Therapeutic physical training( LFK).Therapeutic exercises with osteochondrosis - Causes, symptoms and treatment. MF.

Therapeutic physical training with neurological diseases

Therapeutic gymnastics is a complex of exercises for the majority of chronic human diseases associated with the loss of muscle strength and the volume of movements of the joints.

Therapeutic exercises with neurological manifestations should be performed in positions and under conditions of absence of pain syndrome, or, at least - on the border of pain sensations. Otherwise, the "stealing phenomenon" develops, manifested by compensatory substitutions from the unaffected segments of the body;as a result - intact muscle groups are exposed to training, that is, "weak" is robbed of "strong", and "sick" is "healthy".

Physiotherapy exercises should be combined with care for the patient. Before classes it is necessary to ventilate the wards and cabinets of physiotherapy exercises. It is advisable to conduct classes with open windows, windows, on verandas. Patients are engaged in light sports outfits.

If the patient is in a semi-fast mode, you need to prepare him for classes - throw back the blanket, send the sheet, properly place or remove the extra pillows. At the end of the lesson, with appropriate clinical data, the patient should be given a position that is of therapeutic value( treatment by position): put on straps for stretching, pribintovat longet, move the patient into a sitting position on the chair. It is necessary to monitor the condition and well-being of the patient, keep a record of all observations of instructors or a nurse, inform the doctor.

Morning hygienic gymnastics is held in the morning, after sleep, before breakfast. Classes with patients are conducted by a methodologist of curative physical education, or a ward medical nurse.

Patients with impaired movement, do morning exercises in the ward, faces without restrictions of movement - in the gym or in the air. The room in which the patients are engaged should be well ventilated. In the process of gymnastics, the body leaves the state of inhibition of physiological processes during sleep, the general and emotional tone is increased, the activity of all organs and systems is strengthened. The selection of exercises for hygienic gymnastics and the dosage of physical activity are determined by the patient's age, the nature of the underlying disease, the degree and form of the impaired functions. During the morning exercises, the cardiovascular and respiratory systems are prepared for the upcoming stresses during the day. The complex of exercises is selected with the expectation that it is available to all patients of this group. For patients with motor disorders, the exercises begin in the initial lying position, then the patients go to the sitting position. The duration of morning exercises is 10-20 minutes. The complex of morning exercises includes no more than 8-12 exercises with the repetition of each of them from 3 to 6-8 times.

Therapeutic gymnastics is the main form of therapeutic physical training. Apply two methods of therapeutic gymnastics - individual and group. The lesson of curative gymnastics consists of an introductory, main and final sections.

The introductory section assumes the preparation of the patient for the subsequent physical exercises. The patient explains the purpose of the lesson, calculates the pulse, conducts breathing, general development and preparatory exercises. The duration of this part of the lesson is 5-10 minutes.

The main section includes physical exercises that have a special and general effect on the patient's body. Their goal is to restore and compensate for defective functions, help the patient to master motor skills, improve physical fitness and adapt to the conditions of life. The duration of the main section is 25 - 30 minutes. The final section aims to gradually reduce the overall burden, the activity of the cardiovascular and respiratory systems, reduce emotional stress and bring the patient to the initial state. The duration of this section is 5-10 minutes.

The tasks of the lesson are determined by the doctor. During the exercise, the load is regulated on the basis of the so-called physiological curve - the curve of changes in the pulse rate during the sessions. With the correct construction of the lesson, the maximum increase in the pulse should not exceed more than 50% of the initial heart rate.

Especially responsible is the creation of a set of exercises that meet the challenges of restoring disrupted functions. This, in particular, refers to motor disorders. In accordance with the nature of the lesion and the stages of restorative treatment, passive and active movements are used.

With passive reproduction of a certain movement, impulses enter the cells of the cortex that cause it. In the absence of active movements, passive ones are used with simultaneous sending of volitional impulses to patients.

As the strength of the muscles in the paretic limbs increases, it becomes possible to perform active movements, which are first performed with the help of the personnel, then independently. It is important to observe the sequence in the training of individual muscle groups and to obtain isolated active movements.

