The Physical rehabilitation (PhR) is independent medical theoretical and practical discipline, directed on proceeding in a reduced health level by prevention of progress of the present disease, substituting for the lost functions, returning of capacity by means of physical culture with the use of healthful natural factors.

The most characteristic feature of the PhR method is the use of the severely dosed physical exercises. Their application in PhR requires patient's active participation in a medical process. It is very important to define, which degree of activity is recommended to this or that patient, taking into account the character of disease, degree of functional disorders, general state of a patient and his adaptation to the physical activity. Depending on therapeutic tasks a doctor should measure out and methodically adjust the application of PhR during the course of treatment. PhR as a method of treatment is part of the complex therapy. PhR is applied on all stages of rehabilitation both during sharp periods of illness and finishings, posts-stationary and sanatorium-resort periods, and is successfully combined both with medicinal therapy and with different physical therapy methods of treatment. A physical rehabilitation is applied as a method of active, functional and nosotropic therapy; it is called to restore disturbed functions of a patient, to make him healthier and reinforce him, and also to prevent complication of diseases.

MECHANISMS OF PHYSICAL EXERCISES THERAPEUTIC ACTION

It was considered before that physical exercises influence mainly on a neuromuscular system, and metabolism, blood circulation, respiratory system changes can be explained as a side, secondary effects. Modern researches showed that at muscular activity there is the phenomenon which has got the name of motor-visceral reflexes (M.R. Mogendovich), that is the impulse addressed from workings muscles to internals (pic. 3.6.1). It allows to consider physical exercises to be the reason that influences on the level of metabolism and activity of the major functional systems of organism through the muscles.

The therapeutic action of physical exercises declares itself in difficult psychical, physiology and biological processes which take place in an organism during PhR. A modern view on the physical exercises therapeutic action is developed by professor V.K. Dobrovolsky. He talks about the existence of four basic mechanisms: restorative influence, trophic action, forming of indemnification and normalization of functions. The mechanisms of physical exercises restorative influence appear in the activation of motor-visceral reflexes. A motive analyzer with his receptor apparatus, which is in muscles, copulas, tendons and articulations, takes part in creation and adjusting of tone of skeleton musculature, provides co-ordination of motions, statics and dynamics of a human body. However the influence of proprioception is not limited by the muscular system only. A motive analyzer is the mighty regulator of internals activity, which is carried out according to the mechanism of the motor-visceral reflexes. The vital functions of the whole organism depend on the state of motive analyzer.

Using the mechanisms of the motor-visceral reflexes, by the directed arbitrary change of motive function one can achieve the control over involuntary vegetative reactions. Accordingly selected exercises taking into account their structure allow to promote separate vegetative functions due to activation of the central nervous system (CNS). Thus violation in the cortex of cerebrum stimulates vegetative functions, strengthening biological firmness of an organism.

The mechanisms of physical exercises trophic action are also closely connected with motor-visceral reflexes. Proprioceptive impulses change activity of CNS. It declares itself in its trophic influence on a musculature and internals. Muscle performance influences considerably on metabolic and flexible processes, providing an accordance between a structure and form of organs and their function. The direct dependence between the level of motive activity and intensity of reflexo-trophic processes is established in an organism. High level of proprioception trophic influence on all organs, including the CNS cells, creates an optimum background for realization of convalescence mechanisms.

The mechanisms of functional compensation forming are the basic of patient's adaptation to the existence in the pathology conditions. Compensation, that is balancing and smoothing of sickly processes which began in an organism, is carried out by including of a row of protective and adaptive reactions, aimed at renewal or substituting of damages which have appeared. If the effect of these reactions and mechanisms including turns to be insufficient, there will be another special state – decompensation. The most full conformity to laws of compensation forming is grounded in the theory of the functional systems of academician P.K. Anokhin. PhR is not only the mean of functional and compensatory possibilities of an organism increase but is also a biological stimulator of the regulative systems which support and adjust a homoeostasis. The functions mechanisms normalization are leading in the providing of complete recovery of patients' health and working capacity. The todays means of PhR are considered to be the most effective components of medical rehabilitation. Renewal and normalization of the broken functions are more effective at the use of active treatment methods. Only the systematic training helps in reorganization of the pathological dominant of interoception to proprioception.

Vegetative functions are being normalized with a motive dominant renewing: frequency of palpitation goes down at tachycardia, an arteriotony settles, breathing is normalized et cetera.

Extracardiac blood circulation factors (action mechanism).

Graduated physical exercises are nonspecific nosotropic means of therapy, which influence on an organism on principle of motor-visceral reflexes. They healthfully influence on the whole organism in general and on the cardiovascular system in particular.

This influence is conditioned by the mobilization of not only cardial but also extracardial factors of blood circulation. The thoracic cage absorb function, cardiovascular function of the diaphragm, muscular and arthral “pumps” belong to the extracardial factors of blood circulation.

1. The thoracic cage absorb function. During inhalation the volume of thorax is being increased due to motion of ribs and diaphragm. Negative pressure in a pectoral cavity deepens, the veins located in it broaden, their pressure becomes lower, than in distal veins, that promotes better blood flow to the right heart. During exhalation the volume of pectoral cavity diminishes, pressure rises, and blood from large veins enters the heart under the action of hypertension.
2. Cardiovascular diaphragm function. During inhalation a diaphragm goes down, pressure in an abdominal cavity rises, and in thoracal – falls; it creates the best conditions for the blood outflow from the veins of abdominal cavity to the right heart. During exhalation a diaphragm rises, pressure falls in an abdominal cavity. It creates the best conditions for the blood outflow from the veins of lower extremities to the abdominal cavity.
3. “Muscular pump”. Between and under muscles there is a large network of venous vessels. The alternation of contraction and relaxation of musculature causes compression and relaxation of vessels, which promotes best advancement of venous blood from periphery to the right heart (the presence of venous valves in veins hinders reverse motion of blood).
4. “Arthral pump”. At bending in a joint on an external perimeter there is tension of skin, hypoderm and venous vessels placed in it. At flatteningi of vessels their pressure becomes higher. Pressure which rises in vessels facilitates better blood flow through veins in proximal direction, because the presence of venous valves in them blocks blood flow in distal direction.

