Methods of physical rehabilitation of patients with coronary artery disease at the sanatorium stage. With coronary heart disease Rehabilitation after coronary artery disease
Cardiorehabilitation - EURODOCTOR.ru - 2009
Rehabilitation for IHD aims to restore the state of the cardiovascular system, strengthen the general condition of the body and prepare the body for the previous physical activity.
The first period of rehabilitation for IHD is adaptation. The patient must get used to the new climatic conditions, even if the former were worse. Acclimatization of the patient to new climatic conditions can take about several days. During this period, an initial medical examination of the patient is carried out: doctors assess the patient's health status, his readiness for physical activity (climbing stairs, gymnastics, therapeutic walking). Gradually, the amount of physical activity of the patient grows under the supervision of a physician. This is manifested in self-service, visits to the dining room and walks around the territory of the sanatorium.
The next stage of rehabilitation is the main stage. It is milked for two to three weeks. During this period, physical activity increases, e duration, speed of therapeutic walking.
At the third and final stage of rehabilitation, the final examination of the patient is carried out. At this time, the tolerance of therapeutic exercises, dosed walking and climbing stairs is assessed.
So, as you already understood, the main thing in cardiorehabilitation is dosed physical activity. This is due to the fact that it is physical activity that “trains” the heart muscle and prepares it for future loads during daily activity, work, etc.
In addition, it is now reliably proven that physical activity reduces the risk of developing cardiovascular diseases. Such therapeutic exercises can serve as a preventive measure for both the development of heart attacks and strokes, as well as for rehabilitation treatment.
Terrenkur - another excellent means of rehabilitation for heart diseases, incl. and IBS. Terrenkur is metered by distance, time and angle of inclination on foot ascents. Simply put, health path is a method of treatment by dosed walking along specially organized routes. The terrenkur does not require special equipment or tools. It would be a good hill. In addition, climbing stairs is also a health path. Terrenkur is an effective tool for training the heart affected by coronary artery disease. In addition, with the health path it is impossible to overdo it, since the load has already been calculated and dosed in advance.
However, modern simulators allow you to carry out the health path without slides and stairs. Instead of climbing uphill, a special mechanical path with a varying angle of inclination can be used, and walking up the stairs can be replaced by a step machine. Such simulators allow you to more accurately regulate the load, provide urgent control, feedback and, which is not unimportant, do not depend on the vagaries of the weather.
It is important to remember that the health path is a dosed load. And you should not try to be the first to climb a steep mountain or overcome the stairs faster than anyone else. Terrenkur is not a sport, but physical therapy!
Some may have a question, how can stress on the heart and coronary artery disease be combined? After all, it would seem that in every possible way it is necessary to spare the heart muscle. However, this is not the case, and it is difficult to overestimate the benefits of physical exercise in rehabilitation after coronary artery disease.
First, physical activity helps to reduce body weight, increase strength and muscle tone. During physical activity, blood supply to all organs and tissues in the body improves, oxygen delivery to all cells of the body normalizes.
In addition, the heart itself trains a little bit, and gets used to working with a slightly greater load, but at the same time, without reaching exhaustion. Thus, the heart "learns" to work under such a load, which will be under normal conditions, at work, at home, etc.
It is also worth noting the fact that physical activity helps relieve emotional stress and fight depression and stress. After therapeutic exercises, as a rule, anxiety and anxiety disappear. And with regular classes of therapeutic exercises, insomnia and irritability disappear. And as you know, the emotional component in IHD is an equally important factor. Indeed, according to experts, one of the causes of the development of diseases of the cardiovascular system is neuro-emotional overload. And therapeutic exercises will help to cope with them.
An important point in therapeutic exercises is that not only the heart muscle is trained, but also the blood vessels of the heart (coronary arteries). At the same time, the wall of the vessels becomes stronger, and its ability to adapt to pressure drops also improves.
Depending on the condition of the body, in addition to therapeutic exercises and walking, other types of physical activity can be used, for example, running, vigorous walking, cycling or cycling, swimming, dancing, skating or skiing. But such types of loads as tennis, volleyball, basketball, training on simulators are not suitable for the treatment and prevention of cardiovascular diseases, on the contrary, they are contraindicated, since static long-term loads cause an increase in blood pressure and pain in the heart.
In addition to therapeutic exercises, which is undoubtedly the leading method of rehabilitation in patients with coronary artery disease, herbal medicine and aromatherapy are also used to restore patients after this disease. Physicians-phytotherapists for each patient select therapeutic herbal preparations. The following plants have a beneficial effect on the cardiovascular system: fluffy astragalus, Sarepta mustard, May lily of the valley, carrot seed, peppermint, common viburnum, cardamom.
In addition, today, for the rehabilitation of patients after coronary artery disease, such an interesting method of treatment as aromatherapy. Aromatherapy is a method of prevention and treatment of diseases with the help of various aromas. Such a positive effect of smells on a person has been known since ancient times. It is known that not a single doctor of Ancient Rome, China, Egypt or Greece could do without medicinal aromatic oils. For some time, the use of therapeutic oils in medical practice was undeservedly forgotten. However, modern medicine is once again returning to the experience accumulated over thousands of years of using aromas in the treatment of diseases. To restore the normal functioning of the cardiovascular system, lemon oil, lemon balm, sage, lavender, and rosemary oils are used. The sanatorium has specially equipped rooms for aromatherapy.
