RU2772542C1 - Method for complex medical and psychological rehabilitation of patients using biofeedback (bfb) in the late recovery period after acute ischemic stroke - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, rehabilitation, neurology, psychotherapy and physiotherapy and can be used in the rehabilitation of patients in the late recovery period after acute ischemic stroke (AIS). Daily sessions of rational-emotive-behavioral psychotherapy (REPT) for 40-60 minutes are carried out for 12 days. A session of progressive muscle relaxation is carried out for 15 minutes. Then, breathing training is conducted daily with the use of heart rate BFB based on diaphragmatic relaxation breathing (DRB) according to A.A. Smetankin, 12 sessions. Next, a session of psychophysiological electrical impulse action is carried out using a device: the multifunctional glasses “Mind Spa”. The training program “Progressive Relaxation Alpha Training”, Alpha 1, is used for 22 minutes, the course is 12 days. Moreover, in the case of “Mind Spa” sessions, glasses with blue LEDs are used in the first half of the day, and in the second, with white LEDs.

EFFECT: method provides relief of anxiodepressive symptoms, improvement of the psychological state of the patient, their socialization, psychological adaptation, general motor recovery, improvement of muscle tone, fine motor skills.

1 cl, 1 tbl, 1 ex

Description

The invention relates to medicine, rehabilitation, neurology, psychotherapy and physiotherapy, and can be used in the rehabilitation of patients in the late recovery period after acute ischemic stroke (AIS) in specialized hospitals or in sanatorium-and-spa treatment.

WHO estimates that 6.2 million people died of stroke in 2008. But, given that the number of risk factors for strokes - atherosclerosis, diabetes mellitus, arterial hypertension - is growing in the population, WHO predicts an increase in patients with this pathology: in 2030, about 23.6 million people, and these diseases will remain the main causes of death.

Motor and sensory disorders after a stroke are often accompanied by cognitive and emotional disorders, depressive and neurotic reactions, which makes it difficult for patients to form a positive attitude towards rehabilitation and social activity (Kuzyukova A.A., Odarushchenko O.I., Rachin A.P., 2019 ). Such patients after a stroke often experience subjective discomfort. In their "profile of emotions" anxious and depressive experiences are stable: anxiety, fears, guilt. In a depressive state, recovery is slower, the quality of life worsens, and the frequency of recurrent strokes, heart attacks, and cognitive impairment increases (Parhionov V.A., Hasanova D.R. Ischemic stroke. M .: MIA; 2012). Stroke patients develop psychogenic depression in 80% of cases, and mild and subsyndromal forms account for about 90% of all depressive states.

The psychological (psychotherapeutic) aspect of rehabilitation is aimed at correcting the normalization of the psycho-emotional status, treating somatogeny, forming a rational attitude to treatment, recommendations, and implementing rehabilitation measures, contributing to the mood to overcome the defect that has arisen as a result of acute cerebrovascular accident (ACC), optimistic treatment and life prospects, creation of conditions for the patient's adaptation to the life situation, which has changed due to his illness.

A complex method of rehabilitation after strokes is known, including, in addition to physical (massage, exercise therapy) and physiotherapeutic effects, psychotherapeutic effects, in particular, art therapy, aimed at reducing anxiety, depressive mood, increasing self-esteem, leveling thoughts about one's helplessness, etc. (Karina Borodulina, Marina Kuznetsova, Liga Kalvane. Psychological rehabilitation after a stroke. "Psiholoăijas Pasaule" 2004, No. 5, 8 pp. (52-56. Lpp) - Translation into Russian). However, the methods of art therapy are not acceptable for everyone, if there are no physical capabilities, or if the patient is negative towards them, these methods require a sufficiently long use for their effect to manifest.

Neurotherapy methods are also used in the form of physical effects on the body - acoustic, visual, tactile, temperature stimuli, which is possible both in direct stimulation mode and in biofeedback mode (BFB). Biocontrolled chronophysiotherapy ensures the normalization of the spectrum of blood microcirculation rhythms and the enhancement of plastic recovery processes (Komarov F.I., Zaguskin S.L., Rapoport S.I. Chronobiological direction in medicine: biocontrolled chronophysiotherapy // Therapist, archive, N8. - 1994 - C 3-6; Zueva M.V., Tsapenko I.V., Dnestrova G.I., Zaguskin S.L.).

It is known to irradiate the brain with red and near infrared light for the treatment of patients with stroke of various origins or traumatic brain injuries. The procedures help to accelerate nervous regeneration, improve blood circulation in the brain, helping to reduce the severity of the consequences of stroke, and restore working capacity. Phototherapy sessions help in the prevention of stroke, inflammatory and neurological diseases in the neck and collar and other anatomical areas of the body.

Light-emitting diodes or laser diodes are used as radiating elements, which are located close or close to the skin of the irradiated surface, or the terminal ends of light guides that supply the light flux from laser diodes. During transcranial irradiation, the light flux penetrates through the bones of the skull and affects the molecular targets of the cells of the cortex and subcortical zones at a depth of up to 2 cm from the surface of the cerebral cortex. However, according to available estimates, only 5% to 3% of the flux of red or infrared radiation incident on the surface of the head reaches the cerebral cortex.

There is a known method for restoring impaired brain functions (RU 2355440 C2, publ. 20.05.2009, Fedorov A.B.) using electrical stimulation from electrodes, one of which is installed on the eyelid, with a frequency of electric current pulses not exceeding the values of electrical lability visual system. Additional electrodes are installed in the projection of the affected brain system, and during electrical stimulation, the upper value of the frequency of the electric current corresponds to the value of the electrical lability of the visual system, the lower value is selected from the range of 3-20 Hz. When restoring impaired visual functions of the brain, the lower value of the pulse repetition rate is selected from the range of 7-14 Hz, when restoring auditory functions - from the range of 4-9 Hz, when restoring motor functions - from the range of 8-20 Hz, speech disorders - 4-18 Hz, memory and attention disorders - 3-14 Hz. Additionally, photostimulation with flashes of light with wavelengths selected from the range of 400-700 nm is possible, as well as the presentation of arbitrary-shaped figures in front of the patient's eyes that change the contrast in color. Stimulation of the visual system can lead to a concomitant improvement in the functioning of other brain systems and neurological status. However, not all patients are shown electrical stimulation, there are contraindications.

There is a known method of non-drug correction of psycho-emotional, neurohormonal and immune statuses of a person (RU 2314132 C1, 01/10/2008, Scientific and Production Medical Company "Antistress Center"). At the same time, rhythmic coherent light, sound and vibrotactile effects formed in functional frequency ranges of bioelectrical activity (BEA) of the human brain.Coherently related these effects are carried out on the basis of a harmonic oscillation grid formed from the base frequency by its multiplication.Light exposure is carried out at the base frequency.Sound and vibrotactile - at the base frequency and / or its harmonics. provides a complex effect on the body, however, is not intended for use in post-stroke patients.

A known method of rehabilitation in the late recovery period after a stroke using the Mind Spa system, characterizing the results of our previous studies (Kuzyukova A.A., Odarushchenko O.I., Rachin A.P. Affective disorders in the post-stroke period: clinical and psychological rehabilitation / / BC "Medical Review" No. 4 (11) dated 01.05.2019, p. 66-70, https://www.rmj.ru/articles/newologiya/Affektivnye_rasstroystva_v_postinsulytnom_periode_klinikopsihologicheskaya_reabilitaciya/#ixzz640UBws8E).