An important condition in the method of physical therapy lessons is the dosage of exercise, which is determined by a number of indicators. These include: the selection of physical exercises, which is built on the basis of the principle of gradualness: from simple to complex. The duration of exercise is determined by the time spent by the patient to perform them. The number of repetitions is determined by the nature of the disease and the peculiarity of the exercises. Exercises of general strengthening type should be repeated 5 to 6 times, aimed at strengthening the weakened muscle groups 10 to 20 times.

The choice of the starting positions also depends on the characteristics of the disease and the nature of the exercises performed. There are three main initial positions: lying, sitting and standing. The initial assumptions are regarded as an important element in regulating physical activity.

Distinguish between slow, medium and fast movements. At a slow rate of movement, they are executed for 4 accounts, with an average rate of two, for a fast one, for one account. The choice of the pace of movement depends on the characteristics of the course of the disease, the age of the patient and his individual characteristics. Adjust the load in physical exercises also allow the degree of effort, the accuracy of the movement. The magnitude of the load is affected by the degree of complexity of the movements. It is necessary to gradually complicate the movement as they master and increase the functional capabilities of the body.

Rhythmic movements help improve blood and lymph circulation and reduce fatigue.

Number of distractions. By means of their alternation with the basic ones, an increase in the working capacity of the muscles is achieved. These exercises are also used in the conclusion of the lesson.

The use of the emotional factor consists in causing positive emotions in the patient during physical exercises. This is achieved by incorporating elements of the game or competition, musical accompaniment, etc. into the classroom.

The dosage of exercise during the exercise is provided by careful medical and pedagogical control and individual approach to the patient. Planning of therapeutic use of physical exercises for periods is performed by a methodologist under the supervision of a doctor. Specify the forms of therapeutic physical education, the order of their application in the regime of the day, in combination with other therapeutic effects, exemplary complexes of physical therapy are compiled.

Self-employment of patients is a form of therapeutic physical education. The patient is selected a set of exercises, which he repeats during the day several times. Depending on the characteristics of the disease on the complex of exercises is spent from 2-3 to 10-15 minutes. For patients with severe motor disorders who need intensive treatment, but because of a defect, they can not engage in self-study, it is recommended to conduct classes with the help of relatives who are previously trained in the methods of physical therapy and those exercises that are prescribed for execution with the patient.

When carrying out the system of exercise therapy, one should keep in mind the exercises of the sports-applied type, which include the main types of natural movements of man - walking, running, jumping, crawling, exercises in balance, etc. Walking is widely used in physical therapy asphysical exercise, which is a natural way of movement. Walking increases the metabolism, improves blood circulation and breathing, has a positive effect on the entire body. Walking is used in the practice of therapeutic gymnastics, in walks, etc. Indications for the use of walking as a remedy are very wide.

Running in comparison with walking is a stronger means of therapeutic effect on the patient's body. Running in physiotherapy exercises is used in strictly dosage form with restriction of its speed. Training of the patient in walking and running is carried out on a special schedule based on the principle of gradualness and consistency with careful medical and pedagogical control.

Jumps in their physiological effects are short-term exercises of considerable intensity. The use of jumps is advisable in the period of recovery.

Throwing helps to restore the coordination of movements, improves the mobility of joints, increases the strength of the muscles of the limbs and trunk, the speed of motor reactions, develops accuracy. Use the throwing ball, sticks, disc.

Lasagne on the gymnastic wall helps to increase the mobility of the joints, the development of muscle strength.

Crawl exercises are used primarily to correct various curvatures of the spine.

Exercises in equilibrium are used for diseases associated with impaired function of the vestibular apparatus and the cerebellum.

Sports games in the system of therapeutic physical training are used as one of the important means of physical education of a sick person. Games educate and develop a number of valuable physical and moral-volitional qualities: strength, speed, agility, attention, endurance, etc. The great significance of games is that they stimulate positive emotions and tone up the neuropsychic sphere of patients. Games are mainly used that do not give a big load to the patient's body, they are relatively simple and available for technical implementation. They are divided into inactive, mobile and sports. Low-mobility games are often conducted with bedridden patients. Movable games are made up of various combinations of walking, running, jumping, etc. Sports games within the curative physical culture are applied in a limited way.

Swimming and exercise in the water. Characterized by a combination of the effects of movements and the aquatic environment. Being in the water increases the metabolism, activates the blood circulation. In special conditions( bath, pool), the movements of atrophic, weakened muscles are facilitated. Swimming is also assigned with hardening and recreational purposes.

