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We could recommend our complex programme for treatment of the paravertebral and radicular neuropathic pain.
ACKNOWLEDGMENTS
Authors thank the Council of Medical Science of the Medical University of Sofia for the support via scientific project № 34 / 2014, Contract № 50 / 2014.
References
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5.Boubee M., Bilans analytiques et fonctionnels en rééducation neurologique. Tome 2 - Membres superieurs et bilans specifiques. - Paris: Masson, 1975, pp. 12-25 & 89-97.
6. Boureau F., Willer J.C., La Douleur - exploration, traitement par neurostimulation et électro-acupuncture. - Paris - New York - Barcelone - Milan: Masson, 1979.
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8. Cox J.M., Low Back Pain - Mechanism, Diagnosis and Treatment. 5-th ed. -Baltimore: Williams & Wil-kins, 1990, 437-467.
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10. Koleva I., Repetitorium physiotherapeuticum (basic principles of the modern physical and rehabilitation medicine). Book for English speaking students of Pleven Medical University. - Sofia: Publishing house "SIMEL", 2006, 95 p.
11. Koleva I., Chronic pain and physical analgesia: the impact of physical modalities to reduce pain. - Journal of Biomedical and Clinical Research, 1, 2008, 1, 12-17.
12. Krämer K., Maichl F. Scores, Bewertungsschemata und Klassifikationen in Orthopadie und Traumatologie. Stuttgart - New York: Georg Thieme Verlag, 1993, p.418-444.
13. La Frenière J.G., Le patient lombalgique (techniques de traitements kinesitherapiques). - Paris - New York - Barcelone - Milan - Mexico - Sao Paulo: Masson, 1983, 194 p.
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http://en.wikipedia.org/wiki/Johnsen%E2%80%93Rahbek effect
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21. http ://www. iasp-pain. org
SIGNIFICANCE OF LASERTHERAPY AND ERGOTHERAPY IN THE REHABILITATION OF NEUROPATHIC DIABETIC FOOT
Koleva Ivet B. *, Yoshinov Radoslav D. **
* Doctor in Medical Sciences, Professor in Physical and Rehabilitation Medicine, Medical University of Sofia -
Bulgaria
** Doctor in Informatics, Associate Professor, Laboratory of Telematics,
Bulgarian Academy of Sciences -Sofia, Bulgaria
ABSTRACT:
The purpose of our study is to prove the significance of physical and rehabilitation medicine to the practical problem diabetic polyneuropathy (DPNP) and diabetic foot (DF) and to evaluate quantitatively the effect on signs and symptoms of these patients of a complex physical therapeutic programme, including lasertherapy, physiotherapy and ergotherapy.
Material and methods: The subjects of the study are 132 DPNP-patients (sensorimotor form, distal symmetric type) with developed diabetic foot (DF), divided in control and experimental groups.
The rehabilitation programme includes in both groups: physiotherapy (analytic exercises, massage elements and mobilizations of the lower limbs) and patient education. In the experimental group we added too lasertherapy and ergo-therapeutic activities.
For database management we used t-test (analysis of variances ANOVA) and Wilcoxon signed rank test (non-parametric distribution analysis).
The comparative analysis of results before and after therapy demonstrates a statistically significant beneficial effect of the complex programme in the experimental group on some signs and symptoms (part of them remain stabilized
one month after treatment): irritative sensory signs (VAS), hypopallesthesia (vibroesthesiometer of ' Riedel-Seifert), pression sense (monofilament of Semmes-Weinstein), thermosensibility; altered electroexcitability and conductibility ofperipheral nerves and muscles (excitomotory electrodiagnostics); vegetovasal and vegetotrophic disturbances (Shenaq evaluation). No significant effect on the muscle strength of the paretic muscles (manual muscular testing).
Conclusion: The complex rehabilitation ameliorates quality of life of diabetic patients.
Key words: physical modalities, rehabilitation, diabetic foot, lasertherapy, physiotherapy, patient education
1.INTRODUCTION:
The modern diabetology explains clinical patterns of the continuum: metabolic syndrome (MS) -> non-insu-lino-dependent diabetes melius (NIDDM) -> diabetic polyneuropathy (DPNP) -> neuropathic diabetic foot (DF) [1, 5]. Etiopathogenetic mechanisms include metabolic and vascular factors, converging to oxidative stress and development of segmentary demyelinization and axonal (Waller) degeneration of the peripheral nerves of diabetic patients [2, 3]. The diabetic neuropathy (DN) is a "silent" pathology making the tissues of the feet very sensitive [1, 3, 5]. The neuropathic diabetic foot, as the heaviest complication of the DPNP, is a very frequent cause of amputation of the lower extremities in diabetic patients [1].
