Non-specific indicants of disorder of tissular circulation
To such indicants in the first place they relate the indicants of change of functional state of an organism, which are connected with morphological dislocations in tissues, especially in pericapillar space, with progression of definitive CTI syndrome. Valuable tests for identification of CTI can be some indicants which are not specific for particular diseases, but they can reflect the common disorder of microcirculation system. To such indicants they relate general weakness, increased fatigability, headache, dizziness, sleep disturbance, irritation, puffiness of face, arms and legs and other symptoms (Kaznacheev, Dzizinskiy, 1975). It is important to note that microcirculatory dislocations with the progression of CTI syndrome determine significant disorder of plastic and energetic supporting of cellular tissue architecture, and this finally leads to cell food disorder and oxygen deprivation.
To nonspecific indicants of ischemic kind one should also refer a group of vegetative disorders, including local vasospasm (itch, various kinds of dermographism), sweatiness or xeroderma (skin dryness), common cold, blear-eyedness, salivation, pilomotor activity (goose skin), decrease of temperature of distal parts of extremities, skin transformations in the areas of trophic disorders. Besides this, one should pay attention to complaints about morning constraint in skeletal muscles, especially after physical activity, feeling of heaviness in the head, back, legs, asthenic syndrome, chronic fatigue syndrome.
In the recent years new indicants of functional status of tissular circulation have been worked out with the help of vacuum influence. In spite of the fact that these indicants are quite unbiased, they still should be considered to be non-specific as not only sick people, but healthy people as well, may have them.
Extravasates, which are diagnosed with the help of vacuum influence, local edema, typical stress extravasates, deep cicatrical bands and other changes are important non-specific indicants of disorders of microvasculature of soft tissues.
The possibility of detection of such indicants of tissular CTI syndrome was first demonstrated in the work by P.P. Mikhailichenko (2000). In the basis of results of clinical researches were examinations of more than 5000 patients and healthy people, children and adults, sportsmen and physically inactive people, men and women, in Russia and other countries (in the USA, Switzerland, Italy, Germany, China, India, Australia).
The method of vacuum gradient therapy (VGT) gives an opportunity to get reliable and quite well presented indicants of microcirculation changes in soft tissues of locomotor system. Long-term clinical work helped the author detect a number of common rules of response to VGT of soft tissues of both patients and healthy people. In the first place it is important to note that the initial response of soft tissues of patients and healthy people to vacuum influence is evident in the form extravasates.
1. Characterization of extravasation. Extravasates (serosanguineous exudate cluster and a little of blood) are the result of dermatic vascular response of pathologically morphed tissues to vacuum influence.
Such extravasates are divided into ranges from 0 to 5 according to their intensity (in accordance with our classification). As a rule, they represent quite typical situation of dermatic vascular response, which occurs as dark-blue, florid-cyanotic violet tinction together with small and large point-like hemorrhages, which are sometimes confluent. In particular cases, strongly marked single or multiple loops of venous capillary branch, which look like punctuate, convolute, scolecoid lumps - varicose veins. Extravasates quite objectively show the intensity of venous blood congestions in particular area of a human body. Taking into account the intensity and duration of extravasates forming (from several seconds to 24 hours) and also their physical form, it is possible to estimate the localization of venous stagnation in facial and deep layers of tissues and the degree of its manifestation. Physical form of extravasates gives very valuable information about firming and the territory of extension or, on the contrary, decrease and complete eradication of venous stagnation and also to find out the speed of its regression after the course of treatment is done, to trace some correlations during proceeding pathological disorders and disclose prenosological functional disorders in tissues.
With the help of VGT the author marked stress-dependent areas of a human body, i.e. the areas of soft tissues where one can most frequently detect extravasates, which are formed due to microcirculation disorders and associated with stressogenic factors.
The most usual localizations of extravasates are occipital region, posterior surface of neck, the area between shoulder girdles and posterior triangle of neck, anterior and posterior surfaces of shoulder joints, upper and middle part of back, scapular region (infraspinous and deltoid muscles), back bone projection, posterolateral thigh surface, facial area, anterior surface of breast. Extravasates, which are evident to venous blood stagnation, can occur both on the whole body surface (except for palmary and pelmatic surfaces) and piecewise, i.e. on some of its segments. In clinical studies fragment localization occurs more frequently, for example in the areas of neck, back, blade bones, shoulder joints, face. And at the same time in some other areas such as gluteal region, shin, shoulder, forearm, hand, foot, stomach - there are not any extravasates or they are not so well seen.
