RU2466705C1 - Method of treating verterbrogenic pain syndrome with underlying osteoporosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: functional blocks are treated by muscular-energetic technique of manual therapy with the parameters depending on the bone tissue status. In case of systemic osteopenia (T-criteria -1.0 to -2.5 SD), muscle force 0.5 to 1.0 kg is created in a tension phase; tension phase time makes 5-8 sec, and relaxation phase time is 10-15 sec.; a number of repeats 2-3. One procedure involves relieving blocks of three and less spinal motion segments. In case of systemic osteoporosis (T-criteria less than -2.5 SD), muscle force to 0.5 kg is created in a tension phase; tension phase time makes 8-10 sec, and relaxation phase time is 15-20 sec.; a number of repeats 1-2. One procedure involves relieving blocks of two and less spinal motion segments.

EFFECT: elimination of bone structure fractures, pain management by effect on the involved structure that enables relieving muscle spasm, improving blood supply and innervation in the given region.

3 tbl, 2 dwg

Description

The invention relates to medicine, namely to vertebroneurology, rehabilitation and manual medicine, and can be used in the treatment of vertebrogenic pain syndrome against osteoporosis.

Osteoporosis today is one of the most common diseases, which, along with myocardial infarction, stroke, and cancer, takes a leading place in the structure of morbidity and mortality. The number of patients with osteoporosis, according to analysts, will increase due to increased life expectancy and improved living conditions in developed countries [L. Benevolenskaya General principles for the prevention and treatment of osteoporosis. Cons. med. 2000; 2 (6): 240-4].

Vertebrogenic pain syndromes are leading in the clinic of osteoporosis. The method of manual therapy is widely and successfully used in the treatment of vertebrogenic pathology with pathobiomechanical changes, including functional blocks of joints [Veselovsky VP Practical vertebral neurology and manual therapy. - Riga, 1991 .-- 344 p .; Zhulev N.M., Lobzin B.C., Badzgaradze Yu.D. Manual and reflexology in vertebro-neurology: A guide for doctors. - SPb., 1992. - 589 p .; Ivanichev G.A. Manual therapy. Guide, atlas. - Kazan, 1997 .-- 448 p .; Sitel A.B. Manual therapy. A guide for doctors. - M.: Publ. center, 1998 - 304 s .; Vasilieva L.F. Manual diagnostics and therapy (clinical biomechanics and pathobiomechanics). - SPb .: IKF Foliant, 1999. - 400 p.], It should be noted that the use of this method in people suffering from osteoporosis, some authors refer to the absolute [L. Benevolenskaya, 2005; N.V. Toroptsova, 2007; O.M. Lesnyak, 2009; A.I. Altukhov, 2007] or relative [G.A. Ivanovich, 1997; A.B.Sitel, 2007] contraindications. As a result of this, the manual therapy of vertebrogenic pain syndromes, taking into account the state of bone tissue, remains undeveloped.

When conducting a patent search for data on the use of manual therapy methods for the treatment of vertebrogenic pain syndrome in osteoporosis, it was not found.

Known methods for the treatment of vertebrogenic pain syndrome in osteoporosis, which are based on the method (principle) of symptomatic medical pain relief [Clinical recommendations. Osteoporosis. Diagnosis, prevention and treatment / ed. L.I. Benevolenskaya, O.M. Lesnyak. - M.: GEOTAR-Media, 2005. - 176 p.]. These activities include the appointment of analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, salmon calcitonin, wearing a corset, physiotherapy exercises. In the presence of a neuropathic component of pain, antidepressants and anticonvulsants are recommended [A.I. Altukhova, O.S. Levin. Geriatrics / Volume 9 / No.12 / 2007].

In the article by A.I. Altukhova et al., [Geriatrics / Volume 9 / No.12 / 2007], the authors recommend the use of various physiotherapeutic procedures (TENS, low-frequency magnetotherapy, laser therapy) acupuncture.

Known methods have several significant disadvantages.