For the improvement of quality of life of patients with clinical patterns of the mentioned continuum is obligatory the composition of a complex rehabilitation programme, respecting the basic principles of synergism between active agents, including: strict glycemic control, medication (rheologically active drugs, peripheral vasodi-latators, antioxidants, vitamins of B group); physiotherapy (exercises, soft tissue techniques, massages); preformed physical modalities (electric currents, magnetic fields; light, laser); self control of patients (hypoglucidic diet, daily physical activity, feet care) [1, 2, 3, 4, 5].
2.OBJECTIVE
The purpose of our study was to prove the significance of physical and rehabilitation medicine in the resolution of the practical problem diabetic polyneuropathy (DPNP) and diabetic foot (DF) and to evaluate quantitatively the effect on signs and symptoms of these patients of a complex physical therapeutic programme, including la-sertherapy, physiotherapy and ergotherapy.
3.DESIGN OF THE STUDY
3.1.Material and methods:
The subjects of the study are 132 DPNP-patients (sensorimotor form, distal symmetric type) with developed diabetic foot (DF), divided in control and experimental groups. Patients were randomized to two treatment groups of 66 each one.
The rehabilitation programme includes in both groups: physiotherapy (analytic exercises, massage elements and mobilizations of the lower limbs) and patient education. In the experimental group we added too laserther-apy and ergotherapeutic activities.
The observed group comprised 64 males and 68 females, mean age 54 years (42-65); with type 2 DM at mean duration 7,3 years (7-17); treated with oral medication (stable in the last 3 months) and hypoglucid diet. Duration of DPNP was 4,8 years (from 12 months to 9 years). All patients had: sensory signs - acroparesthesias, dysesthesias, sensation of burning or cold feet, pain (evaluated with Visual analogue scale VAS 0-20); distal hypopallesthesia (measured with the vibroesthesiometer of Riedel-Seyfert 0-8, normal value 6-8); changes of the pression sense
(measured by the 10 g monofilament of Semmes-Wein-stein; altered thermosensibility (measured by tubes with cold or hot water); absent ankle jerks; motor weakness (peroneal paralysis in 72 patients; peroneal and tibial paralysis in 42 patients; peroneal, tibial and femoral paralysis in 18 patients). The Classical Electrodiagnostics (ED) of the lower limb nerves of the patients demonstrated quantitative and qualitative alterations of the excitability of the sensory and motor nerve fibers to galvanic and neofaradic currents (to partial reaction of degeneration /RD/ grade III); including changes in many parameters: reobasis, chronaxie, I/t curves, cutaneous electroresistance. In our patients we observed electromyographic (EMG) signs of segmental de-myelinisation and axonal degeneration of the sensory and motor fibers of the peripheral nerves (diminished sensory and motor conduction velocity; increased latency and diminished amplitude of the M-response in stimulative EMG; missing of SNAP of the sural nerve) [3, 5]. In a lot of patients we observed microcirculatory acral disturbances and trophic alterations (distally in lower limbs), all patients had neuropathic diabetic foot of Charcot type -grade I and II according to Shenaq classification [1, 5]. In laser-doppler-flowmetry we distinguished paradoxal sympathetic axon-reflex veno-arteriolar reactivity, diminished thermo-regulatory vasomotor response and reduced micro-vascular dilatatory capacity [5, 11].
We excluded from the observed group patients with general contra-indications for physical therapy; with comorbidity - grave coronary insufficiency, evident radicular syndrome, significant ulcerations (diabetic foot grade III or more according to Shenaq classification); changes in the medication for the DM in the last two months before our investigation.
Patients were assessed for signs and symptoms of DM, DPNP and DF before and after treatment and one month later, according to the PROTOCOL including the history of disease and nosometric criteria of DM, DPNP and DF (patients' complaints; clinical signs and symptoms - somatic, neurological, functional examination; assessment of pain and vibration sense; manual muscular testing; ED; EMG; laser-doppler-flowmetry; lab exams) [Koleva I. 1998-2005].
3.2.Ethic aspects
The investigation was conducted with consideration for the protection of patients, as outlined in the Declaration of Helsinki, and was approved by the appropriate institutional review board and ethic commission. All patients gave written informed consent before undergoing any examination or study procedure.