In some cases, forming of extravasates is mosaic. For example, on the region of 50x50 mm one can see petechiae of different degrees of manifestation (from 0 to 3-4 degree). There may be absolutely intact tissues on a small area (0.5 - 1 cm) from the region with extravasates of 2nd, 3rd, 4th degrees. It gives ground to some extent to make conclusions about compartmentalization of stagnation processes or about the local kind of their spread on the areas of tissues.
Extravasates differ in the depth of forming; they can be interfacial and deep. Interfacial extravasates are representative of venous hyperemia, located mainly in hypodermic capillary veniplexes; deep ones show venous blood stagnation of microvasculature mainly of fascial-muscle layers. Forming of interfacial extravasates occurs quite quickly (from several seconds to 1 minute) and is seen even with small intensity of influence (falling of pressure to 250-300 mm of mercury). Deep extravasates have longer period of forming (from half an hour to 24 hours) and are usually seen if the pressure is falling to 300-760 mm of mercury.
Extravasates are regarded as some kind of an indicator of venous stagnation in interfacial and deep layers of soft tissues.
It is important to note that in some cases extravasates are accompanied with puffiness and painfulness, convolute, spiroid loops of capillary venous part in the shape of varicose veins are formed inside of them. Especially this situation can be seen in the scapular region - in the region of infraspinous band and muscle, deltoid and cowl muscles.
During the course of treatment and diagnostics, as a rule, the speed of elimination of extravasates increases two- or three-fold, it depends on the number of procedures. At that, even significant increase of intensity of influence even to maximum (degree of vacuum - 1 atm) does not result in extravasates forming.
Possible pathogenetic mechanisms of forming of extravasates, which are studied as indicators of tissular venous hyperemia, condition microvasculature disorders. They are defined by the progression of the following pathological processes:
1. Peripheral circulatory dynamics disorder, caused by unregulated vasoconstriction of some vascular structures and/or paresis of others. At that, in the tissues there appear focuses of angiospastic ischemia and angioparetic hyperemia combined with venous spastic deceleration or even stagnation of the circulation, venous capillary hyperemia and blood sludging.
2. Intravascular pathological changes:
2.1. Disorders of hemorheological properties connected with change of blood viscosity and suspended stability of its cells.
2.2. Blood discongelation and tromboembolism.
2.3. Feebleness of circulation, disorder of blood fluctuation and perfusion through microvasculature.
Intravascular pathological processes come mainly to ischemia or excessive hyperemia of microvessels and disorder of rheological properties of blood. The latter is evident through forming of erythrocytic, trombocytic, leukocytic and combined cellular aggregates. This leads to increase of blood viscosity, its sludging and decrease of perfusion properties. Increase of sludge is attended with emergence of local or extensive capillary and venous stasis. Major hemorheological disorders result in blood coagulation disorder with forming final vessels in the lumen, which are fixed to walls, and freely circulating platelet fibrinous clots. To the consequences of intravascular changes can be referred: volume reduction of transcapillary circulation; hypoxia and metabolic crisis of tissues.
3. Vascular dislocations per se:
3.1. Dysfunction of endothelium and other structures of a microvessel wall, their damage.
3.2. Increase of penetrance of capillars and venules.
3.3. Adhesion of white blood cells and platelets to endothelium.
Vascular pathological changes per se are evident as dysfunction of endothelial nitrogen oxide formation, dystonia and paresis of arterioles and muscle venules, which become sulcated and dilated. Angoiparetic occurrences are attended with acute hyperemia of vessels of all parts of microvasculature, enhancement of their penetrance, edema and suffusion of walls with plasma, diapedesis of erythrocytes. During many diseases structural elements of microvessels are subjected to dystrophic and necrotic changes. In endotheliocytes they are evident as swelling and vacuolization of cytoplasm, karyopyknosis, discomplexation, cytolysis and desquamation; and in balsamic interseptum - as its thickening, maceration and fragmentation. Necrotic processes in arterioles, especially in capillars and venules, are attended with aneurysm formation.
4. Transformation of true (nutritive) capillars into capacitive (deposit) microvessels - postcapaillars, venules etc.
5. Extravascular disorders:
5.1. Damage and dysfunction of perivascular connective tissue.
5.2. Response of polimorphonuclear leukocytes, lymphocytes, macrophages and mast cells to pathogenic factor.
5.3. Difficulty of lymphocytes outflow.
5.4. Involving of microvascular bed into dystrophic process.
Extravascular (stromal) pathological changes of microcirculation system are evident as dehydratation and edema of perivascular and intervascular connective tissue, its mucoid swelling, plasmatic suffusion, less frequently - through fibrinoid necrosis and hemorrhagic infiltration. The consequence of these processes is fibrosis, and sometimes it may be hyalinosis interstitium.