1. Long-term use of drugs.

2. The lack of effectiveness of relief of pain.

3. Side effects of drugs.

4. Frequently encountered contraindications for physiotherapy and acupuncture in this group of patients.

5. Polypharmacy.

Along with this, many patents were found for the treatment of vertebrogenic pain syndromes of various etiologies with manual therapy methods.

A known method of treating patients with osteochondrosis of the cervical or lumbar spine [RF patent No. 2267337 "METHOD FOR TREATING PATIENTS WITH OSTEOCHONDROSIS OF THE CERVICAL OR LUMBAR SPINE", cl. A61N 5/02, A61H 1/00; bull. No. 01, 2006], including exposure to electromagnetic radiation in a course of 10-12 daily procedures on the pathological site and the projection of the lymph nodes of the axillary or inguinal region in the pathology of the cervical or lumbar spine, respectively, and manual therapy, using post-isometric relaxation methods, affecting painful muscle groups with traction and simultaneous external rotation of the limbs, stretching of the muscle groups surrounding the region of regional lymph nodes. The method allows for the correction of biomechanical disturbances, to improve blood circulation and lymph outflow in the limbs and paravertebral muscles, which allows to eliminate pain in a shorter time.

This method has several significant disadvantages.

1. The need for additional physiotherapeutic apparatuses and devices, frequent contraindications for FT in this group of patients.

2. Duration of the procedure and course of treatment

3. The condition of bone tissue is not taken into account, which can lead to the appearance of side effects and complications.

A known method of treating patients with osteochondrosis [RF patent No. 2312650, “METHOD FOR TREATING SPINE OSTEOCHONDROSIS WITH NEUROLOGICAL COMPLICATIONS”, cl. A61H 1/00, A61H 23/04; bull. No. 35, 2007], including manual therapy (30-40% of the time) in combination with 8 stage vacuum - correction of the spine and adjacent areas, which increases the period of remission.

This method also has several significant disadvantages:

1. The need for additional physiotherapeutic apparatuses and devices, frequent contraindications for FT in this group of patients.

2. The duration of the procedure and course of treatment.

3. The condition of bone tissue is not taken into account, which can lead to the appearance of side effects and complications.

A known method of treating CHD [RF patent No. 23235892, “METHOD OF MANUAL THERAPY OF VERTEBRONEUROLOGICAL SYNDROMES”, cl. A61H 1/00, A61M 21/02, A61N 5/067, A61N 2/04; bull. No. 16, 2008], in which they provide complete muscle relaxation of the entire body by intravenous anesthesia and carry out simultaneous correction of the interested parts of the spine by simultaneously traction-impulse effects on the patient’s spine with subsequent temporary fixation of the interested departments. After the pain syndrome decreases or disappears during the day after the manipulation, magneto-laser-light therapy is connected.

The method provides a gentle and safe effect on the spine due to perfect relaxation of the muscles of the whole body, which makes it possible to simultaneously correct all parts of the spine, reduce treatment time, remove the pain "dominant" and reflex pathological static-dynamic stereotype.

This method has several significant disadvantages.

1. The use of invasive treatments

2. The use of potent drugs with a wide range of side effects.

3. The condition of bone tissue is not taken into account, which can lead to the appearance of side effects and complications. The use of traction-impulse exposure.

4. The need for additional physiotherapeutic devices, frequent contraindications for physiotherapy in this group of patients.

The following methods of treating vertebrogenic pain are known - articulation techniques [Levit K., Zahse I., Yanda V. Manual medicine / Trans. with him. - M .: Medicine, 1993. - 512 p .; Greeman P.E. Principles of manual medicine. - Baltimore: Williams & Wilkins, 1989 .-- 347 p. Ivanichev G.A. Manual therapy. Leadership, atlas. - Kazan, 1997 .-- 448 p .; Sitel A.B. Manual therapy. A guide for doctors. - M .: Publishing center, 1998 - 304 S.], which are used on the joints of the spine, pelvis, ribs, sternum and limbs in cases where the movements in the joints and joint play are reversibly disturbed.

