РОССИЙСКАЯ АКАДЕМИЯ МЕДИЦИНСКИХ НАУК
Российское общество врачей восстановительной медицины
ФГБУ «РНЦ медицинской реабилитации и курортологии» МЗ России
«УТВЕРЖДАЮ»
Председатель Научного Совета РАМН
по восстановительной медицине, лечебной
физкультуре и спортивной медицине
Академии РАМН, профессор, д.м.н.
________________________Разумов А.Н.
«_______________________» 2015 г.
Профилактика повышенной метеочувствительности
у больных хроническими неинфекционными заболеваниями
Клинические рекомендации
Москва, 2015
А н н о т а ц и я
Клинические рекомендации освещают механизм метеокорригирующего действия современного бальнеологического средства для ванн «Биолонг». Курсовое применение общих ванн с препаратом «Биолонг» оказывает выраженное терапевтическое влияние на клинико-функциональное состояние больных, способствуют повышению толерантности организма к внешним неблагоприятным воздействиям климато-погодных факторов и уменьшению погодообусловленных обострений хронических неинфекционных заболеваний.
Клинические рекомендации подготовлены Российским научным центром медицинской реабилитации и курортологии Минздрава России.
Составители: к.м.н. Уянаева А.И., д.м.н. профессор Айрапетова Н.С.,
д.м.н. Бадалов Н.Г., к.м.н. Тупицина Ю.Ю.,
к.м.н. Львова Н.В., к.м.н. Нитченко О.В.
В в е д е н и е
В последние годы неуклонно возрастает интерес к изучению влияния факторов внешней среды, в том числе погодных и климатических, на здоровье человека и связанный с этим рост погодообусловленных обострений хронических неинфекционных заболеваний.
Имеющиеся научные данные свидетельствуют о том, что резкие колебания погодных условий могут стать внешним фактором риска, способным вызвать обострение течения таких социально значимых заболеваний, как ишемическая болезнь сердца, нейроциркуляторная астения, гипертоническая болезнь, обструктивная патология легких, заболевания опорно-двигательного аппарата и др., оказывать негативное влияние на функциональное состояние центральной и вегетативной нервной системы, кардиогемодинамики, свертывающую и противосвертывающую систему крови, кислородный режим организма. Возникающие в ответ на влияние погодных факторов метеопатические реакции отягощают течение заболеваний, снижают эффективность лечебных мероприятий и ухудшают качество жизни больных (Хаснулин В.И., 2000; Ксенофонтова И.В., 2003; Поважная Е.Л., 2004; Бабаев Ш.К., 2004; Уянаева А.И., 2011, 2014).
Повышенная метеочувствительность чаще отмечается у людей, занятых умственным трудом, мало бывающих на свежем воздухе, детренированных, что свидетельствует о значительном ослаблении адаптационных процессов и сужении зоны так называемого микроклиматического комфорта.
Реакции, возникающие в ответ на резкие, порой аномальные изменения погоды, называются метеопатическими, а люди, которые болезненно на них реагируют – метеочувствительными. Особенностью таких реакций является то, что они возникают у значительного числа людей синхронно с изменениями метеорологических условий или же несколько опережая их. Метеочувствительность у жителей мегаполисов почти в три раза выше, чем у живущих в сельской местности (Овчарова В.Ф., 1982).
Особенно подвержены влиянию неблагоприятных, биотропных погодных условий больные сердечно-сосудистыми заболеваниями (80-82 %), ХОБЛ (60-64 %), заболеваниями опорно-двигательной системы (72-74 %), психо-эмоциональными нарушениями (82-84 %). Даже практически здоровые люди при колебаниях погодных условий ощущают дискомфорт, общее недомогание, снижение умственной и физической активности. Меняющиеся условия окружающей среды воздействуют на человека посредством метеорологических и гелиогеофизических факторов через основные регуляторные системы организма, приводя к мобилизации приспособительных механизмов. При несостоятельности адаптационных систем организма развиваются погодообусловленные обострения хронических заболеваний. Проводимые в последние годы медико-метеорологические исследования позволили выявить общую картину биотропности погодных условий и сформировать представления о механизме биотропности погодных условий:
— атмосфера влияет на человека как добавочный стресс;
— погода не причина, а толчок для развития острых метеотропных реакций, поскольку метеотропность – одно из свойств организма;
— биотропный максимум наблюдается в регионах со значительными погодными изменениями;
— формы и проявления метеопатических реакций зависят от индивидуальных патологических изменений в организме.
