Category Archives: Therapetic treatment

Chemotherapy

Definition:
Chemotherapy is a medical treatment that is needed in order to stop cancer cells from growing and its tracks. Chemotherapy is extremely effective in treating cancer. It is even more effective when it is used with other treatments like radiotherapy. It is also sometimes needed to relief the symptoms, and it is design to give a longer life by causing the disease to go into remission-the stage in which there are no active symptoms.  Chemotherapy works differently than surgery or radiotherapy – two other treatments designed to fight against the cancer as well. Chemotherapy drugs travel throughout the whole body. This is important because it allows the durgs to reach part of the body where the cancer cells may have spread out. In combination with surgery means that fewer surgical procedures need to be done. Follow-up surgery can often be avoided if chemotherapy is used.

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On the other hand, radiation therapy, or radiotherapy, is the use of high energy rays to treat such disease. Is it very important to know that radiation causes damage to cancer cells, so they stop growing. With each treatment, more of the cells die and the tumor shrinks. The dead cells break down and are carried away by the blood, eventually passing out of the body. Normal cells that are also exposed to the radiation process start to repair themselves afterwards, and the process lasts just a few hours. You might be concerned that radiation hurts, but is actually quite painless. Also, in case you are wondering, the radiation gets into your body and then passes out -it does not cause you to become radioactive.

To understand how chemotherapy works, it is helpful to know some basics about the cells of the body. Everything in your body is made up of cells. A group of cells is called tissue and tissues make up all the organs, the major structures of your body. Tissue stays healthy because cells grow and reproduce, new cells replace the ones that are damaged because of injury. This means that a combination of drugs may be used to attack cancer cells so that each drug can attack the cells in a different phase.

Cancer is a disease in which abnormal cells in the body grow and multiply at a very high rate. There are more than 100 specific types of cancer cells. Cancer also may involve the spread of abnormal cells around the body. Normal cells in our body grow, divide, and die in a way that maintains health and does not damage the body. A majority for the cancer cases are due to age issues because of the fact that in adulthood your cells divide only to replace worn-out or dying cells, or in other cases, to repair injuries. Cells make up all living tissue and stronger throughout your childhood. But cancer cells continue to grow and divide, even though they are no serving in any of the vital functions, and can spread to other parts in the body. These cells clump together and form tumors (lumps) that may destroy normal tissue. If cells break off from a tumor, they can travel  throughout the blood stream or the lymphatic system. When they settle in and grow; eventually, forming other tumors. When a tumor spreads out to a new place, it is called metastasis. Even when cancer spreads, it’s called by the name of the body where it originally started and developed. Leukemia, a type of cancer growing, does not usually form a tumor, it is an exception to the rule. The cancer cells get into the blood and the organs that make blood bone narrow, then they circulate through other tissues, where they eventually develop and grow.

Chemotherapy damages cancer cells, but it also can damage normal cells. Damage to these cells is what causes the side effects of chemotherapy treatment. For instance normal cells that divide quickly, such as blood cells and the cells of hair follicles, are more likely to be damaged by chemotherapy medications. In other words, in healthy cells the damage does not last, and many only happen on the days you are actually taking the drugs. Chemotherapy is usually given is several cycles. Depending on the drug and combination, it may last to a few hours, days, or weeks.

How Chemotherapy Is Given
Just as other medicines can be taken in various forms, there are several ways to get chemotherapy. In most cases, it’s given intravenously into a vein, also referred to as an IV. An IV is a tiny tube inserted into a vein through the skin, usually in the arm. The IV is attached to a bag that holds the medicine. The chemo medicine flows from the bag into the vein, which puts the medicine into the bloodstream. Once the medicine is in the blood, it can travel through the body and attack cancer cells.

Sometimes, a permanent IV called a catheter is placed under the skin into a larger blood vessel of the upper chest. That way, a child can get chemotherapy and other medicines through the catheter without having to always use a vein in the arm. The catheter remains under the skin until all the cancer treatment is completed. It can also be used to obtain blood samples and for other treatments, such as blood transfusions, without repeated needle sticks.

