RU2783493C2 - Method for rehabilitation of patients with panic attacks - Google Patents

Abstract

FIELD: medicine; restorative medicine.

SUBSTANCE: invention relates to the field of medicine, namely to restorative medicine; it can be used in rehabilitation of patients with panic attacks. Trainings using “Carbonic” training machine, soft manual methods, and Jacobson muscle relaxation method are carried out. Examination includes determination of cerebrovascular reaction of brain vessels to hypercapnia, assessment of cardiovascular reaction, cardio-respiratory reserve, by results of which a patient is selected with an individual mode of breathing trainings on “Carbonic” training machine. Trainings on “Carbonic” training machine are carried out daily, 1-2 times a day, for 14-30 days, duration of each training is from 2 to 20 min, with addition of 1 min in good health. Following modes are used: “Preventive” – a composition of a breathing mixture is CO₂ - 3,8-4,8%, O₂ - 17-15%, or “Treating” – a composition of a breathing mixture is CO₂ - 4-5%, O₂ - 15-13%. A working position of a damper of a breathing volume of a dead space is 500-1000 ml, a course of fascial manipulations is carried out once a week, for 4-5 weeks, for 30-45 min, muscle relaxation sessions are carried out in the form of individual trainings 1-2 times a week, for 30-60 min, for 2 weeks, as well as in the form of self-sessions, which are carried out by the patient 1-2 times a day, from 5 to 15 min, for 14-16 days, while a number of hypercapnic-hypoxic trainings on “Carbonic” training machine and sessions of Jacobson muscle relaxation, sufficient for achievement of a positive rehabilitation effect, is 2-3 courses, with an interval between courses of 1-3 months, and a course of fascial manipulations is carried out only with the use of “Treating” individual training mode on “Carbonic” training machine.

EFFECT: method provides reduction in a number of panic attacks and reduction in their severity, as well as improvement of physiological functions of the patient’s body.

2 cl, 2 tbl, 3 ex

Description

The invention relates to medicine, namely to neurology, and can be used in the treatment of patients with panic attacks.

Today, panic attacks are quite common. According to statistics, every fifth person on Earth has experienced a panic attack at least once in their life. Although this does not mean that these seizures have acquired

systematic character. However, there are people who suffer from this

illness for quite a long time, if not constantly. According to various studies, the prevalence of the disease is 2-5%.

It has been established that this mental disorder most often affects people aged 25 to 64 years. Moreover, there are 3-4 times more women among them than men.

Fragmentary information about the use of soft manual techniques for the treatment of panic attacks is known from the prior art. So, from the prior art, it is known to use soft tissue manual therapy for cerebrovascular pathologies, in particular for panic attacks (see Clinic of Neurology and Manual Medicine of Academician I.P. Pavlov First St. Petersburg State Medical University https://www. 1spbgmu.ru/klinika/kliniki-pspbgmu/461-glavnaya/universitet/sructure/universitetskaya-klinika/kliniki/klinika-nevrologii-i-manualnoj-meditsiny/804-klinika-nevrologii-i-manualnoj-meditsiny).

According to experts, these techniques are effective and safe. But there is no complete information about the techniques used and the effectiveness of these techniques.

From the prior art, it is known to use interval hypoxic training and gas-air carbon dioxide baths for the treatment of patients with neurocirculatory asthenia with increased meteosensitivity, characterized very often by "panic attacks" of a sympathetic-adrenal nature (increased blood pressure, tachycardia, fear, feeling cold, weakness, etc. ) (see RF patent No. 2503468, A61 M 16/10, A 61 M 33/02, publ. 10.01.2014).

The procedure for interval hypoxic training with a hypoxic mixture in a known method is carried out with an oxygen content of 16 to 18%, reducing the oxygen concentration by 5-6 procedures to 11%, breathing with the mixture is carried out with the patient sitting through a mask, periods of breathing with a hypoxic mixture alternate with periods of atmospheric breathing air: 1-2 procedures for 4 breathing series; subsequent procedures for 6 series of breathing, the total time of the procedure is from 20 to 60 minutes, then after resting after 1.5-2 hours, the procedures of the gas-air carbon dioxide bath are carried out with the temperature of the air-gas mixture of 28-30 ° C, with the mixture flowing for 3 minutes at a flow rate of 50 l / min, the concentration of carbon dioxide is 30%, the procedure time is 15-20 minutes, for a course of 12 daily procedures against the background of drug therapy.

The technical result of the known method for the treatment of neurocirculatory asthenia in persons with increased weather sensitivity is to increase the effectiveness of treatment, improve the state of many regulatory systems, mobilize the reserve systems of the body, reduce weather sensitivity and increase tolerance to adverse external weather factors.

However, in the description of the known method, there is no information on how the use of this method contributes to the rehabilitation of patients suffering from panic attacks.

From the prior art, it is known to study the effect of carbonic therapy on the cerebral hemodynamics of patients with panic attacks, conducted in order to improve the methods of rehabilitation of this group of patients (see Scientific and Sports Bulletin of the Urals and Siberia 2021 No. 1 (29), pp. 42-47 https://uralgufk.ru/sites/default/files/news/files/2021-1.pdf). This study is selected as the closest analogue of the proposed method.

The inclusion criteria for the study group were women and men aged 21 to 45 years with a verified diagnosis according to ICD-10 "Panic Disorder" (A41.0). The exclusion criteria were acute somatic and infectious diseases, chronic diseases in the acute stage, and individual intolerance to oxygen deficiency and carbon dioxide excess. All patients underwent a comprehensive examination, including a clinical assessment of the neurological status, neuropsychological testing in dynamics, and a study of cerebral hemodynamics. Carbonic testing was carried out to select an individual training regimen. Respiratory training was carried out using the 5th generation breathing simulator "Carbonic" for 5 weeks, 1 time per day, according to the individual training regimen from 3 minutes to 15 minutes. The state of cerebral hemodynamics was studied using extended transcranial duplex scanning (TDKS extended) using modern certified equipment Toshiba Xario 200, according to the standard method of transcranial ultrasound examination. As a result of the study, it was shown that under the influence of Carbonic therapy, disturbances in the vertebrobasilar basin and venous cerebral circulation of cerebral circulation decrease, vascular tone normalizes, hyperresistance of cerebral arteries decreases, autoregulation of cerebral blood flow is restored. According to the authors of this study, therapeutic hypoxia and hypercapnia are promising areas of medicine to improve the functions of vital organs, in particular, the brain.

However, the results of these studies reflect only the prospects of therapeutic hypoxia and hypercapnia for improving the functions of vital organs, in particular, the brain, they were carried out only with the aim of improving the methods of rehabilitation of this group of patients and do not contain specific conclusions and recommendations on how research is improving the methods of rehabilitation of patients diagnosed with panic attacks.

Thus, the technical result, to which the claimed invention is directed, is the creation of a practically feasible method for the rehabilitation of patients diagnosed with panic attacks, which is highly effective, can significantly reduce the number of panic attacks and reduce their severity, improve the physiological functions of the patient's body.

