RU2793418C2 - Method of rehabilitation of patients who have undergone covid-19 coronavirus pneumonia - Google Patents

Abstract

FIELD: medicine; manual therapy.

SUBSTANCE: first half of the day, a course of procedures is carried out using osteopathic methods of correction, massage and exercise therapy. A complex of osteopathic correction techniques aimed at eliminating somatic dysfunctions and restoring breathing is carried out according to a regimen that includes correction of structural dysfunctions of the ribs, respiratory dysfunctions of the ribs, dysfunctions of the thoracic spine, abdominal diaphragm, and auxiliary respiratory muscles of the upper aperture. The first correction procedure is carried out upon admission of the patient for rehabilitation, the second procedure is carried out before the completion of the rehabilitation course, each lasting 30-40 minutes. Also, a course of massage procedures is carried out, consisting of four procedures every other day, the duration of each procedure is 30 minutes. A course of physical therapy is conducted, consisting of four procedures every other day; the duration of each procedure is 30 minutes.

EFFECT: invention provides improved mobility of the diaphragms of the thoracic and upper aperture, mobility of the spinal motion segments, increased chest excursion, improved external respiration function, namely: vital capacity (VC), forced vital capacity (FVC), saturation (SPO2); the degree of shortness of breath decreases, tolerance to physical activity increases, the quality of life of the patient improves significantly in a short time.

1 cl, 4 tbl, 3 ex

Description

The invention relates to medicine, namely to manual medicine (osteopathy and manual therapy), and can be used in rehabilitation centers, outpatient practice and in hospitals in order to restore the function of external respiration during the rehabilitation of patients who have undergone coronavirus pneumonia COVTD-19, preferably aged 60 and over, but not limited to.

Over the past few years, viral infections have increasingly become the cause of lung disease throughout the world, especially during SARS and influenza epidemics. At the moment, in the context of an epidemic of viral pneumonia, the causative agent of which is SARS-CoV-2 called COVID-19, reliable professional information on the provision of medical care for the medical rehabilitation of patients is not enough, since this disease is new [1].

The consequences of viral pneumonia are different for everyone. Some have no residual effects, others have little, and some experience shortness of breath even at rest. Therefore, timely rehabilitation of such patients is of great importance [1].

The pathological process in the bronchopulmonary system has a pronounced negative effect on the state of the respiratory muscles; to ensure oxygen consumption in conditions of alveolar hypoxia, a compensatory increased work of the respiratory muscles develops, which requires large energy costs, leads to fatigue, fatigue of the respiratory muscles. In addition, excessive work of skeletal muscles contributes to their overstrain and the occurrence of muscle imbalance: there are changes in the muscles that are characteristic of myofascial pain syndrome [2].

The use of manual manipulation for pneumonia was first documented during the 1918 Spanish flu pandemic, when patients receiving standard medical care had an estimated mortality rate of 33%, compared with a 10% mortality rate for patients treated by osteopaths. Used in the treatment of pneumonia, manual manipulation techniques enhance lymph flow, respiratory function, and immunological protection by acting on the anatomical structures involved in these systems. [3].

Manual therapy (MT) is a set of therapeutic and diagnostic techniques used to establish the causes and eliminate the identified biomechanical disorders by manipulating the anatomical structures of the skull, spine, sacrum, joints, musculoskeletal apparatus, internal organs in order to restore their mobility and optimal functioning [4].

Osteopathy is a field of clinical medicine that includes the provision of medical care to patients with somatic dysfunctions at the stages of prevention, diagnosis, treatment and rehabilitation, based on the anatomical and functional unity of the body and using manual methods that restore the body's ability to self-correct. This highly effective type of treatment for a wide range of diseases is aimed at the treatment, diagnosis and rehabilitation of dysfunctions and pathological diseases of the patient's musculoskeletal system, visceral organs, excluding the use of any pharmacological preparations [4]. Osteopathic correction (technique) is based on passive movements communicated by the doctor's hands to the patient's body in order to regulate biomechanical disorders in the anatomical structures found during examination [4]. The concepts of "osteopathy", "osteopathic impact", "osteopathic correction (correction techniques)" are well-known from the prior art (see, among other things, the patent for the invention of the Russian Federation No. 2739128, 21.12.2020 [5].

Somatic dysfunction is a violation or change in the function of one of the components of the somatic system (bone, ligament, myofascial) and associated vascular, lymphatic and neural components. Somatic dysfunction is a functional disorder manifested by biomechanical, rhythmogenic and neurodynamic components. The biomechanical component is a functional disorder that manifests itself as a violation of the mobility, compliance and balance of the tissues of the human body. The rhythmogenic component is a functional disorder, manifested by a violation of the production, transmission and acceptance of endogenous rhythms. The neurodynamic component is a functional disorder - in the form of a violation of the nervous regulation. It should also be understood that a functional disorder is a violation of the mechanisms of the vital activity of an organ, the causes of which lie outside the affected organ and are associated with an altered regulation of the function.

Myofascial pain syndrome (MBS) is a variant of somatogenic pain, the source of which is skeletal muscles and adjacent fascia. According to the localization of damage, this type of pain is a deep somatic pain. Pain may be accompanied by a feeling of stiffness after prolonged immobilization of the muscle. Unlike neurogenic pain syndromes, MBS does not reveal neurological symptoms, changes in electromyography, and the distribution of pain is not segmental. Sometimes, with MBS, several muscles suffer at the same time, and the zones of reflected pain overlap each other. As a result, there is a combination of different pain zones caused by trigger points located in several muscles. The muscles of the neck, upper shoulder girdle and trapezius muscles are the most affected [6].

The following pathobiomechanical changes (PBMI) are distinguished: functional block (somatic dysfunction), regional postural muscle imbalance, local hypermobility, myofascial trigger point (mechano-trigger point, trigger point), suboptimal motor stereotype [6].

The basic principle of MT is based on the fact that therapeutic manual effects cause stimuli that, when perceived by the receptors of the musculoskeletal system (MDA), act as an analgesic [4].

The purpose of creating a technical solution is to search for and carry out the rehabilitation of patients who have undergone coronavirus pneumonia (COVID-19) by applying osteopathic correction, intensive massage of asymmetric chest zones according to Kuznetsov and physiotherapy exercises. Particular attention is paid to patients in the age group over 60 years, but not limited to them.

Analysis of the prior art and the search for publicly available sources of information revealed the following closest analogues of the invention.

There is a known method of improving the patient by systemic effects on the body using osteopathic techniques according to the method of Dr. Artemov (RF Patent No. 2296551 (Artemov V.G.), 10.04.2007) [7], which refers to the field of medicine and osteopathy. The invention includes a systemic effect on the body, by conducting a general and osteopathic examination of the structural, visceral and cranial systems, includes electropuncture diagnostics using the Voll method with testing and selection of an effective dose of the necessary biologically active drugs. Subsequently, an osteopathic effect on the above systems of the patient is carried out for eight sessions in two months sequentially, once a week. Then three sessions are carried out with a frequency of once a month, after which a control examination is carried out every three months. During the session, the correction of structural dysfunctions is accompanied by the correction of internal organs innervated from the same segments of the spine. Before its elimination, myofascial release of the lumbar, thoracic and cervical regions is performed for 20-30 minutes. At each session, for an hour, the same segmental zones and internal organs of the body, the dysfunctions of which were eliminated during the session, are additionally affected by laser reflexotherapy or thalassotherapy, or SCENAR therapy, or SCENAR therapy with a medical blanket. The method provides a comprehensive prevention of diseases due to the effect on the body at the systemic and cellular levels and optimal consideration of the interdependence of organs.

The disadvantage of this method is that biologically active drugs and physiotherapy techniques are used. As a result, the significance (role) and effect of osteopathic techniques is lost, as there is a mixed systemic effect with the use of several types of treatment, each of which may have its own contraindications and undesirable effects. The duration of the sessions (lasting 1.5 hours) and the prolongation in time (one session per week, course - 5 months) of the exposure process can lead to loss of adherence to treatment and loss of the possibility of a cure. The proposed method can only be used for prevention. In addition, the complexity of the method determines the high cost of its implementation.

A known method for the treatment of acute pneumonia (RF patent No. 95120446, February 27, 2017 [8]), related to medicine, namely to pulmonology, and can be used to treat patients with acute pneumonia. The essence of the method lies in the fact that external pain is applied by successive pressure with fingers in the area of the cervical and thoracic spine along the paravertebral line from the side of inflammation, interspinous spaces and intercostal spaces of the thoracic spine from the lobes of the lung involved in inflammation with an effort that causes pain , but not more than the level of maximum pain tolerance, within 1-3 s from one to two times with local muscle tension in the area of exposure while holding the breath. Sessions are repeated after 10-48 hours in the amount of 5-8 times.

