The Integration of Reflexotherapy and Transosseus Osteosynthesis: New Rehabilitation Possibilities at the Junction of Two Trends

Prof. V.I. Shevtsov, M.D.
A.N. Yerokhin, M.D., Dip. Ac.
Russian Scientific Center "Restorative Traumatology and Orthopaedics" named after Acad. G.A. Ilizarov
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The development of highly effective rehabilitation complexes for orthopaedic and trauma patients is an actual problem. From the one hand it is promoted by the progressive increase of clinical tasks complexity, including requirements of intensification, radicalism and physiology to the treatment process and, from the other hand, by the constantly increasing versatility of the techniques, way, rehabilitation devices and apparatuses, which are provided for decision of particular problems of the specific pathology.

Therefore, we consider that methodically proven involvement of reflexotherapy in rehabilitation complex based on the transosseous osteosynthesis method developed at RSC "RTO" is one of the promising trend to make an important contribution to the solution of the above problem. The methodical is an important source for successful implementation of rehabilitation potentials of reflexotherapy and transosseous osteosynthesis. The method of transosseous osteosynthesis is a very flexible and mobile system which makes possible to perform delicate graduated interventions in the different parts of locomotor system. Free spaces of the involved limb can be used for corporal reflexotherapy that activates meridian and extrameridian points. But sometimes the identification of the impact points as well as approach to them are difficult or impossible due to the anatomical and functional changes of the limb and overlapping of the biologically active points with the construction elements of the fixation frame. The way out of this situation is the usage of the microacupuncture areas of the body such as plantar surface of the feet, palms, auricle of ear, nasal skin integument for reflexotherapy. The effect of acupuncture, acupressure, electropuncture methods on the above areas in combination with the accessible corporal points helps the doctor to concentrate on the treatment process using the method of transosseous osteosynthesis when he tries to create optimal biomechanical conditions at the site of operative interventions. In this case reflexotherapy should eliminate the negative functional changes taking place in the equilibrium disturbance as well as add and intensify those positive changes that make the physiological basis of the transosseous osteosynthesis.

The potentials of the reflexotherapy and transosseous osteosynthesis integration are mostly uncovered in the evaluation of the clinical indications. Among the major indication we define 3 important ones - pain syndrome, profile diseases and pathologic conditions. The pain syndrome plays the leading role and the most interesting time for the application of the reflexotherapy methods is the postoperative period - the period after the application of the external fixator.

In the detailed schematic of the pain syndrome aetiology during this period we have to define the part regarding joint contracture elimination. The reflexotherapy in the clinical cases with limited ROM of the joint is highly valuable for rehabilitation. The dynamic of subjective and objective data of the patient M., 29 years old, before and after auriculoelectropuncture can illustrate this statement. The patient was diagnosed with post-traumatic fibrous ankylosis of the left knee with the pain syndrome, the state after arthroplasty of the left knee and contructure elimination with the Ilizarov frame. Before the reflexotherapy session the patient complained on the pain in the knee, which increased while walking. The registration of the total electric activity of the rectus femoris while walking with given speed indicated that the activity of the involved limb muscle was practically nil. In 5 min after auriculoelectropuncture pain sensations completely disappeared, pleasant warm feeling appeared in the previously painful area and the total electric activity of the rectal femoral muscle while walking made almost 50 % of contralateral one. Therefore, the application of reflexotherapy in this case could eliminate the pain in the knee without any medications and create optimum conditions for functioning of biomechanical system "joint-muscle". The value of the reflexotherapy and reflexoprophylaxis in the pain syndrome caused by traumatic injury of the peripheral nerve and biologically active points is well reported in the literature. We think the doctor must be very careful in application of acupuncture to prevent rough trauma of the active points and development of the local, generalised and organotypic reactions. In this regard we consider so-called ancient points of the upper and lower limbs to be the most dangerous ones due to the systemic reactions occurring upon their irritation. According to the U-Sin theory and theoretical concepts of the traditional Chinese medicine on Qi energy circulation Qi energy redistributes at these points and the obstacles to the normal course of this universal substance cause the pathological conditions due to the excess or deficit of Qi. At the phenomenological level it is revealed as a fever, pain syndrome and serious visceral function disorders. Developed prophylactic measures let us eliminate these complications during orthopaedic and trauma interventions but nevertheless it is better to avoid rough trauma of the 5 Elements points.

