RU2198004C1 - Method for treating moderate and marked manifestations of articulation syndrome in cases of rheumatoid arthritis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves administering phonophoresis of polyunsaturated fatty acids preparation of

family. Marked local manifestations being the case, pulsating mode is applied with 0,2-0,6 W/cm² intensity. Moderate and feeble manifestations being the case, continuous mode is applied with 0,2-0,8 W/cm² intensity. Treatment is applied with articulation size taken into consideration in course of 6-10 daily procedures. EFFECT: enhanced effectiveness of treatment. 4 tbl

Description

 The invention relates to medicine, namely to physiotherapeutic methods of treatment used in arthrological practice.

 Rheumatoid arthritis is one of the leading places in the structure of diseases of the musculoskeletal system. In the general population, the prevalence of this disease varies from 0.8 to 1% [4], but the ability of rheumatoid arthritis to affect people of young, able-bodied age, as well as a progressive chronic course, determine its high importance in the medical and social aspects. Due to the fact that the disease is systemic in nature, the leading method of treating patients with this pathology is drug therapy with basic drugs (immunosuppressants, cytostatics, cryotherapy, derivatives of aminoquinolines and sulfonamides, glucocorticoids, non-steroidal anti-inflammatory drugs, and some others), which is aimed primarily at reducing disease progression and a decrease in the degree of activity of the inflammatory process. Therefore, despite the numerous side effects of their use (suppression of blood formation, teratogenicity, decreased liver and kidney function, damage to the gastrointestinal tract), they cannot be completely abandoned, especially in case of a malignant or rapidly progressing course [2, 4]. Taking basic drugs does not provide a quick reduction in the severity of the main clinical manifestation of this disease - articular syndrome, due to the complex pharmacodynamic and pharmacokinetic characteristics of these drugs. The basis for the treatment of articular syndrome currently consists of non-steroidal anti-inflammatory drugs and glucocorticoids. They are characterized by a high frequency of side effects from the gastrointestinal tract [2, 3]. Some of these drugs cause asymptomatic renal failure and adversely affect cartilage [3, 9]. Widely used in the treatment of articular syndrome in this category of patients, intraarticular injections are invasive, and therefore, there is a great chance of infection, the development of aseptic necrosis of the bone at the injection site, and the progression of periarticular osteoporosis [1, 9].

 A special place among the methods of local effects on the joint is occupied by physical factors. In the acute period of the disease, taking into account the effectiveness and speed of reducing the manifestations of the articular syndrome, the choice of physiotherapy is limited. At the present stage, laser therapy is the most common among light treatment procedures for rheumatoid arthritis. However, the long-term effects of the laser beam on the body are not well understood [5]. Currently, wave methods (mainly decimeter and millimeter therapy) are widely used in segmental techniques [8]. Pronounced analgesic effects have low-frequency electrical procedures. Here, preference is given to electrophoresis and phonophoresis, which have practically no contraindications for this disease and are well tolerated by patients. The speed of the onset of effect in this case depends on the selected drug substance. The local use of other preformed physical factors is limited due to the lack of a chemical component of the effect on the body, which does not allow them to show their pathogenetic orientation [5, 6, 8].

 One of the leading places among the physical methods of treating rheumatoid arthritis is ultrasound therapy, which has a number of significant advantages. The possibilities of combining the physical factor and the unidirectionally acting drug substance, enhancing the effect of both, are of great importance. Ultrasound freely overcomes the skin barrier, unlike some other methods, and penetrates to a sufficiently large depth (4-9 cm). Due to its low carrier frequency, it does not have a pathological effect on concomitant diseases, unlike high-frequency procedures. The action of ultrasound is aimed at the pathological process, regardless of stage. This is explained by the normalizing effect of ultrasound, causing a shift in the parameters of the internal environment and removing the system from the established pathological equilibrium. Most often with rheumatoid arthritis, among the physical factors aimed at treating the articular syndrome, phonophoresis of hydrocortisone is prescribed [6]. However, the saturation of the body with substances of this series in patients with rheumatoid arthritis in most cases is so high (due to oral, intra-articular and application of their use), and the patterns of their use by the preformed physical factor are so stretched (up to 12-15 procedures that are not always performed daily) that the onset of the therapeutic effect is often delayed, or transferred to the so-called period of aftereffect. As a rule, this does not suit either the doctor or the patient and makes one doubt the effectiveness of the treatment [6, 7, 8]. In addition, the use of hydrocortisone at the local level by phonophoresis can worsen bone tissue in patients simultaneously taking drugs of this series orally or locally in terms of the development of osteoporosis and aseptic necrosis of the bone, as well as in patients suffering from age-related osteoporosis or acquired as a result underlying disease. Existing known medicinal substances administered by phonophoresis (hydrocortisone and non-steroidal anti-inflammatory drugs) are mainly aimed at reducing the synthesis of arachidonic acid, the main precursor of inflammatory mediators, while there are known cases of negative effects of these substances on cartilage tissue [3, 9].