Chemo also can be:

•taken as a pill, capsule, or liquid that is swallowed
•given by injection into a muscle or the skin
•injected into spinal fluid through a needle inserted into a fluid-filled space in the lower spine (below the spinal cord)

Chemotherapy is sometimes used along with other cancer treatments, such as radiation therapy, surgery, or biological therapy (the use of substances to boost the body’s immune system while fighting cancer).

Lots of kids and teens receive combination therapy, which is the use of two or more cancer-fighting drugs. In many cases, combination therapy lessens the chance that a child’s cancer will become resistant to one type of drug — and improves the chances that the cancer will be cured.

When and Where Chemotherapy Is Given
Depending on the method used to administer chemotherapy, it may be given at a hospital, cancer treatment center, doctor’s office, or at home. Many kids receive chemotherapy on an outpatient basis at a clinic or hospital. Others may need to be hospitalized to monitor or treat side effects.

Kids may receive chemotherapy every day, every week, or every month. Doctors sometimes use the term “cycles” to describe a child’s chemotherapy because the treatment periods are interspersed with periods of rest so the child can recover and regain strength.

Dosage :
Dosage of chemotherapy can be difficult: If the dose is too low, it will be ineffective against the tumor, whereas, at excessive doses, the toxicity (side effects, neutropenia) will be intolerable to the patient. This has led to the formation of detailed “dosing schemes” in most hospitals, which give guidance on the correct dose and adjustment in case of toxicity. In immunotherapy, they are in principle used in smaller dosages than in the treatment of malignant diseases.

In most cases, the dose is adjusted for the patient’s body surface area, a measure that correlates with blood volume. The BSA is usually calculated with a mathematical formula or a nomogram, using a patient’s weight and height, rather than by direct measurement.

Side Effects:
Although chemo often effectively damages or eliminates cancer cells, it also can damage normal, healthy cells. And this can lead to some uncomfortable side effects.

The good news is that most side effects are temporary — as the body’s normal cells recover, the side effects gradually go away.

Cancer treatment is multifaceted — that is, patients receive a lot of care (i.e., fluid and nutrition support, transfusion support, physical therapy, and medicines) to help them tolerate the treatments and treat or prevent side effects such as nausea and vomiting.

It’s difficult to pinpoint which side effects a  patient might experience, how long they’ll last, and when they’ll end.

The common side effects are:
1.Fatigue
2.Discomfort and Pain
3.Skin Damage or Changes
4.Hair Loss and Scalp Sensitivity
5.Mouth, Gum, and Throat Sores
6.Gastrointestinal Problems

Other side effects are:
•Anemia
•Blood Clotting
•Increased Risk of Infection

Chemo may cause a reduction in white blood cells, which are part of the immune system and help the body to fight infection. Therefore,  the patient  is more vulnerable to developing infections during and after chemo.

•Long-Term Side Effects
Chemotherapy can cause long-term side effects (sometimes called late effects), depending on the type and dose of chemotherapy and whether it was combined with radiation. These effects may involve any organ, including the heart, lungs, brain, kidneys, liver, thyroid gland, and reproductive organs. Some types of chemotherapy drugs may also increase the risk of cancer later in life. Receiving chemo during childhood also may place some kids at risk for delayed growth and cognitive development, depending on the child’s age, the type of drug used, the dosage, and whether chemotherapy was used in addition to radiation therapy.

Newer anticancer drugs act directly against abnormal proteins in cancer cells; this is termed targeted therapy and is technically not chemotherapy.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:

http://englendd.wordpress.com/2011/06/05/chemotherapy/

http://kidshealth.org/parent/system/ill/chemotherapy.html#

http://en.wikipedia.org/wiki/Chemotherapy

http://medicineworld.org/cancer/lead/11-2008/concurrent-chemotherapy-in-lung-cancer.html

