RU2411025C1 - Method of treating lumbar osteochondrosis with accompanying osteoarthrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to physiotherapy. The method involves treatment both paravertebrally and within affected greater joints of legs. Paravertebrally, extensor of the back is treated with vibromassage. Vibromassage is applied at frequency 40 Hz, for 2-3 minutes, from both sides simultaneously. Point vibromassage covers a projection of facet joints of vertebras L4-S 1 for 30 seconds on each of 6 points. It is followed with regional vibromassage of an area of affected leg joints. 20 - 30 minutes later, vibromassage is followed with the introduction of an ozone-oxygen mixture at ozone concentration 5 mg/l. The ozone-oxygen mixture is introduced in 4 - 6 symmetric paravertebral points at level L4-S1 and in 4 - 6 periarticular points within the affected leg joints.

EFFECT: method reduces length of treatment and provides prolonged remission.

1 dwg, 4 tbl

Description

The invention relates to medicine, namely to physiotherapy, and can be used for reconstructive treatment of neurological manifestations of lumbar osteochondrosis with concomitant osteoarthritis of the hip and knee joints in people of mature and old age.

One of the important aspects of the sanogenetic mechanisms of spinal osteochondrosis and osteoarthritis is the functional activity of blood vessels in the affected region. Neurovascular disorders not only occupy a significant place among the clinical manifestations of osteochondrosis, but are also one of the main pathogenetic mechanisms for the formation of radicular pain - this is caused by edema in the tissues surrounding the root, venous stasis (especially in the area of the dural vein ring and in the place where the root passes through the hard medulla), ischemia of the root as a result of spasm of the vessels that feed it [1, 2, 3]. Along with this, regional neurovascular disorders affect the course of the dystrophic process in the tendon-ligamentous apparatus of the spine and joints of the extremities (articular cartilage, periarticular tissues) and can lead to its progression [4].

Known methods for the treatment of lumbar osteochondrosis using mechanical vibrations, manual massage, involving exposure to the muscles of the spine and limbs, joints of the affected segments of the spine [5, 6]. The main disadvantage of the above methods is that they are aimed at stopping only neuroorthopedic and muscle-tonic disorders and do not take into account the presence of neurovascular disorders, which affect the severity of the main clinical symptoms, the course of the disease and the recovery period after the stage of exacerbation.

There is a method of treating osteochondrosis of the spine by vibro-puncture on muscle-tendon pain zones [7]. On certain palpation-local muscle hypertonicities, a point vibration massage was performed at a frequency of 35 Hz for 8-12 minutes with preliminary exposure to laser radiation in the same areas with the simultaneous use of the red and infrared ranges (λ = 0.66 and 0.89 μm). The method of using vibromassage in combination with laser therapy allows you to get a good therapeutic effect in patients with muscular-tonic and neurodystrophic manifestations of osteochondrosis of the spine, but in the presence of a large number of active local muscle hypertonicities, it has restrictions on the use - in a single procedure, you can affect only a certain number of zones, to affect all altered areas, it is necessary to provide for the alternation of radiation zones, which will lead either to a significant increase the duration of the procedure, or to small for the number of course impacts on each local muscular hypertonicity. In addition, the formation of active local muscle hypertonicities (myogenic triggers), as a rule, is accompanied by the development of regional or general vegetative-vascular disorders. Local effects on the altered neuromuscular structures will not allow influencing the regional and general hemodynamic situation, affect the development of neurovascular disorders and their consequences.

There is also a method of treating lumbar osteochondrosis using acupressure massage on biologically active points [8]. According to this method, the BAT zones were selected, which were selected in accordance with the principles of reflexology according to the Su Jok system (modern Korean acupuncture). The selection of points was carried out in accordance with the clinical manifestations of the disease in a 5-step system and provided for exposure of the points of correspondence to the affected segment of the spine, as well as to the higher and lower lying segments, soft tissues of the paravertebral region, and organs having innervation from the affected segment of the spinal cord. The disadvantages of this method include the difficulty of dosing vibration when exposed to points located in the area of periosteal and periarticular zones (on the feet), due to the high bone conductivity of the energy of mechanical vibrations and the lack of directionality in the selection of factor parameters (frequency, amplitude of vibration, duration of exposure) depending from the presence and severity of neurovascular disorders.

There are also methods of treating lumbar osteochondrosis with concomitant osteoarthritis, involving the use of physiotherapy exercises, EHF waves [9, 10]. But each of these methods involves an impact only on certain pathogenetic links - on the musculoskeletal system or on skin receptors with a reaction of neurovascular structures, does not provide for the impact on deeply located soft tissues of the spine and leg joints, which are most involved in the dystrophic process, system stimulation antioxidant defense, does not have antihypoxic effect, which is of great importance in the implementation of anti-inflammatory and trophic effects of rehabilitation therapy.

There is also a method of treating lumbar osteochondrosis with concomitant osteoarthritis by the integrated use of a pulsed magnetic field, ultrasound therapy and mud therapy [11], which significantly affects the orthopedic situation in the region, the motor activity of the lumbar spine and joints of the lower extremities, allows to obtain an analgesic effect. However, the daily use of ultrasound, mud therapy and magnetotherapy can be stressful for patients with reduced functional reserves, including for the elderly.

