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Basic Basic TTherapeutic herapeutic MMethods in ethods in MMedicineedicine

Ján Jakuš

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Basic Basic TTherapeutic herapeutic MMethodsethods

CLASSIFICATIONCLASSIFICATION

NonNon-I-Invasivenvasive Methods Methods( NO SURGERY)

•MechanicalMechanical•ElectrostimulationElectrostimulation•MagneticMagnetic•ThermThermalal•UltrasoundUltrasound•OpticOptic•Ionizing radiationIonizing radiation

InvasiveInvasive Methods Methods(SURGERY IS NEEDED)

•Mechanical Mechanical && CChemicalhemical•UltrasoundUltrasound•ElectricElectricalal•Methods of vital organ Methods of vital organ supportsupport

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-method of disintegration of cocnrements (in kidneys) by mechanical effect of numerous shock waves (50 – 4000) with frequency 1 – 10 Hz based on pressure, ultrasound or laser energies ( Fig.1)

Efficiency of this methode : 70 – 98%Risks: pain, bleeding

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NON-INVASIVENON-INVASIVE1. Mechanical1. Mechanical Methods Methods

Extracorporal Shock wave Lithotripsy-affects a body surface

Laser Lithotripsy-is introduced into an organIs Is based on based on the the photoacustic phenomenphotoacustic phenomenon.Son.Shock waves hock waves are generated by short light impulses of He-Ne are generated by short light impulses of He-Ne laser laser under a under a duration of 1 duration of 1..5 – 3 ms and 5 – 3 ms and the impulses are the impulses are transmitted by optical transmitted by optical f fibers to the stoneibers to the stone directly. directly.

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-Pressure wwavesaves are are produced produced by by device device outside the patient´s body outside the patient´s body and and are focused are focused through through the the water medium to the stonewater medium to the stone ((concrement)concrement) -- DDifference between ifference between an an resistance resistance of theof the coconncrement and crement and the surrounding tissuethe surrounding tissue resistanceresistance enables the stone destructionenables the stone destruction- R- Rapid start of apid start of destruction by destruction by pressurepressure ((101088 Pa Pa) ) results in results in a a smash smash of the stoneof the stone, , hence the hence the fragments fragments and sand and sand areare eliminaelimina--ted byted by urinurinee

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Extracorporal Shockwave Lithotripsy

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•Source of shock wavesSource of shock waves are: are: (electric, electromagnetic,(electric, electromagnetic, ultrasound or optic -ultrasound or optic -laserlaser)) •The real source of shock The real source of shock waves is the waves is the condenser condenser (as a (as a source of voltagsource of voltage for creation e for creation of wavesof waves))•Litotripter Litotripter is a device for is a device for lithotripsylithotripsy•Focusing deviceFocusing device (acustic len (acustic len--ses)ses)

Extracorporal Shock Extracorporal Shock wwave Lithotripsyave Lithotripsy

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2. 2. Noninvasive Methods of ElectrostimulationNoninvasive Methods of Electrostimulation

Electroconvulsion therapy- Electroshocks

Defibrilation

•used used in psychiatryin psychiatry – pacients with schizophrenia, – pacients with schizophrenia, oligophreniaoligophrenia and other mental diseases and other mental diseases •Condenser current under voltage 2-5 kV / 2-5 ms will Condenser current under voltage 2-5 kV / 2-5 ms will cause cause strong muscles conctractionstrong muscles conctraction, and „, and „offsetoffset“ of “ of an an electric electric brain brain activity. activity.

•live saving therapylive saving therapy•short electric dischargeshort electric discharge is is applied applied to chestto chest•condenser current condenser current with with voltage voltage 5 kV,5 kV, under a under a time 5 mstime 5 ms ,given ,givento the chest 3-timesto the chest 3-times Avoid to ground pAvoid to ground patientatient !