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Radiotherapy

Definition:
Radiotherapy is a way of treating or managing cancer using radiation. It works by damaging cells in the area being treated. Normal cells are able to repair this damage, but cancer cells can’t and are destroyed.
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Radiation therapy is commonly applied to the cancerous tumor because of its ability to control cell growth. Ionizing radiation works by damaging the DNA of exposed tissue, furthermore, it is believed that cancerous cells may be more susceptible to death by this process as many have turned off their DNA repair machinery during the process of becoming cancerous. To spare normal tissues (such as skin or organs which radiation must pass through in order to treat the tumor), shaped radiation beams are aimed from several angles of exposure to intersect at the tumor, providing a much larger absorbed dose there than in the surrounding, healthy tissue. Besides the tumour itself, the radiation fields may also include the draining lymph nodes if they are clinically or radiologically involved with tumor, or if there is thought to be a risk of subclinical malignant spread. It is necessary to include a margin of normal tissue around the tumor to allow for uncertainties in daily set-up and internal tumor motion. These uncertainties can be caused by internal movement (for example, respiration and bladder filling) and movement of external skin marks relative to the tumor position.

Radiation oncology is the medical specialty concerned with prescribing radiation, and is distinct from radiology, the use of radiation in medical imaging and diagnosis). Radiation may be prescribed by a radiation oncologist with intent to cure (“curative”) or for adjuvant therapy. It may also be used as palliative treatment (where cure is not possible and the aim is for local disease control or symptomatic relief) or as therapeutic treatment (where the therapy has survival benefit and it can be curative). It is also common to combine radiation therapy with surgery, chemotherapy, hormone therapy, Immunotherapy or some mixture of the four. Most common cancer types can be treated with radiation therapy in some way. The precise treatment intent (curative, adjuvant, neoadjuvant, therapeutic, or palliative) will depend on the tumor type, location, and stage, as well as the general health of the patient. Total body irradiation (TBI) is a radiation therapy technique used to prepare the body to receive a bone marrow transplant. Brachytherapy, in which a radiation source is placed inside or next to the area requiring treatment, is another form of radiation therapy that minimizes exposure to healthy tissue during procedures to treat cancers of the breast, prostate and other organs.

Radiation therapy has several applications in non-malignant conditions, such as the treatment of trigeminal neuralgia, severe thyroid eye disease, pterygium, pigmented villonodular synovitis, and prevention of keloid scar growth, vascular restenosis , and heterotopic ossification. The use of radiation therapy in non-malignant conditions is limited partly by worries about the risk of radiation-induced cancers.

Method of radiotherapy
Radiotherapy can be given as teletherapy (also known as external beam radiotherapy), when a beam of radiation is aimed at the area to be treated from a machine located away from the patient.

Other forms of radiotherapy are high or low-dose brachytherapy, which involves a radioactive source being placed on or in a tumour.

Dose:
The amount of radiation used in photon radiation therapy is measured in gray (Gy), and varies depending on the type and stage of cancer being treated. For curative cases, the typical dose for a solid epithelial tumor ranges from 60 to 80 Gy, while lymphomas are treated with 20 to 40 Gy.

Preventative (adjuvant) doses are typically around 45 – 60 Gy in 1.8 – 2 Gy fractions (for Breast, Head, and Neck cancers.) Many other factors are considered by radiation oncologists when selecting a dose, including whether the patient is receiving chemotherapy, patient comorbidities, whether radiation therapy is being administered before or after surgery, and the degree of success of surgery.

Delivery parameters of a prescribed dose are determined during treatment planning (part of dosimetry). Treatment planning is generally performed on dedicated computers using specialized treatment planning software. Depending on the radiation delivery method, several angles or sources may be used to sum to the total necessary dose. The planner will try to design a plan that delivers a uniform prescription dose to the tumor and minimizes dose to surrounding healthy tissues.

Treatment planning
All patients who are to have radiotherapy need individually tailored treatment so it is given accurately. A lot of information is needed so the doctor can target the tumour while minimising damage to the healthy tissue. This is called treatment planning and there are a number of ways of doing this.

Simulator planning is done using a specialised x-ray machine that can do the same things as the treatment machines except deliver treatment. The simulator allows the doctor to carefully look at the area that needs treatment and plan it precisely. During the planning, the radiographer will draw some marks on the skin using a pen; when the doctor and radiographer are happy they have an accurate plan, the radiographer may need to make two to three permanent marks called tattoos. These tattoos are the size of a pinhead and are used to ensure the radiotherapy is given to exactly the right place.

