Physiotherapy in disease prophylaxis and treatment: A review of applications

Presenter Dr Vladimir Gurevich EL Physiotherapy

Physiotherapy

Use of specific physical factors for disease prophylaxis and treatment Physiotherapy modalities are used by themselves or in combination with drugs Physiotherapy is one of key fields in modern clinical practice Applies essentially to every clinical discipline Allows effective treatment and prophylaxis of various diseases Often it is the most appropriate clinical approach to achieve a rapid and efficient improvement of the conditions of patients

Advantages of physiotherapy treatment

• Quick – the results are achieved in a rapid fashion • Efficient – addresses both the aetiology and the pathogenesis to eliminate the cause not just symptoms • Safe – causes minimum side effects or adverse reactions • Specific – drugs or treatment delivered to the affected organs or tissues • Painless – uses non-invasive procedures • Stressless – avoids unnecessary surgical procedures and use of general anaesthetics

Use of physiotherapy

Physiotherapy applies to a variety of pathological conditions: • musculoskeletal • respiratory • gynecological • dermatological • gastroenterological • urological • endocrine • neurological • cardiovascular • other diseases Major physiotherapy techniques: • Electrotherapy • Clinical Pilates • Hydrotherapy • Thermal therapy • Cryotherapy • Ozonetherapy • Vacuum therapy • Pressure therapy • Manual therapy • Exercise therapy • Balneotherapy

Electrotherapy

• Electrostimulation • Interferential • Ultrasound • Magnetotherapy • Pharmacological phoresis • SCENAR • Combination therapy

Electrostimulation

Uses various types of electrical currents (e.g. TENS, Russian, Galvanic, Diadynamic etc.) to stimulate the body’s organs and systems Acts through different pathways e.g. high-intensity TENS (50-100 Hz) reduces pain by inducing pre-synaptic inhibition of nociceptive fibers but low-intensity TENS (2-10 Hz) provides antinociceptive effect through releasing endogenous opioids Stimulates secretory and motoric function of the gastrointestinal tract Provides neurostimulating and voluntary and involuntary muscle stimulation activity Can be used in disease treatment and prophylaxis or for cosmetic purposes Helps strengthen muscles and improves their tone

Interferential

Interferes with the transmission of pain messages at the spinal cord level, leading to pain relief Reaches deep muscles and nerves Stimulates voluntary muscles Stimulates peripheral blood circulation Provides immediate and strong analgesia Accelerates bone healing

Ultrasound

Therapeutic effect achieved by using high frequency sound waves which enhance the healing process in injured organs or tissues of the body The mechanical and thermal actions of ultrasound applications lead to physicochemical reactions at the cellular, tissue and systemic levels resulting in the treatment effect Provides vasodilating effect for blood and lymphatic vessels, improves peripheral blood circulation Stimulates enzymatic activity and cellular metabolism Induces processes of pro-inflammatory optimisation Improves membrane permeability, accelerates cellular diffusion and osmosis

Magnetotherapy

Therapeutic effect through creation of a continuous or pulsative magnetic flux (low intensity technique) Stimulates cellular and humoral immunity Modulates endocrine regulation and enzymatic activity Improves blood and lymphatic circulation and modulates haemocoagulation processes Activates metabolic processes in different organs and systems Modulates skeletal and smooth muscle contraction and relaxation Stimulates tissue regeneration

SCENAR therapy

This treatment method uses the SCENAR (Self Controlled Energo-Neuro Adaptive Regulator) device SCENAR helps the body heal itself through locating problem areas and subsequently re activating the body’s self-regulatory mechanism which was destroyed by an accident or disease • • • • • • • Advantages of SCENAR therapy: One of the best electrotherapy tools available No negative side effects Very few contraindications Totally safe No medications required Re actives the body’s self-regulatory mechanism Effects felt after just a few sessions

Pharmacological phoresis

The main problem with the conventional oral and parenteral drug administration is its inability to deliver the drugs specifically to the affected organ or tissue Conventional oral and parenteral drug administration usually creates a need for high doses of the drug to achieve the required effect Pharmacological phoresis utilises different physiotherapy modalities to enhance the delivery of topically applied drugs to the affected organs or tissues In this approach transdermal or transmucosal administration of drugs allows achieving a rapid treatment effect Specific clinical effects are determined by the combined effect of the corresponding drug delivery system e.g. ultrasound and the pharmacological preparation Used for both local topographically specific and systemic drug administration and has proven efficiency in disease treatment Suitable for various drug groups (corticosteroids, NSAIDs, analgesics, vasodilators, hormones, anticoagulants, antibiotics, vaccines, antfungal, antimicrobial etc.)

