Diabetes. Medical rehabilitation by physiotherapeutic methods
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Научно-методический центр
«Медицинские инновационные технологии»
Зубкова С.Т., Жуков В.А., Самосюк Н.И., Чухраева Е.Н.
САХАРНЫЙ ДИАБЕТ.
МЕДИЦИНСКАЯ РЕАБИЛИТАЦИЯ
ФИЗИОТЕРАПЕВТИЧЕСКИМИ МЕТОДАМИ
Редактор Чухраев Н.В.
Киев, Торунь 2023
Scientific and Methodological Center
"Medical innovative technologies" Kyiv, Ukraine
Zubkova S.T., Zukow W., Samosyuk N.I., Chukhraeva E.N.
DIABETES.
MEDICAL REHABILITATION
BY PHYSIOTHERAPEUTIC METHODS
Edited by Chukhraev N.V.
Kyiv, Torun 2023
УДК 616.379-008.64: 615.8 (07)
ББК
Авторы:
Зубкова Светлана Тихоновна, доктор медицинских наук, профессор
Жуков Валерий, доктор медицинских наук, профессор УМК в Торуню
Чухраева Елена Николаевна, кандидат медицинских наук
Самосюк Наталья Ивановна, андидат медицинских наук
Рецензенты: Владимиров А.А., д.мед.н., проф.
Собецкийй В.В., д.мед.н.
Под общей редакций: Чухраев Н.В., доктор психологических наук, профессор
Рекомендовано к печати научно-методической комиссией
НМЦ «Мединтех»
28 декабря 2022 г, протокол №1.
Zubkova S.T., Zukow W., Samosyuk N.I., Chukhraeva E.N. Diabetes. Medical rehabilitation by physiotherapeutic methods. Ed. by Chukhraiev N.V. Medinteh. Kyiv. Torun. 2023. 140 p. ISBN 978-1-4478-9310-3 DOI http://dx.doi.org/10.5281/zenodo.7528776
140 p. Number of characters: 356000 (with abstracts). Number of images: 15 x 1000 characters (lump sum) = 15 000 characters.
Total: Number of characters: 371000 (with abstracts, summaries and graphics) = 9,275 sheet publications.
ISBN 978-1-4478-9310-3 DOI http://dx.doi.org/10.5281/zenodo.7528776
Зубкова С.Т., Жуков В.А., Самосюк Н.И., Чухраева Е.Н.
САХАРНЫЙ ДИАБЕТ. МЕДИЦИНСКАЯ РЕАБИЛИТАЦИЯ ФИЗИОТЕРАПЕВТИЧЕСКИМИ МЕТОДАМИ
К., 2023. – 140 c. ISBN 978-1-4478-9310-3 DOI http://dx.doi.org/10.5281/zenodo.7528776
В монографии изложены общие принципы подхода в реабилитации и повышении качества жизни больных сахарным диабетом на основе применения современных комплементарных методов реабилитации (низкоинтенсивная и регулирующая пунктурная физиотерапия). Основное внимание уделено использованию магнитолазероультразвуковой, синглетно-кислородной и электростимуляционной терапии в комплексном лечении и повышении качества жизни больных сахарным диабетом.
Изложенные материалы будут интересны для врачей физической и реабилитационной медицины, физиотерапевтов, эндокринологов, медицинских психологов, врачей общей практики и семейной медицины, а также для больных сахарным диабетом.
УДК 616.379-008.64: 615.8 (07)
ББК
ISBN 978-1-4478-9310-3 © Зубкова С.Т., Жуков В.А., Чухраева Е.Н., Самосюк Н.И., 2023
UDC 616.379-008.64: 615.8 (07)
BBC
Authors:
Zubkova Svetlana Tikhonovna, Doctor of Medical Sciences, Professor
Zukow Walery, Doctor of Medical Sciences, Professor of the NCU in Torun
Chukhrayeva Elena Nikolaevna, Candidate of Medical Sciences
Samosyuk Natalya Ivanovna, candidate of medical sciences
Reviewers: Vladimirov A.A., DS, prof.
Sobetskiy V.V., DS
Under the general editorship: Chukhraev N.V., Doctor of Psychology, Professor
Recommended for publication by the Scientific and Methodological Commission
NMC Medintech
December 28, 2022, Protocol No. 1.
