Ministry of Health of the Republic of Belarus

educational institution
"Gomel State Medical University"

Department of Neurology and Neurosurgery with courses in medical rehabilitation,

psychiatry and FAT&R

Author:
A.S. Barbarovich, assistant

GUIDELINES
for a practical lesson
in the discipline "Physiotherapy and medical rehabilitation"
with students
6 course of the Faculty of Medicine, FIS,
students in the specialty 1-79 01 01 "General Medicine"

Topic 4: MEDICAL REHABILITATION IN PULMONOLOGY

Time - 6 hours

Approved at a meeting of the Department of Neurology and Neurosurgery with

courses in medical rehabilitation, psychiatry and FAT&R (protocol No. 13 of 12/15/2022)

Gomel, 2022
 LEARNING AND EDUCATIONAL GOALS, OBJECTIVES, MOTIVATION FOR
LEARNING THE TOPIC
Educational goal: the acquisition of knowledge, skills and abilities in medical
rehabilitation in cardiology, in pulmonology .
educational goal:
− develop your value-personal, spiritual potential;
− to form the qualities of a patriot and citizen, ready for active participation in the
economic, industrial, socio-cultural and public life of the country;
− realize the social significance of their future professional activities, learn to
observe educational and labor discipline, the norms of medical ethics and deontology.
Tasks:
As a result of the course, the student must:
know:
− features of medical rehabilitation in cardiology, in pulmonology ;
be able to:
− draw up an IPR;
own:
− fundamentals of medical rehabilitation in cardiology, in pulmonology .
Motivation for mastering the topic:
Rehabilitation is an active process, the purpose of which is to restore functions
disturbed due to illness or injury, the optimal realization of the physical, mental and social
potential of a sick person and a disabled person in order to most adequately integrate him
into society to maintain health and improve the quality of life. This is a wide and complex
system of medical and social events elevated to the rank of state.

MATERIAL EQUIPMENT
Equipment: inpatient card, phonendoscope, tonometer, results of laboratory and
instrumental studies.

CONTROL QUESTIONS FROM RELATED DISCIPLINES

1. "Physiotherapy":
− Methods of physiotherapy used in the medical rehabilitation of patients with
a major disabling pathology.

CONTROL QUESTIONS ON THE TOPIC OF THE LESSON

1. The main contingents of patients subject to medical rehabilitation, assessment of

the functional state, vital activity. Stress tests used in pulmonology.
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 2. Means and methods of medical rehabilitation used in pulmonology.
3. Management of patients with chronic pulmonary diseases. Development of an
individual program of medical rehabilitation of a patient with chronic obstructive
pulmonary disease, bronchial asthma.

STUDY PROCESS

Theoretical part
MEDICAL REHABILITATION IN PULMONOLOGY
The main contingents of patients subject to rehabilitation.
Stress tests used in pulmonology.
Assessment of the functional state, vital activity of patients with chronic
obstructive pulmonary disease and bronchial asthma. The chapter presents the main
provisions of the medical rehabilitation of the two most socially significant lung diseases:
chronic obstructive pulmonary disease (COPD) and asthma.
Chronic obstructive pulmonary disease is an independent nosological form of the
disease, characterized by a progressive increase in irreversible bronchial obstruction as a
result of chronic inflammation induced by pollutants, which is based on gross morphological
changes in all structures of the lung tissue involving the cardiovascular system and
respiratory muscles.
Chronic obstructive pulmonary disease remains one of the most important public health
problems. According to data published by the World Bank and WHO, it is assumed that in
the 20s. In the 21st century, COPD will take the 5th place in terms of damage caused by
diseases on a global scale. COPD is the fourth leading cause of death in the world. Many
people suffer from this disease for many years and die prematurely from it or its
complications. The disease poses a serious threat to public health, it can be both prevented
and treated. To combat it, a complex of therapeutic and preventive measures has been
developed. Over the coming decades, an increase in the incidence of COPD is predicted as
a result of the continuing influence of risk factors and the aging of the population.
Bronchial asthma is a chronic relapsing disease with a predominant lesion of the
bronchi, which is characterized by their hyperactivity due to specific (immunological) and /
or non-specific, congenital or acquired mechanisms. The main symptom of the disease is an
asthma attack and / or status asthmaticus due to bronchial smooth muscle spasm,
hypersecretion, dyskrinia and edema of the bronchial mucosa.
Stress tests used in pulmonology. The following tests apply.
6 minute walk test. This test does not require sophisticated equipment, has few
contraindications, patients themselves regulate the walking speed depending on how they
feel. Walking for 6 minutes is optimal.

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 The 6-minute walk test evaluates the integral response of all systems involved in the
performance of physical work (respiratory, cardiovascular systems, peripheral blood
circulation, neuromuscular system and muscle metabolism). The test evaluates the
submaximal level of physical abilities, i.e. reflects the functionality of the patient in
everyday life and can be used to establish the FC of respiratory failure and control during
the rehabilitation treatment of patients with COPD.
When preparing a patient for a 6-minute test, the usual regimen for taking medications
is maintained, vigorous physical activity is not recommended for 2 hours before the test.
After the test is completed, the pulse rate, dyspnea, and degree of fatigue on the Borg scale
are measured, indicating the reasons due to which the patient could not walk faster. When
conducting a step test, it is necessary to provide for the possibility of providing emergency
medical care.
Absolute contraindications to the 6-minute test: severe arrhythmias; myocarditis;
aneurysm of the heart or aorta; uncontrolled hypertension; acute thrombophlebitis or deep
vein thrombosis of the lower leg; atrioventricular block II and III degree; TELA; acute
pericarditis; decompensated heart failure; severe aortic stenosis; uncontrolled or severe
asthma; pulmonary edema; acute non-cardiogenic and extrapulmonary disorders
exacerbated by exercise.
Relative contraindications to the 6-minute test: heart rate at rest over 120 beats/min;
BP at rest more than 180/100 mm Hg. Art.; inability of the patient to perform the test due to
weakness, pain, fever, shortness of breath, incoordination or psychosis; cor pulmonale;
electrolyte disturbances (hypokalemia, hypomagnesemia); neuromuscular or rheumatic
disorders aggravated after exercise; uncontrolled metabolic disorders (diabetes,
thyrotoxicosis, hypothyroidism, etc.); complicated pregnancy or long-term pregnancy;
hypertrophic cardiomyopathy and other forms of obstruction of the outflow tract of the
heart; non-contact of the patient or his inability to follow the instructions of the medical staff
during the test.
Spirography and pneumotachometry. Spirometry and pneumotachometric studies
make it possible to determine a number of indicators that characterize lung ventilation. This
is a measurement of static volumes and capacities (the capacity includes several volumes),
characterizing the elastic properties of the lungs and chest wall, and dynamic studies
characterizing the amount of air entering and leaving the lungs per unit time. This includes
a number of indicators that are recorded in the calm breathing mode, and dynamic volumes
and flows that are recorded during forced maneuvers (forced vital capacity (FVC),
maximum lung ventilation (MV)) and mainly reflect the state of the airways.
bronchodilation tests. To resolve the issue of obstruction reversibility, a test with
inhaled bronchodilators is used. The bronchodilatory response depends on which
pharmacological group the bronchodilator belongs to; from the technique of inhalation;
prescribed dose; time elapsed after inhalation; bronchial lability during the study; state of
pulmonary function; reproducibility of indicators used for comparison. The volume of
forced air in the first second (OΦB1) is mainly estimated. Other indicators of the flow-
volume curve are less reproducible, which affects the accuracy of the results.
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 On the eve of the test with bronchodilators, short-acting agonists are canceled 6 hours
before, long-acting agonists 12 hours before the start of the study. As a diagnostic
bronchodilator, salbutamol at a dose of 400 mcg or atrovent (ipratropium bromide) at 40
mcg is used. In the first case, a functional study is repeated 15 minutes after inhalation of
the drug, in the second - after 30. In some patients, the drugs used can cause adverse
reactions in the form of pain in the heart, tachycardia, arrhythmia.
The result of the test is evaluated by the degree of increase in the OΦB1 index as a
percentage of the initial value. With its increase by 15% or more, the test is considered
positive and the obstruction detected is assessed as reversible. However, in the case of severe
obstruction at low initial values of expiratory flow, it is necessary to take into account the
absolute values of the increase in OΦB1 (the change in OΦB1 per 160 ml is statistically
significant).
When evaluating the response to a short-acting bronchodilator, additional criteria are
the absolute change in VC per 330 ml as a statistically significant difference or, in the
absence of significant FVC dynamics, a change in maximum volumetric velocity (MOF)
25-75 by 25%.
Bronchial provocation tests. With the help of provocative tests with
bronchoconstrictor stimuli, transient airway obstruction can be obtained, which makes it
possible to measure the degree of the so-called susceptibility of a person's airways to various
agents.
Depending on the bronchoconstrictor agent used, there are tests with pharmacological
(metacholine, histamine, carbachol), physical (non-isotonic aerosols, dry/cold air, exercise)
irritants and sensitizing agents (allergens, occupational sensitizers).
Indications for testing is the study of bronchial hyperreactivity in the following cases:
to obtain objective data on the state of the respiratory tract in cases of doubtful diagnosis of
asthma and early conditions of the disease; for professional selection when hiring with
adverse production or climatic conditions; to control the effectiveness of therapeutic and
diagnostic measures.
Provocative tests with histamine. During the test with histamine, the patient inhales an
increasing amount of the drug. All patients start with a dose of 0.03 mg/ml of the drug. If
after inhalation of the solution with the first concentration of histamine (methacholine) there
is no significant decrease in OΦB1 (less than 5% of the best initial values) and clinical signs
of bronchoconstriction (heaviness in the chest, cough or difficulty breathing) are not
detected, the next dose may be skipped. If concentrations are missed, it is important to
emphasize that before each two-minute inhalation, the patient should remove the mask
(mouthpiece) as soon as he feels respiratory discomfort or chest tightness. After each
inhalation, a spirometric study is performed. The dose of histamine resulting in a 20%
decrease in OΦB1 compared to baseline indicates the degree of bronchial hyperreactivity.
Provocative exercise tests. Exercise tests are not very sensitive, but are highly specific
for diagnosing exercise-induced asthma. The load is carried out either on a bicycle

