THE MIRROR THERAPY EFFECTIVENESS AS A PART OF PHYSICAL REHABILITATION PROGRAM OF SERVICEMEN AFTER LOWER LIMB AMPUTATION DUE TO MINE ‐ EXPLOSIVE INJURY

phantom pain syndrome, which increased in the evening, was evaluated by the visual ‐ analog pain scale, and was from 7 to 9 points at rest. The VAS survey was conducted before and after the mirror therapy session. Peculiarities of mirror therapy: 1) to improve motor function: simple (basic) and functional movements are performed. Therapy is strictly individualized, the technique depends on the strength of the "mirror illusion" and the severity of motor function impairment; 2) for the purpose of correcting neglect, bilateral sensory stimulation is performed and observation of different hand positions in the mirror; 3) to reduce hypertension: unilateral movements are performed with a healthy limb; 4) to restore sensitivity: bilateral sensory stimulation is performed, that is, bilateral synchronous movements are performed; 5) to reduce the pain syndrome: unilateral motor and sensory exercises are performed with the healthy limb. The advantage of the technique of mirror therapy is its effectiveness, simplicity, safety and availability, the possibility of independent use by the patient. This technique corresponds to the basic principles of motor rehabilitation – high intensity and repetition of goal ‐ oriented tasks in combination with feedback. Conclusions. Conducted studies using the mirror therapy method in people with amputation of the lower limb due to mine ‐ explosive injury show that this method of physical therapy can be an effective way to reduce the level of phantom pain, pain in the stump. Also, during the application of mirror therapy, an increase in the amplitude of joint mobility is observed.


