Acta Astronautica 60 (2007) 237 – 246 www.elsevier.com/locate/actaastro
The Russian experience in medical care and health maintenance of the International Space Station crews V.V. Bogomolov∗ , A.I. Grigoriev, I.B. Kozlovskaya Institute for Biomedical Problems of Russian Academy of Sciences, State Research Center of Russian Federation, Khoroschevskoe shosse 76 A, Moscow 123007, Russia Available online 19 October 2006
Abstract The main purpose of the medical support system aboard International Space Station (ISS) is crew health maintenance and high level of work capability assurance prior to during and after in space flights. In the present communication the Russian point of view dealing with the problems and achievements in this branch is presented. An overview on medical operations during flight and after finalization of the space missions based on Russian data of crew health and environment state monitoring, as well as data on the inflight countermeasures (prophylaxis) jointly with data on operational problems that are specific to ISS is presented. The report summarizes results of the medical examination of Russian members of the ISS and taxi crews during and after visits to the ISS. © 2006 Elsevier Ltd. All rights reserved.
The Russian system of International Space Station (ISS) crews’ health care and performance maintenance consists mainly of methods, means and, more generally, the structure of medical care that had been tested in long-duration missions onboard Russian space stations of the Salyut and Mir type [1–4]. This applies primarily to Russian life support systems, in-flight systems for the monitoring of cosmonauts’ health, assessment of the crews’ habitat and the system of countermeasures to prevent adverse disorders in the human body during the implementation of flight programs. At least for Russian members of ISS crews and those participating in the flights of Soyuz TM and Soyuz TMA spacecraft the measures, methods, means, and the structure of medical care and health maintenance for crew members are fairly close to those of the Mir station [3–5].
∗ Corresponding author.
E-mail address:
[email protected] (V.V. Bogomolov). 0094-5765/$ - see front matter © 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.actaastro.2006.08.014
Russian on-board life support systems, means of habitat and radiation monitoring, on-board health monitoring means, means for medical aid key exercise devices are located in the Russian ISS segment—the Zvezda service module and Zarya module, and also in the Russian transport space ships Soyuz TMA (Fig. 1). Unlike Russian long-duration orbital stations of the Salyut and Mir type, the ISS project is international in nature. Therefore, one prerequisite for implementation of the project was integration of space medicine achievements and medical services of all the international partners’ space agencies in order to improve and to better operate medical care and health maintenance systems for international ISS crews. In accordance with the Memorandum of Understanding on the ISS between the Russian Space Agency (RSA), NASA and the other international partners, multilateral medical working bodies have been created to coordinate and to carry out the practical work of standardizing requirements for the medical care of crew members at all stages
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Fig. 1. ISS Russian Segment (2005). The main life support systems, namely, regeneration system, system of air purification and control, water supply and termoregulation, hygienic hardware are located in service module “Zvezda”. In the Russian segments there are located also physical exercises hardware (TVIS, Russian bicycle with force loader) medical monitoring means, Russian means of medical care.
of preparation and implementation of the ISS space program, as well as integrated bodies of operational medical mission control. Roskosmos (Medical Support Group MCC-M and IBMP) is responsible for the medical support of Soyuz TM flights, whereas NASA (JSC) is responsible for Space Shuttle crews. Medical support of main crews is the responsibility of the medical service of the responsible Mission Control Center (MCC-M or MCC-H), backed by the IBMP and KCD. The chief flight surgeon together with the international partners’ flight surgeons is an important element of the medical care system for ISS crews [6,7] (Fig. 2). The highest international medical body to coordinate efforts to maintain the health of crew members is the Multilateral Medical Policy Board (ISS MMOP), which coordinates the activities of two multilateral medical working bodies: the Multilateral Space Medicine Board (ISS MSMB) and the Multilateral Medical Operations Panel (ISS MMOP) (Fig. 3). MSMB certifies the health of ISS crew members and flight surgeons and resolves clinical problems that may emerge in the process of implementing the ISS program. Opinions on the certification of ISS crew members are submitted to the Multilateral Crew Operations Panel (ISS MCOP). MMOP is the key multilateral medical body responsible for the development of requirements and medical working documents for ISS as well as for the practical
