Professor GA Panshin

FGBU "Russian Scientific Center of Radiology" of the Ministry of Health of Russia, Moscow, Russia

The results of a combined use of X-ray and low-intensity laser radiation in the treatment of degenerative and inflammatory diseases of osteoarticular apparatus

Introduction

Inflammatory and degenerative-dystrophic diseases of bones and joints that do not have up to date pathogenetic treatments are of great socio-economic importance because of their high prevalence, frequent disability of patients, especially the older age groups, as well as associated with them, as a rule, a significant reduction in quality of life, leading, eventually, to a significant negative impact on their economic and psychological state (1, 7, 8, 11, 13,14, 15, 18, 22, 23, 24, 28, 29, 34, 35).

In addition to medical treatment, to the methods of the local, including, and analgesic effects of this pathology include physiotherapy, massage, physical therapy, x-ray and laser therapy, and during exacerbation - magnetic therapy, ultraviolet irradiation erythema dose, mud, hydrogen sulfide, radon and pine baths (1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 16, 17, 20, 21, 25, 26, 30, 32, 35, 36, 38). I would like to emphasize the fact that the use of surgical treatment for degenerative - dystrophic diseases of large joints is very wide and very specific problem, and, as a rule, is in this situation, the final and radical step of special treatment in the case of failure to use all of the existing modern therapeutic options (13).

To date, of all the non-neoplastic diseases, which used symptomatic radiation therapy (in most cases it X-ray radiotherapy), are dominated by degenerative and inflammatory degenerative bone and joint diseases – osteoarthritis, scapulohumeral periarteriity, spondylitis, osteochondrosis, heel and elbow bursitis, epicondylitis, rheumatoid arthritis, accompanied by reactive inflammation of soft tissue and severe pain. Providing anti-inflammatory effect on the soft tissues surrounding the joint, radiation therapy leads to a reduction or complete disappearance of pain, thereby increasing the range of motion in the joints or spine. As follows from the numerous studies on the use of anti-inflammatory radiotherapy subjective improvement occurs already during irradiation in approximately 60 - 70% of patients, and the full realization of the effect is usually observed after 2 - 2.5 months after treatment. It often is possible to dramatically reduce the dose of painkillers and anti-inflammatory pharmaceuticals that are used, as a rule, from the onset and duration of which are often indifferent to the body (1, 3, 7, 8, 14, 15, 16, 17, 21, 28, 29, 30, 32, 36).

The main group of patients are those over 50 years outside the reproductive age. Due to the age of patients and the presence of concomitant diseases, which prevent physiotherapy, radiotherapy is often the only possible method of treatment, since even the transferred patients with myocardial infarction and dynamic cerebral circulation are not contraindications to its performance.

Main effective factor when irradiated non-neoplastic diseases is its direct effect on the diseased organs and tissues. Other variants of radiation exposure can be applied only in exceptional cases. In this case, radiation therapy should be performed using the most gentle way of irradiation, in which the absorbed dose in the pathological focus will be the most effective in this clinical situation, and healthy tissues and vital organs, localized in the vicinity of its location, will be secured from the action ionizing radiation (3, 7, 8, 9, 11, 14, 16.18, 19, 24, 29, 38).

By absolute contraindications to radiotherapy nonmalignant diseases include the general plight of the patient with a sharp weakening of immunity, severe concomitant diseases of the cardiovascular, respiratory, hepatic, renal decompensation,

leuko-thrombocytopenia, severe anemia, radiation sickness and radiation damage in history, tuberculosis, mental illness, loss of orientation in time and space.

Besides radiotherapy nonmalignant diseases prohibited for children and pregnant women. Limited its application in the childbearing age, especially when the irradiation zone get organs of internal secretion, and central nervous system.

Relative contraindications are also acute septic and infectious diseases, inflammatory changes in the irradiation caused by a variety of physical and chemical agents, including physiotherapy.

It should be noted that the invention of lasers, fundamentally new sources of coherent monochromatic light emission, identified a new trend in medicine - laser therapy. They were introduced into medical practice recently, about 30 years ago, and yet, the success of their application in medicine today are clear and very impressive. Study the effects of low intensity laser biostimulation radiation opened broad prospects for laser applications in almost all areas of medicine, and in properly selected therapeutic doses of laser treatment is absolutely harmless. The use of laser therapy in the outpatient environment has increased the efficiency of treatment of patients with orthopedic trauma and 10 to 15%.

Thus, on the basis of experience gained as a result of comprehensive research laser therapy is widely used as a prophylactic and therapeutic purposes in various diseases of the musculoskeletal system, including the treatment of orthopedic and trauma patients, using techniques such as outdoor and invasive (intravenous, intra-articular, intraosseous) exposure (2, 4, 5, 9).