Zubkova S.T., Zukow W., Samosyuk N.I., Chukhraeva E.N. Diabetes. Medical rehabilitation by physiotherapeutic methods. Ed. by Chukhraiev N.V. Medinteh. Kyiv. Torun. 2023. 140 p. ISBN 978-1-4478-9310-3 DOI http://dx.doi.org/10.5281/zenodo.7528776
140 p. Number of characters: 356000 (with abstracts). Number of images: 15 x 1000 characters (lump sum) = 15 000 characters.
Total: Number of characters: 371000 (with abstracts, summaries and graphics) = 9,275 sheet publications.
ISBN 978-1-4478-9310-3 DOI http://dx.doi.org/10.5281/zenodo.7528776
Zubkova S.T., Zukow W., Samosyuk N.I., Chukhraeva E.N.
Diabetes. Medical rehabilitation by physiotherapeutic methods
К., 2023. – 140 c. ISBN 978-1-4478-9310-3 DOI http://dx.doi.org/10.5281/zenodo.7528776
The monograph outlines the general principles of the approach to the rehabilitation and improvement of the quality of life of patients with diabetes mellitus based on the use of modern complementary methods of rehabilitation (low-intensity and regulating puncture physiotherapy). The main attention is paid to the use of magneto-laser-ultrasound, singlet-oxygen and electrical stimulation therapy in the complex treatment and improvement of the quality of life of patients with diabetes mellitus.
The presented materials will be of interest to doctors of physical and rehabilitation medicine, physiotherapists, endocrinologists, medical psychologists, general practitioners and family medicine, as well as for patients with diabetes.
UDC 616.379-008.64: 615.8 (07)
BBC
ISBN 978-1-4478-9310-3 © Зубкова С.Т., Жуков В.А., Чухраева Е.Н., Самосюк Н.И., 2023
Оглавление
Перечень принятых сокращений 7
Введение 11
Глава 1. Сахарный диабет и особенности диабетических метаболических нарушений 16
Глава 2. Осложнения у больных сахарным диабетом 29
Глава 3. Принципы медицинской реабилитации больных сахарным диабетом 43
Глава 4. Физиотерапевтические методы реабилитации и повышения качества жизни больных сахарным диабетом 52
4.1. Санаторно-курортный этап реабилитации 54
4.2. Лазерная терапия 57
4.3. Ультразвуковая терапия 84
4.4. Комбинированное и сочетанное использование физических факторов 89
4.5. Общие принципы сочетанного применения магнитолазерной и ультразвукой терапии 94
4.6. Электромиостимуляция 98
4.7. Синглентно-кислородная терапия 101
Глава 5. Частные методики реабилитации диабетических осложнений 109
5.1. Синдром диабетической стопы 109
5.2. Лечение диабетической ретинопатии 110
5.3. Лечение диабетической периферической невропатии 115
5.4. Особенности применения коррекции психофизиологического состояния больных сахарным диабетом 116
Библиография 131
Contents
List of accepted abbreviations 7
Introduction 11
Chapter 1. Diabetes mellitus and features of diabetic metabolic disorders 16
Chapter 2. Complications in patients with diabetes mellitus 29
Chapter 3. Principles of medical rehabilitation of patients with diabetes mellitus 43
Chapter 4. Physiotherapeutic methods of rehabilitation and improvement of the quality of life of patients with diabetes mellitus 52
4.1. Sanatorium-resort stage of rehabilitation 54
4.2. Laser therapy 57
4.3. Ultrasound Therapy 84
4.4. Combined and combined use of physical factors 89
4.5. General principles of the combined use of magneto-laser and ultrasound therapy 94
4.6. Electromyostimulation 98
4.7. Single oxygen therapy 101
Chapter 5. Private methods of rehabilitation of diabetic complications 109
5.1. Diabetic foot syndrome 109
5.2. Treatment of diabetic retinopathy 110
5.3. Treatment of diabetic peripheral neuropathy 115
5.4. Features of the application of the correction of the psychophysiological state of patients with diabetes mellitus 116
References 131
Перечень принятых сокращений
АГ – артериальная гипертензия
АД – артериальное давление
ВЛОК – внутрисосудистое лазерное облучение крови
ВНС – вегетативная нервная система
ГИ – гликемический индекс
ГТТ – глюкозо-толерантный тест
ДАД – диастолическое артериальное давление