The specified technical result is achieved by the fact that in the method

rehabilitation of patients with a diagnosis of panic attacks, including a preliminary examination of the patient, which includes transcranial duplex scanning of the cerebral arteries and neuropsychological testing, examination of the patient at the Karbonik medical diagnostic complex for individual selection of a training regimen, followed by training using the Carbonik breathing simulator, according to the invention, examination of a patient at the Karbonik medical and diagnostic complex with individual selection of a training regimen, includes determining the cerebrovascular reactivity of cerebral vessels to hypercapnia, assessing cardiovascular reactivity, assessing the cardiorespiratory reserve, based on the results of which, based on gas exchange and functional state data, the patient is selected an individual mode of breathing training on the Carbonic simulator, in addition, the method additionally includes the use of soft manual techniques, which are used comfort fascial manipulations by Luigi Stecco, the dynamics and evaluation of which is carried out using ultrasound scanning and the Jacobson myelorelaxation technique, while, when performing fascial manipulations, the selection of coordination centers for the treatment of seals in the fascia is carried out individually for each patient, based on the data of ultrasound examination of the cervical of the spine, by searching for compactions of the main substance of the fascia and softening it by friction-sliding, which is performed by the lateral surface of the elbow or interphalangeal joints of the fingers, hypercapnic-hypoxic training on the "Carbonic" breathing simulator is carried out daily 1-2 times a day for 14-30 days, the duration of each training session is from 2 to 20 minutes, with the addition of 1 minute if you feel well, the following modes are used as individually selected modes: "Preventive" or "Therapeutic", and for the "Therapeutic" mode, the composition of the respiratory mixture CO2-4 is used -5% , O2-15-13%, and for the "Prophylactic" mode - CO2-3.8-4.8%, O2-17-15%, while using the working position of the valve of the respiratory volume of the dead space 500-1000 ml, course fascial manipulations is 1 time per week for 4-5 weeks, with a session duration of 30 to 45 minutes, myelorelaxation sessions according to Jacobson are carried out in the form of individual sessions 1-2 times a week, lasting from 30 to 60 minutes, for 2 weeks, as well as in the form of independent sessions that the patient conducts 1-2 times a day lasting from 5 to 15 minutes for 14-16 days, while the number of hypercapnic-hypoxic training on the Carbonic breathing simulator and myelorelaxation sessions according to Jacobson , sufficient to achieve a positive effect of rehabilitation, is 2-3 courses, with an interval between courses of 1-3 months, and the course of fascial manipulations is carried out only when using an individual training regimen on the Carbonic simulator "Therapeutic".

In addition, the pre-examination additionally includes an ultrasound examination of the cervical spine and ultrasound duplex scanning of the branches of the aortic arch.

At the same time, according to the method of transcranial ultrasound, systolic (Vps), diastolic (Ved) and average (Tamx) blood flow velocities of the middle (MCA), anterior (ACA) and posterior (PCA) cerebral arteries, as well as in the basilar artery (BA) are determined and vertebral arteries (VA) in the V1, V2, and V4 segments, Purcelo resistance indices and Gosling pulsation indices, the Lindegard index is calculated - the hemispheric index of cerebral blood flow, PIMK - the ratio of peak systolic velocity in the MCA and in the homolateral internal carotid artery, metabolic tests are performed: hypercapnic - breath holding for 15 seconds and hypocapnic - rapid breathing for 15 seconds, the average blood flow velocity is measured at rest, in the middle cerebral artery during breath holding and with rapid breathing, cerebral perfusion pressure and cerebrovascular resistance indices are calculated, using ultrasound examination of the branches of the aortic arch is estimated intima media complex in carotid, subclavian and vertebral night arteries, the peak systolic and average blood flow velocity in the vertebral arteries in the V1, V2, V4 segments, the linear blood flow velocity in the vertebral and jugular veins are determined, functional tests are performed with the head turned to the right and left along the vertebral arteries in the V2 and V4 segments.

Examination of a patient at the Karbonik medical and diagnostic complex with individual selection of a training regimen, including the determination of cerebrovascular reactivity of cerebral vessels to hypercapnia, assessment of cardiovascular reactivity, assessment of cardiorespiratory reserve, based on the results of which, based on gas exchange and functional state data, an individual respiratory regimen is selected for the patient training on the Carbonic simulator allows for an individual approach to each patient, taking into account the individual characteristics of each patient, which ensures high efficiency of rehabilitation.

It is the inclusion in the examination of the patient at the Karbonic medical and diagnostic complex with individual selection of the training regimen, the determination of the cerebrovascular reactivity of the cerebral vessels to hypercapnia, the assessment of cardiovascular reactivity, the assessment of the cardiorespiratory reserve, based on the results of which the patient is selected an individual breathing training regimen on the Carbonic simulator, allows to ensure high efficiency of the proposed method.

This is ensured by the fact that with the help of a gas analyzer built into it, the analysis of the concentration of gases in the exhaled air of each patient is carried out individually, which allows, based on the results of this gas analysis in the exhaled air, using an automatic program, to determine an individual training regimen on the Carbonic simulator.

Additional inclusion of soft manual techniques, which use Luigi Stecco's fascial manipulations, and individual for each patient selection of coordination centers for the treatment of seals in the fascia, by searching for seals in the main substance of the fascia and softening it through friction, which is performed by the lateral surface of the elbow or interphalangeal joints of the fingers , provides high efficiency of the claimed method of rehabilitation.

This is ensured due to the fact that the implementation of these manipulations helps to restore the fluid state of the main substance in the fascia, facilitating its transition from the gel state to the sol, which in turn improves cerebral hemodynamics by increasing the cerebral collateral reserve, normalizing the processes of autoregulation of cerebral circulation, which contributes to the high efficiency of the claimed method of rehabilitation by improving the quality of life of patients, a guaranteed high reduction in the severity of psycho-emotional disorders, increasing the tolerance of brain structures and the body to anxiety states, stimulates microcirculation, thereby significantly reducing the level of anxiety.

Due to the fact that fascial manipulations are directly related to the effect on blood vessels, hypertonicity and muscle asymmetry, it improves blood flow in the vertebrobasilar basin and, as a result, contributes to the high efficiency of rehabilitation.

The additional inclusion in the claimed method of rehabilitation of the Jacobson myelorelaxation technique helps the patient cope with anxiety and tension, thereby preventing the occurrence of a panic attack. This is ensured due to the fact that this method of myelorelaxation according to Jacobson allows you to relieve general stress and helps to restore the body. This technique can have a general strengthening effect. Neuromuscular relaxation helps to relax certain, highly stressed areas (such as the arms or legs) and in some cases can reduce anxiety.

Muscle relaxation course according to Jacobson is the prevention of psychogenic muscle spasm and works in conjunction with the “Therapeutic” and “Preventive” modes of the breathing training course on the Carbonic simulator to reduce the presence of the number of panic attacks, alleviate their course and reduce the recurrence of panic attacks.

The implementation of the dynamics and evaluation of ongoing fascial manipulations according to Luigi Stecco, using ultrasound scanning, allows visualizing vertebrogenic and non-vertebrogenic vascular compressions, monitoring their severity in real time in the dynamics of rehabilitation, substantiating the need and duration of the use of soft manual techniques in rehabilitation and their focus, clearly define the points of maximum application, which greatly contributes to the effectiveness of rehabilitation.

