RU2761737C1 - Method for complex spa rehabilitation of patients with postinfarction cardiosclerosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, medical, spa rehabilitation, physical and psychotherapy, and can be used in the rehabilitation of patients in the recovery period after myocardial infarction, with postinfarction cardiosclerosis (PCS). To achieve the effect, daily therapeutic dosed walking is carried out, against the background of drug treatment in accordance with the patient's indications, compliance with a balanced hypocaloric diet with a low content of saturated fats, as well as carrying out Felt therapy sessions 2 times a week, individually or in a group, with the duration of the session 2 hours. Felt therapy is a sequential implementation by the patient during the entire course of rehabilitation of four objects made of dyed colored non-spun sheep wool by felting, figuratively reflecting the corresponding sequential states of the patient: 1) a healthy state - intact, 2) a sick state - damaged by a disease, 3) a state as a result of previous treatment of acute myocardial infarction, 4) a state as a result of rehabilitation against the background of PCS, with discussion and analysis of the results obtained from felting together with a psychotherapist. At the same time, therapeutic dosed walking is carried out in the form of interval training - 5 minutes of walking, then 5 minutes of stopping, then walking again, etc., daily 2 times a day in the morning and evening hours in the fresh air with an increasing level of load in points, which while walking is monitored using the Borg scale shown in Table 1 and using acceptable technical means.

EFFECT: method provides the effect of complex rehabilitation with an improvement in the tolerance of gradually increasing PL and their compliance for a patient with PCS, through both interval physical training in the form of dosed walking, fine motor skills training, the effects of influencing biologically active points of the hands, and by training a psychologically positive perception of the real the environment, searching for real resource objects and states in it, training motivation for successful rehabilitation, by giving a creative motivational meaning to physical training in the dynamics of increasing load, leading to accelerated rehabilitation and socialization of patients, reducing the number of further possible acute cardiovascular conditions.

5 cl, 2 ex, 1 tbl

Description

The invention relates to medicine, medical, spa rehabilitation, physical and psychotherapy, in particular, to the rehabilitation of patients in the recovery period after myocardial infarction, with postinfarction cardiosclerosis (PCS).

The invention can be used in medical, sanatorium and resort institutions and departments, institutions for rehabilitation, social and psychological assistance, short-term and long-term, individual and group rehabilitation.

Relevance of the problem of cardiac rehabilitation

Currently, the relative and absolute growth of diseases of the cardiovascular system (CVS), both in our country and abroad, forces us to search for more and more new means and methods of treating cardiac patients. In all developed countries, CVS diseases are significantly ahead of all other groups of diseases and causes of death [Belenkov Yu. N. Cardiology. - M .: Geotar-media, 2020. - 816 p.]. Improving the effectiveness of treatment of cardiovascular diseases (CVD) is a major medical, demographic, social and economic problem.

In restoring the working capacity of patients with CVD, along with therapy in the acute period, rehabilitation processes are of great importance. The tasks of rehabilitation of patients with CVD are: diagnostics and monitoring of the patient's immediate condition, prevention and correction of possible dysfunctions of the affected organs and body systems, full or partial restoration of the impaired and / or compensation for the lost functions of the affected organs and systems, maintenance of body functions in the process of completing an acutely developed pathological process, prevention and reduction of the degree of possible disability, preservation of working capacity, improving the quality of life and social integration of the patient [Cardiological rehabilitation / O. F. Misyura, V. N. Shestakov, I. A. Zobenko, A. V. Karpukhin. - SPb .: Spetslit, 2016. - 271 p.].

Such a broad concept of cardiac rehabilitation is consistent with the integrative three-component model of the causes of diseases adopted in the modern world - the biopsychosocial model of T. Uexküll and V. Vesiak [Uexküll Th. Grundfragen der psychosomatischen Medizin. - Hamburg: Rowohlt, 1963]. Thus, in the etiology of diseases, along with the biological component, the important role of mental and social factors is recognized. Established psychosomatic etiology of CVD [Breutigam V., Christian P., Rad M. Psychosomatic medicine. - M .: Geotar, Medicine, 1999. - 376 p.]. Therefore, in order to increase the effectiveness of rehabilitation in accordance with the three-component model of the etiology of diseases (especially psychosomatosis), the spectrum of ways of influencing both the patient's body and the sphere of his psyche with the help of psychotherapy is expanded.

In cardiac patients, there are a number of typical mental disorders - increased anxiety, fears, existential problems, asthenic and depressive states. Due to psychosomatic mechanisms, they cause a deterioration in the somatic state, forming a vicious circle of pathogenesis, negatively affecting the physical condition of patients.

Therefore, one of the important components of the rehabilitation process is psychotherapeutic assistance with the tasks of emotional support, correction of the “picture of the disease” (CB) and “picture of health” (CD), reducing the level of anxiety, fears, depressive and aggressive manifestations, and increasing the level of compliance with physical rehabilitation. Correctly selected psychotherapeutic component of the rehabilitation program, developed taking into account the individual characteristics of patients with CVD, significantly affects its final result.

If the "External picture of the disease" is understood as objective data obtained by the doctor using special research methods, then the "Internal picture of the disease" (ICD) is the patient's subjective experiences about the disease, a set of sensations and general well-being, ideas about the causes of the disease. This is "the whole huge inner world of the patient, which consists of very complex combinations of perception and sensations, emotions, affects, conflicts, mental experiences and trauma" [Luria R. A. Internal picture of the disease and iatrogenic diseases // M .: Medicine, - 1977 - p. 111.]. In some cases, the subjective emotional reaction to the disease can be so pronounced negative that its relief in the early stages of therapy is sometimes a more important task than the treatment of a somatic disease.

At the same time, in the structure of the patient's ideas, there is also an "Internal picture of health" (ICH). This is a kind of individual standard, according to which the WKB is formed in the future. Thus, variations in VKB and VKZ largely determine the specificity of the course of the disease, treatment and rehabilitation results in a particular patient.

Individual psychological characteristics that form a subjective attitude towards the disease (temperament, character traits, personality traits) have a particular influence on the onset of the disease and the formation of VKB: alexithymia (inability to perceive and designate feelings with the word), perfectionism, workaholism, high level of anxiety, the predominance of negative emotions over positive, negative background of family or other significant relationships, difficulties in adaptation, acute stress, inability to cope with the demands of life, etc., which requires paying attention to improving the psychoemotional state of the patient.

Rehabilitation in cardiology is carried out using various methods of physiotherapy exercises, physiotherapy, massage and others. At the same time, an integrated, systematic approach is sometimes only declared, and specialists of various profiles act separately. It is necessary to coordinate the use of various means in the process of rehabilitation, especially medication, physical and psychotherapeutic. The contribution of psychological methods can be much more significant, including in solving problems of diagnostics and monitoring of the patient's condition, as well as control and self-control over his condition, if psychotherapy is directly integrated into the rehabilitation system, interconnected with other therapeutic methods, if this relationship is “transparent »For the patient himself. Due to the personal characteristics of cardiac patients, including anxious, depressive traits, lack of faith in oneself and in medicine, in the success of treatment, it can be difficult to select and cause significant positive effects when prescribing various kinds of physical influences to such patients.

One of the important and effective components of the rehabilitation process is psychological assistance with the tasks of emotional support, especially in persons with chronic disorders (Odarushchenko O.I., Samsonova G.O., Nuvakhova M.B. Clinical and psychological criteria for diagnosing the current emotional state of patients with cerebrovascular pathology in hospital practice. Bulletin of Restorative Medicine. 2020; 1: 19-26), correction of CB and CG, reducing the level of depressive and aggressive manifestations, mastering methods of relaxation and dealing with stress, increasing the level of compliance. For this can be used drug and occupational therapy (occupational therapy), body-oriented, rational, behavioral and cognitive-behavioral therapy, autogenic training according to J.G. Schultz, progressive muscle relaxation according to E. Jacobson, therapy by nature and art, a distinctive feature of which is that the interaction of the patient and the psychotherapist is mediated by a work of art (art therapy) or a natural object (therapy by nature) [Lebedeva LD, 2003; Turgel V.A. mat-in IV All-Russian scientific-practical conference. - St. Petersburg-Gryazi: Scythia-print, 2019. - P.83-86; Khayot L. G. Materials of the international conference “Science. Society. Society "15.12.2019. - Nis: "Society for Academic Activity", 2020. - P.14-20].

Unlike many other areas of psychotherapy (psychoanalysis, behavioral therapy, gestalt therapy, transactional analysis, NLP, etc.), art therapy does not have a single generally recognized theoretical and methodological base, as a result of which new theoretical concepts are constantly emerging within its framework. , and new practical techniques (see, for example: Lanberg OA 2016, 2017, 2020].

In particular, the patient can perform, individually or in a group, various works of art on themes set by the psychotherapist, which allows creating conditions for artistic expression, the manifestation of creative expression and awareness of behavior, which contribute to the acceleration and deepening of the patient's rehabilitation in connection with an increase in his motivation.

The role of psychotherapy in the rehabilitation of cardiac patients is further enhanced by the fact that its sessions, by adjusting the patient accordingly, allow him to increase his susceptibility to other therapeutic influences, both physical and medication. The patient must be tuned in, motivated for treatment, rehabilitation. A positive attitude is designed to accelerate and consolidate the manifestation of objective physical positive effects of treatment, to maintain homeostasis both on the mental and physical levels.

In this regard, this invention considers a complex method for the rehabilitation of patients with ACS, including both medication and physical and psychotherapeutic effects in a sanatorium-resort environment.

State of the art

Currently, in the rehabilitation of patients after acute myocardial infarction (AMI) with developed ACL, special attention is paid to non-drug methods, the main place among them is occupied by physical rehabilitation (RF). The ability to tolerate physical activity (FN) is an important component of the quality of life of patients with CVD. Improvement of the oxygen transport system of the body of patients with coronary artery disease occurs as a result of regular physical activity, and the maximum oxygen consumption (V'O2max) can increase by 10-30% or more. The degree of increase in this indicator in the pre-working period is inversely proportional to the ability to tolerate FN during muscle activity. Thus, studies conducted according to various RF programs showed an increase in tolerance to FN in patients with ACL by an average of 4.0-4.9 METs (in the control groups - by 3.0-3.5 METs), while the maximum increase in muscle activity was observed in the first 3 months of training, although an increase in aerobic performance could last 6 months or more [N. B. Perepech et al. Clinical characteristics of patients with myocardial infarction at the inpatient and sanatorium stages of rehabilitation // Heart failure. 2005. T. 6. No. 2. S. 66-68]. In some patients with ACL with residual ischemia caused by FN, there was a reduced level of maximum consumption of O2 and an early dependence on anaerobic metabolism with FN of moderate intensity.

The likelihood of an adequate training effect in these patients is very small. In other patients with ACL, as a result of FN, the level of maximum O2 consumption did not increase, however, physical performance increased.

Theoretically, the effectiveness of cyclic and static-dynamic loads with low or moderate burden is determined by an increase in the arteriovenous oxygen difference, which is an adaptation of the peripheral circulation due to an increase in the BCC, capillary density and desaturation of hemoglobin in the capillary bed. These changes during the performance of work by skeletal muscle are presumably the primary training response in patients with coronary artery disease, including those with arterial hypertension (AH). In some studies, there was an increase in cardiac output, heart ratemax and stroke volume [Aronov D. M. Cardiological rehabilitation at the turn of the century // Heart. 2002. T. 1.No. 3.S. 123-125. Heart disease and rehabilitation / M. L. Polok, D. H. Schmidt, ed. Per. from English Kiev: Olympic Literature, 2000. 407 p.]. EchoCG data confirming an increase in the regional contractility of the left ventricle and an increase in the average speed of circular acceleration of myocardial fibers indicate an increase in cardiac output in FN; an average increase of 18% in stroke volume with submaximal FN (35-65% V'O2max); acceleration of systolic time intervals after exercise; growth of the left ventricular ejection fraction in FN (in the absence of changes at rest); reversibility of the decrease in systolic blood pressure caused by FN and associated with myocardial ischemia.

The main principles and requirements for individually adapted therapeutic FN in order to obtain the expected results from FD are:

- the timeliness of the application of FD methods at different stages of the disease and their continuity up to the lifelong use of FN of the required level;

- the focus of FR methods depending on functional disorders and intermediate rehabilitation tasks (restoration of the function of the respiratory system, increase in strength and endurance of skeletal muscles, activation of volumetric blood flow, etc.);

-planned activation of the FR program by increasing the training loads and by expanding the number of applied techniques;

-Application of RF techniques in combination with other components of rehabilitation treatment - medication, physiotherapy, psychotherapy;

- the availability of basic FR techniques, which allows the patient to adequately, constantly, for life continue physical training on an outpatient basis when returning to work;

- the RF program recommended to the patient after discharge from the hospital or at the end of the course of rehabilitation treatment under the guidance of a doctor must be understandable, executable and have self-control criteria.