5
ergometer or on a motorized treadmill. When working on a bicycle ergometer, to achieve
an adequate heart rate, a load is assigned at the rate of 2.0 W / kg.
Ventilation in liters per minute is measured during the last four minutes of physical
activity for 6-8 minutes. The number of heartbeats should be constantly monitored, and in
the study of patients older than 40 years, an ECG is taken during the test and after its
completion for 5 minutes.
Airway resistance is best measured using OΦB1 as it reflects most of the flow-volume
curve. The largest OΦB1 measurement taken just before the load itself is recorded and used
in the calculations. The intensity of the patient's work is chosen so as to achieve 40-60% of
his due maximum ventilation of the lungs during the last four minutes of the load.
To select the work power for running on a treadmill, you need to know the patient's
body weight. The aim is usually to set the speed and incline of the treadmill to induce 30-
45 ml of oxygen consumption per kilogram of body weight. Running at 5–9 km/h on a 10%
incline is usually sufficient work for most patients. Having reached the desired ventilation,
work is maintained for another four minutes.
The patient should wear a nose clip to allow mouth breathing. The measurement of
OΦB1 is carried out twice at the 1st, 3rd, 3rd, 7th, 10th and 15th minutes after exercise, and
each time the highest values are recorded. At the completion of the study protocol, the
patient should be given an aerosolized bronchodilator.
When interpreting the test results, the spirometric indicators are compared before and
after exercise. The percentage reduction in performance is calculated as the ratio of the
difference between the initial value and the smallest after the test to the initial value,
expressed as a percentage.
A decrease in OΦB1 by 20% is regarded as a mild decrease, 20-40% - moderate, and
more than 40% - as a severe manifestation of bronchial obstruction.
Spirography is a method of recording lung volumes during the performance of
respiratory maneuvers over time.
Indications for spirography:
• determination of the type and degree of pulmonary insufficiency;
• monitoring of pulmonary ventilation indicators in order to determine the degree and
speed of disease progression;
• evaluation of the effectiveness of course treatment of diseases with bronchial
obstruction with bronchodilators, short- and long-acting p2-agonists, anticholinergics,
glucocorticosteroids, inhaled corticosteroids and membrane-stabilizing drugs;
• conducting differential diagnosis between pulmonary and heart failure in combination
with other research methods;

6
• identification of initial signs of ventilation insufficiency in persons at risk of
pulmonary diseases, or in persons working under the influence of harmful production
factors;
• examination of working capacity and military examination based on the assessment
of the function of pulmonary ventilation in combination with clinical indicators;
• carrying out bronchodilatory tests in order to identify the reversibility of bronchial
obstruction, as well as provocative inhalation tests to detect bronchial hyperreactivity.

Despite the wide clinical use, spirography is contraindicated in the following diseases
and pathological conditions:
• severe general condition of the patient;
• progressive angina pectoris, MI, stroke;
• malignant hypertension, hypertensive crisis;
• toxicosis of pregnancy, the second half of pregnancy;
• circulatory failure stage III;
• severe pulmonary insufficiency that does not allow breathing maneuvers.

Means and methods of medical rehabilitation of patients with chronic obstructive

pulmonary disease

Risk factors. These factors include factors that predispose to the development of
COPD and factors that provoke an exacerbation of COPD.
Factors predisposing to the development of COPD:
• smoking (both active and passive);
• exposure to occupational hazards (dust, chemical pollutants, acid and alkali vapors)
and industrial pollutants (SO2, NO2, black smoke, etc.);
• atmospheric and domestic (smoke from cooking and fossil fuels) air pollution;
• hereditary predisposition (deficiency of α 1 -antitrypsin).

Factors provoking an exacerbation of COPD:

• bronchopulmonary infection;
• increased exposure to exogenous damaging factors;
• inadequate physical activity.

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 COPD classification. This lung disease is classified by severity in accordance with the
recommendations of the experts of the international program "Global Initiative for Chronic
Obstructive Lung Disease" (GOLD - Global Strategy for Chronic Obstructive Lung Disease,
2003). The classification is based on two criteria: clinical, taking into account the main
clinical symptoms (cough, sputum and shortness of breath) and functional, taking into
account the degree of irreversibility of airway obstruction. All OΦB1 values given in the
classification are post-bronchodilatory.
Clinical and functional diagnostics in COPD is carried out using the standards of
clinical and functional examination, including the collection of anamnesis; clinical
examination; laboratory research; chest X-ray; spirometry; pneumotachography; analysis of
arterial blood gases; electrocardiography; echocardiography. In the course of clinical and
functional diagnostics, the severity of the manifestations of COPD and its consequences,
which lead to the limitation of the life of patients, are clarified.
Medical criteria for assessing the limitations of the patient's life in COPD are:
• stage and course of COPD;
• the phase of the disease;
• the frequency of exacerbations of the process;
• degree of respiratory failure;
• stage of heart failure.