Thus, the ekstraсardial factors of blood circulation improve haemodynamics, what facilitate the function of сardial factors.

MEANS OF PHYSICAL REHABILITATION

There are several means of physical rehabilitation, such as severely dosed physical exercises, applied on a background of natural factors, massage and manual therapy. Dosed physical exercises are divided into three basic groups: gymnastic, applied and games (pic. 3.6.2). Physical drills are presented by the breathing and general group of exercises. Breathing exercises improve and activate the functions of the external breathing, blood circulation, metabolism, activity of the digestion system. They help to reduce fatigue after heavy physical exercises and help to normalize activity of the cardiovascular and respiratory systems. Therefore respiratory exercises are obligatory component of physical exercises in procedures of medical and hygienical gymnastics. Respiratory exercises depending on the type of breathing are subdivided into thoracal, diaphragmatic and complete. Depending on the character of implementation, respiratory exercises are divided into static and dynamic. Static respiratory exercises are executed without motion of hands, feet and trunk. They are used in order to teach a patient to carry out correctly the pectoral, diaphragmatic and complete breathing, to change the phases of respiratory cycle, combine breathing with pronouncing of sounds, to the even rhythmic breathing, diminishing of amount of respiratory motions, and so on. Dynamic respiratory exercises are executed together with exersices for hands, feet and trunk. Thus inhalation is done simultaneously with straightening of a trunk, feet, and raising or lifting of hands, that in the moment of the biggest volume of a thorax. At implementation of dynamic respiratory exercises it is expediently to combine the rhythm of general motions with the rhythm of breathing. It is necessary to remember that during power static tensions breathing is bothered, and during the exercises with tension breath-holding occurs. Respiratory exercises, which are used for renewal, correction of the pathologically changed structure or function of respiratory apparatus, are named the special. The special exercises are used with different purposes:

• for an improvement of ventilation of separate parts or both lungs;
• for training of muscles which take part in the act of inhalation or exhalation;
• for renewal or increase of mobility of a thorax;
• for the outflow (draining) of sputum from bronchial tubes and improvement of emptying of festerings cavities which are located in the different segments of lungs;
• for the stretch of adhesions in a pleura cavity;
• for warning and liquidation of the stagnant phenomena in lungs.

General health-improving exersices are artificial connections of natural for a man motions, divided on componental elements. General health-improving exersices which influence on pathologically changed organ or system have the special orientation and that is why are called special. General Health-improving exersices according to an anatomic sign are subdivided into exercises for shallow (brush, foot), middle (neck, shin, forearm) and large (thigh, shoulder, trunk) groups. According to the character of muscular reduction physical exercises are subdivided into dynamic (isotonic) and static (isometric). At implementation of dynamic exercises muscles work in the isotonic mode, their length changes. Thus there is an interchange of periods of reduction and weakening of muscles. The example of dynamic exercise of muscles is bending and unbending of leg in a knee-joint, stroke motions of hand in a humeral joint, inclinations and rotations of trunk, et cetera.

Exercises in static tension of muscles must be necessarily accompanied with weakening exercises. Weakening exercises are very important for a patient, because they create favourable terms for rest of the nervous system and workings muscles, help to reduce the tone of muscles and vessels, as a result of this bloodcirculation and lymphokinesis get better, the processes of selection of carbonic acid and utilization of oxygen activate, trophic processes in muscles improve, their elasticity gets better.

These exercises are used at spasmodic paralyses and paresises, obliterating endarteritis, essential hypertension, emphysema of lungs and bronchial asthma, illnesses of organs of digestion, liver, bilious ways, metabolic disturbance and so on. According to the activity of implementation general health-improving exersices (special) are divided into active, passive, according to the pulsing to contractions of muscles there are ideomotor and reflex exersices.

The division of general health-improving exersices according to the activity of implementation is very important for their practical use in procedure of medical gymnastics. Active exercises are executed single-handed, independently, with a conation. Active exercises attract the whole organism of a patient to a reactive response, for them the most characteristic are the process of exercises and trainings. Due to the application of active exercises compensatory mechanisms develop better and responsive activity of a patient is enriched.

Active exercises can be of small, moderate, large and maximal intensity. The active facilitated exercises (small intensity) are executed in the most advantageous, favourable terms with the use of factors which facilitate their implementation (the use of optimum initial positions, reduction of weight of extremity by the use of exercises in water, on slippery surfaces, in hammock, on roller light carts, on the special vehicles et cetera).

The active facilitated exercises are used in an early period of convalescence. They are executed with the insignificant participating of a patient in that case, when a patient can not abide the motion or considerable tension can cause complication. Facilitated active exercises are applied after paralyses and paresises at hardly-moved joints and weakness of muscles, after diseases and trauma of the nervous system, after plastic operations and others like that. Active (free) exercises (of moderate intensity) make the basic group of exercises without tension, from possibly complete amplitude for this patient, and give the middle physical loading on an organism. They include the most exercises, executable from simple initial positions, which do not require large effort, and also exercises, with objects which do not bother an action. Active exercises with effort (of large and maximal intensity) give the heightened physical loading. Volitional tension is applied during their implementation which alternates with weakening, exercises against resistance, with a burden, etc.

Resisted exercises help to increase loading, as during their implementation patient will have to overcome counteraction, which is done by a methodist, the patient, or that person, with whom he works in a pair. These exercises cause a considerable reaction-answer from respiratory, nervous and other systems, promote the metabolism.

Muscle-strengthening exercises are applied using the weight of a patient (by complication of initial position), gymnastic objects and apparatus, the special mechanical-therapeutic vehicles and others like that. The change of initial position substantially influences on the degree of effort during implementation of physical exercises. It depends on initial position, in what groups of muscles and tissues local changes of physiology processes occur.

Exercises with gymnastic apparatus. The influence of exercises with gymnastic apparatus on an organism and their medical utility increase as compared to analogical exercises without increasing weight of an apparatus, lengthening of lever of the moved part of a body, increasing of inertia forces, arising up at stroke and pendular motions, complication of requirements of co-ordination of motions, etc. These exercises help to increase regenerative processes, develop forces in obsolete muscles, recover functions in trauma joints, correct backbone, train cardiovascular and respiratory systems.