implementation of these requirements before, during, and after the flight. MMOP is based on the activities of multilateral working groups on different aspects of medical support for ISS crews (subgroups on medical standards, biomedical training, environment, radiation control, nutrition, flight medicine and health monitoring, countermeasures, medical aid, extravehicular activity, and medical rehabilitation). MMOP documents and recommendations are submitted to the ISS Program Office agencies. Requirements for the medical support of ISS crews—ISS Medical Operations Requirements Document [8] and plans of their implementation (ISS Joint Medical Operations Implementation Plan) as well as crew members’ health standards [9] and other operational medical documents on ISS have been drawn up within the framework of MMOP with an active involvement of all the international partners. The medical care control of the ISS, like the general control of the ISS, is exercised from the joint Mission Control Center, which includes the MCC-M and MCC-H, and the role of the main Mission Control Center may change depending on specific objectives of flight operations. Medical operations control is also exercised from the Medical Support Group (GMO) of the MCC-M and the Medical Group of the MCC-H, which include the flight surgeon and his deputy, the flight surgeons of the partners whose crew members are on orbit, and flight
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Fig. 2. ISS Medical Management. The figure shows the structure of the United ISS Flight Control Center and responsibilities of MCC-M and MCC-H. These structures are supported from Russian side by GMO (Medical Support Group MCC-M) and IBMP, and from American one—by JSC medical department. The activities of the integrated medical group is revised regularly by Medical Operations Team, that are provided with participation of MMOP members and other ISS partners.
Fig. 3. Medical Board during ISS Assembly (see the text).
bioengineers. When flight and medical operations are carried out onboard Russian transport vehicles or in accordance with the Russian program, main medical responsibility lies with the Russian medical services:
when US transport vehicles are used to carry out flight and medical operations or when they are carried out in accordance with the US program, it is the MCCHouston that has medical responsibility. It is important
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Fig. 4. Composition and interaction of the Integrated Medical Group. The Integrated Medical Group (IMG) of MCC-H consists of the Expedition Crew Surgeon and his deputies (DCS), bioengineers, Russian Flight Surgeon and GMO representative (Medical Support Group MCC-M). The IMG of MCC-M consists of leading representative of GMO. IMG works in close interaction in planning and providing of medical operations on the ISS. Space Medical Operation Team (SMOT) and Space Management Team (SMMT) control and support IMG activity. In planning of the crew activity IMG interacts with IMMT (Integrated Mission Management Team). FCT—Flight Control Team.
that the medical services of the MCC-Houston and MCC-Moscow in terms of medical operations planning and implementation interact within the framework of the Integrated Medical Group, which includes US flight surgeons and a Russian surgeon as well as responsible representatives of the Medical Support Group of the MCC-M (Fig. 4). The manned program of ISS deployment and operation has been implemented for over 4.5 yr. The duration of main expeditions ranges from 129 to 196 days. By now 10 main expeditions have completed their flights on ISS, 11 Space Shuttle expeditions and eight visiting expeditions on Soyuz TM and Soyuz TMA spacecraft, a total of 15 Progress cargo ships have brought payloads to ISS, and 16 spacewalks in Russian Orlan-DMA suits have been carried out. At this stage of deploying and operating ISS, the main expedition crews are made up of just Russian cosmonauts and NASA astronauts, whereas visiting short-duration crews on Space Shuttle and Soyuz type spacecraft also include members from the other ISS partners and also participants whose programs are carried out on a commercial basis (“tourists”). It is important to point out that in connection with the grounding of space shuttles in the aftermath of the crash
of space shuttle Columbia (STS-107) in February 2003, the program of ISS operation was adjusted in such a way that the duration of ISS-6 expedition was extended, and starting from ISS-7 the main crews were reduced to two persons and the delivery of crews to ISS and their return to the Earth and also the flow of cargo from the Earth to ISS and from ISS to the Earth has only been carried out by Russian transport spacecraft—Soyuz TMA and Progress cargo space ships. Yet throughout all the ISS expeditions the requisite medical requirements in accordance with ISS MORD have been generally ensured, medical operations have been carried out in accordance with agreed-upon documents. The medical operations control structure that has been created makes it possible to adequately react to emerging problems, ensuring the maintenance of health and performance levels that are required from the crew in order to carry out flight objectives. We have observed no serious clinical problems in crew members, even though there have been some personal differences in the adaptive reactions of the crew members’ functional systems to space flight conditions. Onboard life support systems and means on ISS have been basically sufficient and adequate, and periodically
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Table 1 Russian medical control in space flight on ISS Control of sanitary parameters and radiation conditions Control of health state, physical capacitance and functional reserves of cosmonaut organism in flight different stages at rest, during loading tests, also during complicate modes of the overall activity Diagnostics of disturbances in crew health state and medical treatment realization Crew psychophysiological state control, Work-Rest Schedule, psychological support Control of efficiency of the countermeasures, directed on mitigation of unfavorable flight factors influence Nutrition and water consumption
Medical control includes everyday control of the environment, radiation environment and crew performance and also the periodic assessment of cosmonaut health and physical fitness. When it is needed additional observations and treatments are provided.
