RU2834542C1 - Method for rehabilitation of women with chronic pelvic pain - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to medical rehabilitation, and concerns complex action on functional vegetative disorders and myofascial syndrome of pelvic floor muscles in women with chronic pelvic pain (CPP). There are three stages of correction, which are carried out twice a week for four weeks. First stage involves sensorimotor gymnastics, which reflexively affects the insular and frontal lobes of the brain and reduces pain syndrome. At the second stage, a diaphragmatic breathing pattern is formed with an emphasis on relaxation of the pelvic muscles; reflex massage of cervical and sacral or thoracic spine; segmental massage is performed in reflex zones of pelvic organs – innervation zones Th11-12, L1-5, S1-2 – Zakharyin-Ged zones; using Chapman reflex techniques, manual correction of zones of reflected pains characteristic of CPP: on an anterior abdominal wall under the navel, in the area of pubic bones of the pelvis, inguinal ligament and inguinal canal; soft tissues are handled in the topography of the Alcock canal and in the attachment points of the sacral-spinous and sacral-tuberous ligaments; trigger points in the muscles of the pelvic floor and pelvic region are exposed. At the third stage, postural muscle balancing exercises are performed, which rebuild the pathological motor stereotype and increase activity.

EFFECT: method provides relief or reduction of pain syndrome and improvement of functional vegetative parameters in females with CPP by means of drug-free methods of treatment.

1 cl, 2 dwg, 2 ex

Description

The invention relates to medicine, in particular to medical rehabilitation, and concerns complex restorative treatment of women with chronic pelvic pain (CPP) and myofascial syndrome of the pelvic floor muscles with the aim of relieving or reducing the severity of pain syndrome and improving functional vegetative indicators using non-drug treatment methods.

CPP is a complex, multifactorial disorder characterized by persistent or intermittent pain in the lower abdomen, lower back, sacrum and coccyx, pelvis and genitals, often without signs of inflammation and lasting at least 3-6 months. (Lamvu G et al., 2021). The term "chronic pelvic pain syndrome" (CPPS) is used to describe such conditions (Engeler D et al. EAU guidelines on chronic pelvic pain, 2019).

The etiology of pelvic pain can be gynecological, urological, gastrointestinal, musculoskeletal, neurological or vascular. Perhaps this is why there are currently no unified approved algorithms for the rehabilitation of patients with CPP. In addition to drug treatment, intravaginal manual manipulations on the pelvic floor muscles aimed at relaxing the pelvic floor muscles and eliminating triggers in the pelvic muscles, and special exercises to relax the pelvic floor muscles are most widely used.

A method of influencing trigger points located in the pelvic floor muscles using myopressure is known (Grinberg K, Weissman-Fogel I, Lowenstein L, Abramov L, Granot M. How Does Myofascial Physical Therapy Attenuate Pain in Chronic Pelvic Pain Syndrome? Pain Res Manag. 2019 Dec 12; 2019: 6091257. doi: 10.1155/2019/6091257. PMID: 31915499; PMCID: PMC6930783; Dong, XX., Guo, M., Huang, LX. et al. The efficacy of manipulation as a treatment for myofascial pelvic pain. Int Urol Nephrol 53, 1339-1343 (2021). https://doi.org/10.1007/s11255-021-02840-8). Trigger points are found in the vagina, rectum, pubic bone, coccyx, abdomen, lower back and back and inner thighs, gluteal muscles and hip rotators. The trigger point is squeezed with the fingertips and held for 60-90 sec with a gradual increase in pressure.

A method of influencing trigger points using acupuncture is known (Bezhenar V.F., Barantsevich E.R., Linde V.A. et al. On the use of acupuncture for chronic pelvic pain syndrome (literature review) // Effective pharmacotherapy. 2020. Vol. 16. No. 28. Pp. 18-23. DOI 10.33978/2307-3586-2020-16-28-18-23). In some cases, a “dry” needling procedure is performed - an injection into a trigger point without the introduction of any substance (Tekin L., Akarsu S., Durmus O., Cakar E., et al. The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial // Clin Rheumatol. - 2013; 32(3): 309-315).

