Technika, Ltd.
LASER THERAPY IN MEDICAL PRACTICE
V.A.Buylin
LOW-INTENSITY LASER THERAPY OF JOINT DISEASES
Information and Methodology
INTRODUCTION
Effective therapy and rehabilitation of patients with various joint diseases of inflammatory and degenerative-dystrophic origin continue to present important medical, social and economic problems. One of the most widespread diseases of the locomotor system is osteoarthrosis. Many problems of pathogenesis and treatment of osteoarthrosis need to be further studied and solved.
According to the Institute of Rheumatology, affiliated to the Russian Academy of Medical Sciences, 6.43% of people in this country suffer from this chronic disease with a steadily progressive course. In recent years the incidence of osteoarthrosis among able-bodied people has grown. Successful therapy of people with predominant involvement of leg joints has a special medical and social significance, since the majority of cases of disability and inability of self-care is associated with this localization of pathologic process in osteoarthrosis. Drug therapy of osteoarthrosis does not give any significant results. Therefore new methods of physical therapy and rehabilitation of patients with osteoarthrosis need to be searched for.
Both in Russia and abroad, various methods of physical therapy, such as cryotherapy, permanent and variable magnetic fields, ultrasound, electric current, electromagnetic oscillations at various wavelengths, and combinations thereof, are being widely used. Over the past two decades, a leading place in the treatment of joint diseases has been gained by las
er irradiation, both as a component of multimodality therapy and as an individual curative factor. This is due to a wide range of biological and physiological effects and reactions produced in tissues and the body by laser radiation.
Laser and magnetolaser therapy of joint diseases using new-generation laser therapy devices - Mustang, Mustang-Bio, and Malysh-B - has allowed to raise the efficacy of treatment of this intricate pathologic state, which is often accompanied by various concurrent diseases.
This brochure is intended for physicians of various specialties, who have been trained in laser medicine. For this reason, it does not contain information on safety precautions during work with lasers, on methods of calculation of laser radiation doses, as well as many other things which a physician needs to know for the conscious and safe use of laser radiation in medical practice.
PATHOGENETIC AND CLINICAL ASPECTS OF JOINT DISEASES
Among the reasons of primary disability due to diseases associated with locomotor function disorders, joint diseases account for 20.6% in women and 8.3% in men. At the same time, only 16.5% of disabled persons restore their working capacity by way of medical rehabilitation [Eremenko T.S., Poddubnyy N.P., 1986].
All joint diseases can be divided (which is reflected in various classifications used in many countries of the world) into two main groups: inflammatory (arthritis) and degenerative (arthrosis). In the International Statistical Classification of Diseases, Injuries and Causes of Death [WHO, 1983] there is a section “Osteoarthritis, Osteoarthrosis and Related States” containing “deforming arthrosis” and “degenerative joint disease (multiple)”.
Among arthrites caused by infections, in recent years attention has been increasingly drawn to reactive arthrites, including Reiter’s disease, which often has a chronic course with frequent exacerbation periods. Reactive arthrites mainly manifest themselves in the injury of limb joints, such as mono- and oligoarthritis, or, less commonly, polyarthritis with a marked asymmetry of articular changes, localized predominantly in leg joints. The pain syndrome in reactive arthrites considerably limits physical activity and the working ability of patients; therefore, treatment of such patients is aimed mainly at a decrease in the severity of inflammation and alleviation of pain.
Reactive arthrites can be caused by urinogenital or intestinal infections [Shubin S.V., 1981; Aho, 1984], there are urogenic and enterocolitic forms of the disease. A.I. Shatikhin et al. (1988) established a direct correlation between the severity of morphologic changes in the small and large intestines, the degree of dysbacteriosis and the course of reactive arthrites. Sufficient treatment efficacy was attained only under a combined use of drug and physiotherapeutic therapy aimed at the stabilization of the inflammatory syndrome in the intestines and joints as well as the management of chronic infection sites (sulfalazine, bacteritic preparations, decimetric waves therapy, etc.). In arthritis, blood serum and synovial fluid shows immunoreactive vasoactive intestinal polypeptide, which can be a cause of arthritis.
Reactive arthrites are diagnosed by clinical signs (local hyperemia of the skin over the injury site, swelling, tenderness) and changes in laboratory indices (levels of alpha-globulins, gamma-globulins, seromucoid, C-reactive protein, ESR).
Rheumatoid arthritis (RA) is one of the most severe forms of joint diseases, showing a rather high incidence in all age groups. Laboratory investigations reveal elevated titers of streptococcal antigen, transaminases, leukocytosis, high capillary permeability at the very onset of the disease [Nesterov A.G., Astapenko M.G., 1976], elevated titers of rheumatoid factor, antinuclear antibodies, high levels of immune complexes and ESR [Yunus, 1988], and a decreased level of T lymphocytes, predominantly at the expense of T suppressors [Bisyarina V.P. et al., 1988].
Relative significance of cellular and humoral immunity disorders in the development of inflammatory changes and joint destruction in RA has been poorly studied. Blood serum and synovial fluid of patients show antibodies and, in particular, rheumatoid factors. The synovial membrane is probably the main site of synthesis of rheumatoid factors. Rheumatoid factors containing immune complexes of synovial fluid can play a leading role in the development of inflammatory process due to their ability to activate complement. Complement decay products can stimulate the supply of neutrophils to the joint and enhance permeability of vessels in this area. At the same time, there is growing evidence pointing to the participation of T cells in the pathogenesis of RA. The effect of genes of the major histocompatibility complex on the predisposition to RA can be regarded as a proof that T lymphocytes play a central role in the development of the disease. Immunohistologic investigation of the synovial membrane shows a marked lymphocytic infiltration, with infiltrates comprising predominantly activated T cells. In addition, several methods of treatment of RA patients, aimed mainly at T lymphocytes, proved effective. It cannot be said with certainty yet whether T lymphocytes respond to antigenic stimulation in the joint or migrate to synovial fluid as a result of an active inflammatory process in this fluid. In any case, T cells can contribute to the development of inflammatory changes either directly (as a result of their cytotoxic effect on synoviocytes) or due to the release of lymphokines [Gaston J.S.H et al., 1988].