In the process of rehabilitation according to this known method, the following tasks are solved: 1) reducing psycho-emotional stress; 2) narrowing the zone of the disease and the formation of a positive attitude towards treatment. The narrowing of the disease zone is carried out with the devaluation of the patient's own efforts. He is oriented towards understanding the achievements already achieved in the restoration of functions, using psychotherapeutic persuasion, suggestion, demonstration of the results of training, so that the patient is convinced of the ability of his body to develop new conditioned reflexes and acquire new skills. In the classroom, the psychologist emphasizes the improvement in the patient's condition from session to session. They carry out psychotherapeutic work on the development of emotional response and the formation of emotional regulation with the patient and his relatives, using various psychotherapeutic approaches: autogenic training, rational and behavioral psychotherapy. At the end of the classes, a positive dynamics of the emotional state is noted, confirmed by repeated examinations.

To reduce psycho-emotional stress against the background of appropriate medical treatment (nootropics, vascular drugs, antidepressants according to indications), the Mind Spa system with built-in relaxation programs is used. The system includes a control device, glasses with built-in LEDs and headphones. The work of Mind Spa is based on various programs, both stimulating and relaxing (Instruction and user manual of Mind Spa, A/V Stim, LLC 2, 2013, 25 pp.), and is passive (no need for active efforts of the patient ). Patients usually take the procedure with their eyes closed, sitting or lying in a comfortable relaxed position, on average from 22 to 30 minutes (depending on the device program used). Mind Spa provides the conditions for self-healing and getting out of an excessively stressed state, thanks to the “following the frequency” effect (the brain tunes in to the frequency of light flickers). The most commonly used low-frequency alpha waves correspond to deep relaxation and light meditative states.

A person's eyelids are thin enough to allow flashing light from the device's LEDs to pass through. Then it penetrates in the form of electrical impulses into the brain. This pulsation of light, along with the sound, creates a soft layer due to the natural "frequency following effect". The flashing light is able to change the frequencies of the BEA. Light, especially in combination with the sound supplied to the headphones of the device (the patient can choose the melody he likes), has an even more effective effect on brain activity. However, unlike electrical stimulation, this effect is softer and more natural. For example, the flame of a fire flickers with a frequency corresponding to the alpha rhythm of the brain - the rhythm of peace and pleasure.

The brain produces 4 main types of electromagnetic waves, depending on this, the state of a person varies from a fully awakened active beta state, then to a calm but focused alpha state, then to a deeply meditative theta state, and finally to a deep inhibited sleepy delta - the state of the brain. With the help of Mind Spa, you can learn to easily enter a calm, focused state and maintain it for a long time, even when under psychological pressure, including being initially in an emotionally negative state. The sharpness of perception, clarity of thought and speed of reaction are preserved, as in the period of active wakefulness.

The alpha frequencies of the BEA of the brain are in the range of 8-13 Hz and reflect a relaxed state with simultaneous external and internal focuses of attention. At higher frequencies, this is a state of a clear head and a calm body. Low-frequency alpha waves correspond to deep relaxation and a light meditative state. Alpha training is used for self-healing, accelerated learning, and creative processes. If you need to get out of an overly stressed or, on the contrary, sleepy state, then passive Mind Spa training using alpha frequencies can provide this by eliminating internal stressful dialogue that leads to energy loss, which has a positive effect on well-being. The condition for getting into these states is regular alpha training.

Contraindications to the use of Mind Spa glasses:

- seizure activity, epilepsy, brain injury, mental disorders, increased photosensitivity, any degree of macular degeneration;

- the presence of pacemakers, cardioarrhythmias, other similar heart diseases;

- age up to 18 years;

- being under the influence of drugs or alcohol, any potent medications;

- the need to drive vehicles, control mechanisms.

Stop the electrical impulse during the procedure if dizziness, migraine, severe anxiety appear. Optional use of AudioStrobe mode, which synchronizes music and pulsing light in the glasses, creates a complex sensory effect. For this, CDs are usually supplied in the kit for playing through Mind Spa, which are decoded by the device and converted into digital signals for controlling the glasses. The signals are recorded at frequencies above the level of normal auditory perception, so the quality of the musical material is fully preserved. However, despite passive participation in the procedure, some post-AI patients with a tendency to irritable weakness experience subjective discomfort from the standard modes of Mind Spa sessions.

In Mind Spa glasses, in addition to the usual white LEDs, it is possible to use glasses with blue LEDs. The manufacturer recommends using blue LEDs if the procedure is carried out in the first half of the day, preferably immediately after waking up, this helps to normalize circadian rhythms in healthy people, and activates the body in case of a decrease in well-being. As for patients, especially after a stroke, it is necessary to develop modes of using certain LEDs when using Mind Spa, which was one of the tasks solved in the proposed method.

To relieve muscle tension caused by emotional disturbances, the progressive muscle relaxation (PMR) method is known, developed by the American scientist and physician E. Jacobson in the 1920s and based on a simple fact: after a strong tension, any muscle automatically deeply relaxes. Then, in order to achieve deep relaxation of all skeletal muscles, you need to simultaneously or sequentially strain all these muscles as strongly as possible, for example, for 5-10 seconds, and then concentrate on the feeling of relaxation that has arisen in the muscle for 15-20 seconds. In this case, it is important to first learn to recognize the feeling of tension and then distinguish the feeling of muscle relaxation from it.

According to Jacobson, a different type of emotional response corresponds to the tension of the corresponding muscle group. So, for example, a depressive state is accompanied by tension of the respiratory muscles, fear - by a spasm of the muscles of articulation and phonation. By removing the tension of a certain group of muscles through voluntary self-hypnosis (“differentiated relaxation”), one can selectively influence negative emotions.

By relaxation, E. Jacobson understood not only muscle relaxation, but also a state opposite to mental activity. He called his method "progressive" for the following reasons: with constant daily practice, the patient has a progressive tendency to develop a "habit of rest" - a psychological attitude characterized by less excitability and susceptibility to stress.

A self-study session is usually carried out independently 1-2 times a day, from 30 minutes (individual) to 60 minutes (group). The entire course of study usually takes 3 to 6 months.

PMR according to Jacobson is often used in family therapy to help relatives of patients with serious illnesses, including after strokes, to relieve anxiety and depressive manifestations (Medical Rehabilitation. Textbook. Edited by S.S. Aleksanin. St. Petersburg. 2014. 184 pp. p. 101).

Methods for the treatment of anxiety and depression using BFB are also currently known, for example, during EMG (RU 2717200 C1, Federal State Budgetary Institution "NMIC RK" of the Ministry of Health of Russia, 03/18/2020). EEG biofeedback is also widely used, for example, in epilepsy. In the EEG, there are sensorimotor rhythms (with a frequency of about 15 Hz), the intensification of which makes it possible to prevent epileptic seizures. It is possible to use EEG-BFB for self-regulation of brain activity in the treatment of post-stroke patients. In particular, in a number of US clinics, a 2-stage technique is used. The task of the first stage is the "frequency buildup" of the brain, aimed at making it more plastic, because as a result of the disease, the activity of the brain becomes rigid, rigid, unable to easily change the parameters of the wave activity of the brain in the right direction when interacting with the external environment. To supply BFB signals, a light-sound stimulator is used, with the help of which light and sound effects are carried out with a periodically changing frequency, which makes it possible to increase the plasticity of the brain in a given interval. At the second stage, active EEG-BFB is used, aimed at creating the desired form of the EEG pattern by the patient himself, providing correction of disorders (motor activity, speech, etc.). However, this method is quite complicated and requires the participation of a qualified EEG specialist.

