Therapeutic physical culture in amputation of limbs. Exercise therapy for amputation of the lower limbs Method of using gymnastics for amputations

Ministry of Education of the Republic of Belarus

educational institution

"Brest State University named after A.S. Pushkin"

Faculty of Physical Education

Department of Anatomy, Physiology and Human Safety

Course work

in the academic discipline "Specialization "Physical Rehabilitation""

Physical rehabilitation for amputation of the upper limbs

Completed:

student of the 5th year of the OZO, 55 groups,

Rusavuk Stanislav Leonidovich

Scientific adviser:

Doropievich S S

Introduction

1 Definition of the concept of amputation. Indications and contraindications for amputation of the upper limbs

2 Types of amputations

3 Methods of amputation

4 Stages of amputation of the upper limbs

5 Complications after upper limb amputation

1Goal and objectives of rehabilitation

2Types of rehabilitation of disabled people after amputation of the upper limbs

3 Means of physical rehabilitation after amputation of the upper limbs

4 Prosthetics

Chapter 3

Introduction

amputation physical rehabilitation prosthetics

Amputation of limbs is considered one of the oldest operations. Hippocrates carried out amputation within dead tissues, later Celsus proposed to carry it out by capturing healthy tissues, which was more appropriate, but in the Middle Ages all this was forgotten. In the 16th century, Pare proposed ligation of vessels instead of cauterization with a red-hot iron or immersion in boiling oil, then Louis Petit began to cover the stump with skin, and in the 19th century, Pirogov proposed osteoplastic surgery.

Vascular diseases of the extremities, tumors and severe injuries are the most common indicator for amputation.

Vascular disease of the extremities is the leading cause of amputation in people aged 50 years and older, accounting for 90% of all amputations. Usually, the treatment of complicated vascular diseases consists in prescribing antibiotics, removing infected tissues, prescribing vascular drugs (eg, anticoagulants), and surgical treatment consists of such operations as angioplasty, bypass, stenting. However, when these measures fail to achieve the desired result, the surgeon has to resort to amputation as a life-saving measure.

In addition, vascular damage can also occur with severe (crushed, crushed) injuries, deep burns. As a result of this, there is also a lack of blood supply to the tissues of the limb and their necrosis. If you do not remove the necrotic tissue, then this is fraught with the spread of decay products and infection throughout the body.

One of the most important stages in the recovery of patients after amputation of the upper limbs is prosthetics. Upper limb prostheses compensate for the most important lost functions of the hand - the functions of opening and closing the hand (grabbing, holding and releasing an object), movement in the wrist, elbow and shoulder joints, as well as restoring the appearance (maximum cosmetic effect).

The object of this work is physical rehabilitation as a way to restore the disabled.

The subject of this course work is the physical rehabilitation of the amputation of the upper limbs.

The purpose of the study is to characterize the main means of physical rehabilitation after amputation of the upper limbs.

The implementation of this goal involves the solution of the following tasks:

1.To study educational and methodical and scientific literature on the topic of the course work; open the definition of "amputation";

.Identify the main goals, objectives and means of physical rehabilitation in amputation of the upper limbs;

.Collect material and prepare a multimedia presentation on the topic "Prosthetics of the upper limbs". Describe the main types of upper limb prostheses.

The practical value of the work is that the results are of interest to specialists in physical rehabilitation, medical workers who provide various areas of work with the disabled. In addition, they may be of interest to managers in the fields of medicine, education, physical culture and sports.

Chapter 1. General characteristics of amputation of the upper limbs

1Definition of the concept of amputation. Indications and contraindications for amputation of the upper limbs

amputation (lat. amputation) - truncation of the distal part of the organ as a result of trauma or surgery. Most often, the term is used in the sense of "amputation of a limb" - its truncation over a bone (or several bones), in contrast to disarticulations (disarticulation at the level of the joint).

Absolute readings:

.Complete or almost complete detachment of limb segments as a result of trauma or injury;

.Extensive damage to the limb with crushing of bones and crushing of tissues;

.Gangrene of the limb of various etiologies;

.Progressive purulent infection in the lesion of the limb;

.Malignant tumors of bones and soft tissues with the impossibility of their radical excision.

Relative readingsdetermined by the nature of the pathological process:

.Trophic ulcers that are not amenable to conservative and surgical treatment;

.Chronic osteomyelitis of bones with the threat of amyloidosis of internal organs;

.Anomalies of development and consequences of a limb injury that are not amenable to conservative and surgical correction.

Amputation contraindications:

1.Traumatic shock. It is necessary to bring the wounded out of the state of shock and only then perform the operation. However, the anti-shock period should not last more than 4 hours.

In children, relative indications should be very limited, given the great potential of the child's body for regeneration and adaptive restructuring of the musculoskeletal system. Also, it must be taken into account that amputation can adversely affect the development of the child's skeleton (curvature or shortening of the limb, deformity of the spine, chest, pelvis, etc., and this, in turn, can lead to dysfunction of internal organs.

1.2 Types of amputations

The choice of amputation level depends primarily on the location of the injury. Amputation is performed at the level that gives the greatest guarantee against the possibility of spreading infection from the area of ​​injury. Only with truncations taken about gas gangrene or necrosis with obliterating arteritis, amputation is performed as high as possible. In addition, the level of amputation is determined by the nature of the damage and subsequent rehabilitation, medical and social.

Preliminary amputation- extended surgical debridement, which is performed when it is impossible to initially accurately determine the level of amputation.

Final amputation- treatment of the wound, carried out without subsequent reamputation, they are done in cases where there is no reason to expect dangerous inflammatory complications and the formation of a stump unsuitable for prosthetics.

Depending on the term and indications for amputation, there are primary, secondary and repeated amputations, or reamputations. Primary amputationis performed immediately after the patient is delivered to a medical institution or within 24 hours after the injury, that is, even before the development of inflammation in the area of ​​damage.

The secondary is called amputation.produced at a later date, within 7-8 days. Primary and secondary amputations are operations performed according to early indications.

Reamputation- planned surgical intervention, which aims to complete the surgical preparation of the stump for prosthetics. Indications for this operation are vicious stumps.

Traumatic amputation- rejection of part or all of a limb (or other part of the body) as a result of mechanical violence. A specific variant of the mechanism of traumatic amputation is limb avulsion. Distinguish between complete and incomplete traumatic amputation.

According to the shape of the dissection of soft tissues, several types of amputation are distinguished, and first of all, the need to cover the bone sawdust should be taken into account. For this purpose, soft tissues are transected, taking into account their retraction below the level of bone sawing.

In practice, there are early and late amputations.

Early amputationsare performed according to urgent indications before the development of clinical signs of infection in the wound.

Late amputationslimbs are performed due to severe complications of the wound process, which are life-threatening, or in case of failures in the struggle to save a seriously injured limb

1. 3 Methods of amputation

Guillotine method- the simplest and fastest. Soft tissues are cut at the same level as the bone. It is indicated only in cases where there is a need for rapid truncation of the limb.

circular way- provides for the dissection of the skin, subcutaneous tissue and muscles in the same plane, and the bones - somewhat more proximal.

The greatest benefits are three-stage cone-circular methodaccording to Pirogov: first, the skin and subcutaneous tissue are cut with a circular incision, then all the muscles are cut along the edge of the reduced skin to the bone.

After that, the skin and muscles are retracted proximally and the muscles are re-crossed at the base of the muscle cone with a perpendicular incision.

The bone is sawn in the same plane. The resulting soft-tissue "funnel" closes the bone sawdust. Wound healing occurs with the formation of a central scar.

Indications: truncation of the limb at the level of the shoulder or hip in cases of infectious lesions of the limb, anaerobic infection and uncertainty that further development of the infection is prevented.

Patchwork way. Patchwork-circular amputation to remove the focus of intoxication during crush injuries is performed within healthy tissues and is performed 3-5 cm above the soft tissue destruction zone.

Skin-fascial flaps are cut out with a wide base.

Muscles intersect circularly. The bone is sawn along the edge of the contracted muscles.