However, today the standards for diagnosing myofascial trigger points in chronic pelvic pain syndrome (CPPS) are absent. Like any other non-drug treatment method, they affect each patient with varying degrees of effectiveness. Also, these methods do not take into account the biomechanical disorders of the musculoskeletal system of patients, which often accompany dysfunctions of the pelvic floor muscles, which can subsequently lead to the formation of new trigger points and the return of pain. In addition, such methods do not take into account vegetative disorders in the development of chronic pain.

A method known as post-isometric relaxation of the pelvic floor muscles and pelvic region muscles (piriformis, iliopsoas, etc.) is used to change the biomechanics of the pelvic floor and relieve the myofascial component of pelvic pain (Barulin A.E., Kurushina O.V., Dumtsev V.V. A patient with chronic pelvic pain at a neurologist's appointment. Medical alphabet. 2018; 3(27): 38-41).

But often these muscles are involved in the pathological process secondarily, dysfunctions in them occur in response to imbalance of other muscle groups. Without changing the motor pattern with the help of exercises, it is extremely difficult to break this stereotype. In addition, this method does not take into account vegetative disorders that occur during the development of chronic pain.

A method of activating the vagus nerve in chronic pelvic pain is known (Napadow V, Edwards RR, Cahalan CM, Mensing G, Greenbaum S, Valovska A, Li A, Kim J, Maeda Y, Park K, Wasan AD. Evoked pain analgesia in chronic pelvic pain patients using respiratory-gated auricular vagal afferent nerve stimulation. Pain Med. 2012 Jun; 13(6): 777-89. doi: 10.1111/j.1526-4637.2012.01385.x. Epub 2012 May 8. PMID: 22568773; PMCID: PMC3376238). Currently, this is an actively developing method in the treatment of chronic pain, including CPP. For example, since 2021, a study has been conducted at the Foch Hospital (France) on the treatment of chronic pelvic pain due to endometriosis using transcutaneous stimulation of the auricular branch of the vagus nerve. A 30-minute session is carried out twice a day for 3 months of transcutaneous stimulation of the auricular vagus nerve using TENS Eco Plus. The study will last until 2025. But such manipulations require special equipment and do not take into account the biomechanical factor in the development of pelvic floor muscle dysfunction and viscero-motor disorders.

A method for treating chronic pelvic pain in women based on biological feedback (BFB) is known (RU 2717200 C1, A61B 5/08). Treatment using BFB is carried out individually, under the control of the patient's emotional well-being, for which the emotional well-being assessment technique of Odarushchenko O.I. "Emotional Well-Being Test 1.0" is used, which includes 9 subtests. Depending on the test result, patients undergo breathing training using BFB using the diaphragmatic-relaxation breathing method by A.A. Smetankin in various modes. In case of emotional distress of the patient, an hour-long session of body-oriented psychotherapy is added to the breathing exercises, after which another 15 minutes of breathing training with BFB are carried out. However, this method does not take into account the assessment of the biomechanical status of patients; the use of a body-oriented therapy complex is carried out without taking into account muscle balance disorders in women's bodies.

The invention is based on the task of increasing the effectiveness of a non-drug method of recovery of patients with chronic pelvic pain. In order to reduce pain syndrome, increase the period of remission in patients and improve their quality of life, we have developed a method that takes into account the main links in the pathogenesis of this pathology.