ACQSIM planning is done using a scanner. Some patients may need to have an intravenous injection before the scan to show up the area to be treated better. The scan usually takes about 15 minutes and the information from the scan is used to produce a treatment map. Sometimes it’s necessary to take some x-rays and measurements to check the treatment map and this is done on the simulator.

What radiotherapy involves
When radiotherapy treatment is being given by external beam, it’s important the patient is in exactly the same position each time. The radiographers will often use pillows and wedges to make sure the patient is comfortable and in the correct position.

Patients having radiotherapy to the head or neck area may need to have a mould made to keep them in the right position. Moulds are made from clear Perspex after a plaster cast has been made of the head and neck. Once the Perspex mould has been made, the radiotherapy is planned while the patient is wearing the mould and marks are drawn on the mask instead of the skin.

Once the radiographers are happy that the patient is in the correct position they will leave the room to switch the treatment machine on. When the machine is on it makes a buzzing noise. The radiographers watch closely on a television screen. Treatment only lasts a few minutes and does not hurt.

Side effect of radiotherapy
Side effects are different depending on the part of the body being treated. Most side effects are temporary but some may continue for weeks or months after treatment is finished. They include:

•Hair loss (alopecia)
•Cerebral oedema (excess fluid accumulating in the brain) can cause changes in mental state, restlessness, irritability, impaired pupil reactions, headache, increase in blood pressure, decrease in pulse and respiration, and nausea
•Dry or sore mouth or throat, changes in taste sensation, skin thickening
•Inflammation of the gullet, indigestion, nausea, lung inflammation
•Nausea and vomiting, diarrhoea, cystitis
•Sexual dysfunction. In males treatment of the abdomen area can cause impotence, sterility. In females it can cause sterility, loss of sexual desire. Irradiation of the pelvis may cause tightening of the vagina, loss of vaginal lubrication, inflammation or ulceration of the vagina. Some women may find intercourse painful
•Treatment of red bone marrow may cause infection and impaired healing, anaemia, increased tiredness, bruising and bleeding

As well as treating cancer the radiotherapy temporarily damages the outer layers of skin. During treatment the skin cannot repair itself as it normally would and it can become sore. But once treatment has finished the skin generally recovers quite quickly – usually within a month. The level of reaction can depend on your skin type, the type and number of treatments you have, and how you would normally react to the sun.

Skin side effects usually happen later on in the course of radiotherapy treatment or sometimes a few weeks after treatment has finished. Many patients do not have any skin changes at all. Skin care advice will be given to the patients by the staff treating them.

A common side effect of radiotherapy is tiredness and fatigue, which often prevents patients from doing normal everyday activities. Fatigue and tiredness are normal results of having radiotherapy and begin in the first week of treatment, reaching a peak after two weeks of treatment and gradually disappearing a few weeks after treatment has finished.

Radiation therapy accidents:
There are rigorous procedures in place to minimise the risk of accidental overexposure of radiation therapy to patients. However, mistakes do occasionally occur; for example, the radiation therapy machine Therac-25 was responsible for at least six accidents between 1985 and 1987, where patients were given up to one hundred times the intended dose; two people were killed directly by the radiation overdoses. From 2005 to 2010, a hospital in Missouri overexposed 76 patients (most with brain cancer) during a five-year period because new radiation equipment had been set up incorrectly.  Although medical errors are exceptionally rare, radiation oncologists, medical physicists and other members of the radiation therapy treatment team are working to eliminate them. ASTRO has launched a safety initiative called Target Safely  that, among other things, aims to record errors nationwide so that doctors can learn from each and every mistake and prevent them from happening. ASTRO also publishes a list of questions for patients to ask their doctors about radiation safety to ensure every treatment is as safe as possible.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:

http://en.wikipedia.org/wiki/Radiation_therapy

http://www.bbc.co.uk/health/physical_health/conditions/in_depth/cancer/carecancer_radio.shtml

http://www.allvitalpoints.com/2010/how-radiotherapy-is-performed/

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Electro-Convulsive Therapy

Definition:
Electroconvulsive therapy (ECT) is a procedure in which electric currents are passed through the brain, deliberately triggering a brief seizure. Electroconvulsive therapy seems to cause changes in brain chemistry that can immediately reverse symptoms of certain mental illnesses. It often works when other treatments are unsuccessful.