Table 2 Onboard methods and equipment for ecological monitoring on ISS Methods
Onboard equipment
MO-21 (Control of micro ecosphere of environment) MO-22 (Control of sanitary and epidemiological state)
Set “Ecosphere” Packages with tubes The equipment for microbiological tests of air and from surfaces Operational Control Analyzer Unit An Ar-1M and Ar-1M-F sampler kit Concentrator AK-1M Patronage with IPD NASA equipment—noise dosimeter Dosimetric package ID-3 Dosimeter « Pille-ISS» Dosimeter « R-16» Dosimeters « DB-8»
Air sampling into Station volumes for micromixts determination
Acoustic conditions evaluation Radiation control
occurring temporary failures of certain life support systems have had no impact on the state of health of the crew members (Table 1). Throughout the ISS program and particularly during the first expeditions there have been technical or program failures in the operation of medical hardware, certain life support systems, onboard training simulators and medical computer equipment, which required maintenance and repair work and adequate responses from medical control services. The most problematic device has been TVIS, which has experienced frequent and repeated failures, functioning with an off-nominal SLD system, which interfered with the implementation of the physical countermeasures program and control over their adequacy. It is important to point out that physical exercises on the treadmill in accordance with special programs form the bulk of the Russian system of inflight physical countermeasures. Given frequent failures and unreliability of TVIS the Russian BD-1 device was brought to ISS as an alternative means of the crews’ physical training. Technical measures to repair the inflight medical hardware and exercise devices, to adjust the program of countermeasures and other medical measures were aimed at minimiz-
ing the negative impact of these factors on the crew’s health. The sanitary and hygienic conditions on ISS have been generally satisfactory and have corresponded to ISS MORD rules throughout the flights. At the same time, noise levels that are 4–24 dB higher than normative parameters have constantly been registered on ISS, which calls for extra measures to protect the acoustic analyzers in the form of antinoise earplugs and hearing protection devices. According to medical control data, there have been periodic occurrences of microflora and mycology levels on certain surfaces of the station’s interior in excess of normative requirements, which can be promptly neutralized by onboard means (by treating these surfaces with antiseptics and fungistat). The methodology of monitoring the air environment quality, which brings together current and operational control over chemical compounds, including off-nominal and emergency situations in real time, and an expanded analysis of air samples by means of gas chromatography and chromatography–mass spectrometry on the Earth, make it possible to objectively assess the safety of the habitat and its impact on the health of the crew [10–12] (Table 2).
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Fig. 5. ISS dynamics on the absorbed radiation doses. The measurements are done by “non-protected” sensor—D1 and by “protected” sensor—D2.
The air environment quality throughout the ISS operation has been in line with the requirements of both Russian and international standards. There have been no serious problems with respect to water supply and nutrition systems, except for the late 2004, when a temporary food crunch occurred because of the Progress transport ship’s one-month delay. Nevertheless the attachment of modules, cargo and transport ships saturated with non-metal materials, technical means and gas releases from cargo delivered to ISS were the main sources of extra chemical contamination of the ISS’ air environment. Data collected show the need for an improvement in the toxicological and hygienic measures taken in the process of preparations for the flight on the ground. The dynamics of aggregate pollution on ISS show that an increase in the content of harmful trace contaminants is more often than not related to the arrival of visiting expeditions, new objects and hardware to ISS or to temporary failures in different life support systems [12]. The MMOP’s habitat and offnominal situations subgroups promptly respond to temporary increases in the content of certain trace pollutants. The existing algorithm of toxicological and hygienic support in offnominal and emergency situations has been used to neutralize offnominal situations on ISS and has been taken as the basis for the development of the keynote international document Main Guidelines on Crew Activities in the Event of Toxic Release into the Atmosphere of the ISS, NASA–RSA, 2004.