3.3.Physical and Rehabilitation Medicine (PRM) programme
In all patients the PRM programme includes physiotherapy = kinesitherapy according Bulgarian nomenclature {analytic exercises, massage elements and mobilizations of the lower limbs (active-assisted and active-resisted muscle strengthening exercises, 30 min., XV procedures)}.
In all cases we applied too methods of patient education and a hypoglucid and hypolipid diet (number IX according to Pevzner's list).
In the experimental group (group 2) we applied too preformed modalities (lasertherapy - standard dosage for amelioration of the tissue trophy, 3 min. for every foot, XV procedures)} and occupational therapy methods (designated to training activities of daily living, some of them -oriented to a professional qualification and re-orientation of diabetics).
3.4.Statistical analysis was performed with SPSS electronic package, version 11.5. We applied options for two samples comparison) with parametrical analysis of variances ANOVA and non-parametrical distribution (Wil-coxon signed rank test). The treatment difference was considered to be statistically significant if the p value was < 0.05. In some cases we received lower results of the p-value (p<0.01).
4.RESULTS AND ANALYSIS The comparative analysis of results of exams and measures before (B.Th.) and after therapy (A.Th.) demonstrates a statistically significant beneficial effect (p<0,001) of our complex physical therapeutic and rehabilitation programme on some signs and symptoms (part of them remain
stabilized one month after the end of the treatment): reduction of irritative sensory signs (Visual analogue scale -VAS, fig. 1), enhance of hypopallesthesia (vibroesthesiom-eter of Riedel-Seifert, fig.2), increase of diminished pression sense (monofilament of Semmes-Weinstein, fig.3) and thermo perception (fig.4); tendency to normalization of quantitatively and qualitatively altered electro-excitability of peripheral nerves in response to stimulation with galvanic or neofaradic currents (results of classical electrodi-agnostics, fig.5). We observed a tendency to increase of muscle strength of paretic muscles, but without statistical significance between both groups (results of manual muscular testing).
It is important to note the stability of effect one month after the end of physical therapy (the patient continues the prescribed exercise programme).
The most important (for diabetic patients) effect of the treatment was the reduction of irritative sensory signs - pain relief in lower extremities. Only in patients of the experimental group (with lasertherapy) we observed statistically significant (p<0,001) reduction of acroparesthesias, dysesthesias, sensation of burning or cold feet and pain (visualized by the analysis of Visual analogue scale VAS 0-20) (fig.1).
□ Control
s
□ Group 2
16 14 12 10 8 6 4 2 0
Fig.1. Pain relief (VAS 0-20)
Another favorable effect of the lasertherapy was the reduction of distally diminished vibratory sensibility, pression and thermo perception - objective criteria for qualitative and quantitative evaluation of the treatment efficacy. In all cases of the experimental group we observed statistically significant (p<0,001) increase of the distal hypopallesthesia (measured by vibroesthesiometer of Riedel-
Seyfert for quantitative evaluation of the vibratory sensibility 0-8, normal values 6-8) (fig. 2); ofthe pression sense (10 g monofilament of Semmes-Weinstein 5.07 mm) (fig. 3) and of the thermo-sensibility (hot-cold) (fig. 4). No statistical significance in the control group.
□ Controls
nExperimental group
0
□ Controls
□ Experimental group
Fig.2. Amelioration of the hypopallesthesia (vibroesthesiometer of Riedel-Seyfert 0-
B.Th., A.Th., one month later
8
6
4
2
Fig.3. Dynamics in pression sense (10 g monofilament of Semmes-Weinstein 5.07mm)
К7
□Controls □Group 2
Fig.4. Changes in thermo-sensibility
We observed significant improvement of the indicators of nerve electroexcitability using electroneurogra-phy - classical electrodiagnostic (ED) methods (fig.5). The estimated medians in Wilcoxon statistics are dynamic. The curve of distribution of patients (Gaus-distribution) A.Th.
is transferred to the levels of minor alteration in comparison with the curve B.Th. The results of ED visualize the favorable effect of physical modalities on nerve and muscle excitability and reactions.
SG 7G 6G 5G 4G 3G 2G 1G G
s \
/ , \
/ / \ \
/ / \ \ \ V
/ y
/ /
У
Before Th After Th
Quanti
PRD-I
PRD -
PRD -
Fig.5. Distribution of the electrodiagnostic group (before and after therapy)-quantitative alterations (Quanti), partial reaction of degeneration /PRD/ - levels I, II, III
The results of the manual muscular testing (MMT) showed a tendency to increase of muscle strength of paretic muscles (but without statistical significance).