Work with a psychologist is carried out if it is required. If you suffer from depression, or have experienced stress, then, undoubtedly, psychological rehabilitation is also important, along with physiotherapy exercises. Remember that stress can aggravate the course of the disease, lead to an exacerbation. This is why proper psychological rehabilitation is so important.
Diet is another important aspect of rehabilitation. Proper diet is important for the prevention of atherosclerosis - the main cause of coronary artery disease. A nutritionist will develop a diet specially for you, taking into account your taste preferences. Of course, certain foods will have to be abandoned. Eat less salt and fat, and more vegetables and fruits. This is important, since with the continued excess intake of cholesterol into the body, physiotherapy exercises will be ineffective.
Professor Terentiev Vladimir Petrovich, Doctor of Medical Sciences, Honored Doctor of the Russian Federation, Head of the Department of Internal Medicine No. 1 of Rostov State Medical University, Member of the International Society for Cardiac Rehabilitation, Member of the Board of the All-Russian Scientific Society of Cardiology
Professor Bagmet Alexander Danilovich, Doctor of Medical Sciences, Head of the Department of Polyclinic Therapy, Rostov State Medical University
Professor Kastanayan Alexander Alexandrovich, Doctor of Medical Sciences, Head of the Department of Internal Medicine, Rostov State Medical University, Head of the Rheumatology Department, Rostov State Medical University
Doctor of the highest qualification category, Cardiologist
REHABILITATION OF PATIENTS WITH CORONARY HEART DISEASE
Rehabilitation, i.e., restorative therapy, of patients with cardiovascular diseases, the purpose of which is the fullest possible restoration of the patients' ability to work, has been given serious attention in the USSR for a long time. Back in the 1930s, G. F. Lang formulated the basic principles of restorative therapy for cardiac patients. With regard to the treatment of patients with heart failure, G. F. Lang identified three stages.
At the first stage, in his opinion, restoration of compensation is achieved with the help of medications, diet and rest. The second stage provides for the greatest possible increase in the efficiency of the heart, or rather, the entire circulatory apparatus through physical methods of treatment - gymnastics, massage, physiotherapy exercises, as well as balneotherapeutic and climatic influences.
Rehabilitation of patients. The third stage of treatment, according to G. F. Lang, practically comes down to the establishment and implementation of a work and household regime under medical supervision that corresponds to the patient's condition and the functional ability of his cardiovascular system.
It can be seen that the principles put forward by G. F. Lang retain their significance at the present time. It is also important to consider the proposal of G. F. Lang to differentiate the concepts of restoration of working capacity and ability to work, meaning the first ability to work in general, and the second - the ability of the patient to perform work in his profession. In accordance with these provisions, which essentially followed from the very practice of Soviet health care, a system of rehabilitation treatment of persons with diseases of the cardiovascular system was formed and developed in the USSR. To effectively solve this problem, favorable conditions have been created in our country: the network of hospitals and clinics is steadily expanding, methods of functional diagnostics and treatment are being improved, sanatorium and resort business is developing and taking on more and more advanced forms, labor expertise and employment of patients with diseases of the cardiovascular system are improving. .
Thus, by the time when the term "rehabilitation" was widely used in foreign medicine in relation to patients with cardiovascular diseases, the Soviet Union had already developed the theoretical foundations and practical ways of restorative treatment of these patients. It is no coincidence that the prominent American cardiologist Raab repeatedly drew attention to the fact that every year 5 million Americans are forced to travel outside their country to health centers, while in the USSR thousands of sanatoriums and resorts are provided for the services of citizens, where they undergo one of the important stages rehabilitation (Raab, 1962,1963)
Rehabilitation of patients. The term “rehabilitation”, which appeared for the first time in 1956 on the pages of the Soviet medical press in relation to persons with diseases of the cardiovascular system, was rather a linguistic novelty.
However, it should be said that in recent years in our country there has been a significant increase in interest in the problem of restorative treatment of cardiac patients. Serious research is being carried out to scientifically substantiate the principles, criteria and methods of rehabilitation treatment of patients at various stages of rehabilitation, various institutions involved in the rehabilitation therapy of cardiac patients are being combined into a single system, and rehabilitation centers are being created.
Great attention to the problem of rehabilitation treatment of patients with cardiovascular diseases is dictated by many circumstances, among which the steady increase in the number of patients with these diseases is one of the most significant. In our country, as in other economically developed countries, diseases of the cardiovascular system occupy the first place among the causes of disability.
V. A. Nesterov and V. A. Yakobashvili (1969) report that in 1964 in Krasnodar atherosclerosis of the coronary arteries and myocardial infarction were the most common causes of disability among all cardiovascular diseases, accounting for 69.5-84.3 cases per 10,000 population.
Cardiovascular diseases are mostly the fate of middle-aged and elderly people, who make up a significant part of the population. If we take into account that in recent years there has been a pronounced shift in the incidence of cardiovascular diseases towards a younger age, then the need to successfully solve the problems associated with the problem of rehabilitation becomes even more obvious.