Radiation impacts have not been outside of the expected range. Fig. 5 shows the dynamics of the absorbed dose on ISS. In periods of solar activity and an increasing threat of proton events the Alert regime is called, which provides for strengthened (uninterrupted) radiation control, using both nominal radiometers R-16 and DB-8 and Pile sensors, which were placed in cosmonauts’ suits, and the cosmonauts’ withdrawal to the best protected areas of the stations in the periods of the greatest radiation danger (large diameter of the service module next to onboard training simulators) [13,14] (Fig. 5). Table 3 Russian Program crews health state monitoring in space flights MO-1 Investigation of heart bioelectrical activity at rest MO-2 All day ECG registration MO-3 Fitness periodic evaluation MO-4 Orthostatic tolerance to assessment during LBNP test MO-5 Investigation of cardiovascular system state during graded physical load with cycle ergometer MO-6 Hands muscles apparatus estimation with cycle ergometer MO-7 Calf volume measurement (IZOG) MO-8 Body mass measurement (IMT) MO-9 Biochemical analysis of urea (Urolux, UBIM) MO-10 Determination of hematocrit rate MO-11 Blood biochemical analysis (Reflotron) MO-12 Estimation of heart bioelectrical activity by means orthogonal (DS) electrodes placement Health state periodic evaluation PHS (NASA equipment) Blood analysis with PCBA (NASA equipment) Audiometry (NASA equipment)
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Table 4 Performance of physical training (PhT) by Russian cosmonauts on ISS No.
SF days
PhT once a day
PhT twice a day
TVIS treadmill
Bicycle
IRED (resistive loading)
Cuffs on thigh
“Penguin suit”
Tonus (electrostimulator)
1
142
1–100 days, 100%
From 110th day of SF— 100%
45–126 days, Bi failed
Yes, intensively
No
Yes, without adequate loading
No
2
142
Rare
Mostly
–
Yes, not intensively
No
Systematically with a good loading
No
3
167
First 50 days
The second half Load
Yes
Yes + expanders in FGB
No
Yes, with a good loading
No
4
129
40%, 15%, no PhT
45%
Yes
–
No
50–60% of days
No
5
129
100%
–
Yes
No
No
196
100%
–
Yes, intensively No; expanders
No
6
First 3–4 days of SF
Yes, not adequate regimen 6–8 hr/day
Yes, once a week
7
185
0% 1–30 days, No PhT
100%
8
185
0%
100%
Walking from 11th day; running—up to 7 miles from 47th day, with 40 kg loading The same, V-up to 9 km/h, loading up to 50 kg Repairment up to 56 days, the last month two times, V9-11 km/h, loading 46 kg Up to 20 days—no TVIS SLD, V—up to 12 km/h Reduced usage No TVIS SLD up to 137 days, loading— about 50 kg, low intensity and volumes Passive regimen— intensity up to 13 km, workload up to 10 km Low intensities and workloads. Last 30 days—TVIS two times a day
Yes
Yes
Yes + NS-1 + middle size expander
Yes
Yes, the whole working day
Yes, 10–12 times per flight
Yes
Intensively
Yes
Yes, regularly
Yes, 10–12 times per flight
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Table 4 (continued) SF days
PhT once a day
PhT twice a day
TVIS treadmill
Bicycle
IRED (resistive loading)
Cuffs on thigh
“Penguin suit”
Tonus (electrostimulator)
9
195
0%
100%
Yes
No, NS-1 regularly
50% of SF
No
Occasionally
10
161
0%
100%
Yes
No
Yes, for a long time
No
Yes
11
181
50%
50%
Yes
No, NS-1
First weeks SF
4–5 hr/day, 1 monthbefore landing
1 month before landing
12
188
0%
100%
Low intensity, 2–5 m/h, aerobic running, loading 40 kg from shoulders, at theend—TVIS two times a day TVIS SLD—30 days before landing, V—10– 11 km/h V—2–4 m/h, workload 100%, walking/ running— 13 , loading 45 kg, atthe end50 kg V—below 7 km/h, low loading
Yes, with MO-5 regimen
Highly intensive
First 2–3 weeks of SF
No
No
No.
