Physiotherapy in disease
prophylaxis and treatment:
A review of applications
Presenter
Dr Vladimir Gurevich
EL Physiotherapy
Physiotherapy
Use of specific physical factors for disease prophylaxis and treatment
Physiotherapy modalities are used by themselves or in combination
with drugs
Physiotherapy is one of key fields in modern clinical practice
Applies essentially to every clinical discipline
Allows effective treatment and prophylaxis of various diseases
Often it is the most appropriate clinical approach to achieve a rapid and
efficient improvement of the conditions of patients
Advantages of physiotherapy
treatment
• Quick – the results are achieved in a rapid fashion
• Efficient – addresses both the aetiology and the
pathogenesis to eliminate the cause not just symptoms
• Safe – causes minimum side effects or adverse
reactions
• Specific – drugs or treatment delivered to the affected
organs or tissues
• Painless – uses non-invasive procedures
• Stressless – avoids unnecessary surgical procedures
and use of general anaesthetics
Use of physiotherapy
Physiotherapy applies to a variety
of pathological conditions:
• musculoskeletal
• respiratory
• gynecological
• dermatological
• gastroenterological
• urological
• endocrine
• neurological
• cardiovascular
• other diseases
Major physiotherapy techniques:
• Electrotherapy
• Clinical Pilates
• Hydrotherapy
• Thermal therapy
• Cryotherapy
• Ozonetherapy
• Vacuum therapy
• Pressure therapy
• Manual therapy
• Exercise therapy
• Balneotherapy
Electrotherapy
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Electrostimulation
Interferential
Ultrasound
Magnetotherapy
Pharmacological phoresis
SCENAR
Combination therapy
Electrostimulation
Uses various types of electrical currents (e.g. TENS, Russian, Galvanic, Diadynamic etc.)
to stimulate the body’s organs and systems
Acts through different pathways e.g. high-intensity TENS (50-100 Hz) reduces pain by
inducing pre-synaptic inhibition of nociceptive fibers but low-intensity TENS (2-10 Hz)
provides antinociceptive effect through releasing endogenous opioids
Stimulates secretory and motoric function of the gastrointestinal tract
Provides neurostimulating and voluntary and involuntary muscle stimulation activity
Can be used in disease treatment and prophylaxis or for cosmetic purposes
Helps strengthen muscles and improves their tone
Interferential
Interferes with the transmission of pain messages at the spinal cord
level, leading to pain relief
Reaches deep muscles and nerves
Stimulates voluntary muscles
Stimulates peripheral blood circulation
Provides immediate and strong analgesia
Accelerates bone healing
Ultrasound
Therapeutic effect achieved by using high frequency sound waves which
enhance the healing process in injured organs or tissues of the body
The mechanical and thermal actions of ultrasound applications lead to
physicochemical reactions at the cellular, tissue and systemic levels
resulting in the treatment effect
Provides vasodilating effect for blood and lymphatic vessels, improves
peripheral blood circulation
Stimulates enzymatic activity and cellular metabolism
Induces processes of pro-inflammatory optimisation
Improves membrane permeability, accelerates cellular diffusion and osmosis
Magnetotherapy
Therapeutic effect through creation of a continuous or pulsative
magnetic flux (low intensity technique)
Stimulates cellular and humoral immunity
Modulates endocrine regulation and enzymatic activity
Improves blood and lymphatic circulation and modulates
haemocoagulation processes
Activates metabolic processes in different organs and systems
Modulates skeletal and smooth muscle contraction and relaxation
Stimulates tissue regeneration
SCENAR therapy
This treatment method uses the SCENAR (Self Controlled Energo-Neuro
Adaptive Regulator) device
SCENAR helps the body heal itself through locating problem areas and
subsequently re-activating the body’s self-regulatory mechanism which was
destroyed by an accident or disease
Advantages of SCENAR therapy:
• One of the best electrotherapy tools available
• No negative side effects
• Very few contraindications
• Totally safe
• No medications required
• Re-actives the body’s self-regulatory mechanism
• Effects felt after just a few sessions
Pharmacological phoresis
The main problem with the conventional oral and parenteral drug administration
is its inability to deliver the drugs specifically to the affected organ or tissue
Conventional oral and parenteral drug administration usually creates a need for
high doses of the drug to achieve the required effect
Pharmacological phoresis utilises different physiotherapy modalities to enhance
the delivery of topically applied drugs to the affected organs or tissues
In this approach transdermal or transmucosal administration of drugs allows
achieving a rapid treatment effect
Specific clinical effects are determined by the combined effect of the
corresponding drug delivery system e.g. ultrasound and the
pharmacological preparation
Used for both local topographically specific and systemic drug administration
and has proven efficiency in disease treatment
Suitable for various drug groups (corticosteroids, NSAIDs, analgesics,
vasodilators, hormones, anticoagulants, antibiotics, vaccines, antfungal,
antimicrobial etc.)