The duration of the daily hypercapnic-hypoxic training on the breathing simulator "Carbonic", carried out daily 1 - 2 times a day for 14-30 days, the duration of each training is from 2 to 20 minutes, with the addition of 1 minute in good health, use as individually selected “Preventive” or “Therapeutic” modes, used compositions of the respiratory mixture CO2-4-5%, O2-15-13%, for the “Therapeutic” mode, and for the “Prophylactic” mode - CO2-3.8-4, 8%, O2-17-15%, while using the working position of the dead space tidal volume valve of 500-1000 ml, conducting a course of fascial manipulations once a week for 4-5 weeks, the duration of a session of fascial manipulations is from 30 to 45 minutes, conducting myelorelaxation sessions according to Jacobson in the form of individual sessions 1-2 times a week from 30-60 minutes, as well as in the form of independent sessions that the patient conducts 1-2 times a day from 5 to 15 minutes t within 14-16 days, the applied number of 2-3 rehabilitation courses, including training conducted by the patient on the Carbonic breathing simulator and sessions of myelorelaxation according to Jacobson, as well as a course of fascial manipulations only when using an individual training regimen on the Carbonic simulator "Therapeutic", sufficient to achieve a positive effect of rehabilitation, are selected by the applicant experimentally and are indicators obtained by the applicant as a result of the practical application of this technique for the rehabilitation of patients diagnosed with panic attacks, in which a high efficiency of rehabilitation of patients with this diagnosis is achieved.

Determination of systolic (Vps), diastolic (Ved) and average (Tamx) blood flow velocity in the middle (MCA), anterior (ACA) and posterior (PCA) cerebral arteries, as well as in the basilar artery (BA) and vertebral by the method of transcranial ultrasound examination arteries (PA) in the V1, V2 and V4 segments, Purcelo resistance and Gosling pulsation indices, calculation of the Lindegard index - hemispheric index of cerebral blood flow, PIMK - the ratio of peak systolic velocity in the MCA and in the homolateral internal carotid artery, metabolic test: hypercapnic - delay breathing for 15 seconds and hypocapnic - rapid breathing for 15 seconds, measurement of the average blood flow velocity at rest, in the middle cerebral artery during breath holding and rapid breathing, calculation of cerebral perfusion pressure and cerebrovascular resistance indices, using ultrasound examination of the branches of the aortic arch, assessment of complex intima media in carotid, subclavian and vertebral arteries therapies, determination of peak systolic and mean blood flow velocity in the vertebral arteries in the V1, V2, V4 segments, linear blood flow velocity in the vertebral and jugular veins, functional tests with a head turn to the right and left along the vertebral arteries in the V2 and V4 segments, performed before and after the implementation of the rehabilitation of patients using the proposed method, provides reliable information about the clinical effectiveness of the use of the proposed method in the rehabilitation of patients.

Thus, the measurement of the average blood flow velocity at rest, in the middle cerebral artery during breath holding and rapid breathing, provides an assessment of the reserve of vasodilation and vasoconstriction of the middle cerebral artery.

Calculation of indices of cerebral perfusion pressure and cerebrovascular resistance using ultrasound examination of the branches of the aortic arch, assessment of media complex-intima in carotid, subclavian and vertebral arteries, determination of peak systolic and mean blood flow velocity in vertebral arteries in segments V1, V2, V4, linear blood flow velocity in the vertebral and jugular veins, performing functional tests with turning the head to the right and left along the vertebral arteries in the V2 and V4 segments and the presence of positive dynamics of the resistance index against the background of the rehabilitation, indicates a regression of peripheral vasospasm and an increase in self-regulation mechanisms when using normobaric hypercapnic-hypoxic training , fascial manipulations by Luigi Stecco and myelorelaxation techniques by Jacobson.

An increase in the Lindegard index after rehabilitation indicates the correction of hypoperfusion due to the correction of the cerebrovascular reserve of cerebral circulation, as well as due to a decrease in peripheral vascular resistance.

The applicant, for the first time, on the basis of ultrasound and TKDS data, analyzed the relationship between the clinical manifestations of panic attacks and concomitant cervical muscular-tonic syndrome with the state of cerebral hemodynamics based on the assessment of blood flow velocities at rest and during functional tests, assessment of venous outflow, peripheral resistance indices and the state of blood flow in the vertebrobasilar basin.

The use of the technique of transcranial ultrasound examination and the additional inclusion in the preliminary examination of ultrasound examination of the cervical spine and ultrasound duplex scanning of the branches of the aortic arch, is due to the fact that it is known from psychophysiological studies that psychoemotional disorders lead to a decrease in the rate of cerebral blood flow through the vertebral arteries, venous outflow by level of cerebral veins and veins of the cervical spine.

The use of the proposed method of rehabilitation has a positive effect on the state of cerebral hemodynamics in the form of:

- restoration of indicators of venous circulation in the carotid and vertebrobasilar basins;

- reduction of vertebrogenic effects on the vertebral veins during rehabilitation by 2.1 times;

- reduction of jugular vein compression by 2.3 times,

which proves the effectiveness of the method used.

In the study of the blood flow velocity in the vertebral arteries in the V2 segment, against the background of the rehabilitation measures, an increase in the blood flow velocity in the vertebral arteries was noted in patients who underwent basic therapy + myofascial manipulations + myelorelaxation according to Jacobson + breathing training on the Carbonic simulator.

According to the applicant, these changes in patients are directly related to the effect on myofascial extravasal vascular compression, hypertonicity and muscle asymmetry, which improves blood flow in the vertebrobasilar basin.

In the study of the systolic blood flow velocity in the vertebral arteries in the V4 segment, a significant (p<0.05) increase in blood flow velocity was revealed, which, according to the applicant, is associated with the effect of Carbonic therapy on peripheral vascular resistance, which improves blood flow in the vertebral arteries.

In patients who underwent rehabilitation in the form of fascial manipulations, myorelaxation according to Jacobson and Carbonic therapy, the following was revealed: symmetry of the sternocleidomastoid and precranial muscles, complete restoration of venous outflow indicators at the level of the cerebral veins and veins of the cervical spine, normoperfusion of cerebral blood flow according to the hemispheric index cerebral blood flow - Lindegard index, restored indicators of cardiovascular reactivity, gas analysis. Gas homeostasis has become stable. According to the results of the study, the most significant change in indicators after rehabilitation measures by the claimed method can be noted, such as: LBF in JV decreased by 2.2 times, and increased by 2.35 times; LBF PV decreased by 3-3.5 times, the indicator of cardiovascular reactivity increased by 3.7-5.09 times, the concentration of CO2 in the exhaled air increased by 2.8 times.

Thus, in patients who underwent a complex of rehabilitation procedures by the claimed method, there was a decrease in the level of extravasal effects on the venous circulatory system, an increase in the concentration of CO2 in the alveolar air, restoration of cardiovascular reactivity, which is directly related to the impact of manual techniques and Jacobson's myelorelaxation techniques on the area of myofascial compression, as well as with the influence of Carbonic therapy on the psycho-emotional state of patients in the study group.

In the study of the extravasal effect of the vertebral veins of the studied patients, a positive trend was revealed. According to the applicant, this is due to the positive impact of fascial manipulations directly on the myofascial effect of the vertebral veins, as well as through the use of Jacobson myelorelaxation techniques and patient training on the Carbonic apparatus, which helps to increase the tolerance of brain structures and the patient's body to hypoxia, stimulating microcirculation and reducing the level of anxiety - in combination, having a positive effect on the patient's muscle tone, reducing muscle tension and leading to a decrease in the compression effect of the vertebral veins.

In patients who underwent rehabilitation by the claimed method, there was a decrease in the compression of the jugular veins after rehabilitation, with the greatest change observed in the right jugular vein. According to the applicant, this is due both to the direct effect of the complex of fascial manipulations on the regression of the myofascial syndrome, which contributes to the compression of the veins by the cervical myofascial frame, and also due to the effect of Carbonic therapy on patients' anxiety, which contributes to the aggravation of the myofascial syndrome due to changes in the central nature.