Stage and nature of the course of COPD. There are four stages of the disease.
Stage I - mild COPD. Performing daily physical activity does not cause respiratory
discomfort, but during spirometry, obstructive pulmonary ventilation disorders are
determined: the post-bronchodilation ratio of OΦB1 to FVC is less than 70%, OΦB1 ≥ 80%
of the proper values. Patients are concerned about chronic cough and sputum production.
Stage II - moderate course of COPD. The disease is characterized by an increase in
obstructive pulmonary ventilation disorders: OΦB1 / FVC < 70%, 50% ≤ OΦB1 < 80% of
the expected values. Patients seek medical attention due to shortness of breath and
exacerbation of the disease, they are concerned about chronic cough and sputum production.
Stage III - severe course of COPD. The disease is characterized by further airflow
limitation: OΦB1/FVC < 70%, 30% < OΦB1 < 50% predicted. Shortness of breath and the
frequency of exacerbations of the disease are increasing, which affects the quality of life of
patients.
Stage IV is an extremely severe course of COPD. With the disease, the quality of life
deteriorates markedly, and exacerbations can be life-threatening. The disease acquires a
disabling course, characterized by extremely severe bronchial obstruction: OΦB1 / FVC <
70%, OΦB1 < 30% of the predicted values or less than 50% of the predicted values, in
8
combination with signs of chronic respiratory failure according to arterial blood gasometry
(partial pressure of oxygen in the arterial blood pressure (PaO2) less than 60 mmHg with or
without an increase in partial pressure of carbon dioxide (PaCO2) greater than 45 mmHg)
or arterial blood saturation (SaO2) less than 95% according to pulse oximetry.

Phases of COPD. According to clinical signs, two main phases of the course of COPD
are distinguished: the phase of a controlled, or stable, course of the disease and the phase of
an uncontrolled course of the disease.
A stable course is a state when the progression of the disease can be determined only
with long-term dynamic monitoring of the patient, and the severity of symptoms does not
change significantly for several weeks or even months.
An uncontrolled course is characterized by frequent exacerbations (more than 3-4 times
a year), the progression of clinical symptoms and impaired respiratory function. An
exacerbation is a deterioration in the patient's condition, manifested by an increase in
symptoms and functional disorders, and lasting at least 5 days. Exacerbations can begin
gradually, gradually, or they can be characterized by a rapid deterioration in the patient's
condition with the development of acute respiratory and right ventricular failure.
The frequency of exacerbations of COPD. In the course of clinical and functional
diagnostics, the frequency of exacerbations of COPD over the previous 12 months is
specified on the basis of the analysis of the patient's medical documents. In ITU practice, a
gradation of the frequency of exacerbations into rare, medium frequency and frequent has
been adopted. In COPD, one or two exacerbations are assessed as rare, three or four
exacerbations of average frequency, and five or more exacerbations during the year are
frequent.
Severity of respiratory failure. Respiratory failure (RD) is the inability of the
respiratory system to provide a normal gas composition of arterial blood.
There are three degrees of severity of ND:
I st. - its signs are absent at rest and appear during physical activity of moderate intensity
(brisk walking);
II Art. - its signs are absent at rest and appear with little physical exertion (slow
walking);
III Art. - signs of it are noted at rest.

Clinical and functional diagnosis of DN includes taking into account clinical signs,
spirographic data, blood gasometry (PaO2, PaCO2, SaO2). In ITU practice, when assessing
the severity of a patient's disability, it is customary to single out an intermediate DN of I-II
st.
DN I Art. characterized by shortness of breath when walking fast, climbing a slight
elevation. Respiratory rate (RR) and heart rate at rest were within normal limits. There is no
9
participation of auxiliary muscles in the act of breathing. When examining the function of
external respiration, there is a moderate decrease in VC to 70-80% of the proper values,
OΦB1 - 70-79% of the proper values, OΦB1 / FVC - 60-75%, which indicates the presence
of initial manifestations of bronchial obstruction. Indicators of arterial blood gasometry:
PaO2 - 60-79 mm Hg. Art., PaCO2 - normal.
DN I-II Art. characterized by shortness of breath with moderate exertion. Respiratory rate
at rest up to 20 in 1 min, heart rate - 60-90 in 1 min. Participation of auxiliary muscles in
the act of breathing appears only after exercise. ECG of the right type, signs of right
ventricular hypertrophy. The nature of ventilation disorders becomes mixed: VC - 56-69%
of the due values, OΦB1 - 50-69% of the due values, OΦB1 / FVC - 40-60%. PaO2 - reduced
to 60%, PaCO2 - normal.
DN II Art. characterized by shortness of breath with little exertion. Respiratory rate at rest
up to 25 per minute, heart rate - increases to 90-100 per 1 min. The participation of auxiliary
muscles in the act of breathing is pronounced during physical exertion. Pulmonary
hypertension, hypertrophy and dilatation of the right parts of the heart are detected (ECHO
CG, ECG). Indicators of the function of external respiration significantly deviated from the
proper values: VC - 50-55%, OΦB1 - 35-50%, OΦB1 / FVC - less than 40%, PaO2 - 50-59
mm Hg. Art., PaCO2 at rest less than 45 mm Hg. Art.
DN III Art. characterized by severe shortness of breath and tachycardia at rest: respiratory
rate - more than 28 per 1 min, heart rate - more than 100 per 1 min. A distinct participation
of auxiliary muscles in the act of breathing is revealed. Clinical signs of decompensated cor
pulmonale: VC < 50% predicted, OΦB1 < 35% predicted, OΦB1 / FVC less than 40%,
PaO2 < 50 mm Hg. Art., PaCO2> 45 mm Hg. Art.
In the practice of ITU and rehabilitation, when assessing various indicators
characterizing the dysfunction of the respiratory organs, it is customary to distinguish four
FCs:
• FC-1 - mild (slightly pronounced) dysfunction of the respiratory system, which
corresponds to DNI st.;
• FC-2 - moderate (moderately pronounced) dysfunction of the respiratory system,
which corresponds to DN I-II st.;
• FC-3 - pronounced dysfunction of the respiratory system, which corresponds to DN
II degree;
• FC-4 - pronounced violations of the function of the respiratory system, which
corresponds to DN III Art.

stage of heart failure. CHF in COPD develops as a result of the formation of chronic
cor pulmonale. Its main pathogenetic link in its formation is hypertension in the pulmonary
circulation, leading to an overload of the right heart, right ventricular hypertrophy, followed
by its decompensation.

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 At the origins of hypertension in the pulmonary circulation lies respiratory failure,
accompanied by a violation of the gas composition of the blood, alveolar hypoxemia, the
development of constriction of small pulmonary arteries and arterioles (Euler-Liljestrand
reflex), intrapulmonary blood shunting. In the future, an increase in total vascular resistance
in the lungs causes the formation of stable hypertension in the pulmonary circulation.
Normally, SBP in the pulmonary artery (LA) does not exceed 25 mm Hg. Art. at rest and
30 mm Hg. Art. during physical exertion. There are three degrees of pulmonary
hypertension:
• I st. - GARDEN in LA less than 50 mm Hg. Art.;
• II Art. - GARDEN in LA 50-80 mm Hg. Art.;
• III Art. - GARDEN in LA more than 80 mm Hg. Art.

To assess the severity of CHF in COPD, the Strazhesko-Vasilenko classification is

used, adapted to the conditions of cardiac decompensation in cor pulmonale. The following
stages of CHF are distinguished.
• Stage I - initial, latent heart failure, manifested by the appearance of shortness of
breath, palpitations and fatigue only during exercise. Central and intracardiac
hemodynamics at rest are not changed.
• II A - signs of congestion in the systemic circulation at rest are moderately expressed.
There is hypertrophy and expansion of the cavity of the right ventricle, a decrease in the
contractile function of the right ventricle, pulmonary hypertension of the 1st degree.
• Stage IIB - severe hemodynamic disturbances at rest. Significantly expressed
stagnation in the systemic circulation. Severe edema, hepatomegaly are
characteristic; severe dilatation of the right ventricle; a significant decrease in
his systolic function; pulmonary hypertension II stage.
• Stage III - the final, dystrophic stage with irreversible morphological changes
in the internal organs with a violation of their function. There are pronounced
congestion in the systemic circulation, signs of cardiac cachexia. Pulmonary
hypertension stage III, significant dilatation of the right heart, low ejection
fraction of the right ventricle.
In the practice of ITU and rehabilitation, when assessing various indicators
characterizing the dysfunction of the circulatory system, it is customary to distinguish four
FCs.
• FC-1 - mild (slightly pronounced) dysfunction of the circulatory system, which
corresponds to stage I CHF.
• FC-2 - moderate (moderately pronounced) dysfunction of the circulatory system, which
corresponds to CHF PA stage.