Advantages of pharmacological
phoresis
• Effectively enhances the delivery of topically applied
drugs
• Allows drug delivery specifically to the affected organ or
tissue
• Avoids or minimises adverse reactions of the drug
• Maintains local drug effect for a prolonged period
• Avoids potential gastrointestinal degradation of the drug
• Reduces the dose required
• Permits effective dosage control during the drug
administration
Combination therapy
Simultaneous or interchangeable use of different
physiotherapy modalities to achieve a synergistic
treatment effect
Combination schemes:
• Iontophoresis and magnetotherapy
• Iontophoresis and ultrasound
• SCENAR and iontophoresis
• SCENAR and magnetotherapy
• Interferential and phonophoresis
• Ultrasound and interferential
Clinical effects of electrotherapy
Electrostimulation
Interferential
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Anti-inflammatory
Analgesic
Sedative
Tranquilising
Spasmolytic
Vasodilating
Trophic
Stimulation of secretion function
Metabolic
Analgesic
Trophic
Spasmolytic
Defibrosing
Ultrasound
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Anti-inflammatory
Analgesic
Spasmolytic
Metabolic
Defibrosing
Magnetotherapy
SCENAR therapy
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Sedative
Trophic
Spasmolytic
Vasoactivating
Antiedemic
Hypocoagulating
Myorelaxation
Metabolic
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Metabolic
Immunostimulating
Vasoactivating
Endorphine and encephaline
release
Correction of DNA spontaneous
structural changes
Neurotransmitters release
Clinical effectiveness of electrotherapy modalities for
treatment of some pathological conditions
(shown in descending order)
Analgesic effect:
• Electrostimulation (diadynamic, TENS, galvanic)
• Ultrasound
• Pharmacological phoresis
• Magnetotherapy
Vasoactive and circulatory effect:
• Magnetotherapy
• Pharmacological phoresis
• Ultrasound
• Electrostimulation (diadynamic)
Anti-inflammatory effect:
• Electrostimulation (galvanic)
• Pharmacological phoresis
• Ultrasound
Indications for electrotherapy
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Musculoskeletal pathologies e.g. rheumatoid arthritis, osteoarthritis,
osteochondrosis, tendinitis, bone fractures, plantar fasciitis, etc.
Cardiovascular diseases e.g. hypertension, ischemic heart disease, angina,
vascular dystonia, varicose veins, atherosclerotic occlusions, phlebitis,
thrombophlebitis, etc.
Gynecological diseases e.g. endometritis, salpingits, dysmenorrhea,
mastitis, incontinence, etc.
Dermatological diseases e.g. throphic ulcers, hyperhidrosis and
bromidrosis, eczema, neurodermitis, herpes, etc.
Gastroenterological diseases e.g. gastric and duodenal ulcers, reflux,
oesophagitis, duodenitis, enteritis, gastritis, colitis, biliary dyskinesia,
hepatitis, pancreatitis, cholecystitis, etc.
Respiratory diseases e.g. chronic obstructive pulmonary disease, bronchitis,
bronchial asthma, tonsillitis, pharyngitis, laryngitis, pneumonia, etc.
Neurological diseases e.g. stroke, carpal tunnel syndrome, trigeminal nerve
lesion, neuralgia, peripheral lesion etc.
Urological diseases e.g. pyelonephritis, cystitis, prostatitis, urethritis, etc.
