EFFICIENCY OF APPLICATION OF GRADUAL FIBROTOMY UNDER PROF. ULZIBAT V.B. IN REHABILITATION OF PATIENTS WITH PATHOLOGY OF LOCOMOTOR APPARATUS
JSCCT “Institute of Clinical Rehabilitology” is a non-state scientific and research medical institution. Centre was established 0on 29.06.92 in Tula. 6 patented inventions of Ulzibat V.B., professor, doctor of medical sciences, honoured inventor of RF, Institute’s founder, are laid down in the basis of its activity. Institute’s collaborators have defended 8 theses for candidate’s degree and 1 doctorate thesis and published 165 scientific articles.
One of the priority directions of development of the modern orthopaedics is the search of optimal methods to correct pathological settings, contractures and deformations of the locomotor apparatus (LA). For successful treatment of patients of orthopaedic profile, we consider it necessary to reveal and eliminate organic muscular contractures at the early stage. This makes it possible to carry out correction of pathologic settings, to jugulate the chronic myofascial pain syndrome, to prevent the development of fixed LA deformities and arthrous contractures requiring more complex operative correction.
Method of gradual fibrotomy (GF) under Prof. Ulzibat V.B. consists in elimination of organic muscular contractures and myofascial pain syndrome based on the gradual under-tissue cross-cutting of fibrotic modified muscle fibres in the area of their attachment to bone (USSR Patent no. 1621901 of 24.09.87) by means of special scalpel (micro-fibrillotom under Ulzibat V.B.; USSR Patent no. 1560143 of 17.08.87) in order to improve muscle functions. “Gradual fibrotomy in orthopaedics” method and “micro-fibrillotom of Ulzibat V.B.” are entered into the State Register of Russian Federation (registration certificate no. FS 001/2004 of 06.12.2004; registration certificate no. FS 022b1998/0187-04 of 03.08.2004).
Results of clinical-instrumental and morphologic researches carried out by the Institute’s collaborators with participation of independent physicians-experts have become the pathogenetic substantiation of the GF method under Prof. Ulzibat V.B. used in operative treatment of patients with innate and acquired LA pathology. It was established that development of dystrophic and sclerotic modifications in skeletal muscles is one of the reasons of muscle dysfunction, myofascial pain and locomotory disturbances during LA diseases being different by nosology. Outcome of expressed dystrophic process is fibrosis of muscular fibres, formation of organic muscular contractures representing fixedly shortened and indurated sections of muscles, which are algetic during palpation and do not disappear with muscle relaxation.
In order to differentiate finally functional (muscular-dystonic) and organic (dystrophic) stages of muscular contractures, to establish the form and the intensity degree of contractures and LA deformations, “relaxation sample” is applied in our practice using inhalation anaesthesia (surgical stage, 2-3 level) or local anaesthetics (novocaine, lidocaine): when muscles are palpated in relaxation state, “functional” contractures disappear, while “organic” muscular contracture remain in the form of indurated fibrotic fold.
Merits of the GF method under Prof. Ulzibat V.B. are:
- versatility with various by nosology LA pathologies related with common mechanism of development of similar processes in muscular tissue (dystrophy, necrosis, sclerosis) resulting in formation of organic muscular contractures irrespective of kind to the main etiologic factor;
- functionality provided by simultaneous affection on different muscle groups taking into account their synergism and antagonism; possibility of combined operations on any superficial skeletal muscles of head, body and extremities in order to attain maximal effect;
- minimal traumatism accomplished for the account of precise movements of scalpel of special design; there is no cut on skin, haemorrhage, complete cross-cutting and transplantation of muscles, operations on tendons, as well necessity of subsequent gypsum immobilization, which promotes reduction of the recovery period and early post-operation activation of patient;
- relative technical simplicity permitting operations to be carried out on 14-16 muscles within 15-20 minutes outpatiently promoting quick recovery of patient in conditions familiar to him/her.;
Indications for application of the GF method under Prof. Ulzibat V.B. are:
- availability of organic muscular contractures and chronic myofascial pain syndrome;
- absence of effect from conservative therapy.
Absolute contraindications for operation are considered to be as follows:
- availability of congenital abnormalities and chronic illnesses at the decompensation stage;
- disturbance of functions of vital important organs.
Relative contraindications for operation are:
- acute infection and somatic illnesses (including period of reconvalescence);
- chronic illnesses in the period of recrudescence;
- intolerance of medicinal preparation for anaesthesia;
- availability of damages and inflammatory diseases of skin and soft tissues;
- illnesses accompanied by enhanced haemorrhage;
- post-vaccination state (not earlier than 1 month).