Поскольку оградить людей с повышенной метеочувствительностью полностью от воздействия погодных условий невозможно, необходимо ослабить это влияние. В данном контексте обосновано включение в программы коррекции, профилактики и лечения немедикаментозных методов, обладающих патогенетической направленностью действия, способствующих активации физиологических резервов, естественной резистентности организма, обуславливающих перестройку регуляторных систем и повышающих толерантность организма к внешним неблагоприятным воздействиям погодно-климатических факторов.
Использование немедикаментозных методов в профилактике повышенной метеочувствительности способствует активации эндогенных биорегуляторов и восстановлению адаптационных сдвигов, а также оказывает позитивное влияние на процессы восстановительной коррекции в стадии предболезни и начальных проявлениях повышенной метеочувствительности.
Учитывая большую по сравнению с другими известными методами метеопрофилактическую эффективность гидро- и бальнеологических воздействий, а также существующие сегодня научные обоснования метеокорригирующего действия бальнеологических средств и гидротерапевтических методов, таких как углекислые, хлоридно-натриевые, хвойно-жемчужные ванны, контрастные водные процедуры (Бабаев Ш.К., 2004; Давыдова О.Б. и соавт., 2004; Айрапетова Н.С. и соавт., 2010) является целесообразным и обоснованным применение современного бальнеологического средства для ванн «Биолонг», действующим веществом которого является Митофен, сочетающий свойства антигипоксанта и антиоксиданта. Способность Митофена нейтрализовать избыточно образующихся в организме супероксидные анион-радикалы позволяет в самом начале прерывать опасную для тканей цепь свободнорадикальных превращений (кислород – супероксидный ион-радикал –перекись водорода –высокореакционные радикалы), сохраняя тем самым лабильные клеточные структуры, легко повреждаемые при стрессах и болезнях. Митофен повышает энергообеспечение живых клеток за счет более выгодного использования кислорода в дыхательной цепи митохондрий, а также нейтрализует окислители, активно образующиеся в тканях организма при кислородной недостаточности. Митофен – водорастворимый полимерный структурно-функциональный аналог природного кофермента коэнзима Q10, который во время бальнеопроцедур диффундирует через кожные покровы, что выгодно отличает его от других антигипоксантов-цитохромов и убихинона (коэнзима Q10), действие которых ограничено трудностями преодоления клеточных оболочек и весьма высокими дозировками, необходимыми для достижения терапевтического эффекта.
Материально-техническое обеспечение метода
Средство для ванн «Биолонг» 1% и 3%
Ванна бальнеологическая для отпуска процедур.
Описание медицинской технологии
- Средство для приятия ванн «Биолонг», состав: Митофен, дистиллированная вода, хлористый натрий, этаноламид кокосового масла, лаурил, глюкозид жирных кислот, натрия лаурил сульфат. Концентрация 1% и 3%.
- На ванну с пресной водой объемом 200 литров необходимо 30-50 мл средства «Биолонг».
- Температура воды 37-38°С.
- Длительность процедуры – 10 минут первая, последующие по 15-20 минут, два дня подряд, на тритий день перерыв.
- После процедуры промокнуть тело простыней или полотенцем, не смывая остатки препарата, отдых после ванны 30 минут.
- На курс лечения 10-12 процедур.
- Повторный курс лечения через 6 месяцев.
Показания к использованию метода
Повышенная метеочувствительность при хронических неинфекционных заболеваниях:
— хроническая обструктивная болезнь легких;
— бронхиальная астма;
— нарушения мозговой гемодинамики;
— остеоартроз и дорсопатии различных отделов позвоночника;
— нейроциркуляторная дистония.
Противопоказания:
- Острыне соматические и инфекционные заболевания.