2 of
Note: LBPN, water–salt loading, “Centaurus” suit were used before and during landing according to the standard protocol by all cosmonauts.
The neuropsychic ability and performance of the crews in flights 1–10 on ISS were on the whole in line with the flight conditions, functional reserves maintained were enough to perform mission objectives. The work and rest schedule was tense during joint activities performed together with visiting crews, during the change of the main crews, and also during the preparations for and implementation of EVA, during repair and maintenance works, which was accompanied by sleep shifts, periodic occurrences of disruption of circadian rhythm excessive work loads and work on holidays [15,16]. A nominal Russian medical control system consisted mainly of anthropometric tests, examinations of the cardiovascular system at rest and under physical loads, dynamic flight operations and during EVAs, biochemical blood and urine tests (Table 3).
Typical changes in the form of T-wave amplitude decline have been observed on ECG. The functional state of the blood circulatory system has been characterized mainly by a normal hemodynamic status, but in a number of cases there was a sinus arrhythmia and moderate signs of arterial hypertension. The magnitudes of the stroke volume and the circulation rate per minute have changed within a narrow range and without a particular pattern [17]. Russian members of the ISS crew used a Russian system of countermeasures, which had been delivered earlier and consisted primarily of special sets of four-day physical training cycles with onboard exercise devices—a treadmill and a bicycle ergometer with a system of loaders. The set of countermeasures for an extended-duration flight also included the wearing of the Penguin loading suit, course administration of
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Fig. 6. Russian monitoring of countermeasures efficacy in space flights (see the text).
preventive medications and a cycle of LBNP exercises at the final stage of the flight, and administration of water–salt additives and means of antigravity protection at the stage of descent and landing. Some cosmonauts have actively used electromiostimulation during the flight. It is important to point out that failures or limitations of the use of the TVIS treadmill have created certain difficulties and required adjustments to the implementation of the inflight countermeasures program [1,2,18,19]. Upon completion of the flight the state of health of Russian members of the main crews was considered satisfactory or good. The first five crews landed on space shuttles, the next five used Soyuz TMA spacecraft. It is worth pointing out that the nature of load factors at the disorbiting and landing stages have had a significant impact on the wellbeing and the degree of readapting manifestations. For instance, the ISS-6 crew made a ballistic descent from the orbit with loads up to 8 g at the stage of descent and landed 500 km off the precalculated position, having to wait for several hours for the rescue teams to arrive. Even in such conditions, however, the Russian crew member was capable of independent actions, assisting himself and giving assistance to others upon departing the reentry module. Like after extended-duration missions on Russian orbital stations, members of ISS main crews showed different degrees of physical deconditioning, ortho-
static intolerance, coordination and vestibulo-vegetative disorders [20]. It is important that the nature of adaptive reactions of the cosmonauts’ functional systems during the flight and the degree of readaptive changes during the postflight period depend primarily on how adequate the program of inflight countermeasures was implemented. Table 4 shows personal differences in the use of different countermeasures. These differences are attributable to both limitations of the use of certain countermeasures and personal preferences of cosmonauts and the degree of their readiness to follow the prescribed regimens of countermeasures (Table 4). The Russian inflight system to monitor to the cosmonaut’s physical conditions includes the registration of the level of physical loads on the treadmill in a fourday exercise cycle, assessment of the level of physical conditioning in an 11-min incrementally increasing locomotor test on TVIS—MO-3—and a standard incrementally increasing test on a bicycle ergometer— MO-5. Before performing an EVA in Russian OrlanDMA suits, assessment of physical conditioning, in addition to the MO-5 test, also includes manual bicycle ergometry—MO-6 [16–18] (Fig. 6). Analysis of the results of ISS space missions medical assurance reveals the needed health level of the crew to preserve its work capability that is required for their complex professional activities. It is also required
