The method of complex rehabilitation in the pathology of the musculoskeletal system

 

(57) Abstract:

The invention relates to medicine, and neurology. Provide massage trigger point. Select points massage carried out depending on the type of reflex muscle syndrome. Then the most painful trigger points inactivate pharmacological blockades. Then conduct manual therapy depending on the type of non-specific reflex muscular syndromes. The method improves the efficiency of the treatment. 1 C.p. f-crystals, 8 ill.

The invention relates to neurology, orthopedics and physiotherapy and can be used to improve the quality of rehabilitation neurological manifestations of osteochondrosis of the spine, diseases of articular ligament of various etiologies and some internal organs.

In modern neurology and orthopedics widely used methods of rehabilitation pathology of musculoskeletal system and related systems using the methods of massage, manual therapy and acupuncture (see, for example, N. A. Kassian "Method of treatment of degenerative-dystrophic diseases of the spine according to the method Kasian N. A.", AC N 1331509 in class. A 61 H 23/00, published 23.08.1987 in BI N 16; Hvisc N. And., Makovoz E. M., Allowancea", AC N 1599010 in class. A 61 H 23/00, published, 17.03.1988 in BI N 38; I. N. Kulakov "Method and apparatus for the treatment of degenerative disc disease of the spine", as N 860763 in class. A 61 H 23/00, published in BI N 33, 1981; Karaev R. N. "The Way R. N. Garayev treatment of radicular syndromes and device for its realization", as 2054923 in class. A 61 H 39/04, published 27.02.96 in BI N 6, 1996). However, the principles of pathogenetically substantiated these methods are not yet sufficiently understood, there are no scientifically reasonable rules governing the order, direction, and sequence of their differential use separately or in combination with each other.

The known method of complex rehabilitation pathology of locomotor apparatus, selected as a prototype (Afonichev A. N. "The way rehabilitation treatment of neurological manifestations of osteochondrosis", patent of Russian Federation N 2034530 in class. A 61 H 39/04, 23/00, 15/00, published in BI N 13, 1995), in which differentiated the holding point and classic massage, using techniques of manual therapy depending on the nature and localization pathobiochemistry disorders and direction of functional blocks", with the subsequent exercise of meropriyatiya act only on the "direct damage", and all the differences of therapeutic exercises are reduced to the use of colour and music installation. theoretical rationale for its approach, the author refers only to "local segmental reflex communications, as well as on the empirical experience of acupuncture. Thus, the quoted "the way of complex rehabilitation...", first, does not take into account reflex pathobiochemistry and midimonitor disorders that occur in adjacent and remote from the center of the primary lesion regions of the body; secondly, it does not contain proper pathogenetic substantiation used rehabilitating methods.

The present invention is to improve the quality of rehabilitation of patients with pathologies of the musculoskeletal system.

It is achieved by the fact that in the presence of pathological syndrome stabilization orthostatic synergy consistently massages on the trigger points in the ipsilateral side of the body, respectively, the rear surface of the shank, the outer surface of the thigh, in the middle gluteal muscle and the lumbar-sacral area, along the paravertebral rectifier spine, the outer edge of the lower part of the trapezius muscle, extensor neck and head, and when si points on the posterior surface of tibia, the outside of the thigh, in the middle gluteal muscle and the lumbar-sacral area and at the level of ThVIII- ThXIImove to the opposite side of the body, massaging the point of the contralateral trapezius muscle and the posterior surface of the neck, and the syndrome of pathological stabilization razgibatelno-privadas-promotornoi synergy the hands of the patient in the sitting position massaged the I-th mirasty period, the point on the back surface of the wrist, in the field of external and internal namyslow, dorso-lateral surface of the shoulder, the ventral divisions of the shoulder joint, clavicle part of the pectoralis major muscle, the rear wall of the armpit, supraspinatus and infraspinatus muscles. The most typical for each syndrome and/or painful trigger points additionally inactivate therapeutic and pharmacological blockades. In addition to massage and blockades are purposeful manual therapy. Syndrome of pathological stabilization orthostatic synergy lying on the ipsilateral side are manipulating the rotation of the lumbar spine, manipulation of the thoracic vertebrae and ribs carry the rotation of the torso in the contralateral relative to stable synergy tactics manual therapy differs in place of "transition" her extensor diagonally to the opposite side manipulation of the underlying locked in vertebral motor segment of the vertebra is carried out in counter-and upper - homolateral direction. Manipulation of the cervical spine performed in both directions, regardless of the identified syndrome, tricks with the rotation and latero-lateral displacement of the vertebrae in the supine position.