- Хронические соматические заболевания в фазе декомпенсации.
- Системные заболевания крови.
- Злокачественные и доброкачественные новообразования.
- Недостаточность кровообращения 2-3 ст.
- Гипертоническая болезнь выше IIА-III стадии.
- Недостаточность кровообращения выше I стадии, сложные нарушения ритма сердца.
- Стенокардия III ФК с НК не выше I ст.
- Беременность.
- Индивидуальная непереносимость средства для ванн «Биолонг».
Эффективность использования метода у больных с хронической
обструктивной болезнью легких и бронхиальной астмой
Проведены наблюдения у 52 пациентов ХОБЛ и 57 больных бронхиальной астмой (БА). Пациентам основной группы – 1 группа (26 человек ХОБЛ) и 2 группа (30 чел. БА) получали курс лечения общими ваннами с препаратом «Биолонг». Группы сравнения 3 р. (ХОБЛ 26 чел.); 4 гр. (БА 27 чел.) были идентичны по клинико-функциональной характеристике и получали только ЛФК по стандартной методике и медикаментозную терапию, аналогичную таковой у больных основных групп (бронходилататоры, ингаляционные глюкокортикостероиды, муколитики). Непосредственную эффективность метеокорригирующего действия общих ванн с препаратом «Биолонг» оценивали по разработанным В.Ф.Овчаровой (1983) критериям, учитывающим степень изменения проявления метеочувствительности. Исследования функции внешнего дыхания (ФВД) с оценкой жизненной емкости легких (ЖЕЛ), форсированного выдоха за первую секунду (ОФВ1), индекс Тиффно (ОФВ/ФЖЕЛ), скоростные показатели воздушного потока – пиковая (ПСВ) и мгновенные скорости на уровне 25, 50, 75% ФЖЕЛ, характеризующие проходимость крупных, средних и мелких дыхательных путей (МОС25, 50, 75); нормальные индивидуальные значения рассчитывали по формулам R.Knuolson и оценивали динамику их изменения до и после лечения при формировании неблагоприятных погодных условий. Оценку психологического статута проводили с помощью компьютерной версии теста СМОЛ (сокращенный многофакторный опросник для исследования личности) и теста САН («самочувствие», «активность, «настроение»), которые характеризовали изменение психоэмоциональной адаптации при формировании биотропных погодных условий до и после лечения.
После курсового применения общих ванн с препаратом «Биолонг» наблюдалась положительная динамика клинических симптомов и проявлений метеопатологии. Терапевтическая эффективность сопровождалась улучшением респираторной функции: увеличение исходно сниженного значения МОС50 с 52,2±2,26 до 58,2±2,4%; Р<0,05), уменьшение повышенных уровней ЧД с 17,9±0,67 до 16,7±3,2 в мин, (Р<0,05) и ПО2 с 133,9±3,86% до 124,7±2,29 (Р<0,05), увеличение КИО2 с 27,9±1,38 до 32,0±0,94 мл (Р<0,05), что свидетельствует о снижении спазма бронхов крупного и среднего калибра с отчетливым уменьшением альвеолярной гипоксии.
Общие ванны с препаратом «Биолонг» оказали положительное влияние на психологическое состояние пациентов в основных группах. Улучшение психологической адаптации у 82,7% пациентов выражалось снижением уровня тревожности, ипохондрической настроенности по шкалам «триады тревоги» теста СМОЛ (от 57,8±1,33 до 52,4±2,3 балла, Р<0,05) и уменьшением выраженности астенических проявлений (от 49,9±1,44 до 43,2±1,57, Р<0,05). Показатели теста САН свидетельствовали об улучшении самочувствия (81%), активности (56,7%) и нестроения (63,4%) у пациентов в лечебных группах.