Advantages of pharmacological phoresis

• Effectively enhances the delivery of topically applied drugs • Allows drug delivery specifically to the affected organ or tissue • Avoids or minimises adverse reactions of the drug • Maintains local drug effect for a prolonged period • Avoids potential gastrointestinal degradation of the drug • Reduces the dose required • Permits effective dosage control during the drug administration

Combination therapy

Simultaneous or interchangeable use of different physiotherapy modalities to achieve a synergistic treatment effect Combination schemes: • Iontophoresis and magnetotherapy • Iontophoresis and ultrasound • SCENAR and iontophoresis • SCENAR and magnetotherapy • Interferential and phonophoresis • Ultrasound and interferential

Clinical effects of electrotherapy

• • • • • • • • • Electrostimulation Anti-inflammatory Analgesic Sedative Tranquilising Spasmolytic Vasodilating Trophic Stimulation of secretion function Metabolic • • • • Interferential Analgesic Trophic Spasmolytic Defibrosing • • • • • Ultrasound Anti-inflammatory Analgesic Spasmolytic Metabolic Defibrosing

• • • • • • • • Magnetotherapy Sedative Trophic Spasmolytic Vasoactivating Antiedemic Hypocoagulating Myorelaxation Metabolic • • • • • • SCENAR therapy Metabolic Immunostimulating Vasoactivating Endorphine and encephaline release Correction of DNA spontaneous structural changes Neurotransmitters release

Clinical effectiveness of electrotherapy modalities for treatment of some pathological conditions (shown in descending order) • • • •

Analgesic effect:

Electrostimulation (diadynamic, TENS, galvanic) Ultrasound Pharmacological phoresis Magnetotherapy • • • •

Vasoactive and circulatory effect:

Magnetotherapy Pharmacological phoresis Ultrasound Electrostimulation (diadynamic) • • •

Anti-inflammatory effect:

Electrostimulation (galvanic) Pharmacological phoresis Ultrasound

Indications for electrotherapy

• • • • • • • • • Musculoskeletal pathologies e.g. rheumatoid arthritis, osteoarthritis, osteochondrosis, tendinitis, bone fractures, plantar fasciitis, etc.

Cardiovascular diseases e.g. hypertension, ischemic heart disease, angina, vascular dystonia, varicose veins, atherosclerotic occlusions, phlebitis, thrombophlebitis, etc.

Gynecological diseases e.g. endometritis, salpingits, dysmenorrhea, mastitis, incontinence, etc.

Dermatological diseases e.g. throphic ulcers, hyperhidrosis and bromidrosis, eczema, neurodermitis, herpes, etc. Gastroenterological diseases e.g. gastric and duodenal ulcers, reflux, oesophagitis, duodenitis, enteritis, gastritis, colitis, biliary dyskinesia, hepatitis, pancreatitis, cholecystitis, etc.

Respiratory diseases e.g. chronic obstructive pulmonary disease, bronchitis, bronchial asthma, tonsillitis, pharyngitis, laryngitis, pneumonia, etc.

Neurological diseases e.g. stroke, carpal tunnel syndrome, trigeminal nerve lesion, neuralgia, peripheral lesion etc.

Urological diseases e.g. pyelonephritis, cystitis, prostatitis, urethritis, etc.