Operative treatment is provided in our clinic to patients with various innate and acquired LA diseases: symptomatic torticollis, clubfoot, arthroses deformities, consequences of infantile cerebral paralysis, traumatic and infection affections of LA, neuropathies, scoliosis, chronic myofascial pain syndrome of various localization, muscular-tonic syndrome with vertebrarium osteochondrosis, Dupuytren contracture, etc.
For 15.5 years of our Institute operation, 26,841 were taken for treatment (data on ___.12.07), including 20,925 children (78%). By 2006, about 3,500 patients in average were operated with us annually, including more than 1,500 primary patients with more than 1,200 children among them. In 2006, operative treatment was provided to 4,797 patients, including 3,857 children; 83.4% (2,443 persons) of 2,929 primary patients were children. In 2007, 5,273 patients were taken for treatment, including 4,438 children; 87.7% (2,496 persons) of 2,847 primary patients were children. 1,480 foreign citizens (including 1,157 children) from Spain, Serbia, Mexico, Germany, USA, Italy, Greece, Sweden, India, Poland, Egypt, Israel, Lebanon, Honduras, etc. were patients of our Institute.
All patients with LA pathology taken for treatment were distributed by age as follows: 1 to 3 years – 13.4%; 4 to 7 years – 32.8%; 8 to 10 years – 15.3%; 11 to 15 years – 16.5%; older than 15 years – 22%.
Innate LA pathology (symptomatic torticollis, clubfoot, arthroses deformities) was noted with 1.4% of patients received treatment in our institution.
Acquired LA pathology was revealed with 17.7% of patients: consequences of traumas and infections; scoliosis; arthroses deformities; neuropathies; chronic myofascial pain syndrome. With adult patients, myofascial pains were localizing most often in the area of vertebrarium and major arthroses.
Great importance is attached by us to treatment and control over the most numerous group of patients coming with “infantile cerebral paralysis” (ICP) diagnosis. ICP patients amounted to 80.9% of the total number of patients (21,728 persons), including 18,588 children (85.6%).Children with ICP amounted to 88.8% of all patients in the age of up to 15. Following distribution by age of ICP patients is established: 1 to 3 years – 14.5%; 4 to 7 years – 36.8%; 8 to 10 years – 16.7%; 11 to 15 years – 17.5%; older than 15 years – 14.5%. Distribution patients by the ICP forms was as follows: double hemiplegia – 40.5%; spastic hemiplegia – 36.6%; hemiparethic form – 13.8%; hyperkinetic form – 7.3%; and atonic-astatic form – 1.8%.
During treatment of patients with various kinds of LA pathology, we perform systematically statistic analysis of efficiency of application of the GF method under Prof. Ulzibat V.B. basing on the results of following studies: clinical, laboratory, instrumental (electromyography, angulometry, plantography, X-ray, ultrasound), psychological-algological testing, photo- and video recording.
The operative treatment course using GF method includes several stages. Under statistical data, every patient requires in average 2 stages of treatment; in average, 15 micro-operation on muscles (GF) are performed at each stage.
Analysis of long-term results of treatment of 3,714 patients that was carried out by physicians from various cities of Russia and by the Institute’s collaborators during the period from 1993 to 2007 has shown that “good” clinical effect in the form of increased volume of motions, appearance of new motor skills or significant improvement of previous ones, formation of qualitatively new motor stereotype, elimination or reduction of pain syndrome and hyperkineses was achieved in average in 94.55% cases. With 4.25% of patients, “satisfactory” result was noted: improvement of some motor skills; expansion of functional possibilities within the initial level of motor development. In 1.15% cases, patients’ state remained “without dynamics”. With 0.05% patients, appearance of pain in muscle areas that were not operated earlier was considered as aggravation; however, these modifications were eliminated at the subsequent stages of treatment. With regard to local organic muscular contracture or point of tenderness, efficiency of gradual fibrotomy amounted in average to 97.5%.
In addition to improvement of locomotor development with elimination of muscular contractures, additional positive effects were noted: improvement of speech (62%), mastication (49%), deglutition (50%), mimics (22%),emotional-behavioural indices (64%), sleep (49%), orexia (58%); reduction of heterophthalmia (55%), salivation(56%), nystagmus(22%), frequency and severity of epileptic seizures (25%); increasing of acuity of vision (17%) and hearing (15%). Frequency of qualitative modifications (appearance of speech and mastication; disappearance of heterophthalmia and salivation) amounted to 35%.