Rheumatoid inflammation is associated with activation of phagocytes, which is accompanied by generation of active oxygen forms: superoxide anion, hydrogen peroxide, singlet oxygen and hydroxyl radical [Muldiyarov P.A., 1988]. Potential stimulators of the production of active oxygen forms are phagocytosis (of fibrin, immune complexes, microcrystals), C5a, arachidonic acid, leukotriene B4 and a number of proteases. Free oxygen radicals produce a destructive effect on hyaluronic acid, DNA, and other biological macromolecules. They initiate free radical chain reactions in cell membranes, causing lipid peroxidation (LPO). This is accompanied by the accumulation of intermediate (lipid hydroperoxides) and end (malonic aldehyde) LPO products in cells and extracellular space. Free oxygen radicals and LPO products, together with prostanoids, cause a rise in permeability of the microcirculatory bed. Lipid hydroperoxides can also act as chemotaxic factors. LPO stimulates a non-enzymatic synthesis of prostaglandins and, therefore, produces a secondary toxic effect. Thus, not only active oxygen forms, but also LPO products are efficient antiinflammatory factors and can be ascribed to inflammation mediators. In the development of rheumatoid inflammation not only free radical reactions are significant, but also insufficient natural antioxidant potential, i.e., a decrease in the level of thiol groups, alpha-tocopherol, ascorbate. Active substances in modern drugs used in treatment of RA are superoxide dismutase (orgotein and analogues), cationic catalase and peroxidase, interceptors of active oxygen forms (alpha-tocopherol, chroloquine phosphate, dibunol, etc.), iron ion chelating agents (dysferrioxamine). A number of non-steroid antiinflammatory drugs can inhibit leukocyte chemoluminescence by suppressing generation of active forms of oxygen in leukocytes (auranofin).
E.M. Tareev wrote in his book “Rheumatoid Arthritis” (1959): “Both rheumatoid and rheumatic arthrites can be regarded as polyetiologic diseases, where individual intolerance of various factors, such as cold, trauma, poisons, toxins, infection, is of special significance. The leading role in the development of rheumatoid arthritis is played by non-infection factors, whereas the development of rheumatism is associated with streptococcal infection”.
Among etiologic factors of RA, one cannot exclude also chlamydozoon, mycoplasma, yersinia, rubella virus; the latter, together with specific antibodies, was revealed in one-third of patients with juvenile RA [Ogra et al., 1975]. Familial RA, in some cases traced as far back as four or even six generations [Boyle, Buchanan, 1971], sometimes combined with systemic lupus erythematosus, etc., is attributed to genetic abnormality. Such variant forms as rheumatoid spondylitis, Reiter’s disease, and others, commonly associated with a certain causative factor, show predominance of characteristic genetic changes in tissue-compatible HLA W27 complex, which raises the question of the need to isolate an individual group - “W27 rheumatic disease.” Therefore, antibiotic therapy and prevention in RA fail to produce such an effect as in rheumatism and most commonly lead to severe complications [Tareev E.M., 1976].
Kellgren [1949], an authority in the field of rheumatology and arthrology, distinguishes 10 variant clinical forms of RA, such as: 1) rheumatoid arthritis, associated with the presence of an infection site in the body; 2) classic rheumatoid arthritis, most commonly observed in women; 3) rheumatoid psoriatic arthritis. Other variant forms include RA in Bekhterev’s disease, ulcerative colitis, Still’s disease, Hench’s syndrome, Sjögren’s syndrome, and arthrites associated with lupus. Seronegative rheumatoid arthritis most commonly affects (in decreasing order) knee, humeral, elbow, ankle, wrist, hip, and small hand and foot joints.
Depending on the activity of the process, clinical signs of RA (a rise in local temperature, joint swelling, restricted movements, joint pain, morning stiffness) in various patients may vary very considerably. The X-ray picture of RA has been studied well enough and is widely available in the literature.
Generally accepted X-ray signs of the disease are osteoporosis, narrowing of joint fissures, periarticular (marginal) and intra-articular destruction of bones, bony ankylosis, thickening and deformation of soft tissues [Zevgenidze G.A., Zharkov P.L., 1983; Kosinskaya N.S. et al., 1967].
Arthrosis. Deforming arthrosis (osteoarthrosis) (DOA) is a dystrophic disease of joints caused by degenerative damage of the cartilage with secondary bony changes of epiphyses. The bony changes are manifested in marginal growth (usually in the form of “whiskers”), sclerosis and cystiform osteoporosis. The disease is polyetiologic. The best documented effect is that of a mechanical factor, such as macro- or microtrauma of the cartilage with its subsequent degeneration or impairment of joint statics, which leads to a rise in load on individual parts of the joint surface and the destruction of the joint cartilage. The significance of an angiotrophic factor in the development of DOA is undeniable. Impairment of microcirculation, in particular venous stasis, can cause degenerative changes in the cartilage or contribute to their development. Changes in cartilaginous tissue metabolism in DOA are considered to be well established. In initial degenerative changes of the cartilage, the level of chondroitin sulfate was found to decrease. Oxyproline concentration remains unchanged. The level of mucopolysaccharides in the synovial fluid falls markedly, whereas their blood serum level grows. This changes are considered to be so characteristic of DOA that this is used for differential diagnosis of DOA and joint diseases of inflammatory genesis [Yumashev G.S., 1983].
Some authors attach a great importance to changes in the structure of synovial fluid and the impairment of its “lubricating” function. Other causes contributing to the developing of DOA include involutional tissue changes, neurogenic disorders, heredity, focal chronic infection, endocrine shifts, obesity, and others.
It is necessary to differentiate between primary chronic osteoarthrosis as an individual disease and secondary deforming arthrosis (secondary osteoarthrosis) as a complication of a primary joint disease, such as dysplasia of the hip joint, intra-articular fracture, etc. In some cases, DOA affects adolescents and even children, but most typically the disease develops at the age of 40-50 years and later. In secondary DOA, usually one joint is affected, and in rare cases two or more joints are involved in the process. Most commonly and severely DOA affects legs, especially hip and knee joints. The disease evolves gradually, without an acute onset. Sometimes, the first symptoms are crack during movements and “starting” pain in joints after sleep, rapidly disappearing during movements. Gradually pain in the joint develops. At first, rapidly subsiding pain emerges when a persons starts to move after a period of rest. Then, pain develops also after a long or heavy exercise load. Subsequently, pain acquires a typical daily pattern: In the morning, when the persons starts to move, pain becomes more intensive. As the patients continues to move, the intensity of pain decreases. By the evening, pain in the joint grows with the rise in exercise load. At night, in a state of rest, pain gradually subsides and resumes at movements.
Pain in joints causes a reflex contraction of muscles, which, in its turn, leads to a rise in pressure on the joint surface, aggravates degenerative changes in the cartilage, and enhances pain. A vicious circle is therefore created. Gradually typical contractures develop in joints. For instance, flexion and adduction contractures are characteristic for the hip joint. Deformation of the joint progresses and its movements become restricted.