The disadvantages of this method include the following: duration and treatment without manual, osteopathic correction, resulting in loss of adherence to treatment and effectiveness; the focus of the proposed method only on the treatment of acute pneumonia; the method does not completely stop the pain syndrome; there is no increase in respiratory excursion of the chest.

There is also known a method of respiratory kinesiology rehabilitation of patients after cardiac surgery (RF patent No. 2424787, 03.10.2011 [9]). This method is characterized by the fact that, starting from the first postoperative day, against the background of intensive therapy in the position of the patient "lying", visceral manual therapy is performed on the abdominal organs; then exercise impact on biologically active points, which are selected based on the prevailing organ failure; judging by the state of consciousness of the patient, either passive or active movements are carried out in the joints of the lower extremities, and with active movements, the doctor exerts a dosed resistance to the working limb, in addition, before starting and in the pauses between exercises, rotation is performed in the hip joint; then, ventilation is carried out in the prone position and the patient is smoothly transferred to the “sitting” position, and in this position, the patient’s back is affected by manual therapy techniques; after which the patient is transferred to the orthopedic chair in the "vertically sitting" position with a gradual increase in exposure time. Early respiratory kinesiology rehabilitation (RCR) in the complex of intensive care for multiple organ failure is an effective method for the rapid restoration of adequate external respiration function, the adaptive potential of the cardiovascular system, and stabilization of the vegetative-vascular status.

The disadvantage of this method is that the method is lengthy, does not take into account the correction of somatic dysfunction in lung injury, is aimed at the rehabilitation of patients after cardiac surgery.

There is a method described in the patent for the invention of the Russian Federation No. 2745697, 30.03.2021 "Method of rehabilitation of patients with bronchopulmonary pathology of infectious genesis" [10]. The invention relates to physical therapy and physiotherapy, can be used at all stages of medical rehabilitation. Compression is carried out through a system of connections of pneumocuffs with a compression station. The operating modes of the device allow you to select compression in pneumocuffs of 3 levels. Given the reports in the scientific literature about the need for particularly gentle interventions on the lung tissue of the COVID-19 patient, the chest compression regimen, and therefore the patient's activity, increases gradually from the first to subsequent procedures. A low-frequency vibrator is installed in the projection of the legs of the diaphragm to the right and left of the spine at the level of the costal arch. The impact of the vibrator occurs synchronously with the operation of the compression station for forcing air into the system throughout the cycle of the selected duration. Before performing the procedure, the patient receives an instruction to perform - during compression through the pneumocuff, the patient must take a breath in the direction of chest compression; during a pause in the operation of the apparatus, an exhalation is performed through lips closed by a tube. The course consists of 10 procedures. EFFECT: method provides increased efficiency of a complex of rehabilitation measures and allows obtaining a pronounced and stable clinical effect in patients with bronchopulmonary pathology, including COVID-19, and also increases the functionality of the respiratory muscles with the development of maximum compensatory capabilities due to the recruitment of a larger volume of lung tissue into gas exchange and providing secondary prevention of the occurrence of complications of the bronchopulmonary system.

The disadvantage of this method is that the method is lengthy and does not take into account the correction of somatic dysfunction in case of lung damage.

There is a method described in the patent for the invention of the Russian Federation No. 2735797, 09.11.2020) “A method for improving the oxygenating function of the lungs in patients with a new coronavirus infection (COVID-19) with respiratory failure, who are on respiratory support” [11]. The method includes intravenous administration of a solution of serotonin adipinate at a rate of 10-30 mg/h to a patient with a new coronavirus infection COVID-19 with respiratory failure, who is on respiratory support. As respiratory support, non-invasive ventilation of the lungs, oxygen therapy are carried out, calcium nandroparin or enoxaparin is additionally administered. The use of the invention improves the oxygenating function of the lungs by normalizing the function of the smooth muscles of the microvasculature of the lungs and other organs, and as a result, increasing gas exchange.

The disadvantage of this method is that the method is not aimed at correcting somatic dysfunction in lung damage, the method is invasive, pharmacological preparations are used.

As the closest analogue (prototype), a clinical and research protocol for osteopathic manipulative treatment of elderly patients with pneumonia was chosen, which is aimed at eliminating specific somatic dysfunction unique to the patient [12]. The protocol included osteopathic correction, manipulations: rib lift, domed diaphragm, soft tissue techniques in the thoracic and cervical regions, thoracic inhalation treatment, and thoracic lymph pump techniques. Treatment sessions were carried out twice a day for a maximum duration of 15 minutes. All techniques in the protocol are given with each patient lying on their back in bed. In the presence of orthopnea or shortness of breath, the patient's head can be raised 45 degrees. Following this protocol, the patient first relaxes. Secondly, restrictions in the chest are removed and factors of the musculoskeletal system that can cause non-adaptive sympathetic reactions to the pulmonary process are eliminated. Thirdly, the osteopathic doctor affects the factors of the musculoskeletal system, which may be the cause of the patient's non-adaptive parasympathetic reactions to the pulmonary process. Finally, the patient's circulation and lymph flow are increased in the lung parenchyma and chest.

The disadvantages of this method are:

1. The number and duration of techniques by time, 15 minutes during the day, which makes it impossible to evaluate the effectiveness of osteopathic effects on the function of external respiration.

2. The process of exposure is extended in time, during the day for 15 minutes, on average 7 days.

3. Passive work in the acute period with the muscular-ligamentous capsular apparatus of the chest and ribs leads to a deterioration in gas exchange in the lung tissue, which may cause a deterioration in the patient's condition.

4. “Rib lift”, as a method, does not allow the most effective effect on mobility in the transverse costal joint, intercostal muscles and the total range of motion in the ribs.

5. No impact on the thoracic spine is provided, since one of the main impacts on the ribs is the transverse costal joints.

6. There is no objective assessment for respiratory dysfunctions - inhalation and exhalation.

The method proposed in the prototype is not 100% effective, technically simple, reliable, structured, and physiologically appropriate procedure.

To eliminate the shortcomings of the proposed prototype, we propose a method developed by us for the rehabilitation of patients who have experienced coronavirus pneumonia (COVID-19), using the method of osteopathic correction, intensive massage of asymmetric chest zones according to Kuznetsov and physiotherapy exercises.

As a result of the analysis of the prior art, it can be concluded that the claimed invention can be recognized as meeting the patentability criteria "novelty" and "inventive step" before the priority date claimed.

The technical problem in creating the claimed invention lies in the fact that studies that allow evaluating the impact of osteopathic correction methods on the rehabilitation of patients with coronavirus pneumonia (COVID-19) are few, and there are practically no domestic works.

The objective of the present invention is to create such a method for the rehabilitation of patients who have undergone coronavirus pneumonia (COVID-19), which would allow rehabilitation to be carried out most effectively and painlessly, in the shortest possible time, using the mechanisms of self-regulation of the body, which can be recommended to the largest number of patients over 60 years old, but not limited to them.

Common to the closest analogue and our proposed method are: the therapeutic orientation of the methods, the use of osteopathic techniques, the absence of the use of pharmacological preparations, the non-invasiveness of the rehabilitation method, the contingent of exposure - patients over 60 years of age.

The advantages of the proposed method (the main advantages of our technical solution). Unlike the closest analogue, the proposed method allows us to speed up the rehabilitation of the patient after the disease COVID-19, increase the excursion of the chest, and increase exercise tolerance. Increasing the effectiveness of the proposed method is due to the use of osteopathic correction in combination with the methods of intensive massage of the asymmetric zones of the chest according to Kuznetsov and physiotherapy exercises. The inventive method has a short total duration of procedures, increasing the patient's commitment to rehabilitation and its tolerability. In addition, our method helps to improve the patient's health and quality of life as soon as possible, as it is distinguished by its universal approach and inexpensive implementation.

To solve this problem, a method is proposed for the rehabilitation of patients who have undergone coronavirus pneumonia, COVID-19, in which osteopathic correction procedures, massage of asymmetric zones of the chest according to Kuznetsov and physiotherapy exercises are carried out.

The proposed method is an effective, technically simple, reliable, structured, and physiologically expedient procedure.

The technical result from the implementation of the claimed invention is that the improvement in the mobility of the diaphragms of the thoracic and upper aperture, the mobility of the spinal motion segments, the excursion of the chest increases, the function of external respiration improves, namely the vital capacity of the lungs (VC), the forced vital capacity of the lungs ( FVC), saturation (SPO ₂ ), the degree of dyspnea decreases, exercise tolerance increases, and the quality of life of patients improves in a short time.