Было отчетливо выявлено преимущество применения общих ванн с препаратом «Биолонг» у больных БА, что подтверждалось результатами клинической эффективности (88,4%), которые достоверно (Р<0,05) превосходили этот показатель у пациентов с ХОБЛ (73,2%), при этом изменение степени выраженности метеопатических реакций в обеих группах были практически одинаковыми. Снижение выраженных проявлений метеопатических реакций у больных ХОБЛ с 12,8 до 4,7%, при этом у больных БА после лечения практически отсутствовали метеопатические реакции выраженные (с 16,4 до 2,4%) и тяжелые (с 9,1 до 1,9%). Курсовое применение общих ванн с препаратом «Биолонг» оказывает выраженное терапевтическое влияние на клинико-функциональное состояние больных ХОБЛ и БА, инициирует уменьшение спазма крупных и средних бронхов, способствует быстрому уменьшению альвеолярной гипоксии, улучшению психологической адаптации. Указанные положительные сдвиги сопровождались уменьшением погодообусловленных обострений и повышением толерантности организма к внешним, биотропным факторам погоды.
Методика проведения процедуры:
В ванну объемом 200 л наливают пресную воду температурой 38-39°С, добавляют 30 мл 1% раствора средства для ванн «Биолонг», желательно перемешивают. Процедуры длительностью 15-20 мин каждая, проводят ежедневно, 5 раз в неделю, на курс -12-14 процедур.
Эффективность использования методики у больных
с нейроциркуляторной астенией
Под наблюдением находилось 74 больных с нейроциркуляторной астенией в возрасте от 27 до 40 лет, средний возраст составил 33,0±1,7 лет, из них 44 женщины и 30 мужчин. При анализе анкет и ежедневных дневников самонаблюдении все пациенты отмечали повышенную метеочувствительность разной степени выраженности.
У большинства пациентов проявление метеопатологии по классификации В.Ф.Овчаровой (1983) были выраженные (58,1%), средней тяжести (14,8%), легкие (17,6%), а у 9,5% реакции на погоду были тяжелыми.
Чаще всего метеопатические реакции проявлялись в снижении умственной и физической активности (61,4%), раздражительностью и нарушением сна (57,3%), головными болями (44,2%) и неприятными ощущениями в области сердца (33,4%).
Большинство пациентов 41 (55,4%) отмечали появление метеопатических реакций за одни-два дня до объективных колебаний метеопараметров. Чаще всего (78,2%) развитие погодобусловленных обострений наблюдалось при формировании погод спастического типа (резкое повышение атмосферного давления, вторжение холодного фронта, понижения температуры воздуха, неустойчивый геомагнитный фон).
Пациенты 1 группы (60 человек) получали общие ванны с препаратом «Биолонг», контрольная 2 группа (14 человек) получали общие пресные ванны и базовую медикаментозную терапию.
После курсового лечения существенно менялась степень проявления метеопатических реакций и стали преобладать более легкие у 36 (46,6%) и средней тяжести у 25 (33,8%) . Уменьшились выраженные (19,6%) и исчезли тяжелые проявления метеопатологии.
Анализ психологического профиля по тесту СМОЛ у пациентов с повышенной метеочувствительностью после лечения выявил улучшение психологической адаптации, что сопровождалось снижением показателей по шкалам тревоги (1,2,7), которые были достоверно повышены до лечения, улучшения самочувствия по тесту САН отмечали 69 (93,2%), активности 56 (75,7%) и настроения – 63 (85,1%) пациентов. Эффективность курсового применения общих ванн с препаратом «Биолонг» у пациентов с нейроциркуляторной дистонией составила 82,3 %, тогда как этот показатель в группе контроля составил всего 33,2%, при этом у большинства пациентов -59 (79,7%) — положительная динамика по данным анкетного опроса сохранялась в течение 3-6 месяцев.
Методика проведения процедуры: в ванну объемом 200 л наливают пресную воду температурой 36-37°С, добавляют 50 мл средства для ванн «Биолонг» с концентрацией 1%, тщательно перемешивают, длительность 10-15 минут, на курс 12-14 процедур.