ДН – диабетическая нефропатия
ДР – диабетическая ретинопатия
ДТ1 – диабет тип 1
ДТ2 – диабет тип 2
ИБС – ишемическая болезнь сердца
ИК – инфракрасный
ИМ – инфаркт миокарда
ИМТ – индекс массы тела
ИР – инсулинорезистентность
КВР – кардиоваскулярный риск
ЛИ – лазерное излучение
ЛИИК – лазерное излучение инфракрасного диапазона спектра
ЛИКР – лазерное излучение красного диапазона спектра
ЛП – лазеропунктура
ЛПВП – липопротеиды высокой плотности
ЛПНП – липопротеиды низкой плотности
ЛПОНП – липопротеиды очень низкой плотности
МА – микроальбуминурия
МЛ – магнитолазер
МЛИК – магнитолазерное воздействие инфракрасного диапазона спектра
МЛКР – лазерное воздействие красного диапазона спектра
МЛТ – магнитолазерная терапия
НИЛИ – низкоинтенсивное лазерное излучение
НЭЖК – неэстерифицированные жирные кислоты
ПМП – постоянное магнитное поле
САД – систолическае артериальное давление
СД – сахарный диабет
СКЛ – санаторно-курортное лечение
СКФ – скорость клубочковой фильтрации
СР – свободные радикалы
ТАП – точка акупунктуры
ТГ – триглицериды
УЗ – ультразвук
УЗТ – ультразвуковая терапия
ФН – физическая нагрузка
ФФ – физические факторы
ХЕ – хлебная единица
ХС – холестерин
ЧЛОК – чрескожное облучение крови
ЦНС – центральная нервная система
ЭКС – электрокожное сопротивление
ЭМИ – электромагнитное излучение
ЭМП – электромагнитное поле
ЭМС - электромиостимуляция
ЭПД – электропунктурная диагностика
ADA – Американская диабетическая ассоциация
EASD – Европейская ассоциация по изучению диабета
ESC – Европейское общество кардиологов
IRAS – Insulin Resistance Atherosclerosis Stady
NO – оксидазота
UKPDS – United Kingdom Prospective Diabetes Study
List of accepted abbreviations
AH - arterial hypertension
BP - blood pressure
ILBI - intravascular laser blood irradiation
ANS - autonomic nervous system
GI - glycemic index
GTT - glucose tolerance test
DBP - diastolic blood pressure
DN - diabetic nephropathy
DR - diabetic retinopathy
DT1 - type 1 diabetes
DT2 - type 2 diabetes
IHD - ischemic heart disease
IR - infrared
MI - myocardial infarction
BMI - body mass index
IR - insulin resistance
CVR - cardiovascular risk
LI - laser radiation
LIIK - laser radiation of the infrared range of the spectrum
LICR - laser radiation of the red range of the spectrum
LP - laser puncture
HDL - high density lipoproteins
LDL - low density lipoproteins
VLDL - very low density lipoproteins
MA - microalbuminuria
ML - magneto laser
MLIK - magneto-laser impact of the infrared range of the spectrum
MLKR - laser exposure of the red range of the spectrum
MLT - magneto-laser therapy
LILI - low-intensity laser radiation
NEFA - non-esterified fatty acids
PMF - permanent magnetic field
SBP - systolic blood pressure
DM - diabetes mellitus
SKL - spa treatment
GFR - glomerular filtration rate
SR - free radicals
TAP - acupuncture point
TG - triglycerides
US - ultrasound
UST - ultrasound therapy
FN - physical activity
FF - physical factors
XE - bread unit
CS - cholesterol
PTBI - transcutaneous blood irradiation
CNS - central nervous system
EKS - electroskin resistance
EMP - electromagnetic radiation
EMF - electromagnetic field
EMS - electromyostimulation
EPD - electropuncture diagnostics
ADA - American Diabetes Association
EASD - European Association for the Study of Diabetes
ESC - European Society of Cardiology
IRAS – Insulin Resistance Atherosclerosis Stady
NO - oxidized nitrogen
UKPDS – United Kingdom Prospective Diabetes Study
ВВЕДЕНИЕ
По данным IDF (Международная Федерация Диабета) количество больных сахарным диабетом (СД) увеличивается почти в два раза каждые 15 лет. Если раньше сахарный диабет был заболеванием, встречающемся относительно редко, то сегодня масштабы его распространения настолько значительны, что он по праву считается настоящей эпидемией ХХI века. К сожалению, уже сейчас СД находится на 4 месте в списке неинфекционных заболеваний, преждевременно уносящих жизни человека, провоцируя смерть каждые 7 секунд или более 4,6 миллиона смертей в год.