A known method of rehabilitation for ACL (Mukharlyamov F. Yu., Ivanova E. S., Golovunina I. S., Popov S. N. Medical rehabilitation programs for postinfarction cardiosclerosis and arterial hypertension // Doctor.ru, 2011, 8 (67) , pp. 18-27), including the conduct of interval hypoxic training (IHT) in a certain mode, intravenous laser irradiation of blood and ozone therapy, low-intensity cutaneous laser therapy, low-frequency magnetotherapy, electrophoresis and physical rehabilitation with an individual selection of FN according to the above known principles, depending on from the functional class of heart failure. They also carried out cardio training according to the protocol, which ended with walking on a treadmill. IHT and cardio training, included in the complex of interventions, improved CVS indices in such patients as compared with patients whose rehabilitation did not include these physical effects. However, this known method contains a fairly extensive complex of various effects, the implementation of which requires the time and effort of patients, and therefore their adherence to such rehabilitation can be reduced.

The known method of therapeutic dosed walking - dosed by distance, time and angle of inclination walking is a method of training, treatment of patients with some forms of CVD, bronchopulmonary and other diseases [Badalov NG, Barashkov GN, Persiyanova-Dubrova A.L. Terrenkurs and physical training by walking. // Physiotherapy, balneology and rehabilitation. 2016; 15 (6). - S.317-322. DOI: htpp: //dx.doi.org/10.18821/1681-3456-2016-15-6-317-322.].

It has been proven that regular physical activity lowers blood pressure, improves lipoprotein profile, increases tissue sensitivity to insulin, helps regulate body weight, reduces depression and anxiety [Warburton D.E., Nicol C.W., Bredin S.S. Health benefits of physical activity: the evidence. Can. Med. Assoc. J. 2006; 174 (6): 801-9.].

Walking is the natural and most common form of physical activity. Regular walking in sufficient quantity and at the correct pace (so that the heart rate is within the optimal training zone) trains CVS, reduces mortality and the risk of CVD [Schnohr P., Scharling H., Jensen J.S. Intensity versus duration of walking, impact on mortality: the Copenhagen City Heart Study. Eur. J. Cardiovasc. Prev. Rehabil. 2007; 14: 72-8]. Walking activities affect carbohydrate and fat metabolism [K.M. Relationship of walking to mortality among US adults with diabetes. Arch. Intern. Med. 2003; 163 (12): 1440-7.], Contribute to the preservation of cognitive function in the elderly [Prohaska TR, Eisenstein AR, Satariano WA, Hunter R., Bayles CM, Kurtovich E., Kealey M., Ivey SL Walking and the preservation of cognitive function in older populations. Gerontologist. 2009; 49 (Suppl. 1): S86-93.]. Medical walking is included in the clinical guidelines for the treatment of coronary artery disease, myocardial infarction (MI), arterial hypertension (AH), atherosclerosis of the vessels of the lower extremities (ASNK) and chronic obstructive pulmonary disease (COPD) [Aronov D.M., Bubnova M.G., Barabash O.L. et al. Russian clinical guigelines: Acute ST-elevation myocardial infarction: rehabilitation and secondary prevention. CardioSomatika. 2014; (Pril. No. 1): 42. (in Russian). Diagnosis and Treatment of Arterial Hypertension. Russian National Guidelines (4th update) http://www.scardio.ru/content/Guidelines/recommendation-ag-2010.pdf (in Russian). Hirsch A.T., Haskal Z.J., Hertzer N.R. et al. ACC / AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association. J. Am. Coll. Cardiol. 2006; 47 (6): 1239-312].

Dosed walking is one of the simplest, but most effective means of rehabilitation at the sanatorium stage after suffering AMI, adaptation to increasing FN, despite the irreversibility of the changes that have occurred with the myocardium (Terrain treatment at the sanatorium-resort stage of medical rehabilitation of patients with cardiovascular diseases, uch. manual / M.A. Eremushkin, T.A. Knyazeva, E.M. Styazhkina, M.P. Otto, V.A.

Training in the form of dosed walking in a sanatorium-resort environment can be the first step towards changing the lifestyle, developing the patient's understanding of the need for regular physical activity, setting realistic and simple goals, and creating motivation. A combination of walking and psychotherapeutic intervention can especially help in this. The developed individual program of dosed walking in the conditions of the sanatorium should serve as the basis for further regular walking sessions when the patient returns to his usual environment. This is especially true in patients with ACL, whose physical capabilities in terms of load on the heart are limited (S.A. Gusarova, E.M. Styazhkina, M.V. Gurkina. Methodological features of the use of therapeutic gymnastics in the rehabilitation of patients with postinfarction cardiosclerosis // Questions of balneology, physiotherapy and physical therapy. 2014; 91 (5): 12-15).

According to the research results of M.O. Odzharova. (Physical training in the rehabilitation treatment of patients with postinfarction cardiosclerosis, taking into account the functional state of the left ventricle, dissertation ... Ph.D., Stavropol, 2009, [Electronic resource]: http://medical-diss.com/medicina/fizicheskie-trenirovki -v-vosstanovitelnom-lechenii-bolnyh-s-postinfarktnym-kardiosklerozom-s-uchetom-funktsionalnogo-sost # ixzz6bgyPeyE4), when building a program of physical training, taking into account clinical data and data from instrumental examination: Veloergometry the level of the training load is carried out taking into account the individual threshold power (IPM) of each patient. It ranges from 30% of the IPM at the initial stage of training and up to 50% of the IPM at the final stage. Accordingly, the increase in heart rate during training should not exceed 30-50% of the increase in heart rate at the height of the IPM according to the VEM data upon admission to the sanatorium. Patients 1 and II FC are recommended firstly dosed walking up to 3 km per day along route I (ascent angle 0-1 °, length 1000 m). Then, with good tolerance for walks, patients are recommended to go to route II (the total length of the route is 3000 m), at the final stage - up to 6 km per day. If the patient experiences discomfort while walking in the form of anginal pain or severe shortness of breath, he is advised to interrupt the training and consult a doctor. You can do dosed walking twice a day. Patients of FC III are prescribed dosed walking of 3-5 km during the entire period of treatment in the sanatorium. Patients carry out self-monitoring of heart rate, the increase of which during walking should not exceed the level recommended on the basis of the results of the stress test (VEM).

In addition to the main training time, periods of "work in" (warm-up) and "exit from the load" (cool down, final part), lasting 5-10 minutes, are provided. In this case, you can use low-intensity aerobic activity and stretching exercises. This improves the blood supply to muscles and joints, prepares them for walking, and improves flexibility and range of motion. Exercise after exercise helps to restore heart rate and blood pressure, and reduces the risk of hypotension and ventricular ectopia, which can occur with an abrupt cessation of exercise. The degree of load during the passage of the route is determined by the distance, the value of the ascent angle (from 3 to 20 °), the pace of walking, the number and duration of stops, and other factors. Tracks are usually looped, i.e. the start line is also the finish line.

Before starting training, an individual program is developed based on an assessment of the risks, goals and capabilities of the patients. When assigning a load, the frequency of training, duration and intensity are determined.

It is shown that the best training effect is manifested with dynamic loads of medium intensity.

The intensity of the load can be estimated in different ways, for example, as a percentage of the maximum heart rate, or determined according to the results of a test with FN (an average intensity load will correspond to 55-70% of the maximum heart rate), using the reserve heart rate (maximum heart rate minus resting heart rate) according to the formula : training heart rate = (maximum heart rate - resting heart rate) * desired% intensity + resting heart rate.

An average intensity load will correspond to 40-60% of the reserve heart rate.

This known method can also be used to calculate the load (HR) in the proposed method for the rehabilitation of patients with ACL.

Subjective control of dosing load can be carried out according to the scale of individual perception of load (Borg scale, Ratings of Perceived Exertion or RPE; Scherr J., Wolfarth B., Christle JW, Pressler A., Wagenpfeil S., Halle M. Associations between Borg's rating of perceived exertion and physiological measures of exercise intensity. Eur. J. Appl. Physiol. 2013; 113 (1): 147-55.). In this case, it is necessary to correlate the number on the scale with the severity of the load. Moderate load corresponds to 5-6 points on the 10-point Borg scale [Borg G.A. Psychophysical bases of perceived exertion. Med. Sci. Sports Exerc. 1982; 14 (5): 377-81.], See table 1 below.

Another subjective way to monitor exercise intensity is a speaking test. According to the research results, the ability to maintain a conversation in FN reflects the safety of training [Jeanes E.M., Jeans E.A., Foster C., Porcari J.P., Gibson M. Translation of exercise testing to exercise prescription using the talk test. J. Strength Cond. Res. 2011; 25: 590-6.].

In practice, FN is also often dosed in terms of steps per minute. In the study [Marshall S.J., Levy S.S., Tudor-Locke C.E., Kolkhorst F.W., Wooten K.M., Ji M. et al. Translating physical activity recommendations into a pedometer-based step goal: 3000 steps in 30 minutes. Am. J. Prev. Med. 2009; 36 (5): 410-5.] Using several mathematical methods, treadmill walking with an intensity of 3 METs and the number of steps measured with a pedometer were correlated. Walking with moderate intensity has been shown to correspond to a pace of at least 100 steps / min.

The pace of walking can also be calculated using the formula of D.M. Aronova:

TX = 0.042 x M + 0.15 x HR + 65.5,

where TX is the pace of walking, M is the maximum load during bicycle ergometry, performed for 3 minutes (the load in watts is multiplied by 6), HR is the maximum heart rate during a test with physical activity [Aronov D.M., Bubnova M.G., Barbarash O.L. and other Russian clinical guidelines "Acute myocardial infarction with ST segment elevation of the electrocardiogram: rehabilitation and secondary prevention." CardioSomatika (Cardiosomatics). 2014; (Appendix No. 1): 42.].

Dosing and learning to walk at a given pace can also be carried out using a walking pace meter (for example, EDT-1). The EDT-1 scale has a range from 60 to 180. The pace of walking is set according to the frequency of sound signals. The set pace can also be mastered using a stopwatch, clock, or mobile devices that have a timer device.

Thus, any of these known methods can be used to control the level of load in the proposed method, however, the most simple and understandable for the patients themselves is the method using the Borg scale (table 1).

The choice of the intensity of the load during dosed walking is approached differentially, taking into account the age, lifestyle, diseases, the presence of restrictions on the part of the musculoskeletal system. Elderly and sedentary people, persons exposed to risk factors, should begin exercises with an intensity not exceeding 40% of the reserve heart rate. Even slow, low-intensity walking at a speed of about 3 km / h (2 MET) in untrained people has a beneficial effect, helps to adapt to the load and contributes to further progress.

For the development of the training effect, it is necessary to gradually increase the duration, frequency and intensity of training until the target values are reached: 150 minutes per week of medium-intensity aerobic activity (30-40 minutes per day of walking with an intensity of 55-75% of the maximum heart rate or 40-60% of the reserve Heart rate). In the conditions of the resort, it is impossible to fully implement these recommendations due to the lack of time required for a gradual increase in the load, but while at the resort, the patient can gain knowledge about lifestyle changes, the skills of dosing the intensity of walking and self-control in order to independently continue training at home. conditions, achieve and maintain the required level of physical activity. Psychotherapy can help in the formation of such motivation.

For patients with cardiac pathology, a test with FN is a way not only to assess tolerance to it and calculate its intensity, but also to exclude the presence of ischemia, arrhythmia or hemodynamic disturbances that can cause complications during training [Fihn SD, Gardin JM, Abrams J. et al 2012 ACCF / AHA / ACP / AATS / PCNA / SCAI / STS guideline for the diagnosis and management of patients with stable ischemic heart disease. Circulation. 2012; 126 (25): e354-471.]. With a decrease in the reserves of the cardiorespiratory system, walking by increasing the respiratory rate, improving the blood supply to the heart and lungs, increasing the number of red blood cells in the blood promotes the activation of redox processes in tissues and organs. The mechanisms of normalization of functions during walking can significantly change the ratio of excitatory and inhibitory processes in the cerebral cortex and contribute to the extinction of pathological temporary connections.

Different techniques in the FR system, carried out in different combinations and modes, have different effects on certain links of the disease, with different effectiveness. However, the need to adhere to the regimens of many applied techniques in itself can reduce patient compliance, because rather complicates the whole process of rehabilitation. The patient's motivation for treatment and rehabilitation could be increased by psychotherapy in the system of medical rehabilitation. In particular, various types of creativity therapy are used for this.

A known method for the rehabilitation of patients with sleep disorders, including a combination of breathing exercises and imaginative psychotherapy. The patient is asked to take a certain posture, relax and do the exercises "full breathing", while "imagining himself as a mighty tree." The patient's actions include various types of representations, images, cyclically replacing each other [Yuryeva I. A. Insomnia. - SPb .: Ves, 2006. - 128 p., P. 110]. However, this technique applies to patients with a certain type of functional impairment - sleep disorders, which is not always suitable for the tasks of rehabilitation of patients with ACL.

There is also known a method for the rehabilitation of patients with psychological problems, including the use of an artistic image, which is the object of the patient's projections. Conduct progressive muscle relaxation (PMR) and guided mental visualization using the metaphor "tree" - a mental representation of the body in the form of a tree [RF Patent No. 2525736, A61M 21/00, publ. 08/20/2014].