Three stages are usually distinguished in the DOA course [Kosinskaya N.S., 1967]. Stage 1 is characterized by moderate limitation of joint movements. At rest and under small load, there is no pain in the joint. It emerges usually under a prolonged load or at the onset of movements after a long period of rest. X-ray examination reveals insignificant narrowing of articular fissure, small bony growths of the joint cavity and some areas of ossification of the articular cartilage.
Stage 2 of the disease is characterized by a further limitation of joint movements. Movements are accompanies by a severe crack. Pain syndrome is very marked. Pain subsides only if the joint remains unloaded for a long time. Contracture in the hip or knee joint leads to functional shortening of the leg. The patients develop lameness, functional misalignment of the pelvis, and lumbar scoliosis. Changes in the statics enhance a load on intervertebral disks and contribute to their degeneration. X-ray examination shows narrowing of the articular fissure 2-3 times as compared to the norm and gross bony growths along the margin of the joint cavity. Joint head becomes deformed and develops areas of subchondrial sclerosis and oval-shaped clarifications, i.e., dystrophic cavities.
Stage 3 is characterized by almost complete loss of joint mobility. Only to-and-fro movements are retained. In bilateral damage of hip joints, patients move on crutches, moving femurs together with the pelvis; movements in the hip joint become impossible (“tied up legs” syndrome). In patients with coxarthrosis, femur abductor muscles are affected most of all; they often show compensatory hyperlordosis, scoliosis, shortening of the affected leg, misalignment of pelvis, and organic contractures. Arthrosis of the knee joint, in addition to flexion contracture, can be accompanied by a marked lateral deformation of leg axis (usually varus) at the level of knee joint. An X-ray picture shows a nearly complete absence of joint fissure; both articulating surfaces are markedly deformed and extended at the expense of marginal growths. Osteoporosis is accompanied by gross sclerosis of contacting areas and isolated cystiform clarifications. Joint mice and calcified paraarticular tissues can be seen.
In primary arthrosis, degenerative, atrophic processes prevail. The joint looks desiccated, despite the presence of exostoses, subchondral sclerosis and cystiform cavities in the subchondral zone of bones, which should be regarded as a consequence of aseptic necroses of vascular origin. If the development of DOA is associated with non-specific infectious process, proliferative process is observed, whereas after trauma it is the result of the destruction of joint elements, subsequent inflammation and bone regeneration. The disease is characterized by a gradual development, i.e., although the disease progresses in general, exacerbation periods alternate with more or less lengthy periods of remission. During exacerbation, secondary inflammatory changes of joints can develop. 70% of patients show disfiguration and deformation of joints; in 60% of patients muscle hypotrophy can range from hardly noticeable to very marked. Leg rheograms demonstrate a fall in blood supply of vessels, as well as disturbance of arterial inflow and venous outflow. Thermographically, the difference in the temperature of skin over symmetrical joints in patients with secondary synovitis exceeded usual figures by 1-2o; a rise in ESR and hexose level was also observed in these patients. 42.3% of patients with DOA had an elevated blood level of beta-lipoproteins. Blood levels of 11-oxycorticosteroids remain normal, but usually are at the lower norm limit [Kamenskaya N.S., Fedorova N.E., 1990; Suzdalnitskiy D.V., 1993].
These patients show signs of arterial insufficiency: chilliness of feet or hands, paresthesia, numbness, cramps, intermittent claudication. Symptoms of thrombophlebitis migrans (in 3%) and paroxysmal attacks of Raynaud’s disease (in 5%), not uncommonly observed, are probably caused by concurrent cervical osteochondrosis. The patients showed a so-called spastico-degenerative type of capillaroscopic pattern on toes and fingers, a rise in blood coagulability, and, in particular, a fall in blood fibrinolytic activity [Kotelnikov V.P., 1984; Grigoryeva V.D. et al., 1992].
Laboratory findings help to assess the degree of inflammation in the affected joints. For instance, such indices as ESR, blood levels of hexoses, mucoproteins, C-reactive protein are usually raised in patients with reactive synovitis. The level of oxyproline excretion, which is an indicator of general collagen metabolism, characterizing destructive processes in connective tissue, is, on average, 385.3 umol/day (with normal level being 192-276.9 umol/day). Its highest figures are observed in patients with polyosteoarthrosis [Grigoryeva V.D. et al., 1992].
Arthrites and arthroses of the mandibular joint. A.S. Ivanov (1988) observed a statistically significant fall in the activity of catalase and superoxide dismutase in these patients, with the activity of the antioxidant system remaining unchanged. These changes can be regarded as a decrease in the activity of the antioxidant system of the body, in particular in the ascorbate link of the non-enzymatic part in this system, and the activity of antiperoxide enzymes. In addition, the decrease in total thiol level in these patients points to the disturbance of their synthesis.
Conventional roentgenography, tomography, and orthopantomography are especially important in the diagnosis of inflammatory and degenerative-dystrophic diseases of the mandibular joint. The diagnosis is significantly facilitated by the use of roentgenofunctional investigations. Computer tomography should be used in cases where differential diagnosis presents some problems. X-ray findings allow not only to diagnose the presence of inflammatory or degenerative-dystrophic process in the joint, but also to determine its stage as objectively as possible.
Only now specialists start to unveil the methods used to prevent the development and progression of osteoarthrosis. Osteoarthrosis is, most likely, not a disease, but a physiological disbalance between mechanical loads and the ability of joint tissues to counteract them. This concept was put forward at the beginning of the 20th century, when distinction was made between the destruction of joints as a result of inflammation and due to the effect of mechanical factors. The difficulty in differential diagnosis was also linked with the fact that the destruction of joint tissues under the effect of an excessive load is always accompanied by an inflammatory component as an inevitable reaction to rejectable debris and, vice versa, the tissues with inflammatory changes can be easily destroyed under stress. In arthrosis, tissue reaction to altered conditions is mediated through remodeling of deeper layers of the subchondral bone and, to a less extent, those closer to the joint cartilage. Therefore, the joint can be “healed”, if load is reduced to a level that can be sustained by these tissues. The earlier proposed theory that osteoarthrosis, once emerged, is steadily progressing, has not been duly supported by clinical evidence [Radin, 1987].
