CC BY
13
UDC: 616.728.2 / - 03.2 - 053.1
DOI: 10.24411/1995-5871-2020-10132
METHODOLOGY SYSTEM FOR EVALUATION OF THE PREDICTORS OF CONGENITAL DEFECT OF HIP JOINTS IN CHILDREN UNDER 1 YEAR OF AGE
*1 B.S. Turdaliyeva, 2 G.E. Aimbetova, 3 V.M. Krestyashin, 4 N.B. Duisenov,
*5 N.N. Isayev
Kazakh Medical University of Continuing Education, Almaty 2 NJSC S. D. Asfendiyarov National Medical University, Almaty 3 FSAEI HE N. I. Pirogov Russian National Research Medical University, Russia 4 Kazakh-Russian Medical University, Almaty
SUMMARY
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An integrated system for the clinical evaluation of the functional status of injuries to the bones of the extremities and their effects in children and adolescents has been proposed, including subjective signs and objective indicators (results of special functional tests and motor tasks, clinical and imaging studies). Each sign was evaluated in points: more than 4 points means functional compensation; 3-4 points - subcompensation; less than 3 points - decompensation. The final evaluation of the functional status is an integrated index (quotient obtained when the total score is divided by the number of measured signs). The study involved 26 children with different nosology of traumatic and post-traumatic genesis, who underwent surgical treatment using extrafocal transosseous osteosynthesis, at the age from 5 to 18 years. A course of targeted rehabilitation measures was performed, which allowed to improve the functional condition, reflected in the repeated testing by increase of the integrated index within 1 - 2 points.
Key words: hip dysplasia, hip dislocation, children, early diagnosis, risk factors, evaluation system.
Congenital dislocation of the hip, congenital subluxation of the hip and dysplasia of the hip joints are a severe pathology marked by underdevelopment of all the elements that form the hip joint: its bone base and the surrounding soft tissue formations - ligaments, capsules, muscles, vessels and nerves. Due to serious anatomical changes, function of the largest joint in the human body is impaired, the pelvis shape and position changes, including curvature of the spine. Changes in static-dynamic conditions over time entail the development of diseases such as deforming coxarthrosis and lumbar osteochondrosis. Despite the fact that many studies have been devoted to this problem, it remains relevant to the present day [one].
The etiology of hip dysplasia is still not clear. Numerous studies have been conducted, but none of the revealed facts, separately, gave an answer to the etiology of hip dysplasia, therefore this pathology is currently included in the group of so-called polyetiologic diseases.
The problem of predicting the hip dysplasia remains urgent, its practical importance lies in the determination of risk factors [2].
Early diagnosis of this defect is a ley for addressing the problem of treatment of congenital hip dislocation. It is this treatment and prevention that every specialist - pediatric orthopedist, should pay attention to, regardless of whether he works in outpatient institution or surgical hospital. With each missed month or year of the child's treatment, the perspective for rehabilitation as a healthful worker is becoming more doubtful [3].
It should be noted that the incidence of congenital hip dislocation has been increasing every year recently. According to our sources, in 1972 the ratio of diseases and healthy children was up to 28 per 1000 children, in 2015 this ratio sharply increased up to 90 per 1000 children, which is mainly associated with unfavorable impact of environmental factors on the body of pregnant women and the developing embryo and fetus. In this regard, in
the diagnostics of congenital defect of the hip joints, the prediction of this disease comes to the fore.
Relation with the formation of a system for evaluating the predictors.
The scales described in the literature served as a prototype, including the system for evaluation of the functional status of the limb bones in children and adolescents (Tsykunov M.B., Merkulov V.N., Duisenov N.B., 2009), the system of comprehensive assessment of the hip joint (Sharpar V.D, 2004), modified scale of the rehabilitation potential, Harris Hip score (HHS, 2016), Oxford Hip Joint Scale (OHS, 2016) [3, 4, 5].
The assessment system consists of a
questionnaire divided into 5 groups.
The results are recorded by the child's parents. The identifiable signs are graded in points from 0 to 5, and possible answers correspond to various degrees of functional compensation. Scales for individual signs are uniformly compiled and correlate with the level of functional capacity.
The developed questionnaire contains:
1) Passport data, medical record No., medical history No., anamnesis, previous treatment, clinical diagnosis, surgical interventions. This information is recorded, but not graduated.