At the same time, the main mechanism that connects the human body with the outside world, contributes to its adaptation, can be considered the process of breathing (A.A. Smetankin. General issues of biofeedback. St. Petersburg, 2008). The task of breathing is to provide oxygen to the body and remove carbon dioxide. The main systems involved in maintaining homeostasis are the respiratory and cardiovascular systems, and to maintain it, it is necessary to optimize the work of the respiratory (RS), cardiovascular system (CVS) and synchronize the work of the DS and CVS.

The activities of the CCC are autonomous, practically not subject to conscious control. However, heart rate with the help of BFB can be reduced by an average of 2-4 beats / min, and increased by 5-8 beats / min. Moreover, a decrease or increase in heart rate, as a rule, is not achieved directly, but indirectly. For example, an increase in heart rate is achieved through the reproduction of emotionally colored images, and a decrease in heart rate is associated with mediated neuromuscular relaxation.

Unlike the CCC, the activity of the DS is subject to voluntary control: at will, you can significantly slow down your breathing or, conversely, start breathing frequently. Therefore, the mechanisms of voluntary control of breathing are widely used in various methods of healing and treatment.

In Russia, the methods of K.P. Buteyko and A.N. Strelnikova, abroad - the technique of prof. Eric Pepper (Effortless Diaphragmatic Breathing). In the methods of Buteyko and Strelnikova, if this is possible, the CO2 content in the blood increases. The Buteyko method seems to be more appropriate, because It is aimed at training the exhalation phase and breath holding. It is the phase of exhalation that is most vulnerable and should be most well regulated consciously. The inhalation phase should occur unconditionally reflexively, although the training of fast, phase muscle fibers is also important, especially for people who professionally need it - singers, announcers, lecturers. The main drawback of the Buteyko methodology is the lack of coordinated work of the DS and CCC.

The most competently, from a physiological point of view, the method of prof. Pepper, which indicates the need to coordinate the work of the CP and the CCC. During diaphragmatic breathing, an increase in respiratory arrhythmia of the heart (RAS) is observed, and it begins to change in the phase of the respiratory cycle.

The BFB method of Smetankin A.A. is based on the same effect, which allows you to regulate homeostasis by controlling DAS - a change in heart rate in different phases of the respiratory cycle (DAS - the difference between heart rate on inhalation and exhalation, in bpm), forming a new, adaptive respiratory stereotype (Smetankin A.A. Correction of disorders of the cardiorespiratory system // Biofeedback, review of journal articles 1999-2012, http://service.biosvyaz.com/website/lit/JURNAL_BOS_(2012)_NEW.pdf, p. 14-22). The essence of this well-known method is to develop a new type of breathing: diaphragmatic-relaxation, using RSA changes as a BFB signal (RSA, respiratory sinus arhythmia).

The value of DAS is different in adults and children, depending on the state of the organism (table 1). Table "Health passport and biological age of a person" according to A.A. Smetankin shows the relationship between DAS indicators and a person's biological age in years, while the level of health is estimated in points from 0 to 100. Diagnostics helps to identify how much a person's biological age corresponds to the actual one. Using training with BFB, increasing DAS, it is possible to reduce the biological age, comparing it with the actual one (and possibly even make it less).

According to the severity of DAS, the activity of the parasympathetic nervous system and autonomic balance are judged. During inhalation, the autonomic balance shifts to the sympathetic side, the heart rate increases, during exhalation, parasympathetic influences increase, and the heart rate decreases. Thus, DAS makes it possible to speak about general regulatory relationships in the activity of DS and CVS, which ultimately determine the body's homeostasis. Arbitrary emphasis (attention of the patient) is given to exhalation. On exhalation, he should reach the minimum heart rate (the minimum possible for him), respectively, so the DAS increases as much as possible.

First, the essence of the method is explained to the patient, they are told about its safety, the need for relaxation during the session. Relaxation is helped by a calm emotional environment and a comfortable body position. The patient is instructed to breathe from the abdomen (diaphragmatic breathing). When inhaling, the stomach inflates, while exhaling it slowly retracts. The patient inhales arbitrarily, through the nose, exhales slowly, smoothly, calmly, preferably through slightly closed lips. To make it easier to master the skill, you can offer the patient to put one hand on the lower part of the chest, the other on the stomach. The duration of this stage can be from 1 to several days. The patient is recommended to continue training the skill of diaphragmatic breathing several times a day (T.S. Vartanova, A.A. Smetankin et al. General issues of the application of the BFB method. NOU "Institute of Biofeedback". St. Petersburg. 2008, 102 p. S. 30 -100 [Electronic resource]: https://logobos.ru/Content/litra/pes/General%20questions%20application%20of the%20BOS method.pdf).

Conscious motivation of the patient is necessary for the effective impact of biofeedback. If he takes a dependent position in relation to treatment, then there is no basis for the implementation of the entire biofeedback program.

In the proposed method, to ensure a high level of motivation, it is precisely necessary to have a preliminary impact with the help of REBT, PMR sessions, followed by consolidation by a rather passive acceptance - on the part of the patient - of the Mind Spa procedures, which, through the Alpha Training program, contribute to the activation of the alpha rhythm for entry into the creative process of further independent adaptation (or rather, its motivated continuation) to its new state after AIS.

Considering that against the background of psycho-emotional stress, there is a shift in the balance of the autonomic nervous system towards sympathicotonia, which manifests itself primarily in the violation of associative autonomic connections between the pacemakers of the heart and lungs, the choice of the most optimal method of treatment should be based on the activation effect on the parasympathetic nervous system, which predominantly provides cardiopulmonary interactions and allows you to optimize the balance between the sympathetic and parasympathetic divisions of the autonomic nervous system.

The conducted studies confirm the modulating effect during BFB sessions according to DAS, aimed at activating the parasympathetic nervous system and synchronizing the activity of the cardiovascular and respiratory systems. This technique has been successfully used in various cardiopulmonary pathologies, in particular, in bronchial asthma (Smetankin A.A. Correction of cardiorespiratory system disorders // Biofeedback, review of journal articles 1999-2012, http://service.biosvyaz.com/website /lit/JURNAL_BOS_(2012)_NEW.pdf, accessed 09/20/2019, pp. 14-22).

It is also known to use the BFB method of Smetankin A.A. in the psychophysiological prenatal preparation of pregnant women (Smetankin A.A., Tolkalov A.V., Durnov O.V., Biofeedback, review of articles ..., ibid. - pp. 115-120). The main objective of such training is to combat pain during childbirth by eliminating the feeling of fear of childbirth, mainly fear of pain (RU 2134542 “Method of preparing a pregnant woman for childbirth”, A.A. Smetankin, V.Yu. Ledina, 08/20/1999 , BI No. 23). When using BOS, the following effects are achieved, in particular:

- change in the stereotype in the work of the cardiorespiratory system towards the stabilization of homeostasis;

- improvement of oxygenation and microcirculation;

- increase in the threshold of stress perception.

The technique also provides training in the skills of controlling muscle activity, which allows reducing the degree of psycho-emotional tension and maintaining it at an adaptive level.

Also known is the Smetankin method of training diaphragmatic breathing (RU 2224455, February 27, 2004), which includes training sessions using biofeedback according to heart rate to achieve maximum DAS. Moreover, each session includes periods of training and rest lasting 1-10 minutes each. During the rest period, the patient breathes diaphragmatically without BFB signals, and the ratio of the training and rest periods is set to 1:1-2:1 during the first 1-3 training sessions. Over the next 3-7 sessions, this ratio is increased to 3:1-10:1. In the last 5-10 sessions, it is reduced to 1:5-1:10. In this case, a total of 10-20 sessions are carried out for 10-25 minutes each. The method increases the stability of diaphragmatic breathing produced during training - this skill is consolidated.