Due to the high clinical efficacy, a wide range of indications for use with a small number of side effects, the simplicity of the procedures and the use of high efficiency, laser therapy has become one of the main methods of rehabilitation of patients with disorders of the musculoskeletal system. In view of the pathogenetic mechanism of action of laser radiation on the indications for laser therapy developed, including diseases of the musculoskeletal system in the form of osteochondrosis with radicular syndrome, inflammatory diseases, bone and joint exchange etiology in the acute stage of arthritis and arthritis, diseases and traumatic injuries of muscles and ligaments (myositis, tendovaginitis, bursitis) occupy a very important place.

Among the absolute contraindications for laser therapy are blood diseases, including reducing its coagulation, as well as various types of bleeding.

Materials and methods

We observed for more than 5 years were 3 groups of patients, a total of 122 people, aged 30 to 75 years, who received X-ray and laser therapy in monorezhimnom variant, and in terms of their combined effect in the treatment of degenerative and inflammatory disease shoulder, knee and ankle joints.

In this case, the first group consisted of 50 patients treated with radiotherapy, of which the main diagnosis was made in 15 with the localization process in the shoulder joint, 20 - and 15 knee - ankle.

In the second group of 42 patients treated with laser therapy, the primary diagnosis was diagnosed, respectively, the localization process, 14, 15 and 17 patients.

In the third group of 30 patients were combined (X-ray - laser) treatment with an equal distribution of patients in each location of the main process (for 10 people).

The method of combined therapy was daily for consecutive weeks of sessions of laser therapy during treatment for 3 days (every other day), X-ray, with the interval between treatments to 30 minutes.

In this case, the criteria for evaluating the effectiveness of the treatment is to decrease until the complete disappearance of pain and increase range of motion in affected joints.

Indications for treatment were determined based on the patient's condition, medical history of the underlying disease and the effectiveness of the previously or that kind of special treatment.

The policy plan during X-ray treatment used such physical and technical conditions of irradiation as voltage, current, source-surface distance (SSD), filters with the constitutional features of the patients.

Given the nature of the anti-tumor doses of ionizing radiation to use the minimum dose possible for optimal clinical effect. As a rule, single focal doses were 0,3-0,5-0,7 Gy and were brought to a total focal dose order of 4-6 Gy irradiation rhythm 3 times a week (every other day).

It must be stressed that the key to successful treatment is the careful observance of every patient with a planned installation, taking into account the clinical and radiological data, methods of exposure.

Thus, irradiation of the shoulder joint was used 2-dipole radiation technique using the anterior and posterior fields, size, usually 10 to 15 cm and IRP - 40 cm In this case, the technical conditions of irradiation were as follows: voltage - 180-200 kV , current - 10 mA, filter - 1.0 mm copper.

The pathology of the knee joint irradiation was carried out with 2 lateral fields (medial and lateral), size, usually, 8-10 to 10-15 cm at IRP - 40 cm, voltage - 180-200 kV, a current - 10 mA, using a copper filter - 0.5-1.0 mm.

With the localization of the main process in the ankle irradiation was also carried out on 2-dipole method with the use of lateral fields of 8-10 to 10-15 cm at IRP - 40 cm, voltage - 150-180 kV, a current - 10 mA, using aluminum - 3 mm and 0.5 mm copper-filters. Laser therapy was administered daily for 4-12 minutes with a low-intensity laser that generates the laser light in a continuous mode and Q-switched mode and providing for the change of power at the end of the fiber in the range of 5-50 MW and a frequency of 80 - 1000 Hz.

In this case, laser treatment include the use of labile contact method, which eventually permitted a uniform volume irradiation of the affected joint.

Physical parameters of the impact of low-intensity laser treatment osteoarthritis in study groups of patients were characterized by the following data:

the localization process in the shoulder joint stable technique used laser irradiation with 2 fields with output power equal to 5mW, frequency - 80 Hz exposure and exposure for 2 minutes;

with lesions of the knee used labile irradiation technique using 4 fields with output power of 40 mW, frequency - 100 Hz and the treatment time for 3 minutes;

at osteoarthritis ankle, as well as the shoulder joint, the method used is stable exposure, but now with the use of 3 fields in the output power of 50 mW and a frequency of 1000 Hz, with an exposure of therapeutic effects for 4 minutes.