The stated task is solved using methods that influence the functional indicators of the autonomic nervous system at the central and peripheral levels, relieving spasms from the pelvic floor muscles and correcting the motor stereotype, and is carried out in stages: at the first stage - by performing sensorimotor gymnastics techniques after assessing pain sensations and the functional state of the autonomic nervous system; at the second stage - with the help of diaphragmatic breathing in a supine position on a couch, reflex massage of the cervical and sacral or thoracic spine depending on the patient's vegetative status, the use of Chapman's reflex techniques, manual correction of zones of reflected pain characteristic of CPP on the anterior abdominal wall under the navel area, in the area of the pubic bones of the pelvis, inguinal ligament and inguinal canal and work with soft tissues in the topography of the Alcock canal and in the places of attachment of the sacrospinous and sacrotuberous ligaments by acting on trigger points in the muscles of the pelvic floor and muscles of the pelvic region; at the third stage - exercises to balance the postural muscles, helping to rebuild the pathological motor stereotype and optimize the motor regime, increase daily activity.

The peculiarity of the proposed method is that the proposed method includes three stages of correction of chronic pulmonary disease.

At the first stage of rehabilitation treatment, sensorimotor gymnastics is performed, which reflexively affects the insular and frontal lobes of the brain, reducing pain.

At the second stage, reflex manual techniques are performed, which are based on the reflex connections of dermatomes and myotomes with the pelvic organs. The effect of these manual techniques is due to the impact through the skin receptors on the vegetative supply of the pelvic region, which leads to improved blood and lymph circulation. Work is also carried out with soft tissues in the area of the Alcock canal topography and in the places of attachment of the sacrospinous and sacrotuberous ligaments.

At the third stage, exercises were used to balance the postural muscles of the body and pelvis, helping to rebuild the pathological motor stereotype and return the motor regime, increasing daily activity.

Sessions are held twice a week for 4 weeks.

The method is carried out as follows:

Stage 1 - preliminary testing of pain sensitivity is carried out using the VAS (Visual Analogue Pain Scale) in a calm state and during movement that causes pain. The functional state of the autonomic nervous system (ANS) is also monitored using an orthoclinostatic test. Then sensorimotor gymnastics is carried out for 15 minutes.

Sensorimotor gymnastics includes exercises:

1. I.P. - standing, feet shoulder-width apart, arms extended forward shoulder-width apart with thumbs of both hands raised up to eye level. Back relaxed, breathing voluntary. Gaze focused on the thumb of the right hand.

Imitation of the movement "no". For 30-60 seconds, alternately move your gaze from the right thumb to the left without turning your head. The movement is performed only by the eyeballs.

2. I.P. - the same. For 30-60 seconds, turn your head alternately towards the right and left thumbs, your gaze follows the turn of your head. Then, for 30-60 seconds, do this exercise with your eyes closed.

3. I.P. - standing, feet shoulder-width apart, arms extended forward shoulder-width apart with thumbs of both hands raised up, right arm raised above head, left arm extended forward at sternum level. Back relaxed, breathing voluntary. Gaze focused on thumb of right hand.

Imitation of the movement "yes". For 30-60 seconds, alternately move your gaze from the right thumb to the left finger, without nodding your head. The movement is performed only by the eyeballs.

4. I.P. - the same. For 30-60 seconds, raise and lower your head up/down, your gaze follows your head. Then, for 30-60 seconds, do this exercise with your eyes closed.

5. I.P. - sitting on a gymnastic ball. Feet shoulder-width apart, body relaxed. For 60 seconds, perform balancing movements on the ball, shifting the pelvis to the right, left, forward, backward.

6. I.P. - sitting on a gymnastic ball. Feet shoulder-width apart, back straight. During 60-120 sec., while exhaling, bend your body to the right, left, and forward.

7. I.P. - standing, feet shoulder-width apart, arms extended forward in front of you. Breathing is voluntary. Symmetrical circular movements are performed in the hands of both hands for 60 seconds, then multidirectional circular movements are performed in the hands of both hands.