Follow-up monitoring over patients for 15 years confirms that operative intervention at the early stage of organic muscular contractures prior occurrence of stable contractures and LA deformities is the optimal one. In this connection, in order to obtain maximal result, it is preferable to start with operative treatment at the age of 3-5 having correspondent indications.
Thus, application of the method of gradual fibrotomy under Prof. Ulzibat V.B. for treatment of patients of orthopaedic profile with organic muscular contractures promotes correction of pathological settings and deformities, reduction of the chronic myofascial pain syndrome, which increases general efficiency of rehabilitation measures in the event of LA pathology.
Important role in recovery and improvement of locomotory functions of our patients is assigned to properly arranged post-operational rehabilitation corresponding completely with the main principles of medical rehabilitation: early beginning, stage-by-stage approach, continuity, complex nature, individual approach.
Main destination of the remedial treatment of patients with orthopaedic pathology consists in creation of optimal conditions for LA functions, including muscular system, and restriction of the effect of factors that provoke development of muscular contractures and myofascial pain syndrome: physical and psychical overloads, hypodynamia, muscle traumas and cooling. To this end, it is necessary to organize properly day regimen and locomotory mode, sensible nutrition, revealing and treatment of somatic illnesses, deficiency states, correction of LA anatomic abnormalities, pathologies of vision, hearing, etc.
Proposed system of post-operational rehabilitations is featured by priority application of therapeutic exercises directed toward early correction of pathological poses, formation of new locomotory skills, provision of coordinated functioning of muscles, increasing of resistance to physical load. In order to obtain optimal results, it is necessary to stimulate locomotory activity being various by quality and quantity using different methods and combined physical exercises, simulators adapted to possibilities of a patient.
Within 1-2 months following operation, as well as during rehabilitation of patients of early age, patients with expressed restriction of movement volume and arthral modifications, it is reasonable to include passive motions in the set of exercises in order to train individual elements of locomotory act. With post-operational adaptation of patients, it is necessary to transfer to passive-active and active gymnastics in order secure the locomotory stereotype.
Under data from literature, pathogenesis of myofascial pain syndrome and formation of organic muscular contractures consists of following links: constitutionally conditioned aptitude to micro-traumatism of muscles during stretching, compression and under physical load; presence of special reactivity of tissues, their increased ability to release biologically active substances; predisposition to the development of connective tissue; low ability to increase oxygen exchange under physical load.
Taking into account data of scientific researches, we recommend to our patients to avoid during post-operational rehabilitation the following: intensive and long-lasting loads both of static and dynamic nature; precipitous movements; forced stretching; exercises with poundage; fixed static poses; power motions related with maximal tonic strain of muscles; effects of biologically active substances (peloids, ozocerite); general or local effects of high (40°C and more) or low (20°C and less) temperatures; frequent and long-lasting intra-muscular injections; long immobilization of extremities; intensive stretching and compressing ofmuscles during massage and gymnastics; directional local impact of the pressurized water jet on ther area of muscles.
During elaboration of the individual gymnastic complex, it is necessary to consider the nature and severity of pathology of the patient’s locomotory system. Exercises must be performed systematically, smoothly at the medium rate; load must be moderate, dosed and must be increased gradually with intervals for rest. It is recommended to include in this complex exercises for relaxation and stretching of affected muscles; normalization of static and dynamic poses; exercises in warm water, swimming; moderate by load exercises with stimulators, tramp; elements of respiratory gymnastics, aerobics, outdoor and sportive games; music, dances; training to practice of myorelaxation and auto-training. During massage, it reasonable to use techniques of relaxing superficial or point impact.
Special devices applied for fixing, unloading and correction of pathological settings and LA deformities (ortheses, orthopaedic footwear, insoles, apparatus, splints, etc.) are used under indications. New orthopaedic footwear and insoles must be selected through 1-2 months f0ollowing operation during the period of complete adaptation to the new locomotory stereotype and in accordance with achieved level of correction of LA deformities; usage of previous footwear is unreasonable.
Applied physiotherapeutic methods must contribute to the improvement of blood circulation and metabolism in muscular tissue, to normalization of muscle tone, reduction of pain syndrome and hyperkinesias and must not increase the development of connective tissue. Following is indicated: swimming and therapeutic exercises in warm water; warm therapeutic bathes with sea salt, pine needle extract, sedative phyto-collections; gaseous bathes (“pearl”; oxygen). Within the frames of complex therapy of locomotory disturbances and myofascial pain syndrome, pharmacotherapy and electric treatment are assigned by indications. Application of other rehabilitation methods is desirable to be agreed with attending doctor of the Institute.
JSCCT “Institute of Clinical Rehabilitology”
General Director Ulzibat T.V.