Applying the proposed complex of osteopathic methods of correction by acting on the ribs, intercostal muscles, massage of the asymmetric zones of the chest according to Kuznetsov and physiotherapy exercises, including breathing exercises according to Strelnikova, a technical result is achieved with the following set of essential features, namely:

“A method for the rehabilitation of patients who have undergone coronavirus pneumonia COVID-19, including a course of procedures using osteopathic correction techniques, massage and exercise therapy, characterized in that osteopathic correction is carried out according to the scheme in accordance with Table. 1A:

- correction of structural dysfunctions of the ribs,

- correction of respiratory dysfunctions of the ribs,

- correction of dysfunctions of the thoracic spine,

- correction of dysfunctions of the thoracic diaphragm,

- correction of dysfunctions of the auxiliary respiratory muscles of the upper aperture;

the first procedure of osteopathic correction is carried out upon admission of the patient for rehabilitation, the second procedure is carried out before the completion of the rehabilitation course, the duration of the procedure is 40 minutes each;

as a massage, chest massage according to Kuznetsov is carried out four procedures every other day, the duration of each procedure is 30 minutes;

as physiotherapy exercises, breathing exercises according to Strelnikova are carried out and exercises are performed in accordance with Table 2, while physiotherapy exercises are carried out four times a day, lasting 30 minutes.

The claimed method is carried out using osteopathic correction (see table. 1), massage and physiotherapy exercises - when pain syndromes are detected in a patient against the background of somatic dysfunctions, osteopathic correction is applied by affecting the ribs, thoracic spine, thoracic diaphragm, auxiliary respiratory muscles of the upper aperture according to the following scheme:

• Correction of structural dysfunctions of the ribs.

• Correction of respiratory dysfunctions of the ribs.

• Correction of dysfunctions of the thoracic spine.

• Correction of dysfunctions of the abdominal diaphragm.

• Correction of dysfunctions of the accessory respiratory muscles of the upper aperture.

The osteopathic correction procedure is carried out twice during the course of rehabilitation.

Also, 4 procedures for massaging asymmetric zones of the chest according to Kuznetsov [13] and 4 procedures for physiotherapy exercises - breathing exercises according to Strelnikova and exercises are carried out, as presented below.

Techniques, methods of osteopathic correction of somatic dysfunctions, carried out in the implementation of the proposed method:

• Correction of structural dysfunctions of the ribs.

Myofascial release (release) is carried out - a therapeutic method of manual impact on any contractile structure, based on the plastic-elastic properties of soft tissues, activating somatic and neuroreflex mechanisms and improving its biomechanics. The technique of muscular-fascial release provides for the implementation of three main consecutive actions of the doctor (the technique of the three "T"):

1) pressure (tension) on the changed tissues to a state of prestress,

2) traction (traction) of tissues in opposite directions to the barrier;

3) twisting (twisting) tissues in opposite directions also up to the barrier.

As a result, as a rule, after 10-50 seconds. tissue relaxation occurs [6]. Upper offset of the 1st edge (on the example of the left edge, similarly performed on the right edge):

IPP (initial position of the patient) - lying on his back.

IPV (doctor's starting position) - the doctor stands (sits) behind him.

1. With the right hand, the doctor, controlling the head and neck, performs a lateral tilt and rotation to the left of the patient's cervical spine until occlusion in CVII-ThI. This position creates a condition for the caudal displacement of the 1st rib and relaxation of the scalene muscles.

2. With the fingers of the left hand, the doctor palpates the upper bundle of the trapezius muscle and takes it backwards. 2, 3, 4, fingers are placed on the cranial surface of the anterior part of the dysfunctional rib and the thumb is placed on the back of the body of the 1st rib through the trapezius muscle. With the thumb of the left hand, the doctor exerts pressure in the caudal direction on the back of the body of the 1st rib until prestressing in the costotransverse joint.

3. Voltage phase. According to the doctor's instructions, the patient, on a deep and slow breath, produces a lateral tilt of the head and neck to the right against the movement of the doctor's right hand, activating the scalene muscles on the right and suppressing the activity of the scalene muscles on the left. At the same time, the doctor keeps the created prestress in the costotransverse joint, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

4. During the relaxation phase, the patient exhales and relaxes. The doctor, following the relaxation of the tissues and the movement of the rib, continues to press on the 1st rib, carrying out its caudal displacement, at the same time, increases the lateral tilt and rotation to the left in the CVII-ThI PDS of the patient. The relaxation phase lasts 10-14 seconds.

5. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Front offset of the rib (on the example of the V rib on the right, it is similarly performed from the II to X rib, on both sides):

IPP - the patient sits on a chair, the right hand on the left shoulder.

IPV - the doctor stands behind the patient.

1. The thumb of the doctor's right hand is located on the body of the 5th rib medially from the angle of the patient's rib (applies pressure in the lateral direction to prestress in the costotransverse joint), the remaining fingers on the chest along the fifth rib. With his left hand, the doctor grabs the patient's right elbow in front of the chest and raises his arm up to the same plane with the angle of the rib (and medially to the barrier), finding the motor wave (according to the principle "the higher the rib, the higher the arm");

2. Voltage phase. According to the doctor's instructions, the patient tries to abduct the arm laterally (with dysfunction of the upper ribs) or latero-caudal (with dysfunction of the lower ribs), overcoming the resistance of the doctor's left hand. At the same time, the doctor with the thumb of the right hand holds the created prestress in the costal-transverse joint, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

3. Phase of relaxation. The patient relaxes the hand as much as possible. The doctor, following the relaxation of the tissues and the movement of the rib, continues to press on the medial surface of the angle of the rib in the lateral direction, and at the same time, pulls the patient's hand medially or mediocranially. The relaxation phase lasts 10-14 seconds.

4. During the relaxation phase, the patient with the left palm (fist, hand) can apply pressure to the front of the dysfunctional rib, while moving, applying force from front to back on the dysfunctional rib.

5. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Posterior displacement of the rib (using the V rib on the right as an example, it is similarly performed from the II to X rib, on both sides):

IPP - the patient sits on a chair, the right hand on the left shoulder.

IPV - the doctor stands behind the patient.

1. The doctor puts the thumb of the right hand on the body of the V rib laterally from the angle of the patient's rib (applies pressure in the anterior-medial direction to prestress in the costal-transverse joint), the remaining fingers on the chest along the fifth rib. With his left hand, the doctor grabs the patient's right elbow in front of the chest and raises his hand up to the barrier, finding the motor wave (according to the principle "the higher the rib, the higher the arm").

2. Voltage phase. According to the doctor's instructions, the patient tries to abduct the arm medially and cranially, overcoming the resistance of the doctor's left hand. The doctor with the thumb of the right hand holds the created prestress in the costal-transverse joint, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

3. Phase of relaxation. The patient relaxes the hand as much as possible. The doctor, following the relaxation of the tissues and the movement of the rib, continues the pressure on the lateral surface of the angle of the rib in the anterior-medial direction, and at the same time, pulls the patient's hand laterally or latero-caudally. The relaxation phase lasts 10-14 seconds.

4. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

External torsion of the rib (using the V rib on the right as an example, it is similarly performed from the II to X rib, on both sides) - I option:

IPP - the patient is sitting, the right hand is on the left shoulder.

IPV - the doctor stands behind and to the left of the patient.

1. With the left hand, the doctor fixes the patient's right hand so that the patient's left shoulder is located under the doctor's left shoulder. The doctor also controls the patient's left shoulder blade and his spine. With the right hand, the doctor determines the angle and body of the dysfunctional rib.

2. The doctor performs a slight flexion, lateroflexion and rotation of the spinal column to the left at the level of PDS ThIV - ThV, shifting the V rib to the right anteriorly.

3. The doctor puts the thumb of the right hand on the anterior part of the body of the 5th rib on the right and applies pressure (up to prestress in the costotransverse joint) on the protruding lower edge of the anterior part of the body of the 5th rib.

4. Voltage phase. According to the instructions, the patient presses his right shoulder into the doctor's hand. The doctor, at the same time, counteracts the extension, rotation and lateral tilt of the patient to the right, and with the thumb of the right hand holds the created prestress in the costotransverse joint, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds (on the patient's inspiration) or until the tissues begin to relax.

5. Relaxation phase. The doctor reduces flexion, lateral tilt and rotation to the left of the patient's spine on exhalation and continues to apply pressure on the protruding lower edge of the anterior part of the body of the fifth rib, following the relaxation of the tissues and the movement of the rib to the next barrier and performing its external-internal rotation. The relaxation phase lasts 10-14 seconds.

6. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

External torsion of the rib (on the example of the V rib on the right, similarly performed from the II to X rib, on both sides) - II option:

IPP - the patient is sitting, his right hand is on his left shoulder.