Closest to the proposed is a method for the treatment of lumbar osteochondrosis, including vibration massage of biologically active points (BAP) located in the region of segments L ₁ -S ₁ (V 22-26, 51-54), at a frequency of 25 Hz for 2 minutes at each point with the additional use of electropuncture at the same biologically active points, with a current strength of 200-300 μA and on days free of vibration massage and electropuncture, an ozone-oxygen mixture is introduced at an ozone concentration of 5 mg / l in 4-6 paravertebral points symmetrically L ₁ -S ₁ vertebrae, chickens s consists of 7 sessions of each exposure, while the procedures are carried out every other day for 14-16 days [12]. The combined use of point vibration massage and the effect of pulsed electric current on biologically active points with the additional use of ozone therapy helps to eliminate muscle spasm, improve peripheral hemodynamics, reduces the degree of neurodystrophic disturbances, weakens the flow of pathological impulses from the affected segment of the spine. However, the application of the known method requires a specialist to know the basics of reflexology, which limits the use of the method in practical health care. Along with this, the method does not have a significant effect on other parts of the musculoskeletal system — the joints of the legs, the condition of which determines the orthopedic situation in the region: the spine and large joints of the legs together realize the supporting function of the body, changes in one link (knee or hip joints) leads to an imbalance in other links (the formation of the oblique position of the pelvis, spinal deformities, a decrease in the functional activity of the arched joints and the spine as a whole). Along with this, carrying out the procedures every other day lengthens the course of treatment, and now the shortened terms of sanatorium-resort and rehabilitation treatment are relevant and socially in demand.

A new technical task is to increase the effectiveness of the treatment of neurological manifestations of lumbar osteochondrosis with concomitant osteoarthritis by obtaining a stable therapeutic effect in a shorter time, expanding the scope of the method for the elderly.

To solve the problem in a method of treating lumbar osteochondrosis with concomitant osteoarthritis, including vibration massage and the introduction of an ozone-oxygen mixture at an ozone concentration of 5 mg / l, vibration massage of the common extensor of the back is performed on both sides at a frequency of 40 Hz for 2-3 minutes simultaneously on both side under the additional exposure point on the projection area vibratory facet joints of vertebrae L ₄ -S ₁ to 30 seconds for each of the points 6 and zonal vibratory field of hip and knee joints of 2-3 m n at each joint, and 20-30 minutes after administration of vibratory carried ozone-oxygen mixture for 4-6 paravertebral points symmetrically at the level L ₄ -S ₁ vertebrae and periarticular 4-6 points affected hip and / or knee joints, the course consists from 8-10 daily sessions of each exposure.

The method is as follows. Vibromassage (vibration frequency 40 Hz) of the common extensor of the back on both sides is carried out according to the contact labile technique (using a spherical applicator consisting of two rigid rubber hemispheres) for 2-3 minutes simultaneously on the right and left sides, then a point vibration massage is used (carried tapered applicator tip with a hard rubber with a diameter of 1.27 mm) at a stable manner on the contact projection area facet joints of vertebrae L ₄ -S ₁ (by 30 on each of six points) and then zonal vibratory large joint joints of the legs (hip or knee), which are affected by a round spongy polyurethane applicator with a diameter of 9.5 cm (3 minutes for each joint), while in case of damage to the hip joints, the effect is carried out according to a stable technique on the area of the anterior surface of the joint, in case of damage knee joints - on the area of its posterior surface. With this arrangement of applicators, the effect is carried out not only on the periarticular joint tissues, but also on the area of the neurovascular bundle, which has the smallest depth in these areas (inguinal region, popliteal fossa), which allows not only to reduce the degree of neurodystrophic disorders, but also improve the regional hemodynamic situation. During one procedure, 2 paravertebral fields (3 min), 6 points (3 min) and 1-2 joints (3-6 min) are exposed with a total procedure time of 9-12 min. This work procedure allows improving blood circulation in peripheral vessels, relieving spasm of the muscles of the spinal column, decreasing vertebral and articular pain syndrome, and creating conditions for reducing the degree of trophic disturbances in the area of painful muscle and tendon zones.

20-30 minutes after the vibration massage, the ozone-oxygen mixture is introduced, which is prepared on the apparatus UOTA 060-01 "Medozon" [13]. Using a 20 ml syringe, the prepared ozone-oxygen mixture is extracted from the ozonizer at an ozone concentration of 5 mg / l (up to 20 ml of the mixture is used per session), and parenteral subcutaneous administration of the mixture is carried out in compliance with the antiseptic rules. For one session, 8-12 points are used (4-6 paravertebral and 4-6 periarticular), 1.0-2.0 ml of the mixture is injected into each to a depth of 2-3 cm. The following periarticular points of the affected joints are used:

- along the front-outer surface in the upper third of the thigh (in the area of the projection of the tendon of the muscle that stretches the fascia of the thigh, and in the area of the projection of the greater trochanter;

- on the back surface of the hip joint in the upper outer quadrant of the buttock in the tendon of the middle gluteal muscle;

- on the front surface in the lower third of the thigh (in the area of projection of the suprapatellar bag of the knee joint);

- on the back surface of the lower leg in the upper third (in the area of the popliteal bag of the knee joint);

- to the area of location of the muscle-tendon pain zones (projection of the external and internal condyles of the femur, the internal condyle of the tibia, the external condyle of the fibula).