A clinician needs to know pathophysiology of osteoarthritis and the effects of predisposing factors, causing its progression. In osteoarthrosis, the destruction and degeneration of tissues is accompanied by proliferation by “normal” joint cartilage and bone. This means that the problem is not with cells, but with their reaction to the altered conditions. Predisposing factors include inborn traits of the body. Osteoarthrosis and osteoporosis is never observed in adults in imperfect osteogenesis. Quite the contrary, osteoporosis in adults very often leads to osteoarthritis. In congenital diseases this probably has to do with inadequacy of metabolism of proteoglycans. Any congenital abnormality, causing the incongruence of joint surfaces, results in an inadequate load and, therefore, is harmful as it leads to the development of osteoarthrosis. The classic example is congenital hip dislocation. The incongruence of joint surfaces developing in the 3rd or 4th decade of life leads to osteoarthrosis. Various forms of dysplasia can be predisposed genetically.
One of predisposing factors is obesity. In obesity, as a rule, only knee joints become affected. Perthes disease is often complicated by osteoarthrosis. An early remodeling without destruction of the femur head favors the restoration of normal load on the cartilage and the subchondral bone, which is a good prophylaxis of osteoarthrosis. In coxa valga, due to a rise in the pressure of muscles, acting on a shorter lever, the risk of hip osteoarthrosis can grow. Subluxation of the patella in any angular deformation of the femur leads to osteoarthritic changes.
Age-related changes can be regarded as the most important pathogenetic link of osteoarthrosis. Ageing does not necessarily lead to osteoarthritis, although the incidence of these changes rises with age. It cannot be ruled out that this is due to a mere summation of minor traumatic changes. Secondary osteoarthrites can develop after infection. The total loss of the meniscus in the knee joint leads to the concentration of tensions in this part of the knee joint. In very advanced morphological changes in osteoarthrosis, it is very difficult to make a retrospect judgment about the initial triggering factors.
There exists also an “idiopathic” osteoarthrosis. An experimental model has even been developed on animals exposed to repetitive pulse load. The experiments showed that “idiopathic” osteoarthrosis develops as a result of the disturbance of the mechanism of defense against gradually subsiding loads.
There are two factors causing progression of osteoarthrosis: an inflammatory reaction of the body on primary destruction of joint elements and secondary arthritic changes. Enzymes coming from the synovial membrane can enhance the destruction of the articular cartilage. A fall in the elasticity of subchondral bony plate can be accompanied by progressive changes in the articular cartilage. Microfractures and sclerosis of subchondral trabecules predetermine subsequent destructive changes in the cartilage.
Clinical experience shows that antiinflammatory drugs do not prevent the progression of osteoarthrosis. Preventive measures were developed on the basis of theoretic provisions. The removal of peak loads on the joint improves the course of the pathologic process considerably. It is known that a decrease in vibration allays the course of spondyloarthrosis in truck drivers. Surgical interventions relieving stress loads (thighbone osteotomy, lateralization of the greater trochanter, ventralization of the tuberosity of the tibia) show a high efficacy. Varying osteotomy of the femur can also be used in some situations, since it reduces the degree of muscular traction. Certainly, this operation should be performed at an early stage, when the congruence of joint surfaces is intact.
Epicondylitis, styloiditis, scapulohumeral periarthritis. All these pathologic processes develop at the backdrop of degenerative-dystrophic changes in periarticular tissues that lead to neurodystrophic disorders, pain, limitation of joint movements and long-term disability. Patients usually show a decrease in handgrip by 20-40% as compared to the healthy hand [Krupko I.L., 1959; Ternovoy K.S. et al., 1984].
As a rule, arthrites and arthroses are accompanied by various diseases of other organs and systems of the body, such as essential hypertension, chronic ischemic heart disease with infrequent anginal attacks, chronic adnexitis, prostatitis, chronic tonsillitis, cholecystopancreatitis, peptic ulcer of the stomach and the duodenum. In 85% of patients the dystrophic process was found to involve also the vertebral column.
At present, a great number of drugs and physical factors with various modes of action is used in the treatment of patients with RA and DOA. Most of them suppress inflammatory changes and the pain syndrome in the periods of exacerbation; they, however, are not free from numerous imperfections leading to side effects. For instance, intraarticular administration of corticosteroids produces a rapid analgesic effect due to the suppression of inflammatory changes. By disturbing the sulfopolysaccharide metabolism, however, corticosteroids produce an adverse effect on the course of osteoarthrosis. Therefore, intraarticular administration of hyrdocortisone or other similar drugs is justified only in secondary synovitis [Yumashev G.S., 1983].
Good results were observed under the use of orthopedic therapy (extension by traction applying gaiter, orthopedic apparatus), aimed at the unloading of the affected joint and the elimination of contractures, as well as immobilization of the limb by plaster bandage for a short period of time (in marked pain syndrome). The treatment, however, should be based not on the immobilization of the limb, but on a graded rise in joint movements, combined with its axial unloading. A high efficacy was also shown by exercise therapy in a swimming pool, swimming, massage of regional muscles, mechanotherapy, manual therapy of limb joints and the spine [Barvinchenko A. et al., 1990; Doerti M., Doerti D., 1993].
In the past decade, a low-intensity laser therapy has been increasingly gaining importance in the multimodality treatment of joint disease due to its universal non-specific effect on the tissues and the body as a whole, acting simultaneously on several links of the pathogenetic chain.
PATHOGENETIC GROUNDS FOR THE USE OF LASER THERAPY IN JOINT DISEASES
Close-contact laser irradiation with mild compression of the soft tissues permeates all dermal and subdermal nervous and vascular plexuses and structures, as well as muscular layers. Low-intensity laser irradiation of living tissues was found to be associated with a number of biological and physiological effects, which can be summarized as an influence on the energoplastic metabolism [Prehn, 1985; Sanseverino, 1985; Kamikava, 1988; Basford, 1989].
Investigations of the native blood of patients with acute conditions (injury of locomotor system, burns, etc.), carried out by I.Z. Nemtsov and V.P. Lapshin (1992), showed that exposure to helium-neon laser radiation with power density of 10 mWt/cm2 restored perimembrane aqueous structure and the deformability of erythrocyte membranes, on average, within 6-7 minutes. Thus, the average therapeutic dose of laser radiation was 4 J/cm2 (mean biodose of laser effect on the blood). The use of an excessive individual biodose gradually leads to the inhibition of erythrocyte function. It was shown that treatment efficacy is dependent largely on total exposure energy, rather than on radiation wavelength. While comparing dose-related characteristics of laser radiation at various wavelengths, the differences in energy quantum and especially in the tissue photon absorption need to be taken into consideration. Such a dependence, as a rule, is mostly typical for non-specific factors. Experimental and clinical findings show that a low-intensity laser radiation activates systems of non-specific body resistance [Pasanyuk E.N. et al., 1989; Frenkel I.D., 1991]. Laser-induced effects get accumulated with every procedure and every course of treatment.