In these two methods, a tree is successfully used as an object of the patient's projections, as well as dynamics, "development" of representations. However, the use of only mental images even in combination with PD methods in the absence of a phase of creative expression, self-expression of the patient in specific motor actions with the creation of a complete material object (object), reduces the effectiveness of rehabilitation. At the same time, after severe pathological conditions of a person, in particular, after AMI, with formed ACL, and psychotherapy alone is not enough, complex measures are needed to improve the quality of life.

There is also known a method for the rehabilitation of patients with psychological problems, including the techniques of expressive therapy, consisting in the creation of the patient flat art works - drawings. At the same time, rehabilitation includes the patient's drawing of a tree, interviewing the patient according to the drawings made and interpreting the results. The patient performs one drawing of a tree, black-and-white and color variants are described [J. Beech. Test "House, tree, person" // Projective psychology. - M .: April Press, EKSMO, 2000. - P.260-344.]. The method includes a phase of creative expression of the patient, provides a large amount of diagnostic information about him, but does not take into account the dynamics of conditions and does not describe complex corrective actions, which does not provide the necessary completeness and completeness of the process necessary for cardiac rehabilitation and is directly related to the psychosomatic characteristics of patients.

There is also known a method of rehabilitation for psychological problems, including the technique of the patient's image of a tree as an image of a person. This provides for the implementation of flat art works and work with the patient's existential problems [Turgel V. A., see above]. However, this does not provide for obtaining the required amount of information for conducting a full-fledged psychodiagnostics and psychocorrection, and, in addition, there is no complex RF, including FN, which is necessary for patients with ACL.

There is a known method of rehabilitation using techniques for performing flat artwork by the patient depicting a tree, interviewing the patient, interpreting and discussing the results of a psychocorrectional nature. The patient performs one drawing of a tree [Lebedeva L. D., 2003, p. 115). This method includes both psychodiagnostic and psychocorrectional stages, however, the work is carried out with only one state, giving an insufficient amount of information for carrying out full-fledged psychodiagnostics, psycho- and physical correction, and control of its dynamics.

There is also known a method for the rehabilitation of cardiac patients, described by the co-authors of the invention [Lanberg O. A., Hayet L. G., 2020], which includes a technique for drawing a tree by the patient. In the process of rehabilitation of patients with heart disease, the psychotherapist, "accompanying" the rehabilitation, should be "one step ahead" of the achieved level of restoration of functions. Being "close to the patient" allows you to support him; going “two steps ahead”, giving too difficult instructions, can disappoint the patient and lead to his refusal to study. The problem arises of fixing, identifying the “zone of proximal development” (according to LS Vygotsky) in psychotherapy in the process of rehabilitation. Image psychotherapy offers patients images of recovery, healing, recovery, rebirth, "resurrection", which have great vital force and significant sanogenic resources.

However, the use of such images "directly", "on the forehead" (for example, as in rational psychotherapy) is often met with great resistance due to the action of powerful psychological defenses (especially in male patients, who are the most frequent patients in cardiology departments). In order to purposefully work with this resistance, as is done in psychoanalysis [Hayot L. G. Materials int. conf. "The science. Society. Society "15.12.2019. - Nis: "Society for Academic Activity", 2020. - P.14-20.], There is neither sufficient time nor appropriate personnel during rehabilitation. Moreover, with such pathological conditions as CVD, including ACL. Researchers are looking for ways to bypass psychological defenses using indirect methods of influence.

One of these ways is to replace the image of a recovering person with the image of a recovering animal or bird recovering from damage to a tree or shrub, a house or car being repaired (the latter is especially important for men), etc. The search for an image symbolically similar to the image of a person for projection onto it, demonstrating the processes of recovery and rehabilitation on it, in this regard, is necessary. As such an image can be used the image of a tree [Hayot LG Materials int. conf. "The science. Society. Society "15.12.2019. - Nis: "Society for Academic Activity", 2020. - P.14-20.].

The symbolization of man with a tree has a long history. In animistic cults, Vedic cultures, including Slavic ones, the tree symbolized a person, especially in the processes of extinction, dying (in autumn), sleep (in winter), rebirth, "resurrection" (in spring) and flowering, fruiting (in summer). In various directions of Christianity, the image of a tree as a symbol of a person also received further development [Jung KG Symbols of transformation. - M .: Academic project, 2017. - 529 p.]. The tree as an image of a person was used in psychodiagnostic and psychotherapeutic methods. One of the techniques was used during the implementation of an integrated approach in the rehabilitation of patients on the basis of the "National Medical Research Center for Rehabilitation and Balneology" of the Ministry of Health of Russia [O. A. Lanberg, L. G. Khayet, 2020.]. Classes lasting 2 hours were carried out in the format of an open group in a time free from physiotherapy in a specially equipped room. It was recommended that the frequency of classes is 2 r / week while the patients were in the hospital.

The group included approximately equal numbers of men and women, the age of the patients was from 40 to 80 years. The aim of the work was psychotherapeutic support of the process of complex RF of patients, in particular, with CVD, mainly those who had suffered heart attacks or strokes. The tasks were to identify the actual life (personal, family, professional) situation of the patient; identification and correction of ideas about the "near and distant world" ("picture of the world"); revealing the patient's attitude to his disease (WKB); identifying and correcting ideas about oneself, increasing the patient's self-esteem (VKZ); disclosing creative potential and searching for resources in the internal and external spheres; development of a life strategy, including a compliance mindset and active participation in rehabilitation; actualization of activities for the return and preservation of health based on the use of discovered resources and a developed strategy.

The described technique included drawing and verbal modalities. As D. Buk wrote: “The first phase (drawing) is non-verbal, creative, unstructured. The second phase is verbal, apperceptive, more structured. " The combination of figurative and verbal description of the problem provides more productive communication "therapist-patient" based on a more complete mutual understanding.

After drawing, a post-drawing survey and discussion of drawings were carried out. The principles of analysis of their elements, which have diagnostic value, are disclosed in the publication: [J. Book. Test "House, tree, person" // Projective psychology. - M .: April Press, EKSMO, 2000. - P.260-344.]. In our proposed methodology, similar principles are used.

The technique affects, in addition to the physical, mental and social, also the spiritual sphere of a person, making it possible to identify existential problems that are often manifested in cardiac patients. In the spiritual sphere, it is more often possible to find resources to overcome hopelessness, helplessness, powerlessness in the face of illness - to see the greatness of the world, to seek the meaning of life, to create and create, to live and fight for the sake of life, for the sake of loved ones (more often women), for the sake of self-realization (in the name of science, art, medicine, etc.), for the sake of the Fatherland (usually men). There are also effects from the group form of work: the emergence of a sense of community, mutual assistance "against a common enemy", joint search for resources, replenishment of the lack of communication in conditions of situational isolation from the "healthy".

In all cases of the use of psychotherapy by self-expression, the goal is to improve and stabilize the psychoemotional state of patients. The tasks are: to identify, understand and work out the psychological causes of psychosomatic disorders, as well as the psychoemotional component that accompanies the onset and course of any disease; the patient's attitude to his disease; acceptance of the current situation; awareness of the "secondary benefit" that the patient can receive from his disease; understanding in what other ways he can get what he needs (without going unconsciously into illness); changing stereotypes, behavior strategies and lifestyle; updating activities for the return and preservation of health; increased self-esteem; changing ideas about oneself and others; developing a positive strategy for emotional response; disclosure of creativity; training in relaxation techniques for self-regulation. This, in turn, will increase the patient's motivation for treatment, belief in recovery or adequate socialization despite the illness.

For the prevention and correction of the psychoemotional state, improvement of the general condition of the patient, an integrated approach is needed, the coordinated work of a number of specialists. Professional psychological or psychotherapeutic assistance includes the disclosure of the creative potential of the individual, access to deep resources, acceptance of the versatility of his "I", finding new meanings of personal and professional activities, teaching self-regulation skills, assertive behavior, helps patients learn to look at the products of their creativity and see their inner experiences. The content of the inner "I" of a person is reflected in visual images every time a person creates. During this, there is a harmonization of mental states. This allows you to look in a similarly positive way at your own dynamics in overcoming increasing physical loads (FN) in the process of rehabilitation (“I can - I can!”).

Felt therapy, as one of the directions of psychotherapy, as a material for working with the emotional state of patients, suggests the use of non-spun heat-treated sheep wool. Despite the increasing popularity of this material, there is currently no clear definition for Felt therapy. In working with such wool, different techniques are used: dry and wet felting, laying out pictures from pieces of dyed non-spun wool, creating two-dimensional and three-dimensional compositions from wool with the possibility of adding other materials in order to solve psychological problems, develop and harmonize the personality with a focus on the process of spontaneous self-expression ...

Earlier, even in everyday affairs, people realized their creative potential, drawing strength in harmony with nature. In recent years, there has been a surge in interest in arts and crafts (handicrafts) based on folk traditions and ancient crafts. Since wool undergoes heat treatment during dyeing, it is a hypoallergenic material, which is acceptable and convenient for a wide range of patients.

The laying of art paintings made of wool appeared at the beginning of the twentieth century in Germany. The founder, German philosopher Rudolf Steiner, chose wool as the most widespread and cheapest material in the provincial area. Working with children, he noticed that during this session they relax psychologically, become more balanced, and their personalities acquire greater integrity. Wool has a beneficial effect on the emotional state, awakens creativity. In this case, neither brushes nor paints are used. Each "stroke" is a small piece of non-spun dyed wool. The woolen picture is fixed by placing it in a frame under glass, and if you wish, you can return to work and make changes. In addition to working with color, wool provides a wide range of tactile sensations. It is the warmest natural material with many textures. Non-spun wool of different colors can be laid out on a fabric backing. Interaction with such a physically pleasant to the touch, pliable material and mixing of colors bring mental comfort and aesthetic pleasure. Indirect dyed sheep wool has a wide color palette, and its plasticity is comparable to that of clay and allows you to create both two-dimensional and three-dimensional compositions. You can work in different techniques: dry or wet felting, or a simple layout, similar to a mosaic or collage.

Drawing the patient's attention to environmental friendliness, unique properties, physical - sensory characteristics, the symbolic meaning of wool, you can help him express his state, needs, feelings. Sometimes a new material that is unusual for a client can awaken interest in creativity, reduce the level of resistance.

Before starting the exercise, the participants get acquainted with the material - non-spun sheep wool: they perform various manipulations with it, choose colors, get acquainted with the basic simple work techniques that can be used, for example, felting (or come up with new ones), when creating their work, explore their tactile sensations ... You can create "woolen doodles" (Author's exercise "Resource abode" [Lanberg, O. A., 2017]). Required materials: non-spun wool of different colors, pieces of fabric, threads, paper, photographic materials, magazines, frame with glass and cardboard base A4 or A3, scissors, non-woven cloth (universal napkins), glue stick for gluing the base. The objectives of therapy are:

1. To reveal the individual characteristics of your emotional state, attitude to the disease, to clarify what the “symptom” means and how the “symptom” is felt for each participant in the group lesson. Exercises aimed at exploring various facets of your “I”, the system of relationships, the patient's attitude to his disease, can help in understanding and correcting attitudes towards the disease, behavior and thinking. An example is the drawing up of a role map of the "Faces of my" I "[Kopytin, A. I., Plats, J. Guide to phototherapy. // M .: Kogito-Center, - 2009 - p. 184.].

2. Find a visual image for the "symptom", its embodiment and work it out. Clarifying the basic needs of the “symptom”, the discomfort it brings, the secondary benefit of having it.

3. Recall, find and discuss in pairs of patients those life events or states when the participants were “filled with resources”. What exactly is a resource for everyone, how does a person gain access to their resource part.

4. Integrate the "symptom" and find ways to accept it, "change the emotional attitude towards it." The purpose of this stage is to establish internal contact with that part of the personality that most "suffers from the presence of a symptom", its creative filling with internal resources.

5. Activate the creative potential of the participants, develop skills for transforming a non-resource state into a resource state.

At the first stage of the lesson, after discussing the individual characteristics of the “symptoms” of the group members and identifying the “suffering” part, the participants found a visual embodiment for it: shape, color. We used various materials and techniques: to draw, find an appropriate image and cut it out of a magazine, felted out of wool, pick up images from personal experience, asking questions about the needs of the “suffering” part: what does she want? How does it feel? What kind of attention does she need?

At the next stage, the participants were offered visualization and search for the resource state, for example, the creation of a metaphorical picture "Abode of Resources". The methodology of E.V. Lesovoy "Resource Map" was taken as a basis, but at the same time, non-spun sheep's wool was used as a material for creating a creative product.

The method of directed visualization was suggested as an instruction for creating the painting "Resource Abode". The patient was asked to recall a successful experience of getting out of difficult situations. Each had his own set of resources in the form of certain thoughts, emotions, psychotechnics, people he turns to for help, resource places, etc. (“Remember what helps you most in difficult situations, in conditions of lack of resources, support, temporary and monetary time trouble when you are tired ... "). Each of the participants created his own metaphorical "Abode of Resources", where he placed in symbolic form everything that helped and helps him in life. If these are situations or people, they were also present in the inner world as supporting images. Participants used non-spun sheep wool of different colors for work, laying it on a base.

Then they discussed in pairs what they managed to find and put in their "Abode of Resources", gave names to various elements, described emotions and feelings, bodily sensations that appeared in the course of work. It was possible to add something to the work if, during the discussion, the participant realized that he “forgot” to add some resource.