After the introduction of ozone, a light relaxing massage of the joint area is carried out for 3-5 minutes (for uniform distribution of gas), which is combined with a classic massage of the reflexogenic zone - the lumbar spine.

The course of 8-10 procedures conducted daily. Clinical and experimental studies revealed that changes in the exposure zone (reactive vasodilation, changes in zonal temperature, increased production of prostaglandins E and F, increased synthesis of enkephalins and endorphins), as well as clinical effects, accumulate, reaching a maximum by procedure 7 [14, 15].

Currently, most researchers recognize that the clinical manifestations of lumbar osteochondrosis depend not so much on the degree of degenerative-dystrophic changes in the discs and the size of hernial protrusions, but on the involvement of various anatomical formations in the spinal canal. Syndromes of lumbar osteochondrosis are divided into vertebral and extravertebral. The clinical picture of vertebral syndrome is determined by the defeat of the elements that make up the posterior complex of the vertebral segment (ligamentous apparatus, vertebral joints, muscles), and is represented by muscular-tonic reactions in the region of the affected vertebral-motor segment [1]. In response to the pathology, two main sanogenetic reactions are included, the purpose of which is to stop the action of local and general factors: biomechanical (promotes the immobility of the affected vertebral motor segment, i.e. relieves local overloads) and microcirculatory (enhances trophic processes in the interested disk and tissues involved into the process) [2]. If the severity of sanogenetic reactions is insufficient, then a neurological deficit in the form of extravertebral syndromes develops [1, 2]. Extravertebral syndromes manifest themselves outside the spine and are divided into muscle, neural and neurovascular.

Neurovascular and muscle syndromes mutually reinforce each other - local ischemia develops in the spasmodic muscle, which causes vasomotor and neurodystrophic changes in the tissues and further enhances the activation of muscle fiber nociceptors. Thus, spasmodic muscles become a source of additional impulse to the cells of the posterior horns of the same segment of the spinal cord. An increased flow of pain impulse increases the activity of the anterior horns of the spinal cord, which leads to even more muscle spasm [1, 4]. Along with this, a violation of local tissue circulation leads to pathobiochemical changes in the muscles. Under conditions of tissue hypoxia, the accumulation of biologically active substances, in particular kinins, is possible, which cause an inflammatory process accompanied by swelling and the release of histamine by mast cells, which contributes to fibrous tissue degeneration and, as a result, an increase in peripheral hemodynamic impairment [2, 3, 4].

The development of extravertebral syndromes of lumbar osteochondrosis is also determined by the relationship of peripheral hemodynamics and the nervous system. A comparison of the state of the vessels of the lower extremities with the nature of the tone of the autonomic nervous system revealed the following patterns: during the algic phase, a predominance of functional spasm of arteries and arterioles, as well as the descent of capillaries of the lower extremities with a sympathetic orientation of the vegetative tone, are noted. This is due to the fact that the pain leads to reflex spasm of the vessels of the lower extremities and a violation of the regulation of vascular tone due to the involvement of the spinal cord in segmental formations [4].

Neurovascular disorders lead to the development of a dystrophic process in the bone-cartilage and muscle-ligamentous formations of not only the spine, but also large joints of the lower extremities, which have common peripheral controls for the condition and functioning of the musculoskeletal system, a common pathogenesis link (dystrophic process in the intervertebral disc and articular cartilage) and having a mutual structural and functional effect. Along with this, the severity and pace of development of the pathological dystrophic process often determine the severity and pace of development of the neurological syndrome associated with it; in turn, damage to nerve elements affects the course of the pathological process in the bone-ligamentous apparatus (violation of the trophic function of peripheral nerves leads to aggravation of the dystrophic articular process, which is especially important for people of mature and old age with concomitant osteoarthritis).

In the treatment of lumbar osteochondrosis with concomitant osteoarthrosis, therapeutic measures should involve exposure to all basic levels of the pathogenetic process:

- causing factors - dystrophic processes in the disk, articular cartilage as a result of the presence of dysfunction phenomena in the systems that control the motor stereotype, and local overloads of the vertebral-motor segment and the interested joints of the limbs;

- contributing factors - concomitant diseases (for example, osteoarthritis), in which the lesions are directly or indirectly associated with the centers that regulate the vascular or muscle tone of the limbs;

- on the implementing factors leading to the localization of the symptoms of the disorder in a certain area, which depend on the premorbid state of the muscles and vessels of the limbs [5, 16].

Mechanical vibrations have gained a strong position among a number of factors used to treat neuromuscular disorders. Of particular importance was the identification of the influence of vibration on the neurotrophic role of peripheral nerves, the state of muscle blood flow, the functional state of the neuromuscular apparatus, bradytrophic tissues of the spine, which are most involved in the degenerative process - periosteum, disk, articular cartilage, joints and ligaments of the spine and limbs [17, eighteen].

