MANAGEMENT OF CRISES IN PATIENTS WITH HYPERTENSIVE
DISEASE BY METHODS OF TWIST THERAPY
The most common complication of hypertensive disease (HD) is a hypertension crisis (HC), a sudden increase of arterial blood pressure (ABP) accompanied by clinical symptoms and requiring an immediate reduction to prevent damage of target organs. Though many hypotensive drugs appeared in the past years, this did not result in a lower incidence of HC, which is diagnosed in 20% of patients that required urgent medical aid (5).
Clinical variants of HC are determined mainly by the speed of development of systemic arterial hypertension and by the degree of damage to regional blood circulation. According to prevailing clinical presentations, HC are divided into cerebral, cardial and cardiocerebral. All variants of crises in HD are accompanied by cerebral symptoms in some degree or another, which is determined by hypertentive encephalopathy (2).
Important clinical charasteristics of the severity of HC are complications found, on the average, in 30% of observations. Risk factors for development of complications are the age of patients above 60 years, a long duration of HD, impaired functioning of target organs. Side effects of therapies related to an excess decrease of ABP in management of HC might also be regarded as a risk factor for development of complications such as cerebral ischemia or acute coronary insufficiency. As a rule, therapy of HC begins with hypotensive measures administered by an emergency doctor at home. In the Russian medical practice of the past 20 years, management of HC most often includes ?-adrenoceptor antagonists, calcium antagonists (diltiazem, nimodipin), clonidine, dibasol, urapidil (9).
Most drugs either have a high risk of an excess decrease of ABP or require prolonged infusion, which makes them difficult for using by emergency doctors. In a high risk of development of complications a patient should be immediately taken to hospital, to a cardial resuscitation unit. Untimely and inadequate therapy of HC is fraught with development of life-threatening complications, so the problem of finding means capable of rapid relief of HC at pre-hospital stage is extremely important (10). In this connection, of special significance will be the use of nonmedicamental means that are fast-acting, capable of effective management of HC without a risk of an excess decrease of ABP. One of such methods is therapy by twisting motions and postures (twist therapy) that stimulate peripheral blood circulation, optimize metabolic processes, activate mechanisms of self-regulation and selfrestoration of the body (8).
Light twist of the body stimulates numerous receptor areas of connective tissue formations, muscles, vessels, peripheral nerve ends. Selective activation in the context of the corresponding scleroderma-, and neurotomes brings about a considerable increase of sensory flow at the corresponding levels of the spinal cord. The data on the mechanisms of action of twist motions and postures in yoga asanas, Oriental gymnastics of taiji and qigong are indicative of involvement of the energy system of acupuncture channels (3, 4, 7). The objective of the present study was to evaluate the efficacy of hypotensive action of twist therapy in uncomplicated HC in patients with essential HD.
MATERIALS AND METHODS
The study involved 90 patients aged from 31 to 72 years (average age 53.7±2.4 years) with HD of 2-3 degree, the average duration of disease being 14.9±3.0 years, high values of habitual ABP (average systolic ABP (SABP) 152±5.7 mmHg, diastolic ABP (DABP) -93.7±3.1 mmHg), and a typical clinical picture of HC (sudden and individually significant increase of ABP: SABP - over 180 mmHg, DABP — over 100 mmHg accompanied by cerebral and/or cardial symptoms). The basic group comprised 56 patients — 48 females and 8 males, the average age being 57.1±1.2 years. In this group, for management of HC individually selected twist positions of the head, neck and chest were applied.
Methods of selection of therapeutic positions based on a twist diagnosis included the following steps:
1) finding the preferred (most free and comfortable) direction of turning by slowly and smoothly moving the head first leftward, then rightward (Fig. 1);
2) finding the preferred position of bending by slowly and smoothly bending the head backward, forward, and laterally (Fig. 2);
3) bending the patient’s head in the direction found in p. 2, and in this position turning the head slowly and smoothly in the direction determined in p. 1;
4) on making sure that the therapeutic twist position does not cause discomfort in the patient, it was fixed for 1 minute, with maximum relaxation of the muscles of the neck (for this the patient’s head could lean on a hand, pillow, or on a chair’s back).
5) returning the patient’s head to the initial position slowly and smoothly, after which he or she should take a deep breath and slowly breathe out through the nose three times;
6) if any unpleasant subjective sensations were absent the same position was repeated with a 10-minute hold-up. If it was difficult to determine preferred bend positions and twist directions, a position that causes the most unpleasant sensations in the neck was determined by slow ans smooth circular movements of the patient’s head, and the head was put into the opposite symmetrical (diagonal) position (Fig. 3).
On making sure that it was comfortable, it was fixed for 1 minute to have the muscles of the neck relaxed. Further — as described in pp. 5 and 6. A similar procedure of finding the preferred turn and bend direction was repeated in the area of the chest (Fig. 4).
If it is objectively impossible to change the position of the patient’s body, twist motions were performed in the systems of correspondence to the head and chest (Fig. 5) on the thumbs and/or big toes (6).