 The use of the phonophoresis method of the preparation of polyunsaturated fatty acids ω3 is known in patients with osteoarthrosis during remission (patent 2157198). Given the degenerative-dystrophic nature of this disease, the action of the procedures was aimed at restoring the function of cartilage and inhibiting its progressive degeneration. However, the use of polyunsaturated fatty acids in immuno-inflammatory diseases such as rheumatoid arthritis is not directly known to the joint. In this case, another pathogenetic orientation is needed, namely, blocking the prostaglandin-dependent pain syndrome, which determines the main clinical manifestations of this disease. Simultaneous improvement of cartilage tissue function will enhance the clinical effect. There are a number of works confirming the high effectiveness of the preparation of the polyunsaturated fatty acids of the ω3 family when used internally for the main clinical manifestations of rheumatoid arthritis [10], however, to achieve the desired result, the drug must be used for several weeks, which often leads to the development of various kinds of dyspeptic conditions . The proposed method, due to the introduction of a biologically active substance, shortens the onset of the clinical effect in this category of patients and avoids complications from the use of traditional therapy.

 The objective of the invention is to increase the effectiveness of therapeutic measures for rheumatoid arthritis in the period of moderate and severe manifestations of the articular syndrome, as well as the preventive prevention of secondary degenerative-dystrophic changes in the cartilage by introducing polyunsaturated fatty acids ω3 by phonophoresis on the affected joints, which will reduce the time of onset of the clinical effect, reduce the number of joint complications and expand indications for the use of drug phonophoresis in patients with rheumatoid a trityl, resistant to the action of physical factors or other drugs.

 For the first time, a method is proposed for the local use of the PU3 PUFA preparation in patients with rheumatoid arthritis when administered by phonophoresis in the early stages of the local inflammatory process during its exacerbations, while phonophoresis is recommended in known publications closer to the recovery period. The oily consistency of the preparation of polyunsaturated fatty acids ω3 (hereinafter referred to as PU3 PUFA) creates an optimal contact medium that does not require the addition of other contact media that slow down the conduct of the drug substance; effectively overcomes the skin barrier; acts unidirectionally with a carrier frequency of ultrasonic vibrations, providing a pronounced anti-inflammatory effect; does not lose its physical properties in an ultrasonic medium, which is established in a series of preliminary tests.

 The method is as follows: the preparation of PUFA ω3 spatula is evenly applied to the affected joint. Depending on the size of the joint, various ultrasonic emitters with a diameter of 1 to 4 mm are used.

Phonophoresis is carried out at a frequency of ultrasonic vibrations from 0.2 to 0.8 W / cm ² . For small joints of the hands and feet with severe inflammation (arthralgia, hyperthermia, periarticular edema), frequencies from 0.2 to 0.4 W / cm ² were applied, on average 3-4 days at each frequency; on these joints with moderate local manifestations of inflammation from 0.2 to 0.6 W / cm ² for 2-3 days at each frequency. When a physical factor exposed to medium and large joints (elbow, shoulder, ankle, knee), frequencies from 0.2 to 0.6 W / cm ² for 3-4 days were applied at each frequency, if the severity of these changes was high and from 0 , 4 to 0.8 W / cm ² for 2-3 days at each frequency with moderate and weak local manifestations.

 The technique of conducting contact, labile along the standard fields for each joint. The regime of ultrasonic vibrations with tangible hyperthermia and periarticular edema was applied pulsed, in other cases - continuous. On average, they acted for 1-2-3 minutes per field depending on the size of the joint, but not more than 5-8 minutes per joint, and if several joints were damaged, the total exposure time for one procedure should not exceed 12-15 minutes. Procedures are carried out daily, for a course of 6-10 procedures.

Indications:
1. Rheumatoid arthritis I-III degree of activity with severe pain and moderate manifestations of local hyperthermia and periarticular edema.

 2. In the absence of the effect of the use of other physical factors in patients suffering from rheumatoid arthritis, with varying degrees of severity of the local inflammatory reaction.

 3. It is recommended for use in patients with intolerance to other topical preparations (non-steroidal anti-inflammatory ointments, dimethyl sulfoxide, etc.), as well as those not marking the effect of their use.

 4. The technique is indicated for patients who have complications from the use of intra-articular injections, as well as to prevent repeated injections.

 5. In case of complications from the use of basic drugs (various gastro- and hepatopathies, cytopenia, etc.) in patients with rheumatoid arthritis, who are forced to temporarily refuse to take these drugs, as well as at the stage of selecting a dose of basic drugs.