Sessions are held in an office equipped with a computer complex, with appropriate software, and biofeedback devices (“Cardiac signaling device KS-03” and “Corrector of the psycho-emotional state”). Training is carried out in a separate room, in a pleasant emotional atmosphere and strictly individually.

There are no absolute contraindications. Relative ones are associated with the impossibility of the patient's active participation in the treatment process (gross violations of the intellect and psyche, somatic diseases that do not allow physically fulfilling the task).

When coordinating the functions of the DS and the CVS, a significant stabilizing effect on the activity of the organism as a whole is noted. Using the skill of the diaphragmatic-relaxation type of breathing allows you to form a new functional state, characterized by a change in homeostasis towards balancing the processes of inhibition and excitation. There is a decrease in respiratory rate and heart rate, this is an economical type of breathing that allows you to reduce the excessive load on the cardiovascular system, which is very useful for recovery after a vascular accident.

The closest analogue (prototype) of the proposed method is the previously patented by us method of complex medical and psychological rehabilitation of patients in the late recovery period after stroke (RU 2724284 C1, publ. 06/22/2020, FGBU NMIC RK MOH of Russia). In terms of more than 6 months after AIS, a complex of appropriate medical and physical effects in the form of massage and exercise therapy is carried out, as well as psychological rehabilitation through psychophysiological and psychotherapeutic effects. For this purpose, the method of assessing the individual emotional well-being of the patient according to Odarushchenko O.I. is preliminarily used. "Test for emotional well-being 1.0", which includes 9 subtests that determine 9 psychological parameters: 1) internality in the field of family relations, 2) contact, 3) subjective well-being, 4) creativity, 5) self-acceptance, 6) flexibility of behavior, 7) index of morality, 8) maturity of the individual, 9) self-respect. Their values are used in the ranking and calculation of the generalized criterion (GC) of mental health, reflecting the level of emotional well-being, according to the original formula. If the OK value is equal to or more than 11.2 arb. unit, which reflects the emotional well-being of the patient, then a course of daily sessions of electrical impulse exposure is carried out using multifunctional Mind Spa glasses, using the Alpha 1 Progressive Relaxation Training program of the Mind Spa device for 10 days. In the first three days, the exposure time during one session is set to 10 minutes, in the next - 22 minutes each, and as a psychotherapeutic effect, rational-emotive-behavioral psychotherapy (REBT) is used for a session of 60 minutes, which is carried out after exposure to Mind Spa twice a day. week.

If the value of OK is less than 11.2 arb. units (reflects the emotional distress of the patient), then a 12-day course of daily Mind Spa sessions is carried out, initially using the Theta I Progressive Deep Theta Training program, setting its duration to 10 minutes. Then - a psychotherapeutic effect in the form of a REBT session lasting 60 minutes 2 times a week, after which they again work with the Mind Spa apparatus for 10 minutes, but already with the program "Progressive Relaxation Alpha Training" Alpha II, and on days free from REBT, alpha- training is carried out immediately after the theta training. Not less than 3 hours after this, repeated exposures are carried out sequentially - first 10 minutes according to the Theta I program, then 10 minutes according to the Alpha II program. After a 12-day course, the determination of the patient's OK is repeated, and if its value is higher than or equal to 11.2 srvc. units consider the effects effective and stop. While maintaining OK less than 11.2, the indicated psychophysiological and psychotherapeutic effect is repeated for an emotionally disadvantaged patient in a course of 12 days. This provides an individual, differentiated approach to the rehabilitation of patients in the late recovery period after AIS, taking into account the characteristics of an objectively established emotional status, which increases the rehabilitation effect, improves the quality of life of patients and their loved ones, and accelerates socialization by restoring the emotional state of patients.

However, in subsequent studies, we found that such extended courses (with repetition of exposures during the same course) are quite burdensome for patients, they are not suitable for patients with a tendency to neurotic reactions, easily irritable, since after Mind Spa sessions such patients experience subjective unpleasant sensations. In addition, patients are forced to come to such sessions additionally, since such an extended course (12 days and again - 12 days) is not provided for by the capabilities of the existing hospital. Conducting REBT sessions after training according to the Mind Spa programs, according to the prototype, does not always give a pronounced positive effect, since a patient with anxiety and depressive disorders, when receiving an electrical impulse at first, is rationally-emotionally not ready to realize the benefits of this physical impact, the motivation of such a patient is noticeably reduced.

In this regard, we have developed a four-component mode of exposure in the following sequence: REBT session, PMR session, BFB session based on diaphragmatic relaxation breathing according to A.A. Smetankin, Alpha-1 Mind Spa training. Such a sequence allows at first motivated, consciously (with the help of REBT) to prepare the patient for subsequent sessions of various influences, to provide conscious physical relaxation (with the help of PMR), to “combine” conscious mental relaxation with physical relaxation (using biofeedback according to heart rate according to A.A. Smetankin ), accepting the effect of therapeutic effects, as if “realizing” it with the body, which also contributes to a better consolidation of the rehabilitation effect. Thus, the patient is prepared for the neurophysiological effects of Mind Spa procedures, without experiencing internal resistance to them, and already at this deep level receives a rehabilitation effect that helps smooth out the appearance of fatigue from Mind Spa sessions.

At the same time, in the prototype method, a different task was solved, in comparison with the proposed method: increasing differentiation, individualization of the rehabilitation of such patients, while in the proposed method, the task is, on the contrary, universality for various patients of this group (late recovery period after AIS), while maintaining the same effectiveness of the rehabilitation course.

The technical result of the proposed method is: when the proposed complex is included in the general (basic) complex of physical rehabilitation, in addition to stopping anxiety and depressive symptoms, not only the patient's psychological state improves, his socialization, psychological adaptation, but also overall motor recovery, muscle tone improvement , fine motor skills, quality of life in general (no signs of chronic fatigue, increased physical and mental performance), by increasing the motivation, awareness of patients, the rehabilitation effect is maintained for a long time (at least 6 months).

To achieve this technical result, a method is proposed for complex medical and psychological rehabilitation of patients in the late recovery period after AIS, including psychotherapeutic and physiotherapeutic effects.

At the same time, as a psychotherapeutic effect, daily sessions of rational-emotive-behavioral psychotherapy (REBT) are carried out, aimed at eliminating, by means of persuasion, the patient's irrational attitudes towards himself and his condition in the process of Socratic dialogue, for 40-60 minutes within 12 days.

After each REBT session, a session of progressive muscle relaxation is performed for 15 minutes, and then - daily breathing training using biofeedback according to heart rate based on diaphragmatic relaxation breathing according to A.A. Smetankin, aimed at achieving the maximum possible respiratory arrhythmia (RAS) for the patient - 12 sessions, while the session includes sequentially:

1 minute of voluntary breathing habitual for the patient with simultaneous recording of background indicators of heart rate and respiratory rate,

further - the main stage with diaphragmatic relaxation breathing according to A.A. Smetankin, the duration of which in the 1st-3rd sessions is 3 minutes, in the 4th-7th sessions it is 4 minutes each, in the 8th-9th sessions it is 5 minutes each,

then 1 minute - a break during which the patient breathes again in his usual way,

further, the second main stage is carried out with diaphragmatic relaxation breathing, the duration of which at the 1st-3rd sessions is 3 minutes each, at the 4th-7th sessions it is 4 minutes each, at the 8th-9th sessions it is 5 minutes each.