The results of VGT application are indicative of its direct reconstructive, reparative impact on tissues, because as a result of this reduction and complete disappearance of dermatic extravasates happens, and it is attended with clinical improvement and recovery. It indicates, firstly, about liquidation of venous blood stagnation; secondly, about gradual regeneration of tissular microhemodynamics and, finally, about normalization of metabolism in damaged tissues.
The degree of credibility of detection and elimination of stagnant hyperemia of tissues either within patients with various diseases or healthy people, children, sportsmen with the help of VGT is quite high and is more than 90%.
2 Local edema and some of its characteristics
Unlike edemas, caused by water-salt metabolism disorders and some other causes, in the present work local edema is understood as a kind of derma-vascular response of pathologically changed soft tissues to vacuum influence. With the influence of vacuum of equal force to symmetrical areas of tissues, as a rule, in one or (less frequently) in several loci there is a formation of local swelling (edema).
Local edema is regarded as the indicator which is representative of blocking of local lymphoid chain of the system of microcirculation and microcurrents of interstitial fluid in one of the areas of tissues. Local edemas occur both together with extravasates and independently. The intensity of edema depends both on local microcirculation state and on strength (force and duration) of impact. Local tissular edemas are found in 50% of cases of examined patients and healthy people. Appearances of local edemas can be single and multiple.
Local edema looks like an area of swelling of soft tissues of different size and territory, which swells on the skin surface at the height of 0.1-5 cm; it can be of normal, skin colour, but with hemorrhages - it is respectively red, florid-cyanotic and violet.
Dynamics of appearance of local edemas is of particular interest. During the process of diagnostic and treatment procedure the size of local edema grows, and after the procedure its regression is seen within several minutes, though sometimes an edema can remain 1-2 days. Directly after the impact of negative pressure local edemas disappear quite quickly while extravasates remain up to several days after the procedure. In the long-term plan during the course influence, first normalization of hemomicrocirculation state happens, which results in considerable decrease of extravasates intensity with the same or even increased strength of impact. The normalization of lymphomicrocirculation and therefore interruption of local edema formation come considerably later, i.e. local edema of lymphovascular and interstitial space remains much longer than hemomicrocirculatory one, it is stable and hard to treat. Permanent and stable edema interstition is known to be attended with "obstruction" of internal environment with metabolic products, and accumulation of non-utilizable albuminous compounds in the connective tissue. (Korablev, Nikolaeva, 1999).
Local edemas usually occur in loci of algogenic muscular-connective-tissular indurations, contractures, joints arthrosis, and posttraumatic areas of tissues of different terms of limitations. Their most frequent localization is on posterior surface of neck, paravertebrally in the interscapular region, in superior and inferior angles of scapulas, shoulder and knee joints. In particular cases edema is localized can be an indicator of long-lasting (1 year and more) processes of tissular hemo- and lymphocirculation disorder, and if to compare with venous blood stagnation it is quite stable and hard to be subjected to the therapy with tissular pathology phenomenon.
Discovered laws lead to the conclusion that local edemas indicate about considerable damage of lymphoid chain of microcirculation system and therefore about the longer period, necessary for its regeneration due to therapeutic intervention in comparison with disorders in the hemomicrovasculature.
Local tissular edema formation can occur without any or with an inconsiderable change of ultrastructure of capillary network. Factors which determine its progression might be the following: hemodynamic dislocations, physical and chemical changes in the interstitial tissue and also the change of balance of filtration and lymphatic outflow speeds.
The most significant meaning in local edema formation belongs to two types of extravascular disorders. First of all, it is the response of tissular basophiles, which surround the vessels of connective tissue, to a disturbing factor. During some pathological processes (inflammation, stress) biologically active substances and ferments ejaculate from tissular basophiles to interstitial space during their degranulation. Some of them are known to be important for the increase of anticoagulative activity of blood and for the change of its rheological properties (heparin), for the change of speed of blood flow and vascular penetration (histamine, serotonin). For example, with the influence of histamine there occur processes of aggregation of erythrocytes and platelets and microclots formation. These processes impede microcirculation.
The impact of damaging agents on tissue is attended with release from lysosomes and activation of proteoclastic ferments, which split built-up protein-polysaccharide complexes of basic substance. The consequences of the denoted disorders are destructive changes of basal interseptum of microvessels and of fibrous structure, which form some kind of carcass, which contains microvessels. In the light of this fact we can clearly realize the role of such disorders in the change of vessels penetration, size of their lumen and feebleness of circulation.