Plastic amputation methods:

Tendoplasticoperations are indicated for truncation of the upper limb in the distal part of the shoulder or forearm, for disarticulation in the elbow or wrist joint, for vascular diseases or diabetic gangrene. The tendons of the antagonist muscles are sutured together.

fascioplastica method of amputation, in which the bone sawdust is closed with skin-fascial flaps. The method of high fasciocutaneous amputation was developed to preserve the knee joint during limb amputation due to vascular diseases.

myoplasticThe method of amputation has become widespread in recent years.

The main technical point of the stump muscle plasty is the suturing of the ends of the truncated antagonist muscles over the bone sawdust to create distal muscle attachment points. Bone processing. The most common method of treating a bone stump is the Petit periostoplastic method. When amputating from the removed area of ​​the bone, before sawing it, a periosteal flap is formed, which closes the sawdust of the bone, and after amputation of the lower leg, both tibia bones.

4Stages of amputation of the upper limbs

A patient who is about to have a limb amputated must be prepared not only physically but also psychologically. He must realize that after amputation he will be able to take an active part in work and social life.

Amputation is usually performed under anesthesia, but in some cases the use of local anesthesia is acceptable. Spinal anesthesia for amputations in the condition of injury is unacceptable. Before the amputation operation, as a rule, Esmarch's tourniquet is applied 10-15 cm above the level of amputation of the limb. The exception is amputations due to damage to the main vessels or due to anaerobic infection, in which the operation is performed without a tourniquet.

The main stages of amputation:

1. Dissection of the skin, subcutaneous tissue and fascia;

2. Dissection of muscles;

3. Ligation of blood vessels and treatment of nerve trunks;

4. Dissection of the periosteum and sawing of the bones

Stump formation

The muscles are crossed to the bone in a plane perpendicular to the long axis of the segment, taking into account their contractility from 3 to 6 cm distal to the bone filing.

Important for amputation processing of nerve trunks. At present, it is customary to cross the nerves with a razor or a sharp scalpel while moving the soft tissues in the proximal direction by 5-6 cm; it is recommended not to stretch the nerve. Cutting the nerve with scissors is not allowed.

Bone processing is important for favorable outcomes of amputation and subsequent prosthetics. After a circular dissection of the periosteum, it is recommended to push the periosteum distally with a raspator. The sawing of the bone should be done as slowly as possible, constantly irrigating the place where the saw was cut with a solution of novocaine and sodium chloride. After sawing the bone, the outer edge of the entire bone sawdust is cleaned with a file with a round notch.

The most common method of treating a bone stump is the Petit periostoplastic method. When amputating from the removed area of ​​the bone, before sawing it, a periosteal flap is formed, which closes the sawdust of the bone, and after amputation of the forearm, both of its bones.

Hemostasis is considered the responsible moment of amputation. Before ligation, large vessels are freed from soft tissues. Ligation of large arteries along with muscles can lead to eruption and slippage of the ligatures, followed by bleeding.

Vessels are tied up with catgut. Ligation with catgut is the prevention of ligature fistulas. After ligation of large vessels, the tourniquet or bandage is removed. Appeared bleeding is stitched with catgut. Less tissue should be taken into the ligature so that there are fewer necrotic tissues in the wound.

After amputation, in order to avoid contracture in a straightened position, the limb is immobilized with plaster casts or splints. The splint should be removed after the wound has completely healed.

After amputation of the fingers, hand or forearm in the lower or middle third, reconstructive operations are applied. When the fingers are amputated, an operation is performed to phalange the metacarpal bones, as a result of which partial compensation of the function of the fingers is possible. When amputating the hand and forearm, the forearm is split according to Krukenberg with the formation of two "fingers": the radial and ulnar. As a result of these operations, an active grasping organ is created, which, unlike a prosthesis, has tactile sensitivity, due to which the patient's household and professional working capacity is significantly expanded.

5Complications after amputation of the upper limbs

When performing amputation, the development of the same complications as with other types of surgical intervention is possible. The most frequent and dangerous complication, for example, in traumatic amputation, is traumatic shock. It is the harder, the more proximal the level of traumatic amputation. The most severe, often irreversible shock occurs when both limbs are amputated. The severity of shock is also influenced by frequent (in 80% of victims with traumatic amputation) other injuries of the limbs and internal organs. Damage to the latter can dominate the clinical picture and determine the prognosis. Other general complications (acute renal failure, fat embolism, thromboembolism) are closely related to the severity of shock, the usefulness of its treatment, and the severity of injury.

The most frequent purulent-septic complications: purulent-necrotic process in the wound of the stump, osteomyelitis, rarely sepsis, anaerobic infection in the stump, tetanus.

Specific complications that occur after amputation include contracture (deformity of the limb due to improper fusion of the tendon and muscle contraction), soft tissue hematomas (accumulation of blood due to injury to the vessel), necrosis of the skin in the amputation area (necrosis), impaired wound healing and infection. In rare cases, a second surgical intervention is required.

Amputation pain deserves special attention.

Amputation pains do not occur immediately after surgery or injury, but after a certain time, sometimes they are a continuation of postoperative ones.

The most intense pain occurs after high shoulder amputations.

Types of amputation pain:

1 typical phantom pain (illusory);

2 actually amputation pains, localized mainly at the root of the stump and accompanied by vascular and trophic disorders in the stump. They are aggravated by bright light and loud noise, by changes in barometric pressure and by the influence of mood;

3 pain in the stump, characterized by increased widespread hyperesthesia and stubborn constancy.

phantom pains.Phantom sensations or pain are observed in almost all patients after limb amputation as a vicious perception of the lost limb in their minds.

Illusory-pain symptom complexcharacterized by a sensation of an amputated limb, in which burning, aching pain persists for a long time. Often these pains take on a pulsating, shooting character or resemble the range of pain that the patient experienced at the time of the injury.

Illusory pains are most intensely expressed on the upper limb, especially in the fingertips and palms. These pain sensations do not change their localization and intensity. A relapse, or exacerbation, often occurs at night or during the day under the influence of unrest or external stimuli.

Treatment with novocaine blockade of the neuromas of the stump and sympathetic nodes gives a long-term antalgic effect, the absence of which is an indication for surgical treatment. Reconstructive surgeries are performed on the neurovascular elements of the limb stump: scars and neuromas are excised, and the stumps of nerves and blood vessels are freed from adhesions and blocked with novocaine solution.

If the reconstructive operation does not bring the expected result, they resort to sympathectomy at the appropriate level: for the upper limb - the stellate node and the first two thoracic nodes.

Chapter 2. Rehabilitation of patients after amputation of the upper limbs

2.1Purpose and objectives of rehabilitation

Rehabilitation is a socially necessary, functional, social and labor recovery of sick and disabled people, carried out by the complex implementation of state, public, medical, psychological, pedagogical, professional, legal and other activities.

The concept of rehabilitation includes:

Functional recovery:

a) full recovery;

b) compensation for limited or no recovery;

Adaptation to everyday life;

Joining the labor process;

Dispensary observation of the rehabilitated.

Rehabilitation provides for two main points;

) the return of the victim to work;

) creation of optimal conditions for active participation in the life of society.

Rehabilitation of the disabled is a social problem, the solution of which is within the competence of medicine.

The purpose of rehabilitation is as follows: adaptation at the previous workplace or readaptation - work at a new workplace with changed conditions, but at the same enterprise. If it is impossible to implement the listed items, an appropriate retraining at the same enterprise is necessary; in case of failure or obvious impossibility of recovery - retraining in a rehabilitation center with subsequent job search in a new specialty.

The tasks of motor rehabilitation in amputation of the upper limbs are determined by many factors. The changed conditions of statics and dynamics of the body after amputation of limbs impose new requirements on the musculoskeletal system and the body as a whole.

Mastering prostheses and using them is carried out according to the mechanism of compensatory adaptability, the limits of which are individual and depend mainly on the psychophysical state of the victim. In this regard, in the process of physical therapy, the mechanisms of the tonic and trophic effects of physical exercises are primarily used, which create a favorable background for the successful development of new motor skills that most fully implement the functional capabilities inherent in one or another prosthesis design.

