Results of continuous passive movement method application in physical rehabilitation process of patients with knee joint pathology

Purpose: to present the experience of the continuous passive motion technique application on the joints with the help of domestic apparatuses for automatic development of move- ments in the process of physical rehabilitation of patients with the knee joints pathology in the postoperative period. Material and methods: The survey of the results of rehabilitation of 2 clinical groups of in-patients (52 males and 37 females), identical in terms of gender, age (aged 18 to 60), type of pathology and type of surgical interventions, was carried out. In the postoperative period, the author’s method of rehabilitation through passive development of motions of the affected knee joints with the help of domestic devices for the automatic development of movements was applied for the patients of the 2nd group. Results: own physical rehabilitation technique for the patients with knee joints pathology consisting of several stages, based on comprehensive application of a wide range of rehabilitation means with an individual approach to the course of the postoperative period for each individual patient has been elaborated. Comparison of the results of rehabilitation of the two groups of patients revealed the advantages of the applied methodology before traditional measures. Conclusions: The high efficiency of the elaborated domestic devices for automatic de- velopment of joints in the process of complex rehabilitation of patients with knee joints pathology has been proved, which allows recommending the techniques for wide administration in clinical settings, in rehabilitation centers and orthopedic and traumatology departments.


Introduction
Injuries and diseases of the musculoskeletal system are among the most frequent pathologies, affecting modern humanity. "The epidemic of injuries" and the increase in diseases of the musculoskeletal system did not bypass our country. In the structure of primary disability, the consequences of trauma and orthopedic diseases have been steadily occupying the third place for several decades after cardiovascular and oncological diseases. Every year in Ukraine more than 20 000 patients from injuries become disabled. Particular importance for the state is the loss of disability in persons of working age, which leads to a reduction in the state's labor potential, additional costs for pension provision, treatment and rehabilitation of disabled people [1][2][3].
Rehabilitation of patients with pathology of knee joints (KJ) is a very urgent problem in our country, because surgical interventions that are performed in the treatment of such pathology restore certain anatomical structures, but not completely eliminate their functional inferiority (the limitation of movements in the joints, muscle weakness, the cicatrical-adhesive process, the phenomenon of local osteoporosis develops or progresses, etc.), which in turn requires a long-term recovery treatment [4; 5; 7; 8].
In the domestic literature, there are isolated works describing the method of continuous passive movement (MCPM) in the system of physical rehabilitation of patients after surgical interventions at KJ (P. Bolkhovitin et al., 2013) and indicated its method of use. However, by providing some clinical recom-mendations, they do not detail the timing and duration of this method -a powerful factor in the prevention and elimination of morpho-functional disorders in the postoperative period. They require a methodological solution to the issue of detailing and clarifying the timing of the appointment of MCPM, there was a need to develop a methodology for its application depending on the nature of the surgical procedure (diagnostic arthroscopy, arthroscopic removal of the meniscus, open or arthroscopic restoration of the ligaments of the knee joint, endoprosthetics of the knee joint, interventions for joint injuries and periarticular bone fractures, etc.) and the course of the postoperative period [6; 9].
One of the significant factors hampering the active introduction of the method of continuous passive traffic in Ukraine is the lack of domestic devices for their implementation and the high cost of foreign analogs.
Thus, the creation of domestic devices for the automatic development of movements in KJ and the active introduction of MCPM in the complex physical rehabilitation of patients after knee joint surgery to improve the efficiency and quality of the recovery process is relevant, which led to the choice of the direction of our study.
Purpose of the study: to evaluate the effectiveness of physical rehabilitation of patients with pathology of knee joints in the postoperative period using the method of continuous passive movement in the joints with the help of domestic devices.

SLOBOZhANSKyI heRALD Of ScIeNce AND SPORT
Objectives of the study: 1. Compare the results of the rehabilitation treatment of the control (standard rehabilitation program) and the research group (complex restorative treatment with MCPM) of patients with pathology of knee joints in the postoperative period.
2. Analyze the results of clinical data (the volume of joint movements, the presence and magnitude of contracture in KJ, the intensity of the pain syndrome) and instrumental research methods before, during and after rehabilitation treatment in two groups of patients with pathology of knee joints in the postoperative period.

Material and Methods of the research
A comparative analysis of the results of rehabilitation of two clinical groups of patients was carried out, these groups were identical in gender, age, type of pathology and type of surgical interventions (52 men and 37 women) aged 18 to 60 years with KJ pathology (all patients had monolateral joint damage ), who were on inpatient treatment in the Sytenko Institute of Spine and joint Pathology, Academy of Medical Science, for the period from 2010 to 2016. In the 1st, the control group included 43 patients, and in the 2nd, main group -46 patients ( Table 1). Criterion of selection in the study groups was: patients with KJ pathology who underwent arthroscopic surgical interventions and who required the application of physical rehabilitation methods in the immediate postoperative period.
In the postoperative period, patients of the 1st group received standard rehabilitation treatment, and patients of the 2nd group, in addition to standard rehabilitation measures, performed passive development of movements in the affected KJ with the help of domestic devices for automatic development of movements (DADM), which we developed together with LLC «Svarcon» ( Figure 1) [10; 11].
In the manufacture of DADM, the conditions for medical devices (safety A) are met, and the possibility of changing and smoothly adjusting the speed of the development of movements, the angle of flexion-extension in the joints and the adjustment of the lodgment length, depending on the patient's anthropometric data.
Patients were examined according to conventional methods before surgical treatment, 9-10 days after the beginning of rehabilitation treatment and 3 months after surgery (questioning patients on a visual analogue scale of pain, measuring the volume of movements, dopplerography and rheovasography of vessels, electromyography of the muscles of the affected limbs) and made a special questionnaire, where they noted the individual anatomical and functional features of the KJ and developed an individual plan of rehabilitation measures and an assessment of the condition of each patient. All data from clinical and special research methods were calibrated for the characteristics obtained and a certain score was given in scores. It should be noted that restorative treatment was carried out taking into account the psychological characteristics of patients:

Results of the research and their discussion
-many patients had a negative psychological reaction to the "white coat", and also a slight local pain in the development of movements without DADM often caused severe pain and myotonic reactions, with the development of rigidity of the operated and adjacent joints; -when carrying out rehabilitation measures, there is a need for a constant reminder of the frequent and prolonged repetition of certain exercises or procedures and movements, etc., which in itself can cause a negative reaction.
A retrospective evaluation of clinical data and indices of instrumental research methods showed the positive effect of MCPM on the process of restoring the volume of movements in the joints in the main group as compared to the control group ( Table 2).
Dynamics of recovery of the volume of movements in the joints was determined primarily by the initial condition of the joint and the severity of the pathology and, as can be seen from the data in Table 2, the volume of movements in the joints of both groups was approximately the same: before surgery -81±4,5 in main group and 82±5,1 -in control; immediately after the intervention -86±6,3 in main group and 85±5,5 -in  control (data are given in% to the normal volume of movements, which is taken as 100%). 3 weeks after the first course of restorative treatment in the joints of the patients of the main group, the volume of movements in the joints increased to 97±2,5% of the norm, and in the control group -to 90±3,1%. In 3 months after the repeated course of restorative treatment in the control group of patients, the volume of movements averaged 96±2,4% of the norm, and in the main -98 ± 1,6%, which demonstrates a clear tendency to a better volume of movements in the main group.

fig. 2. Program of physical rehabilitation of patients with KJ pathology using the method of permanent passive movements in the postoperative period
Comparing the intensity of the pain syndrome according to the VAS scale, we determine that the indices differ in two groups. Thus, in the control group before the treatment, pa-tients noted a degree of pain syndrome by 76 units (possibly a discrepancy ±10,1), which is 0.4% more than in the main group (75 units, possibly a discrepancy ±10,5). After the rehabilitation treatment for 3 weeks after the intervention, a significant reduction in the pain syndrome in the main group was obtained in comparison with the control group, in the control group there was a reduction in the pain syndrome to 27 units in the main group and 39 -in control (possibly a discrepancy ±8,5). After a second course of restorative treatment, the degree of pain syndrome is 19 units (±6,5 difference) in the main group and 33 units in the control group (discrepancy ±7,5), the final difference in the VAS score is 14% reduction in pain in favor of the main group.
Analysis of the degree of edema of the tissue shows that in the control group for surgical treatment the degree of edema of the tissues in % to the opposite limb is 34% ±6,0, and the degree of edema of the tissues in % to the opposite limb in the main group was 33% ±5,5. After the treatment and the beginning of rehabilitation activities in the main group, edema of the limb was 37% ±6,5, in control; -39% ±7,5. 3 weeks after the commencement of rehabilitation, there was a significant reduction in edema to 15% ±4,5 in the main group and 24% ±5,5 in the control group, which is 9% less in the main group when compared with the control group. A significant decrease in the degree of edema of the tissues in % to the opposite extremity occurred after 3 months after the onset of restorative treatment: in the main group -5% ±4,5 and in the control -9% ±5,5).
Analyzing the data of the study of the vascular tone of the lower extremities in % to the opposite extremity (elasticity index according to the data of rheovasography), the following data were demonstrated: before treatment in the main group -91% ±11,5 respectively in the control -96% ±7,5), after the surgical treatment, the reduction to 61% ±9,5 and 59% ±10,5 respectively, which is caused by low motor activity of patients.
After restorative treatment, improvement in the elasticity index up to 81% ±10,5 in the main group and up to 69% ±8,5 in the control. The results after 3 months of restorative treatment were 94% ±6,0 and 81% ±8,5, respectively, with the difference between the main and the control group was 13%. conclusions 1. Evaluation of the results of clinical data and instrumental research methods of the two groups shows that the method of continuous passive movement using domestic DADM devices in the complex physical rehabilitation of patients with pathology of the knee joints reliably leads to a reduction in the duration of rehabilitation, an increase in the volume of movements by an average of 7% in the immediate postoperative period (up to 3 weeks after the operation) compared with the control group, with a significant reduction in pain (according to the VAS scale, pain reduction is 14% in favor of the main group), myotonic and neurotrophic syndromes.
2. The expediency and high efficiency of using the developed domestic devices for the automatic development of joint movements in complex restorative treatment of patients with KJ pathology, which significantly improve the quality of life of patients in the first 3 weeks of the postoperative period, which allows them to be recommended for widespread use in clinical use at the stages of physical rehabilitation in rehabilitation centers and orthopedic and trauma units.
Prospect for further research. in this direction are the wide introduction of the method of continuous passive movement in the joints at the stages of physical rehabilitation in rehabilitation centers and orthopedic and traumatological units with the simultaneous establishment of industrial production of developed domestic devices for automatic development of movements.