For implementation of loaded exercises gymnastic sticks, maces, hoops, pulls,skipping ropes, rubber balls of different sizes, volley-, basketballs, stuffed balls (from 1 to 5 kg), dumbbells (from 1 to 5 kg) demountable and spring, rubber bandages, gymnastic poles, rows, etc are frequently used. Exercises on gymnastic apparatus are used frequently in a form of mixed and straight supports, hung, undercuttings and others like that, which are characterized with large intensity of their general influence. These exercises can be applied with the purpose of diversifying of exercises, increasing of the general loading, or for the selective loading on separate parts of locomotorium, on the function of these or those internals etc. For implementation of these exercises such gymnastic apparatus are used: wall bars, bench, rings, log, stairs, mate, and also a medical couch, chair, stool, carpet and so on.

For exercises for coordination of movements there are unusual or difficult connections of different motions. Basic moments which create more difficult co-ordination of motions are: a simultaneous action of synergistic and antagonistic muscles at implementation of the same type of motions in the same joints; introduction of different directions at implementation of exercises and their different rhythm; bringing in of plenty of muscular groups for participating in exercise and usage of objects, applied in PhR. Exercises for coordination of movements are used at the diseases of the central and peripheral nervous system, and also at other hypotaxias. They correct and develop the function of motion in joints, improve co-ordination and rhythm of motions, exactness and speed of reaction, proceed in motive skills and promote emotionality.

Equilibrium training exercises are characterized by moving of vestibular analyzer in different planes at motions of a trunk and head, changes of the size of bearing area, transfering of the general center of body weight. Equilibrium training exercises are used at diseases or traumas which are accompanied by vestibular damages. At the preparation to the patient's standing up after the protracted bed rest equilibrium training exercises help to restore the reflex adjusting of vegetative functions which take place at the change of position of a body. These exercises activate not only vestibular but also tonic, stato-kinetic and vegetative reflexes.

Corrective exercises are applied with a purpose to correct, and also for prophylaxises of different deformations of a thorax, spine, foot, and etc. The most characteristic for them is the initial position that determines strictly the local influence and proper combination of power tension and stretch.

Passive exercises are executed without the conation of a patient, with an extraneous help (of a methodist, special apparatus or a patient's healthy extremity). Such exercises are applied in those cases, when a patient can not independently execute motions, or in that case, when independent implementation of motions can become a reason of complications. Implementation of passive exercises gives the possibility to attain extreme positions in joints, to improve elasticity of muscularly-ligamentary apparatus, to activate trophic processes in tissues.

Ideomotor exercises are accompanied by efferent inflow from the side of CNS (central nervous system). They are a process, which really takes place in an organism and in a great deal imitates processes which take place during the real implementation of that motion, but with the less expense of power resources. It is expedient to use these motions in those cases, when a patient can not or it is forbidden to him to execute active motions, and also then, when there is a requirement in training, and the multiple reiteration of the real motions tires a patient. Implementation of the ideomotor exercises is quite often accompanied by considerable activation of vegetative trophic functions of an organism, increase of metabolism, appearance of fatigue, which diminishes at the settlement of rhythm and breathing depth. In connection with that ideomotor exercises unavoidably lead to considerable excitation of cardiovascular, respiratory, nervous and other systems, and also to the overstrain, application of this method at treatment of heavy patients is unacceptable. However for the middle severity patients early implementation of presenting motions, compensating the absence of real motions, must influence in the most rapid rehabilitation of a patient. The ideomotor exercises hinder fading of dynamic motive stereotype. It is reasonable to recommend a patient, as a task, only well known motions which should be executed in the proper situation, that allows to be concentrated on their implementation. Pulsing exercises on reduction of muscles train the motive cages of cortex, improve conductivity of impulses on centrifugal nerves, prevent fading of motive dynamic stereotype. These exercises cause in muscles, on which they are directed, the reflex expansion of blood vessels, increase of trophic processes, normalization of tone of nervous-muscular apparatus. It is reasonable to alternate exercises in pulsing to reduction of muscles with passive exercises, that results in “opposite thoriation” of ways on centrifugal and centripetal nerves. The noted exercises are applied at impossibility of implementation of active motions, at paralyses and paresises, at the decline of psychophysical tone, at insufficiency of blood circulation of II-B, III degree.

Reflex exercises are based on the use of innate motive reflex reactions. They are used for physical education of children of early age, when unconditioned motive reflexes have not gone out. The same exercises are considerably wider used at the diseases of children of early age and in later periods at a delay and unevenness of psychomotor development. It is not recommended to use those reflexes which have a tendency to fading in certain age. The applied exercises help to capture the basic motive skills in which there are natural methods of man's movement. To the applied exercises belong the varieties of walking, running, jumping, climbing, crawling over, throwing, catching, swimming, rowing, skiing, skating, riding a bike and (relatively) occupational therapy.

Different types of walking. Walking is the most accessible and widespread type of physical exercises, that is widely used for treatment of swingeing majority of diseases and traumas on all stages of rehabilitation. It is directed on activation of the patient's regime and the full-fledged use of favourable conditions of external environment. Walking favour health improvement, stimulates the processes of circulation of blood, breathing, metabolism, fastens mainly the muscles of feet and pelvis, but brings to work muscles of the whole body. The rhythmic alternation of tension and weakening of muscles during walking creates favourable conditions for calming of an organism, at the same time walking in a rapid rate gives the considerable physical loading, training and developing adaptation mechanisms of a convalescent. The physical loading at walking is easily dosed and depends on distance and relief of the route, hours and rate of distance passing, amount of intervals for rest and their duration.

Walking is possible on specially lined “trace” path, on slanting surface, etc. Walking can be executed with unloading by the help of a stick, special apparatus, – “walking frames”, etc.