Particular tasks of therapeutic physical culture after limb amputation are diverse:

1.improvement of blood circulation in the stump in order to quickly eliminate postoperative edema, infiltrate;

.prevention of contractures and muscle atrophy;

3.development of muscle strength, especially those that will carry out the movements of artificial limbs;

.development of strength in general with the aim of increasing compensatory functions;

.increased mobility in all joints;

.development of endurance, muscular-articular sensitivity, coordination, separate and combined movements;

.development of self-service skills, training in the use of working devices, temporary and permanent prostheses.

Thus, one of the distinguishing features of rehabilitation after amputation of the upper limbs is a wide variety of particular tasks and methods used, aimed mainly at normalizing the activity of various body systems in new conditions, at developing motor qualities, developing compensation and developing skills in using artificial limbs.

It should be noted that the formation of the skill of using the prosthesis, as well as other motor skills, goes through three stages:

1.the first - is characterized by insufficient coordination and stiffness of movements, which is due to the irradiation of nervous processes;

.in the second - as a result of repeated repetitions, the movements become coordinated, less constrained - the skill stabilizes;

3.in the third - movements are automated.

The first stage requires special attention, since it is during this period that many superfluous, unnecessary movements are observed, which are fixed in the stabilization stage and subsequently corrected with great difficulty.

2.2Types of rehabilitation of disabled people after amputation of the upper limbs

There are three main types of rehabilitation:

1.Medical rehabilitation.

Includes therapeutic measures aimed at restoring the health of the patient. During this period, the psychological preparation of the victim for the necessary adaptation, re-adaptation or retraining is carried out. Medical rehabilitation begins from the moment the patient goes to the doctor, so the psychological preparation of the victim is within the competence of the doctor.

2.Social rehabilitation.

Social rehabilitation is one of its most important types and sets the main goal of developing the victim's skills for self-service. The main task of the doctor in this case is to teach the disabled person to use the simplest, mostly household appliances.

3.Professional rehabilitation.

Occupational or industrial rehabilitation sets the main goal of preparing a disabled person for work. The time elapsed from medical rehabilitation to professional rehabilitation should be minimal.

Industrial rehabilitation combines the successes of medical and social rehabilitation. It has now been established that rational work improves cardiovascular activity and blood circulation, as well as metabolism. While prolonged immobility will lead to muscle atrophy and premature aging. Therefore, occupational therapy is extremely important in the treatment process.

The main objectives of occupational therapy are:

1. Restoration of physical functions: a) increase in joint mobility, muscle strengthening, restoration of movement coordination, increase and maintenance of the ability to master working skills; b) training in everyday activities (eating, dressing, etc.); c) homework training (child care, home care, cooking, etc.); d) training in the use of prostheses and orthoses, as well as their care.

2. Production in the department of occupational therapy of simplified devices that allow a disabled person to engage in everyday types of work and household activities.

3. Determining the degree of professional ability to work in order to optimally select the type of work that is suitable in a particular case.

Basic principles of rehabilitation:

1. Perhaps an early start of rehabilitation measures, which should organically flow into therapeutic measures and complement them.

2. Continuity of rehabilitation as the basis of its effectiveness.

3. Comprehensive nature of rehabilitation measures. Not only medical workers, but also other specialists should participate in the rehabilitation of disabled people: a psychologist, a sociologist, representatives of the social security organization and trade union, lawyers, etc. Rehabilitation measures must be carried out under the guidance of a doctor.

4. Individuality of the system of rehabilitation measures. The course of the disease process, the nature of people in various conditions of their activity and life are taken into account, which requires a strictly individual compilation of rehabilitation programs for each patient or disabled person.

5. Implementation of rehabilitation in the society of patients (disabled people). This is due to the fact that the goal of rehabilitation is the return of the victim to the team.

6. Return of the disabled to active socially useful work.

2.3 Means of physical rehabilitation after amputation of the upper limbs

Of great importance in the social adaptation of patients after amputation of the upper limbs is physical rehabilitation, which makes it possible to prepare the patient well for prosthetics, and in the future to avoid complications associated with the use of the prosthesis. After the operation, which is performed under general anesthesia, typical postoperative complications are possible: congestion in the lungs; impaired activity of the cardiovascular system; thrombosis and thromboembolism. There is atrophy of the muscles of the stump, caused by the fact that the muscles lose their points of distal attachment, as well as the transection of blood vessels and nerves.

After the operation, due to the pain syndrome, the mobility of the remaining joints of the limb is limited, further interfering with prosthetics. Amputation of the forearms causes contracture in the elbow and shoulder joints, atrophy of the muscles of the forearm. In the upper thoracic spine, a curvature is observed, which is associated with an upward displacement of the shoulder girdle on the side of the amputation.

Exercise therapy after amputation of the upper limbs.

After amputation of limbs in the exercise therapy technique, three main periods are distinguished :

· early postoperative (from the day of surgery to the removal of sutures);

· the period of preparation for prosthetics (from the moment the sutures are removed to the receipt of a permanent prosthesis);

· the period of mastering the prosthesis.

Early postoperative period. During this period, the following tasks of exercise therapy are solved.

· prevention of postoperative complications (congestive pneumonia, intestinal atony, thrombosis, embolism);

· improvement of blood circulation in the stump;

· prevention of muscle atrophy of the stump;

· stimulation of regeneration processes.

Contraindications to the appointment of exercise therapy: acute inflammatory process in the stump; the general serious condition of the patient; height body temperature; danger of bleeding. LH classes should be started on the first day after surgery. They include breathing exercises, exercises for healthy limbs. From the 2-3rd day, isometric tensions are performed for the preserved segments of the amputated limb and truncated muscles; facilitated movements in the joints of the stump free from immobilization; apply phantom gymnastics (mental execution of movements in the absent joint), which is very important for the prevention of contracture, reducing pain and atrophy of the muscles of the stump. After amputation of the upper limb, the patient can sit down, stand up, walk. After the removal of the sutures, the 2nd period begins - the period of preparation for prosthetics. In this case, the main attention is paid to the formation of the stump: it must be of the correct (cylindrical) shape, painless, supportive, strong, resistant to stress. First, mobility is restored in the remaining joints of the amputated limb. As pain decreases and mobility in these joints increases, exercises for the muscles of the stump are included in the classes. Carry out a uniform strengthening of the muscles that determine the correct shape of the stump, necessary for a snug fit of the prosthesis sleeve. LH includes active movements in the distal joint, performed by the patient at first with the support of the stump, and then independently and with the resistance of the instructor's hands. Training of the stump for support consists in pressing its end first on a soft pillow, and then on pillows of various densities (stuffed with cotton, hair, felt) and in exercises with the support of the stump on a special soft stand. Start such a workout with 2 minutes and bring its duration to 15 minutes or more. For the development of muscular-articular feeling and coordination of movements, exercises should be used in the exact reproduction of a given amplitude of movements without visual control.

After amputation of the upper limb (and especially both), much attention is paid to the development of self-care skills for the stump - with the help of such simple devices as a rubber cuff worn on the stump, under which a pencil, spoon, fork, etc. are inserted. Amputation of extremities leads to posture disorders, therefore corrective exercises should be included in the CG complex. When amputating the upper limb - due to the displacement of the shoulder girdle on the side of the amputation up and forward, as well as the development of "pterygoid shoulder blades" - against the background of general developmental exercises for the shoulder girdle, movements are used aimed at lowering the shoulder girdle and bringing the shoulder blades together. Compensatory can develop scoliotic curvature in the opposite direction in the thoracic and cervical spine.

At the final stage of rehabilitation treatment after amputation of a limb, therapeutic exercises are aimed at developing skills in using prostheses. Training depends on the type of prosthesis. For fine work (for example, writing), a prosthesis with a passive grip is used, for more rough physical work, a prosthesis with an active finger grip is used due to the traction of the muscles of the shoulder girdle. Recently, bioelectric prostheses with active finger grip, based on the use of currents that occur at moments of muscle tension, have been widely used.