Other sports activities are also used such as skiing, cycling, etc.

Motor modes. Physiotherapy is an integral part of all motor regimes. The choice of physical exercises, the forms of their conduct, the load in the classes in each individual case must correspond to the motor activity allowed by individual regimes.

Distinguish strict bed rest, bed rest, half-bed, extended, moderately training, oboshchereniruyuschy.

The rehabilitation department receives, as a rule, patients who are on a half-bed or an extended schedule, strict bed rest is observed by patients in the acute period of the disease.

In the semi-fast mode during the therapeutic exercises, the patient is prepared to move to the sitting position in the bed, lowering his legs, moving to a chair, getting up, walking slowly within the chamber. Advanced mode allows you to use all the means of physiotherapy. With a training regime, exercise therapy should facilitate recovery of the patient's performance and serve as one of the main means of rehabilitation.

When applying therapeutic exercise should adhere to the principle of the stage of treatment, observe the gradual increase in the intensity of physical activity in accordance with the clinical condition of the patient.

Examples of exercises of therapeutic gymnastics in neurological diseases, in particular, osteochondrosis of the spine with protrusions and hernias of intervertebral discs.

In the prevention and treatment of spine osteochondrosis, systematic training in special medical gymnastics is essential.

Before teas to start independent exercises in medical gymnastics, it is necessary to consult with a specialist( neurologist, orthopedist-traumatologist, physician LFK).

You can practice therapeutic gymnastics at any time of the day. It is very useful to do several exercises in the morning immediately after sleep( for example: Ш 1,3,13,17,20 acute period), then make a morning toilet and continue the exercises according to the prescribed by the doctor and the methodologist of the exercise complex.

Clothing during exercise should be easy, not restrictive movements, but also not supercooling. Best of all - a woolen training suit.

Some of the exercises recommended for you are useful to perform during the working day( for example, exercise number I of the training period - the period of remission).

P O M IN T E!