Another type of disorders of connective tissue, surrounding microvessels, includes changes of perivascular transportation of interstitial fluid together with dissolved in it substances, disorders of processes of formation and circulation of lymph. Thus, in conditions of pathology, in consequence of insufficiency of resorption mechanisms in blood of intertissular fluid or in consequence of decrease of its inflow into lymphoid capillars, a certain quantity of fluid remains in tissues and it causes edema progression. The increase of transudation of intertissular fluid occurs due to the increase of hydrodynamic blood pressure on microvessels walls. The most frequent reason of it is local or venous stagnation of blood, caused by insufficiency of systematic blood circulation.
Regional features of perivascular connective texture, various spatial relations between specialized cells and microvessels can considerably influence the substances transportation including protein substrate with the help of interstitium. Collagen fibres are known to act as so called "fibreconductor", in microtubules of which there occurs selective transportation of substances with the help of interstitium towards the specialized cells and lymphoid capillars from one side and towards postcapillars and venules from the other. That is why in tissular pathology, for which disorganization of fibre structures and their unregulated neoformation are typical, the disorder of way of pericapillar and interstitial transportation of substances and the level of resorption of interstitial fluid may lead to signified disorders of drainage function and therefore to the formation of local edema. The disorder of permanent and effective drainage of interstitial space is the basis for emergence of insufficiency of lymphoid system. It is common to distinguish its mechanical, dynamic and resorption insufficiency.
Main clinical and pathophysiological evidences of lymphocirculation insufficiency in acute stage are edema, accumulation of albumins and their cleavage products in interstitial tissue and fibrosis progression; in chronic stage sclerosis of tissues is formed.
Thus, the higher the degree of intensity of extravasates, caused by vacuum influence, and local edemas is, the more considerable destructive processes of tissues can be.
According to the data by N.N.Zaiko (1985), particularly severe consequences for tissues occur when venous and lymphoid stagnations progress at the same time, and it is proved by clinical practice.
II-3 Extravasates of stress
This is a kind of dermatic vascular response, which is detected in only those people who underwent diagnostic and treatment course of VGT and in tissues of which complete elimination of venous stagnation was reached. In this case, extravasates considerably differ from other kinds of petechiae, which indicate venous blood stagnation. Such extravasates are usually seen amid arterial hyperemia as single and multiple vascular "stars" of scarlet colour. Their resolution occurs within 1-2 days. The cause of extravasates of stress, as a rule, is psychoemotional stress suffered recently (approximately within 1-2 weeks). Extravasates of stress may be considered to be an indicator of the initial stage of formation of stagnation processes in tissues. Extravasates emergence amid normalized after the VGT course state of microvessels in response to non-specific activity of various stressors gives us the reason to tell about the fact that stress is often evident as the disorder of microcirculation system.
Introduced materials of clinical examinations indicate about the fact that referring to characteristics of formation of extravasates and local edemas due to vacuum influence and their regression due to the treatment lets us see the functional state of tissular microcirculation, speed of regeneration in the system of hemo- and lymphocirculation and, finally, the total potential of tissues.
II-4 Deep muscle indurations, fibrous
Are formations which are not usually diagnosed with classical research techniques and are evident only with the help of vacuum influence. They are usually located in the deep tissular layers of neck, back, gluteal region, thighs and are seen during the diagnostic and treatment course of VGT, often during the third-fifth procedure, when quite high degree of rarefaction of air, and therefore the higher degree of intensity, is used. Detectable formations of different linear dimensions are often attended with painfulness, puffiness or local edema, sometimes with extravasates. And during the palpation tuberous and solid surface of these formations is defined. Such morphological substrates sometimes "come as a surprise" both for patients and specialists. As a rule, these formations are hard to define, but at the same time they indicate morphological features of changing of tissular structures, which are caused by the disorder of tissular blood and lymphocirculation, which cause the formation of myofascial pain syndrome.
Deep fibrous-dystrophic formations are evident both for patients and clinically healthy people as definitive localization in the interscapular region of back, neck, gluteal region and gluteal folds, hips.
The most informative of all indicants are extravasates and local edemas, which, together with fibrous-dystrophic muscular-connective-tissular formations, may be the reason for morphofunctional evaluation of soft tissues state of both healthy people at the prenosological stage and patients with various types of diseases.
Modern ideas about the pathophysiological mechanisms of formation of extravasates and local edema in tissues give grounds to consider that they are caused by disorders in microvasculature of circulatory-lymphoid system and interstitial fluid, which lead to dystrophic processes progression.