2) The list of questions used to assess social risk factors is given in Table №1.
Table №1. Questionnaire for the quality of life in children under 1 year of age with congenital
defect of the hip joints
№. Identifiable signs Possible answers Score
Excellent 5
Assessment of the health status as of today Very good 4
1. Good 3
Bad 2
Very bad 1
It is much better 5
Assessment of the child's It is little better 4
Within normal limits 3
2. health condition after treatment
It is worse 2
It is much worse 1
Same as before injury (unlimited) 5
Participation in outdoor active With few restrictions 4
3. games with peers (cycling, Little difficult, rapid fatigability 3
rollerblading, skateboarding). Possible, but very difficult 2
Impossible 0
Same as before injury (unlimited) 5
Participation in outdoor games With few restrictions 4
4. or sport with peers (basketball, Little difficult, rapid fatigability 3
football, etc.) Possible, but very difficult 2
Impossible 0
No need for physical assistance 5
Physical assistance is rarely required 4
5. Need for physical assistance Need for physical assistance at the end of the 3
day
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Physical assistance is frequently required 2
Need for physical assistance is constant 0
Not used 5
Using additional mobility aids Used rarely during sports activities or other significant load 4
6. The need for use at the end of the day 3
The need for mobility aids is frequent 2
Constant use of orthosis 0
No need 5
Rarely in case of continuous or significant load 4
7. Need for additional support The need at the end of the day 3
The need for support is frequent 2
The need for additional support is constant 0
3) Formalization of data related to the obstetric-gynecological history is presented in
Тable №2.
Table №2. Questionnaire for complaints
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№ Identifiable signs Possible answers Score
1. Complaint about child unrest No unrest 5
Transient, mild pain is observed with heavy or sustained load. 4
Observed constantly with heavy or sustained load, resolves itself 3
Observed constantly with heavy or sustained load, does not resolve itself 2
Observed constantly with ordinary load 1
Constant severe pain is observed 0
2. Swelling of the lower No swelling 5
extremities in a child. Periodically with heavy or sustained load 4
Constantly with heavy or sustained load, resolves itself 3
Constantly with heavy or sustained load, does not resolve itself 2
Observed constantly with ordinary load 1
Observed constantly 0
3. Weakness of the muscles of No muscle weakness 5
lower extremities. Rarely, during sports activities or other significant load 4
Frequently, during sports activities or other significant load 3
Periodically with ordinary load 2
Observed constantly with ordinary load 1
Observed constantly 0
4. Instability of the limb joints No instability observed 5
Periodically with heavy or sustained load 4
Constantly with heavy or sustained load, resolves itself 3
Constantly with heavy or sustained load, does not resolve itself 2
Observed constantly with ordinary load 0
5. Is there a limb deformity Not observed 5
Minor limb deformity is observed 3
Significant limb deformity is observed 1
6. Is there unusual mobility Not observed 5
outside the limb joints? Minor mobility (stiff pseudarthrosis) 3
Significant limb mobility is observed outside the joints (bone defect) 1
4) Common medical risk factors are listed in Table №3.