In PhR there are following types of walking:

a) medical walking on flat terrain;

b) correcting walking, directed on the removal of damages, study and improvement of the correct method of walking;c) Health paths - the dosed ascents – are apply mainly in the conditions of a sanatorium both on resorts and in an unresort environment. The routes of health paths pass with the use of ascents mainly at the corner from 5° to 10°, although sometimes they are assumed at the corner to 20°. The size of the physical loading in health path depends on length of the route (usually 500, 1500 and 3000 m), relief and corner of ascent, amount of stops. It is undesirable to hurry at using any route, and one should walk in a quiet rate, evenly breathing. Before a stop it is necessary to do a few deep inhalations;

d) walks, pedestrian excursions and near tourism are applied in a complex with other resort-sanitary measures. As such loadings are considerable, they are used mainly with the purpose of renewal of patient's general adaptation to production-domestic conditions;

e) Heel-and-toe walk mainly consists of ordinal (combatant) exercises in procedures of hygienical and medical gymnastics (movement, extension and closing, exercises for organization of attention).

According to the rate of passing there are such types of distanses:

• the slow walking is 60-80 steps for a minute or 3-3,5 km for an hour;
• the middle walking is 80-100 steps for a minute or 3,5-4 km for an hour;
• the rapid walking is 100-120 steps for a minute or 4-5 km for an hour;
• very fast walking is 120 and more steps for a minute or 5 and more km for an hour. Walks are conducted in a rate of 2-3 kilometres for an hour. A route of a pedestrian excursion is to 15 kilometres for a day.

Varieties at running and jumping. There are gymnastic run and run with obstacles, high jumps and long jumps. By comparison with walking runnig and jumping are more dynamic motions which give the considerable loading on nervous - muscular, cardiovascular and respiratory systems, promote the metabolism. In PhR they did not find wide application through their speed-power character and complication of implementation. But there are exceptions, such as jogging, exercises during implementation of which the flight of a body alternates with the fast landing. They are executed on tiptoes, by springy motions, slightly bending knees. Leaps are executed in place, with advancement, with skipping rope on both and one leg. These exercises applied with a purpose to increase the metabolism, to stimulate the peristalsis, to remote nephroliths at the urolithiasis (in a period of remission). Climbing on vertical or sloping rope, pole, stairs and gymnastic wall with the help hands and feet. It is used for the increasing of mobility in the joints of extremities, development of muscle force, and with the purpose of spine correction. Crawling are applied in medical aims from a position “on four extremities”. Initial position “on four extremities” is characterized by unloading of the spine from the action of weight force and by maximal mobilization of his mobility. It is used for the correction of spinal curvature at the compression breaks of a spine, at anomalies in placing of internals (stomach, buds, uterus), for stretching of pleura and intra-abdominal joints etc.

Throwing and catching are beautiful facilities of physical development, they comprehensively influence an organism, favour forming of adroitness, speed, measurement with naked eye, perfection of co-ordination of motions, developing sharp and exact muscular sense, fastening of all musculature. The balls of different size and weight are used in this exercise, including stuffed, sticks, rings, hoops and other objects, which can help to renew capture and keeping, to liquidate contracture and stiff joints, to stretch pleura joints, to mobilize diaphragm mobility, etc. Throwing and catching cause positive emotions.

Swimming and water exercises are characterised by the united influence of motions and environment, in which they are executed. Stay in water considerably promotes heat emission and metabolism, pulls out enhanceable requirements to the system of external breathing and hemodynamics. The conditions for the facilitation of motions by sharply hyposthenic atrophy or paretic muscles, correction of deformations of spine, renewing of adaptation to loadings of different intensity, renewal and increase of general endurance of an organism are created by these means.

Rowing allows extraordinarily strong influence on an organism. Rowing favours strengthening of muscles of shoulder girdle, back, prelum abdominale, feet, gives the considerable loading on the system of blood circulation and breathing, promotes the metabolism, causes the rhythmic change of intra-prelum pressure. The ionized air, change of landscape and impressions cause positive emotions and beneficially influence on a convalescent's organism.

Skiing comprehensively develops and fastens an organism, promotes working capacity and endurance, favours tempering and serves as a remarkable rest for the nervous system. In PhR skiing is applied for the improvement of metabolism, cardiovascular system, respiratory and nervous systems, muscle strengthening and improvement of joints mobility, especially after traumatic damages.

Skating pulls out large requirements to the co-ordination of motions and vestibular apparatus, causes considerable increase of vegetative trophic functions, that is why it is used limitedly, mainly for training of the vestibular apparatus and co-ordinations of motions.

Wheeling is an exercise with the large range of medical influences. A rhythmic concussion sharply stimulates an intestine peristalsis. Wheeling considerably strengthens vegetative vestibular reactions. It is applied in a finishing phase of treatment at remaining damages of locomotorium after traumas and operations, at obesity, for training of the cardiovascular and respiratory systems, at the hypoplasia of womanish sexual sphere, at the low-grade hypotaxia of motions and function of vestibular apparatus.

The occupational therapy is the work treatment – active method of renewing the capacity of patient's efficiency. The occupational therapy based on the systematic training of domestic and production motions, renewing of the lost motive skills. The occupational therapy normalizes the patient's psyche, stimulates the functions of the damaged system (of the organ) and it is an important constituent in the general system of patient's rehabilitation. In the occupational therapy different types of activity are applied: labour in a garden and on a vegetable garden (in winter – in a hothouse), cleaning up of apartments, wickerwork, sewing, joinery and modelling, etc. 

Forms and methods of carring out of PhR. The forms FR include medical gymnastics, morning hygienical gymnastics, medical walking, training-health-improvement measures, independent physical exercises, mechanotherapy, water gymnastics.

Medical gymnastics is the basic form of carring out PhR. In the preparatory part of the procedure the patient's preparation to the basic part is carried out, to the growing physical loading. According to the physiology of muscular activity, there is mobilization of vegetative functions in the preparatory part which fall behind in the initial period of work from a motive apparatus, their sinergizm which provides the best action of facilities of PhR. In the basic part of exercises the main medical and treatment-and-consultation tasks are being created, which consist in influence both on the damaged organs and systems and on the whole patient's organism. For their realization, generally developmental and special exercises are used. In addition, there can be used exercises with objects and on gymnastic apparatus, mobile games with the different psychophysical loading, applied exercises. At the ending the physical loading goes down gradually. Exercises which are used in the end must be instrumental in the acceleration of processes of renewal, normalization of function of the cardiovascular and respiratory systems. The four methods of carring out of medical gymnastics are distinguished: individual, littlegroup, group and consultation. An individual method is applied to seriously ill patients with the limited motive possibilities, which need an extraneous help at motions. At a littlegroup method exersices are carried out in a hospital room with the group of patients (6-8 persons) who have the alike functional state.