Это заболевание является одной из основных причин снижения остроты зрения и слепоты, нарушения когнитивных способностей, возникновения психических расстройств, почечной недостаточности, инфарктов, инсультов и ампутаций нижних конечностей. В 2016 году 1,6 миллиона случаев преждевременной смерти были напрямую связаны с диабетом. По оценкам экспертов ВОЗ диабет в 2016 в году занимал седьмое место среди причин преждевременной смертности. Почти половина всех случаев смерти, обусловленных высоким содержанием глюкозы в крови, приходится на больных в возрасте до 70 лет.
По данным ВОЗ (2018) в период с 1980 по 2014 годы во всём мире количество больных СД увеличилось более чем в 4 раза и составляет в настоящее время 425 млн. человек, а глобальная распространенность диабета среди людей старше 18 лет возросла с 4,7% до 8,5%. По оценке IDF уже сейчас более 50 стран мирового сообщества имеют на своей территории более миллиона граждан, страдающих сахарным диабетом. При этом лидерами являются не всегда самые бедные страны, например (2021): Китай - 76402799; Индия - 62651210; США - 17273847; Бразилия - 10829476; Пакистан - 9364490; Россия - 8469062; Япония - 7490176; Мексика - 6174093; Филиппины - 5073040; Вьетнам - 4862517; Германия - 4848506; Египет - 4477495; Эфиопия - 4196268; Турция - 4052583; Иран - 3970776; Таиланд - 3815618; Франция - 3554365; Италия – 3415145. Если в ближайшее время не будут приняты быстрые и адекватные меры, то к уже к 2030 году каждый десятый человек на планете будет страдать диабетом, что потребует выделения не менее одного триллиона долларов ежегодно на медицинское обслуживание этой группы больных.
В Украине за последние 15 лет количество больных СД увеличилось на 42% и составляет, по данным официальной статистики 1 млн. 300 тыс. По данным ВОЗ (2016, https://www.who.int/diabetes/country-profiles/ru/) в Украине распространенность сахарного диабета и сопутствующих факторов риска в процентном отношении к численности населения составляет: Диабет - 9.1%; Ожирение - 21.7%; Избыточный вес - 57.3%; Недостаточная физическая активность 14.4%.
Данное заболевание имеет огромную медико-социальную значимость, так как приводит к ранней инвалидности и частой летальности, которые обусловлены развитием сосудистых осложнений, таких как нефропатия, инфаркт миокарда (ИМ), инсульт, гангрена. У больных СД в 3 раза чаще возникают поражения коронарных сосудов, в 7 раз – почек и в 10 раз – потеря зрения.
СД любого типа является независимым фактором риска развития кардиоваскулярной патологии различных органов, возникновения острых осложнений коронарного кровообращения у лиц любого возраста.
Основной причиной смерти у 80% больных СД являются сердечно-сосудистые осложнения, среди которых 39% занимает смерть от инфаркта миокарда. Кардиоваскулярные осложнения остаются наиболее частой причиной смерти лиц трудоспособного возраста, страдающих СД. В возрасте от 35 до 55 лет от кардиологических заболеваний преждевременно умирает 35% больных сахарным диабетом, что почти в 3 раза больше чем в общей популяции указанной возрастной группы.
Увеличенный риск сердечно-сосудистых заболеваний у больных СД обусловлен сочетанием с большой частотой различных факторов риска. Британским широкомасштабным клиническим исследованием UKPDS установлена корреляция высокого риска развития сердечно-сосудистых осложнений с высоким уровнем липопротеидов низкой плотности (ЛПНП), триглицеридов (ТГ), гликированного гемоглобина, увеличенным систолическим артериальным давлением (АД), большой концентрацией глюкозы натощак, курением. Распространенность артериальной гипертензии (АГ) среди больных СД в 1,5–3 раза выше по сравнению с лицами идентичного возраста, но без СД. АГ является основным фактором риска сердечно-сосудистых осложнений у больных ДТ2, увеличивая частоту возникновения невропатии, ангиопатии, ишемической болезни сердца (ИБС), инсульта, ретинопатии и нефросклероза.