At the 10th-12th sessions, the patient breathes independently with diaphragmatic relaxation breathing during the entire session without the use of BFB, lasting up to 15 minutes, taking into account its individual tolerance.

After the biofeedback session, as a physiotherapeutic effect, a session of psychophysiological electropulse exposure is carried out using the device - multifunctional glasses "Mind Spa", using the training program "Progressive Relaxation Alpha Training" - Alpha 1 for 22 minutes, the course is 12 days. Moreover, in the case of Mind Spa sessions, glasses with blue LEDs are used in the first half of the day, and with white LEDs in the second.

The main goal of REBT in the proposed method is to identify and correct irrational ("magic") beliefs (Elena Romek. Logic of emotions // School psychologist, No. 24, 2006, pp. 24-26). REBT helps to make them meaningful, relevant to reality, the life goals of a person, the interests of his personality. A change in core beliefs entails a change in emotions and behavior. The task of REBT is to show the client that his painful feelings - fear, depression, guilt, etc., are not due to misfortunes that have already happened or may, in his opinion, happen, but by how he perceives them. When people get upset, upset, experiencing negative emotions, then in some cases they adhere to rational beliefs, and in others - irrational ones. Rational beliefs correspond to reality, are logical, non-dogmatic, condition functional emotions and constructive behavior. Irrational beliefs, on the contrary, do not correspond to reality, are illogical, dogmatic, lead to dysfunctional emotions and non-constructive behavior.

It helps to discard irrational beliefs and get rid of dysfunctional feelings by the method of Socratic dialogue in the structure of REBT (debate), when by asking "naive" questions, you can force the patient to admit the falsity of his testimony. Successful disputation leads to the fact that a person learns to independently identify and challenge his irrational beliefs, and he develops a flexible "adult" worldview that allows him to avoid the resumption of neurotic manifestations. Most irrational beliefs are instilled in childhood by parents and caregivers. This explains their stability: they managed to “take root”, become a part of a person’s personality even before he learned to think critically, check certain ideas for truth and got acquainted with more rational forms of thinking.

Another source of "magical" beliefs are the stereotypes of public consciousness, scooped daily from the media, everyday communication, etc. Thus, uncritically learned irrational beliefs are constantly reinforced. To change them, it is necessary: a) to draw attention to them or bring them to a conscious level; b) show that it is they who make us feel unhappy; c) to reveal, with the help of disputing, the illogicality, the falsity of irrational beliefs, their inconsistency with the patient's life goals; d) learn to think differently and articulate their desires, preferences and expectations differently; e) consolidate new rational beliefs and learn to adhere to them in everyday life.

The above constitutes the therapeutic REBT strategy used in our method, using the technology of Socratic dialogue, disputation (see, for example, M.V. Burdin, E.S. Ignatova. Psychological counseling and psychotherapy: Technology of Socratic dialogue. Perm. 2019. 88 With.).

Then a PMR session is performed, which includes the sequential execution of the maximum tension of those muscle groups that are indicated below in the paragraphs, holding this tension for as long as possible for the patient in this state (usually it is only a few seconds), after which the muscles, as it were, reflexively relax . The patient's attention should be paid so that he feels and realizes how sensations change from conscious muscle tension with their subsequent relaxation. If it is impossible to physically perform a particular movement due to paralysis or paresis, the patient performs it ideomotorically, “in the imagination”. Ideomotor training (IT) is a repeated, conscious, active representation and feeling of a mastered skill (Belkin, A.A. Ideomotor training in sports / A.A. Belkin. - M .: FiS, 1983). Active representation of actually performed motor skills contributes to their mastery, their strengthening, correction.

The ideomotor method can significantly increase muscle endurance, physical performance, increase the speed of mastering the technique of movements and its preservation. IT is effectively used in sports both in terms of physical training and in the psychoregulation of emotional states (Zabelsky S.Yu. System of bioeconomical psychomotor health improvement. Innovations in the training of specialists in physical culture and sports: Stavropol: Service school, 2005, 24 p. Alexandrov Yu. I. "Learning and memory: a systemic perspective", Shvyrkov Laboratory of Neurophysiological Foundations of the Psyche, Institute of Psychology of the Russian Academy of Sciences, Moscow).

The sequence of performing PMR movements in our method can be as follows (if a physical action is impossible, it is performed ideomotorically, in particular, using a “mirror” image of the movements of a healthy limb, i.e. causing the same sensations of movement of the affected limb that are experienced by the patient when moving healthy):

1. Dominant hand and forearm (they clench their fist as strongly as possible and bend the hand in any direction). In this case, the dominant is understood as the right hand for right-handed people and the left hand or foot for left-handed people.

2. Dominant shoulder (bend the arm at the elbow and press it firmly against the body).

3. By analogy, movements are performed for the non-dominant hand and forearm.

4. Similarly - for the non-dominant shoulder.

5. Muscles of the upper third of the face (raise the eyebrows as high as possible and open the mouth wide).

6. Muscles of the middle third of the face (close your eyes tightly, frown, wrinkle your nose).

7. Muscles of the lower third of the face (strongly squeeze the jaws and take the corners of the mouth backwards, towards the ears).

8. Muscles of the neck (pull the shoulder joints high to the ears and in this position tilt the chin to the chest).

9. Muscles of the back and abdomen (tighten the abdominal muscles, reduce the shoulder blades, arch the back).

10. Dominant lower leg (pull the foot towards you as much as possible and straighten all the toes of the foot).

11. Dominant foot (extend the ankle joint and squeeze, bend the toes).

12. Non-dominant lower leg (movements are performed similarly to the dominant one).

13. Non-dominant foot (movements are performed similarly to the dominant one).

Usually, the implementation of this set of PMR exercises does not take more than 15 minutes.

At the end of the PMR session, they proceed to the training session of the diaphragmatic relaxation type of breathing (DRD) according to A.A. Smetankin using a hardware-software complex that converts the body's electrophysiological signals into audio and visual feedback signals KAPfs-BOS-"Biosvyaz" (converter of bioelectrical, biomechanical signals of the human body). The technique for developing a diaphragmatic-relaxation type of breathing using the biofeedback method and the equipment for its implementation are patented (see, for example, patents of the Russian Federation: No. 1999).

Usually mastering the skill comes to 5-6 lessons, then it is fixed. By the end of the course, the patient masters a new breathing skill, while achieving:

- increase and / or stabilization of the DAS value (stabilization indicates the achievement of the maximum DAS value for this patient);

- decrease in respiratory rate to 5-7 per minute;

- an increase in peripheral temperature (which indicates the ability to relax, manage one's psycho-emotional state, and improve peripheral blood circulation).

Sessions are held in a separate room equipped with a computer complex, with appropriate software, and biofeedback devices (KC-03 Cardio Signaling Device and Psychoemotional State Corrector), in a pleasant emotional atmosphere and strictly individually.

During the session, the patient is located in a comfortable chair, two sensors are attached to the body under the chest with an elastic band, recording the current heart rate. The data enters the computer complex, where, by means of mathematical processing, they are converted into instantaneous BFB signals. The BFB signal can be an object moving on the monitor screen (or a sound signal), which reflects changes in heart rate during inhalation and exhalation. At the same time, all recorded parameters are displayed on the screen in numerical terms (current heart rate, average heart rate, DAS value, current session time, number of breaths per minute, of which correctly performed, duration of the respiratory cycle). The current heart rate monitor is displayed at the bottom of the screen. At the same time, the rhythm and depth of breathing should be individually comfortable (you need to breathe comfortably, without tension). Inhalation is done through the nose, freely and effortlessly. During inhalation, the abdomen inflates, and the chest should remain motionless and not participate in breathing.