Thus, according to the data obtained, the claimed therapeutic effects with the inclusion of the Carbonic breathing simulator, fascial manipulations according to the method of Luigi Stecco and myelorelaxation techniques according to Jacobson have a positive effect on a number of basic clinical and functional indicators in patients diagnosed with panic attacks. The evaluated technology for the use of respiratory simulators at the outpatient stage of rehabilitation of patients diagnosed with panic attacks has systemic rehabilitation effects in the form of improved blood circulation, cerebral hemodynamics, psycho-emotional sphere, general physical tone, and clinical manifestations of vertebrobasilar insufficiency.

The application of the proposed method allows to improve physiological functions and significantly reduce the severity of manifestations of panic attacks. There were no cases of deterioration in the condition and development of negative reactions under the influence of the conducted impact. This method allows to achieve a high overall efficiency of medical rehabilitation of patients with a diagnosis of "panic attacks" without causing pronounced adverse reactions.

The method for treating patients with a diagnosis of "panic attacks" is aimed at improving the efficiency of rehabilitation treatment for this group of patients and can be applied in outpatient practice.

After the course of rehabilitation, a positive effect on clinical efficacy was manifested in the form of a regression of the clinical manifestations of panic attacks (see Table No. 1). The table for comparison shows the efficiency data of the proposed method (column 2) and the method selected for the closest analogue (column 3).

In the course of the studies, after using the proposed method of rehabilitation, an assessment of hemodynamic parameters in the vessels of the neck and head was carried out (see Table No. 2). For comparison, Table No. 2 presents hemodynamic parameters for three groups of patients who received different treatments:

Group A - treatment of panic attacks only with medication;

Group B - exercise therapy treatment + massage;

Group B - treatment with the use of fascial manipulations + myorelaxation according to Jacobson;

Group G - treatment using fascial manipulations + muscle relaxation according to Jacobson + respiratory training on the simulator.

The method is carried out as follows.

The study and clinical testing of the proposed method was carried out in the department of the Clinic of Professor Kinzersky (Chelyabinsk) and on the basis of the Department of Restorative Medicine and Physical Rehabilitation of the Ural State University of Physical Culture. The study involved 148 people (68 men and 80 women) aged 24 to 45 years. The exclusion criteria were acute somatic and infectious diseases, chronic diseases in the acute stage, and individual intolerance to oxygen deficiency and carbon dioxide excess.

Upon admission, the patient undergoes a preliminary examination, including transcranial duplex scanning of the cerebral arteries and neuropsychological testing. After that, the patient undergoes an examination at the Karbonik medical and diagnostic complex for individual selection of a training regimen. Examination of a patient at the Karbonic medical and diagnostic complex with individual selection of a training regimen, includes determining the cerebrovascular reactivity of cerebral vessels to hypercapnia, assessing cardiovascular reactivity, assessing the cardiorespiratory reserve, based on the results of which, based on gas exchange and functional state data, an individual respiratory regimen is selected for the patient. training on the simulator "Carbonic".

The treatment and diagnostic complex "Carbonic" contains a control unit with a gas analyzer, a damper electric drive, an air flow separation unit and software for a personal computer. This allows you to automatically take into account the state of the body during training. The treatment and diagnostic complex (MDC) "Carbonic" is used for automated selection of the breathing training regimen on the breathing simulator "Carbonic", diagnosing the state of gas exchange, metabolism, cardiorespiratory reserve, cardiovascular reactivity, cerebrovascular reactivity and aerobic performance.

The selection of the training mode allows you to individually recommend the mode of breathing training on the Carbonic simulator, based on the data of gas exchange and the functional state of the patient. Determination of the training regimen consists of two stages: at the first stage, the patient will be required to breathe for 1 minute at a calm rhythm through the gas analysis unit, disconnected from the body of the device with a damper. The program will automatically determine the initial state of respiratory function and make an initial recommendation for choosing a training mode from three integrated options. At the second stage, the program will determine the optimal position of the damper for the patient to achieve an effective CO2 concentration and make a conclusion on the training regimen. According to the program, as soon as the patient manages to keep the CO2 concentration within the specified range (namely, for the Therapeutic 4-5% CO2 mode), in conclusion, the damper position is taken, at which the CO2 concentration was kept as recommended for training on the breathing simulator. At the same time, the patient can independently correct the FetCO2 range in the proposed modes and choose a mode that differs from that recommended by the program.

Each value of the working volume (flap) corresponds to a certain individual concentration of CO2 and O2 in the alveolar air, which is measured using gas analysis and shown on the display of a personal computer and in conclusion. Recommended from 500-1000 ml. For all people in general, the optimal value of CO2 in the body is 6%. The main thing is not only the composition of the concentration of the respiratory mixture in the mode, but also the change in concentration during one workout. That is, in the Therapeutic mode, the patient trains in only one position of the damper (which is individually selected, respectively, and the concentration of the gas mixture will be individually selected), and in the Preventive mode, the position of the damper changes over time during one training session.

After selecting the training mode and determining the optimal position of the damper to achieve an effective concentration of CO2 and O2, the patient proceeds to the stage of training on the Carbonic breathing simulator

The Carbonic simulator, developed under the guidance of Professor Kulikov V.P., allows, by training the body through a short-term decrease in the oxygen content and an increase in the carbon dioxide content in the blood, to radically improve the state of health and quality of life. The breathing simulator allows you to adjust the working volume and concentration of respiratory gases and is designed for use at home and outpatient conditions. "Carbonic" allows you to smoothly change and control the concentration of respiratory gases.

Breathing training is carried out as follows. The patient takes a comfortable position of the body (sitting, reclining, lying down). Sets the damper to the "500" position. Puts on a mask and breathes through the simulator. Breathing should be even, calm, without effort or delay (“breathe as you breathe”). If there are pronounced unpleasant sensations (palpitations, headache, dizziness, rise in blood pressure, etc.), the training is stopped. A second attempt can be made no earlier than an hour later, but preferably the next day or after consultation with a specialist.

Daily hypercapnic-hypoxic training is carried out daily 1-2 times a day for 14-30 days. The duration of each workout is from 2 to 20 minutes, with the addition of 1 minute if you feel good. As individually selected modes, the following modes are used: "Prophylactic" or "Therapeutic". For the "Therapeutic" mode, the composition of the respiratory mixture CO2-4-5%, O2-15-13% is used, and for the "Prophylactic" mode - CO2-3.8-4.8%, O2-17-15%, while , the working position of the valve of the respiratory volume of the dead space is 500-1000 ml.

The rehabilitation course also includes a course of fascial manipulations once a week according to the Luigi Stecco method for 4-5 weeks. The duration of a session of fascial manipulations is from 30 to 45 minutes. The selection of coordination centers for the treatment of seals in the fascia is carried out individually for each patient, depending on the anamnesis, general condition, and individual characteristics. The procedure is performed with the patient lying on his back, on his side, lying on his stomach. The method consists in searching for compactions of the main substance of the fascia and softening it through friction, which is carried out by the lateral surface of the elbow or by the interphalangeal joints of the fingers. The patient is placed on the couch on his back, the doctor begins to check the centers of coordination in different segments and checks the restriction of movement in different planes. Having found the most overloaded plane, the doctor begins to influence the centers of coordination by friction to create heat. After the procedure, aseptic inflammation is created in the affected area and, within a week, mobility is restored and muscle relaxation occurs, fascia sliding is restored. In patients diagnosed with panic attacks, sliding in the horizontal chain was most often disturbed. The course of fascial manipulations is performed only when using an individual training regimen on the "Carbonic" "Therapeutic" simulator.