Other diseases
Mechanisms of action
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Induction of endogenous opioids e.g. endorphins, enkephalins
Opioid receptor activation in the spinal cord and rostral-ventral medulla
Improvement of the oxygen transport and metabolic processes
Reduction of nociceptive response
Stimulation of neurotrophins release
Regulation of the endocrine system secretory activity
Pro-inflammatory optimisation through mobilisation of cellular and humoral
defense mechanisms e.g. lymphocytes, neutrophils, macrophages,
platelets
Modulation of the release of inflammatory mediators (serotonin, histamine,
eicosanoids, prostaglandins, leukotreine, sympatomimetic amines)
Membrane polarisation and improved permeability
Regulation of cellular acid-alkaline balance
Stimulation of processes of cellular diffusion and osmosis
Clinical effectiveness of
electrotherapy
Assessed in:
• RCT (randomised controlled trials)
• Clinical studies
• Practical clinical observations
Results sourced from:
• Journal publications e.g. research, review, clinical papers
• Cochrane library
• Databases e.g. PubMed
• Conference proceeding
Use of low-intensity pulsed ultrasound for fracture
treatment
(J. Busse et al., CMAJ, 2002)
SCENAR therapy of maxillary and mandibular furuncles and
phlegmons
(Y. Perfiliev et al., Rostov State Medical University, Department of Maxillofacial Surgery,
Proceedings of 1st Russian Conference on SCENAR Therapy, 2007)
Duration of inflammation symptoms (days)
Parameters
SCENAR treatment
(n=98)
Standard treatment
(n=105)
Pain
3.4±0.2
5.4±0.3
Purulent exudate
3.3±0.5
5.9±0.4
Oedema and infiltration
2.9±0.3
5.0±0.3
Hyperthermia
2.8±0.2
4.7±0.2
Intoxication (weakness,
headache etc.)
4.8±0.3
9.3±0.3
Period before suture
(days)
6.8±0.2
9.0±0.5
Analgesic effect of interferential treatment on chronic pain
in knee osteoarthritis
(R. Defrin et al., Pain, 2005)
Mean pre- and post-treatment values of chronic pain intensity (VAS scores) in the study groups.
A significant reduction in chronic pain was found in all the active treatment groups (groups 1–4)
(**P<0.01, ***P<0.001) but not in the placebo and control groups (groups 5 and 6, respectively).
Bars denote mean±SD.
Effect of combined interferential and patterned muscle stimulation as
compared to TENS in treatment of knee osteoarthritis
(F. Burch et al., Osteoarthritis and Cartilage, 2005)
Effect of combined ultrasound and interferential therapy on pre- and
post-sleep and sleep pain parameters in fibromyalgia
(T. Almeida et al., Pain, 2003)
Pre- and post sleep parameters
Sleep parameters
Hypoalgesic effect of TENS following inguinal
herniorrhaphy
(J. De Santana et al., The Journal of Pain, 2008)
Mean pain scores for TENS (n=20) and placebo (n=20) groups
Mean number of doses of analgesic (dipyrone)
for TENS and placebo groups (p = 0.001)
Effect of transcutaneous electrical muscle stimulation (TEMS) on blood
pressure and removal of urea and phosphate during haemodialysis
(S. Farese et al., American Journal of Kidney Disease, 2008)
Parameters
TEMS
Control
Statistical
significance
Blood pressure
(mm Hg)
125/66±22/16
121/64±21/15
p < 0.05
Urea removal
(g/dialysis)
19.4±3.7
15.1±3.9
p < 0.001
Phosphate
removal
(g/dialysis)
1197±265
895±202
p < 0.001
Effect of TENS on the symptomatic management of chronic
prostatitis/chronic pelvic pain syndrome
(L. Sikiru et al., International Brazilian Journal of Urology, 2008)
Analgesic group received ibuprofen treatment
Effect of extracorporeal shock wave therapy on the
treatment of chronic pelvic pain syndrome in males
(R. Zimmermann et al., European Urology, 2009)
Changes in parameters for the sham and verum treatment groups
Parameter
IPSS (1 wk)–IPSS (pre)
IPSS (4wk)–IPSS (pre)
IPSS (12wk)–IPSS (pre)
IIEF (1 wk)–IIEF (pre)
IIEF (4wk)–IIEF(pre)
IIEF (12wk)–IIEF(pre)
CPSI (1 wk)–CPSI (pre)
CPSI (4wk)–CPSI (pre)
CPSI (12wk)–CPSI (pre)
VAS (1 wk)–VAS (pre)
VAS (4 wk)–VAS (pre)
VAS (12 wk)–VAS (pre)
Placebo (% )
0
0
0
0
0
0
0
2.1
4.2
−16.7
0
0
Significant changes
No (p = 0.947)
No (p = 0.631)
No (p = 0.280)
No (p = 0.959)
No (p = 0.894)
No (p = 0.569)
No (p = 0.935)
No (p = 0.865)
No (p = 0.935)
No (p = 0.151)
No (p = 0.865)
No (p = 0.227)
Verum (% )
−15.6
−18.8
−25
10.5
5.3
5.3
−16.7
−16.7
−16.7
−33.3
−50
−50
CPSI = Chronic Prostatitis Symptom Index; IIEF = International Index of Erectile
Function; IPSS = International Prostate Symptom Score; VAS = Visual Analog Scale.