In the mechanism of the therapeutic effect of ozone therapy, a number of aspects can be distinguished. Firstly, this antihypoxic effect is one of the most powerful systemic effects of ozone therapy. It is implemented in two directions: through the improvement of oxygen transport and due to the positive impact on the processes of oxygen utilization. Activation of oxygen transport to tissues during ozone therapy is associated with an increase in its partial pressure (pO ₂ ) in arterial and venous blood, with an increase in the deformability of red blood cells that can penetrate into smaller capillaries, and, finally, with a decrease in the connection of hemoglobin with oxygen. The latter circumstance is associated with the activation in the red blood cells of the glycolysis process and 2,3-diphosphoglycerate, a compound that increases hemoglobin oxygen delivery to tissues. The components of the antihypoxic action of ozone include developing vasodilation, which relates primarily to arterioles and postcapillary venules. The vasodilating effect of ozone is associated with the release by the endothelial cells of the so-called "endothelial vascular relaxation factors", which include nitric oxide. No less significant are the interruption of the cycle of formation of prostaglandins due to the oxidation of arachidonic acid and restoration of normal pH and electrolyte balance in the focus of inflammation, a decrease in the degree of tissue hypoxia, which underlie the anti-inflammatory effect of ozone therapy. Ozone has a pronounced analgesic effect. In this case, the decrease in the intensity of acute pain is due to the direct oxidation of the algopeptides that form at the site of tissue damage and are involved in the transmission of the nociceptive signal to the central nervous system. In stopping chronic pain syndromes, a major role is given to restoring the balance between the processes of lipid peroxidation and antioxidant protection, as well as the activation of antinociceptive mediator systems [13]. Ozone therapy also makes it possible to obtain an immunomodulating effect, which is realized through the influence of macrophages and leukocytes on the membrane with the help of secondary cytokines and lymphokines, which are directly involved in the regulation of the activity of cellular and humoral immunity [19, 20].

The antihypoxic effect is one of the most powerful systemic effects of ozone therapy. It is implemented in two directions: through the improvement of oxygen transport to tissues (its partial pressure in arterial and venous blood increases, the deformability of red blood cells that can penetrate into smaller capillaries increases, the connections of hemoglobin with oxygen decrease) and due to a positive effect on oxygen utilization processes ( activation of glycolysis and 2,3-diphosphoglycerate in red blood cells increases hemoglobin oxygen delivery to tissues). The components of the antihypoxic effect of ozone include the developing vasodilation of arterioles and postcapillary venules (nitric oxide refers to the so-called "endothelial factors of vascular relaxation"). No less significant is the anti-inflammatory effect of ozone therapy (it is based on interruption of the formation of prostaglandins, restoration of pH and electrolyte balance in the focus of inflammation, and a decrease in the degree of tissue hypoxia). Ozone has a pronounced analgesic effect. The decrease in the intensity of acute pain is due to the direct oxidation of the algopeptides that form at the site of tissue damage and are involved in the transmission of the nociceptive signal to the central nervous system. In the relief of chronic pain syndromes, a major role is given to restoring balance in lipid peroxidation and antioxidant defense systems, as well as activation of antinociceptive systems. Ozone therapy also allows one to obtain an immunomodulating effect, which is realized through the influence of macrophages and leukocytes on the membrane with the help of secondary cytokines and lymphokines, which are directly involved in the regulation of the activity of cellular and humoral immunity [13, 19]. The rather high activity of subcutaneous injections of ozone was confirmed by numerous clinical observations in the treatment of patients with furunculosis, burn disease, as well as in traumatology [13, 20, 21], which was manifested by a quick and long-term analgesic effect, trophic effect on surrounding tissues (ozone coming into contact with subcutaneous fat, oxidizes fatty acids and forms a depot of ozonides, which are biologically active substances, stimulates local blood circulation). Along with the local effect with subcutaneous injection of ozone, there was a positive dynamics in the general condition of patients, expressed in improved well-being, increased efficiency. The presence of antihypoxic, immunomodulatory and vasoactive effects of ozone therapy can be the basis for the methods of treatment of osteochondrosis and osteoarthritis, which is especially important for elderly patients, since elderly organs undergo serious age-related changes, hemodynamics, cardiac activity, blood flow in organs and tissues change significantly. , transcapillary metabolism and oxygen supply deteriorate [22]. Along with this, in old age the regulatory activity of the central nervous system is weakened, the mobility of the processes of excitation and inhibition, the activity of the peripheral parts of the nervous system are reduced, the development of conditioned reflexes is difficult. In this connection, the use of intense exposure to physical factors is unacceptable in the elderly [22].

Thus, the combined use of vibrotherapy and ozone therapy, which affect all parts of the pathogenetic process, can improve the hemodynamic situation in the affected region, due to antihypoxic and local anti-inflammatory effects, relieve pain, eliminate muscle-tonic, neurotrophic disorders in the spine and joints of the extremities and related with them neurovascular disorders.

Example 1

Patient B., 45 years old, driver. Diagnosis: lumbar osteochondrosis, disc herniation L ₄ -L ₅ with compression of the root L ₅ on the left, stage of incomplete remission; osteoarthritis with a primary lesion of the hip joints, II radiological stage of the process, moderate impairment of joint function (Federal Tax Service 1).