IPV - the doctor stands behind and to the left of the patient.

1. The doctor places the thumb of the right hand on the protruding cranial part of the angle of the patient's rib and applies pressure in the ventro-caudal direction until prestressing in the costotransverse joint, the remaining fingers - on the chest above the 5th rib. With his left hand, the doctor grabs the patient's right elbow from the side of the anterior surface of the chest and raises his hand up to the barrier.

2. Voltage phase. According to the doctor's instructions, the patient, while inhaling, tries to raise and abduct the arm (cranio-laterally), overcoming the resistance of the doctor's left hand. At the same time, the doctor with the thumb of the right hand holds the created prestress in the costal-transverse joint, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

3. Phase of relaxation. The patient relaxes the hand as much as possible. The doctor, following the relaxation of the tissues and the movement of the rib, continues the pressure on the cranial surface of the angle of the rib in the ventro-caudal direction, at the same time, slightly shifts the patient's hand down or medio-caudally (supports). The relaxation phase lasts 10-14 seconds.

4. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Internal torsion (rotation) of the rib:

IPP - the patient is sitting, his right hand is on his left shoulder.

IPV - the doctor stands behind and to the left of the patient.

1. The thumb of the doctor's right hand is located on the caudal surface of the angle of the patient's rib and produces pressure in the ventro-cranial direction until prestressing in the costotransverse joint, the remaining fingers - on the chest under the 5th rib. With his left hand, the doctor grabs the patient's right elbow from the side of the anterior surface of the chest and slightly raises his arm.

2. Voltage phase. According to the doctor's instructions, the patient tries to lower his arm while inhaling, overcoming the resistance of the doctor's left hand. The doctor with the thumb of the right hand holds the created prestress in the costal-transverse joint, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

3. Phase of relaxation. The patient relaxes the hand as much as possible. The doctor, following the relaxation of the tissues and the movement of the rib, continues the pressure on the caudal surface of the angle of the rib in the ventro-cranial direction, and at the same time, raises the patient's arm up. The relaxation phase lasts 10-14 seconds.

4. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Anterior-posterior compression (on the example of the VI rib on the right, similarly performed from the II to X rib, on both sides):

PPI - the patient is sitting.

IPV - the doctor stands on the side opposite to the displaced rib (on the left facing the patient).

1. The right hand of the doctor is located on the side of the back, the left - on the side of the patient's chest. The third fingers of the right and left hands are located towards each other and in parallel over the protruding lateral part of the displaced rib at the level of the midaxillary line. The doctor creates flexion in his body, thereby pressing on the patient's left shoulder, causing a lateral tilt of the patient's torso to the right at the level of PDS ThV - ThVI. This contributes to the medial displacement of the dysfunctional rib. Simultaneously, the third fingers of both hands displace the rib medially until prestressing in the costal-transverse and sternocostal joints.

2. The patient inhales and exhales until the doctor feels the minimum tension of the rib (the position of the greatest freedom of the rib).

3. Voltage phase. According to the doctor's instructions, the patient, while inhaling, actively presses his left side into the chest of the doctor, who resists this movement. The doctor uses his third fingers to hold the created prestress in the costal-transverse and sternocostal joints, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

4. Relaxation phase. The doctor, following the relaxation of the tissues and the movement of the rib, continues the pressure on the lateral part of the rib in the medial direction, at the same time, slightly increases the lateral tilt of the patient to the right. The relaxation phase lasts 10-14 seconds.

5. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Lateral compression (on the example of the 5th rib on the left, similarly applied from the 2nd to the 10th rib, on both sides):

IPP - the patient is sitting, the left hand is located on the right shoulder of the doctor.

IPV - the doctor stands on the side of the patient's dysfunction (left).

1. The base of the palm of the doctor's right hand is located above the angle of the patient's rib, the left - above the anterior part of the displaced rib. Moves the hands towards each other until prestressing in the costal-transverse and sternocostal joints.

2. Voltage phase. According to the doctor's instructions, the patient inhales slowly and deeply. The doctor keeps the created prestress in the costal-transverse and sternocostal joints, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

3. Phase of relaxation. The patient exhales slowly. The doctor, following the relaxation of the tissues and the movement of the rib, continues to move the hands towards each other until the next barrier. The relaxation phase lasts 10-14 seconds.

4. The release is repeated 2-3 times until movement is restored in the costovertebral and sternocostal joints, as well as the symmetry of the rib on the opposite side.

Upper offset (on the example of the II rib on the left, similarly performed on the right):

PPI - the patient lies on his back.

IPV - the doctor stands on the side of the dysfunction facing the patient.

1. The doctor puts his right hand on the upper edge of the body of the second rib of the patient on the left along the middle axillary line, with his left hand pulls down the patient's left hand. Then, instructing the patient to exhale completely towards the left knee, with the left hand, the patient’s neck and head are tilted to the left side until a motor wave appears on the II rib.

2. After several respiratory movements of the patient, increasing the left lateral tilt, the doctor creates a prestress with the right hand and holds the upper edge of the body of the II rib, and with the left hand moves the patient's head to the opposite side.

3. Voltage phase. The patient, while inhaling, tilts his head towards the dysfunction overcoming the resistance of the doctor. The doctor with his right hand holds the created prestress in the costal-transverse and sternocostal joints, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

4. Relaxation phase. The doctor, following the relaxation of the tissues and the movement of the rib, continues the pressure on the upper edge of the body of the II rib along the midaxillary line in the caudal direction, at the same time, slightly increases the lateral tilt of the patient's neck and head to the right. The relaxation phase lasts 10-14 seconds.

II. Correction of respiratory dysfunction of the ribs. Principles of treatment for inspiratory restriction:

1. The doctor applies pressure on the angle of the rib laterally and caudally, releasing the head of the rib in the costovertebral joint.

2. The patient follows the doctor's instructions while inhaling.

3. Muscle groups are reduced: for ribs I and II - stair, for 3-5 ribs - pectoralis major muscle, for 3-9 ribs - anterior serratus muscle.

Treatment principles for expiratory restriction:

1. The patient's position is combined: lateral tilt and flexion towards dysfunction.

2. The doctor works on the upper edge of the body and the costocartilaginous joint of the dysfunctional rib, holding them in position while exhaling.

3. The doctor returns the patient's spine to a neutral position while exhaling while holding the rib position.

Respiratory dysfunctions of I and II ribs. Inspiratory restriction (on the example of the right side, similarly performed on the left side):

PPI - the patient lies on his back.

IPV - the doctor is standing, on the side opposite from the dysfunction (left).

1. The doctor turns the patient on the left side, places the fingers of the left hand medially from the corners of the 1st and 2nd ribs and returns the patient to its original position on the back;

2. The patient puts the wrist with the rear of the right hand (the fascia of the upper limb works) on the forehead. The doctor puts his right hand on the patient's wrist and slightly rotates the patient's head to the healthy side until a motor wave appears on the actual ribs and tension of the scalene muscles. At the same time, with the fingers of the left hand, the doctor creates a pretension of the 1st and 2nd ribs in the costal-transverse joints, applying pressure on the medial surface of the costal angles in the latero-caudal direction.

3. Voltage phase. According to the doctor's instructions, the patient takes a deep breath, raises and lateroflexes his head to the right (with restriction of movement like a bucket handle) against the doctor's right hand that is resisting. At the same time, the doctor, with the fingers of his left hand, holds the created prestress of the 1st and 2nd ribs in the costal-transverse joints, waiting for the relaxation of the tissues and the appearance of movement of the ribs. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

4. Relaxation phase. The patient is relaxed. The doctor, following the relaxation of the tissues and the movement of the ribs, continues the pressure on the medial surface of the angle of the rib in the latero-caudal direction. The relaxation phase lasts 10-14 seconds.

5. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Respiratory dysfunction III - V ribs. Inspiratory restriction (on the example of the right side, similarly performed on the left side):

PPI - the patient lies on his back.

IPV - the doctor stands on the left side of the patient.

1. The doctor turns the patient on the left side, puts the fingertips of the left hand medially from the corners of the III, IV and V ribs and returns the patient to its original position. The patient places the wrist on the forehead. The doctor grasps the patient's right elbow with his right hand and slightly presses on it dorsally and laterally until a motor wave appears on the actual ribs and tension of the pectoralis minor muscle. At the same time, with the fingers of the left hand, the doctor creates a prestress in the costal-transverse joints, applying pressure on the medial surface of the costal angles in the latero-caudal direction.