In extracorporal irradiation of the blood by a helium-neon laser, platelet aggregability shows a dose-dependent reduction, and exposure in excess of the therapeutic dose causes hemolysis [Pluzhnikov M.S. et al., 1992]. Comparing effects of red and near infrared (IR) laser radiation in experimental irradiation of venous blood of rabbits, A.I. Olesin and V.A. Lukin (1989) established that a hypocoagulative effect of red radiation (0.63 um) was considerably greater than that of IR radiation 0.89-0.9 um); the dose of over 3 J/cm2 causes hypercoagulation and activation of lipid peroxidation.
Experimental recording of electric parameters of the sciatic nerve (membrane potential, action potential) showed that the irradiation of the nerve in the red and infrared spectrum range leads to hyperpolarization of membrane potential in the first several minutes of exposure, which corresponds to the blocking of nerve impulse conduction (analgesic effect). Subsequently, action potential amplitude and its conduction speed rose by 10-15%, which could be due to an improved nervous trophicity of tissues.
The response of the sick body to laser exposure includes the improvement of microcirculation and the activation of non-specific defense factors, cellular and humoral immunity systems, and informative-acceptor links, as realized in the enhancement of lipid peroxidation, oxygen utilization by tissues, changes in membrane permeability, oxidation-reduction processes, metabolism. All this strengthens the reparative function of tissues. The wide range of various specific effects of biological stimulation (a decrease in local inflammatory reactions, speeding up of wound healing, restoration of disturbed hemodynamics, and elimination of local pain), observed after low-intensive laser therapy signifies that laser effect can be mediated via systems that integrate adaptation processes. One of such systems is the diffuse endocrine system. Being present in virtually all of the organs and producing vitally important biologically active substances (biogenic amines and peptide hormones), the endocrine cells of this system, functioning under the conditions of intercommunication and interdependence, acts as homeostasis regulators. The end result of the activity of these cells is the control over the course of physiological processes.
Local release of serotonin, a potent vasoconstrictive agent, from mast cells of the skin, blood platelets, and EC-cells of the digestive tract leads to a reflex reaction, aimed at overcoming vascular spasm, and to stable arterial hyperemia of organs or tissues exposed to laser radiation. The most stable and potent effect was recorded at the frequency of 100 Hz for norepinephrine-producing cells and at 10 kHz for those producing epinephrine. In the frequency range of 10Hz-10 kHz, the intensity of serotonin release shows a dose-dependent character. The balance of regulatory peptides changes both in exposed tissues and in the body as a whole, producing an analgesic effect, causing changes in the functional state of immunocompetent cells and regional microcirculation, as well as activating regenerative processes in damaged cells and tissues [Kurzanov A.N., Feldman E.B., 1989].
Literature data on the efficacy of laser therapy in joint diseases are rather controversial. This can be due to the use of different approaches to treatment, different methods and doses of laser irradiation, as well as to the fact that most researchers in this country do not have the possibility to give a sufficiently objective and reliable assessment of the character and degree of pathological changes in the area of the joint.
It is well known that the efficacy of laser therapy depends not only on the dose of laser action (per procedure or course of therapy), but also on the initial state of tissues and the whole body. Medicines, state of the central nervous system, time of the day and season of the year influence electric and optic properties of the skin, which has a significant impact on the character of body response to laser irradiation. At the same time, exposure to laser irradiation, by influencing metabolism, microcirculation and nervous processes, raises sensitivity of the body to physical and drug therapy.
Clinical and experimental data on the use of laser radiation in the treatment of joint diseases are indicative of positive changes in tissues of the exposed area as well as in the whole body. G.V. Tupikin et al. (1985) studied the effect of irradiation of patients with RA using helium-neon and argon lasers. Irradiation of skin over the affected joint was shown to be effective in the process activity of the 1st degree, whereas under its 2nd degree a sufficient effect was observed if laser radiation was delivered via light guide directly to the damaged synovial membrane; the effect was greater if patients took orally photosensitizing drugs. Experimental investigations using the model of arthritis showed that irradiation by an agron laser produced a reduction in exudative phase of inflammation and stimulated fibroblastic processes. This resulted in a quick succession of inflammation stages with a smaller risk of the destruction of articular cartilage by pannus (normal synovial membrane is replaced by granulation tissue, which shows especially abundant growth in areas adjacent to the articular cartilage, where it is called pannus).
External irradiation of joints by a helium-neon laser leads to a decrease in the intensity of lipid peroxidation and produces an effect on the proteoglycan metabolism [Kozlova I.S. et al., 1988]. Using the Uzor device (wavelength, 0.89 um; pulse power, 4 Wt) for external irradiation of the area of the joint and vascular bundles, concurrently with the use of antioxidants, S.Yu. Leshakov et al., (1989) and V.A. Nasonova et al. (1989) observed a significant decrease in inflammatory signs in RA patients: a fall in ESR and the levels of C-reactive protein, seromucoid, and rheumatoid factor titer. The best results of laser therapy were observed by N.P.Shtelmakh et al. (1988) in seronegative RA, in primary DOA without reactive synovitis, and at the initial stage of Bekhterev’s disease. According to N.F. Sorokin (1988) and A.T. Manasaidov (1992) the efficiency of laser therapy rises with a decline in inflammation activity in RA (under the minimum activity the efficiency is the highest) and in elderly patients, i.e., in cases where stimulation of bioenergetic mechanisms and blood supply to the affected area is especially important.
Investigations carried out in our laboratory [Gutikova L.V. et al., 1991] showed that the treatment of RA and DOA using pulsed infrared radiation of the Uzor device induced dose-dependent blood reactions. Optimum doses of laser irradiation should not exceed 0.25 J/cm2 per procedure.