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• FC-3 - pronounced dysfunction of the circulatory system, which corresponds to stage
IIB CHF.
• FC-4 - pronounced dysfunction of the circulatory system, which corresponds to stage
III CHF.

The results of the studies indicate that DN and CHF are the main disabling
consequences of COPD, leading to a pronounced limitation of the life of patients.
The assessment of the severity of disability in patients with COPD is carried out on
the basis of the results of clinical and functional diagnostics, as well as the data of
psychological and social expert rehabilitation diagnostics. As a result of research, it was
found that the consequences of COPD lead to a limitation in the ability of patients to move
independently, self-service and participate in work activities. The presence of these
restrictions and the degree of their severity are due to a significant decrease in exercise
tolerance due to the development of systemic effects of the disease, including the
progression of the systemic inflammatory process, cardiorespiratory disorders with the
development of hypertension in the pulmonary circulation and chronic cor pulmonale, an
imbalance in the proteolysis-antiproteolysis system with the formation of chronic DN,
which is manifested by limitation of ventilation, the phenomenon of dynamic hyperinflation,
impaired gas exchange, as well as dysfunction of the skeletal and respiratory muscles.
Categories such as learning (retraining), orientation, communication, control over one's
behavior in COPD patients do not suffer or are violated to an insignificant extent that does
not lead to social consequences.
The ability to move independently is the ability to effectively move independently
(walk, run, overcome obstacles, maintain body balance, maintain a posture, use personal
and public transport) in one's environment, ensuring human mobility.
FC-0 - maintaining the ability to move in full without restrictions in patients with COPD
stage I or II, mild or moderate course, without signs of respiratory and heart failure.
FC-1 - a slight impairment of the ability to move, periodically occurring moderate or
permanent slight impairment of the static-dynamic function while maintaining the ability to
move independently when the mechanics of movement change, longer time consumption,
fragmentation of performance and reduction in distance using, if necessary, technical and
other aids. FC-1 limitation of the ability to move occurs in patients with COPD with the
development of respiratory failure stage I or stage I-II, heart failure stage I with a slight
decrease in exercise tolerance.
FC-2 - a moderately pronounced impairment of the ability to move, restriction of the ability
to move by the area of residence with a clear change in gait, a slow pace of walking, the
need to use technical and other aids outside the home; incomplete correction by drugs of the
activity of systems that provide movement; use of public transport is difficult, but possible
without the help of others. FC-2 limitation of the ability to move occurs in patients with

12
stage III COPD, severe course, with the development of stage II respiratory failure in
combination with heart failure stage I of the disease.
FC-3 - a pronounced impairment of the ability to move, restriction of movement within the
territory closest to housing with outside help or with the help of complex technical and other
auxiliary vehicles, the use of public transport is sharply difficult without the help of other
persons. FC-3 limitation of the ability to move occurs in patients with stage IV COPD, an
extremely severe course, with the development of stage II or III respiratory failure in
combination with stage IIIA heart failure with a pronounced decrease in exercise tolerance.
FC-4 - a pronounced impairment of the ability to move, a complete loss of independent
movement or the ability to move only within housing with the help of other persons or
complex technical and other auxiliary means. FC-4 limitation of the ability to move occurs
in patients with stage IV COPD, an extremely severe course, with the development of stage
III respiratory failure in combination with heart failure in PB or stage III with a pronounced
decrease in exercise tolerance.
The ability to self-care is the ability to independently cope with basic physiological
needs, perform daily household activities and maintain personal hygiene skills, ensuring an
effective independent (in accordance with age characteristics) existence in the environment
without the help of other persons.
FC-1 - a slight impairment of the ability to self-service, maintaining the ability to
independently implement daily needs when in need of episodic (not more than 1 time per
month) help from other people in the implementation of certain household needs. FC-1
limiting the ability to self-care occurs in patients with COPD stage III with the development
of DN stage I-II.
FC-2 - a moderately pronounced impairment of the ability to self-service, maintaining the
ability to self-service with a longer expenditure of time, fragmentation of its
implementation, reduction in volume, using , if necessary, technical and other aids or
occasional assistance from outsiders; the need for periodic (not more than 1 time per week)
assistance of other persons in the implementation of some household needs while
independently implementing other daily needs. FC-2 limitation of the ability to self-care
occurs in patients with stage III or IV COPD with the development of stage II DN.
FC-3 - a pronounced impairment of the ability to self-service, maintaining the
ability to independently implement unregulated urgent needs when in need of
constant outside help from other people (the use of complex technical and other
assistive devices does not allow you to fully perform daily household activities
and skills). FC-3 limitation of the ability to self-care occurs in patients with
stage IV COPD with the development of stage II DN in combination with heart
failure stage PA or respiratory failure stage III.
FC-4 - a pronounced impairment of the ability to self-service due to a
pronounced dysfunction (or limitation of self-service due to a combination of
pronounced dysfunctions of organs and systems that create a syndrome of
mutual burdening), leading to a pronounced or complete loss of personal
13
 independence and need for care (household, special medical). FC-4 limiting the
ability to self-care occurs in patients with stage IV COPD with the development
of stage III respiratory failure in combination with heart failure of BE or stage
III.
Ability to work - a set of physical, psychophysiological and psychological capabilities
formed as a result of the physical, psychological and cultural development of the individual,
general and special education, the development of labor skills and craftsmanship necessary
and sufficient for the quality performance of any work of ordinary content, in the usual way,
in normal volume and under normal conditions.
Limitation of the ability to work is one of the main indicators characterizing the social
exclusion of patients with COPD. In the course of occupational diagnostics, the patient's
ability to continue working in his profession without restrictions, with a limitation in the
scope of professional activities or a decrease in qualifications, and in case of loss of a
profession, the possibility of choosing a new profession for rational employment are
assessed.
FC-1 (disability less than 25%) - a slight impairment of the ability to work; defined:
• while maintaining the ability to perform work in their profession with minor changes
in the nature and working conditions;
• the possibility of optimizing the working regime (exemption from additional loads,
business trips, night shifts);
• the possibility of transferring from unfavorable working conditions to ordinary ones;
• maintaining the ability to perform another profession of equal qualification without
the need for retraining (in case of loss of the main profession).

FC-1 limitation of the ability to work occurs in patients with COPD stage I or II, mild
or moderate course with rare exacerbations, with the development of DN I or DN I-II stage,
performing contraindicated types of work or working in contraindicated production
conditions, to which relate:
• work with constant or episodic significant physical stress during the working day;
• unfavorable microclimatic conditions (low temperature of the working environment,
temperature and pressure fluctuations, high humidity);
• exposure to industrial pollutants, allergens that cause bronchospasm;
• exposure to bronchotropic and pulmotropic toxic substances;
• work in conditions of strong vibration, at height, under water.
With FC-1 restriction of participation in work, a rational labor arrangement for patients
with COPD is carried out according to the conclusion of the VKK of the healthcare
organization.