Then the participants were asked to include in their “Abode of Resources” the image of a “symptom”: to find a place for him, helpers, a safe and nourishing environment, they could add decorations and everything that was necessary and “wanted”. At the end of the exercise, after the integration of the "symptom", the result of the work was placed in a frame and fixed with glass. On the one hand, such a fixation is a technologically necessary process, since a picture made of wool cannot exist without being fixed, and on the other hand, it is a process endowed with a metaphorical meaning. The frame creates a sense of security, being a visual container that protects what is placed in it (feelings, ideas, values, experience of the author). If feelings are conflicting, the need to use the frame for its protective function may be even stronger. Also, framing in a frame involves exhibiting the work, placing it in a space, gallery or home. From the point of view of the psychodynamic approach, placing an object in a frame is often associated with the mechanism of sublimation, it provides transformation, ennobling of psychological material, its aestheticization. In this way, the frame gives value to the work and the psychic reality of the client behind it. It helps to increase self-esteem, the value of the experience, even if it is difficult and traumatic. Such work allows the patient to accept his experience as a resource, enhances the feeling of having the experience that it reflects. By framing the work, there is an act of appropriating experience, taking responsibility.

After the painting was closed with glass and placed in a frame, the participants were given time to interact with their Resource Abodes. Then the participants gathered in a circle, arranged an opening day of their works and a general final discussion, according to different scenarios. For example, one could offer dramatization, when the participants take turns getting used to the role of their “symptom” and share their feelings: what changed after the integration of the “symptom”, when they took care of it and found a place (role) for it? What emotions did the participants experience when placing the picture in the frame? Did it matter to them? What methods and techniques did they see for themselves in this exercise? What new resources have they discovered in themselves? What of this new knowledge could they take with them into their lives? What are the simplest steps in their life that each participant can take to achieve a more harmonious existence?

Elements of this technique are used in the proposed method.

CVD, as a rule, clinically include both a relatively stable phase (as in the case of an ACL that has taken place) and acute manifestations (hypertensive crisis, myocardial infarction), leaving more or less severe consequences, the recovery of which is dealt with by the rehabilitation system. In this sense, a plant (tree / shrub) as an object of projections of the states of a cardiac patient can also experience age-related periods of development and extinction, clinical stages of damage and recovery. Performing not one, but several images of the tree allows you to reflect the dynamics of the disease, treatment and rehabilitation, and the possibilities of recovery. The presence of such parallelism ensures the emergence of stable psychological projections, including the mechanisms of effective rehabilitation of patients. The use of Felt therapy gives, in addition to purely psychological positive effects, also the training of fine motor skills of the hands, work with different textures of materials during Felt therapy contributes to the impact on biologically active points located in the projection of the patient's working hands, with appropriate stimulation of the central nervous system, improvement of autonomic regulation and other beneficial physical effects of such work.

In the process of rehabilitation, expressive psychotherapy almost always merges with occupational therapy, performing the functions of the latter in terms of providing additional moderate motor, intellectual (cognitive) and emotional stress in conditions of high patient motivation, thereby enhancing the effect of rehabilitation.

The disadvantages of the above-described method of Felt therapy include the lack of structural and functional interaction of psychological methods of rehabilitation with physical methods used in the process of rehabilitation in such a complex group of patients as those suffering from ACS. As a rule, in the corresponding medical, rehabilitation institutions, methods of psychological rehabilitation are applied in parallel, i.e. their formal (parallel) combination with physical methods takes place, without taking into account the interrelationships, the positive functional interaction of various methods on each other and, accordingly, on the patient's condition. So, in the above well-known psychotherapeutic technique [Lanberg O.A., Khayot L.G., 2020] only indicated the feasibility of the combined use of psychotherapy in the rehabilitation of cardiac patients with other methods - physiotherapy, exercise, drug therapy. However, there is no data on how these well-known methods could, by exerting mutual influence, significantly improve the effectiveness of rehabilitation, the quality of life, the motivation of patients, accelerate their socialization, giving the patient the opportunity to fully experience how the motivation formed in him during psychotherapeutic sessions helps to overcome gradually increasing load, gives meaning to these loads and the social role of the patient.

In the well-known art therapy techniques with the execution of a tree drawing, the patient's execution of only flat artistic images limits the patient's possibilities of self-expression and creative expression; the lack of structured description of the content of the patient's survey and the principles of interpreting its results also complicates the possibility of creating full-fledged rehabilitation protocols and a stable therapeutic effect.

Emotionally "closed" patients, especially men, can find it difficult to convey the image of themselves and their illness in the usual flat drawing. In this regard, taking into account the possible desire of men for greater control over any situation, it is possible to modify the imaging of a plant using the felt therapy technique. Not every patient is able to mentally imagine himself in the image of an abstract tree or other plant, it is much easier to do this by associating himself with a real object - seen, for example, while walking a tree, which the patient can modify (perceive in his own way) in his imagination. In this regard, the preliminary obtaining of a photo of a real plant also seems to be significant for obtaining more pronounced therapeutic, motivational effects, especially in patients with a low degree of development of abstract thinking.

Thus, for the rehabilitation of patients with ACL, it seems most appropriate to include a psychotherapeutic technique in the form of Felt therapy sessions in a single rehabilitation scheme, in addition to the indicated drug therapy, a diet low in saturated fats and dosed walking. This will make it possible to achieve such a technical result of the invention as the effect of complex rehabilitation with an improvement in the tolerance of gradually increasing FN and their compliance for a patient with ACL, through both interval physical training (dosed walking), fine motor skills training, the effects of exposure to biologically active points of the hands (on regulation of the autonomic nervous system), and by training a psychologically positive perception of the real environment, searching for real resource objects and states in it, training motivation for successful rehabilitation, by giving a creative motivational meaning to physical training in the dynamics of increasing load, leading to an acceleration of rehabilitation and socialization of patients, reducing the number of further possible acute cardiovascular conditions.

To achieve this technical result, a method of complex sanatorium-resort rehabilitation of patients with ACS is proposed, including daily therapeutic dosed walking.

The complex also includes drug treatment in accordance with the patient's indications, adherence to a balanced hypocaloric diet low in saturated fat, as well as Felt therapy sessions 2 times a week, individually or in a group, with a session duration of 2 hours, in the form of sequential execution by the patient during the entire course of rehabilitation of four objects made of colored colored non-spun sheep wool by felting, figuratively reflecting the corresponding successive states of the patient: 1) healthy state - intact, 2) sick state - damaged by disease, 3) state as a result of previous treatment of acute myocardial infarction , 4) the state as a result of rehabilitation against the background of ACL (recoverable, convalescent), with discussion and analysis of the results obtained from wool felting together with a psychotherapist.

In this case, therapeutic dosed walking is carried out in the form of interval training - 5 minutes of walking, then 5 minutes of stopping, then walking again, and so on, alternating stops and walking, workouts are carried out daily 2 times a day in the morning and evening hours in the fresh air with an increasing level of load in points, which during walking is controlled using the Borg scale, presented in Table 1, and using acceptable technical means (for example, "smart watches", heart rate control programs in a smartphone). Before the beginning of the walking session, a warm-up is carried out, after the end of the session - a cool down for 5-10 minutes, including in these stages the implementation of general strengthening, warming up, aerobic exercises, acceptable for the patient's physical condition.

Moreover, in the case of satisfactory patient tolerance of increasing loads during walking, the patient carries out walking exercises in the form of the following stages.

1) From the 1st to the 3rd day of rehabilitation, the patient spends 2 daily walking sessions with a total duration of each session for 20 minutes at a pace that provides the patient's load level in the range from 7-8 points at the beginning of walking to a maximum load of 9-10 points on the Borg scale, according to table 1 given in the description.

2) From the 4th to the 6th day of rehabilitation, the patient spends 2 daily walking sessions with a total duration of each session for 30 minutes at a pace that provides an increase in the patient's load level in the range from 7-8 points at the beginning of walking to a maximum load of 11-12 points on the Borg scale , according to table 1 given in the description.

3) From the 7th to the 10th day of rehabilitation, the patient spends 2 daily walking sessions with a total duration of each session for 60 minutes at a pace that provides an increase in the patient's load level in the range from 7-8 points at the beginning of walking to a maximum of 11-12 points on the Borg scale, according to table 1 given in the description.

4) From the 11th to the 13th day of rehabilitation, the patient spends 2 daily walking sessions with a total duration of each session for 90 minutes at a pace that provides an increase in the patient's load level in the range from 7-8 points at the beginning of walking to a maximum of 11-12 points on the Borg scale, according to table 1 given in the description.

In the process of practicing therapeutic dosed walking, the patient fixes attention on the sensations of a gradual increase in the load.

In the event that symptoms of a patient's intolerance to the walking load appear, the next walking sessions are not carried out until the patient's previous condition is restored, and the next walking session begins at the level of the load at the stage at which its tolerance worsened.

Moreover, before the first lesson of the course of therapeutic dosed walking, an introductory session of psychotherapy is conducted, lasting 1 hour, at which they get to know the patient, his life history and illness, the patient's attitude to his condition, his plans and hopes for the future, explain to the patient the mode of walking and fell -therapy.

Before the first session of Felt therapy, in the process of practicing therapeutic dosed walking, the patient finds in his natural environment a plant - a tree or a shrub with which he is able to initially associate himself in both a healthy and a pathological state, and takes a photo of this initially selected plant with using a suitable technical means.

Further, at the first session of Felt-therapy, the patient creates with the help of felting from wool an object that the patient associates with the plant initially chosen by him, shown in the photo taken in the process of walking.

At this session of Felt therapy, the psychotherapist interviews the patient about the manufactured object, asking the patient questions that determine the state of the plant and its surrounding environment, allowing the patient to be identified with this plant and, accordingly, with the object made on the basis of its image: based on what signs on photos and sensations in the process of felting, the patient associates himself with this plant, fixes the patient's attention on these signs - sensations and emotions as actual points of contact with the patient's personality, on their reflection in the characteristics of the object made by the patient - used colors, structure, size, volumetric or flat subject, the degree of detailing of its features, noting together with the patient what real characteristics of the patient's personality reflect these characteristics of the subject.

In the second session of Felt therapy, the patient creates a second object associated with the plant of his choice, using his image and photo to display possible damage to the plant with which the patient associates his disease and its symptoms - the AMI experience and its consequences in the form of ACL.

At the same time, with the psychotherapist, they determine the type and causes of possible damage to the plant, their reflection on the second object made by the patient by felting, discuss the change in the patient's perception of the selected plant in the light of the damage, the psychotherapist, during the conversation, fixes the patient's attention on these changes and on possible mechanisms for providing him with assistance using the display of the image of the damaged plant on the second object made by the patient, noting which real symptoms, signs of the patient's illness reflect the corresponding characteristics of the object, reflecting its damage.

Before the third session of Felt therapy, in the process of walking, the patient finds another plant on the ground - a tree or a shrub, with which he is able to associate his resource psychological and physical state - a “helper plant”, and takes a photo of it using a suitable technical means (camera , smartphone, etc.).

In the third session of Felt-therapy, the patient, using felting from dyed non-spun wool, creates a third object that he associates with the “helper plant” of his choice.

At the same time, with the psychotherapist, the characteristics of the resource image fixed by the patient in the photo of the “helper plant” in the form of a third object and the relationship of these characteristics of the resource image with specific therapeutic factors of the previously performed therapy in the patient are discussed. the subject, and its injuries displayed on the second subject, under the influence of the previously received therapy and the possibility of increasing further physical activity for the patient, fix the patient's attention on, together with the psychotherapist, the specific characteristics of the resource image of the selected "helper plant" displayed in the third subject, and on their perception by the patient to improve the tolerance of increasing physical activity.

At the fourth session of Felt-therapy, the patient creates, by felting from dyed non-spun wool, a fourth object - a "recovering plant" (regenerating), reflecting the state of the plant initially selected by the patient, which has experienced damage associated with the improvement of the patient's condition against the background of ongoing rehabilitation, fix the patient's attention to characteristics of the fourth object - colors, structure, volume, shape, size, degree of detail - and their associative relationship with the real characteristics of the patient's current state of health and with the characteristics of the resource image of the “helper plant”.

The psychotherapist discusses and fixes the patient's attention on the associative connection of the patient's changing perception of the specific characteristics of the state of the initially selected plant under the influence of the characteristics of the resource image and, accordingly, the patient himself under the influence of specific methods of the ongoing rehabilitation.

At the last session of Felt therapy, they discuss the dynamics of the patient's perception of himself in the image of the initially chosen plant, its state, attitude to his illness and recovery under the influence of the applied therapeutic and rehabilitation factors, fixing the patient's attention on positive changes in terms of load tolerance, noting the possibility of their continuation , further trend of positive dynamics when using the characteristics of the resource image, displayed in the third completed object - "plant-helper", and the characteristics of the completed fourth object.

Felt therapy sessions on the set days are carried out 2 times a week between sessions of therapeutic dosed walking. The duration of each session of felt therapy is 1.5-2 hours.

The entire course of spa treatment with the days of arrival and departure, respectively, can be up to 15 days.

The objects made by the patient by felting from wool can be flat paintings, collages, volumetric souvenirs, jewelry, garments.