Exercise therapy for reconstructive operations on the stumps of the upper limbs is used in the pre- and postoperative period and contributes to the speedy formation and improvement of motor compensation. Preoperative preparation of the forearm stump consists of massaging the muscles of the stump, retraction of the skin (due to its lack in local plasticity at the time of finger formation), restoration with the help of passive and active movements of pronation and supination of the forearm. After the operation, the goal of therapeutic exercises is to develop a grip due to the reduction and dilution of the newly formed fingers of the forearm stump. This movement is absent under normal conditions. In the future, the patient is taught to write, and first with a specially adapted pen (thicker, with recesses for the ulnar and radial fingers). After splitting the forearm for cosmetic purposes, patients are provided with a prosthetic arm.

Massage after amputation of the upper limbs.

Massage technique .

In the early postoperative period, segmental reflex effects are applied in the area of ​​the corresponding paravertebral zones.

Massage of the stump can be started after the removal of surgical sutures. Healing by secondary intention, the presence of a granulating wound surface, even the presence of fistulas at normal temperature, the absence of a local inflammatory reaction, and also pathological changes in the blood are not a contraindication for massage. Of the massage techniques, various types of stroking, rubbing and light kneading (spiral in the longitudinal direction) are used.

In the first week, massaging near the postoperative suture should be avoided until it gets stronger. In the presence of scar formations soldered to the underlying tissues of the stump, massage is an excellent tool for removing these adhesions. In such cases, first of all, various kneading techniques are used (shifting the scar, etc.). To develop the support ability of the stump in the area of ​​the distal end, vibration is used in the form of tapping, chopping, and quilting.

When massaging an amputated limb, special attention should be paid to the muscles that have survived after the operation and should contribute to the restoration of normal movements. So, after amputation in the area of ​​the middle third of the thigh, it is recommended to strengthen the adductors and extensors of the thigh as much as possible.

After amputation below the knee joint, special attention should be paid to strengthening the quadriceps muscle. After amputation in the middle third of the shoulder, the abductors and muscles that perform external rotation of the shoulder should be selectively strengthened. Abduction exercises (abducting the limb to the side) of the shoulder prevent atrophy of the deltoid and supraspinatus muscles (strengthening the muscles that abduct the shoulder) and atrophy of the infraspinatus and small round muscles (muscles that rotate the shoulder outward).

Massage of the amputation stump at first should not last more than 5-10 minutes; gradually the duration of the massage procedure is adjusted to 15 - 20 minutes. For the development of the function of the stump, the mobility of the nearest joints is very important. During the massage, it is recommended to perform physical exercises, which should be started as early as possible.

These include, first of all, the sending of motor impulses aimed at performing movements of the stump in various directions. Such exercises help to strengthen the crossed muscles, mobilize the scars soldered to the bone and increase the trophism of the stump tissues. Exercises are performed daily 3-5 times a day. Exercises for a healthy limb in all joints are also recommended; such exercises greatly contribute to the recovery process in the stump.

Further, exercises aimed at developing its endurance are used: pressing the end of the stump onto special pads of various hardness (cotton wool, sand, felt, wooden stand), tapping the stump with a wooden mallet lined with felt, etc. In order to develop coordination skills when standing and walking with a prosthesis, as well as restoring tactile, muscular and joint sensations in the remaining part of the limb, it is recommended to combine massage with exercises to develop balance: torso tilts, half-squats and squats on one leg with open and closed eyes. Skin care of the stump in the early postoperative period is also very important.

Physiotherapy after upper limb amputation.

Phantom pain is a postoperative complication that manifests itself as a sensation of pain in the amputated limb, which can be combined with pain in the stump itself. UVR of the stump area is applied in 5-8 biodoses (8-10 exposures in total); diadynamic currents in the stump area (10-12 procedures); darsonvalization; electrophoresis of novocaine and iodine; applications of paraffin, ozocerite; dirt on the stump area; general baths: pearl, radon, coniferous, hydrogen sulfide.

After amputation, as with other types of surgical interventions, an infiltrate may form in the area of ​​the postoperative suture. In the treatment of infiltration in the acute stage, cold is used to limit its development and ultraviolet irradiation. Apply UHF for 10-12 minutes daily, CMW, ultrasound, inductotherapy, ozocerite and paraffin applications on the infiltrate area, UVI. After 2-3 days after the subsidence of acute inflammatory phenomena, they switch to thermal procedures.

General contraindications to physiotherapy procedures also remain unchanged:

state of extreme exhaustion

tendency to bleed

blood diseases

malignant neoplasms

pronounced manifestations of systemic organ failure (cardiovascular failure, respiratory failure, impaired renal function).

In the absence of contraindications, physiotherapy is prescribed as soon as possible and is carried out for a long time, until the start of prosthetics.

Chapter 3

The task of the surgeon during amputation is by no means limited to surgical intervention. An equally important task is the "education" of the stump, preparing it for prosthetics. The amputation stump must meet the following requirements:

) it must have a regular, even outline (not have a conical shape);

) be painless;

- stump tissues should be minimally edematous and maximally reduced in volume;

- the skin of the stump should be well stretched, with difficulty to be captured in the fold, should not have protrusions;

- the end of the stump should be covered with a more or less thick (but without excess) layer of soft tissues;

- the scar on the stump should be narrow, smooth, located away from points subjected to pressure;

) the stump must be hardy, supportable;

) the function of the stump must be fully preserved in terms of muscle strength and range of motion. The foundations of all these conditions are laid on the operating table, but each of the conditions can be lost or increased depending on the mode of the amputation stump, as well as the quality of the subsequent treatment. Thus, the incorrect position of the stump after surgery, insufficient attention to the preservation of its function can lead to the development of contracture and cause a vicious position of the stump. The stump can become sensitive, the end of it can take on a flask shape as a result of improper bandaging or improper massaging. As you know, the process of forming an amputation stump in order to prepare it for prosthetics.

3.1 General characteristics of upper limb prostheses

Upper limb prostheses

Upper limb prostheses should replace the most important lost functions of the hand - the functions of opening and closing the hand, i.e. grabbing, holding and releasing an object, as well as restoring the appearance.

Two types of upper limb prostheses are offered: passive and active.

· The passive ones are cosmetic prostheses, which serve only to restore the natural appearance.

· Active prostheses are mechanical and bioelectric.

Bioelectric upper limb prostheses

Modern upper limb prostheses are designed not only to restore the natural appearance, but also to make up for the most important lost functions of the human hand, such as opening and closing the hand, that is, grasping, holding and releasing various objects.

One of the latest developments in this area is the so-called bioelectric prostheses of the upper limbs, which are actuated by means of electrodes that read the electric current generated by the muscles of the stump at the moment of their contraction. Then the information is transmitted to the microprocessor, and as a result, the prosthesis comes into action. Thanks to the latest technology, artificial hands allow rotational movements in the hand, grasping and holding objects. Bioelectric prostheses make it possible to successfully use such things as a spoon, fork, ballpoint pen, etc. It should be noted that this system is designed not only for adult users, but also for children and adolescents.

The essence of biomechanical prostheses is that after amputation of the stump of the hand, it retains the remnants of the previously existing grasping muscle. When they contract, an electrical impulse of alternating current is received, which is perceived by the control electrodes of the biomechanical prosthesis located on the skin. The electronic amplifying system available in these electrodes, even with a slight contraction of muscle tissue, allows you to turn on / off a small but powerful electric motor that moves the thumb and forefinger.

The latest modifications of the bioelectric brushes of the Otto Bock trademark, produced by the world famous orthopedic concern Otto Bock (Germany), are equipped with special touch sensors that control the force of gripping the object. These sensors are localized in the finger zone. Thanks to them, the user has the ability to take various items, including such fragile things as a glass of thin glass or, say, an ordinary chicken egg, without fear of breaking or crushing them.

The latest models of biomechanical hand prostheses combine an aesthetically flawless appearance with a significant grip force and speed of its implementation, as well as many additional features or combinations of expanding functions. When using microelectronic technology, such artificial hands are even more effective.