A group method is the most widespread method; as a rule, doctors try to gather in one group patients with homogeneous diseases and, what is especially important, with the alike functional state. Exersices are carried out in the cabinet of PhR, the quantity of patients is 13-15 people.

A independent method is applied when a patient is discharged from a hospital or it is difficult for him to visit regularly the medical establishment. In this case a patient does medical gymnastics at home, periodically visiting a doctor with the purpose of the repeated examination and getting new advice as to the further treatment.

A morning hygienical gymnastics makes a patient's organism go out after night sleep from the state of dormancy of physiology processes, promotes general tone of a patient, gives him cheerful mood and helps an organism to pass to the active state. A morning hygienical gymnastics is also an important treatment preventive method under the condition that it is regularly applied as inalienable part of the mode of a day. Duration of hygienical gymnastics must be no longer than 10-30 min, there are 9-16 exercises (for separate muscular groups, respiratory exercises, exercises, for a trunk, on weakening, for the prelum abdominale muscles) in the complex; the use of static exersices which cause tension and breath-holding is contra-indicated. All physical drills must be executed in a free rate, with gradually growing amplitude, with bringing into work the shallow muscles at first, and then larger ones. Every exercise must carry the functional loading. It is recommended to begin a hygienical gymnastics with the slow walking, which from the beginning of txersices causes the even strengthening of breathing and circulation of blood, “influences” on future exercise, and in the end of the exersices favours even deloading, renewing of breathing.

Kinds of medical walking. The medical walking is carried out the general chart. In separate cases walking is connected with physical drills (motions of hands, rarer of trunk and feet, respiratory exercises). The basic part, depending on medical tasks and clinical information, can consist of different variants of walking with unloading (on “walking aids”, with crutches, with sticks); of exercises, directed on renewing of the normal mechanism of step or on the forming of the most valuable indemnifications of the damaged walking; dosed walking with the purpose of renewing of the adaptation to walking or with a purpose treatment influence on the cardiovascular system and metabolism. The graduated exercise is carried out due to the change of degree of the supporting unloading, number of steps for a minute, lengths of steps, passed distance. The variant of the graduated medical walking are walks. They are used for fixing of medical effect, which was attained on medical gymnastics or medical walking, and with the purpose of the most rapid renewal of general adaptation of patients to production-domestic terms.

Mechanotherapy. In the practice of renewal treatment the different types of apparatus are used (pendulum, block, impromptu and such which are got to motion by a motor), applying them mainly at proof motive damages on the late stages of treatment of traumas, diseases of locomotorium and nervous system. Basic measures for prescribing of mechanotherapy are constant contractures, limitation of joints mobility in a late term after traumas, after endured arthritis, and also after the protracted immobilization. Exercises on mechanotherapy apparatus complement medical gymnastics very well and provide the increase of medical effect due to the best localization of exercises, more exact graduating of loading, increase of stretching influence or intensity of muscule tension, etc. In separate cases these apparatus allow carring out passive motions or motions with somebody's help.

Classification of mechanotherapeutic apparatus (V.A. Epifanov, 1997):

• apparatus which help to take into account and exactly estimate the efficiency of motion renewing (goniometers, dynamometers, pronometers, etc.);
• apparatus which help to select the separate phases of free motions are supporting, fixative apparatus (sectional adaptations are for the selection of motions in separate joints);
• apparatus that help to measure out the mechanical loading at motions (parallel squared beams for a movement, suspended road for the studies of walking, etc.); The combined apparatus.

The classification of mechanotherapeutic apparatus: (V.I.Dovgan', I.B.Temkin, 1981)

• apparatus which help to take into account and exactly estimate quality of motion and motive renewal – “diagnostic” apparatuss and apparatus with a biological reversed communication;
• apparatus that help to select the separate phases of free motions – that support, fix;
• apparatus that help to measure out the mechanical loading at implementation of motions and exercises are training apparatus and trainers;
• the combined apparatus, which allow to create not only separate motions but also integral locomotor acts, including the use of stabilografic platforms and feed-back.

According to the construction mechanotherapeutic apparatus are divided into:

• apparatuss of cell-type, intended for the graduated strengthening of different muscular groups of upper and lower extremities;
• apparatus of pendulum type, intended for mobility renewing and increasing of volume in the different joints of extremities;
• at the use of the apparatus a patient carries out active motions in a joint, which increase due to inertia forces which arise up at motion of a pendulum. 

• duration of procedure, course of treatment;
• an amount of exercises, reiterations;
• choice of initial positions (lying, sitting, standing, in motion, facilitated, laboured, etc.);
• a choice of motions rate (slow, normal, rapid, speed-up, maximal);
• a choice of amplitude (small, middle, large);
• a choice of rhythm (usual, unusual);
• a choice of character of exercises (simple, difficult, facilitated, burdened, usual, unusual, etc.);
• a choice of character of loading (principle of dispersion or concentration of the physical loading, its decrease or growth, evenness or intermittence, et cetera);
• choice of tension degree of the neuromuscular system, which is achieved in two ways: by conations and by burden (by body weight, by the use of exercises with objects, on apparatus, with partners, overcoming resistance, on co-ordination, etc.);
• the use of emotionality which facilitates implementation of exercises;
• adjusting of betweenness special, general, respiratory exercises and pauses for rest.

• physical exercises, which were neatly selected for achievement of medical aims are distributed in an order of their growing complication, with the observance of requirements of transition from simple to difficult, from easy to heavy and taking into account a credible process of illness; their approximate gradation is being specified: a number of reiterations, distance at walking, duration of a separate exercise, etc.;
• the varieties of exersices (medical gymnastics, hygienical gymnastics, etc.), order of their carring out (daily, 2-3 times a day, et cetera), their place in the mode of a day, connection, with other treatment exersices and methods (before or after them, and which of them; with a pause which lasts this or that number of minutes, et cetera) are determined;
• the approximate plans of exersices on each of the set varieties are written, where the optimum alternation of exercises and approximate duration of exersices are determined. The planned sequence of exercises and approximate exersices is a scheme. Depending on the patient's state and his reactions on exercises, loading is modified, separate exercises are excluded or included. At worsening of the patient's state more difficult exercises pass to more simple ones.