Stage 2 - carrying out reflex manual techniques and work with soft tissues in the area of the Alcock canal topography and in the places of attachment of the sacrospinous and sacrotuberous ligaments:

a) the patient is in a supine position. Inhalation is through the nose, exhalation is longer than inhalation, through closed lips; diaphragmatic breathing is taught, the perception of the pelvic floor muscles is reinforced by concentrating attention on stretching the pelvic floor muscles during exhalation. For this, the patient is explained that breathing is carried out mainly by the lower ribs and abdomen. During inhalation, the lower ribs move forward, to the sides and to the back, the abdomen inflates, during exhalation, the ribs return to their original position, the abdomen deflates;

b) then reflex-segmental massage of the lumbosacral, cervicoccipital, upper thoracic zones is performed in case of sympathicotonia or the lumbosacral and thoracic spine zones in case of vagotonia in female patients from the prone position. With any functional state of the autonomic nervous system, attention is paid to manual correction of the Zakharyin-Ged zones at the site of innervation of Th11-12, L1-5, S1-2. The impact begins from the underlying zones to the overlying ones. General techniques are used: stroking, kneading, rubbing, as well as special techniques: drilling, moving, sawing, stretching, impact on the interspinous spaces, shaking the pelvis. Vibration is used in areas where increased tone is observed. The intensity of the impact on the zones is weak or medium, according to Wilder's law (O. Glezer, V.A. Dalikho. Segmental massage, 1962);

c) further, if necessary, post-isometric relaxation of the iliopsoas and piriformis muscles, and the quadratus lumborum muscle is performed;

d) then the ventral and dorsal Chapman points are affected. The diagram of the location of the ventral Chapman points is shown in Fig. 1 and the dorsal Chapman points in Fig. 2;

For manual correction of Chapman points, the following points are selected (Fig. 1, 2): point 20 - psychosomatic point (neurasthenia), point 22 - anal-rectal veins, point 23 - fallopian tubes, point 24 - vagina, point 31 - urethra, point 35 - rectum, point 38 - bladder. Work with the points begins with the patient lying on her back. First, the points on the ventral surface of the body are processed. Then the patient lies on her stomach, work is done with the points on the back of the body. To work with the points, the Mitchell technique is used - contact is made with the point with the tips of the index and middle fingers, a circular movement is made with the hand, transmitted to the fingers. The impact is as soft as possible, pain reactions are avoided. The time of impact on each point is 10-20 s (S.V. Novoseltsev. Clinical osteopathy, reflex techniques, 2013).

d) then work is carried out in the zone of reflected pain, characteristic of chronic pulmonary disease. As a rule, patients report pain in the lower abdomen, inguinal fold and pubic bones, in the area of the sacrotuberous and sacrospinous ligaments and ischial tuberosities.

The patient lies on his back, legs are bent at the hip and knee joints at an angle of 90 degrees to reduce the tension of the abdominal wall muscles. The operator is on the side of the patient, working with tissues begins from the healthy side (in case of unilateral complaints) and moves to the side with reflected pain. The operator uses the tips of the 2nd, 3rd, 4th, 5th fingers of both hands to apply gentle pressure with a force of 40 grams with further stretching of the subcutaneous fat and superficial fascia in the lower abdomen ("panty area") until the tissue stops. In the found tension zone (where the tissue stretching stops), he begins to make slow circular movements with the fingers of both hands, plunging into the deeper layers of the subcutaneous fat to the deep fascia and muscle layer and deeper, increasing the pressure force to 80 g until a feeling of relaxation and improved stretching of the tissues lying under the fingers. In this way, we treat the entire area of the anterior abdominal wall below the navel. Next, the doctor places the fingers of both hands on the anterior superior iliac bone in the area of attachment of the inguinal ligament and performs a transverse massage in the inguinal ligament area following from the PVPO to the pubic tubercle for 2-3 minutes until a feeling of tissue relaxation and weakening of the tension of the inguinal ligament is felt. When working on the inguinal ligament area, special attention is paid to the topography zone of the inguinal canal, located just above the inguinal ligament. When working with the inguinal canal, the tissues are stretched at the level of the superficial fascia in the area of the deep inguinal ring: the tips of the 2nd and 3rd fingers of both hands are placed along the circumference of the topographic zone of the deep inguinal ring, immersed in the tissues with a pressure force of 50 g, then slow circular movements are made and the subcutaneous fat and superficial fascia in the area of the deep inguinal ring are stretched until a feeling of tissue movement stopping. Without lifting the fingers from the topography zone of the deep inguinal ring, we wait for a feeling of tissue relaxation and continue stretching the tissues to the next tissue barrier. The area of the topography of the superficial inguinal ring is worked on in the same way, the pressure force is 30 g. Next, the doctor performs a transverse massage in the area of the pubic bones in the places of attachment of the rectus abdominis muscles, simultaneously working on the identified trigger points.