The invention is illustrated by drawings, where Fig. 1-4 presents the spatial-topographical features of nonspecific reflex-muscle syndromes, and Fig. 5-8 Dana neurophysiological verification of dynamics of treatment using non-specific reflex muscular syndromes.

The essence of the method consists in the following: we have a dedicated group of nonspecific reflex muscular syndromes (receiver array), defined as the natural redistribution of muscle tone in the trunk and extremities that occur in response to stimulation of receptors in the muscular-skeletal system and related structures pathomorphological substrate, regardless of its location, and extent of pathogenic impact, and will entail secondary pathobiological stabilization orthostatic synergy (Fig. 1) is characterized mainly homolateral subjective and objective symptoms. With the full manifestation of the syndrome observed a unilateral increase the tone of the whole postural muscles (Fig. 2) due to the simultaneous increase in activity as flexor and extensor (full orthostatic synergy); partial manifestation prevailed tone only extensor muscles (extensor postural synergy).

2. The syndrome of pathological stabilization locomotor synergy (Fig. 3) is characterized by distinct diagonally-contralateral dependencies clinical symptoms. Variant deployed syndrome (full locomotor synergy) consists of two fragments - flexor (Fig. 3 - left) and extensor (Fig. 3 - right) diagonals. At a partial manifestation of the syndrome is expressed only extensor diagonal.

3. In the cases of the syndrome of pathological stabilization razgibatelno-privadas-promotornoi synergy hands all clinical signs are confined to the region of the shoulder girdle and upper limb. Is determined by the predominant interest of the upper tabs of the blades, internal rotators and adductors shoulder, and Etania with orthostatic synergy this relationship is homolytically character, and with locomotor - contralateral.

Almost any patient with clinically relevant manifestations of the pathology of locomotor apparatus, regardless of its nosological nature, using simple clinical techniques (questioning, inspection, palpation) can be diagnosed with the above receiver array. It is proposed to use a dedicated syndromes as a kind of algorithms that regulates the deliberate application of a wide range of treatment and rehabilitation activities. As methods of treatment effect used by massage, manual therapy, therapeutic and medical blockade, electroanalgesia and exercise therapy, and their combination.

The essence of the ongoing rehabilitation activities is the relief of pain and relaxation of muscle groups related to clinically relevant at the time of the survey receiver array. There is no need to influence all stakeholders musculoskeletal system, it is enough to treat only the most affordable extero and proprioceptive reflex zones located in the projection of this synergy.

All treatment of the events the positive sequence (under center means leading pathomorphological substrate or the main source of the pain) stems from the idea of in complex neurophysiological nature of the receiver array bound is the role of chain myotatic synkinesia (K. B. Petrov, 1995). This spinal reflex spread from the primary focus of irritation with some damping (attenuation), so ceteris paribus centrally located muscles will be tighter. But very soon in the peripheral areas of stable synergies are formed foci of self-stimulation in the form of trigger points. If you have an impact only on the main source of the pain, ignoring the "tail" synergy, myotatic reflex begins to spread from its ends toward the center, sometimes completely eliminates the results in the main focus of therapeutic interventions. Pre-correction of peripheral receptive fields in and of itself, reduces the severity of clinical manifestations mainly focus that enables you to apply there more radical therapy (for example, manipulation of the spine).

Initially with the help of massage is being carried out for the relaxation of the skin, subcutaneous tissue and muscles, but its main purpose is to search latent trigger points in these structures. The detected trigger point clicks the change complete disappearance of pain, enough pain decreased by 15-20%. If expressed hyperalgesia trigger point still remains, its localization note (e.g., a marker) and move on to the next part of the body.

In the absence of General and local contraindications massage of reflex zones complemented by manipulation of the spine, which first performed at the maximum distance from the main pathological substrate. For example, when discogenic back pain manual therapy begins with cervical and thoracic vertebral motor segments, and only then attempt to implement it in the area of the lumbar spine. While pushing the shift or rotation of the vertebra is in the opposite direction from the pre-relaxedevening muscles.