Pain bothers the patient in the lumbar region and left leg (on the outer surface of the thigh and lower leg), as well as pain in the left hip joint, especially after sitting, sharp movements, parasthesia in the left foot. The disease arose after lifting 7 years ago. Exacerbations of lumbar osteochondrosis annually for 7-15 days. After 4 years from the onset of the disease, pains in the left hip joint joined. The frequency of exacerbations increased to 2-3 times a year. Vertebral syndrome is represented by straightening of the lumbar lordosis, tension of the paravertebral muscles in the lumbar spine, lumbar and middle gluteus muscles on the left, ipsalateral tension syndrome of the multifid muscles (1) on the right - 1 point, on the left - 2.0 points, limitation of mobility in the lumbar spine (test Schober 4.2 cm), a moderately pronounced restriction on the volume of active movements of the left hip joint on the left (lead 30 °, cast 26 °). The coefficient of vertebral syndrome (FAC) was 6.5 Rel. units: coefficient of spinal flexion (KPB) 2.0 + coefficient of spinal extension (KPI) 2.0 + coefficient of inclination of the spine to the healthy side (KNPz) 1.0 + coefficient of inclination of the spine to the sick side (KNPb) 1.5). In healthy people, the FAC is 4 rel. units. The degree of pain (SBO) = 2.0 points. Thus, the patient before treatment revealed the presence of a mild vertebral syndrome and a mild articular syndrome.

Extrovertebral syndrome was manifested by mild hypotension of the thigh muscles on the left, and hypesthesia in the area of innervation of the root L ₅ on the left. Lasega's symptom was called on the left at an angle of 76 °. Algotonus index - 7.0 points (medium degree). Magnetic resonance imaging revealed the presence of hernial protrusion L ₄ -L ₅ 5 mm.

Neurovascular disorders manifested moderate hyperhidrosis of the left foot. The severity of neurovascular disorders (PVNSS) was equal to 3.1 rel. The coefficient of reactive hyperemia 3.8 rel. On rheovasograms (RVG), there was a decrease in blood flow in the thigh, lower leg and an increase in vascular tone, a decrease in the amplitude of the RVG and an increase in the index of peripheral resistance (α = 0.073 s, A = 0.08 Ohm, IPA = 53.8%). The results of a duplex scan of the posterior tibial artery and arteries of the rear foot of patient B. indicate a decrease in peak systolic velocity (MSS) and final diastolic velocity (CDS) in the studied pools (MSS D = 49.4 cm / s, S = 35.7 cm / s; CDS D = 12.3 cm / s, S = 8.5 cm / s; IR D = 0.74 units, S = 0.75 units). The data presented indicate that the patient had significant peripheral blood flow disturbances in the left lower limb before treatment against a background of moderate vertebral and extravertebral syndromes.

The patient underwent 10 daily sessions of complex treatment according to the proposed method, including vibration massage and ozone therapy of the paravertebral zones and the area of the left hip joint, while the vibration massage was performed for 3 minutes per zone, the introduction of the ozone-oxygen mixture was carried out in 6 paravertebral points and 6 periarticular points 20 minutes after vibromassage.

After treatment, the pain in the lumbar region and the left hip joint disappeared (PBC decreased to 4.0 rel. Units, PBO - 0 points), the full volume of active movements of the spine (Schober test 5.5 cm) and hip joints was restored, the degree of hypotension decreased thigh muscles on the left, left hypesthesia disappeared, Laseg symptom is negative, Algotonus index = 5.0 points, which objectively confirms the disappearance of vertebral, extravertebral and articular syndromes. Neurovascular disorders are not clinically detected (left foot hyperhidrosis disappeared, no paresthesia). The severity of neurovascular disorders (PVNSS) after treatment 2.5 Rel. units The coefficient of reactive hyperemia 2.3 rel. units The rheovasogram values approached those of healthy individuals (α = 0.09 s, α / T = 10.5%, A = 0.14 Ohm, IPA = 46.8%). The blood flow in the back artery on the sore side was restored (MSS S = 47.3 cm / s, CDS S = 13.6 cm / s, IR S = 0.78 units).

Example 2

Patient S., 67 years old, retired. Diagnosis: lumbar osteochondrosis, lumbalgia, stage of incomplete remission; osteoarthrosis with a predominant lesion of the knee joints, X-ray stage III of the process, severe dysfunction of the joints (FTS 2).

The pain worries the patient in the lumbar region, more with bending forward, as well as pain in the knee joints, sharply aggravating when descending the stairs. The disease arose 23 years ago, developed gradually. The frequency of exacerbations up to 4-5 times a year. Vertebral syndrome is represented by hyperlordosis of the lumbar spine, tension of the divided muscles (ipsalateral tension syndrome of the divided muscles (SIN) on the right and left 2 points, moderately limited mobility in the lumbar spine (Schober test 4.5 cm), a significant limitation on the volume of active movements of the knee joints (bending 98 ° and 102 °). Moderately pronounced edema in the knee joints, pronounced tenderness of periariticular tissues were detected visually and by palpation. vertebral syndrome (PBC) was 5.0 rel.un. Degree of vertebral pain (SBO) = 1.0 point, articular pain syndrome - 2 points at rest, 3 points with movements in the knee joints. Thus, the patient before treatment the presence of not pronounced vertebral syndrome and significantly pronounced articular syndrome was revealed. Extravertebral syndrome was manifested by mild hypotension of the muscles of the thighs and lower legs. Laseg symptom is negative. Algotonus index - 7.0 points (medium degree).