2. Voltage phase. According to the doctor's instructions, the patient takes a maximum breath, holds his breath and performs adduction with the right hand against the doctor's resistance when restricting movement like a bucket handle or flexion when restricting movement like a pump handle. At the same time, the doctor with the fingers of his left hand holds the created prestress in the costal-transverse joints, waiting for the relaxation of the tissues and the appearance of movement of the ribs. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

3. Phase of relaxation. During a full exhalation, the patient relaxes. The doctor, following the relaxation of the tissues and the movement of the rib, continues the distraction around the corners of the dysfunctional ribs in the caudal-lateral direction, at the same time, displaces the patient's elbow dorso-laterally to the next barrier. The relaxation phase lasts 10-14 seconds.

4. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Respiratory dysfunctions of the VI-IX ribs, restriction of inhalation (on the example of the right side, similarly performed on the left side):

PPI - the patient lies on his back.

IPV - the doctor stands to the left of the patient.

1. The doctor turns the patient on the left side, puts the fingertips of the left hand medially from the corners of the VI-IX ribs and returns the patient to the supine position;

2. The patient raises the right hand cranially, the doctor grabs the patient's elbow and slightly shifts it medio-dorsally until a motor wave appears in the actual ribs and tension of the anterior serratus and pectoralis major muscles. At the same time, with the fingers of the left hand, the doctor creates a prestress in the costal-transverse joints, applying pressure on the medial surface of the costal angles in the latero-caudal direction.

3. Voltage phase. According to the doctor's instructions, the patient, while taking a deep breath, flexes his right hand against the doctor's resistance when restricting movement like a pump handle or abducts his hand laterally when restricting movement like a bucket handle. At the same time, the doctor with the thumb of the right hand holds the created prestress in the costal-transverse joints, waiting for the relaxation of the tissues and the appearance of movement of the rib. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

4. Relaxation phase. The patient is relaxed. The doctor, following the relaxation of the tissues and the movement of the rib, produces a latero-caudal distraction around the corners of the ribs, at the same time, displaces the patient's right hand cranio-medially to the next barrier. The relaxation phase lasts 10-14 seconds.

5. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Respiratory dysfunctions of the XI-XII ribs. Inspiratory restriction (on the example of the right side, similarly performed on the left side):

PPI - the patient lies on his stomach.

IPV - the doctor stands to the left of the patient.

1. The patient puts his right hand behind his head.

2. The patient's legs are moved to the left, causing a lateral tilt to the left in the lumbar spine.

3. The doctor places the left wrist medially from the angle of the XI or XII ribs and performs a displacement in the latero-cranial direction until prestressing in the costotransverse joints. With his right hand, he grasps the right upper anterior iliac spine and lifts it dorsally (up) to prestress.

4. Voltage phase. The patient takes a maximum breath, holds his breath and presses the ilium ventrally (toward the table). The doctor keeps the created prestress in the tissues, waiting for the relaxation of the tissues and the appearance of the movement of the ribs. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

5. Relaxation phase. The patient relaxes on exhalation. The doctor, following the relaxation of the tissues and the movement of the ribs, produces a latero-caudal distraction around the corners of the ribs, at the same time, lifts up the anterior-superior iliac spine with the right hand to the barrier. The relaxation phase lasts 10-14 seconds.

6. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Respiratory dysfunction. Exhalation restriction, I-II ribs (on the example of the left side, similarly performed on the right side):

PPI - the patient lies on his back.

IPV - the doctor stands on the side of the dysfunction at the head end of the table.

1. The doctor puts the thumb of the left hand on the upper edge of the first rib, capturing the costochondral joints. (In the treatment of "bucket handle" dysfunction, the thumb is located behind the neurovascular bundle, and in the case of "pump handle" dysfunction, on the anterior surface);

2. With the right hand, the doctor grabs the patient's neck and moves it to the position of flexion and lateral tilt towards the dysfunctional rib (to the left) at the level of PDS CVII - ThI until a motor wave appears on the actual ribs. When the respiratory component is limited by the type of pump handle, flexion of the neck and head predominates, while when the respiratory component is limited by the type of bucket handle, lateroflexion prevails.

3. Voltage phase. The patient takes a small breath and a maximum exhalation. At the same time, the doctor presses the thumb of the left hand on the rib caudally to prestress, and with the right hand increases the flexion and lateral inclination of the neck and head of the patient, waiting for the relaxation of the tissues and the appearance of movement of the ribs. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

4. Relaxation phase. The doctor, following the relaxation of the tissues and the movement of the ribs, returns the patient's neck to its original middle position on exhalation, while continuing to hold the rib caudally. The relaxation phase lasts 10-14 seconds.

5. The release is repeated 2-3 times until the movement in the costovertebral joint is restored, as well as the symmetry of the rib on the opposite side.

Respiratory dysfunction. Exhalation restriction, III-VI rib (on the example of the left side, similarly performed on the right side):

PPI - the patient lies on his back.

IPV - the doctor stands to the left of the patient.

1. The thumb of the doctor's left hand is located above the costocartilaginous articulation of the upper edge of the patient's key rib. The right hand of the doctor is located under the head and neck of the patient. Then the doctor flexes the patient's neck and upper chest along the fusion to the key rib (movement of the "pump handle") until a motor wave appears on the actual rib.

2. Voltage phase. The patient takes a moderate breath and maximum exhalation, at this time the doctor increases the flexion and inclination of the chest with the right hand, presses the key rib caudally with the left hand to prestress and holds it in this position; waiting for the relaxation of tissues and the appearance of movement of the ribs. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

3. Phase of relaxation. The doctor, following the relaxation of the tissues and the movement of the ribs, while exhaling, moves the neck and upper chest of the patient to the initial middle position, and keeps the key rib in the caudal position. The relaxation phase lasts 10-14 seconds.

4. The release is repeated 2-3 times, each time increasing the flexion of the patient's neck and chest until movement is restored in the costovertebral joint.

Respiratory dysfunction. Exhalation restriction, VII-X ribs (on the example of the left side, similarly performed on the right side):

PPI - the patient lies on his back.

IPV - the doctor stands to the left of the patient.

1. With the thumb and forefinger of the left hand, the doctor holds the upper edge of the patient's key rib. The right hand of the doctor is located under the head and upper chest of the patient. The doctor performs flexion and lateroflexion to the left of the upper part of the chest towards the key rib (“bucket handle” movement) until a motor wave appears on the actual rib.

2. Voltage phase. The patient takes a weak breath and then exhales as much as possible, at the same time the doctor increases the lateral inclination of the torso with his right hand. With the left hand, the doctor presses on the key rib caudally and holds it in this position; waiting for the relaxation of tissues and the appearance of movement of the ribs. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

3. Phase of relaxation. The doctor, following the relaxation of the tissues and the movement of the ribs, on exhalation returns the patient's chest to its original position, while holding the key rib in the caudal position. The relaxation phase lasts 10-14 seconds.

4. The release is repeated 2-3 times until movement is restored in the costovertebral joint, each time increasing the lateral tilt. When working with IX-X ribs, the lateral slope prevails over flexion.

Respiratory dysfunction. Limitation of exhalation of the XI-XII ribs (on the example of the right side, similarly performed on the left side):

PPI - the patient lies on his stomach.

IPV - the doctor stands to the left of the patient.

1. The patient's legs move to the right, causing a lateral tilt to the right in the lumbar spine. The patient's right hand goes down in the direction of the feet;

2. The doctor places the left wrist medially from the angle of the XI or XII ribs and performs a displacement in the latero-caudal direction until prestressing in the costotransverse joints. With his right hand, he grasps the right anterior-superior iliac spine and shifts it upwards to prestress.

3. Voltage phase. The patient takes a small breath and a maximum exhalation. On exhalation, the patient presses the iliac wing down to the table against the resistance of the doctor. The doctor keeps the created prestress in the tissues, waiting for the relaxation of the tissues and the appearance of the movement of the ribs. The tension phase lasts 5-7 seconds or until the tissues begin to relax.

4. Relaxation phase. The doctor, following the relaxation of the tissues and the movement of the ribs, produces a lateral distraction around the corners of the ribs, at the same time, lifts up the anterior-superior iliac spine with the right hand to the barrier. The relaxation phase lasts 10-14 seconds.

5. The release is repeated 2-3 times until movement is restored in the costovertebral joint.

• Correction of dysfunctions of the thoracic spine.

Technique for correction of extensional dysfunction (ERS) of the upper thoracic region, Th1 - Th5.

IPP - sitting astride the couch, arms down.

IPV - the doctor stands behind and to the side on the opposite side of the dysfunctional joint (DFS).

With the fingers of one hand, the doctor palpates the projection zone of dysfunction (DF) of the facet joint and (or) the transverse process at the level of the upper vertebra of the blocked vertebral motor segment (BPMS). With the other hand, he clasps the head and neck of the patient from the side of the DFS and performs flexion, lateroflexion and rotation of the head and neck of the same name in the opposite direction from the DFS until a motor wave and pretension are felt in the BPJ palpation zone.