Marked earlier trigger point punctured injection needle. They usually entered the local anesthetic with the addition of rumalon, and in the case of pronounced manifestations neuroesthetics - lidz. Therapeutic effect on trigger points can be performed using a laser, for example, the apparatus of the EPL-1. We tested the method of exposure of each point of low-intensity laser beam with a capacity of 3 MW in tecadur laser therapy, however, this method differed absolute painlessness.

The purpose of simultaneous exposure to all departments stable motor synergies recommended surface or needle stimulation. In the first case you can use the "Stimulus 1". It is necessary to provide special cutaneous electrodes small area that allows you to have multiple parallel-connected plates of the positive and the same number of negative polarity. Plates are distributed along an interested synergy. The electrodes with the sign "+" fit closer to the source of the pain, and with the sign " - " is more distal. Selected brake and analgesic options current (L. D. Potekhin, 1989). In the second case, we used a multichannel apparatus electro-heat-webreporter Moscow research Institute "RAFI". In trigger points along the synergies are inserted acupuncture needles, and connect the terminals of the electrodes. Unlike cutaneous methodology the current strength decreases considerably.

Features of the proposed method, depending on the specific non-specific reflex-muscle syndrome

Consider the use of these techniques on Primero nosological diagnosis, the treatment begins with a massage of the ipsilateral side, which is consecutively performed on the rear surface of the thigh, outer thigh, in the middle gluteal muscle and the lumbar-sacral area, along the paravertebral rectifier spine and neck muscles. Then processed the outer edge of the lower part of the trapezius muscle and its upper sections. All the most painful trigger points are indicated by a marker for subsequent exposure to blockages or laser. In cases of full tilt synergy advanced massage flexor part of synergy (the front surface of the leg - hamstring - poparsova link is the bottom edge of the costal arch and the front surface of the chest - scalenus).

In the presence of pathological syndrome stabilization locomotor synergy sequence of massage of the lower limbs and lumbar similar. Approximately at the level of ThYIII- ThXIIextensor diagonal locomotor synergy enters on the opposite side, and therefore focuses on the contralateral lower part of the trapezius muscle, upper arm and back of the neck. If p is further anterior surface of the tibia, hamstring, poparsova ligament and homolateral the bottom edge of the costal arch, the front surface of the chest, scalenus).

In cases razgibatelno-privadas-promotornoi synergy the hands of the patient in the sitting position massaged the I-th mirasty period (dot Gi4), the inside of your wrist, the external and internal namyslow, dorso-lateral surface of the shoulder, ventral divisions of the shoulder joint, clavicle portion of the pectoralis major muscle, the rear wall of the armpit (mm. rhomboideus maior et minir), supraspinatus and infraspinatus muscles. In the presence of the syndrome of upper periostraca undergo additional postisometric relaxation of the proximal muscles of the shoulder girdle and stretching of the joint capsule.

After completion of the massage, lying on the ipsilateral side is the manipulation of rotation of the lumbar spine. Manipulation of the thoracic vertebrae and ribs is carried out by rotation of the trunk to the contralateral relative to stable synergy side in a sitting position on the couch, riding, often it is supplemented with ventro-cranial displacement of the vertebrae with the knee doctor, or the cross. In Lucia underlying locked in vertebral motor segment of the vertebra is in the rear, and overlying in homolateral direction. Manipulation of the neck are held at both sides in the supine position, the commonly used techniques with rotation and latero-lateral displacement of the vertebrae, as well as manipulation of segment C0 - C1 in the direction of the nod ago (K. Lewit, 1987). In conclusion holds blockade on the trigger points.

Upon completion of the above procedures, the patient is asked to stand and take a few provoking pain syndrome movements. The majority of patients with radicular and especially with reflex syndromes of spinal osteochondrosis notice a significant improvement after intervention, what is the reason for the end of the treatment session.

With appropriate motivations patients are offered the original complexes of therapeutic exercises.

On average, the treatment course consists of 5 sessions of 60 minutes, including the above procedure and repeated through the day.

Clinical examples

Example 1. Patient K., 32, turned 6.01.98, with complaints of pain in the lumbar region, more to the right, by irradiating the outer surface of the right thigh to the knee and wearing lamade-nouse-arching nature. In addition, omnoi surface of the right shoulder.