The rehabilitation course may additionally include physiotherapy and / or balneotherapy, if indicated.

At the end of the course of sanatorium-resort rehabilitation, the patient independently continues to adhere to the regimen of daily therapeutic dosed walking, taking into account tolerance, gradually bringing it to 2 sessions per day for 120 minutes, ensuring an increase in the patient's load level in the range from 7-8 points at the beginning of walking to the maximum in 11-12 points on the Borg scale, according to table 1 given in the description, using four previously completed objects as psychotherapeutic support.

Table 1. Assessment of individual load perception (Borg scale)

Load assessment Load assessment, points Patient heart rate, beats / min Very light 7-8 70-80 Easy 9-10 90-100 Moderate 11-12 110-120 Moderately severe 13-14 130-140 Heavy 15-16 150-160 Very heavy 17-18 170-180 Extremely heavy 19-20 190-200

Implementation of the invention

They carry out daily therapeutic dosed walking in the form of interval loads, drug treatment in accordance with the patient's indications, adherence to a balanced hypocaloric diet with a low content of saturated fats, as well as conducting Felt therapy sessions 2 times a week, individually or in a group, with the duration of the session 2 hours, in the form of sequential execution by the patient during the entire course of rehabilitation of four objects of dyed colored non-spun sheep wool by felting, figuratively reflecting the corresponding successive states of the patient: 1) healthy state - intact, 2) sick state - damaged, 3) state as a result previous treatment of acute myocardial infarction, 4) condition as a result of rehabilitation against the background of ACL, with discussion and analysis of the obtained results of felting together with a psychotherapist.

Therapeutic dosed walking is carried out every day, 2 times a day in the morning and evening hours in the fresh air, in dry weather, the load gradually increases. Its level during walking is controlled by the patient himself using the Borg scale, presented in Table 1, and using appropriate acceptable technical means, such as smart watches, programs, applications designed to control the heart rate in a smartphone. First, a warm-up is carried out, at the end of the lesson - a hitch, for 5-10 minutes, performing warming up, aerobic exercises. Walking is carried out in the mode: walking for 5 minutes, 5 minutes - stop, then again 5 minutes of walking, etc., according to the lesson scheme presented below. During the stops, the patient performs, among other things, the tasks of the psychotherapist to find an object for use in psychotherapy sessions and obtain a photograph of this object.

With a satisfactory patient tolerance of the loads, gradually increasing from session to session when walking, the patient carries out walking exercises in the form of the following stages.

1) From the 1st to the 3rd day of rehabilitation in a sanatorium-resort environment, the patient spends 2 daily walking sessions for 20 minutes at a pace that provides a load in the range from 7-8 points at the beginning of walking to a maximum load of 9-10 points on the Borg scale, given in table 1.

2) From the 4th to the 6th day of rehabilitation, the patient spends 2 daily walking sessions for 30 minutes at a pace that provides an increase in the patient's load in the range from 7-8 points at the beginning of walking to a maximum load of 11-12 points on the Borg scale, given in Table 1 ...

3) From 7 to 10 days of rehabilitation, the patient spends 2 daily walking sessions for 60 minutes at a pace that provides an increase in the patient's load in the range from 7-8 points at the beginning of walking to a maximum of 11-12 points on the Borg scale, given in Table 1.

4) From the 11th to the 13th day of rehabilitation, the patient spends 2 daily walking sessions for 90 minutes at a pace that provides an increase in the patient's load in the range from 7-8 points at the beginning of walking to a maximum of 11-12 points on the Borg scale, shown in Table 1.

After being discharged from the sanatorium, on the following days, in a usual environment for himself, the patient continues daily walking exercises 2 times a day: first, at the level of physical activity achieved in the sanatorium, with a gradual increase (depending on individual tolerance) until 2 times daily walking per day for 120 minutes at a pace that provides an increase in the patient's load in the range from 7-8 points at the beginning of walking to a maximum of 11-12 points on the Borg scale, given in table 1, also with the obligatory warm-up and cool down.

During the exercise of therapeutic dosed walking, the patient fixes attention on his sensations under conditions of a gradual increase in the load.

In the event of symptoms of intolerance by the patient to the load when walking (the appearance of pain in the legs, back, heart area, headache, shortness of breath, nausea, dizziness, a feeling of hot flashes, increased frequency, decreased heart rate, etc.), regular walking sessions are not carried out until the previous satisfactory the patient's condition, and the next walking session begins with the load of the stage at which there was a deterioration in its tolerance.

In any case, before the first lesson of the course of therapeutic dosed walking, an introductory session of psychotherapy is conducted, lasting 1 hour, at which they get to know the patient, his life history and illness (the presence of concomitant diseases, the circumstances accompanying the onset of acute myocardial infarction, what treatment was used, was there a surgical treatment, when the diagnosis of ACL was established, what circumstances were it accompanied), the patient's attitude to his condition, with his plans and hopes for the future, explain to the patient the mode of walking and Felt therapy.

Before the first session of Felt therapy, in the process of practicing therapeutic dosed walking, the patient finds in his natural environment a plant - a tree or a shrub with which he is able to initially associate himself in both a healthy and a pathological state, and takes a photo of this initially selected plant with using a suitable technical means, for example, a camera phone, a camera.

Further, at the first session of Felt-therapy, the patient creates, using felting from wool, an object that the patient associates with the plant of his choice, shown in the photo taken in the process of walking.

During this session of Felt therapy, the psychotherapist interviews the patient about the manufactured object, asking the patient questions that determine the state of the plant and its surrounding environment, allowing the patient to be identified with this plant and, accordingly, with the object made on the basis of its image: based on what signs in the photo and sensations in the process of felting, the patient associated himself with this plant. The patient's attention is fixed on these signs, as well as on the patient's sensations, emotions as actual points of contact with his personality, on their reflection in specific characteristics (signs) of the object made by the patient - the colors used, structure, size, volumetric or flat object, the degree of its detailing signs. They note what real characteristics of the patient's personality reflect these characteristics of the plant and the object, discuss them with the patient, their relationship with the patient's personality, their possible influence (specific characteristics of the patient, figuratively reflected in the characteristics of the plant and the object created from its image) on events in the patient's life ... For example, the patient used dark colors of wool in the manufacture of an object, during the discussion it became clear that, in his opinion, those around him consider him a gloomy person, a recluse; It is discussed with the patient whether this could have influenced the fact that he accumulated his negative emotions in himself for a long time, this was a favorable background for the development of AMI and subsequent ACL, since this painful background did not disappear, was not psychotherapeutically worked out.

For the first manufactured item, it is advisable for the patient to ask questions that determine the internal state of the plant he has chosen and the state of its external environment (for example: "What is the age of the tree: is it young, mature or old?" And "What is the weather around it?" tree? "and" why do you think? "); as well as questions that determine the depth of the projection of the patient's personality onto the image of a plant and its identification with this image (for example: “how do you resemble this tree, how do you differ from it?” and “remember a person who is important to you, what would he change in this picture what is unacceptable for him here? ”This is necessary so that the patient himself, during the session, understands how deep his psychological connection with this object is, identifies himself with it, motivating himself to help the tree (self-help), on faith in the ability to change your lifestyle, emotions, recovery, rebirth, defining the target points of a possible psychotherapeutic effect.

In the second session of Felt therapy, after several sessions of therapeutic walking, during which he fixates his attention on the sensations from increased physical activity, the patient creates a second object that he associates with the plant of his choice, using his image and photo as a basis for displaying possible damage to the plant, with which the patient associates his disease and its symptoms - the experienced AMI and the formation of ACL.

Together with the psychotherapist, they determine the type and causes of possible damage to the plant, their reflection in the second object made by the patient by felting from wool, discuss the change in the patient's perception of the selected plant in the light of these injuries. During the conversation, the psychotherapist fixes the patient's attention on these changes and on the possible mechanisms for helping him, using the expression of the image of the damaged plant in the second object made by the patient, noting which real symptoms, signs of the patient's illness reflect the corresponding characteristics of the plant itself and the object made by the patient. For example, the appearance of dark tones or broken lines in the manufactured second object, which were not in the first object, can be interpreted with the help of the patient himself as the appearance of depressive moods, difficult to bear pains, feelings of helplessness, etc.

For the second manufactured item, the patient, together with the psychotherapist, determine the type and possible causes of damage to the plant, chosen as the patient's image (for example: "was the damage to the tree expected or unexpected, sudden?" And "Is the cause of damage external or is it rooted in the tree itself?"); as well as its possible pests, aggressors and defenders, saviors (for example: “from what or from whom the damage occurred, how?” and “what or who could protect the tree, and how exactly?”). These questions help the patient to understand the causes of his illness, disorder, to understand from which side, from whom or from what a negative impact on his condition can be expected, and from whom / what - a positive influence, help, positive dynamics, help to understand how the patient himself and how exactly can influence this.

At the same session, the psychotherapist and the patient discuss the change in the patient's perception of the initially selected plant (in the form of the first manufactured object) in the light of its stable growth and the occurrence of possible damage. During the conversation, the psychotherapist fixes the patient's attention on these changes and on the possible mechanisms for providing him with assistance, including the dynamics of the increase in the level of FN. Thus, a continuous and dynamic connection is established between the stages: the patient's life - his illness - possible help, which helps the patient to understand his capabilities and abilities to change his state for the better under the influence of specific factors of treatment and rehabilitation, in particular, with the help of therapeutic walking.

Before the third session of Felt-therapy, the patient in the process of walking finds another plant on the ground - a tree or a shrub, with which he is able to associate his resource psychological and physical state - a "helper plant", and takes a photo of it using a suitable technical means.

During the third session of Felt-therapy, the patient, using felting from wool, creates a third object that he associates with receiving help from the “helper plant” of his choice, which he found directly in the process of therapeutic dosed walking.

At the same time, together with the psychotherapist, the characteristics of the resource image of the "helper plant", fixed by the patient in the photo, are identified, and the relationship of these characteristics of the resource image with specific therapeutic factors of previous therapy and current physical influences (therapeutic walking), as well as, possibly, the influence of loved ones patient (family, friends, colleagues). The patient displays all this when making a third item by felting from dyed non-spun wool. This can be any additional element - a "branch" of a plant, its rich, luxurious crown or roots, etc., which the "helper plant" is capable of or can share with the damaged plant. The dynamics, change in the patient's perception of the initially selected image of the plant displayed in the first object, and its damage displayed in the second object, under the influence of the previously received therapy and the possibility of increasing further physical activity for the patient, fix the patient's attention on the selected specific characteristics of the resource image of the selected "Helper plants", displayed as helping, healing in the third object (colors, volume, airiness - lightness, increased size - strength, etc.), and on their perception by the patient to form in him faith in improving the tolerance of increasing therapeutic walking of physical activity (FN) and faith in the very training and healing power of such loads.

It should be noted that the psychotherapist (or even the patient himself) can offer completely unexpected interpretations of certain characteristics to the patient. In this case, what matters is not what specific characteristic (color or size, or otherwise in the appearance of an object; young shoots of a "helper plant" or otherwise) is discussed in terms of its potential, resource possibilities of rendering assistance to the damaged image of the patient, but that it is on it that the patient's attention can be drawn as a resource. For example, not only the increased size of the “helper” element, but also its small size (if we describe it, for example, as “able to penetrate more deeply” and “help from the inside”) can act as a helping characteristic. Even dark color shades prevailing in a manufactured object can be interpreted not as depressive, but as related, for example, to wise old age, stamina, etc. The main thing is the formation, modification of the perception of these characteristics by the patient, so that he was able to accept these sensations, to realize their possibility as positive, resourceful . At the same time, on subsequent sessions of therapeutic dosed walking, the patient can try to remember these positive sensations, emotions, evaluate their influence on facilitating their tolerance of increasing FN during therapeutic walking.

Thus, on the basis of the manufactured third object, the psychotherapist discusses the relationship between the characteristics of the resource image of the “helper plant” recorded by the patient in the photo, their perception by the patient and his feelings from the received FN with the specific therapeutic factors of this and previously performed therapy, which affects the patient's condition and his perception of the image of the initially selected, but then damaged plant. Together with the psychotherapist, they discuss the change in the patient's perception of the image of a damaged plant under the influence of the previously received AMI therapy and the possibilities of further increasing the FN for the patient, relying on the resource image of the “helper plant” chosen by him - its characteristics and their perception by the patient, expressed in the third object he made as already received from the "helper" and had a positive therapeutic effect. For these purposes, for subsequent walking sessions, the patient can take with him this object (“helper plant”) as a stimulus for sensations of support, help in overcoming the increasing load, taking into account the resource qualities obtained with the psychotherapist.