Phase 1 - the patient presses his head against the adequate resistance of the doctor, in the direction of extension and lateroflexion towards the DFS.

Phase 2 - relaxation, the doctor shifts the head and neck into flexion, lateroflexion and rotation of the same name in the opposite direction from the DFS, following relaxation to a new barrier, which contributes to the opening of the DFS. The technique is repeated 3-5 times.

Correction of flexion dysfunction (FRS) of the upper thoracic region Th1-Th5.

IPP - the patient sits astride the couch, arms down, torso in a neutral position.

IPV - the doctor stands behind and to the side on the opposite side of the DF.

With the fingers of one hand, the doctor palpates the projection zone of the DF of the facet joint and (or) the transverse process of the upper vertebra of the BPJ. With the other hand, he fixes the head and neck on the opposite side of the DF joint. The doctor's elbow is pressed against the patient's chest. Then the doctor performs lateroflexion, rotation of the same name and extension of the head and upper HOP towards the DF joint to the barrier, which contributes to the closure of the DFS.

Phase 1 - the patient performs lateroflexion and rotation of the head in the opposite direction from the starting position.

Phase 2 - relaxation. The doctor performs lateroflexion, rotation and extension, following the relaxation to a new barrier, towards the DF joint, closing it. The technique is repeated 3-5 times.

Correction of extensional dysfunction (ERS) of the lower thoracic region. Th5-Th12.

IPP - the patient sits astride the couch.

IPV - the doctor stands behind and to the side on the opposite side of the DF, the doctor fixes the posterolateral surface of the patient's neck with one hand from the side of the DFS, supports the elbow with the other hand.

With one hand held in a triangle between the shoulder and forearm, the doctor fixes the patient's shoulder girdle from the side of the DF. The index and middle fingers of the second hand palpate the projection zone of the DF of the facet joint and (or) the transverse process of the upper vertebra of the BPJ. The axillary area fixes the patient's shoulder girdle and performs successively flexion, lateroflexion in the opposite direction from the DFS and the rotation of the same name to the body until a motor wave is felt at the level of the actual SMS, which contributes to the opening of the DFS.

Phase 1 - the patient presses his shoulder up against the adequate resistance of the doctor, trying to straighten the torso.

Phase 2 - the doctor consistently increases flexion, lateroflexion and rotation in the above directions, following relaxation to a new barrier, revealing a dysfunctional joint. The technique is repeated 3-5 times.

Correction of flexion dysfunction (FRS) of the lower thoracic region. Thc-Th12.

IPP - sitting astride a couch. The trunk is in a neutral position or in a slight extension, the arms are lowered.

IPV - the doctor sits behind the patient.

1. The first stage - with the fingers of one hand, the doctor palpates the projection zone of the DF of the facet joint and (or) the transverse process of the upper vertebra of the BPJ.

With the other hand, he performs lateroflexion of the body in the opposite direction from the DFS, opening even more of the DF of the open joint. Then he rotates his hand on the patient's shoulder girdle and lateroflexes the torso towards the DFS with an extension element until a motor wave is felt in the area of the actual SMS to the barrier, closing the DFS joint.

Phase 1 - first, the patient protrudes the abdomen towards the knee of the leg from the side of the DFS. And then presses the shoulder upwards, against the adequate resistance of the doctor, trying to straighten the torso.

Phase 2 - the doctor increases lateroflexion, rotation of the trunk towards the DF and extension, following relaxation to a new barrier. Phases are repeated 3-5 times.

2. The second stage - the "balancing" part of the technique is performed to completely close the facet joints.

The patient returns to a neutral position, maintaining the extensional position of the trunk in the area of the current PDS. The doctor is standing at the back. Using the base of one hand, the doctor fixes the underlying vertebra of the blocked SMS and displaces it ventrally to the barrier. With the brush and forearm of the other hand, the doctor grabs the patient's shoulders from the front.

Phase 1 - the patient tries to bring the shoulders forward and increase kyphosis in the thoracic spine (TSS), against adequate resistance from the doctor.

Phase 2 - relaxation, the doctor displaces the fixed vertebra in the ventral direction with the base of the palm, extending the HOP, which contributes to the closure of the DFS. Phases are performed 2-3 times.

• Correction of dysfunctions of the abdominal diaphragm.

Release of the region of the thoracolumbar transition:

IPP - lying on the stomach, feet hanging over the edge of the couch.

IPV - doctor on the side, at the level of the patient's pelvis.

With the palms of both hands, the doctor fixes the patient's torso at the level of the thoracolumbar junction so that the thumbs are located above the costal-transverse joints (Th10 - Th12), and the rest along the ribs (elbow joints are straightened). Then the doctor sequentially performs pressure with the thumbs in the ventral direction, stretching in the lateral directions (the patient's skin between the fingers of the doctor should turn white) and twisting (the thumb of one hand is in the cranial direction, the other in the caudal direction) to the barrier and then obtaining a feeling of relaxation. Moreover, twisting is performed, as it were, around the cylinder, in the form of a displacement of the chest tissues clockwise and counterclockwise. This technique resembles the “steering wheel” technique with a mandatory change in direction of movement. The technique can be repeated several times.

Aperture release.

IPP - lying on your back, legs bent at the knee joints (KC) and hip joints (HJ), feet on the couch.

IPV - the doctor stands on the opposite side of the zone of tension and spasm of the diaphragm.

With the thumbs of both hands, the doctor fixes the spasmodic and painful zone of the diaphragm through the abdominal wall in the area of its attachment to the costal arch, creating a prestress of the actual zone, the remaining fingers are located on top of the ribs, and performs the technique of three "T". After a clear sensation of relaxation of the tense zone of the diaphragm, the doctor reverses the direction of movement of the thumbs. The technique is performed 2-3 times.

• Correction of dysfunctions of the accessory muscles of the upper aperture.

Postisometric relaxation (PIR) of the anterior scalene and sternocleidomastoid muscles:

PPI - the patient sits on a chair, in a neutral position.

IPV - the doctor stands behind the patient.

With one hand, the doctor fixes the upper ribs on the anterior surface of the patient's chest from the side of the shortened anterior scalene and sternocleidomastoid muscles and displaces them caudally to the barrier. With the hand and forearm of the other hand, it clasps the head and neck in front and laterally and performs rotation and lateroflexion (to relax mainly the anterior scalene muscle) in the opposite direction from the shortened muscle or rotation, lateroflexion and additional extension (to relax mainly the nodding muscle) until a feeling of springy resistance.

Phase 1 - inhale, the patient tries to straighten and bring the head and neck to a neutral position, against adequate resistance of the doctor for 7-10 seconds, which leads to tension in the anterior scalene and sternocleidomastoid muscles.

Phase 2 - relaxation, exhalation, the doctor increases the range of motion in the directions of the created prestress, following the relaxation and stretching of the actual muscle to a new barrier. The technique is performed 3-5 times.

Procedures are performed in the first half of the day, 2 times during the course of rehabilitation, the total duration of each procedure is 40 minutes.

Also, 4 procedures of intensive massage of asymmetric zones of the chest according to Kuznetsov [13] and 4 procedures of physiotherapy exercises - breathing exercises according to Strelnikova and exercises are carried out.

Techniques, techniques for intensive massage of asymmetric zones of the chest according to Kuznetsov, carried out when implementing the proposed method:

• Massage of the anterior surface of the chest (3 - 3.5 minutes).

Guidelines

1. In the longitudinal direction, massage is carried out from the lower edge of the costal arches to the collarbones, shoulders and armpits with an arcuate bypass of the mammary glands in women and nipples in men. The massaging hand is located parallel to the sternum, the ends of the fingers are turned towards the collarbones. Massage starts from the middle sections of the chest and ends with the lateral sections.

2. In the transverse direction, massage is carried out from the sternum along the intercostal spaces to the axillary line. The massaging hand is parallel to the ribs, the ends of the fingers are facing the axillary line. The massage starts from the lower parts of the chest and ends with the upper parts.

3. Rubbing the intercostal spaces is performed with one hand on each half of the chest alternately.

4. Rubbing techniques are repeated 2-3 times within 15-30 seconds.

5. Massage of the anterior chest wall lasts no more than 3-3.5 minutes.

2. Back massage (7-8 min).

IPP - lying on the stomach, a pillow is placed under the stomach; the patient's arms, bent at the elbow joints, serve as a support for his head.

Guidelines

• In the longitudinal direction, the massage is carried out from the lower edge of the ribs (rib 12) to the back of the head, shoulders and armpits. The massaging hand is located parallel to the spine, the ends of the fingers are facing the back of the head. Massage begins with the sections adjacent to the spine and ends with the lateral sections of the back.