In every new period planning is carried out, based on the dynamics of illness development and information of influence of medical application of physical exercises in a previous period. It should be stressed that firmness of forming and fixing of the acquired conditioned reflexes is very important for successful medical application of physical exercises both with the purpose of normalization of functions and with the purpose of forming of indemnifications. It is also necessary to remember, that the vegetative components of motive skill are formed and fastened considerably slower than neuromuscular ones, and that is why they require more protracted systematic application of physical exercises.

The account of medical influence of physical exercises. The main task of the account of medical influence of physical exercises is a detection of changes in the state of a patient and in the development of pathological processes with the purpose of the correct planning and timely correction of selection and methods of exercises.

The methods of the account depend on a disease and facilities of medical physical culture, which are used. They must give the possibility to determine influence of physical exercises in the process of their implementation, after implementation and as a result of their the protracted application. At the use of mechanisms of restorative influence (for example, with a patient who is on the bed rest) people take into account the revival of mimicry, strengthening of voice sonority, established by the patient facilitation of breathing, change of objective indicators of cardiovascular and respiratory systems. At the use of exercises which mobilize the mechanisms of blood circulation for a patient with the myocardial infarction, their influence can be taken into account according to the changes of skin colouring and mucous tunic (as indexes of diminishing or growing scarcity of oxygen), according to the number of inhalations and to the change of breathing character (deepening and more liquid breathing is a favourable sign), to the number of heartbeats and character of pulse (more liquid pulse, an improvement of its filling, disappearance of arrhythmia, is an effect of favourable influence). The account of nearest medical application afteraction of physical exercises can be carried out by looking after expressiveness and firmness of changes in the general state, by a degree and duration of changes in activity of the cardiovascular system, after the onset of shortbreathing,hyperhidrosis, and others like that, diminishing or increase of complaints, including pain of different localization, force and duration, etc. The account of remote afteraction of exersices is carried out by questioning, supervisions and examinations.

For the account of physical exercises influence functionally diagnostic methods can also be used (information is got here estimated on the basis of comparison of the results at the beginning and at the end of the period of supervision). For a patient with the myocardial infarction such method will be a research of electrocardiogram before exersices, during exersices and directly after medical gymnastics. For a patient who had brain concussion, it is an orthostatic test. Normalization of the test along with disappearance of dizziness and nausea, diminishing of headaches gives sufficient information for the detection of positive influence of exersices and bringing of the proper additions in their method. A graduation and selection of facilities and forms of PhR depend on the regimens of motion activity of a patient.

Regimens of motion activity.

The motion regimen is the constituent of the medical regimen, and PhR is the part of the motion regimen. All facilities, forms, methods and methodical principles of PhR are used in the regimens of motion activity, and they are appointed in the proper graduation depending on the clinical state of illness, state of functional possibilities and adaptation capabilities of a patient's organism. They are the basis of the rational regimens. For prescribing of PhR to the patients with different illnesses the compatible regimens of motive activity are offered. Prescribing of the new regimen of motion activity is carried out with the patient's adaptation to the physical loading of the previous regimen. In the conditions of the profiled sanatoriums and policlinics for treatment of patients three types of the regimens are used which foresee successive and gradual improvement of physical possibilities of patients for implementation of the domestic and production loadings, they are: sparing, sparing-training and training.

The sparing regimen (№1) according to the character of the applied physical exercises is analogical to the free regimen in the in-patient [hospital] department.

Sparing-training (restorative) regimen (№2) consists in participating in excursions, entertainments, dances, games (mobile, with the use of elements of sporting games), walks near the sanatorium, bathings.       

Training regimen (№3) includes long walks (near tourism) and participating in all measures, which take place in the sanatorium. As a rule, the regime of patient's bed rest is not characteristic for a sanatorium as lmedicinal-preventive establishment, located in the favourable conditions of outdoor environment. The motion regimen must be set severely individually depending on personality of patient, features of his character and disease. The motions regimen in sanatoriums must include concrete measures, justified both by medical indications and by the conditions of a resort. As part of the general treatment and rest regimens, the individual motion and rest regimens must be determined by a doctor in every special case depending on medical symptoms, type, geographical location of a resort, and also on a season, and provide: sequence of different elements of PhR during a day; their connection with the application of other medical factors of this resort. Correctly developed and the exactly executed motion regimen is a mighty factor in the treatment of patients on resorts and in sanatoriums.

The medical swimming is the use of different methods of swimming for treatment and prophylaxis of different diseases. At the use of swimming with a medical purpose in sanatorium-resort conditions it must be adapted to the features of this or that disease. In the medical swimming, unlike sporting, three methods of swimming are used: crawl on breast, crawl on back and breaststroke. They are economic and easy in studies styles of swimming. In swimming crawl on a breast the respiratory system practices more. For strengthening of a spine it is useful to apply crawl on a back and breaststroke on a back. Medical swimming at a sea, river or pool, evenly influences all organs and systems of an organism, and this advantageously differs it from other types of the physical loading. It allows to keep a wonderful physical shape. According to the loss of energy 100 m of swimming is equal to about 1000 m of running. Breaststroke is the most economical style of swimming.