Table №3. Questionnaire for the subjective assessment of the upper limb function
№ Identifiable signs Possible answers Score
1. Can the child do the morning Very easy 5
toilet on his own (washing and Easy 4
drying hands and face, using toothbrush, combing). With effort 3
Needs help 2
Cannot do 0
2. Can the child use various Very easy 5
household appliances Easy 4
(telephone, TV remote control, computer). With effort 3
Needs help 2
Cannot do 0
3. Does the child do light Very easy 5
housekeeping (washing dishes, Easy 4
sweeping the floor, washing clothes). With effort 3
Needs help 2
Cannot do 0
4. Can the child dress on his own Very easy 5
(putting on clothes, buttoning Easy 4
up, lace up shoes). With effort 3
Needs help 2
Cannot do 0
5. Does the child eat on his own? Very easy 5
Easy 4
With effort 3
Needs help 2
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Cannot do 0
6. Has the child's handwriting Handwriting did not change 5
changed? Minor changes 4
Significant changes 3
Writes with effort 2
Cannot write 0
Table №4. Questionnaire for the subjective assessment of the lower limb function
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No. Identifiable signs Possible answers Score
1. Whether the child has lameness Not observed 5
Periodically with heavy or sustained load 4
Constantly with heavy or sustained load, resolves itself 3
Constantly with heavy or sustained load, does not resolve itself 2
Observed constantly 1
2. Support ability of the child's legs Support ability of the legs is not limited 5
Support ability of the legs periodically reduces, but the load is allowed when using soft orthosis 4
Support ability of the legs is constantly reduced, but the load is allowed when using soft orthosis 3
Support ability of the legs is constantly reduced, but the load is allowed when using rigid orthosis or orthopedic apparatus 2
Weight bearing is impossible 0
3. Can the child walk a block or a longer distance? Very easy 5
Easy 4
With effort 3
Cannot do 1
4. Can the child run a short distance? Very easy 5
Easy 4
With effort 3
Cannot do 1
5. Can a child go up to the 2nd floor? Very easy 5
Easy 4
With effort 3
Cannot do 1
6. Can the child put on shoes on his own? Putting on shoes is not difficult 5
Putting on shoes is rather difficult 4
Putting on shoes with effort 3
Putting on shoes is impossible 1
Table №5. Special motor tasks for the lower extremities
No. Identifiable signs Possible answers Score
1. Standing on affected leg Possible as before the injury 5
Little difficult 4
Possible for a short period of time 3
Standing on affected leg is impossible 0
2. Walking Possible as before the injury 5
Light limping 4
Lameness 3
Walking only with additional support 2
Walking is impossible 0
3. Jumping on affected leg Possible as before the injury 5
Little difficult 4
Possible only in place (no rotation and movement) 3
Jumping is impossible 1
4. Running Possible as before the injury 5
Little difficult 4
Possible only over short distances 3
Running is impossible 1
5. Ability to sit The ability to sit is not limited 5
Sitting for no more than 1 hour is possible in a chair of any design 4
Sitting is possible only in a low chair 3
Sitting is impossible 0
6. Squats The ability to squat is not limited 5
Squatting is little difficult 4
The squat is full, but hand assistance is necessary 3
Squatting is difficult due to limited motion in the joints of the lower extremities 2
Squatting is impossible 0
7. Stair climbing Free 5
Little difficult 4
Possible step by step, holding on to handrails 3
Possible with effort, lifting one leg and placing the other near 2
Impossible 0
8. Motion amplitude in the joints of the lower extremities Full mobility without restrictions within physiological limits (normal) 5
Limited mobility, but within functionally acceptable limits 4
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Ankylosis in a functionally favorable position 3
Vicious setting, i.e. mobility is limited to functionally unfavorable limits 2
Ankylosis in a functionally unfavorable position or a vicious attitude resulting in the complete functional unsuitability of the limb 0
Table №6. Objective assessment of the knee joint function
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No. Identifiable signs Possible answers Score
1. The presence of hypotrophy of No hypotrophy 5
the thigh area Medium (10 - 15%) 3
Expressed (more than 15%) 1
2. Knee circumference No difference 5
Increase 10 - 15% 3
Increase over 15% 1
3. Functional hip shortening No shortening 5
Limb shortening that does not require 3
correction
Limb shortening requiring correction 1
4. Revealing functional insufficiency of the thigh muscles according to MMT The movement is carried out in full under the action of gravity with maximum external resistance 5
The movement is carried out in full under the 4
action of gravity and with minimal external
resistance
The movement is performed in full under the 3
action of gravity
The movement is carried out only in light 2
conditions
Only muscle tension is felt when attempting 1
voluntary movement
There are no signs of muscle tension when 0
attempting voluntary movement
5. Thigh muscle endurance for 80-100% of the norm is not reduced 5
static work Reduced, but sufficient for sports or other significant loads 60-80% of the norm 4
Reduced, but sufficient for long-term 3
performance of normal loads 40-60% of the
norm
Reduced, but sufficient for short-term 2
performance of normal loads 20-40% of the
norm
Reduced significantly, the implementation of normal loads is difficult to less than 20% 1