During the discussion at the third session, we are talking about conditions that figuratively express the result of therapy in the acute period (resuscitation, surgery, injections, etc.) and the result of treatment in a hospital. For example, a patient can be told: “You worried about your tree and tried to somehow help him,“ heal ”him. Picture what could help him, what restoration work could be done. Depict your tree in the subject after the "restoration" work. " “Time passed, everything calmed down. The life-giving forces of nature, as always, have fulfilled their task. Depict how things began to look over time. What helped the plant? "

When discussing the third manufactured object, such questions as the experience of states of dominance and subordination are raised (for example, the patient is asked: “how did you feel when the tree was helped,“ treated ”it?” And “how did the tree feel during the“ treatment ”, receiving help? "); as well as methods for verifying the patient's hypotheses regarding the state of the tree and its dynamics, and the patient's leading sensory system - visual, auditory, or kinesthetic (for example: “how did you determine whether the tree is alive or dead?” and “how did you make sure that your“ treatment "Was successful?"). Determining the experiences of states of dominance and subordination helps the patient to feel what he can and should rely on only on himself when undergoing rehabilitation and in the formation of a subsequent lifestyle, and in what - on medical personnel, relatives and / or friends, and in what - on joint efforts. This helps to realize their illness, their capabilities, a realistic perception of oneself, self-esteem. And this, in turn, contributes to the formation of a realistic and persistent motivation for treatment and rehabilitation.

Determination of the leading sensory system helps to formulate appropriate recommendations for further rehabilitation for the final psychotherapeutic session, which the patient will follow already at home - what aspects of the life of a tree / shrub, i.e. the patient's own lifestyle will be easier for him to pay attention to, to support them - from the point of view of the patient's leading sensory system (see, for example, General Physiology of Sensory Systems, https://lektsii.net/2-36076.html). So, for example, if the visual system is the leading system, the patient is asked to take care of the appearance of the tree / shrub (to maintain harmony, posture, neat appearance, etc.). This is said on the basis of the brightness of the colors of the executed object, the accuracy of the work. If the auditory system is the leading system, the patient can be recommended to subsequently maintain his positive state, for example, by listening to his favorite music, which motivates him to recover, imagining which songbirds could live in the branches of his favorite plant, protecting him from pests (they can be figuratively depicted within the framework of a third object made of wool using felting; what could be the sounds of nature, among which a real tree is growing, chosen by the patient, and the image of which is made of wool by the patient; it is possible to sing your favorite tunes to the sound of this tree etc.); take care of your own correct, calm speech, working on improving articulation, pronunciation and breathing rhythm during speech (you can use various types of recreational breathing exercises, in the absence of appropriate contraindications). On the third subject, this can be shown by increasing the airiness of the material used.

If the kinesthetic system is the leading system, the patient is subsequently invited to use, to maintain his own motivation, light physical exercises that he likes to perform (taking into account the contraindications available to a particular patient), self-massage to control the shapes of his own body (for example, to reduce body fat felt during palpation ), surrounding oneself with objects that the patient likes to touch. The third and fourth objects made by felting from wool should also become such objects.

Thus, in the fourth session of Felt-therapy, the patient creates a fourth object by felting from dyed non-spinning wool, reflecting the state of the damaged plant selected by the patient, associated with the improvement of the patient's condition against the background of ongoing rehabilitation. The patient's attention is fixed on the characteristics of the fourth object - colors, structure, volume, shape, size, degree of detail - and their relationship with the actual improved characteristics of the patient's current state of health (mood, physical endurance - increased tolerance to FN when walking, a positive outlook on the future , and etc.). In this case, these relationships can also be any, i.e. the interpretation and quality of individual characteristics may be different, but it should be clearly associated with a corresponding positive perception of the situation of improvement by the patient himself.

At this session with the psychotherapist, the patient's attention is discussed and fixed on the relationship of the patient's changing perception of the specific characteristics of the state of the plant initially selected by the patient under the influence of the characteristics of the resource image and, accordingly, the patient himself under the influence of specific methods of the ongoing rehabilitation - primarily, therapeutic dosed walking with increasing loads. Discuss the effect of "using" the characteristics of the resource image of the "helper plant" fixed by the patient, already obtained in the previous sessions with dosed walking, which will further increase the FN.

Thus, the conversation, discussion on the fourth subject made by the patient includes a discussion of the balance of the values of stability (preservation) and further possibilities for the development of the "plant" (changing the patient's lifestyle). For example, they ask: "Has everything become for the plant as before, has everything returned" to square one? " and also discuss the balance of interests of an individual and a group (his personality, social ties, social significance, self-sufficiency, family interests, clan) (for example: “what is the mortality of a tree?” and “what is the immortality of a tree?”, what or who helps this / help in the future?). On the one hand, this allows us to conclude about the dynamics of the patient's psychoemotional state (which is important for monitoring the effectiveness of the entire course of rehabilitation) - does the patient believe that further improvements and their active preservation are possible, which increases his motivation for rehabilitation, recovery, and return to normal life. On the other hand - due to what are these further positive changes possible: whose greatest contribution can be, or the balance - of the patient himself as a person and / or the surrounding close group. This allows you to control the influence of therapeutic, rehabilitative influences on the patient's condition and, accordingly, modify the direction of work of specific methods of rehabilitation, in particular, psychotherapy, physiotherapy, incl. FN, on one side or another of a person's life.

At the last session of Felt therapy, the dynamics of the patient's perception of himself in the image of the initially chosen plant, its state, attitude to his illness and recovery under the influence of the applied therapeutic and rehabilitation factors, first of all, the increasing FN during the sessions of therapeutic dosed walking, are discussed, fixing attention the patient on positive changes in terms of FN tolerance, noting the possibility of their continuation using the characteristics of the resource image of the “helper plant”. At the same time, the entire row of objects made by the patient is built in the corresponding correct sequence. If necessary, each object (if it is a painting, collage or a similar object that is not durable and dense) can be placed in a frame (for example, under safe unbreakable plexiglass), for aesthetics and completeness. This creates an additional perception of objects by the patient as completed results, which increases his confidence that all this has already been done, achieved by him. This arrangement of objects clearly shows the positive dynamics of the state and gives the patient the opportunity to be convinced of this again and again. At the end of the entire course of rehabilitation, the patient takes this set of items home and can use it to recall these feelings of completeness and, at the same time, the positive dynamics of the rehabilitation process in the process of continuing to walk in his usual environment.

Felt therapy sessions on the set days are carried out between sessions of therapeutic dosed walking. For example, if the regimen of Felt therapy sessions is 2 times a week, they can be held on Tuesday and Friday between morning and evening walking sessions.

The objects made by the patient by felting from wool can be flat paintings, collages, volumetric souvenirs, jewelry, garments.

The rehabilitation course may additionally include other physiotherapeutic and / or balneotherapy measures - according to the patient's indications.

At the end of the course of sanatorium-resort rehabilitation, the patient independently continues the regimen of daily therapeutic dosed walking at the achieved duration and level of maximum FN, reducing or temporarily stopping it only in case of a possible deterioration, or, with good tolerance, increasing the load. In the case of a temporary cessation of walking, the recovery of the FN mode occurs after the stabilization of a satisfactory state according to the same principles that were used in the sanatorium: on the day of returning to the loads, the patient resumes them from the FN level at which he stopped at the moment of his condition deterioration. Further, in a stable state, it can gradually increase. The patient is recommended to carry out such FN for life.

To control, assess the psycho-emotional state and motivation of the patient, objects made by felting from wool, their elements, characteristics can be interpreted, for example, using the following concepts (similar to the prototype method):

subject 1 - "picture of the patient's health" (self-attitude, self-esteem, self-presentation, relations with the outside world, near and far), is necessary to diagnose his internal state, readiness for positive changes during rehabilitation;

subject 2 - "picture of the disease" of the patient, is also necessary for the diagnosis and monitoring of the condition, how the patient saw, understood, realized his illness;

subject 3 - changes in the object (tree / bush) - individual (personal, personal) changes in the course of the disease under the influence of its treatment, rehabilitation, which allows tracking changes in the patient's psychoemotional state - whether he sees positive dynamics or not, whether he understands the reasons for this ;

subject 4 - changes in the environment of the object (tree / shrub) - systemic (group, family) changes in the process of the disease and its treatment / rehabilitation (how the change in these circumstances affects the patient's experience of his illness, how his worldview changes, which is necessary to understand the pattern of alignment further process of self-rehabilitation (walking - as an analogue of passing the path of life), already outside the sanatorium-resort conditions, i.e. broader, existential problems are discussed than during the sessions on the previous three subjects).

In the proposed method, the analysis of the differences between the executed objects (their dynamics) may include the interpretation of the patient's ideas (and their dynamics, as well as the patient's entire life path) as follows: object 2 relative to object 1 - the severity of the disease, disorder; subject 3 in relation to subject 2 - contribution to the patient's recovery of therapy after an acute condition and his personal efforts; subject 4 in relation to subject 3 - contribution to the recovery of the patient of rehabilitation and the natural surrounding forces, the human environment; subject 4 relative to subject 1 - the possibilities of recovery, lifestyle changes, the patient's hopes for the future (summary results of therapy and rehabilitation: negative - exhaustion, limitation, disability; positive - overcoming, acceptance, development, path to the future).

To implement the proposed method in the framework of psychotherapy sessions, patients can be given, for example, the following step-by-step instructions.

During the Felt Therapy session with the making of the first object: “Sit at the table comfortable for work. You can use in your work wool of any color that is on the table, as well as other objects (water, scissors, cellophane, containers). I will show you the basic techniques of wet and dry felting, making collages and paintings from wool. Use in your creative work what suits you best now, at the moment. For the next session, you can bring any objects and materials and include them in your creative composition. "

“Look at the photo you have taken of the plant you like. Depict it with wool, as you perceive it, imagining yourself healthy in its place. Depict it in the form or who it (the plant) seems to you. It can be any item: jewelry, souvenir, garment, accessory, or something else. You can also use any auxiliary means for the manufacture of this item: pins, paper, beads, etc. Make it the way you want, noting in this item the main thing that, as you think, unites you with the plant you have chosen. "

During the session with the manufacture of the second item:

“Look at the photo of the plant of your choice and depict your favorite plant damaged in the form of any object with which you associate this damaged plant. This can be any damage that you think you might notice in him. These injuries, his pain are similar to yours. Depict them by any means and techniques that you consider necessary in the manufacture of such an item. It can be any item: decoration, souvenir, etc. You can also use any auxiliary means for making this item: pins, paper, beads, etc. "

During the session with the manufacture of the third item:

“You worried about your tree and tried to somehow help it,“ heal ”it. Involved in this your "helper plant". Draw it in the form of any object you like: jewelry, souvenir, item of clothing, accessory. Think and depict, if you deem it necessary, as your resource plant, with the help of what qualities you could transfer your help to the patient. "

At the session with the manufacture of the fourth item:

“Time has passed, everything calms down. The life-giving forces of nature, the familiar helper plant, as always, fulfilled their task and provided assistance. Your active walking lessons, overcoming this difficult stage in your life helped you a lot in this. Depict in a new object how things began to look over time. You can still use whatever you see on the table (paper, cellophane, beads, pins, etc.). Reflect this in the object being made - how the “helper” influenced its image, how did it affect the image of the plant, its damage by walking as a way of overcoming difficulties on the path of life ”.

In the final psychotherapy session:

“Think about all the objects you made: what are they in common, what are different, what they look like, what they mean to you. What your attention is focused on in each of them. How it changes from subject to subject. What does this mean for you. How Your Walking Activities Affect This Perception ”.

“This work helps to substantively discuss your life situation and your opportunities, to achieve a deeper understanding of your condition and your opportunities in the future. The objects made by your creative power and the answers to questions make you look at your situation from different angles, give impetus to thoughts and, possibly, your future actions to continue physical training in the form of walking. "

Thus, after each session of Felt therapy, the patient is interviewed and the manufactured items are discussed, taking into account the dynamics of the patient as the FN level increases during therapeutic walking. Questions at the beginning can be aimed at verbal clarification of the characteristics of the object selected for analysis: what kind of tree it is (for simplicity and brevity, the text sometimes indicates a tree, although in accordance with the method it can be a plant - a tree or a shrub, as the largest plant species ) what kind it is; where is this tree, where does it grow; how old the tree is, is it young or old; what is the size of the tree, is it small or large; what is the weather in this picture; what the tree feels, what is its condition. Answers to this block of questions allow us to clarify the characteristics of the object and, thereby, the characteristics of self-presentation and self-attitude of the author, his self-esteem in accordance with the principle of considering any object as a self-portrait (since the patient explains exactly why during the session, on the basis of what he associated himself with this particular plant ).

The questions are also aimed at revealing the author's attitude to the object, the image of which is fixed in the object made by felting from wool: what is pleasant in this picture, evokes positive emotions; what is unpleasant on it, causes negative emotions. How are you similar to this tree, how are you different from it; would your parents agree with this picture, which is unacceptable for them here (the question is asked with caution, perhaps the parents are no longer there or they are unknown!); Would your loved one agree with this picture, which is unacceptable for him here (the question is asked with caution, perhaps such a person does not exist yet or not already!); Would your children agree with this drawing, which is unacceptable for them here (the question is asked with caution, perhaps the children are no longer there, not yet or cannot be!). The answers to this block of questions allow us to establish the sources of positive and negative emotions in the patient's life, the ability to identify, as well as relationships within the family, often shedding light on pathogenic factors of a psychological nature that could be involved in the development of the patient's illness.

Questions in the second subject are directed to the study of damage to a plant (tree / bush): how long ago it happened, is it a long-term or recent damage; damage to the tree was expected or unexpected, sudden; from whom or from what the damage occurred, what is its cause; what or who could protect him; what could help him. The answers make it possible to establish the patient's attitude to the problem, characterize its sources as external or internal (external or internal locus of the patient's control), and also characterize the support system, as the patient sees it, the place of rehabilitation processes in it.