 Contraindications: general for physiotherapy.

 There were 112 patients with a verified diagnosis of rheumatoid arthritis (83 women, 29 men) aged 17 to 77 years with a disease duration from several weeks to 20 years. I degree of activity of the process was observed in 18 (16.1%) people, II - in 55 (49.1%), III - in 39 (34.8%) patients. Radiologically, stage I of articular changes was registered in 33 (29.5%) patients, II - in 41 (36.6%), III - in 31 (27.6%), IV - in 7 (6.3%) patients. Impaired joint function of the first degree was observed in 45 (40.1%) people, II in 61 (54.5%), III in 1 (0.9%) patients, 5 (4.5%) were observed without impaired joints ) patients.

 Criteria objectifying the effect of rehabilitation were chosen in accordance with generally accepted principles for evaluating the effectiveness of treatment of patients with rheumatic diseases. Tests were evaluated using a three-point system (the intensity of the pain syndrome according to the patient and the doctor, the presence of hyperemia and periarticular edema, as well as morning stiffness). Limit the range of motion in the joint was estimated in%. The severity of local inflammation and the degree of activity of the process were also judged by laboratory parameters (clinical analysis of blood, total protein and fractions, fibrinogen, seromucoid, C-reactive protein), immunological (levels of circulating immune complexes, complement titer), the presence of metabolic disorders was evaluated by uric acid levels. The results were processed statistically by the student method.

 The treatment complex included the prescription of basic drugs for each patient individually, phonophoresis was performed on the affected joints: the first observation group (65 people) - the PU3 drug ω3, the second comparison group (47 patients) - hydrocortisone (the most commonly used technique for supporting motor apparatus); upon achievement of the clinical effect, physiotherapy exercises and massage were connected to the treatment of patients. The groups were similar in the clinical picture of the disease, age and gender.

 A comprehensive assessment of the results of the use of medical complexes showed their rather high effect. Almost all indicators of the functional state of the joints underwent a reverse development with significant improvement, a decrease in the activity of the inflammatory process. When analyzing the data of clinical and laboratory parameters in dynamics, it was found that there were no significant differences between the two methods with respect to each other in the main indicators (Tables 1 and 2).

 However, this fact alone can be attributed to the clear advantages of phonophoresis of the PU3 PU3 preparation, given the fact that the use of glucocorticoids, although it has proven its effectiveness, is associated with a number of side effects already listed above.

 In the observation group, the decrease in the severity of the main symptoms (pain, hyperthermia, local edema) occurred on average 3-4 days from the start of the procedures, which can be explained by the high biological activity of the PU3 PU3 preparation and the ability of polyene fatty acids to easily integrate into cell membranes. Perhaps this is due to the fact that tissue saturation with glucocorticoids in most patients with rheumatoid arthritis is quite high, which is associated not only with their oral use, but also with intraarticular injection, which in turn leads to the need to increase the dose and frequency of the administered substance, since at the same time, tissue accumulation of arachidonic acid, the main substrate of inflammatory mediators, increases.

 There are differences between the two methods and in the structure of balneoreaction. In total, the phonophoresis of the PUFA preparation was recorded in 31.6% of cases (pathological 16.7% of them), while hydrocortisone phonophoresis in 22.2% (pathological 50.0% of them). The severity of balneoreaction and the period of its occurrence are approximately the same in both groups (Table 3). But in the observation group, to a greater extent, the manifestations of balneoreaction stopped on their own and in almost half the number of cases than in the comparison group, it required the connection of drug therapy. From which we can conclude that phonophoresis of polyunsaturated fatty acids is easier to tolerate by patients, is less stressful, which allows more widespread use of this method, including in patients with combined pathology.

 EXAMPLE 1. Patient P., 37 years old, was admitted for treatment to the rheumatology department of the Regional Clinical Hospital in Vladivostok with complaints of inflammatory rhythm pain mainly in the joints of both hands (proximal phalangeal, metacarpophalangeal, interphalangeal, and wrist joints), as well as less intense pain mixed, mainly mechanical rhythm in the knee joints, pain on palpation in the small joints of the hands, moderate swelling and limitation of movements in them, morning stiffness for 20-30 minutes.

 From the anamnesis of the disease: I was sick for a year, when for the first time after a catarrhal disease, pains of an inflammatory rhythm appeared in the proximal interphalangeal joints of the II-III fingers of the left hand, swelling in them, new joints were gradually involved in the process, including symmetrical ones, was treated independently, took non-steroidal anti-inflammatory drugs, without significant effect.

 Features of the anamnesis of life: in childhood, often had tonsillitis.