14
FC-2 (possible III group of disability) - moderately pronounced limitation of the ability to
work; is determined while maintaining the ability to perform labor activity in normal
production conditions:
• with a decrease in qualifications or a decrease in the volume of production activities;
• maintaining the ability to work in their profession with a significant reduction
(narrowing) of the volume of work;
• the need to equip the workplace with special devices, equipment, etc.
FC-2 limitation of participation in work occurs in patients with COPD in stage III, in
severe cases with exacerbations of moderate frequency, the development of DNII stage. in
combination with compensated chronic pulmonary heart. Such patients are contraindicated
in work with constant or episodic moderate physical stress; intellectual work with
pronounced neuropsychic stress (grade 3); labor with prolonged strain of speech functions.
With FC-2 restrictions on participation in labor, light physical labor in favorable
sanitary and hygienic conditions and intellectual labor with moderate neuropsychic stress
are available.
FC-2 restrictions on participation in work can also occur in patients with COPD stage
I or II, mild or moderate course with rare exacerbations, with the development of DN I-II
stage, working in contraindicated conditions, if it is impossible for them to have a rational
labor arrangement on the recommendation of the VKK and the need to acquire a new
profession.
FC-3 (possible II or III disability group) - a pronounced violation of the ability to
work; is determined: while maintaining the ability to perform labor activity in special
conditions using technical and other auxiliary means or with the help of other persons or
with a pronounced limitation of the amount of work performed due to a pronounced
reduction in working time.
FC-3 limitation of participation in work is determined in patients with COPD stage III
or GV, severe or extremely severe course, with frequent exacerbations of the process, with
DN II st. in combination with heart failure at the stage.
FC-4 (I or II group of disability is possible) - a pronounced limitation of the ability to
work, inability to work, the impossibility or presence of medical contraindications for any
type of work. FC-4 limitation of participation in work is determined in patients with COPD
stage IV, extremely severe course, with DN stage III.
Medical rehabilitation of patients with COPD is a set of measures aimed at restoring
health and ability to work, personal and social status of the patient. Treatment and
rehabilitation of such patients in the vast majority is carried out on an outpatient basis,
hospitalization is indicated only in case of exacerbation, infection, deterioration, stroke, for
bronchial lavage.
The main tasks of rehabilitation of patients with COPD:

15
 • suppression of the inflammatory process in the bronchi and the achievement of
clinical remission;
• stabilization and prolongation of remission;
• prevention of recurrence of the disease;
• limitation of bronchial obstruction;
• improving the quality of life of patients and its duration;
• refusal of the patient to smoke;
• increased tolerance to physical activity;
• optimization of the load mode;
• improvement of the psycho-emotional state;
• maintaining social status;
• disability prevention;
• the most complete return to work.
An individual patient rehabilitation program should include various methods.
non-drug methods. Applicable:
• to give up smoking;
• expansion of motor activity;
• psychological correction and, if necessary, psychotherapy;
• elimination of harmful production factors;
• reduction of household allergization;
• sanitation of foci of extrapulmonary localization: paranasal sinuses, otitis media; bile
ducts; gynecology, urology;
• hardening;
• rational balanced diet.
Diet therapy. Nutritional status (a set of clinical, anthropometric and laboratory
parameters that characterize the quantitative ratio of the patient's muscle and fat mass) is an
important determinant of disease symptoms, disability and prognosis in COPD. Both
overweight and underweight can be a problem. Approximately 25% of patients with GOLD
grade 2-4 (moderate to very severe COPD) have a decrease in body mass index, which is an
independent risk factor for mortality in this disease. The available evidence suggests that
nutritional support alone is not sufficient to significantly improve the condition. Increased
intake of calories should be accompanied by physical activity, which has a non-specific
anabolic effect. There is some evidence that this helps even those patients who are not
severely malnourished.
16
 Kinesiotherapy. The mechanism of development of pathological disorders consists in
the violation of mucociliary clearance, which, in combination with hereditary deficiency of
α1-antitrypsin leads to impaired evacuation of sputum from the bronchial tree. Developing
inflammation is secondary.
Diffuse non-allergic inflammation of the bronchi leads to a progressive impairment of
pulmonary ventilation and gas exchange in an obstructive manner.
Tasks of kinesitherapy:
• elimination of acute inflammatory phenomena;
• improved sputum evacuation;
• improvement of lung ventilation;
• increase in the excursion of the chest, maintaining the elasticity of the lung tissue;
• strengthening the respiratory muscles;
• prevention of chest deformity, normalization of posture;
• training of the cardiorespiratory system.

Breathing exercises are prescribed with an emphasis on lengthening the expiratory

phase. Exercises to strengthen the abdominal muscles and to improve the movements of the
diaphragm are also included.
Contraindication to kinesitherapy: acute stage of the disease (high temperature,
bronchospastic syndrome, etc.).
The use of kinesitherapy is effective after the temperature has normalized (to
subfebrile), after overcoming the acute stage and in the period between attacks of the disease
(remission phase).
Kinesiotherapy includes the following techniques.
position drainage. Drainage exercises are used outside the main complex of
kinesitherapy, as they are tiring for the patient and are combined with breathing exercises in
the form of jerky exhalation and elements of vibration massage. Frequent change of starting
positions, active movements associated with the rotation of the torso are necessary. The
duration of drainage positions is from 10 to 30 minutes for each procedure, repeated 3-4
times a day, usually before meals.
Morning hygienic gymnastics. It is carried out with an average load and a duration of
up to 10 minutes. The pace of movement is moderate (80-100 steps / min), breathing follows
the rhythm of steps with an extended exhalation. Classical and segmental massage has a
positive effect.
Voice gymnastics with emphasis on individual phases of breathing, diaphragmatic
breathing training. With emphysema, physical exercises are aimed at teaching the skills of
proper breathing with an extended exhalation to reduce residual air. With obstructive
17
syndrome, it is advisable to use sound gymnastics with its subsequent addition to breathing
exercises (with the formation of positive expiratory pressure).
Walking. Includes hiking, dosed walking.
Active sports. These include skiing, swimming, cycling.
Massage. Massage is contraindicated in the period of exacerbation of the disease, in a
serious condition of the patient, the formation of chronic cor pulmonale in the stage of
decompensation, DN III stage, KN II B-III stage.
Massage tasks:
• to strengthen local ventilation of the lungs;
• improve blood and lymph circulation;
• stimulate the discharge and liquefaction of sputum;
• eliminate spasm of the respiratory muscles;
• strengthen the respiratory muscles;
• reduce cough and pain;
• improve the function of external respiration;
• improve overall physical performance and normalize sleep.

The following types of massage are used: classic manual, acupressure, segmental-
reflex, mechanical vibration, cold massage, cupping, acupressure, self-massage.
Psychotherapy. Classes with patients are conducted by a psychologist or
psychotherapist.
Tasks of psychotherapy:
• suppression of psychosomatic manifestations;
• development of positive motivation for rehabilitation activities;
• freeing the patient from bad habits;
• combined with kinesitherapy techniques to normalize breathing (for example,
relaxation breathing). For this purpose, various methods of psychotherapy are used:
hypnotherapy, autogenic training, rational psychotherapy (individual and in a group of
patients), group psychotherapy.

Hardware physiotherapy. Physiotherapy procedures for COPD are prescribed to

overcome inflammatory and degenerative processes in the bronchial mucosa and
peribronchial tissue, to ensure optimal patency and self-purification of the bronchi:
• circular ozocerite chest wraps have an anti-inflammatory effect;
18
• aerosol inhalations are combined with endobronchial sanitation;
• ultrasonic and negative charge electric aerosols are effective;
• heat-moist inhalations help to remove inflammation products, moisturize the mucous
membrane;
• inhalation administration of desensitizing, anti-inflammatory, expectorant, mucolytic,
bronchodilator drugs, as well as phytopreparations is used;
• intraorganic electrophoresis is also used, based on the concentration of the drug
inhaled into the inflammation site using transverse galvanization of the chest after inhalation
of the appropriate aerosol;
• in DN in patients with pulmonary emphysema, transcutaneous electrical stimulation
of the diaphragm has been successfully tested.