A.S. Ivanov (1988) noted elimination of inflammation and pain in arthrites and arthroses of the mandibular joint, regardless of its roentgenological picture, under external irradiation of the affected joint area by a helium-neon laser (power density, 4 mWt/cm2; exposure time, 60 sec; 14 procedures per course of treatment) in combination with antioxidants. V.I. Ruzov et al. (1991) established that antioxidant insufficiency under the conditions of hypodynamia can be corrected by both intravenous and external irradiation of the vasculature area by a helium-neon laser (power, 2 mWt; exposure time, 4 min) modulated by the frequency of 150 Hz. A.S. Kryuk et al. (1986) reported that the most marked analgesic and antiinflammatory effects in RA patients were observed under a combined irradiation of the affected joints by helium-cadmium (blue) and helium-neon (red) lasers, together with the use of drugs and other methods of treatment. This therapy resulted in a fall in ESR and the levels of acid cathepsins, acid phosphatase, hexosamines, neuraminic acid. A course of laser therapy needs to be followed by maintenance drug therapy. A favorable effect of the multimodality therapy including laser irradiation persists for 3-12 months. Positive changes in the clinical picture of the disease (alleviation of pain, improvement of joint function, less marked reaction to weather changes, etc.) gradually increase. The same multimodality therapy approach is effective in DOA, and the authors believe that changes in humoral immunity do not play a major role in this respect. Normalization of the most important biochemical reactions in the body, as assessed by the change in activity of lysosomic hydrolases (acid cathepsins and acid phosphatase), and of the blood serum glycoproteins is of a great importance for successful treatment of degenerative-dystrophic diseases.
V.E. Illarionov (1990) showed that the use of infrared laser radiation (4 mWt/cm2; wavelength, 0.81-0.89 um; exposure time, 2-4 min per area) in combination with permanent magnet field (30 mT) causes a maximum restructuring of the subchondral bony plate and enhances blood circulation in the endosteum, which prevents necrosis of the joint tissue. At the same time, the deep layer of the cartilage is preserved, and the structure of the cartilage attains a marked fibrous-fibrillar character. If the number of procedures exceeds 15, this produces an inhibitory effect on the vital activity of joint tissues, which is manifested in the emergence of osteosclerosis sites.
In intravenous laser blood irradiation, 17% of patients with RA show infectious complications in the process of treatment (exacerbation of chronic tonsillitis, chronic cholecystitis, chronic pyelonephritis, etc.), acute respiratory viral infections, bacterial pneumonia [Tupikin G.V. et al., 1992]. Clinical immunological analysis showed that the exacerbation of infectious processes was preceded by a significant decrease in the level of cellular immunoreactivity (suppression of spontaneous E-rosetting lymphocytes, of the blast-transformation reaction to phytohemagglutinin, of the activity of interleukin-2), which was concurrent with the development of the primary exacerbation (photoreaction). This was accompanied by a rise in titers of antistreptoccocic antibodies. Using antibacterial therapy and local anti-infectious treatment in combination with repeated procedures of intravenous laser blood irradiation, the authors managed to cure infectious processes in young persons with primary exacerbation. In elderly patients, especially in those who had been given cytostatic drugs for a long time, as well as in patients with a secondary exacerbation syndrome, exposed to intravenous laser irradiation, infectious processes showed a persistent character. Immunologic parameters in these patients pointed to secondary immunodeficiency.
Thus, the multimodality treatment of RA with the use of laser radiation requires a serious individualized approach in each specific case and a dynamic objectivization of the process course for a timely adjustment of therapeutic interventions. In the treatment of DOA, the main tasks are to decrease the activity of inflammatory process and the pain syndrome, and to stop degeneration of joint tissues.
Reference patterns of laser therapy in patients with RA and DOA are given below.
METHODOLOGICAL ASPECTS OF LASER THERAPY IN JOINT DISEASES
Laser irradiation as a component of multimodality therapy in diseases of joints should preferably be used in subacute period of the disease. In view of the presence of concurrent diseases, long duration of the main process, the development of adaptive compensatory mechanisms, and the difficulty of fulfilling the main condition of a successful therapy, i.e., to unload and to give a rest to the affected joint, therapy should be planned as several courses to be given over the period of 3-4 years. Laser therapy is especially effective in the spring and the autumn. A course of treatment should be started 2 weeks before expected exacerbation. In any case, the patient should be advised not to miss an incipient exacerbation and start treatment immediately.
A course of therapy consists of 12-13 procedures carried out daily (except Saturday and Sunday). Treatment should preferably be started on Monday, so as to carry out five daily procedures a week. At first, low doses are used, which are then increased and again lowered by the end of the course. The course can be repeated after three weeks; doses may be increased or decreased in a way somewhat different from that given in reference patterns, taking into account individual reaction of the patient to laser irradiation. In all cases, however, the guiding principle should be not to exceed the dose of 0.3 J/cm2 per procedure for pulsed infrared laser radiation (laser therapy devices Uzor, Mustang) and 3 J/cm2 for red helium-neon laser radiation. If continuous radiation of an infrared laser is used, the dose should not exceed 1.0-1.5 J/cm2. These doses are calculated for direct laser irradiation of the affected joint area (a stable contact-mirror method of irradiation). In remote irradiation, it needs to be taken into consideration that about 35% of infrared radiation at a wavelength of 0.89 um is reflected from the skin surface.
Another important principle in the tactics of laser therapy of joint diseases is not to attempt to treat all of the affected joints. The joint that bothers the patient most of all should be selected. Other joints and internal organs can also be exposed, but observing the principle: not to exceed the total dose per procedure. Total dose should be divided into the number of areas to be exposed, with the exposure time of the most painful areas being the most lengthy. Total time of one procedure should not exceed 10 minutes.
The practice shows that the physician should not strive to achieve a marked therapeutic effect by all means. First, there are no universal remedies, and laser therapy is not one, either. Second, the consequences of laser radiation overdosage can be more serious than the joint disease itself (blood disorders, etc.); in addition, even at the price of developing complications, the main disease often cannot be cured. One should also bear in mind that chronic diseases are rather profoundly compensated for by virtually all functional systems of the body; and the resulting pathological patterns - programs for the existence of the body under new conditions - become fixed in the central nervous system. Therefore, potent and rapid interventions with respect to such a body usually lead to the breakdown of functional systems and the wreckage of links between them, rather than the restructuring and rearrangements in the body in conformity with its genetic programs. Clinically, this is manifested in various forms of exacerbation of the main disease, the aggravation of previous pathologic conditions remembered only by the central nervous system, the emergence of secondary immunodeficiencies, reaction of different of blood-forming elements, etc.
Treatment of joint diseases requires great tolerance on the part of both the patients and the physician. The state of patient, his blood count and ECG need to be monitored constantly. The period between the spring and autumn courses should not be less than 6 months. In the first year, the main tasks of laser therapy are to eliminate periprocesses, to stop inflammation, to normalize microcirculation in the affected joint area, to provide body with more “energy”, and to cure concurrent diseases. On the second and third years, the task is to stop the progression of degenerative process.