Neurovascular disorders were manifested by moderate cyanosis, pasty feet. The severity of neurovascular disorders (PVNSS) 3.8 rel. Rheovasograms (RVG) showed a decrease in blood flow in both legs and an increase in vascular tone (α = 0.081 s, A = 0.07 Ohm, IPA = 64.7%). The results of duplex scanning of the arteries of the back of the feet indicate a decrease in peak systolic velocity (MSS) and final diastolic velocity (CDS) in the studied pools (MSS D = 37.6 cm / s, S = 34.9 cm / s; CDS D = 9, 5 cm / s, S = 8.7 cm / s). Thus, the patient before treatment on the background of not expressed vertebral and extravertebral syndromes, expressed articular syndrome had significant disturbances in peripheral blood flow in the lower extremities.

The patient received 8 daily sessions of complex treatment according to the proposed method, including vibration massage and ozone therapy of the paravertebral zones and the knee joints, while the vibration massage was carried out for 2 minutes per zone, the ozone-oxygen mixture was injected into 4 paravertebral points at the level of L ₅ -S ₁ and 4 periarticular points 30 minutes after vibration massage.

After treatment, the pain in the lumbar region disappeared and the pain in the knee joint area significantly decreased (PBC decreased to 4.0 rel.units, PBO - 0 points), the full volume of active movements of the spine was restored, the degree of functional disorders in the knee joints decreased (FTS 1 ) and hypotension of the leg muscles, edema and soreness of periarticular tissues in the area of the knee joints significantly decreased, the algotonus index = 5.5 points (vertebral and extravertebral syndromes practically disappeared, articular syndrome decreased). The degree of neurovascular disorders is insignificant (edema is insignificant, there is no cyanosis). The severity of neurovascular disorders (PVNSS) after treatment 2.1 Rel. Rheovasograms (α = 0.89 s, A = 0.11 Ohm, IPA = 56.7%) and blood flow in the dorsal arteries of the feet (PSS = 39-42.3 cm / s, CDS = 10.1-9 improved) , 8 cm / s).

Treatment in accordance with the claimed method received 96 patients with neurological manifestations of lumbar osteochondrosis with concomitant osteoarthritis aged 41 to 68 years (first group). The control (second) group consisted of 42 people with similar clinical manifestations, receiving only vibration massage without additional use of ozone therapy.

In 62% of patients, reactive synovitis was noted. In 65% of patients, the X-ray stage of osteoarthritis was found, in 15% of the patients - III and in 20% - I. Severe joint dysfunctions (FTS 2) were detected in 17% of patients, moderate (FTS 1) in 70% of patients. Upon admission to treatment, all patients complained of moderate and severe pain in the joints, 66% of patients had pain in the spine during movement, 63% of patients had pain in the joints at rest, 92% of the examined had palpation, 77% of patients had an analgesic limitation of range of motion in the joints of the limbs and spine, in all patients there was a crack in the joints during movements, muscle weakness in 57% of patients. In 64% of cases, joint deformation in the form of nodules of Heberden, Bouchard, hallux valgus deviation of the first metatarsophalangeal joints of the feet was determined.

An echographic study made it possible to register, at stage II of osteoarthritis, a moderately pronounced swelling of the soft tissues of the joints, proliferative changes in the synovial membrane, manifested in the form of a uniform or villous thickening up to 2 mm. In 61% of patients with inflammatory changes in the synovial membrane in its thickness and in the sub-synovial space, dilated vessels, a homogeneous effusion in 1-2 synovial bags with a volume of up to 6-8 ml, and an effusion in the articular cavity in a small amount were visualized. The articular cartilage, as a rule, was thinned (up to 1.0-1.4 mm), its echogenicity was increased. Joint surfaces are significantly deformed, with multiple osteophytes. At stage III of the disease, edema of periarticular tissues was significantly expressed, the synovial membrane was thickened to 3.0 mm, effusion was detected in 2 or more bags, as well as in the articular cavity, articular cartilage was significantly thinned (less than 1.0 mm), often defragmented, articular surfaces are significantly deformed, rough massive bone growths were visualized.

The criteria for evaluating the effectiveness were: vertebro-neurological status and level of pain, the severity of neurovascular disorders, regional hemodynamics according to rheovasography and ultrasound scanning, speed parameters of peripheral nerves. Long-term results were studied using the questionnaire method and were evaluated during repeated examinations after 1 and 2 years.

Vertebral neurological examination (by the method of Veselovsky V.P., 1990), carried out before treatment, revealed that in patients of both groups the vertebral syndrome was moderately expressed. KBC is the sum of a number of coefficients (KSP + KRP + KNPb + KNPz), which are calculated by the corresponding formulas:

и

,

and

,

where NP is the angle of inclination of the spine to the side (normal 15 °);

NPb - the angle of inclination of the spine to the sick side;

Oil refinery - the angle of inclination of the spine to the healthy side.