Other diseases

Mechanisms of action

• • • • • • • • • • • Induction of endogenous opioids e.g. endorphins, enkephalins Opioid receptor activation in the spinal cord and rostral-ventral medulla Improvement of the oxygen transport and metabolic processes Reduction of nociceptive response Stimulation of neurotrophins release Regulation of the endocrine system secretory activity Pro-inflammatory optimisation through mobilisation of cellular and humoral defense mechanisms e.g. lymphocytes, neutrophils, macrophages, platelets Modulation of the release of inflammatory mediators (serotonin, histamine, eicosanoids, prostaglandins, leukotreine, sympatomimetic amines) Membrane polarisation and improved permeability Regulation of cellular acid-alkaline balance Stimulation of processes of cellular diffusion and osmosis

Clinical effectiveness of electrotherapy

Assessed in: • RCT (randomised controlled trials) • Clinical studies • Practical clinical observations Results sourced from: • Journal publications e.g. research, review, clinical papers • Cochrane library • Databases e.g. PubMed • Conference proceeding

Use of low-intensity pulsed ultrasound for fracture treatment (J. Busse

et al

., CMAJ, 2002)

SCENAR therapy of maxillary and mandibular furuncles and phlegmons (Y. Perfiliev

et al

., Rostov State Medical University, Department of Maxillofacial Surgery, Proceedings of 1st Russian Conference on SCENAR Therapy, 2007) Parameters Pain Purulent exudate Oedema and infiltration Hyperthermia Intoxication (weakness, headache etc.) Period before suture (days) Duration of inflammation symptoms (days) SCENAR treatment (n=98) 3.4

±0.2

3.3

±0.5

2.9

±0.3

2.8

±0.2

Standard treatment (n=105) 5.4

±0.3

5.9

5.0

4.7

±0.4

±0.3

±0.2

4.8

±0.3

9.3

±0.3

6.8

±0.2

9.0

±0.5

Analgesic effect of interferential treatment on chronic pain in knee osteoarthritis (R. Defrin

et al

., Pain, 2005) Mean pre- and post-treatment values of chronic pain intensity (VAS scores) in the study groups. A significant reduction in chronic pain was found in all the active treatment groups (groups 1 –4) (**

P

<0.01, ***

P

<0.001) but not in the placebo and control groups (groups 5 and 6, respectively). Bars denote mean±SD.

Effect of combined interferential and patterned muscle stimulation as compared to TENS in treatment of knee osteoarthritis (F. Burch

et al

., Osteoarthritis and Cartilage, 2005)

Effect of combined ultrasound and interferential therapy on pre- and post-sleep and sleep pain parameters in fibromyalgia (T. Almeida

et al

., Pain, 2003) Pre- and post sleep parameters Sleep parameters

Hypoalgesic effect of TENS following inguinal herniorrhaphy (J. De Santana

et al

., The Journal of Pain, 2008) Mean pain scores for TENS (n=20) and placebo (n=20) groups Mean number of doses of analgesic (dipyrone) for TENS and placebo groups (p = 0.001)

Effect of transcutaneous electrical muscle stimulation (TEMS) on blood pressure and removal of urea and phosphate during haemodialysis (S. Farese

et al

., American Journal of Kidney Disease, 2008)

Parameters TEMS Control Statistical significance

Blood pressure (mm Hg) 125/66 ±22/16 121/64 ±21/15 p < 0.05

Urea removal (g/dialysis) Phosphate removal (g/dialysis) 19.4

±3.7

1197 ±265 15.1

±3.9

895 ±202 p < 0.001

p < 0.001

Effect of TENS on the symptomatic management of chronic prostatitis/chronic pelvic pain syndrome (L. Sikiru

et al

., International Brazilian Journal of Urology, 2008) Analgesic group received ibuprofen treatment

Effect of extracorporeal shock wave therapy on the treatment of chronic pelvic pain syndrome in males (R. Zimmermann

et al

., European Urology, 2009) Changes in parameters for the sham and verum treatment groups

