Physiotherapy in disease prophylaxis and treatment:

A review of applications Presenter

Dr Vladimir Gurevich

EL Physiotherapy

PhysiotherapyUse 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

UltrasoundTherapeutic 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

MagnetotherapyTherapeutic 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 phoresisThe main problem with the conventional oral and parenteral drug administration

is its inability to deliver the drugs specifically to the affected organ or tissueConventional 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 tissuesIn this approach transdermal or transmucosal administration of drugs allows

achieving a rapid treatment effectSpecific 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

Duration of inflammation symptoms (days)

SCENAR treatment (n=98)

Standard treatment (n=105)

Pain 3.4±0.2 5.4±0.3

Purulent exudate 3.3±0.5 5.9±0.4

Oedema and infiltration 2.9±0.3 5.0±0.3

Hyperthermia 2.8±0.2 4.7±0.2

Intoxication (weakness, headache etc.) 4.8±0.3 9.3±0.3

Period before suture (days) 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)

GROUP POSTOPERATIVE

PERIOD BEFORE TENS

AFTER TENS

P

TENS 2 h after surgery 5.2 ± 1.8 1.4 ± 1.2 .007

4 h after surgery 3.7 ± 1.3 0.9 ± 0.8 .007

Placebo TENS

2 h after surgery 5.3 ± 2.5 5.0 ± 3.4 .216

4 h after surgery 5.0 ± 3.1 4.7 ± 3.7 .713

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 ControlStatistical

significance

Blood pressure (mm Hg)

125/66±22/16 121/64±21/15 p < 0.05

Urea removal (g/dialysis)

19.4±3.7 15.1±3.9 p < 0.001

Phosphate removal

(g/dialysis)1197±265 895±202 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 Placebo (% ) Significant changes Verum (% ) Significant changes IPSS (1 wk)–IPSS (pre) 0 No (p = 0.947) −15.6 Yes (p ≤ 0.001 ) IPSS (4wk)–IPSS (pre) 0 No (p = 0.631) −18.8 Yes (p ≤ 0.001 )

IPSS (12wk)–IPSS (pre) 0 No (p = 0.280) −25 Yes (p ≤ 0.001 ) IIEF (1 wk)–IIEF (pre) 0 No (p = 0.959) 10.5 Yes (p = 0.029) IIEF (4wk)–IIEF(pre) 0 No (p = 0.894) 5.3 Yes (p = 0.034)

IIEF (12wk)–IIEF(pre) 0 No (p = 0.569) 5.3 Yes (p = 0.036) CPSI (1 wk)–CPSI (pre) 0 No (p = 0.935) −16.7 Yes (p ≤ 0.001 ) CPSI (4wk)–CPSI (pre) 2.1 No (p = 0.865) −16.7 Yes (p ≤ 0.001 )

CPSI (12wk)–CPSI (pre) 4.2 No (p = 0.935) −16.7 Yes (p ≤ 0.001 ) VAS (1 wk)–VAS (pre) −16.7 No (p = 0.151) −33.3 Yes (p ≤ 0.001 ) VAS (4 wk)–VAS (pre) 0 No (p = 0.865) −50 Yes (p ≤ 0.001 )

VAS (12 wk)–VAS (pre) 0 No (p = 0.227) −50 Yes (p ≤ 0.001 )

CPSI = Chronic Prostatitis Symptom Index; IIEF = International Index of Erectile Function; IPSS = International Prostate Symptom Score; VAS = Visual Analog Scale.

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

(S. Liu et al., Neurogastroenterlogy & Motility, 2008)

Group NPY (pg/mL) before treatment

NPY (pg/ml) after treatment

Statistical significance

TEA 53.94±7.33 99.45±13.52 p = 0.01 Sham TEA 65.75±8.50 60.67±12.51 p > 0.05

Plasma neuropeptide Y levels

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)

ParametersBefore

treatmentAfter

treatmentStatistical

significanceHalftime for

gastric emptying (min)

150.3±48.4 118.9±29.6 p = 0.007

Symptom score 8.2±3.3 1.6±1.1 p < 0.001

Percentage of normal frequency

(%)21.99±19.38 48.92±19.56 p < 0.001

Serum human pancreatic polypeptide

56.96±27.64 73.11±22.37 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)

ParametersActive 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 -1.91±1.72 p = 0.004

Days to transfer from bed to chair

14.33±2.53 10.75±2.41 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)

ParametersBefore

treatmentAfter

treatmentStatistical

significanceCanadian

Cardiovascular Society functional

class score

2.7±0.2 1.8±0.2 p < 0.01

Nitroglycerin use (per week)

5.4±2.5 0.3±0.3 p < 0.05

Dipyridamole stress thallium scintigraphy severity score (%

improvement)

washout rate

N/A

20±3

25.2±7.2

34±3

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 consistedof the basal pain level on the days before the first rTMS session. Months 3–18 correspondedto 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 monthsfollowing 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 Treatment Author Source

Lateral epicondylitis Naproxen iontophoresis F. Baskurt et al.Clinical Rehabilitation,

2003

Chronic wounds Ultrasound W.J. Ennis et al.Advances in Skin and

Wound Care, 2008

Low back painPENS (percutaneous nerve

stimulation), TENSM. Yokoyama et al.

Anesthesia and Analgesia, 2004

Cervical fusion Magnetotherapy K.T. Folev et al. The Spine Journal, 2008

Duodenal ulcers SCENAR therapy I. Tsimmerman et al.Clinical Medicine (Moscow), 2006

Diarrhea- predominant irritable bowel syndrome

Acu-TENS W.B. Xiao and Y.L. LiuDigestive Diseases and

Sciences, 2004

Chronic salpingo-oophoritis Interferential A. Razumov et al.VKFLFK (Physiotherapy Journal, Moscow), 2002

Dysmenorrhoea TENS H. Schiotz et al.Journal of Obstetrics and

Gynaecology, 2007

Pathology Treatment Author Source

Chronic heart failure NMES M.J. Sillen et al. Chest, 2009

Peripheral arterial occlusive disease

Prostaglandin E1 iontophoresis

K. YamamuraThe Annals of

Pharmacotherapy, 2003

Cerebral palsyGlutamic acid

magnetophoresisN. Gurova and L. Babina

Neuroscience & Behavioral Physiology, 2008

Ischemic stroke UltrasoundM. Daffertshofer and M.

HennericiLancet Neurology, 2003

Motor restoration in hemiplegia

NMES J. Chae et al.Topics in Stroke

Rehabilitation, 2008

Generalised anxiety disoder (GAD)

CES (cranial electrotherapy stimulation), rTMS

A. Bystritsky et al.The Journal of Clinical

Psychiatry, 2008

HyperhidrosisIontophoresis with tap

waterM. Connolly and D. de

BerkerAmerican Journal of

Clinical Dermatology, 2003

Chronic maxillary and frontal sinusitis

Ultrasound N.N. Ansari et al.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 tablesUse of real-time ultrasound to help train “core stability”

muscles and monitor the progressThe program is formed based on the outcome of the

diagnostic assessmentThe effect of treatment sessions is regularly monitored and

the conditions are reassessed at regular intervals

Indications for clinical pilatesMusculoskeletal 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 rehabilitationPost-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 musclesImproving 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