The exhalation is slow and smooth through slightly closed lips, with the greatest possible relaxation. On exhalation, the stomach is drawn in. The patient can control the respiratory movements with the help of hands, placing them on the chest and abdomen. On inspiration, the hand lying on the stomach (in the midline below the navel) should feel the movement of the abdominal wall, and the hand on the chest should remain at rest. On exhalation, the same thing happens - the hand on the stomach controls the movement of the abdominal wall, and the hand on the chest is at rest. The patient should make a strong-willed emphasis on the exhalation. The patient needs to be explained that on inhalation, the heart rate unconditionally increases reflexively, and on exhalation it decreases. It is necessary to strive for the maximum decrease in heart rate on exhalation due to maximum relaxation. The more easily, effortlessly this exercise is performed, the better the final result of training. During the session, the patient has a monitor screen in front of him, on which he sees a plot with a moving object, for example, a brush painting over a fence (one of the plots of this program). On inhalation, the brush should move up, and on exhalation, more slowly, down. The patient needs to find such a mode of breathing in which the moving brush performs the task (opens the picture or paints over the strip). So the patient sees how his heart works, and on the basis of instructions he learns to coordinate his work with breathing. During the session, the work mode is replaced by rest, during which the patient can listen to pleasant music or watch videos of his choice. Based on the physiological capabilities of each patient, you can change the complexity and duration of tasks in the program. At the end of the lesson, they give homework to breathe diaphragmatically for several minutes daily.

During operation, the device captures the heart rate, individual for the patient. For example, the pulse is 60 beats / min. The upper and lower limits of heart rate changes are set at 5 bpm (for less motivated, anxious patients, the limits can be set even lower, for example, in increments of 1 bpm). Then the patient can control changes in heart rate in the range from 55 to 65 bpm using visual and auditory biofeedback. For example, if the heart rate is 65 bpm, the top LED of the 12-level scale lights up, and if the heart rate drops to 55 bpm, the light spot will go down one bulb. Smooth movement of the light spot on the scale will correspond to a smooth change in heart rate from 55 to 65 beats/min (i.e. DAS will be 10 beats/min).

Then the patient begins to breathe diaphragmatically, synchronizing breathing with fluctuations in heart rate (inhalation - heart rate increases, exhalation - heart rate decreases). At this time, the specialist adjusts the heart rate thresholds, setting them at values corresponding to the achieved individual DAS. Moreover, the patient is instructed to make an arbitrary emphasis only on exhalation, reaching the minimum heart rate for him, and inhalation occurs unconditionally reflexively. Be sure to warn that the more comfortable, relaxed the patient performs the exercises, the better they get. It is very important at this stage to ensure that the patient achieves synchronization of individual phases of breathing with changes in heart rate. This gives motivation for further studies. Therefore, it is necessary to set those thresholds (the lower one is especially important), which the patient will definitely cope with at this stage of his individual training. The patient should be praised. At the same time, it is imperative to ensure that he breathes with his stomach, does not strain, is not distracted, etc.

We use the following sequence of the BFB session:

1 minute of voluntary breathing habitual for the patient with simultaneous recording of background indicators of heart rate and respiratory rate,

further - the main stage with diaphragmatic relaxation breathing (DRD) according to A.A. Smetankin, the duration of which in the 1st-3rd sessions is 3 minutes, in the 4th-7th sessions it is 4 minutes each, in the 8th-9th sessions it is 5 minutes each,

then 1 minute - a break during which the patient breathes again in his usual way. During this rest period, the computer in a hidden mode continues to record the current heart rate values, which makes it possible to obtain a comparison of changes in heart rate, respiratory rate and DAS in periods when BF is present and when it is not used. Comparing the results of the work period and the break, one can assess how effectively the correct type of breathing is mastered. Presenting these results to a patient can be used to demonstrate their progress in mastering the DDD skill.

Then the second main stage is carried out with diaphragmatic relaxation breathing, the duration of which at the 1st-3rd sessions is 3 minutes, at the 4th-7th sessions it is 4 minutes each, at the 8-9th sessions it is 5 minutes each, t .e. similar to the first stage of the corresponding session.

Accordingly, using the device program, the upper and lower limits of heart rate changes are increased by 1-5 beats/min when the patient reaches the previous change in DAS. For example, if the patient managed to achieve DAS of 10 beats/min at the previous stage with diaphragmatic breathing (after the upper and lower limits for DAS of 65 and 55 beats/min were set at a background heart rate of 60 beats/min: 65-55 =10), the difference is increased, for example, by another 10 beats/min, i.e. limits will already be 50 and 70 beats / min (+5-5), respectively, and when this DAS = 70-50 = 20 beats / min is reached, the difference is again increased: for example, the upper and lower limits of heart rate, respectively, are set to program as 75 and 45 beats / min. With an increase in the DAS indicator, an indicator of the success in mastering the DRD technique, achieving a respiratory rate of 5-8 breaths per minute, all subsequent exercises, in fact, reinforce this skill to the maximum possible values for a given patient at the moment. In reality, a patient after AIS, mastering the skill of DID, can increase DAS by 2-3 beats / min per session, so the upper and lower limits of heart rate are usually set in increments of 1-2 units (bpm) so that the patient can see his real progress during each BFB session.

At the 10th-12th sessions, the patient is already able to breathe DRD on his own during the entire session without the use of biofeedback. However, the duration of these last sessions, taking into account individual tolerance, the condition of a particular patient, should not exceed 15 minutes.

Usually, patients begin to develop the skill of DRD by the 5-6th session, after which it becomes possible to further consolidate the skill of DRD (diaphragmatic-relaxation breathing) and the ability to exercise self-control and self-regulation by the patient of their heart rate.

After completing a course of 12 biofeedback sessions, the patient already knows how to independently use this technique and, in the event of the return of disturbing thoughts, is able to regulate his heart rate during emotional stress, mood depression in his normal, everyday life, outside the hospital.

During periods of work, the program uses, for example, such subjects as "Column". On the screen there is a colored column of variable height (visual biofeedback signal), the height of which changes depending on the changes in the pulse. When the pulse value reaches the upper threshold, the height of the bar is equal to the height of the window (the bar fills the entire window); when the pulse value decreases, the colored column decreases accordingly, and when the lower threshold is reached, the height of the column is zero (the window is empty).

Simultaneously with the movement of the column, a tone signal sounds - an audio BOS. The pitch changes according to the changing value of the heart rate from low to high with an increase in heart rate and from high to low with a decrease in heart rate. There are three options for this plot: the column is located on the background of one thematic slide or on a neutral background; background slides replace each other according to the principle of sequential pictures (animation), the background gradually turns into a collage of small images. The change of background, in any case, is associated with a correctly performed exhalation.

It is important to ensure that the patient does not increase the depth and duration of inspiration to reach the upper heart rate threshold. Inhalation should be calm, short. On exhalation, you must completely relax and reach the lowest possible heart rate. Therefore, the lower threshold becomes progressively more difficult to reach. This forces (motivates) the patient to strive for maximum relaxation on exhalation.

At the same time, it must be remembered that the exhalation is done smoothly and without effort, while the inhalation occurs unconditionally reflexively. The calmer, more comfortable a person feels, the better it is to perform the exercise.

At the end of the sessions, patients are given recommendations for additional self-study 2-3 times a day for 10-15 minutes in the following form.