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Chronaximetry Electrostimulation of peripheral nerves and muscles

using DC current as a diagnostical test for determi-nation of chronaxy (i.e.the shortest time under which DC current with double intensity of Rheobase cau-ses AP. Rheobase is the lowest intensity of stimula-ting current (mA) that can cause AP

HOORWEG –WEISS´S CURVE (Strenght-duration curveHOORWEG –WEISS´S CURVE (Strenght-duration curve))

is valid for artificial is valid for artificial electricelectric stimulationstimulation

Used for proof of efficie-ncy of the neurosurgery treatment or in rehabili-tation

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Diadynamic currentsDiadynamic currents

AC AC currents of different shapes or magnetic fields are used for stimulation of muscles and nerves as a therapy

Note: Note: High-frequency electric therapyHigh-frequency electric therapy by AC by AC currents currents with with ff >> 100 kHz, 100 kHz, has has heating effectheating effect and are and are used used toto heat heat thethe tissues tissues:: look a look a Diathermy (Nave and Nave book)

EEffectsffects: stimulation of tissues, spasmo-lytic, analgetic, antioedematous, tonizing using in treatment and rehabilitation

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Electrolytic Electrolytic MethodsMethods

•treatment of skin treatment of skin and and paralyzed muscles paralyzed muscles •application of application of anodal anodal ++DCDC results results in in fall of pH under 7fall of pH under 7..36 36 (Acidosis) (Acidosis) and thand this is reducreduceses the pain feeling the pain feeling ((strong analgestrong analgesia)sia)•application of application of cathodcathodalal - - DCDC results results in a in a riserise of of pH above 7 pH above 7..4 4 (Alkalosis) (Alkalosis) thus increasthus increasinging the pain feeling the pain feeling –stimulatory –stimulatory effecteffect

2. Galvanism2. Galvanism

1. Ionophoresis

•method based on the fact that ions with the same charge as the electrode are repelled e.g + +, or –drugs are inserted into a body by an effect of DC electric current(under time of 20 – 30 min)

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3. 3. MagneticMagnetic Noninvasive Methods Noninvasive Methods• magnetotherapy as a therapeutic methode • in healthy subjects has no or minimal effects, curative effect can not be proved in all casses, problem with„dosis“• application of static magnets and electromagnets on the body surface during 10 – 45 min , with intensity 5 – 80 mT.

Effects of magnetic fields:• hyperaemia (tisues are oversupplied)• spasmolytic ( muscle relaxation• analgetic ( against pain)• antioedematous ( against swelling)• antiinflammatory(against inflamat)

Indications: diseases of joints, muscles, nerves

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4. 4. Thermic Noninvasive MethodsThermic Noninvasive Methods• heat can be given to the body – positive thermotherapy , or can be taken away – negative thermotherapy• effects: hyperaemia, reflex vasodilatation, spasmolytic and analgetic effects, myorelaxation

Thermotherapeutical methods use: 1. conduction of heat -packs, compresses (cold/warm, dry (45 -55°C)/moist,, paraffin) 2. convection of heat2a . Hydrotherapy

whole body bath:hypothermic (10 – 34 °C)izothermic (34 – 36 °C)hyperthermic (37 – 42°C)

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2c Whirling baths and underwater massage

2b. Scottish torrents

2.D Sauna

The method uses streams of cold and warm water- immunity rises up

hyperthermic baths with activation of skin receptors and hyperaemia of tissue

effect effect of hotof hot (80 – 100°C) and (80 – 100°C) and dry airdry air and a and a final final bath inbath in cold cold waterwater result result in in healing healing effecteffect

Methods which use: 3.3. IR radiationIR radiation

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Infrared lamp

Enables a local surface heating of the tissues, used in stomatology and dermatology

4. Methods which use the high frequency electric currents, elmg. fields, microwaves (all with the thermal effect : DIATHERMY )

5. Noninvasive Ultrasound Methods• diathermy and micromasage of the tissue, most of the heat is created on the border between fat and muscle tissue, and bet-ween skin and muscle• 1/3 of absorbed ultrasound is transformed to the heat