• In the transverse direction, massage is carried out from the spine along the intercostal spaces to the axillary line and vice versa. The massaging hand is parallel to the ribs, the ends of the fingers are facing the axillary line. The movement starts from the lower sections of the chest and ends with the upper sections.

• Rubbing, kneading and vibration in the back should be started from the healthy side with unilateral lung disease or from the less affected side, with bilateral localization of the pathological process.

• Sawing techniques are carried out vigorously.

• Each technique is repeated 2-3 times. The initial and final deep stroking of the chest is repeated 4-5 times.

• Each rubbing technique together with repetition should last no more than 20-30 seconds, and kneading techniques should take no more than 40 seconds.

• Back massage lasts 7-8 minutes in total.

• After the massage procedure, the patient is recommended to rest (at least 15-20 minutes) and warm clothes made of soft fabric for the rest period.

• Some adjustments need to be made in connection with the peculiarity of the pathological process. In particular, in patients with a predominance of the productive nature of bronchopulmonary changes (pneumosclerosis), a greater number of rubbing techniques - stretching (linear, semicircular, circular rubbing, various types of sawing, stretching with one or two hands, etc.) should be introduced into the massage technique.

• In patients with a predominance of the destructive process (bronchiectasis), the number of vibration techniques should be increased (continuous labile vibration, chopping, tapping, shaking, etc.).

Massage of asymmetric zones of the chest according to Kuznetsov, 4 procedures every other day, lasting 30 minutes.

Techniques, methods of physical therapy, carried out in the implementation of the proposed method (see table. 2A):

Before the start of the first lesson, the exercise therapy instructor conducts a 6-minute walk test to assess exercise tolerance. 1 exercise therapy procedure includes breathing exercises, which are aimed at improving blood and lymph circulation in the affected lobe of the lung, improving the drainage function of the affected lung, accelerating the resorption of inflammatory foci in the lung tissue, as well as improving the ventilation of a healthy lung [1].

Exercises begin in the starting position (IP) lying on your back, with exercises for small and medium muscle groups (fingers, hands, feet), combined with static and dynamic breathing exercises. Exercises are performed at a slow pace, gradually increasing the depth of inhalation and exhalation, do not use exercises with forced and intense inhalation or exhalation, try to avoid delaying both inhalation and exhalation. During the procedure, the patient is asked to cough into a tissue, which is disposed of after the procedure. If pain, dizziness or other negative reactions occur, the patient pauses until these phenomena are eliminated.

Any exercise therapy procedure should consist of an introductory, main and final part. At the initial stage of rehabilitation for COVID-19 pneumonia, the total number of exercises can be in the range of 10-12, the ratio of special breathing exercises and exercises for training limb muscles is 1:1. Subsequently, it can change to 1:2.

The course of exercise therapy includes 4 procedures every other day, lasting 30 minutes.

To substantiate the proposed rehabilitation method, clinical studies were conducted at the clinic of the Institute of Vertebroneurology and Manual Medicine (Vladivostok).

The results of the performed studies are presented in tables 1 and 2.

On the basis of voluntary informed consent, the study included 160 patients aged 60 years and older (mean age of patients 63.71 ± 0.63 years) who had experienced coronavirus pneumonia (COVID-19), of which 36.25% were men and 63.75% women. Patients received 2 osteopathic corrections, 4 massage treatments and 4 exercise therapy treatments.

To control the dynamics of the patient's condition, the following criteria and indicators were selected:

- the clinical condition and the effectiveness of rehabilitation were judged by the change in saturation index (SpO2) in %, which was measured before the manual correction procedure (MC) and after the entire course of rehabilitation;

- also used indicators of the following scales and questionnaire: mMRC dyspnoea scale, Borg scale, 6-minute walk test, Hospital Anxiety and Depression Scale (NADS), European Quality of Life Questionnaire EQ-5 and Chest Circumference (CG);

- to assess the function of external respiration, spirometry was performed and the main indicators of lung vital capacity (VC), forced vital lung capacity (FVC) were assessed before treatment and after the entire course of rehabilitation, in% of the due;

Evaluation of the effectiveness of clinical control was carried out in accordance with the Interim Guidelines "Medical Rehabilitation in the New Coronavirus Infection (COVID-19)" [1].

An analysis of the effectiveness of the rehabilitation of patients with the use of osteopathic correction after suffering coronavirus pneumonia (COVID-19) showed a positive trend in subjective and objective data. Against the background of rehabilitation, all patients showed an improvement in the general condition and quality of life, a decrease in the symptoms of respiratory discomfort, an increase in chest excursion, and an increase in exercise tolerance.

The primary measure of efficacy was the change in saturation (SpO ₂ , %) (Table 1).

As a result, data were obtained: a comparative analysis of the effectiveness of rehabilitation in the process of implementing the proposed method showed an increase in the parameters of the function of external respiration (Table 1), namely, VC (p<0.05), FVC (p<0.05), increases hemoglobin saturation arterial blood oxygen (SPO2). All patients showed an improvement in their general condition, namely, a decrease in the level of anxiety and depression (p<0.05), a decrease in the degree of dyspnea (p<0.05) and an increase in chest excursion (p<0.05), an increase in tolerance to physical load (p<0.05) and improvement in the quality of life of patients (Table 2).

The results of the study allow us to conclude that the proposed method for the rehabilitation of patients who have experienced coronavirus pneumonia (COVID-19) using osteopathic correction, massage and exercise therapy has a positive effect on the condition of patients, improves external respiration function, namely vital capacity (VC), forced lung capacity (FVC), increases arterial hemoglobin saturation with oxygen (SPO2), increases exercise tolerance, reduces anxiety and depression, which favorably affects the further health and quality of life of patients.

Based on the foregoing, the claims under the claims are confirmed by the following examples of the implementation of the proposed method, but not limited to them. This will make it possible to recognize the proposed invention as meeting the patentability criterion "Industrial applicability" before the priority date claimed.

Clinical examples of the implementation of the proposed method.

Example 1

Patient Ch., 73 years old, was undergoing rehabilitation at the Institute of Vertebroneurology and Manual Medicine from 02/03/2021 to 02/12/2021. Coronavirus infection caused by COVID-19 (confirmed), moderate form. International Classification of Diseases (ICD): U07/1/J12. Complication: community-acquired bilateral polysegmental pneumonia, severe course. Computed tomography of the chest organs (CCT) from 12/25/2020 - the total percentage of lung parenchyma lesions is 68%.

Upon admission, it was found:

- assessment of the function of external respiration - vital capacity (VC) - 3.07 l (130.29%); forced vital capacity (FVC) - 2.91 l (111.5%); hemoglobin saturation of arterial blood with oxygen (SPO ₂ ) -97%.

During the initial examination by a chiropractor, dysfunctions of the chest and ribs were revealed: structural - posterior displacement of the VIII rib on the left; functional (respiratory) - limitation of inhalation.

- assessment of the severity of shortness of breath on the MRC scale - 0.

- Evaluation of exercise tolerance: 6-minute walk test 6MWD (i) = 410.91 m (proper value) - 333 m; Borg scale - 1.

- Assessment of the intensity of anxiety and depression according to the Hospital Anxiety and Depression Scale (HADS) (patient) - 5.

- Assessment of the quality of life according to the results of the European Quality of Life Questionnaire EQ-5. (patient) - 8.

- Chest circumference - 86 cm.

Rehabilitation was carried out, including osteopathic correction of dysfunctions identified during examination of the patient, according to the method described above. The procedure was performed in the morning, the total duration of the procedure was 40 minutes. A course of massage and exercise therapy was also prescribed, according to the method described above. The total duration of one procedure is 30 minutes.

Functional indicators after the course of rehabilitation: assessment of the function of external respiration - vital capacity (VC) - 3.23 l (137.16%); forced vital capacity of the lungs (FVC) - 3.08 l (118.3%); hemoglobin saturation of arterial blood with oxygen (SPO ₂ ) - 98%.

- Evaluation of the severity of shortness of breath on the MRC scale - 0.

- Assessment of exercise tolerance: 6-minute walk test 6MWD (i) = 410.91 m (proper value) - 360 m; Borg scale - 0.

- Assessment of the intensity of anxiety and depression according to the Hospital Anxiety and Depression Scale (HADS) (patient) - 0.

- Assessment of the quality of life according to the results of the European Quality of Life Questionnaire EQ-5. (patient) - 6.

- Chest circumference - 89 cm.

Objectively: the patient's condition is satisfactory, she notes an increase in exercise tolerance, a decrease in dyspnea.