Next, work is carried out with soft tissues in the topography of the Alcock canal and in the places of attachment of the sacrospinous and sacrotuberous ligaments. The patient lies on her healthy side facing the doctor, the lower leg is straight, the upper leg is bent at an angle of 90 degrees at the hip and knee joints. The doctor stands facing the patient. The knee of the patient's upper leg rests on the doctor's thigh. The doctor uses the fingers of one hand to shift and roll the soft tissues of the pelvic area along the ischial bone, starting from the ischial tuberosity and rising to the ischial spine, as if pulling the tissues from the pelvic floor muscle area outward from under the ischial bone, until a feeling of tissue relaxation is felt. The movements are performed slowly, with a pressure force of 80 g on the tissue.

e) intravaginal work on trigger points of the pelvic floor muscles and massage of the pelvic diaphragm.

Stage 3 - a set of exercises is used aimed at teaching control of the core muscles and balancing the pelvic region.

Exercise #1

I.p. - lying on your back, while exhaling (diaphragmatic breathing), the rectus abdominis muscles are tensed in order to improve sensory and motor control of these muscles.

Exercise #2

I. p. lying on the back, legs bent at the hip and knee joints. The patient is given the command to place the fingers of the hands 2 fingers lower along the anterior superior iliac spines (ASIS) and apply pressure with the fingers deep into the tissues. Then, on exhalation (diaphragmatic breathing), imagine the convergence of the ASIS, which will cause tension in the transverse abdominal muscle. The rectus abdominis and gluteal muscles should take minimal part in the movement. Perform the exercise until sensorimotor control of the transverse lumbar muscle is formed.

Exercise #3

I.p. - lying on the back, legs bent at the hip and knee joints. Diaphragmatic breathing, the patient inhales with an emphasis on relaxing the pelvic floor muscles. On exhalation, the patient activates the transverse abdominal muscle and simultaneously twists the pelvis, moving it into a backward tilt and pressing the lower back to the couch. The gluteal muscles are strained minimally. Repeat 5-7 times.

Exercise #4

I.p. - lying on the back, legs bent at the hip and knee joints. The patient's pelvis is tilted backwards, the lower back is pressed to the couch. Hands are raised in front of you. Diaphragmatic breathing. The patient slowly, one by one, straightens her legs, sliding her heel along the couch. Repeat 5-7 times

Exercise #5

I.P. - lying on the back, legs bent at the hip and knee joints. The patient's pelvis and lower back are in a neutral position. Hands are raised in front of you. Diaphragmatic breathing. The patient slowly, one by one, pulls her legs to her chest, trying to control her lower back and abdominal muscles, not allowing straining. Repeat 10 times.

Exercise #6

I. p. - lying on the back, pelvis and lower back in a neutral position, diaphragmatic breathing. On exhalation, the patient raises the left leg, bent at the hip and knee joints 90° and applies moderate pressure with the left hand on the left knee. At the same time, the foot of the right leg is pressed down on the floor and the right buttock is raised a few centimeters. Then the patient slowly lowers the leg. Repeats the same on the other side. Repeat 5 times on each side.

Exercise #7

I. p. - lying on your back, legs bent at the hip and knee joints, pelvis and lower back in a neutral position, diaphragmatic breathing. A rubber elastic band is put on the thigh area near the knee joints, a pillow is placed between the legs in the hip area. As you inhale, the knees are slowly simultaneously spread apart, overcoming the resistance of the rubber band. Then a slow exhale is made, the knees are brought together, the hips rest on the pillow. The movements are performed in a comfortable range. Repeat 5 times.