Sessions of myelorelaxation according to Jacobson are carried out in the form of individual sessions 1-2 times a week for 30-60 minutes for 2 weeks, and then in the form of independent sessions, which the patient conducts 1-2 times a day for 15 minutes for 14 -16 days.

Methods of myelorelaxation according to Jacobson were carried out as follows. The goal is for the patient to learn to induce voluntary relaxation of the striated muscles at rest. At stage I, the patient performs the following exercises:

- lie on your back, bend your arms at the elbow joint and sharply tighten your muscles

hands (be sure to pay attention to the emerging sensation of muscle

voltage);

- relax the muscles and let the arms fall freely (pay attention to

the resulting muscle relaxation and repeat the tension as much as possible and

muscle relaxation several times);

- strain the biceps at first strongly, then more and more weakly

(be aware of weak muscle contractions and remain in a state of complete

immobility with relaxed flexor muscles).

After that, the patient performs exercises aimed at relaxing the rest of the muscles - the flexors and extensors of the trunk, neck, shoulder girdle, etc. last of all, the muscles of the face and eyes (take their eyes to the side and cause sensations of muscle tension), the muscles of the larynx and tongue involved in the act of speech.

At the second stage, differential relaxation is performed.

The patient, sitting, relaxes the muscles that are not involved in maintaining the body in an upright position, then, after special exercises, relaxes the muscles when writing and reading, which are not involved in these acts.

At the third stage, the patient in everyday life notes:

- tension of what muscles occurs in him during affective states, from which he would like to get rid of (fear, anxiety, embarrassment);

- reduces and then prevents the accompanying local muscle tension and thus gets rid of these unwanted emotions.

Individual myelorelaxation classes according to Jacobson are held 1-2 times a week for 30-60 minutes for 2 weeks. In addition, the patient independently conducts sessions 1-2 times a day for 5-15 minutes for 14-16 days.

When performing the procedure of fascial manipulations, myelorelaxation according to Jacobson and Carbonic training on the same day, the sequence of procedures and the duration of the interval between them did not significantly affect their effectiveness and was carried out in the most convenient mode for the patient

Example No. 1. Patient N., 38 years old. She complained of anxiety attacks accompanied by fear of death, anxiety of waiting for the next attack for more than a month, tension, palpitations, severe sweating, trembling, a feeling of stiffness, tension in the muscles of the neck and shoulders, slight dizziness, nausea, a feeling of lack of air, a sensation of a lump in the throat. , tingling in the limbs, frequent urination. Since childhood, she was anxious, impressionable, emotionally labile. After stress, the patient developed panic attacks, recurring up to 3-4 times a day and at night at 4-5 o'clock in the morning.

She was observed and examined by a psychotherapist. She took antidepressants - escitalopram 20 mg once a day for 3 months. She underwent sessions of cognitive behavioral therapy (CBT): she kept a self-observation diary with fixation in it of her thoughts, feelings, actions during the development of anxiety and panic attacks. But her condition improved slightly. Panic attacks persisted at the time of examination. These complaints persist for more than a month. Before contacting the clinic, all differential diagnostic studies were performed to exclude endocrine pathology, heart and lung diseases, which confirmed the diagnosis of paroxysmal anxiety disorder (panic attacks). Upon admission, the patient is tense, emotionally labile, her hands are wet, tremor of the eyelids and fingers, the paravertebral muscles are tense in the precranial region and the collar zone, more on the right. In neurological status without features. Tested on the Hospital Anxiety and Depression Scale 15b/6b, which corresponds to clinically significant anxiety (panic attacks). According to the visual analog scale of pain 7b heart rate - 95 beats / min, blood pressure 110/80 mm Hg. Art. Instrumental and laboratory functional indicators: heart rate - 95 beats / min, blood pressure 110/80 mm Hg. Art. Ultrasound examination of the SHOP: violation of the C1-C2 ratio - rotational dystopia of the atlas to the right by 1.8 mm, hypertonicity of the right sternocleidomastoid muscle and precranial muscles on the right. There are no data for instability and discogenic compression.

TKDS extended: blood flow (Vps, TAMX) in both MCA, ACA, PCA, GA is not disturbed, norm-resistant. Hyperresistant norm-velocity type of blood flow in both PAs in the V4 segment. Significant asymmetry of blood flow was not revealed. Violations of the myogenic mechanism of regulation were not revealed on both sides. The coefficient of cerebrovascular reactivity of cerebral blood flow in the hypercapnic test - 0.93 - insufficient vasodilation, in the hypocapnic test - 1.66 - excessive vasoconstriction. Lindegard's index PSMA was 1.01, LSMA 0.98 - hypoperfusion in the basin of both MCAs. Signs of venous discirculation in the vein of Rosenthal on the right 23 cm/s, pulsation index 0.2 — increased flow rate and increased phase of blood flow, on the left the blood flow in the vein of Rosetal was within the normal range.

Ultrasound examination of the VCA extended: CIM without features. The blood flow in the basin of both PAs in the V1, V2 and V4 segments is at a sufficient level, the gradient is within the normal range, functional tests in the V2 segment are negative (during turns without dynamics). There were no signs of extravasal PA exposure in the V4 segment. Signs of venous discirculation: increased flow velocity in the right internal jugular vein LBF 87 cm/s and vertebral veins on both sides: on the right LBF 37 cm/s, on the left LBF 29 cm/s, PV phlebectasia on both sides (PV diameter 3 mm on the right, left 2.5 mm).

The index of cerebrovascular reactivity to hypercapnia in the basin of both middle cerebral arteries (MCA) is not disturbed: in the right middle cerebral artery Vrhyper _PSMA = 2.4, in the left middle cerebral artery VRhyper _LCMA = 2.7. The reserve of cerebral vasodilation (RV) in the territory of both MCAs was within the normal range: RV _PSMA = -0.11, RV _LSMA = -0.12. The relative reactivity coefficient (CRR) of the vessels was within the normal range on both sides: CRR _PSMA = 1.7, CRR _LCMA = 1.5.

The cardiorespiratory reserve is not impaired, the breath holding time is 45 seconds, the ability to restore gas homeostasis is within the normal range PetCO2max: 118 mm Hg; PetCO2min: -25 mmHg

Cardiovascular reactivity to hypercapnia is reduced: blood pressure reactivity by 1 min Hg. CO2: 0.13; heart rate reactivity at 1 min Hg. CO2: 0.21.

1. According to the individual selection of the training regimen in

in the alveolar air, the content of CO2 is reduced (Hypocapnia), and the content of O2 is normal (Normoxia). Fet O2, %: 18; PetO2, mmHg: 128; Fet CO2, %: 2.5, PetCO2 mmHg: 110.5. Gas homeostasis is not stable. The patient was assigned the "Therapeutic" mode, the operating position of the damper was "725" ml, the composition of the air mixture: CO2 - 4%, O2 15%. The patient was prescribed breathing exercises from 2 minutes, adding, if you feel well, + 1 minute daily, for 14 days, training 2 times a day: in the first 3 days for 4 minutes each, the next 3 days for 6 minutes, then for 8-10 minutes .

Fascial manipulations were performed once a week for 5 weeks for 45 minutes.

Muscle relaxation according to Jacobson was carried out in the form of individual lessons once a week for 60 minutes for 2 weeks. In addition, the patient performed myelorelaxation independently 2 times a day for 15 minutes daily for 2 weeks.