However, these techniques can be accompanied by sufficient pain, the formation of blockades in adjacent vertebral motor segments, the appearance of hypermobility in the affected joint and are characterized by frequent relapses of functional blocks, in addition, this method does not provide for the use of manual therapy for osteoporosis, which can lead to increased pain syndrome, as well as complications such as fractures of the vertebrae, ribs, and other bone structures in this group of patients. After performing manipulations (low-amplitude, high-speed articulations), the literature describes cases of vertebrobasilar insufficiency, spinal cord damage, fractures of skeleton bone elements (ribs, processes of the vertebrae, atlas of the atlas, vertebral body), etc. [Willem JJ Assendelft, Lex M. Bouter, Paul G .Knopschild; Complications of spinal manipulation: a comprehensive review of the literature // Journal of Family Practice, May, 1996; Ivanichev G.A. Manual therapy. Leadership, atlas. - Kazan, 1997. - 448 p.].

A known method based on the neurophysiology of muscle tissue. In manual therapy, he was the first to express ideas and develop the methodology of F. Mitchell. [Mitchell F.L. Jr, Moran P.S., Pruzzo N.A. An Evaluation and Treatment Manual of Osteopathic Muscle Energy Procedures. 1979, Institute for Continuing Education in Osteopathic Principles, Missouri]. In their final form, they were formulated by F. Greenman [Greeman P.E. Principles of manual medicine. - Baltimore: Williams & Wilkins, 1989. - 347 p.] And are called muscle-energy techniques or neuromuscular techniques. One of these techniques is postisometric relaxation. Currently, there are many modifications and descriptions of this technique [The Burnham Review. Muscle Energy Technique and Health // Consider Manual Therapy and Complementary and Alternative Medicine for Optimal Health, Issue 5-18, 2007; Ivanichev G.A. Manual therapy. Guide, atlas. - Kazan, 1997 .-- 448 p .; Sitel A.B. Manual therapy. A guide for doctors. - M.: Publishing Center, 1998 - 304 p .; Merzenyuk O.S. A practical guide to manual therapy. Ed. 2nd. - Novokuznetsk, 2005], but they all come down to the following steps. First, the doctor enters the motor barrier of restriction and holds the joint there, creates a state of prestress in the dysfunctional joint in the direction of restricting movement depending on the biomechanical situation, maximally "closing" or "opening" the joint (position phase). Then the patient is offered to strain the muscles of the segment in isometric mode (the strength of the doctor is equal to the strength of the patient). In this case, the patient's muscular effort is from 20 to 30% of the maximum, which according to our study is 1.6-7.4 kg. Muscle resistance time is 3-7 seconds. A conditional countdown is carried out after establishing an equal intensity of mutual opposition (voltage phase). Then the patient relaxes, the doctor withstands a pause for the beginning of complete tissue relaxation (3-10 seconds) (relaxation phase) and sprains the muscles to a new motor barrier (block resolution phase). Reception is repeated 2-4 times and then retest.

The effect of this technique is increased in cooperation with respiratory and oculomotor synkinesias. Inhalation has a general fascinating effect, while exhalation has a relaxing effect. Eye movements greatly facilitate the movement of the head and body in the direction of view and inhibit them in the opposite direction. Therefore, the phase of tension is carried out on the inhalation of the patient, the phase of relaxation - on the exhale. In the phase of stress, the patient is asked to look in the direction of the stress vector, in the phase of relaxation - in the opposite direction.

Muscle-energy technique is a fairly effective method of stopping the functional blocks of various joints, however, it does not take into account the state of bone tissue, and recommendations for implementation are general in nature without clear indications of the selection of individual loads.

The closest in technical essence is a method for the treatment of vertebral pain syndromes, taken as a prototype [RF patent No. 2342116, class. A61H 1/00, A61B 5/04; bull. No. 36, 2008], in which the time of the procedure and the amount of manual therapy depends on the patient’s vegetative system, so if the level of VLF is above 32.0 ms ² and HF below 12.0 ms is reduced to 15-20 minutes, the number of vertebrates processed is limited -motor segments up to two, which makes it possible to effectively use the muscle-energy technique of manual therapy in patients with impaired autonomic regulation of the body.