Approximate complex of therapeutic ginastika.applied in an acute period( initial stage)
I.p.lying down. Flexion and extension of the feet and fingers of the hands into a fist.
lying, the left leg is bent at the knee. Flexion and extension of the right leg, gliding along the bed. After 8-10 repetitions - the same with the other leg.
leka. Alternate lifting hands up.
leka, the left leg is bent at the knee. Take the right foot to the side. After 8-10 repetitions - the same other leg.
lying, hands to shoulders. Circles bent forward and backward.
leka. Alternate straightening of the legs in the knees, leaning on the hips on the roller.
Leka, legs bent. Alternate bending of bent legs to a kyvote.
leka. Bending of arms to the shoulders in combination with breathing.
Leka, legs bent. Alternate retraction of the knees in the sides.
Leka, legs bent. Hands up - inhale, squeeze the knee to the kyvote - exhale. The same - the other leg.
Leka, legs apart. Rotation of the legs inwards and outwards "
Ip.-leka. Diaphragmatic respiration
Special exercises used in the second stage of the acute period
Ip lying, legs bent. Preparation of the sacrum with support on the lower thoracic spine and foot due to kifosis of the lumbarDepartment of the spine
Ip lying, legs bent Lifting of the head with simultaneous straining of the abdominal muscles
Ip lying, Static tension of the gluteus maximus 8-10 voltages each for 4-6 seconds
Iplying down, legs bent apart.up, inhale, lower hand inward and forward, raise head and shoulders, reach for the right knee - exhale, the same with the other hand
Ip lying, alternate bending of the legs, when straightening, push the foot onto the bed, kyphosis whenthis is the lumbar spine. The
is lying flat, the same exercise as No. 17, but carried out with two legs simultaneously.
lying under the feet of the roller, lifting the pelvis due to kyphosis of the lumbar spine.
emphasis on the knees. Sit on your heels, without lifting your hands from the bed and return to the ip. When you return to the IS.do not sag!
emphasis on the knees. Flexion of the spine( without bending when returning to it!)
Exemplary complex of therapeutic gymnastics, applicable in the SECOND( PODOSTROM) period
I.p.lying down. Simultaneous flexion and extension of the feet.
lying down. Alternate flexion and extension of the legs in the knees.
I. lying down. Alternate lifting of hands upwards with the subsequent passive extension by their instructor LFK.
I. lying down, the left leg is bent. Take the right foot to the side. After several repetitions, the same with the left foot.
lying, hands to shoulders. Circles with bent hands.
lying, the left leg is pressed to the stomach. Raise your right foot forward. After several repetitions, the same with the left foot.
lying, legs bent. Lifting of the sacrum with simultaneous kifozirovaniem lumbar spine.
lying, legs bent, Hands on stomach. Lifting of the head and shoulders. The fixation of this position is 2-4 seconds.
lying down. Static stress of the gluteus maximus muscles. The voltage time is 6-8 s.
lying, legs bent. Simultaneous bending of the legs to the abdomen.
emphasis on the knees. Sit on your heels, without taking your hands off the couch.
emphasis on the knees, legs apart. Turn left, left hand to the side. The same to the right.
emphasis on the knees. Flexion of the spine. When you return to the IS.do not sag.
emphasis on the knees. Straightening the left leg, make an emphasis on the right knee. Do not raise your foot high. The same with the other leg.
emphasis on the knees, legs apart. Bending the right leg to the left-up, touch the right knee of the left arm. The same with the other leg.
emphasis on the knees. With the left leg retracted, sit on the right heel( half-string).The same with the other leg. Do not tear your hands from the couch.
lying on his stomach( under the belly of a cushion).Alternate raising of the feet from the couch by 3-5 cm to keep them in this position 4-6 seconds.
lying on his stomach, hands in the sides. Raise the head and shoulders from the couch for 3-5 cm and hold in this position for 4-6 seconds.
lying on his stomach. Alternate taking the legs apart. Keep your feet from the couch high.
lying on his stomach. Alternate flexion of the legs in the knees.
emphasis on the right knee, the left leg is straightened forward,( side of the couch).Leaving the left leg to the side. The same with the other leg.
lying on his side. Simultaneous bending of the legs forward. The same on the other side.
lying, feet on the platen. Elevation of the sacrum due to kifozirovan lumbar spine.
lying down. Alternate "stretching" the legs down.
lying down."One" - hands up."Two" - bending the right leg forward, press the knee to the stomach.
lying down, legs apart. Rotation of straight legs in and out.
SPECIAL EXERCISES recommended for inclusion in the complex of therapeutic gymnastics used during remission
Kifosis of the lumbar spine with fixation of this position 10-60 sec.: a) supported by a wall;feet at a distance of 40 cm from the wall;B) in the IS.standing.
standing on the gymnastic wall, arms bent. Bending the legs, go to the mixed hanging in the squat.
emphasis on the knees, legs apart. Crossing the arms to the left, bend the trunk to the left. The same in the other direction.
rack on the lap. Sed on the hip to the right, hands to the left. The same in the other direction.
lying, legs bent forward. The slopes of the knees to the left and to the right.
lying, legs bent, hands behind head. Sit down - lie down.
back from the gymnastic wall. Simultaneous bending of the legs forward.
on the front of the gymnastic wall. With the turn of the pelvis to the left, bend the legs forward. The same in the other direction.
lying on his stomach on a gym bench, his hands behind his head, his legs fixed. Extension of the trunk back. Strongly not sag!
lying, legs pressed to the stomach. The rolls do not back up and back
.standing on the gymnastic wall, arms bent. Bending the right leg and straightening his arms, go to the mixed vises crouching on the right foot. The same on the other leg.
lying on his stomach, hands on his head. Bending the trunk to the left, the simultaneous removal of the legs to the left. The same in the other direction.
lying on his stomach at the edge of the couch, legs down, grip his hands from below the couch. Leg extension. Do not sag!
lying down. Bending forward, move to the position of the saddle, legs cross. Carry out with the support of hands behind and without support.
emphasis squatting. Straightening his legs, move into a standing position standing upright.
emphasis lying. Crossing his hands back, go into the standing position standing up, bent over.
feet apart, hands to the shoulders. Bending the left leg to the right and forward, touch the right elbow of the left hip. The same with the other leg.
lying down, hands up. Raising the left leg forward, touch the right hand of the left shin. The same with the other leg.
lying, legs bent forward, rubber bandage fixed at one end behind the shin, the second - behind the gymnastic wall. Leg extension.
20)	WALK: on the toes, on the heels, on the outer edge of the foot, lunges with bends of the trunk to the left and right, walking with high hip lifting, walking with bending the legs back, etc.