The effectiveness of treatment after the 1st course.

After the first course of rehabilitation, the symmetry of the sternocleidomastoid muscles D=S was restored, the hypertonicity of the precranial muscles on the right is preserved. The C1-C2 ratio is normal.

The Lindegard index after the first course of rehabilitation was 1.5 in PSMA and 1.6 in LCMA, which indicates the correction of hypoperfusion due to the restoration of the cerebrovascular reserve of cerebral blood flow. The coefficient of cerebrovascular reactivity of cerebral blood flow in the hypercapnic test was -1.2, in the hypocapnic test - 1.4, which corresponds to the norm. There were no signs of venous discirculation in the vein of Rosenthal on the right side, LBF 13.5 cm/s, pulsation index 0.06.

Restoration of venous discirculation: in the right internal jugular internal jugular vein, LBF 45 cm/s and vertebral veins on both sides: LBF 11 cm/s on the right, LBF 9 cm/s on the left, no PV phlebectasia was detected on both sides (PV diameter 1, 7 mm, left 1.5 mm).

After the first course of rehabilitation, the index of cerebrovascular reactivity to hypercapnia Vrhyper, the reserve of cerebral vasodilation (RV), the coefficient of relative reactivity (CRR) of vessels, the cardiorespiratory reserve also remained within the normal range, without dynamics.

A month after the first course of rehabilitation, the patient was scheduled for 2 courses of breathing training on the Carbonic simulator, a course of fascial manipulations according to Luigi Stecco and a course of myelorelaxation according to Jacobson.

Before the 2nd course, according to the data of the Karbonik diagnostic and treatment complex, with an individual selection of the training regimen, the content of CO2 (Hypocapnia) and the normal content of O2 (Normoxia) were reduced in the alveolar air. FetO2, %: 18.1; PetO2, mmHg: 119 Fet CO2, %: 10.5, PetCO2 mmHg: 102. Gas homeostasis is not stable. The patient is assigned the "Therapeutic" mode, the working position of the damper is "925" ml. A repeated course of breathing exercises for 7 minutes 2 times a day for 14 days is recommended. Indicators of the index of cerebrovascular reactivity to hypercapnia Vrhyper, cerebral vasodilation reserve (RV), relative vascular reactivity ratio (CRR), cardiorespiratory reserve also remain within the normal range. Cardiovascular reactivity to hypercapnia is reduced: blood pressure reactivity for min. Hg CO2: 0.19; heart rate reactivity for 1 min. rt. st.: 0.29.

The course of fascial manipulations was carried out once a week for 4 weeks, the duration of the manipulation was 40 minutes.

The course of myelorelaxation according to Jacobson was carried out in the form of individual lessons 1 time per week for 30 minutes for 2 weeks. In addition, the patient performed myelorelaxation independently 1 time per day for 10 minutes daily for 16 days.

The effectiveness of rehabilitation after a repeated course of rehabilitation.

According to the individual selection of the training regimen, respiratory function is normal. In the alveolar air, the normal content of CO2 (Normoxia) and the normal content of O2 (Normoxia). FetO2 20%; PetO2 128 mmHg, Fet CO2 6%, PetCO2 92 mmHg

Indicators of the index of cerebrovascular reactivity to hypercapnia Vrhyper, cerebral vasodilation reserve (RV), relative vascular reactivity ratio (CRR), cardiorespiratory reserve also remain within the normal range, cardiovascular reactivity to hypercapnia has recovered.

To consolidate the result obtained, the patient was prescribed an additional course of training on the "Carbonic" "Prophylactic" simulator, and a course of myelorelaxation according to Jacobson, which was carried out 1 month after the end of the second course of rehabilitation.

During the first 5 minutes, set the valve to "500" ml, during the next 5 minutes, set the valve to "725", and during the last 5 minutes, set the valve to "500". Training was performed for 30 days, daily according to the scheme of 15 minutes. The composition of the air mixture: CO2 - 3.8%; O2 - 17%.

During the 3rd course of rehabilitation using the “Preventive” mode during training on the Carbonic simulator, the course of fascial manipulations according to Luigi Stecco was not performed.

The course of myelorelaxation according to Jacobson is performed in the form of self-study according to the scheme 1 time per day for 5 minutes for 16 days.

As a result of rehabilitation by the claimed method, the number of panic attacks in the patient was reduced to 1 attack in two weeks. Night panic attacks regressed. The pain and stiffness of the neck muscles regressed.

Example 2. Patient K., 32 years old.

She complained of anxiety attacks accompanied by fear of death, tension, palpitations and pulsation of blood vessels, a feeling of lack of air, shortness of breath, a feeling of depression, a feeling of pressure in the chest, sweating and a sensation of hot flashes to the head, fear of loss of control and recurrence of attacks, expectation anxiety the next attack, a feeling of stiffness, tension in the muscles of the upper shoulder girdle, dizziness, nausea. Panic attacks, recurring up to 2 times a day and at night. She was observed and examined by a psychotherapist. She took antidepressants - escitalopram 20 mg once a day for 3 months. She underwent sessions of cognitive behavioral therapy (CBT): she kept a self-observation diary with fixation in it of her thoughts, sensations, actions during the development of anxiety and PA attacks. But the situation has improved slightly. Panic attacks persisted at the time of examination.

These complaints persist for more than a month. Before contacting the clinic, all differential diagnostic studies were performed to exclude endocrine pathology, heart and lung diseases, which confirmed the diagnosis of paroxysmal anxiety disorder (panic attacks). Upon admission, the patient is emotionally labile, anxious, her hands are wet, tremor of the eyelids and fingers, the paravertebral muscles are tense in the precranial region and the collar zone, more on the left. In neurological status without features. Tested on the Hospital Anxiety and Depression Scale 12b/5b, which corresponds to clinically significant anxiety. According to the visual analog scale of pain 5b heart rate - 98 beats / min, blood pressure 100/70 mm Hg. Art.

Instrumental and laboratory functional indicators.

Ultrasound examination of the SHOP: hypertonicity of the left sternocleidomastoid muscle and precranial muscles on the right. There are no data for instability and discogenic compression.

Advanced TKDS: blood flow (Vps, TAMX) in both MCA, ACA, PCA, GA is not disturbed, moderately hyporesistant. Hyperresistant norm-velocity type of blood flow in both PAs in the V4 segment. Significant asymmetry of blood flow was not revealed. Violations of the myogenic mechanism of regulation were not revealed on both sides. The coefficient of cerebrovascular reactivity of cerebral blood flow in the hypercapnic test was 1.1, and in the hypocapnic test it was 1.4, which corresponds to the norm. Lindegard index PSMA was 1.1, LSMA 0.93 - hypoperfusion in the basin of both MCAs. There were no signs of venous discirculation in the Rosenthal vein on the right and left: on the right 13 cm/s, pulsation index 0.06; right 14 cm/s, pulsation index 0.08.

Ultrasound examination of the VCA extended: CIM without features. The blood flow in the basin of both PAs in the V1, V2 and V4 segments is at a sufficient level, the gradient is within the normal range, functional tests in the V2 segment are negative (during turns without dynamics). There were no signs of extravasal influence of the right and left VA in the V4 segment when the head was turned to the left and to the right. Signs of venous discirculation: increased flow velocity in the left internal jugular vein LBF 101 cm/s and vertebral vein on the left LBF 36 cm/s, LBF 11 cm/s is not disturbed on the right, PV phlebectasia on the left (PV diameter 1.1 mm on the right, 2 on the left .5 mm).