Mechanism of action. The medical swimming in a pool causes great changes in the physiology systems and organs of a man and promotes in a complex with other methods the increase of efficiency of treatment. So, including in the medical complex of the course of bathings in a pool and medical swimming crawl on a breast improves the state of the cardiovascular system, hemodynamics in the small circle of blood circulation, reducing the overload of the right part of a heart, improving a trophism and diminishing the hypoxia of the myocardium; it also normalizes the function of the external respiration, improving the airway conductance, promoting the efficiency of respiratory reserves using; promotes immune responsiveness; stimulates the sympathoadrenal system and normalizes the tone of the parasympathetic nervous system. The medical swimming in a pool carries out the training influence on termoadatative mechanisms, improves the state of the cardiovascular system, dermatovascular reactivity, and also results in the decline of the level of general lipids and β-lipoproteins in the blood serum, in the normalization of choline esterase activity and functional state of the sympathoadrenal system. The medical swimming has the special value for prophylaxis and treatment of spine diseases. It was so, for example, well-proven by scientific researches, that after 45-minute session of the medical swimming in a pool the height of a man can be increased to 3 cm due to unloading of a spine, absence of gravitation and hoe-type motions of hands which “stretch” a spine. The space between separate vertebrae becomes larger, there is a decompression of nervous roots and vertebral disks. Thus, we can consider the medical swimming to one of the variants of distraction therapy. Swimming is also a muscle-strengthening exercise. The training effect on different muscular groups and their strengthening is achieved depending on the technique of swimming motions. The breaststroke is characterised by strengthening of muscles of thigh, of knee-joint, tricipital muscle of a shoulder. Thigh quadriceps, instep insole, pectoral muscles, the widest muscle of a back, triceps of a shoulde are strengthened at crawl swimming. In addition, at swimming regardless of style, strengthening of muscles of the back and stomach is achieved. Translational movement is instrumental in buoying of a man's body as a result of implementation of series of rhythmic, severely co-ordinated motions of hands and feet. At crawl swimming a quadriceps muscle of thigh and instep insoles become stronger. The recurrence of motion implementation, their continuity, what is characteristic for swimming, have a large training influence on the muscular system. The amount of the physical activity is regulated by duration and rate of the medical swimming, and also by the technique of swimming motions – method of swimming.

Indications.

At the the graduated swimming there can be realized tasks, related to the necessity of medicinal-preventive influence on background and concomitant diseases and processes. The most frequent are degenerative-dystrophic and metabolic damages (thoracocervical and lumbar osteochondrosis, decline of tolerance to the carbonhydrates and diabetes, obesity, hypodynamia, respiratory dysfunctions, etc.)

A wide range of physiological, metabolic influence is a substantial feature of the graduated medical swimming as a rehabilitative training factor.

Medical effects.

A direct reaction on a procedure of bathing in a pool consists of few phases. The first phase of reaction on bathing (the so-called phase of the primary cooling) is usually brief and poorly expressed, or in general absent, and at once there is the second phase of reaction (the so-called phase of the reactive warming). After bathing patients have a feeling of cheerfulness, their mood gets better, intensity of headaches, noise in a head and dizzinesses diminishe (if they were present before bathing). At the bathing overdose there can arise up the third phase – the second chill which is the result of exhaustion of the mechanisms of thermoregulation and indicates on the necessity of the immediate stop of bathing. A reaction on the medical swimming in a pool can be physiology and pathological. At the physiology reaction there are no noticeable changes from the cardiovascular system. At once after the first procedure of bathing in a pool the temperature of skin goes down on 0,5-2,1°C, frequency of a pulse rises on 4-24 blows per minute, an arteriotony rises on 5-15 mm Hg, there are physiology changes of electrocardiography indexes. At a pathological reaction there is the considerable increase of the frequency of pulse (more than 30 blows per minute), increase of systolic pressure on 30 mm Hg and more, onset of heart arrhythmia which needs consultation of a doctor with subsequent individual adjustment of the level of physical activity. Physical loadings dosing.

The dosed swimming must be accompanied by the control of a doctor, nurse and instructor of remedial gymnastics, and also by self-control. A task of the control is the achievement of optimum of loading and prophylaxis of complications, overloads, severe observance of safety, rules of attendance of pools and beachs of rivers. At medical control such indices are estimated: 1) the way one feels and feeling; 2) frequency of heartbeats (FHB) as to a pulse, arteriotony (AT) and ECG; 3) general and local diseases are excluded, which are contra-indicated for swimming. Control of subjective and objective indications is carried out before, during and after swimming; electrocardiographic control is carried out according to individual indications. Self-control before the medical swimming is the general positive inclining on implementation of the swimming loading, correct estimation of the state on this concrete moment, taking of pulse. During swimming it is the concentration of attention on the correct breathing with exhalation in water and its co-ordination with swimming motions; after swimming criteria of adequacy of loading and its training efficiency are good feeling, pleasant fatigue, “muscular gladness”, absence of the phenomena of hyperventilation(weakness, headache, dizziness, general discomfort). All patients must be instructed about it, especially out-of-training ones. Self-control includes also the taking of pulse before and after loadings and its comparing with individual indicators. Adequate self-control and optimum psychological set on swimming must form the culture of swimming behavior and the necessity of its observance in the process of the course of treatment. The state of indications of the medical swimming serves as the basic for a decision about admission of implementation of the set swimming loading at every attendance of a pool. Swimming is allowed at a normal feeling and absence of damages of pulse, AT and stability of ECG, positive set on a procedure. The state of indices during the medical swimming. During the rest feel and pulse are controlled in water. A pulse is determined during 10 seconds on a carotid artery at once after a distance, that it is possible to carry out at presence of certain skills and training. The pulse reaction is estimated by comparison: the got rates per minute is compared with the rates at the level of threshold power at implementation of physical exersice with loading and submaximal age level (number “175” minus age in years). After the control swimming on ten next distance is possible if a patient has normal feel, desire to continue procedure, has no complaints, arrhythmia of pulse and breathing, expressed palpitation, heartaches; pulse rate must be not higher than age-old submaximal level (or 75% of heart rate at the level of threshold power at determination of individual tolerance to the physical loading).

The state of indices after the medical swimming. Good feel, absence of complaints and normal pulse rates, AT in the period of renewal in 5-10 minutes after swimming are signs of adequacy of the executed loading. Unsatisfactory feel, expressed shortbreathing, unusual fatigue, skeletal-muscle and arthral complaints, heartaches, feeling of palpitation and interruptions, dizziness, headache at once after swimming and in the period of renewal are the signs of inadequacy of loading, that demand the following observation with ECG-control to decide if it is possible to continue graduated medical swimming with lessening of loading.

THE METHOD OF MEDICAL SWIMMING IN THE POOL

Bathing in a pool and medical swimming can be prescribed only when there is no skin diseases and other deep affections of any localization, after the examining of the state of the cardiovascular system. Before the medical swimming in a pool patients take a hygienical shower with warm fresh water of 31-40°C. Bathing in a pool is compared with the medical swimming in a quiet, slow rate and weak or middle physical loading which is achieved at crawl swimming on a breast with the frequency of motions near 15-30 strokes per minute.