Significant changes
Yes (p ≤ 0.001)
Yes (p ≤ 0.001)
Yes (p ≤ 0.001)
Yes (p = 0.029)
Yes (p = 0.034)
Yes (p = 0.036)
Yes (p ≤ 0.001)
Yes (p ≤ 0.001)
Yes (p ≤ 0.001)
Yes (p ≤ 0.001)
Yes (p ≤ 0.001)
Yes (p ≤ 0.001)
Effect of transcutaneous electrical stimulation of specific acupuncture
sites on functional dyspepsia symptoms and neuropeptide Y levels
(S. Liu et al., Neurogastroenterlogy & Motility, 2008)
Plasma neuropeptide Y levels
Group
TEA
Sham TEA
NPY (pg/mL)
before treatment
53.94±7.33
65.75±8.50
NPY (pg/ml)
after treatment
99.45±13.52
60.67±12.51
Statistical
significance
p = 0.01
p > 0.05
Effect of electroacupuncture on gastric motoric function and dyspepsia
symptoms (S. Xu et al., Digestive Diseases and Sciences, 2006 and C.
Chang et al., Digestion, 2001)
Parameters
Before
treatment
After
treatment
Statistical
significance
Halftime for
gastric emptying
(min)
150.3±48.4
118.9±29.6
p = 0.007
Symptom score
8.2±3.3
1.6±1.1
p < 0.001
Percentage of
normal frequency
(%)
21.99±19.38
48.92±19.56
p < 0.001
Serum human
pancreatic
polypeptide
56.96±27.64
73.11±22.37
p < 0.05
Peripheral trancutaneous neuromodulation (posterior tibial nerve
electrical stimulation) in the treatment of idiopathic fecal incontinence
(M. Queralto et al., International Journal of Colorectal Diseases, 2006)
Incontinence score pre- and post-4-week neuromodulation
Effect of transcutaneous electrical muscle stimulation on
exercise capacity of patients with COPD
(G. Bourjeily-Habr et al., Thorax, 2002)
Effect of electrical stimulation on change of parameters in bed-bound
patients with COPD receiving mechanical ventilation
(E. Zanotti et al., Chest, 2003)
Parameters
Active limb
mobilisation
(ALM) group
ALM/ES
group
Statistical
significance
Muscle strength
1.25±0.75
2.16±1.02
p = 0.02
Respiratory rate
0.41±1.88
-1.91±1.72
p = 0.004
Days to transfer
from bed to chair
14.33±2.53
10.75±2.41
p = 0.001
Effect of Acu-TENS on the respiratory function of patients with asthma
(S. Ngai et al., Respiratory Physiology & Neurobiology, 2009)
Percentage change of forced expiratory volume in one second (FEV1)
at 0 min (immediately post), 20 min, 40 min and 60 min post-exercise.
Group 1 = pre-ex TENS, Group 2 = continuous TENS, Group 3 = placebo TENS.
† Denotes difference between Groups 1 and 3 (p < 0.05);
‡ denotes difference between Groups 2 and 3 (p < 0.05).
Percentage change of forced vital capacity (FVC)
at 0 min (immediately post), 20 min, 40 min and 60 min post-exercise.