The index of cerebrovascular reactivity to hypercapnia in the basin of both middle cerebral arteries (MCA) is not disturbed: in the right middle cerebral artery Vrhyper _PSMA = 2, in the left middle cerebral artery VRhyper _LCMA = 2. The reserve of cerebral vasodilation (RV) in the basin of both MCAs is within the normal range : RV _LSMA = -0.1, RV _LSMA = -0.1. The relative reactivity coefficient (CRR) of the vessels was within the normal range on both sides: CRR _PSMA = 1.5, CRR _LCMA = 1.5.

The cardiorespiratory reserve is not impaired, the breath holding time is 50 seconds, the ability to restore gas homeostasis is within the normal range PetCO2max: 121 mm Hg; PetCO2min: -29 mmHg

Cardiovascular reactivity to hypercapnia within the normal range: BP reactivity per 1 min Hg. CO2: 0.4; heart rate reactivity at 1 min Hg. CO2: 0.55.

According to the individual selection of the training regimen, the content of CO2 in the alveolar air is reduced (Hypocapnia), and the content of O2 is normal (Normoxia). FetO2, %: 18.9; PetO2, mmHg: 125; Fet CO2, %: 2.8, PetCO2 mmHg: 121. Gas homeostasis is not stable.

The mode "Therapeutic" is assigned, the operating position of the damper is "925" ml. Appointed breathing exercises for 2 minutes 2 times a day for 30 days. The composition of the respiratory mixture: CO2 - 5%, O2 - 13%.

Fascial manipulations were performed once a week for 5 weeks for 30 minutes.

Muscle relaxation according to Jacobson was carried out in the form of individual sessions 2 times a week for 30 minutes for 2 weeks. In addition, the patient performed myelorelaxation independently 2 times a day for 15 minutes daily for 2 weeks (14 days).

Efficacy of treatment after 30 days.

After treatment, the symmetry of the sternocleidomastoid and precranial muscles D=S was restored. The Lindegard index after treatment was 1.4 in PSMA and 1.3 in LCMA, which indicates the correction of hypoperfusion due to the restoration of the cerebrovascular reserve of cerebral blood flow. The coefficient of cerebrovascular reactivity of cerebral blood flow in hypercapnic and hypocapnic test is normal. There were no signs of venous discirculation in the Rosenthal vein on the right and left.

There were no signs of extravasal effects of both PAs in the V4 segment. Restoration of venous discirculation: in the left internal jugular internal jugular vein LBF 54 cm/s and the left vertebral vein LBF 15 cm/s, phlebectasia of the left PV was not detected (PV diameter 1.1 mm on the right, 1.6 mm on the left).

After treatment, the index of cerebrovascular reactivity to hypercapnia Vrhyper, the reserve of cerebral vasodilation (RV), the coefficient of relative reactivity (CRR) of vessels, cardiorespiratory reserve, cardiovascular reactivity to hypercapnia also remained within the normal range, without dynamics.

According to the individual selection of the training regimen, respiratory function is normal. In the alveolar air, the normal content of CO2 (Normoxia) and the normal content of O2 (Normoxia). FetO2 16.6%; PetO2 127 mmHg, Fet CO2 6.1%, PetCO2 92 mmHg

To consolidate the result, the patient was prescribed an additional course of rehabilitation after 2 months. Assigned training regimen "Prophylactic". During the first 6 minutes the damper was set to "675" ml, during the next 7 minutes the damper was set to "925", and during the last 7 minutes to "675". The duration of training is 30 days, daily 1 time per day according to the scheme of 20 minutes.

The composition of the respiratory mixture: CO2 - 5.4%, O2 - 14%.

Muscle relaxation according to Jacobson, the patient independently performed 1 time per day for 15 minutes for 16 days.

As a result of treatment, the patient's number of panic attacks was reduced to 1 attack in 2 weeks. Night panic attacks regressed. Pain and stiffness of the muscles of the upper shoulder girdle regressed.

Example 3. Patient P. 28l.

She complained of palpitations, hot flashes with sweating, fear of death, fear of loss of control and recurrence of attacks, anxious expectation of the next attack, feeling short of breath, shortness of breath during an attack, sensation of a lump in the throat, a feeling of pressure in the chest, a feeling of slight tension neck muscles. Panic attacks recurring up to 3 times a week. She was observed and examined by a psychotherapist. She took antidepressants - escitalopram 20 mg once a day for 3 months. She underwent sessions of cognitive behavioral therapy (CBT): she kept a self-observation diary with fixation in it of her thoughts, feelings, actions during the development of anxiety and PA attacks. But the situation has improved slightly. Panic attacks persisted at the time of examination. These complaints persist for more than a month. Before contacting the clinic, all differential diagnostic studies were performed to exclude endocrine pathology, heart and lung diseases, which confirmed the diagnosis of paroxysmal anxiety disorder (panic attacks). Upon admission, the patient is emotionally labile, anxious, her hands are wet, tremor of the eyelids and fingers, the paravertebral muscles are tense in the precranial region on both sides. According to the visual analog scale of pain 3b In the neurological status without features.

Tested on the Hospital Anxiety and Depression Scale 11b/2b, which corresponds to clinically significant anxiety. Heart rate - 112 beats / min, blood pressure 100/70 mm Hg. Art.

Instrumental and laboratory functional indicators.

Ultrasound examination of the SHOP: moderate hypertonicity of the left sternocleidomastoid muscle. There are no data for instability and discogenic compression.

TKDS extended: blood flow (Vps, TAMX) in both MCA, ACA, PCA, GA is not disturbed, norm-resistant. Norm-resistant norm-velocity type of blood flow in both PAs in the V4 segment. Significant asymmetry of blood flow was not revealed. Violations of the myogenic mechanism of regulation were not revealed on both sides. The coefficient of cerebrovascular reactivity of cerebral blood flow in the hypercapnic test is 1.2 - the norm, in the hypocapnic test - 1.58 - moderate excessive vasoconstriction. Lindegard's index PSMA was 1.11, LSMA 0.95 - hypoperfusion in the basin of both MCAs. There were no signs of venous discirculation in the Rosenthal vein on the right and left.

Ultrasound examination of the VCA extended: CIM without features. The blood flow in the basin of both PAs in the V1, V2 and V4 segments is at a sufficient level, the gradient is within the normal range, functional tests in the V2 segment are negative (during turns without dynamics). There were no signs of extravasal influence of the right and left VA in the V4 segment when turning the head to the right and to the left. Signs of venous discirculation: increased flow velocity in the vertebral veins on both sides: on the right LBF 31 cm/s, on the left LBF 34 cm/s, PV phlebectasia on both sides (PV diameter 2.7 mm on the right, 2.6 mm on the left), venous outflow in the jugular veins is not disturbed.

The index of cerebrovascular reactivity to hypercapnia in the basin of both middle cerebral arteries (MCA) is not disturbed: in the right middle cerebral artery Vrhyper _PSMA = 2.8 in the left middle cerebral artery VRhyper _LCMA = 2.8. The reserve of cerebral vasodilation (RV) in the territory of both MCAs was within the normal range: RV _PSMA = -0.19, RV _LCMA = -0.19. The relative reactivity coefficient (CRR) of the vessels was within the normal range on both sides: CRR _PSMA = 2, CRR _LCMA = 2.