Общепризнанным является мнение, что в основе частого поражения сердечно-сосудистой системы у лиц, болеющих СД, является раннее развитие атеросклероза сосудов той или иной локализации, связанное с наличием специфических патогенетических факторов риска, к которым относятся: инсулинорезистентность, гипергликемия, гиперинсулинемия, нарушения коагуляциoнной системы крови и эндотелиальная дисфункция сосудов. Кроме того, многочисленные наблюдения исследователей разных стран позволили сделать заключение о том, что в условиях пандемии COVID-19, осложнения, вызванные ИР, приводят к более тяжелым последствиям и осложнениям для больных СД.
Несмотря на существующий современный арсенал эффективных медикаментов, направленных на снижение гипергликемии, достичь адекватного контроля уровня глюкозы в крови достаточно часто не удается. Так, по данным К.М. Fox с соавт. в Великобритании целевой уровень глюкозы в крови зарегистрирован только у 42% больных.
Между тем современная тактика профилактики и своевременная реабилитация больных СД может обеспечить снижение степени риска преждевременной смерти больных этой группы. Реабилитация должна включать комплексное использование методов первичной и вторичной профилактики, в том числе изменение образа жизни, переход на сбалансированный диетический режим питания, применение дозированных физических нагрузок, самоконтроль, психологическая помощь и аутотренинг, медикаментозную реабилитацию (гипотензивная, гипогликемическая, гиполипидемическая и антитромботическая), физиотерапию и терапию с использованием природных факторов рекреационных зон. При назначении физиотерапевтических методов реабилитации большую роль играет правильный и адекватный выбор параметров и зон воздействия с учетом патогенеза заболевания у конкретного больного, в том числе наличие сердечно-сосудистых осложнений, метаболических показателей и состояния органов-мишеней.
В своем первом Глобальном докладе по диабету эксперты ВОЗ (2016) подчеркивали не только огромные масштабы проблемы диабета, но и наличие потенциала для изменения сложившейся ситуации. В этом докладе ВОЗ указала на необходимость наращивать масштабы профилактики и реабилитации больных диабетом. В настоящее время уже сформирована политическая основа для принятия согласованных действий по борьбе с сахарным диабетом, и она обозначена в целях в области устойчивого развития, Политической декларации ООН по неинфекционным заболеваниям и Глобальном плане действий ВОЗ по НИЗ.
Авторы искренне надеются, что представленный материал окажется полезным не только специалистам, занимающимся проблемами диабетологии, но и широкому кругу медицинской общественности.
INTRODUCTION
According to the IDF (International Diabetes Federation), the number of patients with diabetes mellitus (DM) is almost doubling every 15 years. If earlier diabetes mellitus was a relatively rare disease, today its prevalence is so significant that it is rightfully considered a real epidemic of the 21st century. Unfortunately, diabetes is already on the 4th place in the list of non-communicable diseases that prematurely kill a person, causing death every 7 seconds or more than 4.6 million deaths per year.
This disease is one of the main causes of reduced visual acuity and blindness, cognitive impairment, mental disorders, kidney failure, heart attacks, strokes and amputations of the lower extremities. In 2016, 1.6 million premature deaths were directly related to diabetes. According to WHO experts, in 2016 diabetes ranked seventh among the causes of premature death. Almost half of all deaths due to high blood glucose occur in patients under the age of 70 years.
According to WHO (2018), in the period from 1980 to 2014, the number of patients with diabetes worldwide increased more than 4 times and currently stands at 425 million people, and the global prevalence of diabetes among people over 18 years of age has increased from 4.7% up to 8.5%. According to the IDF, more than 50 countries of the world community already have more than a million citizens suffering from diabetes on their territory. At the same time, the leaders are not always the poorest countries, for example (2021): China - 76402799; India - 62651210; USA - 17273847; Brazil - 10829476; Pakistan - 9364490; Russia - 8469062; Japan - 7490176; Mexico - 6174093; Philippines - 5073040; Vietnam - 4862517; Germany - 4848506; Egypt - 4477495; Ethiopia - 4196268; Turkey - 4052583; Iran - 3970776; Thailand - 3815618; France - 3554365; Italy - 3415145. If quick and adequate measures are not taken soon, then by 2030 one in ten people on the planet will suffer from diabetes, which will require the allocation of at least one trillion dollars annually for the medical care of this group of patients.