• short wave (27 MHz) resistive connection• ultra short wave (434 MHz) condenser connection• microwave (2400 MHz) inductive connection

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Ultrasound Ultrasound HHigh igh FFrequency requency MMassagassage - stimulation e - stimulation and and heating of the tissueheating of the tissuess

Frequency Frequency : 0: 0..8 – 1 MHz8 – 1 MHzIntensityIntensity: 0: 0..2 – 02 – 0..3 W. cm-2 3 W. cm-2 The surface of treatmentThe surface of treatment: 1 – 10 cm2: 1 – 10 cm2

Effects:Effects: - - Spasmolytic effectSpasmolytic effectAnalgeticAnalgetic – – removal of removal of painpainBiostimulatBiostimulatoryory––healinghealing effecteffect

IndicationsIndications: chronic diseases of joints, muscles, tendons and nervesContraindicationContraindicationss: the-rapy of malignant tumors

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5. Light5. Light Noninvasive Methods Noninvasive Methods1.Phototherapy

Heliotherapy – treatment by sun radiationTherapy with visible light – blue part of the spectrum – therapy of icterus (yellow coloured skin- in newborns)

2. Photodynamic TherapyPhotosensitive drug is given into the body and then is activated by visible or laser lights while reacting with tissue oxygen. This activation results in disorder of tumor metabolism, and a tumor is destroyed. It does not affect DNA.

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3. Ultraviolet light therapyUltraviolet light therapy

4. Laser radiation therapy

Types:UV-A (λ = 315 - 400nm), UV-B (280 -315nm),UV-C (100 - 280nm)•Source: Mercury lamp•Biological effects: Early erythema. Delayed pigmentation (within 48 – 72 hours). Production of vitamine D, Killing efect on bacteries, therefore it is used for disinfection of surgical and autopsy rooms at hospitals

•Point is : light amplification by stimulated emission of fotons.•Laser consists of 3 main parts: effective substance, excitation device, optic resonator•types: solid/liquid/gas/ semiconductor, continual/pulse, soft/hard

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Principle of laser: atom of a substance reaches an exci-tation due to a drift of electrones from basic to higher energetic levels. Laser radiation is produced by massive replacement of electrons back to their basic levels, under amplification by optic resonator (Fotons amplification)

a/ a/ Low Low PPower ower LLasersasers• soft – lasers with a maximal power of 500 mW• Treatment effects: analgetic, anti- inflamatory, biostimulating• local application – skin (the lasers of a visible light spectrum are used)• deep application – muscles, bones, (the lasers with longer wavelengths in IR spectrum are used,as well)

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bb/ / High High PPower ower LLasersasers

Solid YAG laser- used for photocoagulation ofLens-cataract (emits radiation in green part of light spectrum, power supply up to 1,5 W)Excimer laser – for therapy of myopy and astig-matism.This laser emits UV radiation causing pho-tochemical reaction when connecting with eye and thus takes off the corneal tissue (1 impulse remo-ves about 0.25 mm of cornea)-works as a „contac-tless“ scalpel YAG laser

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6. 6. Methods of Methods of Ionizing Ionizing RRadiationadiation• Therapy by nuclear (α, β, γ, neutrons) and non-nuclear (X- ray) radiations• Principle of effect: direct effect -production of non-stable electric charged particles (cations, anions) in cells or non-direct effect - creation of reactive radicals because water radiolysis

Comparison of stochastic (non

depending on dosis) and deterministic

(depending on dosis) effects of

ionizing radiation

Radiation geometry: intensity of radiation decreases with square of the length

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TherapyTherapy with low energy with low energy of radiationof radiation (biggest dosis remains on surface and close under the surface of the body)• conventional X-ray radiation (electr- ons with energy of 10 MeV)• gama radiation from radioactive source 60CO (radioisotop of cobalt)• streams of neutrons (deuterons with 50MeV)

Therapy with Therapy with high high energy of radienergy of radia- a- tiontion (dosis grows with the depth)- reaching the tumor precisely-stream of protons (140 MeV)- stream of П-mesons 953 MeV)- O2 ions (3,6 GeV)