By the way, in relation to the above-mentioned company Otto Bock, it should be noted that it was founded back in 1919 by the German orthopedic technician Otto Bock, after whom it was named. The parent company of the concern is located in the city of Duderstadt (Lower Saxony), subsidiaries are located in more than thirty countries of the world, including Russia (since 1989). Over the past years, the Otto Bock company has taken a stable position in the Russian market and has become one of the leading suppliers of modern technical means of rehabilitation, as well as orthopedic products, materials, components and equipment necessary for prosthetic and orthopedic production.

Mechanical upper limb prostheses

Mechanical prostheses are active prostheses that simultaneously solve two tasks: social and work. The hand of a mechanical prosthesis recreates, as far as possible, the natural appearance of the hand, which allows a person to feel confident and comfortable in the company of people, and performs the functions of capturing and holding an object. The hand is actuated by means of a bandage fixed on the shoulder girdle. If a person needs to provide a wider range of activities, for example, when working in production, on a personal plot, etc., then the brush can be easily replaced with working nozzles, selected depending on the type of activity.

Cosmetic (passive) upper limb prostheses

Cosmetic or passive prostheses are designed purely to recreate the natural appearance and are used, respectively, in cases where the shape, weight, wearing comfort and ease of use of the artificial hand are of paramount importance, and the patient does not seek to compensate for the motor functions of the lost upper limb.

Such prostheses are absolutely suitable for any level of arm amputation, but they are of particular importance for high amputations, when functional prostheses cannot be used or it is not possible to restore the missing functions. The possibilities of such a hand are limited to simply holding objects, but it looks quite natural, and fully satisfies the desires of those individuals who gave preference to it.

Classical cosmetic prostheses consist of a stump, a hand frame, and a cosmetic glove. To meet the aesthetic and functional needs of patients, there are currently so-called systemic prostheses of the upper limbs, also consisting of a stump receiver, a frame and a cosmetic shell, but in addition, having a special body with a mechanical assembly. The capture function directly depends on the design of the latter. Thus, they provide a natural look of the upper limb, and have a fairly wide functionality.

Now the color, shape and structure of the outer surface of the latest cosmetic gloves fully reproduce the external features of a natural brush. For example, OTTO Bock (Germany) prostheses offer forty-three models of men's and women's gloves for individual selection, each of them in eighteen color shades. At the same time, cleaning and replacement of cosmetic gloves, if necessary, is carried out without any problems.

The molded foam frame of the hand, with its minimum weight, gives it high stability and thus increases wearing comfort. In addition, thanks to various mounting options, this frame has an almost universal application. In case of partial loss of the brush, it is made individually. For traditional cosmetic prostheses, passive systemic hands are used, which open with the help of a saved hand, and close independently.

In a word, modern cosmetic upper limb prostheses are easy to use, optimal in weight and easy to maintain. The problem of contamination has already been solved by 100%, so the care of products is no longer a problem.

Over time, dentures should be changed. It is unacceptable when the prostheses become too large for the patient, they dangle, which leads to scuffs and reflex contractures.

Sensitive prosthetic arm SmartHand

The bioadaptive SmartHand prosthesis is an artificial upper limb that the patient can feel like their real hand. The invention belongs to a group of developers from the engineering department of Tel Aviv University (Israel) led by Professor Yossi Shacham-Diamand (Yosi Shacham-Diamand). In collaboration with their colleagues from the European Union, they brought to life a technique for creating an upper limb prosthesis, which uses the preserved nerve endings left in the stump of an amputated hand.

The device called "SmartHand" not only looks like the hand of an ordinary person, it allows the patient to return after amputation what until recently was considered impossible - sensitivity in his upper limb.

In Sweden, clinical trials of prototypes of this invention have already been carried out, which have shown very encouraging results. The first patient to receive such a prosthesis was a man who needed only a few training sessions to get used to the artificial limb and learn how to use it, not only for manipulating the type of food intake, but also for writing.

The development of SmartHand was originally aimed not only at restoring the function of a lost limb, but also at creating feedback with the prosthesis by stimulating peripheral nerve endings. In fact, we are talking about making the artificial hand sensitive to the user and not only partially return the functions of the hand, but also eliminate such a problem as phantom pain. After all, for people who have lost their upper limbs, the consequences can turn into a disaster: in addition to the fact that they had to lose a very complex and important motor mechanism of their body - their hands, their psyche often suffers - self-esteem decreases and self-consciousness is distorted. In addition, sometimes they have exhausting phantom pains. All this significantly worsens the quality of life.

Thanks to the SmartHand prosthesis, it was possible to achieve that the human brain began to process the signals received from the artificial hand and perceive them as natural afferent impulses. This is achieved through a special neural interface in which four dozen sensors perceive information coming from the prosthesis and transmit it further to the remaining intact nerve endings located on the forearm, shoulder, shoulder girdle or chest, and from there to a certain somatosensory area in the cerebral cortex. Thus, the artificial hand actually restores sensitivity in the lost upper limb.

In fact, the SmartHand project should not only solve medical issues by raising the process of rehabilitation of people with lost upper limbs to a completely new level, it also has a huge social significance. After all, a person's hands in a sense determine his essence, thanks to their anatomical and functional features, people can write, draw, play the piano, etc.

1.I have studied educational and methodical and scientific literature on the topic of course work. Based on the material studied, amputation can be defined as a truncation of a limb along a bone (or several bones). The term amputation is also used to truncate the peripheral part or even the whole organ, for example, the rectum, the mammary gland.

.The purpose of the physical rehabilitation of disabled people after amputation of the upper limbs is their recovery and adaptation in society. In this regard, the tasks of physical rehabilitation can be distinguished, such as:

· functional recovery;

· adaptation to everyday life;

· participation in the labor process.

To solve the tasks, the following tools are used:

· Healing Fitness;

·massage;

· physiotherapy procedures.

3. After analyzing modern upper limb prosthetics, we can conclude that modern upper limb prostheses differ in their functional features. Depending on the level of amputation, various prostheses are made: fingers, forearm, shoulder and the entire arm (after disarticulation in the shoulder joint). To date, there are two types of upper limb prostheses: therapeutic and training and permanent. Therapeutic and training prostheses are designed to prepare the patient for prosthetics. If we talk about permanent prostheses, then modern medicine distinguishes two types of them: active and passive. Passive are cosmetic hand prostheses. They are intended only to give the lost limb a natural appearance. As for active prostheses, they can be called mechanical. Mechanical prostheses are designed to perform two functions: social and work.

List of sources used

1. Azolov V.V. Rehabilitation of patients with certain diseases and injuries of the hand: Sat. scientific works of the Gorky Research Institute of Traumatology and Orthopedics / ed. V.V. Azolova. - Gorky, 1987. - 207 p.

Belousov P. I. Corrective and preventive exercises after amputation of the upper extremities. L., 1954. Belousov P. I. Orthopedist, traumatol., 1963.

The loss of a limb is an event that forever changes the quality of a person's life. Thanks to the development of medicine, today amputation does not become a sentence, does not entail a complete loss of business and social activity, but it is still a difficult psychological and, above all, physical test.

Rehabilitation after leg amputation begins already in the postoperative period, its features are determined by the type of injury. The importance of medical procedures and moderate physical activity at every stage of the return to health must be clearly recognized.

Amputation is a complex surgical procedure in which the patient loses a limb, partially or completely. Indications for such an operation are different: infectious infection, a consequence of illness or injury. The most common cause of limb loss is mechanical damage, which results in avulsion, severe fragmentation of the bone, and soft tissue necrosis in the case when assistance was not provided in a timely manner.

There are two types of amputations:

• primary - it is carried out in case of an absolute need to remove part of the leg;
• secondary (also "reamputation") - the need for an additional operation may arise if a person's health continues to be endangered (for example, the process of tissue necrosis has gone higher), in the case when an incorrect stump formation is observed, with a number of other indications.

Important! The decision to carry out amputation can only be made when all other treatment options are not effective, and surgery is the only way to save the patient's health and life.