The aggravation started 3 days ago after lifting heavy. Initially, the patient felt a sharp pain in the lower back, but after a few hours it had spread to the thigh, and the next morning, joined by pain in the region of the shoulder girdle.

Suffering from lumbar osteochondrosis within 3-4 years, increasing to 1-2 times per year, in history there were several "neck shot".

On physical examination, lying on the stomach is observed visually noticeable rotation of the spinous processes of the lower lumbar vertebrae to the right, thickening of the right paravertebral muscle cushion, lumbar multifidus muscle and the lower part of the trapezius muscle on the right. Palpation of the study found the toning and muscle soreness right half of the body related to extensor postural synergies (calf, outer head of the quadriceps femoris, middle gluteal muscle, the rectifier of the spine, both parts of the trapezius muscle) and signs of interest in the muscles included in razgibatelno-privadas-promotornoi synergy of the right hand (pain 1 megastage period, the back surface of the wrist, both namyslow, nualnoi diagnostics revealed syndrome oblique pelvis to the right, functional blocks of thoracolumbar and cervical-thoracic transition.

Conducted x-ray examination in the supine position confirmed the presence of right-sided lumbar scoliosis and straightening of the lumbar lordosis, found signs of osteochondrosis in the form of intradiscal degeneration at the level of L5'S1segment.

Diagnosis. Lumbar osteochondrosis (intradiscal dystrophy, leading to the crack of disk L5'S1). Pathological stabilization orthostatic synergy (extensor postural synergy) to the right and right razgibatelno-privadas-promotornoi synergy hands. The right-hand syndrome lumboischialgia, cervicobrachialgia right. III the severity of clinical manifestations.

The patient in the prone position on his stomach was conducted acupressure right half of the body with the processing of circular movements active and latent trigger points that lie within the posterior surface of the tibia, the lower and upper portions of the outer surface of the femur, middle gluteal muscles, paravertebral in the course of the rectifier of the spine and on the outer edge of the lower part of the trapezius muscle. Similarly in the sitting position of Bisti wrist, the outer and inner namesake, rear outer surface of the shoulder, the front surface of the shoulder joint, the anterior chest wall and the lateral surface of the neck.

In point most severe painfulness put 2-3 ml of 0.5% solution of novocaine with the addition of 0.2 ml of rumalon (total 5 points). The criteria for getting in the trigger point served as the subjective feelings of the patient in the form of bloating, burning or aches (j. Travel and D. Siemens, 1989).

At the conclusion of each session was performed manipulation of the spine. Manipulation of the cervical vertebral motor segments (PDS) was performed in the supine position by means of rotation and lateroflexion in both directions (Leviticus K., Sachse J., Janda Century Manual medicine /Per. s nem. - M, Medicine, 1993. - 510 C.). Manipulation of the thoracic MPD was carried out in the position of sitting on the couch by rotation of the top departments of pre-kitsilano body to the left. Manipulation of the lumbar PDS was performed in the supine position on the right side of rotational displacement of the vertebrae from right to left.

Already after a single treatment session marked a significant improvement. Pain in the neck and hand, significantly decreased the intensity of the clinic is similar procedures. The treatment has resulted in a complete clinical recovery.

Example 2. Patient B. , age 17. Work. Filed complaints paasive-constricting pain in the lower thoracic spine, which increase during exercise; feeling of swelling in the right upper quadrant after eating fatty foods and boiled water. Two years ago, was beaten, was hit with a metal rod on the spine, medical care is not addressed, however, after 2 weeks felt pain in nijaguna spine, which was intensified when working with outstretched arms. X-ray examination, conducted a year after the injury, discovered consolidated compression fracture of the body of ThXIand signs of post-traumatic osteoarthritis in the segments of ThX- ThXI- ThXII. At the age of 14 years underwent viral hepatitis. By ultrasound - symptoms of chronic hepatitis, congenital hydronephrosis of both kidneys.

At objective inspection there is some smoothness of the lumbar lordosis and thoracic kyphosis. * Palpation revealed increased tone and tenderness, respectively extensor diagonal locomotor synergies, clostridiales on the right half of the thorax and shoulder girdle (proximal sections of the rectifier of the spine, the lower and upper part of the trapezius muscle).