Take a comfortable, comfortable position (lying, sitting). In the sitting position - the shoulders are relaxed and lowered, the hands are on the knees. Take a shallow slow breath through your nose with your mouth closed and try to inflate your stomach at the same time. Then make a smooth, slow exhalation through the mouth, lips should be half-closed (folded in a tube). Air leaves the lungs freely. He is only slightly resisted by half-closed lips. When exhaling, the abdomen returns to its original position. Make sure that the muscles of the chest and shoulder girdle do not participate in breathing. For control, one hand can be placed on the chest and the other on the stomach. Only the hand on the stomach should move. The chest is at rest. Try to make the exhalation at least twice as long as the inhalation. For example, inhale for “one-two”, and exhale for “one-two-three-four”. You can not exhale through force, you must try to completely relax, there should not be any unpleasant sensations.

When performed correctly, the respiratory rate should be 5-8 breaths per 1 minute. Gradually, diaphragmatic breathing will become a normal, habitual type of breathing, subject to constant training.

Attention should be focused on remembering one's own sensations that arise during the correct execution of diaphragmatic inhalation-exhalation. This is necessary so that the trainee can easily reproduce in the future a similar state at moments of deterioration in well-being without the help of biofeedback signals, arbitrarily reducing his heart rate, relaxing.

During the formation of a new breathing pattern, it should be remembered that the main thing in this case is exhalation. Starting from the 4th session, patients are asked to try to perform DRD playback during periods of rest (breaks), i.e. already like a habitual type of breathing.

If, with correct breathing, the plot is still not fully executed (for example, the column does not go down to the end, the brush on the fence does not paint over to the very bottom, etc.), it is necessary to correct the upper and lower limits of heart rate, for example, return to the limits of the previous stage .

Achieving harmony between the work of breathing and the work of the heart will allow reaching the maximum DAS value for each organism. This will mean that each person, at his own request, can turn on (activate) internal health reserves, protect himself from the negative effects of stress, and recover faster from diseases. The body will begin to function in the most optimal mode for itself, without forcing organs and systems to work for a long time in the mode of extreme loads. The main goal is to achieve complete synchronization of the phases of the respiratory cycle with changes in heart rate within the limits of individual capabilities.

By the end of the BFB training course, when mastering a new breathing skill, the following results can be achieved:

- increase and / or stabilization of DAS with a decrease in the average heart rate (and heart rate on exhalation);

- Decreased respiratory rate.

With the daily reproduction of the acquired skill of DRD, the following are noted:

- improvement of skeletal muscle relaxation skills and stress response management;

- improvement of the psycho-emotional state (increase in self-confidence, concentration, organization, efficiency; reduction of reactive and personal anxiety, improvement of sleep and normalization of its structure).

This skill can be reproduced in any situation, relying only on one's own inner feelings and confidence in the correctness of breathing with the stomach, already without the participation of the biofeedback device.

After the biofeedback session in the proposed method, a session of electropulse exposure is carried out as a physiotherapeutic effect using the device - multifunctional glasses "Mind Spa", using the training program "Progressive Relaxation Alpha Training" - Alpha 1 for 22 minutes, the course is 12 days. Moreover, in the case of Mind Spa sessions, glasses with blue LEDs are used in the first half of the day, and with white LEDs, which are supplied with the system, in the second half of the day.

An example of the implementation of the method.

To evaluate the effectiveness of our proposed method, we conducted a study of two groups of patients who received complex rehabilitation, respectively, according to the prototype method (control) and the proposed method (main group). A total of 33 patients in the late recovery period of AIS who signed an informed consent to participate in the study participated in the study. The control group - 18 people (9 men and 9 women), the main group - 15 people (8 men and 7 women), age - from 45 to 75 years.

The criteria for inclusion of patients in the study were:

1. Patients aged 45 to 75 years in the late recovery period after stroke (AIS), who are at the rehabilitation stage.

2. Pronounced indicators of the degree of chronic fatigue, a high level of psycho-emotional tension, a high level of anxiety, pronounced indicators of anxious and depressive emotions.

3. The severity of depression and anxiety.

Patient Exclusion Criteria:

1. Refusal to sign informed consent to participate in the study.

2. Neuroimaging signs of a brain tumor, arteriovenous malformation, brain abscess, vascular aneurysm.

3. Lying patients with severe neurological, motor disorders.

4. Extremely low rehabilitation potential of the patient.

5. Concomitant fractures of the vertebrae on the background of a stroke.

6. Neurodegenerative diseases, diseases of the muscular system, musculoskeletal system, severe bone deformities that can affect the basic motor abilities of patients.

7. All diseases, including infectious ones, in the acute stage, chronic diseases in the acute stage.

8. Cachexia of any origin.

9. Benign neoplasms that require clarification of the diagnosis and dynamic observation.

10. Malignant neoplasms requiring radical treatment.

11. All diseases and conditions requiring inpatient treatment, including surgery.

12. All diseases in which patients are not capable of independent movement and self-care and need constant special care.

13. Frequent or profuse bleeding.

14. Mental illness with symptoms of acute mental disorder, schizophrenia, schizotypal and delusional disorders, Alzheimer's disease, dementia, severe behavioral and social adaptation disorders. All forms of drug addiction and chronic alcoholism.

15. Convulsive seizures and their equivalents, mental retardation, pathological personality development with severe behavioral disorders and social adaptation.

16. Pediculosis, scabies and other parasitic diseases.

17. The presence of general contraindications for physical therapy.

18. Pregnant women, military personnel and minor patients.

20. Patients with pacemakers, cardiac arrhythmias, or other similar heart conditions.

When implementing the method, the following diagnostic methods were used:

1. Hamilton Rating Scale for Depression (HDRS).

2. Computer program, including:

- the technique "Scale of States" (Russian-language adaptation by A.B. Leonova, 1984),

- Methodology "Scale of differential emotions" (Russian-language adaptation of A.B. Leonova and M.S. Kapitsa, 2003),

- the technique "The degree of chronic fatigue" A.B. Leonov and I.V. Shishkin; modification - 2003,

- Spielberger-Khanin scale (STAI, State Trait Anxiety Invertory).

3. Questionnaire-scale for assessing the quality of life in stroke (SS-QOL).

4. Data from neurological examinations and objective research methods (including EMG, vascular ultrasound, MRI or CT of the brain).

5. Tests for assessing the state of muscles and motor function (Ashworth scale, Rivermead mobility index, stroke scale, motor deficit assessment scale).

The criteria for the effectiveness of the method were a decrease in the degree of chronic fatigue and the severity of anxiety-depressive emotions, a decrease in the level of reactive and personal anxiety according to the Spielberger-Khanin test, a decrease in the level of depression, an improvement in motor tests (Ashworth scale for assessing muscle tone, the National Institutes of Health Stroke Scale (NIHSS). ), motor deficit assessment scale (MDC), Rivermead mobility index), improvement of the patient's quality of life parameters (SS-QOL questionnaire), reduction in the incidence of adverse events.

The duration of inpatient rehabilitation was 14 days. The control outpatient appointment was carried out 6 months after the patient was discharged.

All patients (main and control groups) received appropriate medication (nootropics, vascular, antihypertensive drugs), basic physiotherapy procedures (according to accepted, current clinical guidelines for rehabilitation after AIS (see, for example: Clinical guidelines: Ischemic stroke and transient ischemic attack in adults Developers: All-Russian Society of Neurologists, National Stroke Association, Association of Neurosurgeons of Russia, Association of Neuroanesthesiologists and Neuroresuscitators, Union of Rehabilitologists of Russia, 2020, 208 pp., https://npcpn.ru/doc/2020/rf -kr-insult.pdf ), exercise therapy and massage, taking into account the movement disorders present in patients of the main and control groups.