The prototype describes an effective method of treating vertebrogenic pain syndrome with muscular-energetic technique, but it does not take into account the state of bone tissue.

The basis of the present invention is to develop a method for the treatment of vertebrogenic pain syndrome against osteoporosis.

The technical result of the invention is the expansion of indications for manual therapy due to the exclusion of complications such as fractures of the vertebrae, ribs and other bone structures in this group of patients; relief of pain by targeted action on the damaged structure, which allows you to relieve muscle spasm, improve blood circulation or innervation in this area.

The task is achieved by first conducting a study of the state of bone tissue by ultrasonic densitometry (Cuba Clinical, USA) and diagnosing functional blocks, and then correcting them using muscle-energy techniques, the parameters of which depend on the state of bone tissue.

In order to select the optimal load level of muscle-energy equipment, the authors performed preliminary studies. We analyzed the degree of decrease in the intensity of vertebrogenic pain syndrome (on an NRS scale in points from 0 to 10), the effectiveness of stopping the functional block, the frequency of relapse of the functional block, the frequency of strengthening of the pain syndrome, the development of compensatory functional blocks in other joints and hypermobility in the affected joint.

The inventors have found that in the classical muscle-energy technique in patients with osteoporosis, the effectiveness of the technique is lower, more often complications develop in the form of increased pain, the development of compensatory functional blocks in other joints and hypermobility in the affected joint.

The studies conducted allowed us to develop a technique of muscle-energy technique in patients with vertebrogenic pain syndrome, depending on the state of the bone tissue.

It was proposed for systemic osteopenia (T-test from -1.0 to -2.5 SD) in the stress phase to create muscle effort in the range from 0.5 to 1.0 kg, the time of the stress phase should be 5-8 s, the relaxation phase 10 -15 s, the number of repetitions is 2-3, while in the course of one procedure, blocks are removed in no more than three vertebral-motor segments. The intensity of muscle effort was measured using an Electronic Scale (Portable Electronic Scale), adapted to measure the strength of muscle resistance.

With systemic osteoporosis (T-criterion below -2.5 SD), a muscle effort of up to 0.5 kg is created in the stress phase, and the time for the stress phase is 8-10 s, the relaxation phase is 15-20 s, the number of repetitions is 1-2, with this, in the course of one procedure, blocks are removed in no more than two vertebral-motor segments.

In case of systemic osteoporosis with low-traumatic fractures in history, other techniques of manual therapy are performed - myofascial releasing, strain-counterstrain of ligamentous balanced tension. This group of patients was not included in this study.

The invention is illustrated by the following examples.

Example 1. Patient P., 54 years old. Diagnosis: Vertebrogenic pain syndrome, lumbalgia, chronically relapsing course, period of exacerbation. Systemic osteopenia (T - 1.74 SD). Pain in the lumbar region has been troubling for 10 years. The intensity of pain according to NRS is 6-7 points. The course of the disease is chronic, with prolonged (up to three weeks) and frequent (4-5 times a year) exacerbations. The patient is registered with an osteopathologist for 9 months and fulfills all the prescribed recommendations.

The patient underwent a standard clinical and neurological examination. Objectively, a violation of the motor stereotype, a limitation of the range of motion in the lumbar spine, sharp tension of the muscles that extend the spinal column, pain points are palpated paravertebrally on both sides are noted. On manual examination, functional shortening of the left leg, left sacrum torsion along the right oblique axis, anterior iliac rotation, three-plane extension block left-LV-SI, shortening of the left square muscle of the lower back, and a functional block in the cervical-occipital transition to the right are noted. An additional x-ray examination revealed signs of spondylosis, osteochondrosis of the lumbar spine.