Medical supportive therapy. Medical supportive care includes:

• bronchodilators: iprotropium bromide;
• hormonal agents: prednisolone with a gradual decrease in dose and the
transition to budesonide;
• mucolytic agents: bromhexine, ambroxol;
• antimicrobial treatment in the presence of a bacterial infection with drugs of
the penicillin groups (amoxicillin) in combination with aminoglycosides
(amikacin, gentamicin), cephalosporins (cephalexin), macrolides
(erythromycin);
• antithrombotic and antihemorrhagic drugs;
• antihypertensive agents and diuretics in the presence of signs of pulmonary
hypertension;
• immunomodulators.

Surgery. Means of technical compensation and reconstructive operations. Ultrasonic

inhalations are used through a nebulizer of bronchodilators and mucolytics.
Lung Volume Reduction Operation (LUOL). It is an operation in which part of the lung
is removed to reduce hyperinflation and achieve more effective pumping of the respiratory
muscles (as measured by the ratio of length: tension, curvature of the dome of the diaphragm
and area of contact). In addition, LEAL increases the elastic recoil of the lungs, thus
increasing the exhaled air velocity and reducing the incidence of complications. The use of
this method is more effective than drug therapy in patients with upper lobe emphysema and
low exercise tolerance before treatment. A prospective economic analysis has shown that
OUOL is cost-competitive with other non-surgical health care programs. It was found that

19
the operation allows to increase the survival rate in patients with severe upper lobe
emphysema and low exercise tolerance after rehabilitation compared with drug therapy.
In patients with high exercise tolerance after pulmonary rehabilitation, the
implementation of LMWH does not lead to an increase in survival, although there is an
increase in health-related quality of life and working capacity. In patients with severe
emphysema and OΦB1 < 20% predicted, widespread emphysema on high-resolution CT,
surgery leads to an increase in mortality compared with drug treatment.
Bronchoscopic lung volume reduction (BUOL). Based on a retrospective analysis,
BUOL in patients with severe airflow limitation (OΦB1 15–45% predicted), heterogeneous
emphysema on CT, and hyperinflation (total lung capacity greater than 100% and residual
lung volume greater than 150% predicted) results in moderate improved lung function,
increased exercise tolerance, and reduced symptoms at the expense of increased rates of
pneumonia and hemoptysis after implantation.
Lung transplant. It has been shown that with careful selection of patients with advanced
COPD, lung transplantation can improve the quality of life and functionality. The main
complications of the operation, in addition to postoperative mortality, are acute graft
rejection, bronchiolitis obliterans, cytomegalovirus infection, other opportunistic fungal or
bacterial infections, and lymphoproliferative diseases. The use of lung transplantation is
limited by the scarcity of donor organs and cost. The indication for lung transplantation is
COPD with a BODE score greater than 5.
Bullectomy. It is a surgical procedure for bullous emphysema. Removal of the large
bulla, which does not take part in gas exchange, leads to the expansion of the surrounding
lung parenchyma. Pulmonary hypertension, hypercapnia, and severe emphysema are not
absolute contraindications for bullectomy.
School of the patient. Rehabilitation at the outpatient stage has recently been enriched
with new organizational forms of work with patients in terms of optimizing their dispensary
observation. These are "asthma clubs", "pulmo clubs", as well as the organization of family
rehabilitation and medical examination.
Frequent, medium-term and long-term exacerbations cause pronounced disturbances
in vital activity, which makes it impossible for patients who can work in specially created
conditions to participate in the labor activity. When referring to the MREK, they determine
the I disability group.
Means and methods of medical rehabilitation of patients with bronchial asthma

Asthma classification: allergic, non-allergic, mixed.

Variants of BA: BA of the elderly; occupational asthma, which is combined with
lesions of the upper respiratory tract and atopic dermatitis; BA seasonal (polynosis); cough
variant of asthma (especially cough at night).
: mild (episodic or intermittent); persistent; moderate; heavy.

20
 During MR, CRH of patients with BA is isolated.
KRG 1.1:
• patients with acute bronchitis, severe exacerbations and other complications of
asthma with which they were admitted to the intensive care unit;
• acute severe asthma;
• asthmatic status;
• unstable asthma;
• fatal asthma;
• patients with asthma who underwent surgical interventions (lavage, bronchoscopy,
correction of the nasal septum, polypectomy, vagotomy, etc.).
KRG 1.2: rehabilitation of patients with asthma is carried out at all stages of MR:
• patients with BA with initial manifestations without maladjustment consequences or
with mild consequences at the level of the respiratory system (mild BA that does not require
medical support in remission);
• patients undergoing continuous or continuous course rehabilitation;
• patients with BA intensely persistent.

Courses are conducted by MR on an outpatient basis.

KRG 2.1: moderately severe asthma of a stable nature.
KRG 2.2: proportion of patients from KRG 2.1; moderate and severe BA of unstable course.
KRG 3.1: moderate BA severity, disabled group III or sometimes II group with high RP.
KRG 3.2: moderate or severe asthma; disabled group II with an average RP.
KRG 3.3: severe, extremely severe asthma, low RP; invalids of II or I group.
The main tasks of rehabilitation of patients with BA:
• elimination of acute phenomena;
• relief of repeated and prolonged seizures;
• improvement of the psycho-emotional state;
• optimization of the load mode;
• seizure prevention;
• maintaining social status;
• if possible, the most complete return to work;
• achievement of the set goal with minimal material costs.

21
 An individual patient rehabilitation program should include various methods of
restorative treatment.
Non-pharmacological methods of rehabilitation. Applicable:
• rational nutrition (hypoallergenic diet): should be excluded (limited): citrus fruits;
nuts (hazelnuts, almonds, peanuts, etc.); fish, fish products (fresh, salted); poultry (goose,
duck, etc.) and products from it; chocolate and chocolate products; coffee; smoked products;
vinegar, mustard, mayonnaise, spices; horseradish, radish, radish; tomatoes, eggplants;
mushrooms; eggs, milk; strawberries, strawberries, melon, pineapple; sweet dough; honey.
All alcoholic beverages are strictly prohibited , since the vast majority of alcohol is excreted
through the lungs. Recommended: boiled beef meat; cereal soups, vegetable soups on a
secondary beef broth; vegetarian soups; butter, olive, sunflower oil; Boiled potatoes; cereals;
one-day dairy products (cottage cheese, kefir, yogurt); cucumbers, parsley, dill; baked
apples; watermelon; tea, sugar; compotes from apples, plums, currants, cherries, dried fruits;
white lean bread;
• normalization of body weight;
• to give up smoking;
• expansion of motor activity;
• psychological correction and, if necessary, psychotherapy;
• elimination of harmful production factors;
• reduction of household allergization;
• sanitation of foci of extrapulmonary localization: diseases of the nose, ears, throat,
biliary tract, gynecological, urological;
• hardening;
• psychotherapy;
• exercise therapy.
Kinesiotherapy. The peculiarities of the patient's breathing during an asthma attack are
that additional resistance to the air flow is created on exhalation. To alleviate this condition,
the patient breathes as often as possible (hyperventilation), resorting to the help of the
auxiliary respiratory muscles, leans forward with emphasis on the arms, raised and flattened
shoulders. At the same time, upper chest breathing is formed, as a result of which the greatest
load falls on the muscles of the upper body and cabbage soup, which do not have time to
relax during exhalation and maintain constant tension: at first only during periods of
exacerbation, and then during remission. The diaphragm is in the same state. As a result of
constantly spasmodic fibers and their shorter length, it develops less force. Increased work
of the muscular apparatus increases oxygen consumption. Under conditions of hypoxia,
muscle fatigue occurs faster, which determines the vicious circle, severity and prognosis of
the disease.
22
 The consequence of respiratory disorders, as a rule, are changes in the cardiovascular
system, which in turn lead to a decrease in exercise tolerance. Therefore, in BA, the basis of
kinesitherapy is the formation of breathing with predominant ventilation of the lower-middle
sections of the lungs with a slow, extended breath (diaphragmatic breathing).
Apply:
• post-isometric relaxation of the neck muscles;
• diaphragmatic breathing (abdominal breathing);
• volitional regulation of breathing (after a short breath, the patient makes a passive
exhalation with additional muscle relaxation and some breath holding until the first desire
to breathe).
To increase the compensatory capabilities of the respiratory system, apply:
• exercises to train flaccid and relaxed muscles of the trunk and limbs;
• posture correction;
• exercises for the distal limbs;
• training on a bicycle ergometer in aerobic mode;
• when the condition improves - walking up to 2 hours a day, dosed walking 30-60
minutes, 100-120 steps / min;
• upon reaching remission - cycling and swimming in the open air, skiing.
Drainage exercises are prescribed to improve the removal of sputum from the lower
and middle lobes. In the draining position, the inhalation gradually deepens and, when there
is a desire to cough, several careful coughs are performed when moving to the position
opposite to the draining one.
Massage. Massage is contraindicated in the period of exacerbation, in severe condition
of the patient, the formation of chronic cor pulmonale in the stage of decompensation, DN
stage III, circulatory failure stage IIB-III.
Massage tasks:
• to strengthen local ventilation of the lungs;
• improve blood and lymph circulation;
• stimulate the discharge and liquefaction of sputum;
• eliminate spasm of the respiratory muscles and swelling of the mucous membrane;
• relieve fatigue of auxiliary muscles;
• strengthen the respiratory muscles;
• improve overall physical performance and normalize sleep.