of the norm
Test execution not possible 0
6. Endurance of the thigh muscles 80-100% of the norm is not reduced 5
for dynamic work Reduced, but sufficient for sports or other significant loads 60-80% of the norm 4
Reduced, but sufficient for long-term 3
performance of normal loads 40-60% of the
norm
Reduced, but sufficient for short-term 2
performance of normal loads 20-40% of the
norm
Reduced significantly, the implementation of normal loads is difficult to less than 20% 1
of the norm
Test execution not possible 0
7. The amplitude of active The amplitude reaches 80-100% 5
movements in the knee joint (a The amplitude reaches 60-80% 4
comparative measurement of movements relative to a healthy limb is made) The amplitude reaches 40-60% 3
The amplitude reaches 20-40% 2
Amplitude reaches less than 20% 1
Test execution not possible 0
8. Amplitude of passive The amplitude reaches 80-100% 5
movements in the knee joint The amplitude reaches 60-80% 4
(comparative measurement of movements relative to a healthy limb is made) The amplitude reaches 40-60% 3
The amplitude reaches 20-40% 2
Amplitude reaches less than 20% 1
Test execution not possible 0
9. Functional characteristics of knee joint contracture Contract within functionally advantageous limits 4
The contracture is in a vicious position, 3
amenable to corrective action (the ability to
withdraw to functionally beneficial limits)
The presence of contracture in a vicious 1
position, the corrective effect is not effective
10. Compliance of the knee joint to It lends itself to corrective action easily 4
corrective action It is difficult to correct corrective action 3
Does not lend itself to corrective action 1
11. The presence of pathological Not marked 5
mobility in the hip area Slight mobility is noted (slow healing fracture, tight pseudarthrosis) 3
There is significant limb mobility outside the joints (dangling pseudarthrosis, femur defect) 1
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12. Deformity of the thigh area Not marked 5
Deformation is noted 3
Deformation is noted in combination with shortening 1
Social factors:
Unfavorable living conditions
Secondary or secondary special education of the mother
Secondary or secondary special education of the father
Bad habits (smoking) in the mother
Bad habits (smoking) in the father
Family income below subsistence level
Irregular visits to women's consultation clinic
Obstetrics
Threatening miscarriage Oligoamnios
Premature rupture of membranes Discoloration (green, brown) of amniotic fluid Cesarean section
Pelvic presentation of the fetus during pregnancy Fetal asphyxia
Rhesus conflict between mother and child
Anemia
Chronic diseases of the cardiovascular system Chronic diseases of the nervous system Chronic diseases of the pelvic organs Pathology of the musculoskeletal system ARVI during pregnancy Bodily injury during pregnancy Operations during pregnancy Sexually transmitted infections
Common medical factors
Mother's age at the time of conception is under 20 years. Father's age at the time of conception is under 20 years. Mother's age at the time of conception is over 40 years. Father's age at the time of conception is over 50 years. Spinal cord injury in relatives
Each identifiable sign is evaluated in relation to healthy contralateral limb in points from 0 to 5, depending on the degree of functional compensation. The final assessment of the functional status of extremities in children is an integrated index or average score (quotient obtained when the total score is divided by the number of measured signs), obtained from the results at the time
of examination. If one or several signs cannot be determined, the average score is calculated from the involved signs.
Depending on the value of the integrated index, we identified three degrees of limb compensation in children:
• more than 4 points - compensation;
• 3-4 points - subcompensation;
• less than 3 points - decompensation.
At the premises of pediatric traumatology clinic and rehabilitation department of FSI N.N. Priorov Central Institute of Traumatology and Orthopedics, during 2006 - 2007, 26 children were examined with various nosology of traumatic and post-traumatic genesis, who underwent surgical treatment using extrafocal transosseous osteosynthesis, at the age from 5 to 18 years, namely, 10 boys, 16 girls.
According to results of the examination, decompensation was detected in 7 patients (integrated index 1.72 ± 1.06 points) prior to treatment, subcompensation in 10 children (integrated index 3.5 ± 0.43 points), compensation in 9 patients.
Decompensation was observed in children with severe traumatic injury to the extremities,pseudoarthrosis.Subcompensation of the limb function was detected in relatively minor injuries and few post-traumatic injuries of the extremities (old Montage laceration, club hand). Compensation was observed for stubby limbs since during case follow-up, compensation is achieved using functional aids (lining, sole elevation).
The analysis of individual indicators enables to determine the target and objectives
of the rehabilitation process. Thus, with low scores of the general section, basic motor stereotypes (running, walking, standing, etc.) were corrected, in case of impairment in the special section, rehabilitation is focused on increase in joint motion or strengthening.
In the event that marked structural and functional changes identified by imaging studies determine a significant, less than 3 points, uniform decrease in all sections, surgical treatment was recommended.