The coefficient of flexion of the spine (PCB) and the coefficient of extension of the spine (CRP) according to the formulas

и

,

and

,

where SP - flexion of the spine (normal 30 mm by curvimeter);

SPx - flexion of the spine in the subject;

RP - extension of the spine (normal 12 mm in a curvimeter);

RPx - extension of the spine in the subject.

The patients had tension of the divided muscles, as evidenced by ipsalateral tension syndrome (SYN), which was 2.0 points.

Differences in SIN and FAC indices of patients of the main and control groups after treatment were statistically significant. Indicators of vertebral neurological examination of patients of the first group after treatment: SBR was 0.7 points, SIN - 0.4 points, FAC - 4.3 rel. In patients of the control group, the degree of pain (SBO) decreased to 1.2 points, in these patients the tension of the divided muscle remained - SIN was equal to 1.85 points, which helped to maintain the coefficient of vertebral syndrome (PBC) at the level of 5.9 rel. .

Before treatment, in patients of both groups, the PBP corresponded to a moderate degree and amounted to 1.8 ± 0.16 points. After treatment, in patients of the second group, it decreased to 1.2 points, in patients of the first group - to 0.4 points. The pre-treatment algotonus index was 8.3 ± 0.6 points, after treatment in the second group it decreased to 5.6 ± 0.4 points and in the first group to 2.4 ± 0.2 points. The dynamics of the pain indicator and the threshold of pain sensitivity in the muscle-tendon zones are presented in the drawing (Note to the drawing: * Dynamics of spontaneous pain (SB) syndrome (according to YOUR); ПБЧ - threshold of pain sensitivity in the muscle-tendon zones; * - significance of differences in group compared with the data before treatment, where p <0.05).

The dynamics of clinical symptoms in patients with lumbar osteochondrosis with concomitant osteoarthritis are presented in table 1 (Note: the significance of differences in the group: * - p <0.05, ** - p <0.01, *** - p <0.00; ^ - significance of differences between groups, p <0.05). The dynamics of the articular syndrome under the influence of the integrated use of ozone therapy was evident - after treatment in patients of group I it was 2.2 ± 0.3 points, in a number of patients (35%) the pain syndrome disappeared. In patients of group II, it decreased to 4.5 ± 0.6 points. In addition, an increase in the threshold of pain sensitivity in local algogenic zones testified to the effectiveness of treatment (see drawing).

The dynamics of the echographic picture was observed in 84% of the examined patients of group I and was manifested by a decrease in the degree of soft tissue edema, thickening of the synovial membrane and the volume of intraarticular fluid by 30-40%. In patients of the control group, the ultrasonographic picture did not change significantly.

The severity index of neurovascular syndrome (PVNSS) is equal to the sum of the coefficient (CAD) of blood pressure (measured in the popliteal region), which is the quotient of dividing the systolic blood pressure before and after exercise (10 squats serve as a load) and reactive hyperemia coefficient (KRG). KAD in healthy subjects is 1.0 rel. 0.1 points were added for an increase in the SBP after loading for every 5 mmHg in comparison with the initial one. Definition of KRH: after an artificial interruption of blood circulation in a limb for a few seconds, a sharp expansion of arterioles and capillaries occurs in it, this is manifested by hyperemia of the peripheral parts of the limbs. Normally, hyperemia appears on the toes after 10 seconds (PVNSS of healthy individuals 2.0 rel. Units). Before treatment, PVNSS in patients of both groups is 3.6 ± 0.2 rel. After treatment in patients of the second group, it decreased to 2.6 ± 0.3 rel.ed., in the first group, neurovascular disorders disappeared.

Therefore, the use of vibration massage and ozone therapy in patients with neurological manifestations of lumbar osteochondrosis with concomitant osteoarthritis contributed to the regression of not only the clinical manifestations of vertebral, extravertebral and articular syndromes, but also neurovascular disorders.

The dynamics of electromyographic indicators is presented in table 2 (Note: * - significance of differences in the group, p <0.05, ^ - significance of differences between the groups, p <0.05). According to the data of electroneuromyography in patients receiving ozone therapy and vibration massage, there was a significant increase in the amplitude parameters of EMG arbitrary muscle contraction, providing movement in the affected joints. At the same time, the patients of the control group retained signs of functional disorders in the studied muscles. Along with this, the condition of the peripheral nerves of the legs improved: before treatment, patients in both groups had a significant decrease in the rate of propagation of excitation along the peroneal and tibial nerves (38.3 ± 4.4 m / s and 34.4 ± 4.2 m / s, respectively) . After treatment, there was a significant increase in SRV (up to 50.5 ± 4.5 m / s in group I and up to 42.2 ± 4.1 m / s in group II).