Appearance of pain during exercise is a signal to reduce the amplitude of the exercise, their intensity or to complete cessation of their implementation.

In order to exercise the most therapeutic exercises, you should:
a) perform the exercises daily;
b) perform the exercises diligently, at a slow pace, without distorting the form, speed and intensity of the exercises performed arbitrarily;C) do not hold your breath while doing the exercises;
d) consult with a doctor periodically, not hiding his illness from him.

Methodical recommendations of the motor state in the acute period

In acute period, in the presence of acute pain, strict bed rest should be observed. LFK is used mainly for hygienic purposes and has a general strengthening effect. When moving the lower extremities, do not allow the lumbar lordosis to increase, which can increase the pain syndrome. In this respect, when performing physical exercises, a soft roller should be placed under the tibia.
In the second stage of the acute period, with a certain decrease in the intensity of pain, it is necessary to carefully include isometric exercises for training the muscles of the abdominal and large gluteal muscles.
Exercises that cause pain should be limited in amplitude, degree of muscular tension or eliminated altogether. Do not exercise through pain!
The number of repetitions of each exercise is 8-10 times. The pace of doing exercises is slow.

Methodical recommendations of the motor regimen in the second( subacute) period

With the reduction of the pain syndrome, the possibilities of using special and general development exercises are increasing. In this period, in addition to exercises that increase the strength of the muscles of the abdominal and the thigh extensor muscles, the exercises that order the lumbar spine become effective( No. 7,8,10,11,13,15, 22,23,).
When selecting both special and general development exercises, it is important to ensure that they do not increase lumbar lordosis. Painful sensations are a signal to change the structure of the exercise( to the side of relief) or to the exclusion of it.
At the end of the second period, exercises that increase the strength of the back muscles should be gradually incorporated.
Exercises 7,6,9 and 10 can be performed on a circular system 2-3 times. They are the most important.
The number of repetitions of special exercises to bring to 15-50 times. The pace of the exercises can be gradually increased.
Once again, it should be recalled: exercises should not cause pain!

Methodical recommendations of the third period( remission)

In this period, the task of increasing the mobility of the spinal column is added to the tasks and methodological features of the second period. However, the exercises aimed at solving this problem should be carried out cautiously and in lightweight starting positions. It is necessary to achieve the automaticity of maintaining a specific posture in standing and walking, when the lumbar spine is kyphosis.
The number of repetitions of special exercises of the second period increases to 50-100 times( it is possible to breakdown during the day).Of other means, exercise therapy should be considered appropriate to use those that will not affect the negative plan for degenerated discs: swimming, health path, skiing, running track, veloergometer, exercises with rubber bandage. Use such means as volleyball, tennis( big and small), road bike, cross-country running, fast dances, rhythmic gymnastics should be extremely cautious, tk.sharp, often uncoordinated movements and turns can provoke an exacerbation of osteochondrosis. Exercises with dumbbells are preferably performed in the i.p.lying( on the back, abdomen) to exclude vertical loads on the spine.
It should be considered inadvisable to use a clean hairspray for allegedly stretching the lumbar spine. The obstacle to this is the powerful tension of the stretched muscles of the trunk. Also, jumps in depth from the elevation, exercises on a rowing machine, throwing are also undesirable. In any case, when exercising exercise therapy should be remembered that the constant microtrauma and spinal congestion, uncoordinated movements, shocks along the axis of the spine prepare the appropriate background for rupturing the degenerated disc and exacerbating the pain syndrome. These recommendations should be taken into account when choosing the means and forms of physical exercises at the sanatorium and polyclinic stages of rehabilitation.
In the third period, the use of therapeutic gymnastics in the pool is recommended. It should be noted that therapeutic gymnastics in the pool does not replace, but complements the main "dry" exercises in therapeutic gymnastics.