Introduction.
Preserving the lives and health of servicemen directly involved in a fullscale war is a top priority for the country's leadership.However, there is currently no single comprehensive rehabilitation program.
According to the literature, the loss of a limb as a result of a combat injury is one of the leading causes of amputation in most countries.According to the U.S. Center for Limb Injury and Amputation, 1718 servicemen had at least one limb amputation (excluding finger amputation) between 2001 and 2017 [1,2].At the same time, about 31% of servicemen had two or more amputations.The main cause of limb loss was explosive trauma (73%).In the United Kingdom, the total number of servicemen with amputations in 2013-2018 was 176, of which 113 were due to combat trauma [1,3,4].The urgency of this problem in Ukraine has increased significantly since 2014, due to the outbreak of hostilities as a result of Russian aggression in the East.According to research, limb injuries prevail in the overall structure of injuries of ATO and JFO participants -62.5% [5].At the same time, the main cause of limb loss is damage by high-energy weapons.Thus, 74.8% of amputations are caused by mine-blast trauma [5].It is worth noting that despite significant improvements in the organization of medical care, the rate of amputations remains relatively highabout 4% (168) as of the end of 2016 [6].Such conditions necessitate improving the quality of medical care at the stages of treatment and rehabilitation, creating clear algorithms based on the experience of advanced NATO countries.
In the medical service system of the Armed Forces of Ukraine, rehabilitation is understood as a set of medical, military-professional, socioeconomic and pedagogical measures aimed at restoring health, combat capability (performance), impaired or lost by a serviceman due to illness or injury [7].The use of physical therapy should be comprehensive and coordinated with a surgeon or orthopedist.Physical therapy of servicemen after surgical treatment of combat wounds should fully satisfy the need for movement, create a basis for the development and improvement of physical qualities in the posthospital stage of treatment [8].
The relevance of the study results lies in the possibility of using the developed program of physical therapy for servicemen after amputation of the lower extremities due to mine-explosive injury with the use of kinesiotherapy and mirror therapy in phantom pain syndrome in trauma hospitals.
The purpose of this research was to determine the effectiveness of the physical therapy program with the use of mirror therapy in military personnel after amputation of the lower extremities due to mine-explosive injury.
Materials and methods.The program of physical therapy of servicemen (Fig. 1) was built taking into account the phases of stump formation and the International Classification of Functioning, Disability and Health (Table 1).For this study, 14 patients with lower limb amputation were selected for each group (main and control).These materials do not pose a high risk to research participants and was performed following the ethical standards of the 1964 Declaration of Helsinki and its later amendments.The age of the patients ranged from 19 to 54 years, and the average was 42 ± 0.2 years.
Patients were selected who did not have the following comorbidities: Eye trauma; Acubarotrauma; Complications in the process of postoperative wound healing; Osteomyelitis.Before the study, the intensity of phantom pain syndrome and pain in the stump was assessed using the Visual Analogue Scale (VAS) scale.This was used to calculate the contribution of the main types of complications at the initial stage of the study (Table 2).The VAS scale was used to assess the results of physical therapy aimed at reducing phantom pain syndrome by mirror therapy.
Mathematical processing of digital data was carried out by methods of variation statistics with the subtraction of Arithmetic mean (x); Standard deviation (S); Student's criterion (t); Value of changes (p).The Statistica 6.0 program was used for mathematical processing of the data.
During the study, the patients' condition was monitored to effectively build a physical therapy program that included therapeutic exercises in the form of mirror therapy to reduce pain in the postoperative period.Also, this method was used to reduce pain in the stump.
Results.In order to assess the dynamics of the studied indicators, patients of both groups were examined on days 2, 7, 12 and 21 after the start of the proposed method of physical therapy.
At the initial (2 days) stage of mirror therapy, the intensity of phantom pain syndrome in group 2 was 8 points in 28% of patients, the minimum -3 points in 35% of patients, and pain in the stump was 8 points -14.3%, the minimum 3 points -32% (Fig. 2) (Table 3).Phantom pain was observed and intensified mainly in the evening.Pregabalin was prescribed to reduce the pain syndrome.
On the seventh day from the start of the study, the intensity of both phantom and stump pain remained almost unchanged (Fig. 3).
Comparison of pain intensity in the main (2) and control (1) groups on day 7 is presented in Table 4.
The results of pain assessment in the main group on day 12 are shown in Fig. 4.
Comparison of pain intensity in the main (2) and control (1) groups on day 12 is presented in Table 5.
On the 21st day of mirror therapy, the level of phantom pain and pain in the stump was assessed (Fig. 5).
The difference in phantom pain and pain in the stifle at the end of the proposed physical therapy program showed significant differences between the main and control groups (Table 6).The results obtained during the application of the proposed exercises during the use of mirror therapy showed positive dynamics in reducing the sensation of pain (both phantom and stifle pain).Physical therapy conducted for 21 days allowed to reduce the feeling of phantom pain by 5.5 times (p<0.05).The results are shown in Figs. 6 and 7.  To assess the amplitude in the hip and knee joints, we performed an initial assessment using goniometry.The results are shown in When reassessed, the comparison between the control (1) and intervention groups (2) showed that mirror therapy resulted in a better level of hip and knee joint mobility compared to the control group that did not use mirror therapy (Table 8).However, there was no significant difference in abduction and adduction.During the rehabilitation, blood pressure slightly improved from 145.1± 7,0 to 133.62.± 5.7 mm Hg and they decreased from 90.0±4.3 to 85.5±4.4,P<0.1.The decrease in the minute circulation volume was more pronounced, its decrease in comparison with healthy people of the same age ranged from 20.5 to 33.3%, respectively.Thus, there is a proportional decrease in the circulating blood volume and minute blood volume circulation, which can be considered as a manifestation of the adaptation of the circulatory system to the reduction of the vascular bed.At the same time, it is important to note that the indexed values of the stroke and cardiac indices calculated in relation to the reduced body surface area remain within the normal range. Discussion.
The methodological quality of most publications in this field is very limited, highlighting the need for additional, high-quality studies to develop clinical protocols that could maximise the benefits of mirror therapy for patients with lower limb amputation [9].Despite the fact that in the latest review [10] this therapy did not always have a positive effect according to other literary sources.In spite of the small number of examined patients in our study, positive results from the use of mirror therapy, nevertheless, have been obtained.Conclusions 1. Physical therapy conducted for 21 days allowed to reduce the sensation of phantom pain by 5.5 times (p<0.05),and the sensation of pain in the stump by 1.8 times.
2. Assessment of the hip and knee joint range of motion showed a significant improvement in flexion and extension in the hip joint after 21 days of mirror therapy compared to the initial assessment (p<0.05).External and internal rotation showed positive dynamics compared to the initial assessment (p<0.05).Abduction in the hip joint after mirror therapy did not have a significant difference compared to the results of the initial assessment (p>0.05), while adduction showed a significant positive trend (p<0.05).
3. Using the method of mirror therapy in people with lower limb amputation due to mineexplosive injury confirmed that this method of physical therapy can be an effective way to reduce the level of phantom pain, pain in the stump.Also, during the application of mirror therapy, an increase in the amplitude of joint mobility was observed.
Prospects for further research.It is advisable to pay attention to the issue of using virtual reality technology in combination with mirror therapy as a means of pain relief and an alternative to pharmacological methods at the stages of physical rehabilitation, including the stage of preparation for prosthetics.

Figure 1 .
Figure 1.Flowchart of the physical therapy program for servicemen with lower limb amputation due to mine-explosive injury

Figure 2 -
Figure 2 -Intensity of pain in group 2 according to the VAS scale at the initial stage of mirror therapy, %

Figure 3 -
Figure 3-Intensity of pain in group 2 on the VAS scale on day 7 of mirror therapy, %

Figure 6 -Figure 7 -
Figure 6 -Evaluation of phantom pain indicators when using mirror therapy, %

Figure 8 -Figure 9 -
Figure 8 -Evaluation of pain in the stifle with the use of mirror therapy, %

Table 4 Intensity of pain according to the VAS scale on day 7 of mirror therapy, %.
Figure 4 -Intensity of pain in group 2 on the VAS scale on day 12 of mirror therapy, %

Table 5 Intensity of pain according to the VAS scale on day 12 of mirror therapy, %. Figure 5.
Intensity of pain in group 2 on the VAS scale on day 21 of mirror therapy, %