According to the level of seizure, operations on the legs are as follows:

• disarticulation of fingers - removal (often prescribed in the last stages of diabetes, with severe frostbite);
• transtibial (in the ankle area) - amputation does not capture the knee joint, as a rule, its mobility is preserved;
• knee disarticulation - removal of the leg up to the thigh;
• transfemoral - the entire femoral part;
• exarticulation of the hip joint - the operation captures the pelvis;
• hemipelvectomy - partial removal of the pelvis;
• hemicorporectomy - complete amputation with both legs.

Exercise therapy after leg amputation

With good indicators of the patient's health, it is shown to start rehabilitation after amputation of the leg already on the first day. In the initial period of recovery, the patient must learn to control his body, get used to the changed load on the muscles, independently perform elementary actions to facilitate self-care (lifting the body, turning, etc.). For this purpose, basic exercises are performed to strengthen the muscles, accompanied by breathing exercises.

By the end of the first week, if there are no negative symptoms, you can include in the warm-up the load on the remaining joint, contract and relax the muscles of the formed stump. Regular exercise helps to get rid of postoperative edema, accelerates the healing process, tissue repair.

After removing the sutures, the second period of rehabilitation begins: the load increases significantly, exercises with crutches and shells are performed. Preparations are underway for the installation of the prosthesis, therefore, the stump is involved to a large extent.

The support of the stump is restored first by walking on a soft surface (Fig. A above), then on a hard one (Fig. B).

Complexes of therapeutic exercises

To a large extent, the choice of exercises depends on the type of operation performed, so rehabilitation after a below-the-knee amputation will differ from a similar recovery process after a more difficult or easier procedure with the removal of most of the leg or its preservation.

Lying down (facing the ceiling):

1. Flexion and extension of healthy preserved joints (three sets of 10 times).
2. Holding with palms, the hips are pulled up until they touch the stomach (10 times in two sets).
3. Exercise "bicycle" (performed as far as possible in order to develop joints and strengthen muscles).

In a standing position (emphasis on a healthy leg):

1. Raising arms and tilts (8 times in three sets).
2. Squats (10 times in two sets).
3. Raising and lowering the stump with retraction back to the stop (10 times, two sets).
4. Stand exactly with balance, as far as possible for a long time.

Attention! Any amputation in the region of the lower extremities inevitably leads to disturbances in the functioning of the musculoskeletal system, due to the fact that the patient's center of gravity shifts. Great care must be taken when performing the exercises, trying to maintain balance.

Rules for exercises after leg amputation

First of all, when performing exercises, you should protect the stump from contamination and injury. For this purpose, a special cover made of natural fabric, which is well breathable, is put on the injured leg. In case of divergence of surgical sutures, redness and irritation, you should immediately seek medical help.

Crutches and canes are selected according to height, they should be light and easy to handle, like other training aids.

Incorrect selection of support means leads to a change in posture, lameness. The strong pressure of the crossbars of crutches on the axillary zone can provoke inflammation of the lymph nodes, in especially difficult cases - paralysis of the muscles of the hands.

Exercises should be performed in front of a mirror, following the correct technique, maintaining balance.

Application of massage procedures

In the recovery process, massage procedures are very helpful, which help in preparing the limb for further prosthetics, stimulate blood flow to the tissues. You can start massage from the end of the second week of the rehabilitation period.

Procedures begin with simple stroking, rubbing, in which all fingers of both hands are involved.

The pressure should not be excessive, the movements are soft, undulating, diverging, the load is distributed evenly.

This helps in reducing puffiness. For better resorption of the postoperative scar, light tingling, stroking, rubbing in a spiral, and work with a soft roller are used.

Immediately after the removal of the sutures, when the swelling of the tissues subsides, it is permissible to use sharper and rougher techniques in order to train the endurance of the stump: increased rubbing, finger pressure, patting, tapping.

Despite the importance of the patient's independent activity, the recovery process should proceed under the supervision of specialists, with full control of the correct fusion, the formation of a stump with the prospect of further prosthetics. Given the complexity of the operation and the risks associated with it, in case of any suspicion of violations in the rehabilitation process, you should consult with your doctor.

Where it is better to undergo rehabilitation after leg amputation, you can find out at the place of residence, in the regional centers of Russia, for example, in Kemerovo, Volgograd and a number of others, clinics have been opened that specialize in the preparation and implementation of high-quality installation of prostheses.

Finally

Losing a limb is a terrible prospect, but with the right therapy, a competent approach to the recovery process and, most importantly, the desire to return to normal life, nothing is impossible.

Therapeutic physical culture (exercise therapy) is a method of treatment that uses the means of physical culture with a therapeutic and prophylactic purpose to restore the health and working capacity of the patient, prevent complications and consequences of the pathological process.

Methods of therapeutic physical culture according to L.V. Shapkova (2007)

Amputation is an operation to remove the peripheral part of a limb. The term amputation is more often used in relation to the operation to remove part of the limb when crossing it between the joints. Cutting off a limb or part of it through a joint is called exarticulation (exarticulation). Amputation is performed with a complete or partial separation of the limb; severe injuries associated with rupture of the main vessels, nerves, crushing of a large number of bones and extensive crushing of muscles; with gangrene of the limb caused by obliterating endarteritis, thromboembolism, frostbite and other diseases, as well as with malignant neoplasms (sarcoma, cancer). The level at which amputation is performed depends on the nature, localization and severity of the injury, and it is customary to determine it within a third of the segment: the lower, middle or upper third of the thigh, lower leg. The rest of the truncated limb is called the stump. Most often, limb amputation is performed in wartime according to vital signs. In peacetime, the issue of amputation is discussed for a long time, since the operation is morally difficult for patients to endure, making them disabled.

In the postoperative period after amputation of the lower extremities, physical exercises begin the next day after the operation.

Breathing exercises are performed with an extended exhalation, elementary movements in the joints of the preserved limbs and spine. Postoperative gymnastics contributes to the prevention of pulmonary complications (bronchitis, pneumonia), disorders of the gastrointestinal tract. In the absence of contraindications, it is allowed to move to a sitting position on the bed for 2-3 minutes with the help of medical personnel, turn to the side, etc. From the 3-4th day, the intensity of the exercises increases and preparation for getting up is provided. Staying in a sitting position is allowed 3-5 times during the day for 10-15 minutes.

After unilateral amputations of the lower extremities, it is allowed to stand up with support on crutches, move from bed to a wheelchair, move on it within the ward. When selecting gymnastic exercises in the postoperative period, the general condition, the level and method of amputation, the reason for amputation, the presence of complications, etc., should be taken into account. Active movements in the preserved joints of the truncated limb and exercises in a static mode are used from the 2-3rd day. These exercises help reduce postoperative swelling and increase joint mobility (see Appendix 2).

Performing exercises to develop the ability to balance and prevent postural disorders begins after moving to a standing position on a healthy leg. The first 2-3 days, classes lasting 7-10 minutes are held 2-3 times a day. In the following days, the time of classes increases to 15-20 minutes (see Appendix 3).

On the 5-6th day after the operation, motor activity expands in order to prepare for walking. During this period, crutches should be selected for children with defects in the lower extremities. It should be noted that improper use of crutches adversely affects the development of walking, delays the formation of motor skills, distorts gait, and can also cause paresis of the upper limbs due to compression of the neurovascular bundle in the armpit. When using crutches, the support should be carried out mainly on the hands, limiting the support to the armpits. When using crutches, you need to maintain the correct posture. After the selection of crutches, learning to walk begins, which, as a rule, is mastered quickly.

After removing the sutures, exercise should contribute to:

1) restoration of optimal mobility in all preserved joints of the truncated limb, mobilization of maximum mobility in the joints of the preserved limb and spine;

2) development of dynamic and static muscle strength, muscle-articular sensitivity of the truncated limb, improvement of balance, standing on one leg and coordination of movements of the upper and lower limbs;

3) the formation of walking skills based on crutches with unilateral defects of the lower extremities, correct posture, preparation for the upcoming prosthetics.

During the period of preparation for prosthetics, all preparatory measures are built in accordance with the characteristic clinical and anatomical and functional features of the child's motor status and are aimed at the fullest possible compensation and restoration of impaired motor functions.