5.DISCUSSION
It's proved that some pre-formed modalities (e.g. laser) provoque local vasodilatation, stimulate the metabolism and throphics of the tissues; help the regeneration of peripheral nerves and ameliorate the nerve irritability and conductivity [5, 6, 7, 8 , 9, 10]. In case of synergic combination between physical modalities the efficacy of physical therapy and rehabilitation is increasing.
The hypoesthesia, hypopallesthesia, disturbances of thermoperception, vegetovasal and vegetotrophic alterations in lower extremities of diabetics are improved significantly by laser. The peripheral motor weakness is favorably influenced by physiotherapy and occupational therapy activities - evaluated by manual muscle testing and classical electrodiagnostics (some of parameters without statistical significance for a 20-days course). It's important to remind that for every diabetic patient even the simply delay of the progression of DPNP and DF is considered as a success. Most resistant to treatment are the "old" and "heaviest" paralyses, localized distally - in the extensors of the toes (especially m.extensor hallucis).
Our results proved that the complex rehabilitation ameliorates quality of life of diabetic patients. The complex PRM programme of care is able to recover consequences of neuronal dysfunctions, positive and negative neuropathic symptoms and pain. This is not only a symptomatic treatment, but also a pathogenetically oriented therapy and may delay, stop or even reverse the progression of the clinical continuum: metabolic syndrome -> NIDDM-> DPNP -> DF.
6.CONCLUSION
We could recommend our complex rehabilitation programme for treatment of the neuropathic DF. Intermittent courses of PRM programmes of care may be a successful adjuvant to drug treatment of DM, DPNP and DF. The
development of the disease of these patients can be slowed down by organized and systematic physical therapy in specialized hospitals, combined with adequate medication, everyday physical activity and a strict glycemic control.
In our opinion the observation of diabetics should be done by a multi-disciplinary team (doctors - specialists in physical and rehabilitation medicine, in endocrinology and in neurology, specialists in dietology and physiotherapy, bachelors of kinesitherapy and medical rehabilitation and ergotherapy); following the scheme: clinic of neurology -> clinic of neurorehabilitation -> balneotherapeutic center -> rehabilitation service in the regional therapeutic center.
References
1. American Podiatric Medical Association. 1997 diabetes survey: statistical results. J Am Podiatr Med Assoc;1997;87(12):575-583.
2.Apfel S.C., Kessler J.A., Adornato B.T., Litchy W.J., Sanders C., Rask C.A., and the NGF Study Group. Recombinant human nerve growth factor in the treatment of diabetic polyneuropathy. Neurology;1998;51:695-702.
3.Echeverry D., Sherman A., Diabetic Neuropathy. E-Medicine Journal,2001;2:12.
4.Fletcher G., Balady G., Amsterdam E., Exercise standards for testing and training: a statement for health professionals from the American Heart Association. Circulation; 2001;104(14):1694-1704.
5.Koleva I.B., Contemporaneous possibilities of rehabilitation in diabetic neuropathy and diabetic foot. Monograph. Sofia: B.Stamenov, 2005. P.148. (In Bulgarian)
6. Koleva I.B., Peripheral paralyses - changing the weakness management paradigm (pharmacological or non-pharmacological intervention - from disconnection to combination). Neurorehabilitation;2008;2(1):12-8.
7. Koleva I.B., Impact of physical modalities in prevention and rehabilitation of diabetic polyneuropathy
and neuropathic diabetic foot. - In: Diabetic Medications 2015: International Conference on Targeting Diabetes and Novel Therapeutics, Sept 2015 / U.S.A, Las Vegas, NV. Available at:
http://diabeticmedications.conferenceseries.com/
8. Koleva I.B., Dikova M., Ioshinov R.D., Lishev N.S., Quantitative evaluation of efficacy of some physical therapeutic complexes on irritative sensory signs of diabetic polyneuropathy. European Journal of Neurology;2004;11 Suppl.2: S36-182.
9. Koleva I.B., Iochinov R.D., Dikova M., Physical Therapy and Rehabilitation in Diabetic Polyneuropathy
Patients. In: WJ Peek & GJ Lankhorst Editors. Physical and Rehabilitation Medicine. MEDIMOND: Monduzzi Editore; 2001. p.677-681.