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Electroconvulsive therapy (ECT), formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown. Today, ECT is most often recommended for use as a treatment for severe depression which has not responded to other treatment, and is also used in the treatment of mania and catatonia. It was first introduced in the 1938 and gained widespread use as a form of treatment in the 1940s and 1950s.

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Informed consent is a standard of modern electroconvulsive therapy. According to the Surgeon General, involuntary treatment is uncommon in the United States and is typically only used in cases of great extremity, and only when all other treatment options have been exhausted and the use of ECT is believed to be a potentially life saving treatment. However, caution must be exercised in interpreting this assertion as, in an American context, there does not appear to have been any attempt to survey at national level the usage of ECT as either an elective or involuntary procedure in almost twenty years. In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent

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Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and positive outcomes. After treatment, drug therapy is usually continued, and some patients receive continuation/maintenance ECT. In the United Kingdom and Ireland, drug therapy is continued during ECT.

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The treatment involves placing electrodes on the temples, on one or both sides of the patient’s head, and delivering a small electrical current across the brain, with the patient sedated or under anaesthetic. The aim is to produce a seizure lasting up to a minute, after which the brain activity should return to normal. Patients may have one or more treatment a week, and perhaps more than a dozen treatments in total.

Although ECT has been used since the 1930s, there is still no generally accepted theory to explain how it works. One of the most popular ideas is that it causes an alteration in how the brain responds to chemical signals or neurotransmitters.

Why & when it is done?
Electroconvulsive therapy (ECT) can provide rapid, significant improvements in severe symptoms of a number of mental health conditions. It may be an effective treatment in someone who is suicidal, for instance, or end an episode of severe mania.

ECT is used to treat:
*Severe depression, particularly when accompanied by detachment from reality (psychosis), a desire to commit suicide or refusal to eat.

*Treatment-resistant depression, long-term depression that doesn’t improve with medications or other treatments.

*Schizophrenia, particularly when accompanied by psychosis, a desire to commit suicide or hurt someone else, or refusal to eat.

*Severe mania, a state of intense euphoria, agitation or hyperactivity that occurs as part of bipolar disorder. Other signs of mania include impaired decision making, impulsive or risky behavior, substance abuse and psychosis.

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*Catatonia, characterized by lack of movement, fast or strange movements, lack of speech, and other symptoms. It’s associated with schizophrenia and some other psychiatric disorders. In some cases, catatonia is caused by a medical illness.

Electroconvulsive therapy is sometimes used as a last-resort treatment for:

#Treatment-resistant obsessive compulsive disorder, severe obsessive compulsive disorder that doesn’t improve with medications or other treatments

#Parkinson’s disease, epilepsy, and certain other conditions that cause movement problems or seizures

*Tourette syndrome that doesn’t improve with medications or other treatments

ECT may be a good treatment option when medications aren’t tolerated or other forms of therapy haven’t worked. In some cases ECT is used:

#During pregnancy, when medications can’t be taken because they might harm the developing fetus

#In older adults who can’t tolerate drug side effects

#In people who prefer ECT treatments over taking medications

#When ECT has been successful in the past

Risk factor:-
Patients are given short-acting anaesthetics, muscle relaxants and breathe pure oxygen during the short procedure in order to minimise the risks. However, although ECT is much safer than it was, there are still side effects to the treatment. The most common are headache, stiffness, confusion and temporary memory loss on awaking from the treatment – some of these can be reduced by placing electrodes only on one side of the head. Memory loss can be permanent in a few cases, and the spasms associated with the seizure can cause fractured vertebrae and tooth damage. However, the recommended use of muscle relaxant nowadays makes the latter a very rare occurrence. Patients can also experience numbness in the fingers and toes.

The death rate from ECT used to be quoted as one for every 1,000 patients, but with smaller amounts of electric current used in modern treatments, accompanied by more safety techniques, this has been reduced to as little as four or five in 100,000 patients.