The laser therapy schemes given below are not differentiated nosologically, and they are identical for rheumatoid arthritis, DOA, epicondylites of the humerus, tibia and femur, etc. The signs of a successful therapy and the correct dosage of laser radiation are alleviation or elimination of pain (including nocturnal one), morning stiffness, reactive synovitis, and muscular atrophy; a decrease in edema; gradual restoration of joint function; facilitation of its bending and unbending; a fall in ESR and other blood indices.
During the period of treatment, the joint should be unloaded as much as possible; the patient should preferably walk with a stick. Treatment efficiency is the highest under hospital settings.
The patient should be in a sitting or lying position, with the limb placed comfortably so as to remove any muscular tension. If the patient is exposed to laser irradiation for the first time, the recommendations given below should preferably be followed. The patients needs to be given some basic information about laser therapy, and his consent to this form of therapy has to be obtained.
“During the communication between the physician and the patient, the former acquaints the latter with the relevant psychopathologic knowledge; elucidates the processes underlying his disease; exerts a direct influence on patient’s world outlook and his ability to assess the situation; helps the patient to improve his self-perception, self-awareness, and efficient self-care” [Jaspers, 1955].
Contraindications to laser therapy are tumors, active tuberculosis, severe cardiovascular diseases, systemic blood diseases, infectious and endocrine diseases (thyrotoxicosis, noncompensated diabetes mellitus, and others).
The scheme of treatment using the Mustang laser therapy device (pulse recurrence frequency, 80 Hz; in marked pain syndrome, 150 Hz can be used after the 4th-5th procedure, 1500 Hz after the 7th procedure, and again 80 Hz after the 10th procedure; pulse power, 4-7 Wt; stable contact-mirror method) is: 1st procedure: two painful sites in the vicinity of the affected joint, 32-64 sec per each; 2nd procedure: three painful sites near the joint, 32-64 sec each; 3rd procedure: three painful sites near the joint, 64 sec each, two segmental sites paravertebrally, 32 sec each; 4th procedure: same as the 3rd procedure; 5th procedure: three painful sites near the joint, 64 sec each; liver area, 128 sec; 6th procedure: two painful sites in the joint area, 128 sec each; two segmental sites, 32 sec each; liver area, 128 sec; 7th procedure: two sites near the joint, 128 sec each; two sites in the large intestine area, 128 sec each; 8th procedure: two sites near the joint, 128 sec each; two sites in the large intestine area, 128 sec; two segmental sites, 32 sec each; 9th procedure, same as the 8th procedure; 10th procedure: two sites near the joint, 128 sec each; two painful sites in the abdominal area (determined by palpation), 128 sec each; 11th procedure: two sites near the joint, 128 sec each; two sites in the intestine area, 128 sec each; 12th procedure: three sites near the joint, 64 sec each; liver area and projection of the sigmoid colon, 64 sec each. Laser irradiation using two radiators simultaneously is more convenient and produces a greater effect on the body. The matrix radiator MLO1K is usually used for the irradiation of areas of the liver, intestine and large painful areas (10-12 cm2); heads of the LO type (LO2, LO3, etc.) are used to irradiate small painful areas (sites) in the vicinity of the joint.
Fig. 1. Irradiation of pain from articular and periarticular structures.
a - shoulder joint (rotating shoulder “cuff”); b - hip joint; c - trochanterian bursitis; d - de Quervain’s tenosynovitis; e - lumbar facet joints syndrome; f - sacroiliac joint; g - tennis elbow ( lateral epycondylitis of the humerus).
The highest efficacy was shown under magnetolaser therapy using magneto-optic attachments (set KM-2) at magnetic field strength of 25 or 75 mT. The time of exposure to magnetolaser irradiation with such parameters was 32-64 sec per painful site (contact-mirror method, with soft tissue compression; pulse power, 3-4 Wt; pulse recurrence frequency, 1500 Hz).
In marked inflammatory signs in tissues in the joint area, 5-10 minutes prior to the procedure, the painful areas should preferably be anointed with dimexid; laser irradiation should be performed at a distance of 5-7 mm (from the LO or MLO1K radiator to the skin surface), with the exposure of 64 sec per area (3-4 irradiation areas near a large joint). The main methodological principle of laser therapy in joint diseases is to deliver laser irradiation to the site of the greatest pain, which is determined by palpation.
Localization of the pain syndrome needs to be verified. Patient’s terminology (such as “shoulder” or “thigh”) can fail to be true to reality. The patient should be asked to show the most painful site and delineate the area of pain propagation.
Fig. 2. Localization of pain in the damage of the knee joint (a) and origin of pain irradiating to the knee: b - spine; c - hip joint.
Both articular and periarticular pain can be irradiated to a wide range of areas distant from the site of its origin (Fig. 1,2). Such a “referred” pain is caused by false sensory cortical perception due to overlapping innervation of structures that have developed from a common embryonic germ, which is divided into dermatome, myotome and sclerotome. Cortical cells receive impulses mainly from the skin. Therefore, when a pain impulse first arrives at these cells from deeper embedded myotome/sclerotome structures, they interpret it in accordance with their past experience and “sense” pain, reflecting this overlapping, in the area of the skin (dermatome). An important distinctive feature is that this pain is perceived deeper than simply in the skin, and its bounds are vague. Therefore:
- referred pain is irradiated segmentally, without crossing the median line;
- dermatome often extends more distally than myotome, therefore the pain as a whole propagates at a greater distance. The more distal the pain origin is, the more definitely its location can be spotted;
- in addition to the irradiation of pain, these sites can be painful at palpation;
- dermatomes vary in different people. Thus, the precise area of pain irradiation can also differ in various patients with the same injury of the locomotor system;
- in general, the closer to the surface a soft tissue structure is located, the more precise pain localization is (pain from deeply embedded, but firm structures, such as bone and periosteum, shows virtually no irradiation);
- massage of the irradiated pain area, as a rule, brings relief, rather than intensification of pain (whereas the pressure directly on the pain origination site can provoke it).
Pain, associated with joint movement points to its mechanical character, especially if it is enhanced under functional load and subsides rapidly upon its removal. Rest pain or pain which is more intense at the beginning of movement than at its end, points to a marked inflammation. Nocturnal pain is a severe symptom, exhausting the patient, and reflects intraosseous hypertension; it usually accompanies such pathologic states as vascular necrosis or the collapse of bone tissue in the area of a marked arthropathy. Constant (day and night) “bone pain” is characteristic of tumor metastases.