Orthopedic prophylaxis of osteochondrosis of the spine

In order to slow the degenerative processes in the spine, as well as to prevent recurrences of exacerbation of the pain syndrome, it is recommended to observe a specific posture with kifozirovannym position of the lumbar spine in various situations when doing household, labor and other activities. In the prevention of osteochondrosis, an important role is played by the reduction of micro- and macro-traumatization of intervertebral disks, as well as static and dynamic overloads of the spine.
It is necessary to recognize as especially unfavorable the torso of the trunk forward from the standing position. When straightening from this position, even a shift of degenerated vertebrae relative to each other is possible. In this regard, the slopes forward( especially those performed with simultaneous rotation of the trunk) should be excluded as an exercise from regular physical therapy exercises.
When doing household tasks related to torso bending forward( washing clothes, rinsing, sweeping and nagging floors), it is advisable to unload the spine, having any support under the free hand. For cleaning the apartment with a vacuum cleaner, it is desirable to increase the vacuum cleaner tube so that the trunk does not bend forward, becauseotherwise rhythmic movements in the half-forward direction when working with an unconfigured vacuum cleaner will cause overload of the spine.
It should be especially cautioned against work associated with stresses of the same type( especially in the forward tilt of the floor), for example: sawing and chopping firewood, gardening with shovel and chopper, jerky movements when throwing heavy objects, washing on a washboard, etc., t. Loads on vertebrae, ligaments and muscles sharply increase.
The wrong position of the trunk and the uncoordinated work of the muscles when lifting and carrying weights are especially unfavorable. The best option - straightened back, when the backbone firmly rests against the pelvis. In this case, intervertebral disks are loaded evenly and do not deform. Along with this, carrying and especially lifting of even not very heavy cargo with a bent back( for example, ahead of yourself and on outstretched hands) often leads to aggravation.
The tables show pictures of the correct( black) and incorrect( shaded) position of the trunk when lifting and carrying weights. As can be seen from the figures, when carrying weights, a straightened torso position is recommended. The cargo should be kept as close as possible to the body. When lifting weights from the ground, you can not lean forward and lift the load, straightening the trunk. You have to bend your knees, sit down, leaving your back straight and lift the load by straightening your knees.
When driving in a car, a roller is placed under the lumbar spine. And a head restraint is necessary to avoid traumatization of the cervical spine with sharp jerks of the car.
Zashnurovyvaya shoes need to stand on one knee, touch the trunk of the thigh and only then zashnurovyvat shoes.
However, a comfortable position of the body can cause unwanted changes in the spine if the professional posture remains unchanged. Therefore, it is necessary to periodically change the position of the body during operation. For example, in the standing position, the periodic change of the support of one leg to the bench not only rest the legs, but also facilitates the kyphosis of the lumbar spine in light conditions.
In the case of tranporting in an elevator, it is advisable to take an easing posture to reduce the vertical load on the degenerated disks during acceleration and deceleration of the elevator. This pose is recommended to be taken during the day as often as 10-60 seconds.and as a physical exercise.

Preventive measures include treatment of the situation. When the roller is sufficiently high under the shins, lumbar lordosis decreases, the strained muscles relax, the pressure on the posterior parts of the degenerated disks of the lumbar spine decreases, and the pain decreases. After a day's work, it is advisable to hold in this position at home 30-60 minutes before going to bed.

The growing weakness( detunement) of the muscles of the trunk in patients not engaged in therapeutic gymnastics is quite common. A trained and well-developed muscle "trunk" of the trunk greatly facilitates and unloads the "spring" apparatus of the spine. Exercises that strengthen the muscles of the abdominal muscles, large gluteus muscles, back muscles and lumbar kifozirovanie training( especially in standing) should be part of the patient's movement and be conducted throughout the day.
Undoubtedly influenced by the overload of the spine is irrationally selected working furniture, especially the chairs. In this aspect, it is advisable to use chairs with a low seat, with its internal inclination and with a slightly convex backrest in place of the lumbar flexure of the spine. It is better if in a sitting position the knees will be slightly higher than the hip joints.
It should also be considered appropriate to wear shoes on elastic soles, becauseAt the same time, the damping overload of degenerated disks is reduced. It is not recommended long driving in a motor vehicle, especially on uneven roads.
Factors that increase lumbar lordosis should be eliminated: wearing high-heeled shoes, overweight. Sleep should be on a firm bed, for which a wooden shield and a thin mattress are used.
Constant wearing of corsets of all kinds or belt weightlifters in some cases gives a good effect. Mechanical limitation of the mobility of the spine( especially in the lumbar region) is of great importance for the prevention of exacerbations, especially in the presence of instability of the spine.

Memo prepared by instructor LFK TsKB LOO at the USSR SM O.B.Rubailov
under the general editorship of the head physician of LFK V.Zubkov