Exercises to increase mobility in the joints of a truncated and preserved limb, prevent the formation of stiffness in the joints and contractures (see Appendix 4).

1. Movement of the truncated limb in various directions in the prone, sitting and standing positions.

2. Abduction and adduction, flexion and extension of the stump in the presence of additional resistance from the methodologist or in the form of a bag of sand, a suspended ball, an elastic bandage attached to a healthy leg, etc. in a prone, sitting and standing position.

3. Cross movements of the stumps, in a standing position (after amputation of one lower limb), lying on your back, sitting on a chair or gymnastic bench, lying on your side.

4. Adduction of the stump with resistance.

5. Circular movements of the stumps in the hip joint.

6. Flexion and extension of the stump in the knee and hip joints, exercise "bike".

7. Stump strikes on a suspended balloon, inflatable or leather ball, while sitting or standing.

Simultaneously with gymnastic exercises, contractures and stiffness in the joints are eliminated by manual redressing.

Development of movements in the joints by passively increasing the elasticity of muscles. Manual redressing in severe flexion contractures of the hip joint is carried out in the supine position, while the preserved limb is bent at the hip joint; abduction contractures - in the supine position on the side of the preserved limb. With flexion-abduction contractures, the child lies on his back, the redressing movement is directed back and inward, while the methodologist keeps the patient's pelvis from moving. With a slight or moderate limitation of extension in the hip joint, redressing can be performed in the supine position. At the same time, the methodologist presses the child's pelvis to the surface of the couch with one hand, the other covers the distal stump from below and extends the hip joint.

With contractures of the knee joints, along with gymnastic exercises, manual redressing is also carried out, which are performed in various starting positions - lying on the stomach, on the back, sitting. After their completion, it is advisable to fix the achieved result with the help of various fixators (orthoses). The elimination of contractures is most effective in combination with physiotherapy, in particular thermal procedures.

With short femoral stumps, attention is focused on extension and adduction, as flexion and abduction contractures develop. When retracting the stump back, in order to avoid movements of the pelvis and trunk, it is necessary to fix the pelvis in the prone position with sandbags or by restricting movements by a methodologist.

First stage. It starts from the moment you receive the prosthesis. The goal is to form the ability to maintain a vertical posture and move from a sitting to a standing position.

Private tasks:

1. Create an idea of ​​a rational way to move on the prosthesis.

2. To teach the uniform distribution of body weight on both limbs in a standing position at a fixed support.

3. Achieve the stability of a vertical posture in a standing position.

4. Teach the transition from a sitting position to a standing position and vice versa.

5. Achieve a transition from a standing position at a fixed support to a standing position without additional support.

Second phase. The criterion for the transition to the second stage of learning to walk is the ability to maintain balance on the prosthetic limb while maintaining the correct posture for 2-3 s. The purpose of the stage is to form the ability to walk rhythmically in the two-support phase of the step. Step elements include: bending the knee joint, moving the prosthesis forward, resting on the heel of the artificial foot, rolling from heel to toe while transferring body weight to the prosthesis. The four elements of the step correspond to the four phases of prosthesis control.

In the first phase, flexion in the knee joint is achieved by moving the stump forward. The second phase is carried out due to the further removal of the stump forward until the knee joint is extended under the action of the ankle-folding mechanism. Moving on to the third phase, it is necessary to lean on the heel of the artificial foot and at the same time move the stumps back by pressing on the back wall of the receiving sleeve. In the fourth phase of the step, while continuing to lean the stump on the back wall of the receiving sleeve, you should transfer the body weight to the prosthesis, while simultaneously rolling from heel to toe.

Private tasks:

1. Achieve retention of the prosthesis in the extended position of the hip joint.

2. Achieve a complete roll of the foot from the back to the front.

3. Achieve symmetry in the length of the steps.

4. Achieve timely transfer of body weight from the prosthesis to a healthy leg.

5. Achieve full extension in the knee joint and maintain correct posture while walking.

6. Achieve uniformity and rhythm of gait.

Third stage. At this stage, the main goal is to improve walking technique. Exercises aimed at the formation of additional walking options in various external conditions are widely used.

Methods of therapeutic physical culture according to A.F. Kaptelina (1999)

Of great importance in the social adaptation of disabled people with amputations of the lower extremities is physical rehabilitation, which makes it possible to prepare the patient well for prosthetics, and in the future to avoid complications associated with the use of the prosthesis.

After the operation, typical postoperative complications are possible: congestion in the lungs; impaired activity of the cardiovascular system; thrombosis and thromboembolism. When a lower limb is amputated, the statics of the body is significantly disturbed, the center of gravity moves towards the preserved limb, causing tension in the neuromuscular apparatus necessary to maintain balance. The consequence of this is the tilt of the pelvis to the side where there is no support, which in turn entails a curvature of the spine in the lumbar region in the frontal plane. Compensatory can develop scoliotic curvature in the opposite direction in the thoracic and cervical spine. There is atrophy of the muscles of the stump, caused by the fact that the muscles lose their points of distal attachment, as well as transection of blood vessels and nerves.

After the operation, due to the pain syndrome, the mobility of the remaining joints of the limb is limited, further interfering with prosthetics. With the stumps of the lower leg, a flexion-extension contracture of the knee joint is formed, with the stumps of the thigh, a flexion and abduction contracture of the hip joint. When walking on crutches and with a stick, patients quickly develop fatigue of the muscles of the shoulder girdle; and since the patient mainly leans on the remaining leg, the development of flat feet of the remaining limb is observed.

After amputation of limbs, three main periods are distinguished in the use of exercise therapy:

1. Early postoperative (from the day of surgery to the removal of sutures).

2. The period of preparation for prosthetics (from the day the sutures were removed to the receipt of a permanent prosthesis).

3. The period of mastering the prosthesis.

Early postoperative period.

The tasks of exercise therapy during this period are:

1) prevention of postoperative complications (congestive pneumonia, intestinal atony, thrombosis, embolism);

2) improvement of blood circulation in the stump;

3) prevention of muscle atrophy of the stump;

4) stimulation of regeneration processes.

Contraindications in the appointment of physiotherapy exercises - acute inflammatory diseases of the stump; the general serious condition of the patient; high body temperature; risk of bleeding.

Therapeutic exercises should be started on the first day after the operation. The classes include breathing exercises, exercises for healthy limbs, from the 2nd-3rd day, isometric stresses are performed for the preserved segments of the amputated limb and truncated muscles; facilitated movements in the joints of the stump free from immobilization; body movements - raising the pelvis, turns. From the 5-6th day, phantom gymnastics is used (mental execution of movements in the missing joint), which is very important for the prevention of contracture and atrophy of the muscles of the stump.

After the amputation of the lower extremity, the patient generally observes bed rest. However, with a satisfactory general condition, from the 3-4th day, the patient can take a vertical position in order to train the balance and support ability of a healthy limb. Patients are taught to walk on crutches.

The period of preparation for prosthetics

After removing the sutures, the patient begins to prepare for prosthetics, focusing on the formation of a stump. The stump must be of the correct form, painless, supportable, strong and resistant to stress. First, mobility is restored in the remaining joints of the amputated limb. As pain decreases and mobility in these joints increases, exercises for the muscles of the stump are included in the classes. So, during amputation of the lower leg, the extensors of the knee joint are strengthened, with amputation of the thigh, the extensors and abductors of the hip joint are strengthened. A uniform strengthening of the muscles is carried out, which determines the correct (cylindrical) shape of the stump, which is necessary for a snug fit of the prosthesis sleeve.

Therapeutic gymnastics includes active movements, performed at first with the support of the stump, and then performed by the patient independently and with the resistance of the instructor's hands. Training the stump for support first consists in pressing its end on a soft pillow, and then on pillows of various densities (stuffed with cotton wool, hair, felt) and walking with the stump supported on a special soft bench. Start such a workout with 2 minutes and bring it up to 15 or more. For the development of muscular-articular feeling and coordination of movements, exercises should be used to accurately reproduce the specified amplitude of movements without visual control.