Parameter

IPSS (1 wk)–IPSS (pre) IPSS (4wk)–IPSS (pre) IPSS (12wk)–IPSS (pre) IIEF (1 wk)–IIEF (pre) IIEF (4wk)–IIEF(pre) IIEF (12wk)–IIEF(pre) CPSI (1 wk)–CPSI (pre) CPSI (4wk)–CPSI (pre) CPSI (12wk)–CPSI (pre) VAS (1 wk)–VAS (pre) VAS (4 wk)–VAS (pre) VAS (12 wk)–VAS (pre)

Placebo (% )

0 0 0 0 0 0 0 2.1 4.2 −16.7 0 0

Significant changes

No (p = 0.947) No (p = 0.631) No (p = 0.280) No (p = 0.959) No (p = 0.894) No (p = 0.569) No (p = 0.935) No (p = 0.865) No (p = 0.935) No (p = 0.151) No (p = 0.865) No (p = 0.227)

Verum (% )

−15.6 −18.8 −25 10.5 5.3 5.3 −16.7 −16.7 −16.7 −33.3 −50 −50 CPSI = Chronic Prostatitis Symptom Index; IIEF = International Index of Erectile Function; IPSS = International Prostate Symptom Score; VAS = Visual Analog Scale.

Significant changes

Yes (p ≤ 0.001) Yes (p ≤ 0.001) Yes (p ≤ 0.001) Yes (p = 0.029) Yes (p = 0.034) Yes (p = 0.036) Yes (p ≤ 0.001) Yes (p ≤ 0.001) Yes (p ≤ 0.001) Yes (p ≤ 0.001) Yes (p ≤ 0.001) Yes (p ≤ 0.001)

Effect of transcutaneous electrical stimulation of specific acupuncture sites on functional dyspepsia symptoms and neuropeptide Y levels (S. Liu

et al

., Neurogastroenterlogy & Motility, 2008) Plasma neuropeptide Y levels Group TEA Sham TEA NPY (pg/mL) before treatment 53.94±7.33 65.75±8.50 NPY (pg/ml) after treatment 99.45±13.52 60.67±12.51 Statistical significance p = 0.01 p > 0.05

Effect of electroacupuncture on gastric motoric function and dyspepsia symptoms (S. Xu et al., Digestive Diseases and Sciences, 2006 and C. Chang

et al

., Digestion, 2001) Parameters Halftime for gastric emptying (min) Symptom score Percentage of normal frequency (%) Serum human pancreatic polypeptide Before treatment 150.3

±48.4

8.2

±3.3

21.99

±19.38

56.96

±27.64

After treatment 118.9

±29.6

1.6

±1.1

48.92

±19.56

73.11

±22.37

Statistical significance p = 0.007

p < 0.001

p < 0.001

p < 0.05

Peripheral trancutaneous neuromodulation (posterior tibial nerve electrical stimulation) in the treatment of idiopathic fecal incontinence (M. Queralto

et al

., International Journal of Colorectal Diseases, 2006) Incontinence score pre- and post-4-week neuromodulation

Effect of transcutaneous electrical muscle stimulation on exercise capacity of patients with COPD (G. Bourjeily-Habr

et al

., Thorax, 2002)

Effect of electrical stimulation on change of parameters in bed-bound patients with COPD receiving mechanical ventilation (E. Zanotti

et al

., Chest, 2003)

Parameters Active limb mobilisation (ALM) group ALM/ES group Statistical significance

Muscle strength 1.25

±0.75

2.16

±1.02

p = 0.02

Respiratory rate 0.41

±1.88

Days to transfer from bed to chair 14.33

±2.53

-1.91

±1.72

10.75

±2.41

p = 0.004

p = 0.001

Effect of Acu-TENS on the respiratory function of patients with asthma (S. Ngai

et al

., Respiratory Physiology & Neurobiology, 2009) Percentage change of forced expiratory volume in one second (FEV1) at 0 min (immediately post), 20 min, 40 min and 60 min post-exercise. Group 1 = pre-ex TENS, Group 2 = continuous TENS, Group 3 = placebo TENS.

† Denotes difference between Groups 1 and 3 (

p

< 0.05); ‡ denotes difference between Groups 2 and 3 (

p

< 0.05). Percentage change of forced vital capacity (FVC) at 0 min (immediately post), 20 min, 40 min and 60 min post-exercise.