Patients who cannot swim move on the bottom of a pool, imitating swimming in the indicated rate. Through each 25 meters there are must be brief stops – quiet standing in water. For the medical swimming in modern pools of small and medium sizes there are special systems of counterflow, which allows to swim against the stream with managed speed on any distance, without being distracted on implementation of great number of turns during the distance. After swimming in a pool patients take a warm shower with fresh water. Then a rest is recommended during 20-30 minutes.

Compatibility is with other procedures. The medical swimming is carried out daily or every other day. It is combined with air-baths, ultraviolet irradiations, and also with the different types of “apparatus” physiotherapy. But, when the medical swimming is carried out, thermal procedures are eliminated (paraffin, dirt, ozocerite, etc.).

The medical swimming at the sea, in rivers, thermal and mineral pools in sanatorium-resort conditions allows to activate the medical program and considerably promote efficiency of the treatment.

MASSAGE

Massage is an aggregate of the special methods of the mechanical dosed influence on the man's body, carried out with hands or special apparatus with a medical or prophylactic purpose. Massage can be general, when all parts of a body are massaged, and local at which only certain parts of a body are massaged. According to tasks the followings types of massage are distinguished: hygienical, cosmetic, medicinal, sporting, self-massage.

Hygienical massage. This type of massage is the active way of health strengthening, diseases prophylaxis, maintainance of working capacity. It is applied more frequently l in the form of general massage. At its implementation different techniques of hand massage, special apparatus and self-massage are used (combining it with morning gymnastics) in a sauna, Russian bath-house, bath, while taking a shower. Cosmetic massage is a kind of hygienical massage the purpose of which is taking care of normal and damaged skin, prevention of its senilism, treating from different cosmetic defects (for example, cicatrical changes of skin, etc.).

Sporting massage. This type of massage is applied in sporting practice to perfect a sportsman physically, to attain a good sporting form and to keep it for a long time, to renew and improve working capacity before competitions, to overcome fatigue, prevent traumas and facilitate their convalescence. Self-massage is one of facilities of your own body care at the holiatry of some diseases and traumas of locomotorium and is used within sporting, hygienical, cosmetic and medical massage. Such massage can be both general and local. During self-massage it is possible to use different massagers, brushes, oscillation apparatus and others like that.

Massotherapy. This type of massage, that is applied at different diseases and traumas, is scientifically grounded, the most adequate and physiological for a man's organism medical method. There are following kinds of massotherapy: classic (Russian, Swedish, Finnish), segmentary-reflex, connective-tissued, periosteal, pressure point, by Manakovi, apparatus, etc. Manual massage is the most widespread method of massotherapy. A classic massage is a massage at implementation of which there are four basic classic methods (by A.F. Verbow): stroking, rubbing, petrissage, vibration. Except the basic methods, there are their different variants – auxiliary methods.

Stroking is one of the oldest and most widespread methods, which are used both with a medical purpose and in a sporting, cosmetic massage, as sliding of a masseur's hand on a skin without the change of the last. It is recommended to begin and conclude any procedure of massage with this method, and also to use it in transition from one method of massage to another.

Rubbing influences an organism more vigorously, than stroking. It consists in a change or stretch of skin together with tissues in different directions. This method is like stroking, but differs from the last that during rubbing large force of pressure is used, a hand does not slide on a skin, but moves it at motion. Rubbings are executed both in the direction of lymth and blood current and in the opposite direction.

Petrissage is a massage method at implementation of which the fingers of a masseur take elastically, draw off, move, stretch, squeeze tissues. Petrissage is a method at which each hand executes 2-3 phases:

a) fixing, capture of the massed area;

b) prelum, clench;

c) pinning-out, squashing, directly petrissage.

Vibration. Vibration is name of the massage method, by which there are fluctuating motions of different speed and amplitude in the massed tissues. Due to the resiliency of tissues mechanical vibrations, arising on superior surface, spread deeper as waves. Thus, depending on force and power of vibrations, waves can only go through superficial tissues and muscles, and can penetrate inward and cause the vibration of internals, vessels and nerves which lie deeper. Manual therapy is the medical actions which use methods in the physiology range of joints motions with the purpose of support of normal structure and function of motive apparatus. The basic tasks of manual therapy is a correction of the pathological settings of locomotorium, improvement of joints mobility, normalization of muscles tone, forming of compensatory reactions, from the side of separate muscular groups, supporting and antigravity reactions, training of mechanisms of support rational stato-dynamic equilibrium, positive influence on psychoemotional status, gravity unloading of a spine, heterospecific stimulation of immunity.

Basic medical methods of manual therapy:

• mobilization is the methods which are executed within the limits of physiology range of joints motions;
• manipulation is the mrthods which are executed within the limits of anatomic volume of joints motions;
• myoneural therapy is a complex of medical mobilizational methods, at the use of which muscular reduction and myoneural reflex mechanisms cause weakening and stretch of muscles.

There are several motive damages which are considered to be functional: functional block (circulating limitation of mobility of vertebral segment or joint at the change of location inwardly arthral connecting tissue elements, that is realized through reflex periarticular myofixation): hypermobility (increase of joint mobility); muscular disbalance (myotone damage as combination of hypo- and hypertonia); damage of motive stereotype (usual statico-dinamic actions and loadings).

Contraindications. Oncopathology of any localization. Apparent osteoporosis. Acute respiratory diseases. Inflammatory diseases of bones, joints. Acute traumas, fractures. Specific infection of any localization. Spondylolisthesis, apparent spinal instability. Herniation of intervertebral disk (complicated). Acute bleeding. Blood diseases. Internals diseases in the stage of decompensation. Dermatopathia. Psychical pathology. Alcoholic intoxication. Age more than 65 years. Acute damages of cerebral blood flow (in the early stage). Osseous abnormality. Post-neurosurgery surgery state. Patient's negative attitude to this methhod of treatment.

O.G. Yushkovska, N.I. Vladimirova, N.G. Nikolaeva, I.K. Babova, T.I. Malikhina