In the signs of overtraction the application of auricle and corporal acupuncture combined with methodical possibilities of transosseous osteosynthesis has a good clinical effect in dependence on the rate and rhythm of distraction.

In the group of profile diseases we think a leading anatomical and functional component of the disorders should be defined. Thus, the patients with functional disorders of the nerve-vascular apparatus, for example, with traumatic neuritis are the most perspective ones for the reflexotherapy. Rehabilitation importance of reflexotherapy in this pathology is demonstrated by the dynamics of the summary myogram in maximal volitional exertion of the patient B., 30 years old, with the diagnosis: closed fracture of the right humerus, traumatic neuritis of the radial nerve. The analysis of the activity of the long muscle abducting the first digit of hand before session, 10 sec after session, 5 min after session and after 20 sessions, i.e. by the end of the course, indicated that in similar conditions of registry the electrical activity increases right after the session, remains the same at this level for some time and by the end of the course achieves the value that can transform the volitional exertion into real motion of the involved segment.

The complex approach to the rehabilitation of patients with joint function disorder makes possible to combine the methods of reflexo- and physiotherapy which results in reduction of the treatment time in the patients with knee extension contracture. It is proved by growth dynamic of the active knee flexion amplitude in the group where reflexotherapy combined with femoral muscles electrostimulation were applied. Thus, even after 5 sessions statistically true deviations of the control (8,3+0,6 grad., n=4 ) and experimental ( 11,5+0,9 grad, n=4 ) selections (p<0,05) were observed and they were increasing within the course and by the end of the course ( after 15 sessions ) made 16,8+0,8 grad and 27,8+1,0 grad, accordingly p<0,001.

Pathologic conditions upon stress impacts can considerable complicate the rehabilitation of the orthopaedic and trauma patients. Depression and desynchronise are rather widespread phenomena in orthopaedics and traumatology and the reflexotherapy combined with optimum regime of motor activity has a good clinical effect. But the most critical and complicated problem in this group is the condition of bony tissue reparative activity reduction. Our experience of 11 clinical observations testifies that in low osteogenesis the reflexotherapy has a stimulating effect. In particular, under reflexotherapy the qualitative changes of distractional regenerate are observed which is clearly registered with ultrasonography. For example, in the patient B., 15 years old, diagnosed with 11 cm right lower limb shortening the process of bony regenerate formation was delayed during femoral lengthening. After distractional regenerate ultrasonography the area free echosignal was revealed which in morphological interpretation means weak filling in with tissue substrate according to the research of Dr.E.M. Yermak from our Center. After 10 sessions of reflexotherapy this rupture in the regenerate structure was eliminated.

Therefore, the involved of reflexotherapy methods in rehabilitation complexes based on the clinic of transosseous osteosynthesis is caused, first of all, by the tasks of optimisation of formation processes in organs and tissues. Since the nature of transosseeous osteosynthesis as a clinical method comprises the possibility of directed influence on quantitative and qualitative characteristics of tissues and organs, the addition of reflexotherapy should stimulate the growth and differentiation processes at the tissue and organic levels, regulate tissue structure plasticity, increase total body adaptive potentials and eliminate those negative signs that can accompany intensive formation process, i e. pain syndrome, decrease of functional abilities and disturbance of biomedical correlation in some links of locomotor apparatus. The realisation of therapeutic potential of reflexotherapy is performed in two directions - specific and non-specific ones - which results in optimisation of general and local neurohumoral status.

In conclusion it must be noted that the reflexotherapy does not consume power which is its most significant feature that can cause directed changes in redistribution of bioenergopotential of the entire body using the forces of small intensity. This peculiarity gives a ground to consider reflexotherapy a type of energetic and information influence that represents a close functional relationship with clinical essence of transosseous ostesynthesis which can be expressed in possibility " to control the restorative and formation processes" based on the "graduated" and "bloodless" effects as it was said by Prof. G.A. Ilizarov, the creator of the method.