During retest, after a rehabilitation course, increase of the integrated index within 1 - 2 points was observed: decompensation was detected in 5 patients (integrated index 2.42 ± 0.76 points), subcompensation in 8 children (integrated index 3.6 ± 0.43 points), and compensation in 13 patients.
Thus, the system of comprehensive assessment of the recovery and compensation of the functional status in traumatic injuries to the limb bones and their effects in children and adolescents using extrafocal transosseous osteosynthesis enables to objectively determine the level of functional compensation, outline the target and tasks of the recovery period, and evaluate the effectiveness of rehabilitation measures.
REFERENCES
1. Karabekov A.K., Plekhanov G.V, Duisenov N.B, Karabekova R.A. Clinical findings, diagnosis and treatment of congenital hip dislocation in children: Training manual - Shymkent, 2000 - p. 107
2. Malakhov O.A., Kralina S.E. Congenital hip dislocation (clinical findings, diagnosis, expectant treatment). M: Medicine, 2006, p.128
3. Duisenov N.B. Comparative assessment of the effectiveness of surgical treatment of congenital hip dislocation in children. / Author's abstract. Cand. - Almaty, 2001 - p. 24 ^
4. Sharpar V. D. Dynamics of developmental disorders of the hip joint in children and S adolescents. Surgical treatment and rehabilitation system. / Author's abstract. PhD - Moscow, 2004 - p. 38 ^
5. Duisenov N.B. A new method to assess the functional status of injured limb bones | in children.//Journal of the Russian Association for Sports Medicine and Rehabilitation of ^ Diseases and Disabled People. - M, 2007. - No. 2 (22). - p. 17-18. |
6. Cherkasova M.A., Bilyk S.S., Kovalenko A.N., Trofimov A.A. Comparative assessment of the validity of Russian versions of the Harris (HHS) and Oxford (OHS) scales for the hip | joint. / Selected problems of the hip surgery. - S-Pb, 2016 -- p. 148-152. |
7. Belova A.N., Shchepetova O.N. Scales, tests, and questionnaires in medical
rehabilitation: Guide for Physicians and Researchers - M, 2002 - p. 440. §
ЭД1СТЕМЕ 1 ЖАСКА ДЕЙ1НГ1 БАЛАЛАРДАFЫ ЖАМБАС БУЫНДАРЫНЫН ТУА Б1ТКЕН ПАТОЛОГИЯСЫНДАFЫ БОЛЖАМДЫ КАУ1П ФАКТОРЛАРЫН БАFАЛАУ
ЖYЙЕСI
* 1 Б.С. Турдалиева, 2 Г.Е. Аимбетова, 3 В.М. Крестьяшин, 4 Н.Б. Дуйсенов,
*5 Н.Н. Исаев
*1, 5 ^азак медициналык Yздiксiз бiлiм беру университетi, Алматы к-сы 2 КЕА^ «С.Д. Асфендияров атындагы ^азак ¥лттык медициналык университет»,
Алматы к-сы
3 «НИ. Пирогов атындагы Ресей ¥лттык зерттеу медициналык университета,
Ресей к-сы
4 ^азакстан-Ресей медицина университетi, Алматы к-сы
ТУЙ1НД1
Балалар мен жасeспiрiмдерде аяк-кол сYЙекгершщ закымдануы жэне олардьщ салдары кезiндегi функционалдык жагдайды клиникалык багалаудыц кешендi жYЙесi усынылган, оньщ iшiнде субъекгивгi белгiлер мен объективт кeрсегкiшгер (арнайы функционалдык тесгтер мен козгалыс тапсырмаларыныц, клиникалык жэне аспаптык зерттеулердщ нэтижелерi). Эрбiр белгi баллдармен багаланды: 4 балдан жогары функция етемакысына сэйкес келедi; 3-4 балл - субкомпенсация; 3 балдан темен декомпенсация. Функционалдык жагдайдыц соцгы багасы-интегралдык кeрсеткiш (баллдардыц жалпы сомасын есепке алынган белгiлер санына белуден белектенген). Травматикалык жэне жаракаттан кейiнгi шыгу тегi эртYрлi нозологиясы бар, 5 жастан 18 жаска дейiнгi 26 бала тексерiлдi. Максатты оцалту iс - шаралары курсы етюзшд^ бул функционалды жагдайды жаксартуга мYмкiндiк бердi, бул интегралды керсетюштщ 1-2 балл шегiнде кайта тестшеуге эсер еггi.