23
 The following types of massage are used: classic manual, acupressure, segmental-
reflex, mechanical vibration, cold massage, acupressure and self-massage. Scope: chest,
back and back of the neck, lower limbs.
Psychotherapy. Patients with asthma, along with a high desire for a cure, are
characterized by a fear of an attack turning into a panic, an increased level of situational and
personal anxiety.
Deep psychological features in patients with AD: aggressive urges with a simultaneous
hidden desire for tenderness and intimacy; emotional instability; hysterical and egocentric
traits (often socially disguised).
Personal structure of patients with AD: inability to constructively resolve conflicts;
fearfulness; anxiety; touchiness; internal need for constant protection and care; tendency to
listen to your feelings.
Problems of psychotherapy: fear of close therapeutic contact, fear of suppression of his
personality; guilt; ambivalence of attraction and repulsion.
Medical tactics: smooth and constant attention; prevention and suppression of relapses;
careful selection of patients for psychotherapy.

Hardware physiotherapy. It is used for mild asthma that does not require medical
support. In the interictal period appoint:
• heat-moist inhalations of eufillin;
• electrosleep;
• electric field - UHF, UHF;
• inductothermy;
• ultrasound on the chest;
• inhalation and massage;
• foot or hand baths;
• UV blood.

Patients with allergic and non- allergic asthma are prescribed hyposensitizing therapy:
• UFO local by fields and general;
• autohemotherapy by age;
• electrophoresis with CaCl2 0.25% (according to Vorobyov);
• extracorporeal blood irradiation;

24
• hemosorption, plasmapheresis;
• enterosorption;
• normalization of the psycho-vegetative status through water and mud therapy.

In the remission stage , when referring to the sanatorium stage, you can use:
• natural healing factors (climatotherapy);
• balneotherapy;
• pelloidotherapy;
• speleotherapy.

At the same time, a decrease in the pathogenic sphere and allergens is achieved;
constancy of temperature, blood pressure, gas and ionic composition of air; low relative
humidity; increased ionization with a predominance of negative charged air ions, salts and
other therapeutic factors.
Aerotherapy is also used - open air treatment. This method contributes to hardening,
reducing meteo-lability. Special types of aerotherapy include walks, outdoor air baths, on a
climatic veranda, in a ward with open transoms.
non-traditional methods. Non-traditional methods include speleotherapy, unloading
and dietary therapy, barotherapy, reflexology (RT).
Speleotherapy provides both the effect of elimination and bronchodilation, its use is
indicated for patients with BA with FC-I and FC-2.
Unloading and dietary therapy has proven itself well . It is carried out in a hospital
with a duration of sessions of 10-15 days (2 courses). Particular attention is paid to the
recovery period, which in AD should exceed the fasting period. Unloading and dietary
therapy is indicated for patients with BA with FC-1, FC-2 and FC-3.
Barotherapy is prescribed in a hypobaric chamber and can be used in patients with BA
in FC-1 and FC-2.
With the help of reflexology , bronchodilator, mucolytic and desensitizing effects are
achieved. The method is used in patients with BA in all FCs, including those with acute BA.
The course of treatment is 10 sessions, but repeated courses should be used.
Supportive care is the medical aspect of rehabilitation. With maintenance therapy, the
following drugs are used:
• drugs used for long-term treatment of patients with asthma:
• NSAIDs (cromolyns);
• inhaled and systemic corticosteroids;

25
 • leukotriene receptor antagonists;
• long-acting theophylline;
• long-acting inhaled and oral p2-agonists;
• oral antiallergic drugs of the second generation;
• drugs for emergency care that quickly alleviate the condition of a patient with
asthma:
• short-acting inhaled and oral p2-agonists;
• anticholinergic drugs;
• short acting theophyllines;
• drugs that reduce the sensitivity to the drug when taking very low doses of
aspirin - for patients with aspirin asthma.

Means of technical compensation and reconstructive operations. Patients with BA,

regardless of the scheme of therapy, are recommended to keep a diary with the recording of
respiratory parameters in it using a peak flow meter. This measures the peak expiratory flow
rate, which is a highly sensitive method in the diagnosis of bronchial obstruction syndrome.
School of the patient with AD. Asthma School is a special educational program for
people with asthma and their relatives.
The objectives of the school include a number of factors:
• features of the course of the disease depending on the nature of the allergen;
• risk factors for AD;
• piflowmetry in the diagnosis and evaluation of the effectiveness of the treatment of
asthma in children;
• diagnosis of BA;
• benefits of inhaled medicines;
• nocturnal asthma;
• breathing and treatment;
• exercise therapy for BA;
• hardening;
• nutrition of a child with allergic diseases;
• psychological aspects of AD in children.

26
 At school, the patient receives information on his disease, masters the necessary skills
of self-control and self-management.
A patient with AD communicates with a doctor for approximately 0.5 hours per year.
The rest of the time he is alone with asthma. That is why it is so important to master the
technique of self-control. The task of the "asthma school" is to educate this patient, to give
him a plan of action.
Asthma School covers the following topics:
• what is BA;
• how to manage asthma;
• inhalation devices for the treatment of asthma;
• proper inhalation is the key to effective and safe treatment of asthma;
• types of inhalation treatment of the disease;
• treatment and prevention of colds as a provocateur of asthma exacerbations;
• nutrition of a patient with asthma;
• breathing exercises and physical education for patients, hardening;
• self-massage of the face, basics of general massage;
• how to treat exacerbation of asthma.

Practical part
Curation of patients, preparation of IPR, analysis of medical documentation,
laboratory, instrumental research methods.
Control of the assimilation of the topic
Testing.