Found painful tension of the soft tissues in the right hypochondrium, between the xiphoid process and the umbilicus (the projection of the round ligament of the liver) and in the supraclavicular fossa to the right (point of Musci).

Diagnosis. Post-traumatic osteoarthritis, caused by the consequences compressional fracture of the body of ThXI. Chronic hepatitis. Pathological stabilization locomotor synergy (extensor diagonal) to the left. Interest umbilical-abdominal-mediastinal-bronkholegochnoy-costal ministerially relations internal organs. Segmental of viscero-vertebral reflected syndrome. Torically complex Genesis. II-III degree of clinical manifestations.

The patient in the prone position on his stomach held acupressure kneading in a circular motion the most significant trigger points lying in the projection extensor diagonal locomotor synergy. Then in the supine position atlassian round ligament of the liver (compacted strand lying between the umbilicus and xiphoid process) treated trigger points located along the bottom edge of the right costal arch, in the projection body of piles is hernych points (the back surface of the tibia and the outer surface of the left thigh, the upper sections of the rectifier of the spine to the right, the region of the right hypochondrium and right supraclavicular fossa.

Manipulation of the spine performed by the method of rotation. "Resetting" interested lumbar MPD was carried out from a position lying on the left side in the direction from left to right. Manipulation of the bottom of the thorax was performed in the sitting position on the couch top and were also sent left-to-right and upper-breast; on the contrary, right-to-left. In the latter case, additionally applied the manipulation of ELVs in ventro-cranial direction through the knee doctor. Manipulative effect on the cervical spine was performed from a position lying on your back by means of rotation in both directions.

The patient was held laser therapy with the aforementioned method. Processed points that lie in the projection of the extensor diagonal locomotor synergies and points corresponding to segmental zones of reflection from the liver and gall bladder (paravertebral area on the right side at the level of ThXIand the area right costal arch).

There were 5 treatment sessions. The result was achieved first unsaturated level of rehabilitation (significant improvement).

At objective examination noticed the elevation of the right shoulder girdle and easily pronounced symptom of a winged scapula on the right. Passive motion in the shoulder joint are not limited to, all active movements, especially related to abduction, external rotation and the subsequent lowering of the shoulder, sharply painful.

Additional palpation revealed a sharp pain 1 megastage period, the back surface of the wrist, external and internal namyslow, the area of the greater tubercle of the humerus, above - and infraclavicular fossae. Special techniques found signs of stress subscapularis, small breast and anterior serratus.

Methods manual diagnostics testified pain and restriction of passive and active movements in the lower and mid-neck MPD.

X-ray of the right shoulder revealed no pathological the mobility in the form of symptom of the stairs, the lower altitude and a violation of the fixation capacity disks5- C6and C6- C7.

Diagnosis. Cervical osteochondrosis C5- C6and C6- C7on the background of constitutional instability PDS. Pathological stabilization razgibatelno-privadas-promotornoi synergy hands to the right. The syndrome of upper periarthritis (mostly muscle). III the severity of clinical manifestations.

The patient was held on 5 treatment sessions with an interval of 1-2 days, including the typical massage of trigger points located in the projection razgibatelno-privadas-promotornoi synergy hands. In the most painful of them introduced a 0.5% solution of novocaine with the addition of rumalon. In the point corresponding to a large tubercle of the humerus, once introduced 40 mg of kenalog, diluted with novocaine. Subdeltoid was introduced oxygen in the amount of 100 ml was Administered exercises therapeutic exercises aimed at postisometric relaxation of adductors and internal rotators of the shoulder. In the lower cervical spine has been manipulated MPD in both directions.

Two weeks after the start of treatment was achieved full clinicaloutcome method of rehabilitation was carried out according to the results of neurophysiological and clinical research.

According to the multi-channel electromyography (EMG), after a single procedure and after treatment at rest in patients with pathological syndromes stabilization orthostatic and locomotor synergy was observed signs of deceleration of the most pathogenetically significant components - extensor postural synergies and extensor diagonal locomotor synergy (Fig. 5, 6), and in patients with the syndrome of stabilizing synergy hands raised previously reduced tone in most of the studied muscles (Fig. 7).

The learning curve recovery of excitability" of motoneurons of the spinal cord also shows that conducted therapeutic measures reduce the activity of spinal motoneurons, as well as smooth out individually for each receiver array features of their excitability (Fig. 8).