Exercises #8

I. p. - lying on your back, legs bent at the hip and knee joints, pelvis and lower back in a neutral position, diaphragmatic breathing. A pillow is placed between the legs in the hip area. As you exhale, bring the thighs together, resting on the pillow, as you inhale, return the legs to the starting position. Repeat 5 times.

Next, diaphragmatic breathing is performed with an emphasis on relaxing the pelvic floor muscles and exercises to stretch the external rotators of the hip, the quadratus lumborum muscles, and the iliopsoas muscles.

Sensorimotor gymnastics and exercises aimed at teaching core muscle control and pelvic region balancing are given to patients to perform at home. The first two exercises must be performed under the supervision of a doctor. Sensorimotor gymnastics and exercises 1 and 2 from the complex for core muscle control and pelvic region balancing are performed daily. The remaining exercises are recommended to be performed 2-3 times a week as they are mastered. All exercises are performed in a comfortable amplitude and should not be accompanied by painful sensations.

Clinical examples:

Example 1. Patient Sh., born in 1986, complains of dull, intense pain in the lower abdomen, more on the right, radiating to the hip joint, pain in the pubic region. History: recurrent gastritis since 2006, right oophorectomy since 2015, chronic pelvic pain, pelvic varicose veins since 2019, right ACL plastic surgery since 2021. Examined by a gynecologist and a neurologist.

After the rehabilitation measures carried out according to the proposed method, the following was observed: a decrease in pain syndrome from 6 to 2 points on the VAS scale, a decrease from 51 to 30 points according to the central sensitization questionnaire, and from 2 to 0 points according to the DNS questionnaire (neuropathic pain); the formation of a diaphragmatic breathing pattern is noted, according to the Naimigentsky questionnaire (the presence of hyperventilation) - a decrease from 20 to 13 points, according to the PHQ questionnaire - 9 (the presence of depression) - a decrease from 10 to 6 points, according to the PFIQ-7 questionnaire - a decrease from 143 to 80 points. When assessing the vegetative status, the following results were obtained - Kerdo vegetative index - a decrease from 11 to 9 points (tendency to vagotonia), orthoclinostatic test - a return to normal functional vegetative status. Thermal imaging data showed a decrease in temperature readings with an initial predominance of vagotonia in the projection zone of the lower right and left hypogastric nerve plexuses and Zakharyin-Ged zones in the projection of the pubic symphysis, in Zakharyin-Ged zones at the level of Th12, L2, S4, S5, measured on the right lateral by 3-4 cm from the spinous processes of the vertebrae on the back surface of the body and in the projection zone of the vagus nerves on the right and left on the lateral surfaces of the neck. Orthopedic tests showed an increase in muscle strength in the right gluteus maximus, a decrease in the limitation of movement of the right middle and small gluteal muscles, and the right internal rotators of the hip.

Example 2. Patient D., born in 1986, Complaints of pain in the pelvis, in the pubic symphysis, along the anterior abdominal wall, in the sacrum and right buttock since 2018, appeared after 2 natural births. History: painful bladder syndrome, endometriosis, chronic pelvic pain, fibrocystic spondylitis since 2021. Examined by a urologist, gynecologist, neurologist.