In Ukraine, over the past 15 years, the number of patients with diabetes has increased by 42% and, according to official statistics, is 1 million 300 thousand. According to WHO (2016, https://www.who.int/diabetes/country-profiles/ru/ ) in Ukraine, the prevalence of diabetes mellitus and associated risk factors as a percentage of the population is: Diabetes - 9.1%; Obesity - 21.7%; Overweight - 57.3%; Insufficient physical activity 14.4%.
This disease is of great medical and social significance, as it leads to early disability and frequent mortality, which are caused by the development of vascular complications such as nephropathy, myocardial infarction (MI), stroke, gangrene. Patients with diabetes are 3 times more likely to develop lesions of the coronary vessels, 7 times more often to the kidneys, and 10 times more often to lose vision.
DM of any type is an independent risk factor for the development of cardiovascular pathology of various organs, the occurrence of acute complications of the coronary circulation in people of any age.
The main cause of death in 80% of patients with diabetes is cardiovascular complications, among which 39% is death from myocardial infarction. Cardiovascular complications remain the most common cause of death in people of working age with diabetes. At the age of 35 to 55, 35% of diabetic patients die prematurely from cardiac diseases, which is almost 3 times more than in the general population of this age group.
The increased risk of cardiovascular disease in diabetic patients is due to a combination of various risk factors with a high frequency. The British large-scale clinical study UKPDS established a correlation between a high risk of developing cardiovascular complications and high levels of low-density lipoprotein (LDL), triglycerides (TG), glycated hemoglobin, increased systolic blood pressure (BP), high fasting glucose, smoking. The prevalence of arterial hypertension (AH) among patients with DM is 1.5–3 times higher than in people of the same age, but without DM. AH is the main risk factor for cardiovascular complications in patients with TD2, increasing the incidence of neuropathy, angiopathy, coronary heart disease (CHD), stroke, retinopathy, and nephrosclerosis.
It is generally accepted that the basis of frequent damage to the cardiovascular system in people with diabetes is the early development of atherosclerosis of vessels of one or another localization, associated with the presence of specific pathogenetic risk factors, which include: insulin resistance, hyperglycemia, hyperinsulinemia, disorders of the coagulation system blood and vascular endothelial dysfunction. In addition, numerous observations by researchers from different countries led to the conclusion that in the context of the COVID-19 pandemic, complications caused by insulin resistance (IR) lead to more severe consequences and complications for patients with DM.
Despite the existing modern arsenal of effective drugs aimed at reducing hyperglycemia, it is often not possible to achieve adequate control of blood glucose levels. So, according to K.M. Fox et al. in the UK, target blood glucose levels are reported in only 42% of patients.
Meanwhile, modern tactics of prevention and timely rehabilitation of patients with DM can reduce the risk of premature death in this group of patients. Rehabilitation should include the complex use of methods of primary and secondary prevention, including lifestyle changes, the transition to a balanced dietary diet, the use of dosed physical activity, self-control, psychological assistance and auto-training, drug rehabilitation (hypotensive, hypoglycemic, hypolipidemic and antithrombotic), physiotherapy and therapy using natural factors of recreational areas. When prescribing physiotherapeutic methods of rehabilitation, an important role is played by the correct and adequate choice of parameters and zones of influence, taking into account the pathogenesis of the disease in a particular patient, including the presence of cardiovascular complications, metabolic parameters and the state of target organs.
In their first Global Report on Diabetes, WHO experts (2016) emphasized not only the magnitude of the diabetes problem, but also the potential to change the situation. In this report, WHO highlighted the need to scale up the prevention and rehabilitation of people with diabetes. The policy framework for concerted action on diabetes mellitus is now in place and is outlined in the Sustainable Development Goals, the UN Political Declaration on Noncommunicable Diseases and the WHO Global Action Plan on NCDs.
The authors sincerely hope that the presented material will be useful not only to specialists dealing with diabetology problems, but also to a wide range of the medical community.
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References
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