Findings

A comparative analysis of the results revealed that in all cases of only treatment option using or X-ray or laser irradiation was aggravation of pain after the start of the therapeutic intervention. However, with their combined use, on average, only half of the patients had a worsening of the underlying disease. In this case, the reduction in the treatment of pain in only X-ray or only laser irradiation, on average, after 7-8 sessions of X-ray and 9-10 sessions of laser therapy, whereas in the combined treatment - after 4-5 sessions. Significant, up to complete, relief of pain and increase range of motion in the joints were observed in 44 of 50 patients (88.0%) of the first group and was shown, usually 30-40 days after X-ray treatment, 34 of 42 (80.9%) patients of the second group - 20-40 days after laser therapy, and in 28 of 30 (93.3%) patients in the third group, on average, 15-20 days after the end of the combined use of these two methods of therapeutic intervention . In general, side effects associated with conducting the above treatments degenerative and inflammatory diseases of bones and joints of the device during their execution, as well as short-and long-term period after the end has been identified. Recurrence in the treated areas, as a rule, there were 3.5 years after the end of treatment in the first and second groups, and after 4.5 years - in the third group of patients. Undoubtedly, this fact proves, in the end, good tolerability and significant efficacy as X-ray and laser treatment not only in independent version, but, especially, in their combined use.

Discussion

X-ray radiotherapy is one of the local methods of treatment, although, unfortunately, to date, has a sufficiently broad clinical use, despite the fact that it is well designed and defined the precise indications for its use. This is due to the fact common among physicians and patients about the opinion of a significant risk of the specific effects of irradiation (radiation damage, secondary tumors), which to date has not confirmed the actual facts (7, 8, 11, 14, 27, 31, 34, 37).

At the same time, the local non-specific anti-inflammatory and analgesic effect of radiotherapy has been known for a long time (3, 7, 8, 14, 15, 17, 24, 25, 32, 35, 36, 38), and positive effects from its use in most possible cases, even when all other methods of non-drug treatments are ineffective.

These data are confirmed in numerous publications, both domestic and foreign researchers, showing real performance X-ray radiotherapy, and is based on a synthesis of more than a century of experience in clinical application of radiation therapy and achieved to date results of radiobiological studies. So, Seegenschmidt M. H. and colleagues studied the experience of 134 German institutions, 30 university hospitals and 104 hospitals in radiotherapy in patients with non-tumor diseases 20,082 in 1994, 1995 and 1996 (33, 34, 35,36).

The authors stated that radiation therapy is commonly used and effective form of treatment of many non-neoplastic diseases.

It should be noted that the study of long-term results of radiation therapy as a non-neoplastic diseases in our country and abroad showed no complications or adverse consequences of its use in remote periods after treatment.

In this respect deserves to research carried out in our country M.V.Makarova Application X-ray radiation therapy in the symptomatic treatment of osteoarthritis of the limbs. In particular, she pointed to the example of the treatment of 412 patients with primary arthritis of the joints of different locations that the method of X-ray small doses does not lead to the development of radiation-induced tumors in the field of radiation, including to morphological changes in the skin, get more than just a pathological hearth, the dose of ionizing radiation. These results were obtained on the basis of qualitative and quantitative morphological analyzes of biopsies 12-15 years ago exposed skin compared with symmetric non-irradiated areas to identify microscopic late radiation damage (8).

However, in spite of the pathogenetic basis and adequacy of the high efficiency of radiation therapy degenerative and inflammatory diseases of bones and joints system, to further improve the results of treatment of this disease, is a very complex and social problems for the world community, the need to search for new perspective and relatively safe methods of therapeutic effects, which include, in particular, further emission efficiency of laser radiation (12).

The positive effects of laser therapy has helped expand the volume of orthopedic care to patients of advanced age, with concomitant diseases of the cardiovascular and endocrine systems, in particular, in patients with diabetic angiopathy and arthropathy, as well as significantly improve the efficiency of providing care to patients with severe large joints with reflex back pain syndromes, and early arthritis of various locations.

In this case, it must be emphasized that the combination of laser with other medical factors including radiation therapy, along with minimal risk to the patient, it is very promising method of treatment not only of various diseases of the musculoskeletal system, but the vast majority of non-neoplastic diseases and certainly deserves more widespread use in clinical practice.

Findings

Thus, the analysis of the results of X-ray and low-intensity laser treatment, mainly pain and limitation of motion in degenerative and inflammatory diseases of osteoarticular apparatus showed the highest efficiency is at their combined use. Here, as at the time of therapeutic procedures, as well as during the subsequent long period of observation of patients for more than 5 years did not reveal any adverse effects on the method of treatment. Along with the efficiency of this method of treatment non-neoplastic diseases advantage of it is also in the simplicity and the possibility of exposure of the majority of patients in the outpatient setting, which makes it a cost-effective and feasible in the absence of a positive effect of other therapeutic measures. At the same time, we believe that to be effective therapy nonmalignant diseases that our country is very complex and socially significant problems, an integrated approach to solving it, including through the development of promising new and relatively safe treatment, in addition to the existing today radiation and laser therapy.

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