A therapeutic position in HC as a combined twist position of the neck and chest or their correspondence areas was individually selected (8). The control group comprised 34 patients with HC in HD (average age 56.8±2.2 years, duration of disease 11.4±1.9 years) who received clonidine therapy in the dose 1.5 mg in a 0.9 % solution of sodium chloride, introduced intravenously for 5 minutes. The study also involved 40 volunteers aged from 35 to 75 years (average age 53.7±2.4) without any signs of an increase of ABP indices or revealed pathologies of the cardiovascular system. They all performed complexes of twist therapy similar to those applied to patients with HC. ABP was determined as the average of three measurements with a mechanical sphygmomanometer (Japan) with the degree of accuracy B/B by protocol BHS in the patient’s sitting position (1).
A statistical analysis was made using the programme SPSS 8.0. Quantitative variables are presented as a mean ± standard variation. An analysis of variance and Student’s criterion were used for comparing quantitative variables. Differences were consireded reliable in р‹0.05. RESULTS AND DISCUSSION The study demonstrated that performance of an individually selected adequate twist posture contributed to a reliable decrease of ABP indices within 15 to 30 minutes from the beginning of treatment.
A decrease of SABP was obtained within the first 15 minutes by 18.3±2.6 mmHg, of DABP by 9.8±1.6 mmHg, on the average. During the next 15 minutes a decrease of SABP by 11.1±1.8, of DABP by 4.6±1.5 mmHg was observed. The hypotensive effect of clonidine during the first 30 minutes after introduction of the drug was more marked. The variability of average ABP indices in the basic and control groups was 9.1±1.1 and 15.9±2.0 mmHg, respectively. By the 60th munite of treatment the patients of both groups felt better, and the indices of SABP and DABP did not display reliable differences. In the control group episodes of an excess decrease of SABP (below 140 mmHg) were registered in 12.5% of cases, of relative arterial hypotension (SABP below 120 mmHg) — in 9.4% of cases, of arterial hypotension (SABP below 100 mmHg) — in 6.25% of cases, which was not observed in the basic grop of patients. The heart rate (HR) in the basic group reliably decreased by the 60th minute from the beginning of treatment, and in the control group by the 15th minute after introduction of the drug.
The indices of ABP and HR in the group of volunteers without pathology of the cardiovascular system who applied a similar complex of twist therapy did not display any reliable differences before and after a 30-minute therapeutic procedure. It was found that the most effective twist motions that resulted in a relief of the clinical symptoms of HC and a decrease of ABP indices were turning the head and chest leftward with bending in the left-back direction (57.3% of cases) and turning the head and chest rightward with bending in the front-lower direction (21.7% of cases) (Fig. 6).
A gradual decrease of ABP indices owing to twist therapy and the absence of a sharp decrease of SABP and HR, as in treatment with clonidine, reduced a risk of side effects and cerebral complications of hypotensive therapy. Since therapeutic motions are preferred twist motions performed in the most comfortable position of the body, their performance not only normalizes hemodynamic indices but also decreases psychoemotional tension that plays a considerable role in pathogenesis of HC. It was observed that practically healthy individuals with a normally functioning proprioceptive system of self-regulation adopt preferred twist postures by intuition, thus making natural prophylaxis of cardiovascular diseases. In patients with the chronic form of HD this ability is considerably lower. So it is important to purposefully select a proper posture that the patient could adopt on his own to maintain and strengthen the obtained therapeutic effect.
Opposite bend positions and twist directions, as a rule, are accompanied by sensations of discomfort, tension or pain. If the patient with HC finds such umpleasant positions and directions for his head, neck and chest, the opposite positions and motions will promote a subjective improvement of his well-being and normalization of ABP indices. Twist motions of the hands and feet also play a considerable role in obtaining a mild hypotensive effect in HC owing to stimulation of systems of correspondence to the brain, heart and also to activation of peripheral capillary circulation.
The possibility of an individual approach to selecting a therapeutically valid twist motion, absence of a need for any accessory tools, absence of a risk of an excess decrease of ABP, possibility of urgent application in the first minutes of the development of an HC episode by an emergency doctor and even by the patient himself who mastered simple methods of twist diagnosis permit to consider twist motions and postures (twist therapy) as one of effective means of urgent therapy of HC.
CONCLUSIONS
1. Application of adequate twist positions of the body (twist therapy) permits to obtain a reliable decrease of ABP indices in patients with HC within the first 15 minutes after the beginning of treatment. 2. In comparison with clonidine, twist therapy has a more smooth hypotensive effect, against the background of which a regress of clinical presentations of HC is observed. 3. The method of twist therapy does not cause episodes of an excess decrease of ABP. 4. Owing to high efficacy, cost-efficiency and safety of application and a considerablly fast effect, the method of twist therapy might be recommended for management of HC in patients with HD at the pre-hospital stage.
N.V. Borisova, MD,
S.D. Nanzanova, physician, Smile Academy, Moscow
V.V. Malakhovsky, MD, chair of nonmedication methods of treatment and clinical physiology,
I.M. Sechenov Medical Academy, Moscow
N.L. Shimanovsky, Professor, corresponding member of Russian Academy of Medical Sciences,
chair of molecular pharmacology and radiobiology, Russian State Medical University, Moscow
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