10. Koleva I.B., Iochinov R.D., Stoyneva Z.B., Dikova M., Ontcheva G., Transcutaneous electroneu-rostimulation and fangotherapy in Diabetic Polyneuropathy Patients. Abstracts Book of the 3rd World Congress in Neurological Rehabilitation, Venice, April 2002: 497.
11. Stoyneva Z.B., Koleva I.B., Assessment of the physical therapy effect on diabetic distal autonomic and microcirculatory dysfunction by Laser Doppler flowmetry. Diabetes, Stoffwechsel und Herz; 2008;17:24-25.
ПРОЯВЛЕНИЯ КАТАРАЛЬНОГО И ГИПЕРТРОФИЧЕСКОГО ГИНГИВИТА У ПАЦИЕНТОВ С НЕСЪЕМНЫМИ ОРТОДОНТИЧЕСКИМИ КОНСТРУКЦИЯМИ
Косюга Светлана Юрьевна
д.м.н., доцент, заведующий кафедрой стоматологии детского возраста ГБОУ ВПО «НижГМА» Минздрава России, г. Нижний Новгород, Россия Ботова Дарья Игоревна
Аспирант кафедры стоматологии детского возраста ГБОУ ВПО «НижГМА» Минздрава России, г.
Нижний Новгород, Россия
АННОТАЦИЯ.
Целью исследования является изучение распространенности и особенностей проявления хронического катарального и гипертрофического гингивита у пациентов с несъемными ортодонтическими конструкциями. Материал и методы. В нашем исследовании участвовали 70 человек, находящихся на ортодонтическом лечении с помощью брекет-систем в течение 1, 6, 12 месяцев. Стоматологический статус пациентов оценивали в соответствии с рекомендациями и критериями ВОЗ (2013). Результаты исследования. Через полгода использования брекет-систем воспалительный процесс в тканях пародонта увеличивается, а гигиеническое состояние полости рта ухудшается. Заключение. Распространенность хронического катарального и хронического гипертрофического гингивита увеличивается спустя 6 месяцев лечения с помощью несъемных ортодонтических конструкций.
CATARRHAL AND HYPERTROPHIC GINGIVITIS IN PATIENTS WITH FIXED ORTHODONTIC APPLIANCES.
ABSTRACT.
This research aimed to examine prevalence and disease specialty of catarrhal and hypertrophic gingivitis in patients with fixed orthodontic appliances. Material and methods. 70 patients undergoing orthodontic treatment with braces are involved into the study. They are divided into three groups by month of the treatment: 1, 6, 12 month respectively. Dental status ofpatients was assessed according to criteria and recommendations of WHO (2013). Results of the study. Half year treatment using fixed orthodontic appliances starts inflammatory process in periodontal tissues, as well as status of oral hygiene degrades. Conclusions. The prevalence of catarrhal and hypertrophic gingivitis in patients with fixed orthodontic appliances increases after 6 months treatment.
Ключевые слова: хронический катаральный и гипертрофический гингивит, ортодонтическое лечение, несъемная ортодонтическая техника (НОТ).
Key words: catarrhal and hypertrophic gingivitis, orthodontic treatment, non-removable orthodontic technique.
Введение. В настоящее время растет число обращений пациентов, имеющих сформировавшуюся зу-бочелюстную систему, к врачу стоматологу-ортодонту. Это приводит к возрастанию сроков ортодонти-ческого лечения и увеличению рисков развития осложнений.
При ортодонтическом лечении частота воспалительных явлений в пародонте остается высокой (2038%) [2, с.44-45; 6, с.5]. В процессе лечения пациентов с зубочелюстными аномалиями с помощью НОТ развиваются различные неблагоприятные изменения, такие как: ухудшение процессов микроциркуляции и параметров ротовой жидкости, появление деструктивных процессов в тканях периодонта, что сопровождается неудовлетворительным уровнем гигиенического
состояния полости рта. Данное состояние требует проведения комплекса лечебно-профилактических мероприятий [4, с.23-27].
Присутствие в полости рта брекетов, дуг, колец, лигатур, цепочек, кнопок и других ортодонтических конструкций значительно затрудняет проведение ежедневных гигиенических процедур, что создает благоприятные условия для скопления налета и развития в пародонте воспалительного процесса [3, с.15-18; 5, с. 36-43].
Отмечается, что налет вокруг основания брекета по своему составу схож с твердым дентальным налетом, который представляет собой симбиоз различных микроорганизмов, что и обуславливает возникновение и развитие хронического гингивита [1, с.102-106].