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for further ISS development including the integration of the Partners medical structures and flight operations management. References [1] O.G. Gazenko, A.I. Grigoriev, I.B. Kozlovskaya, Mechanisms of acute and chronic effects of microgravity, Physiologist 29 (1986) S48–S50. [2] I.B. Kozlovskaya, Countermeasures for long-term space flights, Lessons learned from the Russian space program, Journal of Gravitational Physiology 9 (1) (2002) 313. [3] V.V. Bogomolov, G.. Samarin, A review of programs of biomedical research aboard the “Mir” orbital station, Result and Perspectives of Fundamental Space Research on the Orbital Manned Stations “Mir” and ISS, Publications of RAS at RSC “Energia”, Moscow, 1999, pp. 135–137. [4] V.V. Bogomolov, G.I. Samarin, Medical health and performance care on orbital station “Mir”, in: Orbital Station “Mir”, Space Biology and Medicine, vol. 1, Medical Care in Long Term Space Flight, 2001, pp. 20–41. [5] V.V. Morgun, L.I. Voronin, R.R. Kaspranskiy, S.L. Pool, M.R. Barrat, A.L. Navinkov, Development of US–Russian medical support procedures for long-duration spaceflight: the NASA–Mir experience, Aviation, Space, and Environmental Medicine 73 (2) (2002) 147–155. [6] C.L. Fischer, V.V. Bogomolov, A.E. Sargsyan, Management of the International Space Station (ISS) System of Joint Medical Support, Presented at Aerospace Medical Association (AsMA) 74th Annual Scientific Meeting, San Antonio, TX, USA, May 5–9, 2003. [7] V.V. Bogomolov, Medical health care for the crews of ISS, in: Third International Aerospace Congress IAC, 2000, p. 261. [8] International Space Station Medical Operations Requirements Documents (ISS MORD), SSP 50260, Revision C, March 2004. [9] Medical Evaluation Documents (MED) Volume A, B, Medical Standards for ISS Crewmembers (AMERD 2A), SSP 50667, 2005.
[10] N.D. Novikova, The main features of formation of environment on orbital complex “Mir”, Journal of Aviaspace and Ecology Medicine 4 (2001) 32–40. [11] N.D. Novikova, Microbiological risks in extended space missions, in: Proceedings of the 11th International Conference on Space Activity and Relevant Insurance Implications, The Human Factor in Space, Rome, March 15–16, 2001. [12] L.N. Mukhamedieva, V.Z. Aksel-Rubinstein, K.N. Mikos, E.I. Nikifin, The main lows of gas environment in living compartments and piloted orbital station, in: Organism and Environment Life Support and Safety in Extremal Situation, vol. 1, 2000, pp. 301–302. [13] A.V. Shafirkin, Yu.G. Grigoriev, V.M. Petrov, Analysis of documentation on radiation safety of orbital flights and suggestion to their improvements, Journal of Aviaspace and Ecology Medicine 33 (6) (1999) 21–32. [14] A.V. Shafirkin, Y.G. Grigoriev, A.V. Kolomensky, Radiation risks for cosmonauts during flight to Mars, Journal of Aviaspace and Ecology Medicine 38 (2) (2004) 3–14. [15] V.I. Miasnikov, S.I. Stepanova, Problems of Astenisation in Longterm Space Flight. Moscow, 2000. [16] O.P. Kozerenko, V.I. Gushin, A.D. Sled, et al., Some problems of group interaction in prolonged space flight, Journal of Human Performance in Extreme Environments 4 (1) (1999) 146–152. [17] V.V. Bogomolov, I.V. Alferova, I.B. Goncharov, V.V. Krivolapov, Medical control in the system of regulation of functional body reorganization under spaceflight conditions, in: Organism and Environment: Adaptation to Extremal Conditions, vol. M, 2003, pp. 60–61. [18] I.B. Kozlovskaya, A.I. Grigoriev, V.I. Stepantzov, Countermeasure of the negative effects of weightlessness on physiological systems in long-term space flights, Acta Astronautica 36 (1995) 661–668. [19] I.B. Kozlovskaya, A.I. Grigoriev, Russian system of countermeasures on board of the International Space Station (ISS): the first results, Acta Astronautica 55 (2004) 233–237. [20] A.I. Grigoriev, V.V. Bogomolov, V.V. Morgun, Medical rehabilitation of cosmonauts after longterm space flight, in: V.I. Pokrovsky (Ed.), Handbook of Rehabilitation for Subject Underwent Stress Loading, 2004, pp. 86–97 (Chapter 6).