After the rehabilitation measures carried out according to the proposed method, the following was observed: a decrease in pain syndrome from 8 to 3 points on the VAS scale, a decrease from 73 to 49 points according to the central sensitization questionnaire, a decrease from 4 to 3 points according to the DNS questionnaire (neuropathic pain); the formation of a diaphragmatic breathing pattern is noted, according to the Naimigentsky questionnaire (the presence of hyperventilation) - a decrease from 31 to 23 points, according to the PHQ questionnaire - 9 (the presence of depression) - a decrease from 18 to 5 points, according to the PFIQ-7 questionnaire - a decrease from 101 to 30 points. When assessing the vegetative status, the following results were obtained - Kerdo vegetative index - normotension is noted, orthoclinostatic test - a return to normal functional vegetative status. Thermal imaging data showed an increase in temperature with an initial predominance of sympathicotonia in the projection zone of the lower right and left hypogastric nerve plexuses and Zakharyin-Ged zones in the projection of the pubic symphysis, in Zakharyin-Ged zones at the level of Th12, L2, S4, S5, measured on the right lateral by 3-4 cm from the spinous processes of the vertebrae on the back of the body and in the projection zone of the vagus nerves on the right and left on the lateral surfaces of the neck. Orthopedic tests showed an increase in muscle strength in the right gluteus maximus, a decrease in movement limitation in the right internal rotators of the hip, a decrease in pain syndrome from 4 to 1 point on the VAS.

Thus, when using the claimed method, the functional indicators of the autonomic nervous system are improved and the severity of myofascial pain syndrome in the pelvic floor muscles is reduced, which leads to an increase in the quality of life and normalization of the psychological status of women with chronic pelvic pain.

Claims (24)