Recomendations:-
A common argument against ECT is that it destroys brain cells, with experiments conducted on animals in the 1940s often cited as evidence. However, modern studies have yet to reproduce these findings in the human brain.

Some activists, however, still campaign against the widespread use of ECT in psychiatry, quoting those cases which have resulted in long-term damage or even death, whether because of the built-in chance of problems, or through errors by doctors.

Experts say that given the correct staff training, and when used for the right clinical conditions, ECT can ‘dramatically’ benefit the patient. An audit of ECT in Scotland between February 1996 and August 1999 said concerns about unacceptable side effects, effectiveness of the treatment and disproportionate use on elderly people were ‘largely without foundation’.

It said that in nearly three quarters of cases people with depressive illness showed ‘a definite improvement’ after ECT. Women were more likely to receive the treatment than men, but the auditors said this was because they were twice as likely to suffer from depression. Only 12 per cent of patients who got ECT were aged over 75. However, the Royal College of Psychiatrists has admitted that in the past the treatment has been administered by untrained, unsupervised junior doctors. However, modern guidelines have changed this and ECTAS (ECT Accreditation Services) exist to check that such treatment is being given safely and efficiently.

Guidelines on ECT from NICE (2003) recommend that it’s used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment. options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:

•Severe depressive illness
•Catatonia
•Prolonged or severe manic episode

NICE also says that ‘valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent. The decision to use ECT should be made jointly by the individual and the clinician(s) responsible for treatment, on the basis of an informed discussion. This discussion should be enabled by the provision of full and appropriate information about the general risks associated with ECT and about the risks and potential benefits specific to that individual. Consent should be obtained without pressure or coercion, which may occur as a result of the circumstances and clinical setting, and the individual should be reminded of their right to withdraw consent at any point. There should be strict adherence to recognised guidelines about consent and the involvement of patient advocates and/or carers to facilitate informed discussion is strongly encouraged.’

 

Click to learn more  in detail  about  Electro-Convulsive Therapy

You may click to see:-

Keep fighting even when depression treatments don’t work
Video:Electroconvulsive therapy

DSM-IV Codes
Harold A. Sackeim
Insulin shock therapy
History of electroconvulsive therapy in the United Kingdom
Psychiatric survivors movement
Consumer/Survivor/Ex-Patient Movement
List of people who have undergone electroconvulsive therapy

 

Resources:

http://www.mayoclinic.com/health/electroconvulsive-therapy/MY00129

http://www.bbc.co.uk/health/physical_health/conditions/electro_convulsive_therapy.shtml

http://en.wikipedia.org/wiki/Electroconvulsive_therapy

http://www.minddisorders.com/Del-Fi/Electroconvulsive-therapy.html

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The Healing Power of Magnets

Magnets have been used for their healing properties since ancient times, and now a new study has found that they can reduce swelling when applied immediately after an inflammatory injury.

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In their initial study, researchers from the University of Virginia set out to investigate the effect of magnetic therapy on microcirculation, which is blood flow through tiny blood vessels.

They placed magnets of 70 milliTesla (mT) field strength, which is about 10 times the strength of the common refrigerator magnet, near rats’ blood vessels and found that they dilated constricted blood vessels, and constricted vessels that were dilated. The results suggested that the magnetic filed could relax blood vessels and increase blood flow.

In the more recent study, the researchers used magnets on rats’ paws that had been treated with inflammatory agents to simulate tissue injury. The magnets significantly reduced swelling in the rats’ paws by up to 50 percent when applied immediately after the injury.

Dilation of blood vessels is a major cause of swelling, and it’s thought that the magnets worked by limiting blood flow.

Muscle bruising and joint sprains are the most common injuries worldwide, and since injuries that don’t swell heal faster, the magnet therapy could have widespread applications.

The researchers envisioned using magnets in place of ice packs and compression to treat injuries in high school, college, and professional sports teams, as well as among retirement communities.

Click to learn  more about magnet healing………..(1)..……(2).…….(3)
Sources:
Science Daily January 3, 2008
American Journal of Physiology: Heart and Circulatory Physiology November 2, 2007