Based on the results of the examination (T criterion in the range of -1.0 - -2.5 SD), the method of muscle-energy technique of the functional blocks of the vertebral-motor segments C0-CI, LV-SI and the sacrum was treated. In this case, during the correction of C0-CI in the phase of tension, a muscle effort of 0.5-0.6 kg was created, the time of the phase of stress was 5 s, the phases of relaxation were 10 s, the number of repetitions was 2 times, while the correction of LV-SI in the phase of tension was created muscle 0.7-0.8 kg, the time of the stress phase was 8 s, the relaxation phase was 15 s, the number of repetitions was 3 times, with the correction of the sacrum in the stress phase, a muscle effort of 0.9-1.0 kg was created, the time of the stress phase was 7 s , relaxation phases 14 s, number of repetitions 3 times.

The intensity of vertebrogenic pain syndrome decreased to 2 points according to NRS. During the observation period of 1.5 months, relapses of stopped functional blocks were not observed.

Example 2. Patient N., 62 years old. Diagnosis: Vertebrogenic pain syndrome, thoracalgia, lumbalgia, progressive course, period of exacerbation. Systemic osteoporosis (T criterion -2.83 SD). Pain in the thoracic region has been troubling for 15 years, in the lumbar region for about 10-12 years. The intensity of pain in the thoracic region was 5–7 points according to NRS, and 4–5 points in the lumbar region. Over the past 3 years, progression of pain has been noted: the intensity of pain, the frequency (from 1 time in 2-3 years to 2-3 times a year) and the duration of exacerbations (up to 4-6 weeks) have increased. The duration of the last exacerbation is one week. The patient is registered with an osteopathologist for two years and fulfills all the prescribed recommendations.

The patient underwent a standard clinical and neurological examination. Objectively, there is a violation of the static and motor stereotype, limitation of the range of motion in all parts of the spine, tension of the paravertebral muscles, shortening of the left square muscle of the lower back and lumbar iliac muscle. On manual examination, functional shortening of the left leg, right sacrum torsion along the right oblique axis, anterior iliac rotation, three-plane flexion functional block on the left LIII-LIV, a functional block according to the tripod type ThVI-ThVII, a functional block in C0-CI on the right are noted. An additional x-ray examination revealed signs of spondylosis, osteochondrosis of the thoracic and lumbar spine.

Based on the results of the examination (T criterion less than -2.5 SD), the first procedure was treated using the muscle-energy technique of functional blocks of the vertebral-motor segments of ThVI-ThVII and the sacrum. At the same time, during the correction of ThVI-ThVII, a muscle effort of 0.3-0.4 kg was created in the stress phase, the time of the stress phase was 10 s, the relaxation phases were 18 s, the number of repetitions was 2 times, while the correction of the sacrum in the stress phase was created muscle 0 , 4-0.5 kg, the time of the stress phase was 8 s, the relaxation phase was 16 s, the number of repetitions was 2 times; in the second procedure, the treatment was carried out using the muscle-energy technique using functional blocks of the vertebral-motor segments C0-CI, LIII-LIV.

The intensity of vertebrogenic pain syndrome decreased to 1 point according to NRS in the thoracic and lumbar regions. During the observation period of 2 months, relapses of stopped functional blocks were not observed.

The proposed method treated 92 women aged 39 to 76 years with vertebrogenic pain syndrome of various localization on the background of systemic osteoporosis and systemic osteopenia according to the results of ultrasound examination of the calcaneus (according to the T-criterion from -1.6 SD to -3.2 SD). As a control group, 56 patients with osteoporosis (according to the T-criterion from -1.7 SD to -3.1 SD) were treated with the generally accepted technique of muscle energy. Each group was divided into two subgroups depending on bone density (Table 1).