Клт свздер: жамбас дисплазиясы, жамбас дислокациясы, балалар, ерте диагностика, цаут факторлары, багалау ЖYйесi.
2
3
МЕТОДОЛОГИЯ СИСТЕМА ОЦЕНКИ ПРОГНОСТИЧЕСКИХ ФАКТОРОВ РИСКА ПРИ ВРОЖДЕННОЙ ПАТОЛОГИИ ТАЗОБЕДРЕННЫХ СУСТАВОВ
У ДЕТЕЙ ДО 1 ГОДА
* 1 Б.С. Турдалиева, 2 Г.Е. Аимбетова, 3 В.М. Крестьяшин, 4 Н.Б. Дуйсенов,
*5 Н.Н. Исаев
*1, 5Казахский медицинский университет непрерывного образования, г. Алматы НАО «Национальный медицинский университет им. С.Д. Асфендиярова», г. Алматы ФГАОУ ВО «Российский национальный исследовательский медицинский университет
имени Н.И. Пирогова», г.Россия 4 Казахстанско-Российский медицинский университет, г. Алматы
АННОТАЦИЯ
Предложена комплексная система клинической оценки функционального статуса при повреждениях костей конечностей и их последствиях у детей и подростков включающая субъективные признаки и объективные показатели (результаты специальных функциональных тестов и двигательных заданий, клинических и инструментальных исследований). Каждый признак оценивался в баллах: выше 4 баллов соответствует ком-
пенсации функции; 3-4 балла - субкомпенсация; менее 3 баллов декомпенсация. Конечная оценка функционального состояния - интегральный показатель (частное от деления общей суммы баллов на число учтенных признаков). Обследовано 26 детей, с различной нозологией травматического и посттравматического генеза, которым производилось оперативное лечение методом внеочагового чрескостного остеосинтеза, в возрасте от 5 до 18 лет. Проведен курс целенаправленных реабилитационных мероприятий, позволивших улучшить функциональное состояние, отразившимся на повторном тестировании приростом интегрального показателя в пределах 1 - 2 баллов.
Ключевые слова: дисплазия тазобедренных суставов, вывих бедра, дети, ранняя диагностика, факторы риска, система оценки.
UDC: 614.2
DOI: 10.24411/1995-5871-2020-10133
СОВРЕМЕННОЕ СОСТОЯНИЕ ВОПРОСА ВОССТАНОВЛЕНИЯ РАБОТОСПОСОБНОСТИ ВЫСОКОКВАЛИФИЦИРОВАННЫХ СПОРТСМЕНОВ
Ж.М. Андасова, *А.Т. Тулендиева
Казахский медицинский университет непрерывного образования, г. Алматы
АННОТАЦИЯ
В статье представлен анализ зарубежной научно-методической литературы в области медицинского обеспечения тренировочного процесса, некоторые аспекты организации системы восстановления в ходе спортивной подготовки, применения средств восстановления. Проведен анализ результатов научных исследований в медицинском обеспечении спорта высших достижений, выделены наиболее значимые тенденции в совершенствовании системы восстановления спортсменов.
Ключевые слова: восстановление работоспособности спортсменов, адаптация, средства восстановления.
Intrоductiоn. Today, physical performance is the most important element of an athlete's readiness for competitions (Platonov V.N., 1984; 1997; Ozolin N.G., 2004, etc.).
Functional preparedness of an athlete and level of his physical performance are key factors for development of all basic physical qualities, it is a basis of body's ability to withstand high specific loads and largely determine sports result at almost all stages of long-term training [1, 2, 3].
Purpose of the research is to identify current challenges, collect and review information on research efforts carried out in the field of sports medicine, physiology, biochemistry of sports activities.
Matеrial and mеthоds. Search and collection of information sources (articles, collections of academic papers, conference materials, abstracts, and journals) were carried out. Found sources were subject to scientific editing and review.
Rеsults and discusston. In case of long-term sports activities, solution of a challenge of adaptation of athlete's body to progressive impact of repeatedly used variants of physical loads comes into importance. The higher the qualification level of an athlete, the closer to the limit of his biological capabilities is a state of his organism functioning. The more difficult it is to expect an adequate effect from use of repeating variants of training exposures, and intensification of load often causes overfatigue
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