Clinical efficacy of treatment was assessed according to the degree of violation of adaptive activity patients (O. G. Kogan et al. 1983). In most cases (67.19%) managed to reach the first maximum level of rehabilitation that was seen as the cure, the first unsaturated level (significant improvement) was determined at 21.48%, the second natvie effect). Significant differences on the results of treatment in groups of patients with different receiver array was not observed. The data presented were significantly better than the results of our earlier co-authored with L. F. Vasilyeva and B. F. by Malavika (1987) in the treatment of 579 patients with neurological manifestations of osteochondrosis methods of manual therapy, but without a receiver array. Then the first limit level rehabilitation was achieved when POH in 35.1%, and at the DEMONSTRATION in 54.2%; first unsaturated, respectively, in 42.7% and 36.4%; second unsaturated - 13.7% and 8.5%, the third unsaturated - 1.5% and 0.8%.

1. The method of complex rehabilitation in the pathology of locomotor apparatus, due to osteochondrosis, is the impact point massage, manual therapy, and therapeutic and pharmacological blockades, characterized in that in the presence of nonspecific reflex-muscle syndrome pathological stabilization orthostatic synergy consistently massages on the trigger points in the ipsilateral side of the body, respectively, the rear surface of the shank, the outer surface of the thigh, in the middle gluteal muscle and the lumbar-sacral area, is atela neck and head, and in non-reflex muscle syndrome pathological stabilization locomotor synergies provide a consistent massage trigger point on the posterior surface of the thigh, outer thigh, in the middle gluteal muscle and the lumbar-sacral area and at the level of Th VIII Th XII pass on the opposite side of the body, massaging the point of the contralateral trapezius muscle and the posterior surface of the neck, and in non-reflex muscle syndrome pathological stabilization razgibatelno-privadas-promotornoi synergy the hands of the patient in the sitting position massaged 1st mirasty period, the point on the back surface of the wrist, in the field of external and internal namyslow, dorso-lateral surface of the shoulder, the ventral divisions of the shoulder joint, clavicle part of the pectoralis major muscle, the rear wall of the armpit, supraspinatus and infraspinatus muscles, the most typical for each syndrome and/or painful trigger points additionally inactivate therapeutic and pharmacological blockades, after a massage and blockades typical trigger points are purposeful manual therapy, syndrome of pathological stabilization orthostatics is onecznika, manipulation of the thoracic vertebrae and ribs carry the rotation of the torso in the contralateral relative to stable synergy side in a sitting position on the couch, riding, syndrome of pathological stabilization locomotor synergies in place of "transition" her extensor diagonally to the opposite side manipulation of the underlying locked in vertebral motor segment of the vertebra is carried out in counter-and upper - homolateral direction, and manipulation of the cervical spine performed in both directions, regardless of the identified syndrome, tricks with the rotation and latero-lateral displacement of the vertebrae in the supine position.

2. The method according to p. 1, characterized in that the treatment course is 5 sessions lasting 60 min intervals through the day.

 

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FIELD: medicine, narcology.

SUBSTANCE: one should detect satisfaction insufficiency syndrome due to performing genetic analysis by the presence of, at least, one of the genes coding the exchange of neuromediators being the constituents of human satisfaction system. One should compensate satisfaction insufficiency due to performing, at least, one complex of physical exercises. Moreover, in case of availability of pathological gene allele of dopamine D2 receptor and/or protein gene of reverse dopamine capture in patient one should apply the complex of physical exercises including those to provide sedative effect, and in case of availability of pathological gene allele of dopamine-beta-hydroxylase protein one should apply the complex of physical exercises including those that induce an activating effect. In case of availability of pathological gene allele of dopamine D2 receptor and/or protein gene of reverse dopamine capture one should apply additional food biologically active additives based upon amino acids being the precursors of neuromediators, such as taurine, D-, L-phenylalanine in combination with 5-hydroxytryptophan, hypericin and vitamin B6, and in case of pathological gene allele of dopamine-beta-hydroxylase protein one should additionally apply food biologically active additives based upon amino acids being the precursors of neuromediators, such as: taurine, tyrosine and/or dimethylaminoethanol, lecithin and group B-vitamins. The present innovation enables to take into account pathological disease mechanism.

EFFECT: higher efficiency of prophylaxis.

14 cl, 5 ex

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