle tone of the affected limbs, improve movements for coordination and balance, reduce synkinesis, prevent the development of contractures, and general strengthening of the body (A. E. Shterengerts, N. A. Belaya, 1994).

Tasks of massage: to promote the restoration of disturbed ratios of excitatory and inhibitory processes in the cerebral cortex; relieve or reduce pain; improve tissue nutrition; stimulate reparative processes; restore nerve conduction and function of the neuromuscular apparatus; prevent atrophy and contractures; have a positive effect on psycho-emotional activity.

Contraindications for the use of massage for paresis and paralysis: severe and extremely serious condition of the patient, requiring intensive care or resuscitation; unconscious, coma of the patient; acute mental disorders; severe spontaneous pain; high body temperature (above 38 ° C); suppurative (associated) diseases: furunculosis, carbuncle, phlegmon, abscess; skin diseases; vascular thrombosis.

Massage plan

It is advisable to start the procedure with a massage of the paravertebral spinal segments: for the impact on the upper limb, the segments C 3 - D 6 are massaged, on the lower - S 5 -D 10, using stroking, rubbing, kneading, vibration techniques. Then the corresponding limb is massaged.

The massage technique for paresis and paralysis depends on the state of muscle tone. Central paralysis is usually spastic, while peripheral paresis and paralysis are flaccid.

Initially, shortened, spasmodic muscles are massaged to relieve their increased tone (relaxation and stretching). To do this, apply the techniques of light, superficial stroking and rubbing at a slow pace. The massage of the upper limb begins with the flexors, the lower - with the extensors.

The next step is to massage the stretched muscles (extensors on the arm, flexors on the leg). To do this, use deeper and more energetic techniques of stroking, rubbing, kneading and vibration.

After the massage, therapeutic exercises and positional treatment are carried out.

With central spastic hemiparesis, a segmental-reflex massage of the paravertebral zones C 3 -D 6 is performed; massage of arm flexors, extensors and joints; segmental-reflex massage of paravertebral zones S 5 - D 10; massage of leg extensors, flexors and joints. The duration of the massage should gradually increase (from 7-10 min.), the number of procedures per course should be from 20 to 30, the courses can be repeated every other day.

Flaccid paresis and paralysis require daily, regular deeper massage compared to spastic paresis.

Tasks of massage: to stimulate the conduction of impulses along. neuromuscular fibers (by activating the mediator function of acetylcholine); improve the contractile function of muscles; restore muscle tone and tendon reflexes; stimulate blood and lymph circulation, trophic and metabolic processes in the nervous and muscle tissue; prevent muscle atrophy.

The greatest effect of the procedure is achieved if the corresponding paravertebral segments are massaged before the limb massage.

According to the classical massage technique, stroking, rubbing, kneading and vibration techniques are performed on the flexor muscles, and then on the extensor muscles. Receptions are performed quite deeply and at a faster pace.

However, excessively strong and prolonged massage can cause overwork and, consequently, negative dynamics in the clinic. The duration of the massage in the first 5-7 days is 7-10 minutes, and then min. The number of procedures per course is 20. The course is repeated after 1.5-2 months.

Pirogova L.A., Ulashchik V.S.

Massage (from the French. massage - rub) - a set of scientifically based methods of mechanical dosed impact on the surface of the human body, produced by the hands of a massage therapist, apparatus or water jet.

The test is used in CT, during mass preventive examinations, staged medical control of athletes and athletes of mass categories. The subject sits at the edge of the table to the left of the doctor.

They offer to stand with closed feet, a raised head, arms outstretched forward and eyes closed. The test can be made more difficult by placing the legs one after the other along the same line, or you can test this position while standing on one leg.

Video about sanatorium Egle, Druskininkai, Lithuania

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