Additionally, in the control group, patients were exposed according to the prototype method by conducting REBT sessions (Socratic dialogue, disputation) after procedures carried out using a system of psychophysiological - electrical impulse effects with built-in Mind Spa relaxation programs (control device, glasses with built-in LEDs and headphones ) in the mode according to the prototype method (using two modes of operation of the system depending on the individual state of emotional well-being/discomfort, varying the duration of exposure).

For patients of the main group, instead of exposures according to the prototype method, exposures were performed in a different mode: first, a REBT session, then a PMR session according to Jacobson for 15 minutes, then a DRD session according to A.A. Smetankin to achieve the maximum DAS for the patient, and then - a procedure using Mind Spa according to the program "Progressive Relaxation Alpha Training" Alpha I (22 minutes). Moreover, if the Mind Spa procedure was performed by patients in the first half of the day, the session was performed using glasses with blue LEDs, and if the procedure of electrical impulse exposure fell on the second half of the day, then with white LEDs. For the same patient, on different days of the rehabilitation course, either blue or white LEDs could be used, depending on what time of the day the procedure itself fell on. Patients took the Mind Spa treatment with their eyes closed, sitting or lying down in a comfortable position, for 22 minutes per program. Only one program was used: "Progressive Relaxation Alpha Training" - Alpha I.

When conducting a REBT session for 40-60 minutes (in the same patient from session to session, it could last from 40 to 60 minutes, depending on the goals of the session being achieved or individual tolerance at the moment, the patient's condition), gradually during the course patients were oriented towards the awareness of the achievements already achieved in the restoration of functions, the development of emotional response and the formation of emotional regulation; new skills from lesson to lesson. Persuasion was carried out through a Socratic dialogue with the patient. The development of conditioned reflexes and the acquisition of new skills, in addition to physical methods of influence (exercise therapy, massage, physiotherapy), was facilitated by the procedure for conducting complex procedures: first, REBT, then procedures for physical and psychophysical relaxation and adjustment of functions (VMR and diaphragmatic relaxation breathing according to the biofeedback program) with by conducting a Mind Spa session as a final procedure.

The criteria for evaluating the effectiveness were:

- the frequency of positive dynamics in the emotional state,

- lack of chronic fatigue,

- decrease in the severity of indicators of psycho-emotional stress and anxiety,

- improving the quality of life indicators,

- Improving the performance of the motor sphere.

In statistical processing, variables were used that were expressed as a median with indication of interquartile intervals and compared using the nonparametric Mann-Whitney test with a distribution that deviated from normal (a check was made for normal distribution using the Shapiro-Wilk test). Categorical variables were expressed as percentages and absolute values. The weighted averages provided the mean values of the parameters as a percentage. Two-tailed p<0.05 denoted a statistically significant difference (CI 0.95). The analysis was performed using the STATISTICA 6.0 software package (StatSoft Inc., Tulsa, OK, USA).

The value of the total score on the NSS scale was chosen as the main variable for the analysis of its dynamics. The value of the level of change in indicators by 3 points was taken as significant.

The above diagnostic methods were used before the start of the rehabilitation course, at the end of it, as well as at the control examination 6 months after the end of the rehabilitation course.

In patients of the main group, compared with the beginning of the rehabilitation course, by the end of it, there was a statistically significant (p<0.05) positive dynamics in the tests: the Ashworth scale for assessing muscle tone, the Rivermead mobility index, a decrease in the levels of reactive and personal anxiety according to the Spielberger-Khanin test, a decrease in the level of depression on the Hamilton scale, and after 6 months, a statistically significant (p<0.05) positive dynamics was also established according to the results of tests for motor and emotional functions of patients, respectively: according to the Ashworth scale for assessing muscle tone, MDC, the Rivermead mobility index, SS-QOL questionnaire, Hamilton depression scale, Spielberger-Khanin anxiety scale, positive dynamics according to the “Degree of chronic fatigue” method.

In the main group, by the end of the rehabilitation course, a significant decrease in the severity of patient complaints (p<0.05) was observed: anxiety ~ by 43%, irritability ~ by 55%, sleep disorders ~ by 42%, somatization disorders ~ by 34%, depressive manifestations ~ by 41%. In the control group, patients were less pronounced (p<0.1): anxiety ~ by 36%, irritability ~ by 28%, sleep disturbances by ~ 16%, somatization disorders by ~ 20%, depressive complaints by ~ 35%.

Thus, patients in the control group showed only a positive trend according to the results of a number of tests: the Ashworth scale, NIHSS, the Spielberger-Khanin scale, the “State Scale”, both immediately after the end of the rehabilitation course and 6 months after it, however, these changes did not were statistically significant (p<0.1). After 6 months, noticeable positive results persisted only in motor function assessment tests (Ashworth scale, NIHSS), while the emotional state of patients tended to worsen (an increase in anxiety and depressive experiences, although not statistically significant).

Such results give grounds to believe that the complexes of rehabilitation techniques used by us with psychophysiologically substantiated modes of exposure can most successfully contribute to obtaining various recorded rehabilitation effects in post-stroke patients, depending on the modes used, the sequence of effects (for example, more aimed at reducing anxiety and depressive manifestations, or improvements on the part of the propulsion system). The most universal in terms of statistically significant positive effects can be considered the method of complex rehabilitation proposed as this invention, including sequential psychotherapeutic and psychophysiological effects: REBT - PMR - BFB with diaphragmatic relaxation breathing according to A.A. Smetankin - Mind Spa.

Claims (7)

A method for complex medical and psychological rehabilitation of patients in the late recovery period after acute ischemic stroke (AIS), including psychotherapeutic and physiotherapeutic effects, characterized in that, as a psychotherapeutic effect, daily sessions of rational-emotive-behavioral psychotherapy (REBT) are performed for 40-60 minutes within 12 days, after each session of REBT, a session of progressive muscle relaxation (PMR) is performed for 15 minutes, during which tension and retention of this tension are sequentially performed first, and then relaxation of the muscles of the hand, forearm, shoulder, muscles of the face, neck, back and of the abdomen, muscles of the lower leg and foot, and then - daily breathing training is carried out using biofeedback according to heart rate based on diaphragmatic relaxation breathing according to A.A. Smetankin - 12 sessions, while the session includes in sequence: 1 minute of voluntary breathing habitual for the patient with simultaneous recording of background indicators of heart rate and respiratory rate, then - the main stage with diaphragmatic relaxation breathing according to A.A. Smetankin, the duration of which at the 1st-3rd sessions is 3 minutes, at the 4th-7th sessions it is 4 minutes each, at the 8th-9th sessions it is 5 minutes each, then 1 min - a break during which the patient breathes again in his usual way, further - the second main stage is carried out with diaphragmatic relaxation breathing, the duration of which at the 1st-3rd sessions is 3 minutes, at the 4th-7th sessions it is 4 minutes each, at the 8-9th sessions it is 5 minutes each, and in the 10th-12th sessions, the patient independently breathes diaphragmatic-relaxation breathing during the entire session without the use of BFB, lasting up to 15 minutes; after the biofeedback session, a session of psychophysiological electropulse exposure is carried out as a physiotherapeutic effect using a device - multifunctional glasses Mind Spa, using the training program of Progressive Relaxation Alpha Training - Alpha 1 for 22 minutes, the course is 12 days, and in the case of Mind Spa sessions in the first half of the day they use glasses with blue LEDs, and in the second - with white LEDs.