Group 1 = pre-ex TENS, Group 2 = continuous TENS, Group 3 = placebo TENS.

† Denotes difference between Groups 1 and 3 (

p

< 0.05); ‡ denotes difference between Groups 2 and 3 (

p

< 0.05).

Effect of electrical neurostimulation for treating refractory angina pectoris (J. de Vries

et al

., European Journal of Pain, 2007)

Effect of extracorporeal cardiac shock wave therapy on myocardial ischemia in patients with severe coronary artery disease (Y. Fukumoto

et al

., Coronary Artery Disease, 2006) Parameters Canadian Cardiovascular Society functional class score Nitroglycerin use (per week) Dipyridamole stress thallium scintigraphy severity score (% improvement) washout rate

Before treatment

2.7

±0.2

5.4

±2.5

N/A 20 ±3

After treatment Statistical significance

1.8

±0.2

0.3

±0.3

25.2

±7.2

34 ±3 p < 0.01

p < 0.05

p < 0.05

p < 0.05

Effect of functional electrical stimulation on stress, exercise capacity and some other parameters in patients with chronic heart failure (A. Karavidas

et al

., European Journal of Heart Failure, 2008)

Effect of extracorporeal shock wave therapy (ESWT) on upper limb hypertonia in patients after stroke (P. Manganotti and E. Amelio, Stroke, 2005) Ashworth scale of finger flexors before and after treatment (p < 0.001) Ashworth scale for the finger flexors after different intervals following the ESWT (p < 0.001)

Ultrasound treatment of carpal tunnel syndrome (D. O’Connor et al, Cochrane Database Systematic Review, 2003) Sensation Self-reported improvement

Neuropathic pain (thoracic outlet syndrome with a lesion of the left brachial plexus) controlled using rTMS stimulation of the motor cortex (J. Lefaucheur et al., Clinical Neurophysiology, 2004) Effects of monthly sessions of repetitive transcranial magnetic stimulation (rTMS) of the motor cortex on pain level scored on a 0 –10 visual analog scale (mean of daily scores for 5 days +/ – standard deviation). Months 1 and 2 consisted of the basal pain level on the days before the first rTMS session. Months 3 –18 corresponded to the days following each rTMS session. At months 6, 9 and 13 (*), the “real” coil was replaced by a “sham” coil. Months 22 and 25 took place 3 and 6 months following the surgical implantation of the cortical stimulator.

Comparison of electric stimulation and oxybutynin chloride in management of overactive bladder with reference to urinary urgency (A. Wang

et al

., Urology, 2006) ES = electrical stimulation; Oxy = oxybutynin; Pl = placebo Data presented as measurements after treatment minus that before treatment † All measures are number of episodes per 24 hours

Effect of interferential and biofeedback treatment on urinary stress incontinence (F. Demiturk

et al

., Swiss Medical Weekly, 2008)

Effect of Acu-TENS treatment on pain relieve during the first stage of labour (A. Chao

et al

., Pain, 2007) a Only the first applications were counted

Reduction of itch in allergic dermatitis following electrical cutaneous field stimulation (J. Wallengren, Allergy, 2002) 1 – reactions after 1 h of CSF treatment administered 30 min prior to provocation (n = 12) 2 – reactions after 4 daily (CSF) treatments, the last treatment given 1 day before provocation (n = 10)

Use of electrotherapy which demonstrated effective clinical results (PubMed database)

Pathology

Lateral epicondylitis Chronic wounds Low back pain Cervical fusion Duodenal ulcers Diarrhea- predominant irritable bowel syndrome Chronic salpingo-oophoritis Dysmenorrhoea

Treatment

Naproxen iontophoresis Ultrasound PENS (percutaneous nerve stimulation), TENS Magnetotherapy SCENAR therapy Acu-TENS Interferential TENS

Author

F. Baskurt W.J. Ennis

et al.

et al.

M. Yokoyama K.T. Folev H. Schiotz

et al.

et al.

I. Tsimmerman

et al.