A method for the rehabilitation of women with chronic pelvic pain, including an assessment of pain sensations and the functional state of the autonomic nervous system, characterized in that three stages of correction are carried out twice a week for four weeks, with preliminary testing of pain sensitivity according to the VAS and an orthoclinostatic test; moreover, at the first stage, sensorimotor gymnastics is carried out for 15 minutes, including exercises: 1) from the starting position (SP) - standing, feet shoulder-width apart, arms extended forward shoulder-width apart, with thumbs of both hands raised up to eye level, back relaxed, breathing voluntary, gaze focused on the thumb of the right hand, for 30-60 seconds alternately move gaze from right thumb to left without turning head, movement is performed only by eyeballs; 2) I.P. - the same, for 30-60 seconds, turn your head alternately towards the right and left thumbs, your gaze follows the turn of your head, then perform this exercise with your eyes closed for 30-60 seconds; 3) I.P. - standing, feet shoulder-width apart, arms extended forward shoulder-width apart, with thumbs of both hands raised up, right arm raised above head, left arm extended forward at sternum level, back relaxed, breathing voluntary, gaze focused on the thumb of the right hand, for 30-60 seconds alternately move gaze from right thumb to left finger, without nodding head, movement is performed only by eyeballs; 4) I.P. - the same, for 30-60 seconds raise and lower the head up/down, the gaze follows the head, then for 30-60 seconds perform this exercise with closed eyes; 5) I.P. - sitting on a gymnastic ball, feet shoulder-width apart, body relaxed, perform balancing movements on the ball for 60 seconds, shifting the pelvis to the right, left, forward, backward; 6) I.P. - sitting on a gymnastic ball, feet shoulder-width apart, back straight, for 60-120 seconds, while exhaling, bend your body to the right, left, forward; 7) I.P. - standing, feet shoulder-width apart, arms extended forward in front of you, breathing is arbitrary, for 60 seconds perform symmetrical circular movements in the hands of both hands, then perform multidirectional circular movements in the hands of both hands; At the second stage, the following is carried out: a) the patient is in a supine position, inhaling through the nose, exhaling through closed lips; diaphragmatic breathing is performed using the lower ribs and abdomen, while concentrating on stretching the pelvic floor muscles on exhalation; b) then a reflex-segmental massage is performed on the lumbosacral, cervicoccipital, upper thoracic zones in case of sympathicotonia or on the lumbosacral and thoracic spine zones in case of vagotonia in female patients from a prone position, while stroking, kneading, and rubbing the Zakharyin-Ged zones at the site of innervation Th11-12, L1-5, S1-2 are performed, the effect begins from the underlying zones to the overlying ones; c) then post-isometric relaxation of the iliopsoas and piriformis muscles, and the quadratus lumborum muscle is performed; d) then they act on the ventral and dorsal Chapman points - they touch the points with the tips of the index and middle fingers, make a circular movement with the hand, the time of action on each point is 10-20 seconds; d) then the patient lies on her back, legs bent at the hip and knee joints at an angle of 90 degrees, the operator is on the side of the patient, work with tissues begins from the healthy side, the operator uses the tips of the 2nd, 3rd, 4th, 5th fingers of both hands to apply pressure with a force of 40 g, further stretching the subcutaneous fat and superficial fascia in the lower abdomen, in the found zone of tension he begins to make circular movements with the fingers of both hands, increasing the pressure force to 80 g until a feeling of relaxation and improved stretching of the tissues lying under the fingers, thus treating the entire area of the anterior abdominal wall below the navel, then the operator performs a transverse massage in the area of the inguinal ligament following from the anterior superior iliac spine to the pubic tubercle for 2-3 minutes until a feeling of tissue relaxation, the tips of the 2nd and 3rd fingers of both hands are placed along the circumference of the topographic zone of the deep inguinal ring, immersed in the tissue with a pressure force of 50 g, then make circular movements and stretching of the subcutaneous fat and superficial fascia in the area of the deep inguinal ring until the sensation of tissue movement stopping, the area of the topography of the superficial inguinal ring is worked out in a similar way, the pressure force is 30 g, then the patient lies on the healthy side facing the doctor, the lower leg is straight, the upper leg is bent at an angle of 90 degrees at the hip and knee joints, the operator stands facing the patient, the knee of the patient's upper leg rests on the operator's thigh, while the operator uses the fingers of one hand to shift and roll the soft tissues of the pelvic area along the ischial bone, starting from the ischial tuberosity and rising to the ischial spine, the movements are performed with a pressure force of 80 g on the tissue; e) intravaginal work on trigger points of the pelvic floor muscles and massage of the pelvic diaphragm is performed; at the third stage, exercises are carried out: 1) I.P. - lying on your back, perform diaphragmatic breathing, while exhaling, tense the rectus abdominis muscles; 2) I.P. - lying on the back, legs bent at the hip and knee joints, the patient places her fingers 2 fingers below the anterior superior iliac bones and applies pressure with her fingers deep into the tissues, then, on exhalation with diaphragmatic breathing, tense the transverse abdominal muscle; 3) I.P. - lying on the back, legs bent at the hip and knee joints, diaphragmatic breathing, the patient inhales and relaxes the pelvic floor muscles, on exhalation the patient tenses the transverse abdominal muscle and moves the pelvis into a backward tilt and presses the lower back to the couch, repeat 5-7 times; 4) I.P. - lying on the back, legs bent at the hip and knee joints, the patient's pelvis is tilted backwards, the lower back is pressed against the couch, arms are raised in front of you, diaphragmatic breathing, the patient straightens her legs one by one, sliding her heel along the couch, repeat 5-7 times; 5) I.P. - lying on your back, legs bent at the hip and knee joints, arms raised in front of you, diaphragmatic breathing, the patient alternately pulls her legs to her chest, without straining the lower back and abdominal muscles, repeat 10 times; 6) I.P. - lying on the back, diaphragmatic breathing, on exhalation, the patient raises the left leg, bent at the hip and knee joints by 90 degrees, and presses with the left hand on the left knee, while pressing with the foot of the right leg down to the floor and lifting the right buttock a few centimeters, then lower the leg, repeat the same on the other side, repeat 5 times on each side; 7) I.P. - lying on your back, legs bent at the hip and knee joints, pelvis and lower back in a neutral position, diaphragmatic breathing, put a rubber elastic band on the thigh area near the knee joints, place a pillow between the legs in the hip area, while inhaling, simultaneously spread the knees to the sides, overcoming the resistance of the rubber band, then exhale, bring the knees together, rest the hips on the pillow, repeat 5 times; 8) I.P. - lying on your back, legs bent at the hip and knee joints, pelvis and lower back in a neutral position, diaphragmatic breathing, a pillow is placed between the legs in the hip area, on exhalation the thighs are brought together and rest against the pillow, on inhalation the legs are returned to the starting position, repeat 5 times.