Эффективность использования метода у больных остеоартрозом
и дорсопатиями различных отделов позвоночника
Под наблюдением находились 20 больных с остеоартрозом и 26 пациентов с дорсопатиями различных отделов позвоночника, которые по данным анкет преимущественными причинами обострения и ухудшения самочувствия считали резкие колебания погодных и факторов и считали себя метеочувствительными. У большинства 29 (63,0%) реакции были выраженные и тяжелые 9 (19,6%) и 8 (17,4%) легкие. При клиническом обследовании у 23 (50,0%) пациентов помимо основного заболевания была диагностирована артериальная гипертония и нейроциркуляторная дистония у 14 (30,4%). Общие ванны с препаратом «Биолонг» получали 33 больных, 13 пациентов (контрольная группа) получали только ЛФК и базовую медикаментозную терапию.
Эффективность лечения подтверждалась достоверным снижением погодообусловленных обострений и изменением структуры метеопатических реакций.
После лечения преобладали реакции легкого течения у 21 (45,6% и не наблюдалось тяжелых метеопатических реакций. Наиболее выраженная положительная динамика проявлений метеопатологии отмечалась у пациентов с сопутствующими сосудистыми нарушениями: нормализация артериального давления, улучшение психо–эмоционального состояния. В основной группе достоверно улучшилось качество жизни по шкале (баллы) «энергичность» с 35,8±2,7 до 23,9±2,1, по шкале «болевые ощущения» с 11,9±4 до 9±2,3; по шкале «физическая активность» с 22,8±3,7 до 19,9±4,6, по шкале «эмоциональные реакции» с 29,1±2,7 до 13,8±1,9; по шкале «сон» с 26,6±3,4 до 16,4±2,4 (Р<0,05), которая оценивалась по 1 части Ноттингемского профиля здоровья.
После лечения отмечалось уменьшение интенсивности боли, подавление выраженности местных признаков воспалительной реакции, субъективное восприятие боли в суставах (ВАШ) почти всеми больными основной группы, в группе сравнения такая динамика выявлена только у 4 (8,6%). Наряду с динамикой болевого синдрома отмечалось уменьшение статико-динамических нарушений, улучшение показателей микроциркуляции и температуры в области пораженных суставов по данным термографии с холодовой пробой. Эмоциональная оценка комфортности и хорошей переносимости составила 87 %, в группе сравнения эти показатели были не значительными. Полученные положительные результаты сохранялись при формировании неблагоприятных погодных условий в течение 3 месяцев у 63% и 6 месяцев у 41% больных
Методика проведения процедуры:
В ванну объемом 200 л наливают пресную воду температурой 38-39°С и добавляют 50 мл средства для ванн «Биолонг» с концентрацией 3%, тщательно перемешивают, длительность процедуры 10-15 минут, с расстановкой ванн через день, при хорошей переносимости, 2 дня подряд, на 3 день перерыв, на курс 12-14 процедур.
Полученные результаты позволяют использовать общие ванны с препаратом «Биолонг» как метод коррекции и профилактики повышенной метеочувствительности и может быть средством выбора при невозможности применять другие лечебные факторы.
Оценка безопасности
Общие ванны с препаратом «Биолонг» являются безопасными и комфортными, обуславливают хорошую переносимость, отсутствие отрицательных, бальнеологических реакций. В практике использования такие реакции были отмечены только у 2 пациентов и были обусловлены сезонным развитием острой респираторной патологии.
Л и т е р а т у р а
- Айрапетова Н.С., Уянаева А.И., Рассулова М.А. и др. Влияние климато-погодных факторов на формирование метеопатических реакций у больных с бронхообструктивными заболеваниями. Ж. Вестник восстановительной медицины, 2015; 5, 26-31.
- Уянаева А.И. Механизмы формирования повышенной метеочувствительности. Ж. Санаторно-курортные организации: менеджмент, маркетинг, экономика, финансы, 2011, 1, 43-50.
- Проявления метеочувствительности у лиц с мягкой артериальной гипертензией. Ж. Физиотерапевт, 2012; 3, 9-16.
- Применение средства для ванн «Биолонг» с профилактической и лечебной целью у больных с синдромом хронической усталости, дорсопатиями и заболеваниями кожи. Пособие для врачей, М. 2003.
- Медведев Ю.В. «Биолонг» — средство комплексного воздействия на различные звенья патогенеза, обусловленные хронической кислородной недостаточностью. Национальный вестник физиотерапевта, 2010; 1 (4), 16-16.
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