Thus, the use of this method of rehabilitation made it possible to: improve the parameters of the function of external respiration, increase the saturation of arterial blood hemoglobin with oxygen, stabilize hemodynamics, reduce the severity of somatic dysfunction, improve objective health indicators and the general condition of the patient.

Example 2

Patient K., 67 years old, was undergoing rehabilitation at the Institute of Vertebroneurology and Manual Medicine from 05/05/2021 to 05/14/2021. Coronavirus infection caused by COVID-19 (confirmed), moderate form. International Classification of Diseases (ICD): U07/1/J12. Complication: community-acquired bilateral polysegmental pneumonia, severe course. Computed tomography of the chest organs (CCT) from 01/27/2021 - the total percentage of lung parenchyma lesions is 49%.

Upon admission, it was found:

• Evaluation of the function of external respiration - vital capacity (VC) - 3.11 l (79.2%); forced vital capacity (FVC) - 3.04 l (75.9%); hemoglobin saturation of arterial blood with oxygen (SPO ₂ ) - 97%.

• During the initial examination by a chiropractor, dysfunctions of the chest and ribs were revealed: structural - external torsion of the III rib on the left, internal torsion of the IV rib on the right; functional (respiratory) - limiting the mobility of the diaphragm on the left.

- Evaluation of the severity of shortness of breath on the MRC scale - 2.

- Assessment of exercise tolerance: 6-minute walk test 6MWD (i) = 487.21 m (proper value) - 342 m; Borg scale - 3.

- Assessment of the intensity of anxiety and depression according to the Hospital Anxiety and Depression Scale (HADS) (patient) - 17.

- Assessment of the quality of life according to the results of the European Quality of Life Questionnaire EQ-5. (patient) - 11.

- Chest circumference - 100 cm.

Rehabilitation was carried out, including osteopathic correction of dysfunctions identified during examination of the patient, according to the method described above. The procedure was performed in the morning, the total duration of the procedure was 40 minutes. A course of massage and exercise therapy was also prescribed, according to the method described above. The total duration of one procedure is 30 minutes.

Functional indicators after the course of rehabilitation: evaluation of the function of external respiration - vital capacity (VC) - 3.25 l (82.7%); forced vital capacity (FVC) - 3.18 l (79.4%); hemoglobin saturation of arterial blood with oxygen (SP02) - 98%.

- Evaluation of the severity of shortness of breath on the MRC scale - 1.

- Assessment of exercise tolerance: 6-minute walk test 6MWD (i) = 487.21 m (proper value) - 351 m; Borg scale - 2.

- Assessment of the intensity of anxiety and depression according to the Hospital Anxiety and Depression Scale (HADS) (patient) - 9.

- Assessment of the quality of life according to the results of the European Quality of Life Questionnaire EQ-5. (patient) - 8.

- Chest circumference - 101 cm.

Objectively: the patient's condition is satisfactory, he notes an increase in exercise tolerance, improvement in functional parameters, and a decrease in dyspnea.

Thus, the use of this method of rehabilitation made it possible to: improve the parameters of the function of external respiration, increase the saturation of arterial blood hemoglobin with oxygen, stabilize hemodynamics, reduce the severity of somatic dysfunction, improve objective health indicators and the general condition of the patient.

Example 3

Patient F., 71 years old, was undergoing rehabilitation at the Institute of Vertebroneurology and Manual Medicine from 12/23/2020 to 12/30/2020. diagnosed with Coronavirus infection caused by COVID-19 (confirmed), severe form. International Classification of Diseases (ICD): U07/1/J12. Complication: community-acquired bilateral polysegmental pneumonia, severe course. Computed tomography of the chest organs (CCT) from 12/27/2020 - the total percentage of lung parenchymal lesions is 82%.

Upon admission, it was found:

- assessment of the function of external respiration - vital capacity (VC) - 3.02 l (71.1%); forced vital capacity of the lungs (FVC) - 3.18 l (74.5%); hemoglobin saturation of arterial blood with oxygen (SPO ₂ ) - 95%.

ERS C6-C7 on the left, FRS D4-D5 on the left, ERS L3-L4, L5-S1 on the right, FRS D5-D6, D8-D9 on the right, chest and rib dysfunctions: structural - upper displacement of the 1st rib on the left, anterior displacement of the 5th rib on the left and 3 ribs on the right, internal torsion 4 ribs on the right, superior lateral flexion 2 ribs on the right; functional (respiratory) - restriction of diaphragm mobility

- assessment of the severity of shortness of breath on the MRC scale - 2.

- Evaluation of exercise tolerance: 6-minute walk test 6MWD (i) = 415 m (proper value) - 452 m; Borg scale - 3.

- Assessment of the intensity of anxiety and depression according to the Hospital Anxiety and Depression Scale (HADS) (patient) - 4.

- Assessment of the quality of life according to the results of the European Quality of Life Questionnaire EQ-5. (patient) - 9.

- Chest circumference - 101 cm.

Rehabilitation was carried out, including osteopathic correction of dysfunctions identified during examination of the patient, according to the above method. The procedure was performed in the morning, the total duration of the procedure was 40 minutes. A course of massage and exercise therapy was also prescribed, according to the method described above. The total duration of one procedure is 30 minutes.

Functional indicators after the course of rehabilitation: assessment of the function of external respiration - vital capacity (VC) - 4.11 l (96.76%); forced vital capacity (FVC) - 4.11 l (96.3%); hemoglobin saturation of arterial blood with oxygen (SPO2) - 99%.

- Evaluation of the severity of shortness of breath on the MRC scale - 0.

- Assessment of exercise tolerance: 6-minute walk test 6MWD (i) = 425 m (proper value) - 452 m; Borg scale - 1.

- Assessment of the intensity of anxiety and depression according to the Hospital Anxiety and Depression Scale (HADS) (patient) - 0.

- Assessment of the quality of life according to the results of the European Quality of Life Questionnaire EQ-5. (patient) - 6.

- Chest circumference - 104 cm.

Objectively: the patient's condition is satisfactory, he notes an increase in exercise tolerance, a decrease in shortness of breath.

Thus, the use of this method of rehabilitation made it possible to: improve the parameters of the function of external respiration, increase the saturation of arterial blood hemoglobin with oxygen, stabilize hemodynamics, reduce the severity of somatic dysfunction, improve objective health indicators and the general condition of the patient.

The given examples of the implementation of the method in no way limit the scope of claims under the claims.

The claimed method, which is a technically simple, reliable, structured, and also physiologically expedient rehabilitation procedure that improves the function of external respiration against the background of somatic dysfunctions in patients with previous coronavirus pneumonia (COVID-19) using osteopathic correction, massage and exercise therapy, which is effective, maximum safety, contributes to the normalization of the act of breathing, significantly improving the health and well-being of the patient.

The introduction of this method of manual, osteopathic impact will allow the most effective and safe, in the shortest possible time, to rehabilitate patients who have had coronavirus pneumonia (COVED-19), against the background of somatic dysfunctions.

This method can be widely recommended for use in the rehabilitation of patients with coronavirus pneumonia (COVID-19).

Information sources

• Temporary guidelines. Medical rehabilitation for novel coronavirus infection (COVID-19). Version 2/31.07.2020.

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• Yao S, Hassani J, Gagne M, George G, Gilliar W. Osteopathic manipulative treatment as a useful adjunct tool in pneumonia. J Vis Exp.2014 May 6;(87):50687. doi: 10.3791/50687. PMID: 24836893; PMCID: PMC4173698.

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• RF patent RU 2296551 C1, 2007.

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• Patent for the invention of the Russian Federation No. 2735797 (KHADARTSEV ALEXANDER AGUBECHIROVICH, SIMONENKOV ALEXEY PAVLOVICH, TOKAREV ALEXEY RAFAILOVICH), 09.11.2020).

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Claims (9)

A method for the rehabilitation of patients who have undergone coronavirus pneumonia COVID-19, including a course of procedures using osteopathic correction techniques, massage and exercise therapy, characterized in that osteopathic correction is performed according to the scheme in accordance with Table 1A: - correction of structural dysfunctions of the ribs, - correction of respiratory dysfunctions of the ribs, - correction of dysfunctions of the thoracic spine, - correction of dysfunctions of the thoracic diaphragm, - correction of dysfunctions of the auxiliary respiratory muscles of the upper aperture; the first procedure of osteopathic correction is carried out upon admission of the patient for rehabilitation, the second procedure is carried out before the completion of the rehabilitation course, the duration of the procedure is 40 minutes each; as a massage, chest massage according to Kuznetsov is carried out four procedures every other day, the duration of each procedure is 30 minutes; as physiotherapy exercises, breathing exercises according to Strelnikova are carried out and exercises are performed in accordance with the table. 2A, while physiotherapy exercises are carried out four times a day for 30 minutes.