 On examination: the patient's condition is satisfactory; over the indicated small joints of the hands, slight swelling, pain on palpation, compression force of the hand and movement in the joints are limited due to pain. Table 4 presents laboratory examination data.

 According to the results of functional research methods, the following data were obtained: electrocardiography - sinus rhythm of 76 beats per minute; on radiography of the joints of the hands in a direct projection, periarticular osteoporosis, small racemose enlightenments in the bones of the wrist on both sides, narrowing of the joint spaces in the same place are determined; capillaroscopy is a moderate spastic state of capillaries.

 Based on the data of clinical, laboratory, functional research methods, a clinical diagnosis was made: rheumatoid arthritis, polyarthritis, progressive course, activity of the III degree, radiological changes of the II stage, in combination with deforming osteoarthritis in the stage of subcompensation, insufficiency of joint function of the II stage.

 The patient was treated: basic and microcirculation-improving therapy, phonophoresis of polyunsaturated fatty acids on the area of both hands and wrist joints 10 daily.

 Against the background of the therapy, the patient's well-being improved, the pain syndrome in the joints was significantly reduced by 3-4 procedures, due to which the range of movements of both hands increased, exudative manifestations in the joints decreased, and the patient did not notice morning stiffness. All this allowed for 3-4 days to connect physical therapy and massage. A tendency toward a decrease in activity, including immune activity, was noted: indicators of seromucoid, circulating immune complexes, and complement titer decreased (Table 1).

 The patient was discharged in satisfactory condition under the supervision of a specialist in the community. After discharge, she was observed on an outpatient basis, took maintenance doses of basic drugs, the patient had no exacerbations, and joint pain was not disturbed.

 Based on the above example, it can be seen that despite the activity of the inflammatory process, the early appointment of the proposed method allows reducing pain syndrome in a short time and connecting other rehabilitation measures that improve joint functions.

 Thus, the introduction of a biologically active substance with the help of preformed physical factors makes it possible to approximate the onset of the clinical effect, improve the clinical condition of patients, in some cases stabilize the process, improve the function of the affected joints and avoid the negative effects of drug therapy.

 It seems promising to further study the action of polyunsaturated fatty acids. However, already now the practical implementation of the developed treatment method using biologically active substances in public health has made it possible to apply it at the stationary stage of treatment, to achieve clinical improvement in a shorter time period, to involve extensive rehabilitation measures, and thereby reduce the number of complications both from the disease itself and from the medical means used with it.

Sources of information
1. Bazhenov AN, Trusov VV Rheumatoid arthritis and osteoporosis // Klin. the medicine. - 1998. - 7. - C 15-20.

 2. Bokarev I.N., Kanevskaya M. 3. Experience of long-term basic therapy of rheumatoid arthritis // Klin. the medicine. - 1997. - 7. - S. 22-25.

 3. Bunchuk N. Century. Nonsteroidal anti-inflammatory drugs in the treatment of rheumatoid arthritis // Klin. pharmacol. and therapy. -1994. - 1. - p. 42-45.

 4. Sigidin Ya. A., Guseva N.G., Ivanova M.M. Diffuse connective tissue diseases. - M., "M.", 1994. - 542s.

 5. V. Ulashchik. New methods and techniques of physical therapy. Minsk "Belarus", 1986. - 174s.

 6. The clerk V.S., Chirkin A.A. Ultrasound Therapy - Minsk "Belarus", 1983. - 253p.

 7. Fomina L.L., Salikhov I.G. On tolerance to local therapy with glucocorticoids of rheumatoid arthritis // Kazan honey. Journal. - 1996. - T.77, 1. - P.32-36.

 8. Tsafris P.G., Frenkel I.D. Biochemical basis of physical therapy. - M. "Higher School", 1991. - 157p.

 9. Tsurko V.V., Ivanova M.M., Tokmachev Yu.K. Corticosteroid therapy and aseptic necrosis in patients with rheumatoid arthritis // Therapist, arch. - 1995. - T. 67, 7. - S. 71-74.

 10. Astoga G., Cubillos A., Masson L., Silva J. Active reumatoid arthritis: effect of dietary supplementation with omega-3 oils. A controlled double-blind trial // Rev. Med. Chil. - 1991. - Vol; 119, 3. - R. 267-272.

Claims (1)

A method of treating patients with rheumatoid arthritis, including basic therapy and phonophoresis of the preparation of the polyunsaturated fatty acids of the ω3 family in a continuous mode, characterized in that phonophoresis is carried out depending on the size of the joint and the severity of the joint syndrome, using also a pulsed mode of exposure, with pronounced local manifestations use a pulsed mode with an intensity of 0.2 to 0.6 W / cm ² , and for moderate and weak manifestations use a continuous mode with an intensity of 0.2 to 0.8 W / cm ² a course of 6-10 daily procedures.

Images