With amputation of the lower extremities, as mentioned above, a curvature of the spine is formed in the frontal plane, which should also be taken into account when conducting therapeutic exercises, including corrective exercises. Overloading the remaining leg leads to the development of flat feet, and therefore it is necessary to use exercises aimed at strengthening the muscular and ligamentous apparatus of the feet. Much attention in the period of preparation for prosthetics is paid to exercises aimed at increasing the strength and endurance of the muscles of the upper shoulder girdle and general strengthening, since when walking on crutches, the main load falls on the hands, and the energy expenditure of the body is 4 times more than during normal walking. 3-4 weeks after the operation, training of standing and walking on a medical-training prosthesis begins, which facilitates the transition to walking on permanent prostheses.

The period of mastering the prosthesis.

At the final stage of rehabilitation treatment after amputation of a limb, the patient is taught to use the prosthesis. Before teaching the patient to walk, it is necessary to check the correct fit of the prosthesis to the stump and the correct fit. The technique of walking and the method of teaching it are determined by the design of the prosthesis, the characteristics of the amputation and the condition of the patient. When conducting classes with patients after amputation of the lower extremities due to obliterating endarteritis, diabetes, atherosclerosis, as well as in old age, it is necessary to especially carefully and consistently increase the load, controlling the reaction from the cardiovascular system.

Training to walk on prostheses consists of three stages. At the first stage, they teach standing with uniform support on both limbs, transferring body weight in the frontal plane. On the second stage, the body weight is transferred in the sagittal plane, the support and transfer phases of the step of the prosthetic and preserved limb are trained. At the third stage, uniform step movements are developed. In the future, the patient masters walking on an inclined plane, turns, walking up stairs and rough terrain. Activities with young and middle-aged patients include elements of volleyball, basketball, badminton, table tennis, etc.

After lower limb amputations lessons exercise therapy it is necessary to start a few hours after the operation (first period). Classes should include breathing exercises and exercises for the arms, trunk and healthy lower limb. This ensures the activation of vegetative functions, the prevention of complications from the lungs, cardiovascular system, gastrointestinal tract and urinary organs, a tonic effect on the central nervous system, and the prevention of disturbances in homeostasis. The patient learns the elementary movements necessary for self-service (raising the pelvis, turning to the side, etc.). From the 3-5th day, careful movements are added in the free joints of the stump, rhythmically alternating tension and relaxation of the truncated muscles (impulse gymnastics) and the muscles of the remaining segments of the truncated limb, etc.

Exercises for the stump help to reduce postoperative edema. From the 5-6th day, in the absence of contraindications, the patient is allowed to get up. The classes include exercises in balance, exercises that prepare a healthy limb for the upcoming increased loads, exercises performed in the initial standing position, exercises for “posture”. The patient is learning to walk with two crutches. Movements in all joints of the truncated limb should be performed with the maximum possible amplitude. In combination with removable gypsum splints, traction, and various “laying” of the stump, these exercises prevent the formation of contractures.

After removing the stitches (second period), the total load (in the classroom and while walking with crutches) is significantly increased. Exercises are used with gradually increasing pressure on certain areas of the surface of the stump (with the exception of the distal end and the area where the skin suture is located) in order to prepare the skin of the stump for the pressure of the prosthesis sleeve. Movements are widely used in all joints of a truncated limb to prevent contractures and develop balance ( rice. 52). 2-3 days before using the training prosthesis, exercises are included in light pressure on the end of the stump. In case of osteoplastic amputations, the preparation of the “support” of the stump should be carried out taking into account the stimulating effect of exercises on the processes of sawdust fusion with the graft ( rice. 53).

Rice. 52. Typical exercises in the second period of training after amputation of the lower extremities.

Rice. 53. Typical exercises in the second period of training after amputation of the lower extremities.

During the use of a training prosthesis, exercises are performed in a standing position with gradually increasing pressure on the stump, exercises in the movement of the prosthesis, standing on a healthy leg, exercises in balance, standing on a prosthesis and a healthy leg, learning to walk on a prosthesis ( rice. 54). The technique of walking and the method of teaching it are determined by the design of the prosthesis, the features of the amputation performed, the condition of the patient and the degree of “maturation” of the stump. Both in general health-improving exercises and in special ones, the load is gradually increased. Rice. 54. Typical exercises in the second period of training on temporary plaster prostheses.

When conducting classes with patients after lower limb amputations about obliterating endarteritis, diabetes; atherosclerosis and other diseases, as well as in old age, it is necessary to increase the load especially carefully and consistently, controlling the reaction from the cardiovascular system; avoid static stress; change starting positions more often; alternate active movements with passive ones; include more breathing and relaxation exercises, classes with young and middle-aged patients can include elements of sports exercises and games performed without and with a prosthesis.

During the period of preparation of a permanent prosthesis and mastery of full-fledged walking (third period), the main attention should be paid to improving the technique of walking and learning to walk in conditions as close to natural as possible.

In this final period, classes are held at the training ground, which should have: asphalt, sand, cobblestone paths and an obstacle course. Traces of steps with different distances between them are painted on the asphalt path. Between the sandy cobblestone paths, railings of different heights are installed for those who cannot do without additional support at first. For training in ascent and descent on an inclined plane, the training ground should have a small slide with different slope steepness, and for training in entering and exiting a tram, trolleybus and bus, a platform with steps and railings (Fig. 55). Rice. 55. Training ground for learning to walk on prostheses.

When starting to learn to walk on prostheses (temporary and permanent), it is necessary first of all to choose the right crutches, canes and teach how to use them. Incorrectly selected crutches and canes negatively affect the development of a motor skill (the act of walking), posture, distort gait, and require extra effort. In addition, the inept use of crutches can cause a number of complications - hydroadenitis, abrasions and even paresis of the outer limbs: The length of the crutches is determined in a standing position by the distance from the armpit to the floor. The handle should be located at the level of the greater trochanter, so that when resting on the hands, the armpits are freed from the heavy load. The length of the cane can be determined in two ways: by the distance from the greater trochanter to the floor, or from the hand to the floor with the elbow joint bent at an angle of 135°. The cane is used on the side of a healthy lower limb or a more complete stump.

Learning to use dentures begins with putting on the dentures. Prostheses after amputation of the legs are put on while sitting; after amputation of the thigh - standing and sitting; after amputation of both thighs - lying and sitting. A woolen cover or stocking without seams and folds is put on the stump. The sleeve of the prosthesis should fit snugly around the stump. For walking on prostheses, the ability to maintain balance is of great importance. Therefore, before allowing the patient to move, it is necessary to teach him to stand straight, distributing the weight of the body on both legs. The first steps should be done only in a straight line, they should be small and of the same length. To develop a rhythmic gait, it is recommended to teach walking to music or a metronome. It is necessary to pay the patient's attention to the individual elements of the step: the transfer of body weight to the front leg (or prosthesis) and then, due to the pendulum movement of the prosthesis in combination with the active movement of the stump, the removal of the prosthesis forward (avoiding movement through the side).

To improve the motor functions of patients and develop skills in using artificial limbs, along with the well-known gymnastic equipment (stuffed balls, gymnastic sticks, wall, benches, etc.), it is necessary to use special equipment: tragus, simple and sliding canes, portable barriers, crutches and canes - dynamometers; devices and devices for the development of end support of the stumps, strength, endurance, musculo-articular sensitivity, coordination of movements, prevention of contractures, flat feet and postural disorders caused by amputation.

To control the level of development of motor qualities, it is necessary to have appropriate measuring instruments that allow you to determine: the strength of the muscles of the stump, endurance, end support, deviations in posture, the degree of load on the cane or crutches during their use. In addition, in the cabinet of therapeutic physical culture there should be: two large mirrors (on opposite walls) to control movements and posture during training in the use of prostheses; metronome or tape recorder to develop rhythmic walking; paths of various widths with traces applied with paint (to develop steps of the same length and limit the wide spacing of the legs when walking on prostheses after amputation of both hips). The floor must be smooth, not slippery, wooden or cork.

Amputation of the lower extremities is always accompanied by a great mental trauma, which must be taken into account in order to increase the mental tone of those involved and create confidence that everyone can learn how to use the prosthesis.