Figure 3 shows arches of painfulness: the patient experiences pain while slowly raising his arm sidewise and then slowly taking it down. The initial 90o of this complex movement are performed by abducting the shoulder joint; the next 70o is mainly the rotation of the shoulder blade; and the remaining 20o are again performed by moving the shoulder joint. The second half of this complex movement is also accompanied by the motion of the sternoclavicular and acromioclavicular joints, and many people try to turn the arm here. Painfulness arch can be of two main types - mid-level and upper [Doerti M., Doerti D., 1993].
Fig. 3. Types of painfulness arch [after M. and D. Doerti, 1993].
a - mid-level arch (bursitis of the supraspinal/subacromial muscles); b - upper arch (acromioclavicular joint).
If the blood needs to be irradiated in order to stimulate immunity, this can be performed transcutaneously in the area of large neurovascular fascicles: radial, ulnar and subclavian (radiating matrix MLO1K; pulse recurrence frequency, 150 Hz; pulse power, 7-10 Wt; exposure time, 128 sec). Such procedures can be performed 2-3 times a week (5-6 procedures per course of laser therapy).
The efficacy of laser therapy is significantly enhanced if acupuncture sites are stimulated additionally [Balabanova R.M. et al., 1988; Bisyarina V.P. et al., 1988; Kapinos E.N., 1988; Timen A.E. et al., 1989]. (For principles of laser reflexotherapy see: Kozlov V.I., Buylin V.A. “Laser therapy”, 1992). In this cohort of patients, psychotherapy [Shavianidze G.O., 1991] and reflexotherapy are well justified and effective due to the state of psychoemotional depression caused by the disease. An excessive sensitivity of the patients to even minor aggravations in the course of the disease is due to the concentration of attention on the pain, which prevents these people from performing physical and mental work. They develop a fear of complete stiffness of joints and disability. This is accompanied by the disturbance of sleep, sexual function and leads to social disharmonization of personality.
The long duration of the sufferings, negative emotional reactions, modulated by genetic and individual peculiarities of the body, age-related neural and endocrine changes, past experience, and memory, lead to the evolvement of a purely somatic disorder into a psychosomatic disease. This disease requires a corresponding basic therapy, aimed at the stabilization of activity of antistressor systems and the attainment of distinct sedative and antidepressive effects.
The formation of organic articular disorders, changes in peripheral neural mechanisms of pain and the above central disturbances lead to the fact that the conventional analgesic drugs (antipyretics, nonsteroid antiinflammatory drugs) show low efficacy, whereas drugs acting on mediator processes (parlodel, anaprilin, pyrroxan, etc.) can produce an obvious therapeutic effect.
Age-related hemodynamic changes not only lead to the insufficiency of local arterial blood supply to the area of the joint and, later, to its degenerative-dystrophic disorders, but also disturb the functioning of the vessels themselves. An age-related rise in arterial pressure, having an adaptive nature, accelerates atherosclerotic processes, above all in those vessels which have already undergone fatty degeneration. The development of plaques and a rise in their number and size narrow the area of receptor-active inner surface of the arterial vessels. Disregard of this fact and the use of means causing a greater vasodilatation (active thermal procedures, potent spasmolytic drugs, such as complamin, diprofene) can lead to the development of the reverse steal syndrome and, as a result, a still further impairment of blood supply. An alternative therapy, which allows to take into consideration sanogenic procedures and to avoid the above processes or correct them in a mild physiologic fashion, is laser physical and reflexotherapy, combined with the use of capillaroprotective, antioxidant and venostimulating drugs (venoruton, rutin, troxevasin, etc.). The choice of the dose of laser radiation and drugs is a difficult task, which should be dealt with in each individual case by a physician (laser therapy is a physical therapy performed by a physician). The solution of the problem of laser radiation dose is greatly facilitated if the Mustang-Bio laser therapy device is used. The probability of overdosage and negative reaction of a cell markedly diminishes with a decrease in metabolism, whereas sensitivity rises by an order of magnitude, if laser effect on the cell is modulated by the entire hierarchy of periods of its own biorhythms. The elimination of desynchronism in these frequencies as they rise, with the preservation of the optimum ratio of periods, results in a steady, rather than transient, intensification of biosynthetic restorative processes with respect to destructive ones. The restoration of temporary cell organization harmony ensures a stable therapeutic action without any adverse side effects. The necessary prerequisite for its manifestation at the tissue and organic levels is the correlation of the intensity of laser irradiation with the blood flow rate, which is ensured by control signals from patient’s pulse and respiration sensors [Zaguskin S.L. et al., 1994]. Biologically controlled laser chronotherapy with automatic account of biorhythmic peculiarities of the patient increases the efficacy of treatment of patients with joint diseases by 90%.
V.S. Shukhov (1992) believes that, in order to work out a comprehensive scheme of therapy of a patient with locomotor disorders, the following aspects should be taken into consideration: 1) psychological characteristics of the patient; 2) severity and character of the pain syndrome; 3) the duration of pain history (flexibility of noniceptive processes, pain chronicity); 4) stressogenic significance of pain for the preservation of integrity of neuroendocrine, vascular and neuromotor processes; 5) subjective peculiarities of the means to stop pain; 6) the degree of involvement into the process (layer-by-layer) of anatomo-physiological structures linked with the execution of movement; 7) the extent of motor disorders in the responsible pathologic motor system; 8) indirect secondary mechanisms aggravating (modifying) the main process; 9) leading factors provoking pain and the entire process; 10) the preservation of the motor stereotype; 11) the involvement into the general process of other motor systems, together with the primary injury sire; 12) the involvement in the general process of the spinal column; 13) the involvement into the general process of motor systems of the opposite limb; 14) the involvement into the general process of internal organs and systems; 15) the dynamics of the elaboration of a new behavioral stereotype; 16) sanogenoadaptive capabilities of the body of a patient.
The above sequence of diagnostic steps can seem cumbersome, but it unites the three fundamental questions related to the provision of care to the patient: information about the personal traits of the patient and his attitude toward the pain that annoys him; information about the disturbance of a motor act in an individual system; information about the targets and body reserves for the prevention and treatment.
The presented material shows that to treat joint diseases means to treat a sick person in his social and biologic entirety.
Therapy should be not only complex as regards the set of means and methods used, but also systemic. The physician needs above all to show himself as a personality who understands another person and cares for him. With such an approach to this matter, laser radiation in hands of a physician will indeed be healing.
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