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INVASIVE METHODS 1. Mechanical and chemical1. Mechanical and chemical

Are widely used in surgery and stomatology (scalpels, tweezers, peans)

1. Rotary and elevator instruments

2. Water scalpel

Instruments

• cuts tissues by narrow water torrent ( isotonic solution of NaCl)• device consists of: pressure pump, high pressure hose and water engine• skin cuts are smooth and thin

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Are used for deep freezing of tissues (from 25°C to -190°C) – liquid N2 is used. The cooling must be fast. If the cooling is slow , than water molecules change into the ice crystals and these may damage the cells during rewarming.Advantage: anaesthetic effect of cold, small destruction of the tissue, no bleedingUsing: ophthalmology, gyneacology, urology, oncology

3. Cryocauthery instruments

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• ultrasound (US) with high intensity (50 – 1000 W/cm2)• selective destruction of tissues

High frequency focusing US (1 – 3 MHz) Low frequency US (20 – 50 kHz)

Ultrasound is produced by piezo-electric crystal and conducted by special wave- conducting system, that amlifies the amplitude by 10 times. US scalpel oscilates in re-sonance with transformer´s fre-quency. It is widely used in oto-laryngology and neurosurgery.

2. Ultrasound2. Ultrasound Invasive Methods Invasive Methods

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PhacPhacoemulsifioemulsificcatorator

This device is utilised for This device is utilised for extracextrac--tiontion of cloudy lenseof cloudy lense (cataract). (cataract). Method is based on Method is based on low frequency low frequency ultrasound applicationultrasound application, which , which destructs the cloudy lensedestructs the cloudy lense.. LLense ense is then is then coagulatedcoagulated and sucked off. and sucked off.3.Electric3.Electrical Invasive M.al Invasive M.Electrotomy and electrocoagulation

extraction of cloudy lense

• use effect of HF electric currents > 100 KHz• production of heat by contact of different electrode with tissue – result: water is evaporated and cells are destructed. This enables a tissue coagulation and clos- ng the vessels – i.e the skin cuts do not bleedcuts do not bleed

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4. 4. Noninvasive mNoninvasive methods of vital organ supportethods of vital organ support

1. Breathing support – artificial respiration

• is used when no spontaneous respi-ration is present apnoe, or by pulmo-nary insufficiency- partial presure ofoxygen in arterial blood is < 5kPa, pH<7.25 VENTILATORSVENTILATORS•pressure controled ventilators-switch inspiration to expiration by setting of pressure of inhaled air•volume controled ventilators-can set inspiratory volume of breathing and its frequency - optimal value of pulmo- nary ventilation

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Parameters which can by setParameters which can by set up up on the ventilator on the ventilator::(normal values)(normal values)

• respiratory exchange ratio (respiratory exchange ratio (TI:TE=TI:TE=1:1.5 or 1:2)1:1.5 or 1:2)• respiratory frequency (8 – 24 respiratory frequency (8 – 24 //min)min)• inspiratory oxygen concentration (20 – 100inspiratory oxygen concentration (20 – 100%%))• inspiratory pressure (maximal value is 7 kPa)inspiratory pressure (maximal value is 7 kPa)• postinspiration time (between end of inspiration postinspiration time (between end of inspiration and and the the start of expirationstart of expiration )) control of control of PaOPaO22 (by (by oxymetry) and oxymetry) and PaCOPaCO22 (by capnogram)(by capnogram)

Special type: CPAP (continuous positive airway pressure)

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2. Substitution of Substitution of Heart function Heart function –– EExtracorporaxtracorporal l CCirculationirculation Supporting Device Supporting DeviceBlood pump – elastic tube and rotor with 2 valves – they rotate, compress the tube and drive the blood forward. Amount and pressure of blood is regulated by turning the pump rotationOxygenator – substitutes the lung function, blood is eliminated from

CO2 and is saturated by O2 Warmer device – modifies the temperature of oxygenated blood which returnes to the body to 37.5 °C