Table 1. Characterization of study groups by the degree of decrease in bone density. The degree of decrease in bone density Main group Control group abs % abs % Osteopenia 55 59.8 34 60.7 Osteoporosis 37 40,2 22 39.3 Total 92 one hundred 56 one hundred

Table 2. Comparison of groups according to the main clinical characteristics of treatment effectiveness. Clinical characteristics Systemic osteopenia Systemic osteoporosis Main group Control group Main group Control group abs. % abs. % abs. % abs. % Stopping the function block after the first procedure 52 94.5 27 79,4 34 91.9 16 72.7 The frequency of relapse of the functional block during the course; intensification of pain after performing the technique four 7.3 6 17.6 four 10.8 6 27.3 The appearance of functional blocks in other joints; development of hypermobility in the affected joint 5 9.1 5 14.7 3 8.1 3 13.6 R 0.032 (<0.05) 0.005 (> 0.01) χ ² 6.9 10.7

The effectiveness of the course of treatment was evaluated using a specific section of the scale for a brief assessment of pain (BPI) (0-100%), while a decrease in pain intensity of 20% was considered the minimum significant, moderately significant by 20% -50%, and a decrease of more than 50% Significant pain relief (recommended by The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials, IMMPACT). As a result of treatment, in the main group with systemic osteopenia, a significant decrease in pain syndrome was noted in 42 (76.4%) patients, 12 (21.8%) - moderate and in 1 (1.8%) - a slight, with a significant decrease in systemic osteoporosis 26 (70.3%) pains were noted, moderate - 10 (27.0%), insignificant 1 (2.7%). In the control group, a significant effect was observed in 20 (58.8%), moderate in 11 (32.4%), insignificant in 3 (8.8%) in the subgroup with systemic osteopenia, with osteoporosis 12 (54.5%) - significant result, 8 (36.4%) - moderate and 2 (9.1%) - insignificant (Table 3).

Table 3. The effectiveness of the course of treatment in groups using a specific section of the scale of a brief assessment of pain (BPI) (0-100%). The degree of pain intensity reduction Systemic osteopenia Systemic osteoporosis Main group Control group Main group Control group abs % abs % abs % abs % Significant (more than 50%) 42 76,4 twenty 58.8 26 70.3 12 54.5 Moderate (20-50%) 12 21.8 eleven 32,4 10 27.0 8 36,4 Insignificant (up to 20%) one 1.8 3 8.8 one 2.7 2 9.1 Total 55 one hundred 34 one hundred 37 one hundred 22 one hundred p 0.01 0,03 χ ² 8.99 6.7

In patients in the main group, vertebrogenic pain syndrome decreased by 4.4 ± 1.16 points according to NRS or 82.7 ± 15.5%. In the control group, the intensity of the pain syndrome decreased by 3.9 ± 1.4 points or 67.7 ± 17.6% (Figs. 1, 2).

Thus, the proposed manual therapy technique can significantly reduce the intensity of vertebrogenic pain due to more effective treatment of functional blocks in patients suffering from systemic osteoporosis. The use of exclusively “soft” techniques of manual therapy, taking into account the condition of the bone tissue, allows minimizing the risk of complications in the form of fractures of skeleton bone elements (ribs, vertebral processes, atlas, vertebral arch).

The inventive method can be used in vertebral neurology, rehabilitation and manual medicine, therapy.

Claims (2)

1. A method of treating vertebrogenic pain syndrome against osteoporosis, including the study of bone tissue by ultrasound densitometry and the diagnosis of the functional block of the spinal motion segment, characterized in that in systemic osteopenia (T-test from - 1.0 to - 2.5 SD ) when the functional blocks are eliminated by the muscle-energy technique, in the phase of tension create muscle effort in the range from 0.5 to 1.0 kg, the time of the phase of tension should be 5-8 s, the phases of relaxation 10-15 s, the number of repetitions 2-3 , while in the process of one procedure, blocks are removed in no more than three vertebral-motor segments. 2. A method for the treatment of vertebrogenic pain syndrome against osteoporosis, including the study of bone tissue by ultrasound densitometry and the diagnosis of the functional block of the spinal motion segment, characterized in that with systemic osteoporosis (T-criterion below - 2.5 SD) while removing functional blocks muscle-energy techniques in the phase of tension create muscle effort of up to 0.5 kg, and the time for the phase of tension should be 8-10 s, the relaxation phase - 15-20 s, the number of repetitions is 1-2, with this, in the course of one procedure, blocks are removed in no more than two vertebral-motor segments.

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