The cardiorespiratory reserve is not disturbed, the breath holding time is 58 seconds, the ability to restore gas homeostasis is within the normal range PetCO2max: 115 mm Hg; PetCO2min: -24 mmHg

Cardiovascular reactivity to hypercapnia within normal limits: BP reactivity at 1 min Hg. CO2: 0.57; heart rate reactivity at 1 min Hg. CO2: 0.8.

According to the individual selection of the training regimen, the content of CO2 in the alveolar air is reduced (Hypocapnia), and the content of O2 is normal (Normoxia). FetO2, %: 15; PetO2, mmHg: 118; Fet CO2, %: 3.3, PetCO2 mm Hg: 119. Gas homeostasis is not stable. The mode "Therapeutic" is assigned, the operating position of the damper is "1000" ml. Assigned to breathing exercises for 7 minutes 2 times a day for 7 days, then 10 minutes 1 time per day for 7 days, with a total course of 14 days.

Fascial manipulations were performed once a week for 4 weeks for 30 minutes.

Muscle relaxation according to Jacobson was performed by the patient in the form of individual sessions 2 times a week for 30 minutes for 2 weeks. In addition, the patient performed myelorelaxation independently 2 times a day for 15 minutes daily for 2 weeks (14 days).

Treatment effectiveness:

After treatment, the symmetry of the sternocleidomastoid muscles D=S was restored. The Lindegard index after treatment was 1.7 in PSMA and 1.4 in LCMA, which indicates the correction of hypoperfusion due to the restoration of the cerebrovascular reserve of cerebral blood flow. The coefficient of cerebrovascular reactivity of cerebral blood flow in hypercapnic and hypocapnic test is normal. There were no signs of venous discirculation in the Rosenthal vein on the right and left.

There were no signs of extravasal effects of both PAs in the V4 segment. Restoration of venous discirculation: in the vertebral veins on both sides: on the right LBF 12 cm/s, on the left LBF 14 cm/s, restoration of the diameter of both PVs (PV diameter 1.4 mm on the right, 1.6 mm on the left).

After treatment, the index of cerebrovascular reactivity to hypercapnia Vrhyper 2.6/2.7, cerebral vasodilation reserve (RV) -0.17/0.18, relative vascular reactivity ratio (CRR) 2.1/2.3, cardiorespiratory reserve 55 ( sec), cardiovascular reactivity to hypercapnia also remains within the normal range, without dynamics.

According to the individual selection of the training regimen, respiratory function is normal. In the alveolar air, the normal content of CO2 (Normoxia) and the normal content of O2 (Normoxia). FetO2 14%; PetO2 124 mmHg, Fet CO2 6.5%, PetCO2 100 mmHg

To consolidate the result obtained, the patient was prescribed an additional course of training on the Carbonic simulator "Prophylactic" and a course of myelorelaxation according to Jacobson, which were carried out 3 months after the end of the first course of rehabilitation. A long break is due to a milder course, severity and rapid recovery after PA.

During the “Prophylactic” training regimen, during the first 5 minutes the valve was set to “825” ml, during the next 5 minutes the valve was set to “1000” ml, and during the last 5 minutes it was set to “825” ml. Assigned to conduct training daily 1 time per day for 15 minutes for 30 days.

As a result of treatment, the patient's number of panic attacks decreased to 1 attack per month. Night panic attacks regressed. Pain and stiffness of the muscles of the upper shoulder girdle regressed.

Claims (3)

1. A method for the rehabilitation of patients with a diagnosis of panic attacks, including a preliminary examination of the patient, which includes transcranial duplex scanning of the cerebral arteries and neuropsychological testing, as well as examination of the patient at the Karbonik medical diagnostic complex for individual selection of a training regimen, followed by training using the Carbonik breathing simulator, characterized in that the preliminary examination is additionally provides for ultrasound examination of the cervical spine, ultrasound duplex scanning of the branches of the aortic arch, as well as measurement of the linear velocity of blood flow in the vertebral arteries and jugular veins, while examining the patient at the Karbonik medical and diagnostic complex with individual selection of the training regimen includes determining the cerebrovascular reactivity of cerebral vessels on hypercapnia, assessment of cardiovascular reactivity, assessment of cardiorespiratory reserve, the results of which, based on data on gas exchange and functional condition, the patient is selected an individual breathing training regimen on the Carbonic simulator, in addition, the method additionally includes the use of soft manual techniques, which use fascial manipulations by Luigi Stecco, the dynamics and evaluation of which is carried out using ultrasound scanning, and the Jacobson myelorelaxation technique , while when performing fascial manipulations, the selection of coordination centers for the treatment of seals in the fascia is carried out on the basis of ultrasound data of the cervical spine, by searching for seals in the main substance of the fascia and softening it through friction-sliding, which is performed by the lateral surface of the elbow or interphalangeal joints of the fingers, moreover study using transcranial duplex scanning of the cerebral arteries, neuropsychological testing, ultrasound examination of the cervical spine, ultrasound duplex scanning of the branches of the aortic arch, measurements e linear velocity of blood flow in the vertebral arteries and jugular veins is additionally carried out after the end of the rehabilitation course, hypercapnic-hypoxic training on the breathing simulator "Carbonic" is carried out daily 1-2 times a day for 14-30 days, the duration of each training is from 2 to 20 min, with the addition of 1 minute with good health, as individually selected modes, the following modes are used: "Preventive" or "Therapeutic", and for the "Therapeutic" mode, the composition of the respiratory mixture is CO ₂ - 4-5%, O ₂ - 15-13 %, and for the "Prophylactic" mode - CO ₂ - 3.8-5.4%, O ₂ - 17-15%, while using the working position of the valve of the respiratory volume of the dead space 500-1000 ml, the course of fascial manipulations is 1 time per week for 4-5 weeks, with a session duration of 30 to 45 minutes, sessions of myelorelaxation according to Jacobson are carried out in the form of individual sessions 1-2 times a week, lasting from 30 to 60 minutes, for 2 weeks l, as well as in the form of independent sessions that the patient conducts 1-2 times a day lasting from 5 to 15 minutes for 14-16 days, while the number of hypercapnic-hypoxic trainings on the Carbonic breathing simulator and myelorelaxation sessions according to Jacobson, sufficient to achieve a positive effect of rehabilitation, is 2-3 courses, with an interval between courses of 1-3 months, and the course of fascial manipulations is carried out only when using an individual training regimen on the Carbonic simulator "Therapeutic". 2. The method according to claim 1, characterized in that the method of transcranial ultrasound determines the systolic (Vps), diastolic (Ved) and average (Tamx) blood flow velocity of the middle (MCA), anterior (AcA) and posterior (PCA) cerebral arteries , as well as in the basilar artery (BA) and vertebral arteries (VA) in segments V1, V2, and V4, the Purcelo resistivity and Gosling pulsation indices, the Lindegard index is calculated - the hemispheric index of cerebral blood flow, PIMK - the ratio of peak systolic velocity in MCA and in of the homolateral internal carotid artery, metabolic tests are carried out: hypercapnic - holding the breath for 15 s and hypocapnic - rapid breathing for 15 s, the average blood flow velocity at rest is measured, in the middle cerebral artery with holding the breath and with rapid breathing, the indices of cerebral perfusion pressure and cerebrovascular resistance are calculated, with the help of ultrasound examination of the branches of the aortic arch, the intima-media complex in sleep is assessed th, subclavian and vertebral arteries, the peak systolic and average blood flow velocity in the vertebral arteries in segments V1, V2, V4, the linear velocity of blood flow in the vertebral and jugular veins are determined, functional tests are performed with the head turned to the right and left along the vertebral arteries in segments V2 and V4.

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