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2. Extracorporeal Circulation - scheme

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2. Heart substitutions

artificial artificial heartheart

• transplatantion of human´s heart, problems with donors• implantation of artificial heart dri-ving of pump is provided by pressure of compressed air, suitable non-iritable material is used (imunology)• surgery substitution of coronary ar- teries (bypass) and heart valves (be- cause of stenosis or insufficiency) PACEMAKING – uses DC current to treat the „sick sinus syndrom“ therapy pacemakepacemake

rr

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3. Artificial kidney - hemodialysisArtificial kidney - hemodialysis

Basic parts of this device:• Extracorporeal blood circulation - see the previous chapter• Dialysing circulation – circle which provides flow and preparation of dialysing solution – by mixing water and NaHCO3,pH is changed to 7.36 and osmolarity to 5300 mOsm/l (as in blood plasma). Integrity of dialysing membrane is controled by detection of hemoglobine amount. Temperature of dialysing solution is kept on the same value.

Enables to treat the intoxications or disorders affecting the function of kidney– it is based upon filtration, resorbtion

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• Dialyser – is divided into 2 parts (blood part and dialy-sing part) by dialysing membrane. Blood flows by laminary streaming (200 – 300 ml/min) on the one side of the membrane and passes the dialysing membrane. Dialysing solution flows in an opposit direction by turbulent streaming (500ml/min) on the other side of the membrane.

It results in increasing of concentration gradient, which leads to rapid diffusion of low weight molecules-toxic substances (urea, aceton) from blood to dialysing solution. Velocity of ultrafiltration and amount of water can be regulated by transmembrane pressure .

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3. Artificial kidney-scheme of hemodialysis and peritoneal dialysis

Peritoneal dialysis– peritoneum works as a filter for hemo-perfusion, hemofiltration ( intoxication treatment and liver failure disorders)

Hemodialysis Peritoneal dialysis

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4. Artificial lenses4. Artificial lenses

are implanted because of eye injuries or the cataract Composition of lens:

• optic part – increases refractive power of the eye• haptic part – for mechanical fixation in the eye ball

Types:• solid and hard (polyme- tacrylate)• soft ( hydrogels,jelly matters)

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5. Cochlear electrode implants

Multiple electrode stimulating sys-tem consists of 2 parts: External part• sound processor• sensitive microphone amplifier• transmitterInternal part• receiver implanted under the skin• electrode system -is inserted into Scala media of the Cochlea near to basilar membrane in the vicini-ty of the acustic nerve

for deaf patients whose conduction of APs through the acoustic nerve retained intact

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6. Prothesis of limbs6. Prothesis of limbs

• Mechanical prothesisMechanical prothesis – – of of knee and ankle, enable knee and ankle, enable walking with assistwalking with assistaance nce • Bioprothesis Bioprothesis – biosignals conducted – biosignals conducted from device from device by by needle electrodes into preserved muscles. There is a needle electrodes into preserved muscles. There is a lack lack of of feedback between afferent and efferent signals. feedback between afferent and efferent signals. Mechanism of unit can be electricMechanism of unit can be electric and and hydraulic. hydraulic.• BiomanipulatorBiomanipulator – bioprothesis of new generation – – bioprothesis of new generation – more complicated functionsmore complicated functions with feedback from sensors with feedback from sensors • EndoprothesisEndoprothesis – artificial joints – artificial joints being being made from made from special steel (knee, hip joint)special steel (knee, hip joint)

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7. Injection pumps7. Injection pumps•enable to assure an exact timetable for drug´s application into the blood circulation•to speed a dose, quantify of injcted solution, a time of application, all functions can be seen on display•operation of the pump is controlled by PC microprocessor, with ability to choose the mode

Trombolytic pumpsDrug e.g.heparine (which dissolve the clots or prevents its formation) is applied into the blood by a pulse of compressed air Insulin pumps

Automatic programmable insu-lin applicator device with auto-matic control of sugar level in blood

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