METHODOLOGICAL RECOMMENDATIONS FOR ORGANIZING AND

IMPLEMENTING CDS
The time allotted for independent work can be used by students for :
‒ preparation for practical exercises;
‒ note-taking of educational literature;
‒ performance of test tasks for self-control of knowledge.
The main methods of organizing independent work :
‒ study of the topic and preparation of oral answers to the questions submitted to
the SRS.

27
 List of tasks SRS :
‒ performance of test tasks;
‒ preparation of oral answers to the following questions:

1. Aerotherapy.
2. Heliotherapy.
3. Physiotherapy for multiple sclerosis.
4. Physiotherapy for arterial hypertension.
5. Physiotherapy for diabetic polyneuropathy.
6. Physiotherapy for cerebral palsy.
7. Physiotherapy for migraine.
8. Physiotherapy for ischemic heart disease.
9. Physiotherapy for TBI.
10. Thalassotherapy.
11. Aeroionotherapy.
12. Oxygenobarotherapy.

SRS control is carried out in the form :

‒ testing;
‒ assessment of an oral answer to a question or a solution to a problem in practical
classes.

METHODOLOGICAL RECOMMENDATIONS FOR THE ORGANIZATION

AND IMPLEMENTATION OF USRS
The recommended forms of organization of the USRS are :
‒ writing an essay on a given topic;
‒ preparation of a multimedia presentation on a given topic;
‒ preparation of brief informational messages on a given topic.

List of USRS tasks :

Topics of abstracts, multimedia presentations, information messages:

1. Aerotherapy.
2. Heliotherapy.
3. Physiotherapy for multiple sclerosis.
4. Physiotherapy for arterial hypertension.
5. Physiotherapy for diabetic polyneuropathy.
6. Physiotherapy for cerebral palsy.
7. Physiotherapy for migraine.
8. Physiotherapy for IHD.
9. Physiotherapy for TBI.
10. Thalassotherapy.
28
 11. Aeroionotherapy.
12. Oxygenobarotherapy.

Forms of monitoring the implementation of the USRS:

‒ checking and evaluating the abstract on a given topic;
‒ checking and evaluating a multimedia presentation on a given topic;
‒ checking and evaluating a brief informational message on a given topic.

LIST OF USED SOURCES:

MAIN LITERATURE
1. Medical rehabilitation: textbook. allowance / V. Ya. Latysheva [and others]. -
Minsk: Vysh. school, 2020. - 351 p.
2. Medical rehabilitation for major gynecological diseases: textbook.-method.
allowance / V. Ya. Latysheva, S. M. Yakovets. - Gomel: GomGMU, 2020. - 102 p.
3. Latysheva, V. Ya. Medical rehabilitation in pediatrics: textbook. allowance /
V. Ya. Latysheva, L. L. Kozlovsky, D. A. Kozlovsky. - Minsk: New knowledge, 2021.
- 280 p.
4. Susan B. O'Sullivan Physical Rehabilitation / Susan B. O'Sullivan [et al.]. –
7th ed . By FA Davis Company, 2019. - 1505 p.
5. David X. Cifu Braddom's physical medicine & rehabilitation / David X. Cifu
[et al.]. – 5th ed. by Elsevier, Inc., 2016. - 1280 p.
6. Medical rehabilitation: a textbook for students. inst. higher prof. image. / ed.
A.V. Epifanova, E.E. Achkasova, V.A. Epifanov. - Moscow: GEOTAR-Media, 2015.
- 668 p.: ill., skh., tab.
7. Epifanov V.A., Rehabilitation in traumatology and orthopedics [Electronic
resource] / V.A. Epifanov, A.V. Epifanov. - 2nd ed., revised. and additional - M. :
GEOTAR-Media, 2015. - 416 p. – Access mode:
http://www.studmedlib.ru/book/ISBN9785970434451.html – Access date:
04/24/2020.
8. Epifanov V.A., Rehabilitation in neurology [Electronic resource] / Epifanov
V.A., Epifanov A.V. - M. : GEOTAR-Media, 2015. - 416 p. (Library of a specialist
doctor) - Access mode: http://www.studmedlib.ru/book/ISBN9785970434420.html -
Access date: 04/24/2019.
9. Physical medicine and rehabilitation board review / ed. by SJ Cuccurullo. –
3rd ed. - New York: Demos Medical, [2015]. – xxxix, 1011 p.: phot., ill., tab.

ADDITIONAL LITERATURE

29
 1. Test tasks to control the level of knowledge in physiotherapy and medical
rehabilitation: textbook-method. manual for 5th and 6th year students of medical and
diagnostic faculties of institutions of higher medical education / V. Ya. Latysheva [et
al.]. - Gomel: GomGMU, 2019. - 40 p.
2. Expert and rehabilitation diagnostics of pain in the lower back: Educational
and methodological manual / E.F. Svyatskaya and [others]. - Minsk: BelMAPO, 2018.
- 35 p.
3. Methodological foundations of expert rehabilitation diagnostics for motor
disorders: Educational and methodological manual / I.S. Sikorskaya, G.A. Emelyanov
[i dr.]. - Minsk: BelMAPO, 2017. - 24 p.
4. Postoperative management and rehabilitation of patients with chronic
pancreatitis: study method. Allowance / A.T. Shchastny - Vitebsk: VSMU, 2017. - 76
p.
5. Minina, E. S. Bronchial asthma in children: features of treatment and
rehabilitation: monograph / E. S. Minina, V. I. Novikova; Ministry of Education of
the Republic of Belarus, Vitebsk State Order of Peoples' Friendship Medical
University. - Vitebsk: [VSMU], 2017. - 274 p.
6. Rolando T. Lazaro Umphred's neurological rehabilitation / Rolando T. Lazaro
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outcomes / Frank R. Noyes [et al.]. – 2nd ed. by Elsevier, Inc., 2017. - 1264 p.
8. Donald A. Neumann Kinesiology of the musculoskeletal system: foundations
for rehabilitation / Donald A. Neumann [et al.]. – third ed. By Elsevier, Inc., 2017. -
792 p.
9. William E. DeTurk Cardiovascular and Pulmonary Physical Therapy / William
E. DeTurk [et al.]. – third ed. by McGraw-Hill Education, 2018. - 830 p.
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 REGULATIONS
1. “On the state register (list) of technical means of social rehabilitation and the
procedure for providing certain categories of citizens with them” Resolution of the
Council of Ministers of the Republic of Belarus dated 11.12.2007 No. 17226: with
amendments and additions.
2. On the establishment of a list of simple medical interventions: Decree of the
Ministry of Health of the Republic of Belarus dated May 31, 2011 No. 49.
3. “On approval of time standards for the performance of physiotherapeutic
procedures by physiotherapists and physiotherapy nurses of healthcare organizations”
order of the Ministry of Health of the Republic of Belarus dated 03.01.2005 No. 4.
ELECTRONIC DATABASES
1. Physician's consultant. Electronic Medical Library = Consultant of the doctor.
Electronic medical library [Electronic resource] / Publishing group "GEOTAR-
Media", LLC "IPUZ". – Access mode: http://www.rosmedlib.ru/ . – Access date:
04/24/2020.
2. Student advisor. Electronic library of a medical university = Student
consultant. Electronic library of medical high school [Electronic resource] /
Publishing group "GEOTAR-Media", LLC "IPUZ". – Access mode:
http://www.studmedlib.ru. – Access date: 04/24/2020.
3. Scientific electronic library eLIBRARY.RU = Scientific electronic library
eLIBRARY.RU [Electronic resource]. – Access mode: https://elibrary.ru/ . – Access
date: 04/24/2020.
4. Oxford Medicine Online [Electronic resource] / Oxford University Press. –
Access mode: www.oxfordmedicine.com . – Date of access: 04/24/2020.
5. Springer Link [Electronic resource] / Springer International Publishing AG. –
Access mode: https:link.springer.com. – Date of access: 24.04.2020

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