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DOI 10.14526/01_2017_198
PROPRIOCEPTIVE SENSITIVITY MULTISYSTEM INJURY OF MENISCUS AND THE ANTERIOR CRUCIATE LIGAMENT OF A KNEE-JOINT
Daria V. Fedulova - graduate student "Ural Federal University named after the first President of Russia B.N. Yeltsin" "Ural Institute of Traumatology and Orthopedics named after V.D. Chaklin" 4, Comintern, Ekaterinburg, 620078, Russia
E-mail: darya-fedulova@yandex .ru
Annotation: Most authors, using different methods of proprioceptive function of the anterior cruciate ligament of a knee-joint (ACL) registration, came to the conclusion that even in case of perfectly held reconstructive operations, sensory function of a transplant stays low, it means a kind of proprioception deficiency. There is a range of research works, which, on the basis of the reason of ACL injuries analysis, lead to the conclusion, that very often the reasons for the second rupture become biomechanical and nervous-muscular asymmetry of the extremity. Material. The article describes the mechanism of proprioception and the influence of meniscus and the anterior cruciate ligament injury on motional sensitivity. Research methods: scientific literature analysis and summarizing, vestibular tolerance test, Romberg's test, functional tests, methods of mathematical statistics. Results. The statistics was held within the period since 2012 till 2016 at "Ural Institute of Traumatology and Orthopedics named after V.D. Chaklin" among patients after surgery concerning chronic injuries of knee-joint. Pedagogical principles of lessons and a complex of remedial gymnastics organization were considered and the main directions of proprioception development in case of this kind of knee-joint injury were studied. After operations patients of the main group were offered the lessons of remedial physical culture (RPC) in the form of remedial gymnastics with the additional complex of proprioceptive exercises since the 5th week of remedial therapy. 6 months after the operation, connected with the multisystem injury of meniscus and the anterior cruciate ligament, it was possible to achieve asymmetry of the extremities both in nervous-muscular control and in the main group functional term. Conclusion. The research work showed that a purposeful work over the balance and coordination after multisystem injury of meniscus and the anterior cruciate ligament provides proprioceptive sensitivity renewal.
Keywords: coordination, balance, proprioception, the anterior cruciate ligament, remedial gymnastics.
Introduction
Most authors, using different methods of proprioceptive function of the anterior cruciate ligament of a knee-joint (ACL) registration, came to the conclusion that even in case of perfectly held reconstructive operations, sensory function of a transplant stays low, it means a kind of proprioception deficiency [2]. Moreover, there is a range of research works, which, on the basis of the reason of ACL injuries analysis, lead to the conclusion, that very often the reasons for the second rupture become biomechanical and
nervous-muscular asymmetry of the extremity [4-6].
The whole process of movements organization and regulation, as describes N.A. Bernshteyn (1896-1966), whose contribution is one of the main in physiology of motional act formation, is realized through the scheme of a reflex circle.
The scheme of a reflex circle [1] is a definite form of interaction between afferent and effector processes (picture 1). Afferent process is a centripetal process of a neural excitation, which happens in the direction
from the organ towards central nervous system (CNS). Effector process provides the
signal according to reverse reactions from CNS to a moving organ.
Picture 1 - The scheme of a proprioceptive reflex circle Эффекторное ядро- effector nucleus Центральные синапсы- central synapses Рецепторное ядро-receptor nucleus Эффекторный импульс- effector impulse Рецепторный импульс-receptor impulse Движущаяся система-moving system Реактивные силы-reactive forces Внешние силы- external forces
In order to define afferent basis of a person's movements Sherrington C. S. in 1906 introduces the notion "proprioception". Proprioceptors (receptors of motor sensation) transfer the signals concerning body position in space and play the main role in movements regulation of a person. That is why the work over coordination and balance rehabilitation after anterior cruciate ligament trauma is one of the priority aims of remedial therapy.
Research methods and research organization
The research was held on the basis of the state budgetary establishment of public health of Sverdlov region "Center of the specialized kinds of medical aid "Ural Institute of Traumatology and Orthopedics named after V.D. Chaklin"". 75 people took
part in the research: patients, who had an operation of anterior cruciate ligament regeneration from the tendon of semitendinous and gracilis vastus. Apart from the main injury (ACL rupture) patients had meniscus disorder (67% - medial and 33% -lateral). The age range of the patients: 20-35 years old. The patients didn't have knee-joint injuries before. Two groups were formed: the main group (38 people) and the control group (37 people). After the operation the patients from the main group were offered to go in for remedial physical culture (RPC) in the form of remedial gymnastics with an additional complex of proprioceptive exercises since the 5th week of remedial therapy; the patients from the control group were offered only to go in for remedial gymnastics.