Questions on the third and fourth subjects are consistently aimed at studying the possibility of transforming the depicted image of an object: whether this tree can become different, and which one; what would happen if this tree became lower / higher; thinner / thicker; grown in a gorge / on top of a mountain; if the foliage of the opal / tree was covered with flowers. How would this item change if you created it a year ago or a year later. The answers make it possible to establish the patient's readiness for personal transformation, changes in behavior, his adaptation to a new state after an illness, as well as the possible direction of transformations, the resources necessary for this, a subjective attitude to the dynamics of rehabilitation, primarily in connection with an increase in FN during therapeutic dosed walking ...

It should be noted that all artistic elements and means for the image of the plant initially chosen by the patient are chosen by the patient himself, both the colors of the wool for felting and any possible additional acceptable materials, including fabrics, paper for collage, appliques, beads, beads, pins, etc. P. In the process of therapy, psychotherapeutic classes, focusing on the existential association of the meaning of therapeutic dosed walking as a life path from the first object (the first image of an object, a tree) to the next, with an awareness of positive dynamics, hopes for the future can also be used.

At the same time, in the process of spa rehabilitation, the patient receives the drug therapy that was prescribed by the attending physician, cardiologist (antihypertensive drugs, including sartans, diuretics, ACE inhibitors, nitrates, drugs that improve myocardial metabolism, beta-blockers, antioxidants, antihypoxants , statins, antithrombotic agents such as thrombosis, psychotropic drugs if necessary, etc.).

Other, additional types of physiotherapeutic effects (magnetic laser, balneotherapy, etc.) during spa rehabilitation are selected based on the patient's capabilities and indications, other medical indications and contraindications (for example, in connection with background, concomitant diseases). However, in this case, they are optional. The main - and universal from the point of view of the possibility of using in the presence of various concomitant diseases of the patient (including chronic diseases of the gastrointestinal tract, nervous, endocrine, musculoskeletal system) acting rehabilitation factors in this method are - dosed interval FN during therapeutic walking, supported by the patient's motivation, increasing compliance through psychotherapeutic exercises in Felt-therapy, contributing to the patient's awareness and acceptance of the picture of his own health, illness and its dynamics under the influence of the ongoing treatment and rehabilitation measures, improving the psycho-emotional state, cognitive functions in the process of creative self-expression and taking personal, personal responsibility for his life, against the background of appropriate medication support and proper nutrition.

In terms of adherence to a diet within the framework of this method, we note the following. Compliance with a full regimen and diet for ACL has always been one of the main elements of effective treatment. Meals should be regular, at least 4 times a day, always in small portions, so as not to put a significant load on the internal organs (a full stomach can put pressure on the diaphragm, and it, in turn, on the heart). The daily calorie content should not exceed 2500-2700 thousand kcal.

First of all, they limit the intake of salt, which negatively affects the condition of the heart and blood vessels. Steaming is recommended. The daily diet includes more fresh fruits and vegetables, which contain a large amount of vitamins and minerals, in particular, magnesium and calcium, which are necessary to improve the functioning of the cardiovascular system. Foods that should be excluded from the daily diet: fried, cholesterol-rich foods (fatty meats, lard, fatty fish, sausage); vegetables (onions, parsley, garlic, cabbage, peas, radishes); alcoholic beverages (alcohol); it is necessary to reduce the amount of fluid consumed - no more than 1 liter per day; energy drinks that increase blood pressure and contribute to the development of hypertension (coffee, strong tea, cocoa). Healthy, in addition to fresh fruits (grapes, bananas, nuts, kiwi, tangerines, apples, cherries), vegetables (carrots, tomatoes, tsibulya, potatoes) are soups (buckwheat, oatmeal, pearl barley); milk porridge (buckwheat, rice); fruit juices (orange, apple, carrot); foods that contain large amounts of calcium and phosphorus (low-fat cottage cheese, low-fat fish).

Examples of implementation of the invention

Example 1. Patient, 56 years old, divorced, has a daughter, owns two specialties. For 3 years she suffered from ischemic heart disease (IHD), 3 months ago she suffered an acute myocardial infarction of moderate severity, was in rehabilitation for small focal myocardial infarction, ACL, FCII. In addition to the underlying disease, complaints of periodic increases in blood pressure up to 160/110 mm Hg (the diagnosis of arterial hypertension is not confirmed), high anxiety, fear of a second heart attack, depression, existential problems.

Received rehabilitation in a sanatorium near Moscow using the proposed method. Exercises of therapeutic dosed walking tolerated well, no adverse reactions were noted.

In addition to the first individual psychotherapy session, all other sessions were conducted in a Felt therapy rehabilitation group. Other members of the group also took part in the work. During the sessions, sufficiently deep and painful interpretations of the objects made were avoided.

A favorable self-attitude and attitude was recorded before the onset of the disease, apparently associated with a happy marriage and the birth of a child. At the same time, a lack of emotional closeness and mutual understanding with her husband was noted as potentially possible pathogenic factors.

Item No. 2 was a rather shapeless ball of wool, which, according to the patient, reflected the almost complete destruction of the tree, in fact, only its roots were left. The object elicited a strong emotional response from all group members, which obviously served as a factor in the patient's emotional support. She answered questions like this: “the damage was sudden,” “the cause of the damage was external,” “the husband’s mother,” “I was alone.” It turned out that the difficult divorce was followed by a deterioration in relations with her daughter and other family members. Perhaps the stress experienced triggered the subsequent myocardial infarction.

During the session, when discussing the third subject (in the form of a resource napkin made of wool - support, neatness, cleanliness), the “treatment” was of an emotional nature. The patient was turned into the past. Answers to the questions: “when I helped - my usual state”, “the tree does not feel anything”, “I don’t know”, “I think so”. The answers revealed the patient's obvious communication problems, especially in relationships with loved ones, the features of alexithymia. The napkin represented a delicate, vulnerable object (a thin bush was chosen as a helper plant, but at the same time, flexible). The patient noted how pleasant she was to the touch. "From one touch it becomes easier, the heart calms down, everything smoothes out."

In the session with the fourth object (a resource brooch made of wool), the severity of negative emotions, judging by the analysis of the object (the brightness of colors, the courage to choose additional elements for making), decreased. Answers to the questions: "no, nothing came back", "experience of suffering, but still I step on the same rake", "everything is mortal", "there is no immortality." The pessimism has diminished.

In the final session, there was a consistent interpretation and discussion of all four subjects received. The patient's initial complaints about the doctors (“they didn’t help me”) were gradually replaced by the admission that “in general, they did what they could”. They also came to an understanding of the need for active cooperation in the rehabilitation process, deeper compliance, discussed ways to get out of the situation of rehabilitation in society, establish a new life in new conditions of limited opportunities: "It's not so bad." The patient compared the course of rehabilitation she underwent with the use of walking to the road that gradually led her from illness to a relatively healthy state, when she was quite confident in herself and her strengths, albeit small ones.

Subsequently, telephone support was provided with increasing pauses, the patient's psychological state improved, relations with her daughter improved, a permanent partner appeared, went to work part-time, there were no bouts of depression, angina pectoris was not noted during the year of observation. She noted that she periodically analyzes the sequence of objects made by her, and this vision of her success helps the patient to continue physical activity and live in general.

The level of personal / situational anxiety according to the Spielberger-Khanin scale decreased from 48/49 points (high anxiety) upon admission to rehabilitation to 30/28 points upon discharge from the sanatorium (low anxiety), the severity of manifestations of depression (according to the Beck scale) - from 18 points (moderate depression) to 11 (mild), respectively. There were no anginal attacks. According to the data of bicycle ergometry, the tolerance to FN increased by 1.5 times. A number of ECG indicators have improved (there are no new ischemic manifestations); hemodynamic indices stabilized (pulse - 76 beats per minute; blood pressure 135/85 mm Hg), the dose of constantly taken cardiac drugs decreased, and antihypertensive drugs (enap, kapoten) were used less frequently. The quality of life improved according to the SF-36 questionnaire - on average, from 40-48 points (according to various scales of the questionnaire) to 64-70 at the end of the rehabilitation period.

Example 2. Patient, male, 67 years old, single, has adult children, retired. 3 months ago he had AMI with an outcome in ACL, FCIII. Disturbed by pains in the heart, fears about their future, increases in blood pressure to 170/120 mm Hg.

Received a course of rehabilitation in a sanatorium near Moscow using the proposed method.

Walking was tolerated well, without adverse reactions.

At the first, introductory individual psychotherapy session, the history and course of the disease, associated social and psychological factors were considered. They recorded increased anxiety, fear of death, loneliness, depression. The rest of the sessions were carried out in a group.

The patient performed the first object as a monochromatic, dark green, rather shapeless. However, starting from the second session, he brought with him several small twigs with leaves and included them in the composition (collage, paintings), gluing them to the sheet along with pieces of wool.

The age of the selected tree and the age of the patient were close, reflecting an acute rejection of both age-related extinction and the disease that aggravated it. He answered questions like this: “the tree is aged”, “the weather is normal”, “they are similar in age”, “yes, she would not like everything”. But he left the development of the topic of relations with a loved one.

In the image of a damaged tree (item # 2 was a collage), it was reflected as being split. Apparently, in this state, it is not viable. The message can be interpreted as "I can not live sick." He answered questions like this: “the damage was sudden,” “the damage was caused from the outside,” “circumstances,” “when you feel good, you have a lot of friends, when you feel bad, you are alone.”

When depicting the “helper” (item no. 3, also a collage), I reflected it in the form of planting seedlings in the soil (I used the appropriate colors). The solution and treatment was radical. It turned out that this is rather the ideal than the real behavior of the patient. He answered questions like this: “it was pleasant to help,” “being in the position of a patient is unpleasant,” “I don’t know, but I acted as if the tree was still alive,” “only time will tell this, as in life.” The collage was supposed to be used as a stand for hot dishes. "This is my support." Associated with young shoots near the roots of an old tree.

At the session with the manufacture of object No. 4 (a tree after rehabilitation, also in the form of a collage, a three-dimensional picture) I made a planted tree, which was covered with fresh foliage (bright green wool with pieces of twigs and leaves from a real tree - as a partial characteristic of the resource image of a “tree- assistant "). The patient again said: "This is probably what I want, what I hope for." From the very beginning, he accepted that the tree reflects his fate, and he himself walks, as during therapeutic walking sessions. "Not easy, but necessary." He answered questions like this: “no, nothing will be the same as before”, “experience of suffering”, “there are accidents in life, therefore a person is mortal”, “immortality is in what will remain after me” (young shoots - an association with the patient's children , its resource). This topic helped to overcome the patient's initial pessimism, in part, ostentatious.

In the final session, there was an in-depth interpretation and discussion of the four consecutive images. Patient: “Yes, there was something inside me that caused the disease. I don’t know what yet. ” There was a willingness to "do something" and a transition from reflection to action. I was interested in the possibilities of physiotherapy and further rehabilitation. From the joke "the boys don't cry" passed to the "grain of truth" in this maxim, the patient behaved as at a production operational meeting, the program of self-massage and therapeutic exercises, which the patient was ready to undergo at home, was discussed in detail. He noted that in the process of making all four items "my hands began to move better, faster and more accurately every time, this will be useful to me later on in the household."

In the future, communication was provided via a smartphone, but he did not abuse the calls, the improvement in his condition also caused a feeling of gratitude to the doctors and medical staff and patronizing notes: "I did it, but could you - it is still unknown." The general state of health is not bad, the feeling of loneliness has significantly decreased, the self-assessment of the rehabilitation process is positive. The patient is active, continues walking with the achieved tolerance to FN. Warm relations with children and grandchildren.

As a result of rehabilitation, the doses of nitrates, thrombolytics and beta-blockers taken by the patient are reduced. Pain in the region of the heart began to bother less often, the state of health improved, blood pressure stabilized. ECG - no negative dynamics.

The level of personal / situational anxiety according to the Spielberger-Khanin scale decreased from 52/46 points (high anxiety) upon admission to rehabilitation to 38/33 points upon discharge from the sanatorium (moderate anxiety), the severity of manifestations of depression (according to the Beck scale) - from 19 points (moderate depression) to 13 (moderate), respectively. According to the data of bicycle ergometry, the tolerance to FN increased by 0.7 times. A number of ECG indicators have improved (there are no new ischemic manifestations); hemodynamic indices are stable (heart rate - 78 beats per minute; blood pressure 135/80 mm Hg), the dose and frequency of taking constantly taken drugs have been reduced. The quality of life improved according to the SF-36 questionnaire - on average, from 41-44 points (according to various scales of the questionnaire) to 58-65 at the end of the rehabilitation period.

The proposed method of treatment was applied during 2019 in 25 patients with ACL of various FCs (from I to III), including in five patients with concomitant hypertension, 3 patients in history underwent coronary artery bypass grafting, one - coronary stenting. arteries. The patients' age is from 56 to 68 years. The total duration of the disease was 1-8 years before admission to rehabilitation. In 56% of patients (14 people), chronic heart failure of the 1st stage was revealed. (NYHA classification). 16% of patients (4 people) had concomitant type 2 diabetes mellitus.