Group 1 = pre-ex TENS, Group 2 = continuous TENS, Group 3 = placebo TENS.
† Denotes difference between Groups 1 and 3 (p < 0.05);
‡ denotes difference between Groups 2 and 3 (p < 0.05).
Effect of electrical neurostimulation for treating refractory
angina pectoris
(J. de Vries et al., European Journal of Pain, 2007)
Effect of extracorporeal cardiac shock wave therapy on myocardial
ischemia in patients with severe coronary artery disease
(Y. Fukumoto et al., Coronary Artery Disease, 2006)
Parameters
Before
treatment
After
treatment
Statistical
significance
Canadian
Cardiovascular
Society functional
class score
2.7±0.2
1.8±0.2
p < 0.01
Nitroglycerin use
(per week)
5.4±2.5
0.3±0.3
p < 0.05
N/A
20±3
25.2±7.2
34±3
p < 0.05
p < 0.05
Dipyridamole stress
thallium scintigraphy
severity score (%
improvement)
washout rate
Effect of functional electrical stimulation on stress, exercise capacity
and some other parameters in patients with chronic heart failure
(A. Karavidas et al., European Journal of Heart Failure, 2008)
Effect of extracorporeal shock wave therapy (ESWT) on
upper limb hypertonia in patients after stroke
(P. Manganotti and E. Amelio, Stroke, 2005)
Ashworth scale of finger flexors before
and after treatment (p < 0.001)
Ashworth scale for the finger flexors after
different intervals following the ESWT (p < 0.001)
Ultrasound treatment of carpal tunnel syndrome
(D. O’Connor et al, Cochrane Database Systematic
Review, 2003)
Sensation
Self-reported improvement
Neuropathic pain (thoracic outlet syndrome with a lesion of the left
brachial plexus) controlled using rTMS stimulation of the motor cortex
(J. Lefaucheur et al., Clinical Neurophysiology, 2004)
Effects of monthly sessions of repetitive transcranial magnetic
stimulation (rTMS) of the motor cortex on pain level scored on a 0–10 visual analog scale
(mean of daily scores for 5 days +/– standard deviation). Months 1 and 2 consisted
of the basal pain level on the days before the first rTMS session. Months 3–18 corresponded
to the days following each rTMS session. At months 6, 9 and 13 (*), the “real” coil was
replaced by a “sham” coil. Months 22 and 25 took place 3 and 6 months
following the surgical implantation of the cortical stimulator.
Comparison of electric stimulation and oxybutynin chloride in
management of overactive bladder with reference to urinary urgency
(A. Wang et al., Urology, 2006)
ES = electrical stimulation; Oxy = oxybutynin; Pl = placebo
Data presented as measurements after treatment minus that before treatment
† All measures are number of episodes per 24 hours
Effect of interferential and biofeedback treatment on urinary
stress incontinence
(F. Demiturk et al., Swiss Medical Weekly, 2008)
Effect of Acu-TENS treatment on pain relieve during the
first stage of labour
(A. Chao et al., Pain, 2007)
a Only
the first applications were counted
Reduction of itch in allergic dermatitis following electrical
cutaneous field stimulation
(J. Wallengren, Allergy, 2002)
1 – reactions after 1 h of CSF treatment administered 30 min prior to provocation (n = 12)
2 – reactions after 4 daily (CSF) treatments, the last treatment given 1 day before provocation (n = 10)
Use of electrotherapy which demonstrated
effective clinical results (PubMed database)
Pathology
Treatment
Author
Source
Lateral epicondylitis
Naproxen iontophoresis
F. Baskurt et al.
Clinical Rehabilitation, 2003
Chronic wounds
Ultrasound
W.J. Ennis et al.
Advances in Skin and
Wound Care, 2008
Low back pain
PENS (percutaneous nerve
stimulation), TENS
M. Yokoyama et al.
Anesthesia and Analgesia,
2004
Cervical fusion
Magnetotherapy
K.T. Folev et al.