W.B. Xiao and Y.L. Liu A. Razumov

et al.

et al.

Source

Clinical Rehabilitation, 2003 Advances in Skin and Wound Care, 2008 Anesthesia and Analgesia, 2004 The Spine Journal, 2008 Clinical Medicine (Moscow), 2006 Digestive Diseases and Sciences, 2004 VKFLFK (Physiotherapy Journal, Moscow), 2002 Journal of Obstetrics and Gynaecology, 2007

Pathology Treatment Author Source

Chronic heart failure Peripheral arterial occlusive disease Cerebral palsy Ischemic stroke Motor restoration in hemiplegia Generalised anxiety disoder (GAD) Hyperhidrosis Chronic maxillary and frontal sinusitis NMES Prostaglandin E 1 iontophoresis Glutamic acid magnetophoresis Ultrasound NMES CES (cranial electrotherapy stimulation), rTMS Iontophoresis with tap water Ultrasound M.J. Sillen

et al.

K. Yamamura N. Gurova and L. Babina M. Daffertshofer and M. Hennerici J. Chae

et al.

A. Bystritsky Berker N.N. Ansari

et al.

M. Connolly and D. de

et al.

Chest, 2009 The Annals of Pharmacotherapy, 2003 Neuroscience & Behavioral Physiology, 2008 Lancet Neurology, 2003 Topics in Stroke Rehabilitation, 2008 The Journal of Clinical Psychiatry, 2008 American Journal of Clinical Dermatology, 2003 Physiotherapy Theory and Practice, 2007

Clinical Pilates

The aim is to develop “core stability” Helps to restore and maintain the musculoskeletal health Uses specialised Pilates equipment e.g. reformer machines and trapeze tables Use of real time ultrasound to help train “core stability” muscles and monitor the progress The program is formed based on the outcome of the diagnostic assessment The effect of treatment sessions is regularly monitored and the conditions are reassessed at regular intervals

Indications for clinical pilates

Musculoskeletal pathologies • Back and neck conditions such as scoliosis, disc bulge/prolapse, degenerative changes and others • Joint pathologies, such as muscle tears, ligament sprains, impingement syndromes and others • Osteoarthritis and rheumatoid arthritis • Post fracture rehabilitation Metabolic disorders e.g. obesity, diabetes Sports injuries and post-traumatic rehabilitation Post-surgical rehabilitation e.g. hip and knee replacements etc.

Rehabilitation after cardiovascular diseases e.g. myocardial infarction, coronary artery by-pass surgery etc.

Prenatal, antenatal and postnatal training of deep abdominal (core stability) and pelvic floor muscles Improving muscle tone, strength, body shape and overall image

Advantages of clinical pilates

• Training and strengthening core stability muscles • Improving respiratory and cardiac function • Stimulating peripheral blood circulation • Improving body balance and coordination • Stimulating metabolic processes

Combination of electrotherapy and clinical pilates

Treatment combining clinical pilates with different electrotherapy modalities Performed during the same or alternate sessions or in blocks Treatment schemes usually start with electrotherapy and then clinical pilates is applied to prolong and maintain the effect Efficient for treating both acute and chronic processes and disease prophylaxis

Summary

Physiotherapy is very efficient in disease prophylaxis and treatment Treatment is prescribed based on thorough diagnostic procedure including general clinical examination, imaging techniques e.g. ultrasound, MRI, CT etc., haematological and biochemical analyses, and special physiotherapy techniques Physiotherapy offers a wide range of treatment modalities for disease to select the most suitable techniques or their combination based on the conditions of the patient Use of pharmacological phoresis enables drug delivery specifically to the affected organ or tissue

Treatment avoids or minimises any side effects or adverse reactions associated with the procedures Involves non-invasive procedures, is painless and does not lead to dependency Physiotherapy treatment is used alone or in combination with other medical approaches Physiotherapy treatment addresses the aetiology of the disease, effectively alleviates pain and reduces or eliminates other symptoms, and accelerates the rehabilitation process to enable a speedy recovery of the patient – the ultimate goal of any medical intervention