Nine patients underwent rehabilitation at the branches of our center according to the proposed method (group 1) , nine were engaged only in therapeutic dosed walking and received appropriate medications and a diet, as well as a set of physiotherapy methods according to indications, without receiving psychotherapy (group 2) , and seven patients were engaged in according to the method in which Felt therapy was applied in parallel without connection with therapeutic walking and physiotherapeutic influences (it was not associated with a specific regimen of these exercises, Felt therapy sessions were held 2 times a week, however, they were not thematically related to walking - patients they were engaged in the manufacture of any resource items, the image of the plant was not selected, not used) (group 3).

All patients received standard drug therapy appropriate to their medical indications, as well as an appropriate diet (low calorie, reduced saturated fat, predominantly fish, fruits and vegetables in the diet, as well as lean meats, adequate drinking, fortified foods).

After the course of rehabilitation by the proposed method , a positive trend in clinical symptoms was noted. Anginal attacks decreased in 77.7% of patients of group 1 , headaches, dizziness - in 66% of patients. There was a decrease in the sensation of interruptions in the area of the heart, as well as palpitations in 89% of patients, improved sleep and psychological status of all patients in this group. The body mass index decreased due to weight loss by an average of 2 kg and waist volume by 1 cm.

The changes in physical activity were significant, which was found when performing the test with 6-minute walking of patients. After the course of rehabilitation, patients with functional class I (NYHA) heart failure underwent 450.3 ± 9.9 m (before treatment 427.1 ± 9.1 m), p <0.05;

Thus, there was a positive dynamics of the main clinical manifestations, which was accompanied by a decrease in the severity of heart failure FC I (NYHA) (according to the results of the 6-minute walk test) when implementing the proposed method in patients of group 1.

In patients who received rehabilitation in groups 2 and 3, similar improvements, although they did take place, however, did not show statistical significance. In addition, the improvements in the psychoemotional state of patients achieved directly in the process of rehabilitation were leveled out approximately 2 months after their return to home conditions, in contrast to patients who received rehabilitation according to the claimed method (according to subsequent telephone interviews of patients, as well as control examinations during 2020. , 2 times per year).

It should also be noted that the positive dynamics in patients who received rehabilitation according to the claimed method (group 1) was also characterized by positive dynamics of the parameters of 24-hour blood pressure monitoring, and the latter was statistically significant, namely: the total number of episodes of myocardial ischemia decreased from 6.1 ± 0 , 82 to 4.2 ± 0.60, p <0.02, duration of ischemia - from 37.9 ± 4.9 to 25.4 ± 3.5 min, p <0.05; the number of episodes of painless ischemia decreased from 3.8 ± 0.47 to 2.73 ± 0.42, p <0.05, their duration - from 28.9 + 4.1 to 20.7 ± 2.2 min, p <0.01, pain ischemia - from 2.22 ± 0.27 to 1.51 ± 0.16, p <0.01, their duration - from 9.8 ± 1.23 to 6.41 ± 0.66 min, p <0.02.

There was also an economization of cardiac activity in the form of a decrease in heart rate per standard load from 103.4 ± 2.2 to 97.4 ± 2.0 beats / min, p <0.05. The coronary reserve increased - the power of the threshold load increased from 370.3 ± 18.4 to 437.5 ± 20.1 kgm / min, p <0.01.

The index of tension of regulatory systems, which was increased before the beginning of rehabilitation in patients of group 1, decreased from 2787 ± 831 to 1056.5 ± 311 ms2 (P <0.05), the stress index from 520.6 ± 86 to 416 ± 62 conventional units. (P <0.05), the centralization index increased from 0.6 ± 0.03 to 1.2 ± 0.01 conventional units. (P <0.05), the anxiety index decreased, which indicated a positive effect of this course on the psychological status of patients. The use of the course also had a positive effect on the lipid spectrum of blood in the form of a significant decrease in the level of total cholesterol - from 6.92 ± 0.30 to 5.85 ± 0.22 mmol / L, p <0.05, the level of triglycerides - from 1, 61 ± 0.11 to 1.42 ± 0.10 mmol / L, p <0.1, increase in HDL - from 1.14 ± 0.03 to 1.48 ± 0.18 mmol / L, p <0, one.

Improvement of central hemodynamics, microcirculation and rheology, a decrease in sympathoadrenal influences contributed to an improvement in the psychoemotional status of patients, antianginal and antiarrhythmic effects, which was manifested by a decrease in the number and duration of ischemic episodes in the myocardium, especially painful ones, and a tendency to normalize the heart rhythm. There was an improvement in left ventricular diastolic function, an increase in tolerance to FN, which was manifested by a decrease in the manifestations of circulatory failure and an increase in physical activity, including in patients with chronic heart failure I FC (NYHA).

Against the background of the observed positive dynamics of the physical state, the quality of life of patients, according to the survey conducted on SF-36 one month after the end of the course, increased on average by 25%. All patients made a decision and then continued to practice therapeutic dosed walking according to the proposed scheme outside the sanatorium, at home, on an outpatient basis. Thus, the proposed method made it possible to enhance compliance, support the motivation of patients to an active lifestyle, sufficient, tolerable FN, increasing their self-esteem, self-confidence and the possibility of rehabilitation and return to normal social life, even against the background of existing chronic CVD and severe cardiovascular diseases. history of vascular events. In the group of patients who received the proposed complex of rehabilitation, repeated acute coronary events were not observed during the year. In the group of patients who received only rehabilitation by walking and physiotherapy, during the same period, there were 2 cases of repeated AMI, in the group receiving psychotherapeutic assistance in parallel, but not related to the physical rehabilitation of patients, there was 1 repeated AMI that required surgical treatment.

Claims (26)

1. A method of complex sanatorium-resort rehabilitation of patients with postinfarction cardiosclerosis (PCS), including daily therapeutic dosed walking, characterized in that the complex also includes drug treatment in accordance with the patient's indications, adherence to a balanced hypocaloric diet with a low content of saturated fats, as well as conducting Felt-therapy sessions 2 times a week, individually or in a group, with a session duration of 2 hours, in the form of sequential execution by the patient during the entire course of rehabilitation of four objects made of dyed colored non-spun sheep wool by felting, figuratively reflecting the corresponding successive states of the patient: 1) a healthy state - intact, 2) a sick state - damaged by a disease, 3) a condition as a result of previous treatment of acute myocardial infarction, 4) a condition as a result of rehabilitation against the background of ACL, with a discussion and analysis of the results of felting combined with a psychotherapist, in this case, therapeutic dosed walking is carried out in the form of interval training - 5 minutes of walking, then 5 minutes of stopping, then walking again, daily 2 times a day in the morning and evening hours in the fresh air with an increasing level of load in points, which is controlled during walking with using the Borg scale shown in Table 1 and using appropriate technical means; Moreover, in the case of satisfactory tolerance by the patient of increasing loads during walking, the patient carries out walking exercises in the form of the following stages: 1) from the 1st to the 3rd day of rehabilitation, the patient spends 2 daily walking sessions with a total duration of each session for 20 minutes at a pace that provides the patient's load level in the range from 7-8 points at the beginning of walking to a maximum load of 9-10 points on a scale Borga, according to table 1 given in the description, 2) from the 4th to the 6th day of rehabilitation, the patient spends 2 daily walking sessions with a total duration of each session for 30 minutes at a pace that provides an increase in the patient's load level in the range from 7-8 points at the beginning of walking to a maximum load of 11-12 points according to Borg scale, according to table 1, given in the description, 3) from the 7th to the 10th day of rehabilitation, the patient spends 2 daily walking sessions with a total duration of each session for 60 minutes at a pace that provides an increase in the patient's load level in the range from 7-8 points at the beginning of walking to a maximum of 11-12 points on the scale Borga, according to table 1 given in the description, 4) from the 11th to the 13th day of rehabilitation, the patient spends 2 daily walking sessions with a total duration of each session for 90 minutes at a pace that provides an increase in the patient's load level in the range from 7-8 points at the beginning of walking to a maximum of 11-12 points on the scale Borga, according to table 1 given in the description, in the process of practicing therapeutic dosed walking, the patient fixes attention on the sensations of a gradual increase in the load; and in the case of symptoms of intolerance by the patient to the load by walking, the next walking sessions are not carried out until the patient's previous condition is restored, and the next walking session begins from the level of the load of the stage at which its tolerance worsened; moreover, before the first lesson of the course of therapeutic dosed walking, an introductory session of psychotherapy is conducted, lasting 1 hour, during which they get to know the patient, his life history and illness, the patient's attitude to his condition, his plans and hopes for the future, explain to the patient the mode of walking and fell -therapy; before the first session of Felt therapy, the patient, in the process of doing therapeutic dosed walking, finds in his natural environment a plant - a tree or a shrub with which he is able to initially associate himself in both a healthy and a pathological state, and takes a photo of this initially selected plant with using a suitable technical means, further, at the first session of Felt-therapy, the patient creates with the help of felting wool an object that the patient associates with the plant initially chosen by him, shown in the photo taken in the process of walking, at a Felt therapy session, the psychotherapist interviews the patient on the manufactured object, asking the patient questions that determine the state of the plant and its surrounding environment, allowing the patient to be identified with this plant and, accordingly, with the object made on the basis of his image: based on what signs in the photo and sensations in the process of felting, the patient associated himself with this plant, the patient's attention is fixed on these signs - sensations and emotions as actual points of contact with the patient's personality, on their reflection in the characteristics of the object made by the patient - used colors, structure, size, volumetric or flat object , the degree of detailing of its features, noting, together with the patient, which real characteristics of the patient's personality reflect these characteristics of the object; in the second session of Felt therapy, the patient creates a second object associated with the plant of his choice, using his image and photo to display possible damage to the plant, with which the patient associates his disease and its symptoms - an experienced myocardial infarction, at the same time, with the psychotherapist they determine the type and causes of possible damage to the plant, their reflection on the second object made by the patient by felting, discuss the change in the patient's perception of the plant of his choice in the light of the damage, the psychotherapist, during the conversation, fixes the patient's attention on these changes and on possible mechanisms of providing him with assistance using the display of the image of the damaged plant on the second object made by the patient, noting which real symptoms, signs of the patient's illness reflect the corresponding characteristics of the object, reflecting its damage; before the third session of Felt therapy, in the process of walking, the patient finds another plant on the ground - a tree or shrub, with which he is able to associate his resource psychological and physical state - a “helper plant”, and takes a photo of it using a suitable technical means; at the third session of Felt-therapy, the patient, using felting from wool, creates a third object associated with his chosen "helper plant" at the same time, with the psychotherapist, the characteristics of the resource image fixed by the patient in the photo of the "helper plant" in the form of a third object and the connection of these characteristics of the resource image with specific therapeutic factors of the previously performed therapy in the patient are discussed; subject, and its injuries displayed on the second subject, under the influence of the previously received therapy and the possibility of increasing further physical activity for the patient, fix the patient's attention to, together with the psychotherapist, the specific characteristics of the resource image of the selected "helper plant" displayed in the third subject, and on their perception by the patient to improve the tolerance of increasing physical activity; at the fourth session of Felt-therapy, the patient creates by felting a fourth object - a "healing plant", reflecting the state of the initially selected plant by the patient, which has experienced damage, associated with an improvement in the patient's condition against the background of ongoing rehabilitation, fix the patient's attention on the characteristics of the fourth object - colors, structure , volume, shape, size, degree of detail - and their associative relationship with the real characteristics of the current state of health of the patient himself and with the characteristics of the resource image of the “helper plant”, with the psychotherapist, discuss and fix the patient's attention on the associative relationship of the patient's changing perception of the specific characteristics of the state of the initially selected plant under the influence of the characteristics of the resource image and, accordingly, the patient himself under the influence of specific methods of the ongoing rehabilitation; at the last session of Felt therapy, they discuss the dynamics of the patient's perception of himself in the image of the initially chosen plant, its state, attitude to his illness and recovery under the influence of the applied therapeutic and rehabilitation factors, fixing the patient's attention on positive changes in terms of load tolerance, noting the possibility of their continuation when using the characteristics of the resource image displayed in the third completed object - "helper plant", and the characteristics of the completed fourth object; Felt therapy sessions on the set days are carried out 2 times a week between sessions of therapeutic dosed walking. 2. The method according to claim 1, characterized in that the objects made by the patient by felting can be flat paintings, collages, volumetric souvenirs, jewelry, and garments. 3. The method according to claim 1, characterized in that the course of rehabilitation may additionally include physiotherapeutic and / or balneotherapy measures according to indications. 4. The method according to claim 1, characterized in that at the end of the course of sanatorium-resort rehabilitation, the patient independently continues to adhere to the daily therapeutic dosed walking regimen, taking into account the tolerance, gradually bringing it to 2 sessions per day for 120 minutes, ensuring an increase in the patient's load in range from 7-8 points at the beginning of walking to a maximum of 11-12 points on the Borg scale, according to table 1, given in the description, using four previously performed objects as psychotherapeutic support. 5. The method according to claim 1, characterized in that “smart watches” or programs for monitoring the heart rate in a smartphone are used as acceptable technical means of monitoring the increasing level of load during dosed walking.