The Spine Journal, 2008
Duodenal ulcers
SCENAR therapy
I. Tsimmerman et al.
Clinical Medicine
(Moscow), 2006
Diarrhea- predominant
irritable bowel syndrome
Acu-TENS
W.B. Xiao and Y.L. Liu
Digestive Diseases and
Sciences, 2004
Chronic salpingo-oophoritis
Interferential
A. Razumov et al.
VKFLFK (Physiotherapy
Journal, Moscow), 2002
Dysmenorrhoea
TENS
H. Schiotz et al.
Journal of Obstetrics and
Gynaecology, 2007
Pathology
Treatment
Author
Source
Chronic heart failure
NMES
M.J. Sillen et al.
Chest, 2009
Peripheral arterial occlusive
disease
Prostaglandin E1
iontophoresis
K. Yamamura
The Annals of
Pharmacotherapy, 2003
Cerebral palsy
Glutamic acid
magnetophoresis
N. Gurova and L. Babina
Neuroscience & Behavioral
Physiology, 2008
Ischemic stroke
Ultrasound
M. Daffertshofer and M.
Hennerici
Lancet Neurology, 2003
Motor restoration in
hemiplegia
NMES
J. Chae et al.
Topics in Stroke
Rehabilitation, 2008
Generalised anxiety
disoder (GAD)
CES (cranial electrotherapy
stimulation), rTMS
A. Bystritsky et al.
The Journal of Clinical
Psychiatry, 2008
Hyperhidrosis
Iontophoresis with tap
water
M. Connolly and D. de
Berker
American Journal of
Clinical Dermatology, 2003
Chronic maxillary and
frontal sinusitis
Ultrasound
N.N. Ansari et al.
Physiotherapy Theory and
Practice, 2007
Clinical Pilates
The aim is to develop “core stability”
Helps to restore and maintain the musculoskeletal health
Uses specialised Pilates equipment e.g. reformer machines
and trapeze tables
Use of real-time ultrasound to help train “core stability”
muscles and monitor the progress
The program is formed based on the outcome of the
diagnostic assessment
The effect of treatment sessions is regularly monitored and
the conditions are reassessed at regular intervals
Indications for clinical pilates
Musculoskeletal pathologies
• Back and neck conditions such as scoliosis, disc bulge/prolapse,
degenerative changes and others
• Joint pathologies, such as muscle tears, ligament sprains,
impingement syndromes and others
• Osteoarthritis and rheumatoid arthritis
• Post fracture rehabilitation
Metabolic disorders e.g. obesity, diabetes
Sports injuries and post-traumatic rehabilitation
Post-surgical rehabilitation e.g. hip and knee replacements etc.
Rehabilitation after cardiovascular diseases e.g. myocardial infarction,
coronary artery by-pass surgery etc.
Prenatal, antenatal and postnatal training of deep abdominal (core
stability) and pelvic floor muscles
Improving muscle tone, strength, body shape and overall image
Advantages of clinical pilates
• Training and strengthening core stability
muscles
• Improving respiratory and cardiac function
• Stimulating peripheral blood circulation
• Improving body balance and coordination
• Stimulating metabolic processes
Combination of electrotherapy and
clinical pilates
Treatment combining clinical pilates with
different electrotherapy modalities
Performed during the same or alternate
sessions or in blocks
Treatment schemes usually start with
electrotherapy and then clinical pilates is
applied to prolong and maintain the effect
Efficient for treating both acute and chronic
processes and disease prophylaxis
Summary
Physiotherapy is very efficient in disease prophylaxis and treatment
Treatment is prescribed based on thorough diagnostic procedure
including general clinical examination, imaging techniques e.g.
ultrasound, MRI, CT etc., haematological and biochemical analyses,
and special physiotherapy techniques
Physiotherapy offers a wide range of treatment modalities for disease
to select the most suitable techniques or their combination based on
the conditions of the patient
Use of pharmacological phoresis enables drug delivery specifically to
the affected organ or tissue
Treatment avoids or minimises any side effects or adverse reactions
associated with the procedures
Involves non-invasive procedures, is painless and does not lead to
dependency
Physiotherapy treatment is used alone or in combination with other
medical approaches
Physiotherapy treatment addresses the aetiology of the disease,
effectively alleviates pain and reduces or eliminates other
symptoms, and accelerates the rehabilitation process to enable a
speedy recovery of the patient – the ultimate goal of any medical
intervention