The following research methods were used in the work:
- scientific literature analysis and summarizing;
- vestibular tolerance test;
- Romberg's test;
- functional tests;
- methods of mathematical statistics (Student t-test)
In order to estimate the functions of proprioception two tests were held: Romberg's test (in modifications) and functional tests. However, in order to eliminate the disorders of vestibular apparatus, we held one more selective vestibular tolerance test. The essence of the test: at a smooth platform a circle (diameter is 50 meters) is drawn. To the left of the circle three corridors (width is 25 centimeters) are marked. The participant of the test fulfills 15 spins within 20 seconds in a bent position, when the head is at an angle of 90° to the legs, hands down. After the end of the spin it is necessary to stand up straight and go through the 1st corridor. Vestibular tolerance is estimated according to the volume of swerve from the first corridor in centimeters. Didn't go out of the circle during the spin and didn't overstep the bound of the corridor -excellent; overstepped the limits of the circle or the 1st corridor into the 2nd corridor- good; in case of body bent with overstep into the 3rd corridor - satisfactorily.
In the research we had the patients, who had "good" and "excellent" according to this test. After that Romberg's test and functional tests were fulfilled.
Romberg's test was fulfilled in three modifications. In all variants the aim is one-to feel the body balance and stay in this position:
• Start position (S.p.) - standing, legs together, hands extended forward, eyes closed.
• From the same S.p. move the legs to one line, so that the heel of the one foot touched the point of the other foot (first the
right is in front, then the left foot).
• S.p. - standing at one leg, the other is bent and the heel is set against a knee-joint of a skating foot, hands straight. The result of the operated and a healthy extremity with closed and open eyes is estimated.
Maximum time limit (seconds), within which a patient can hold the start position, not disturbing the balance.
Noyes Functional tests [7]: complex includes 4 jumps, which are fulfilled first at a healthy leg, then at an operated extremity: standing long-jump, triple jump, zigzag triple jump and 6 meters distance jump. After each jump, apart from 6 meters distance jump, a patient fixates himself after landing within 2 seconds holding the balance. Two attempts of each test are fulfilled. By means of this test the index of extremities symmetry is calculated: the average value of 2 attempts, fulfilled at an operated leg, is divided by the average value of 2 attempts, fulfilled at a healthy leg; the result is multiplied by 100.
Proprioceptive abilities testing was held 4,5 and 6 months after the operation on anterior cruciate ligament rehabilitation.
Research results and their discussion
During the period since 01.01.2012 till 31.12.2016 at "Ural Institute of Traumatology and Orthopedics named after V.D. Chaklin" 1923 patient with a chronic injury of a knee-joint were operated. Among them 961 patients (224 - women, 737 - men) within the age range 20-35 years old. With traumatic injury of anterior cruciate ligament- 615 patients. Among them 295 people had multisystem injury of internal meniscus, 77 people had only the injury of exterior meniscus, 160 patients had the injury of both internal and exterior meniscuses.
Thus, we see that this trauma most often happens among men, in case of multisystem injury internal meniscus is injured more often than exterior meniscus.
During remedial gymnastics for the patients with multisystem injury of meniscus
and anterior cruciate ligament we used the following pedagogical teaching principles in order to make new movements mastering easier:
- scientific content and theory connection with practice principle (the essence of this principle is in the fact that during new movements teaching the connection of theory and practice is fully realized, as scientific knowledge is presented as structurally integral: first theoretical study, explanation, then mastering in practice and then exercises fulfillment);
-the principle of system character (the system of lessons organization is an integral process and each further knowledge and skill is based on the previous one or continues it);
- the principle of consciousness and activity in teaching (a person should be interested in the process of remedial treatment; with this principle we try to master new knowledge with own active actions);
- the principle of visualization (new movements and exercises teaching is realized through the principle of visualization, when a new exercise is not only explained and described, but also is shown by a teacher and a person, who trains, in order to involve more analyzers; and also sports equipment and methodical manuals are used for demonstration);
- the principle of availability (material should be available for each person, pedagogical process of teaching new movements is realized "from simple to difficult");
- the principle of stability (is realized through recurrence of the fulfilled exercises );
-the principle of positive motivation and a favorable emotional climate of teaching (motivation formation for recovery is one of the main aims of remedial treatment. Favorable emotional climate provides easier material mastering and additional motivation to train);
- the principle of individual and collective forms of teaching combination (this principle is realized, when during group lessons there are the elements of independent cognitive and transforming activity. For
example, during the exercise fulfillment in pairs, independent formation of the movement elements is realized for known in advance result achievement).
In spite of the fact that every principle is independent, the mechanism of lessons formation is based on the combination of these principles into one methodology. The methodology of a complex of proprioceptive exercises organization (as addition to general complex of remedial gymnastics) is directed to the following:
1) the pose and the accuracy of the fulfilled movements control;
2) coordination and balance in case of external resistance.