The dynamics of shin rheovasogram indices is presented in table 3 (Note: A - total blood flow; α / T - vascular wall tone; IPA - peripheral resistance index; * - significance of differences between groups after treatment, where p <0.05). An analysis of the values of rheovasogram parameters before treatment indicated a decrease in total blood flow with a simultaneous increase in vascular tone. The complex use of ozone therapy (group I) eliminated regional neurovascular disorders (Table 3). After treatment, a statistically significant decrease in the amplitude of the RVG and an increase in the values of the index of peripheral resistance remained in the control group patients. Duplex scanning with color Doppler mapping is the most modern and informative technique that allows you to obtain objective information about the state of the structure of large, medium and small vessels and their functions. Based on the objectives, the peak systolic velocity (PSS) was determined — the maximum linear velocity of blood flow to the systole; final diastolic velocity (CDS) - the linear velocity of blood flow into the diastole; resistance index (IR) - calculated by the formula

Before treatment, a decrease in MSS and CDS in the distal parts of the lower extremities was recorded; after treatment, an increase in MSS was observed in patients of the first group (57.8 ± 5.7 cm / s - posterior tibial artery; 49.6 ± 5.5 cm / s - back artery of the foot) and CDS (16.7 ± 1.8 cm / s - the posterior tibial artery; 12.6 ± 1.2 cm / s - the dorsal artery of the foot), in the second group, the dynamics of the indicators were unreliable.

Immediate results of the use of vibration massage and ozone therapy: significant improvement and improvement was achieved in 95% of patients. In patients of the control group, this indicator was 68%. Follow-up was studied in 70% of patients: the maintenance of the therapeutic effect for 2 years was detected in 87% of patients of the first group and in 42% of patients of the second group. The long-term results of treatment in% are presented in table 4 (Note: ^ - significance of the difference between groups I and II, p <0.05). An analysis of the long-term results of treatment revealed that the average duration of the therapeutic effect during the combined use of ozone therapy was 7.14 ± 1.02 months, in the control group - 4.63 ± 0.57 months (p <0.05) (Table 4) .

The results obtained indicate that complex treatment carried out in accordance with the new method of treatment is adequate to the capabilities of the patient’s body, including the elderly, and allows to obtain a significant therapeutic effect, leads to an expansion of functional capabilities, increases the social activity of patients in the coming and remote dates.

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Table 1. Symptoms I group II group Before treatment After treatment Before treatment After treatment Joint pain during movement (points) 6.47 ± 0.14 2.03 ± 0.09 *** 6.09 ± 0.24 2.84 ± 0.20 * ^ Joint pain at rest (points) 2,50 ± 0,09 0.76 ± 0.09 *** 3.19 ± 0.16 1.51 ± 0.12 * Sore joints on palpation (points) 1.48 ± 0.14 0.52 ± 0.12 *** 1.29 ± 0.24 0.69 ± 0.12 * Pain in the spine (points) 4.16 ± 0.09 1.40 ± 0.09 ** 3.49 ± 0.24 1.83 ± 0.26 Reactive synovitis (points) 2.24 ± 0.32 0.61 ± 0.14 *** 2.31 ± 0.18 1.65 ± 0.11 * ^ Asymmetry of the circumference of the knee joints (cm) 2.48 ± 0.25 0.44 ± 0.12 *** 2.38 ± 0.15 1.78 ± 0.26 * ^ Range of motion (flexion) in the knee joints (degrees), (norm-135-150 °) 108.2 ± 5.3 138.6 ± 4.7 ** 104.3 ± 11.3 119.8 ± 5.72 ^ Range of motion in the hip joints (degrees): - bending (norm-120 °) 72.8 ± 5.7 96.2 ± 7.7 * 87.3 ± 9.4 100.4 ± 8.7 - abduction (norm-45 °) 21.2 ± 3.4 41.3 ± 9.4 * 29.4 ± 7.3 38.6 ± 9.1 - reduction (norm-30-40 °) 27.8 ± 2.2 37.1 ± 2.8 ** 25.2 ± 5.2 33.2 ± 2.7 Table 2. Group The amplitude of the average interference EMG (μV) Before treatment After treatment I 130.95 ± 16.50 153.90 ± 14.42 * II 128.55 ± 9.60 134.25 ± 13.05 ^ Table 3. RVG indicators (M ± m) Before treatment After treatment I group II group α / T (%) 14.6 ± 1.3 10.5 ± 1.1 13.8 ± 1.3 * A (ohm) 0.08 ± 0.01 0.16 ± 0.03 0.09 ± 0.02 * IPA (%) 78.7 ± 5.8 58.7 ± 5.8 75.6 ± 7.6 * Table 4. The persistence of the therapeutic effect I group II group Up to 3 months 72 40 Up to 6 months 61 twenty Up to 9 months 23 5 Up to 12 months 7 0 Over 12 months 0 0 The average duration of the preservation of the therapeutic effect (in months) 6.72 ± 0.43 2.40 ± 0.18 ^

Claims (1)

A method for the treatment of lumbar osteochondrosis with concomitant osteoarthritis, including the impact of paravertebral and in the area of the affected large joints of the legs, characterized in that the paravertebral effect on the common extensor of the back with a vibration massage with a frequency of 40 Hz, for 2-3 minutes, simultaneously from both sides, carry out the action of point vibration massage on the projection area of the arcuate joints of the vertebrae L4-S1 for 30 s to each of 6 points and carry out zonal vibration massage of the affected large joints of the legs, then after 20-30 mi vibromassage performed after the introduction of the ozone-oxygen mixture with the ozone concentration of 5 mg / l in 4-6 paravertebral point symmetrical at L4-S1 and periarticular points 4-6 in the field of large joints affected leg.

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