For this purpose the exercises (picture 1-3) for static balance with a balance-pillow and for body position holding (since the 5th week) were used, for a dynamic balance (since the 9th week), exercises for the direction of movement change and external resistance with the help of elastic band and a partner (in the training-rehabilitation period since the 16th till 24th week), and also zigzag running, shuttle running, lumps with effort and direction change (since the 20th week, depending on individual peculiarities and abilities of a person). The exercises were held with the eyes closed and open because of the dominating importance of visual analyzer in controlling movements (during the exercises fulfillment, with the eyes closed, the load was on compensatory analyzers and proprioceptics).
During the values of functional tests comparison (exercises for static and dynamic balance) it is seen, that the initial results within 4,5 months are higher in the main group, than in the control group, to 6 months this difference increases, as since the 20th week plyometric exercises are added to the complex. In the control group, in spite of the fact that extremity symmetry index is high enough, the indices themselves are lower than the indices in the main group. According to the criterion of results validity statistically valid results we see in operated extremity and it proves the effectiveness of the offered exercises. In the control group almost all
values, apart from "zigzag" test, are statistically not valid and it proves that the difference to the next period of testing was minimal, changes were insignificant.
Romberg's test was held in three modifications, the results were estimated in seconds. The first two tests: standing, legs together, hands forward, eyes closed and "leg by leg" test were held in order to understand how steady a person is. And if a person was in a steady position, holding the balance more than one minute test came to an end, as this result is the index of his steadiness. All patients, who took part in the experiment, were steady. The results of
Romberg's test showed that it was more difficult to stand on one leg with the eyes closed and not every person can manage with this task. Visual analyzer is the leading in movements control [3] and when it is absent, the sense of position in space changes, inner mechanisms are activated, load is on proprioceptics, that is why this test was very important. The results of the operated extremity in the main group are higher and are close to the results of a healthy extremity. In the control group there is a considerable difference according to these indices: the values are lower and asymmetric.
Tables 1 and 2 present the results of the functional tests and Romberg's test in different modifications. The results were considered statistically valid in case p<0,05
Ta ble 1 - Results of functional tests (jumps)
Standing, m Triple jump, m Zigzag, m 6 meters, sec.
on two legs HE OE HE OE HE OE
In the main group
4,5 months
Result 183±5,6 4,7±0,3 3,6±0,3 3,5±0,2 2,7±0,2 2,3±0,1 2,5±0,1
Index - 76,6% 77, 1% 92%
6 months
Result 190±6,2 Picture 3. The exerci i se with a partner i 2,1±0,1 2,2±0,1
Index - 92,2% 93,5% 95,5%
t-test 0,413 0,359 0,028 0,007 0,0002 0,131 0,022
In the control group
4,5 months
Result 177,5±5,8 4,5±0,3 3,6±0,3 3,2±0,2 2,5±0,2 2,4±0,1 2,8±0,2
Index - 80% 78% 86%
6 months
Result 183±6,7 4,8±0,3 4±0,3 4,2±0,3 3,5±0,3 2,3±0,2 2,6±0,2
Index - 83% 83% 88%
t-test 0,539 0,432 0,3 0,025 0,013 0,648 0,457
Table 2 - Romberg's test result in modifications
Standing, sec. Leg by leg, sec. Standing on HE, sec. Standing on OE, sec.
Legs together RL forward LL forward EO EC EO EC
In the main group
4,5 months
Result
>1 min
>1 min
>1 min
52,4±3,4
19±1,2
35,2±3
11,1±1
6 months
Result >1 min >1 min >1 min 68,4±4,1 27,4±1,5 43±4,9 21,9±1,8
t-test - - - 0,009 0,0005 0,195 0,000008
In the control group
4,5 months
Result
>1 min
>1 min
>1 min
39,1±2,1
14,9±1,3
26,9±2,4
5,6±0,7
6 months
Result
>1 min
>1 min
>1 min
45,2±3,5
20,6±1,9
31,1±3,4
9,5±1,1
t-test
0,163
0,027
0,331
0,008
abbr: HE - healthy extremity, OE - operatec RL eyes closed
Conclusion
1. The research work showed that a purposeful work over the balance and coordination after multisystem injury of meniscus and the anterior cruciate ligament provides proprioceptive sensitivity renewal.
2. 6 months after the operation, connected with the multisystem injury of meniscus and the anterior cruciate ligament, it was possible to achieve asymmetry of the extremities both in nervous-muscular control and in a functional term in the main group.
References
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Submitted: 23.02.2017 Received: 26.02.2017
Daria V. Fedulova - graduate student "Ural Federal University named after the first President of Russia B.N. Yeltsin", "Ural Institute of Traumatology and Orthopedics named after V.D. Chaklin", 4, Comintern, Ekaterinburg, 620078, Russia, E-mail: darya-fedulova@yandex.ru
For citations: Fedulova D.V. Proprioceptive sensitivity multisystem injury of meniscus and the anterior cruciate ligament of a knee-joint, The Russian journal of physical education and sport (pedagogical-psychological and medico-biological problems of physical culture and sports), 2017, Vol. 12, No. 1, pp. 136-143. DOI 10.14526/01_2017_198