Rehabilitation of patients. The successes achieved in the treatment of patients with acute myocardial infarction have reduced the lethality of myocardial infarction by about 2 times.
In this regard, the number of people who have had a myocardial infarction and at the same time lost their ability to work has noticeably increased. According to Pell and D'Alonzo (1964), about 75% of people who have had a first myocardial infarction remain alive over the next 5 years. This category includes more often people who are at the most productive and creative age, endowed with great life and professional experience, bringing invaluable benefits to society.
According to CIETIN (1970), based on an analysis of 364 cases of myocardial infarction, 51% of patients were aged 50-59 years, 29% - aged 40-49 years, 9% - aged 30-39 years. There was a significant difference in age by disability groups: among the limited able-bodied persons aged 40-49 years there were 35.5%, aged 30-39 years - 16.8%, which is almost 3 times more than in the group of the disabled.
The departure of patients from active working life is associated with considerable damage to the state, in whatever area of professional activity they have previously worked. Let us illustrate this situation with the data of Helander (1970), reflecting the magnitude of the damage caused to national production due to cardiovascular diseases. We are talking, in particular, about the Swedish city of Alvsborg with a population of 375,000 people, where in 1963 there were 2,657 patients and they were paid a disability pension for an average of 90 days. Appropriate calculations established that about 2.5% of the national income was lost due to the disability of the mentioned patients. If these patients were able-bodied, then in 1970 they could produce products worth 125 million US dollars.
Rehabilitation of patients. When it comes to people of older age groups, here the problem of rehabilitation is no less important, in particular its social and family aspects.
Although in these cases, rehabilitation treatment does not always aim to return the patient to work, nevertheless, the successful restoration of the ability for self-care in such patients, the ability to cope with daily household chores, alleviates the situation of other family members and allows $m to return to work.
The above, of course, does not exhaust the enormous importance of rehabilitation in the complex of measures to combat cardiovascular diseases and their consequences. The diversity and complexity of this section of cardiovascular pathology force the author to dwell on the characterization of only some aspects of this problem.
First of all, it is necessary to touch upon the content of the concept of rehabilitation. According to the WHO definition (1965), rehabilitation, or restorative treatment, is a set of therapeutic and socio-economic activities designed to provide persons with disabilities as a result of illness in such a physical, mental and social condition that would allow them to re-engage in life and take an appropriate their position in society.
Rehabilitation of patients. Medical aspects include issues of early diagnosis and timely hospitalization of patients, possibly early application of pathogenetic therapy, etc.
the physical aspect, which is part of medical rehabilitation, provides for all possible measures to restore physical performance, which is achieved by timely and adequate activation of patients, the use of physiotherapy exercises, and also by gradually increasing in intensity physical training for a more or less long period of time.
Of great importance is the psychological (or mental) aspect of the problem, which involves overcoming negative reactions from the patient's psyche that arise in connection with the disease and the resulting change in the material and social situation of the patient.
Professional and socio-economic aspects affect the adaptation of the patient to the appropriate type of work in the specialty or his retraining, which provides the patient with the opportunity for material self-sufficiency in connection with independence in labor activity. Thus, the professional and socio-economic aspects of rehabilitation relate to the area associated with working capacity, employment, the relationship between the patient and society, the patient and his family members, etc.
Rehabilitation of patients. There is ambiguity in the definition and interpretation of the various stages of rehabilitation.
Often, various aspects of rehabilitation are mixed with its stages, there is no unity in understanding the beginning of the rehabilitation period.
First of all, it should be emphasized that the idea of rehabilitation should be at the center of the doctor's attention from the time of his first contact with the patient. At the same time, physiological, psychological, clinical, socio-economic problems that the disease that has arisen for the patient should be taken into account. Rehabilitation should be considered as an integral part of medical treatment, which is a set of organically related therapeutic measures. Rehabilitation of patients with cardiovascular diseases, in particular patients with coronary artery disease, is one of the sections of the general problem of rehabilitation, requiring medical workers and society to take all possible measures that would allow a person who has temporarily become disabled to return to productive work.
Until recently, the phases of rehabilitation were understood by different authors differently; there was no generally accepted classification. E. I. Chazov (1970), Askanas (1968) distinguish hospital and post-hospital stages. The post-hospital stage consists of: a) sanatorium, b) polyclinic, c) at the place of work. These stages correspond to: 1) stabilization period (consolidation of myocardial infarction under the influence of early and complex treatment in a hospital setting); 2) the period of mobilization, mainly continuing in sanatorium conditions and aimed at identifying and developing the greatest compensatory capabilities of the body; 3) the period of reactivation associated with the return of the patient to professional activities (E. I. Chazov, 1970; Konig, 1969).
Rehabilitation of patients. There are other classifications that currently have only historical significance.
As an example, refer to the definition of the stages of rehabilitation given by Rulli and Venerando (1968). The authors distinguish three stages, the first of which consists in determining the patient's condition, the second in adapting him to new conditions, and the third - incorporating him into work if this is compatible with the actual working capacity of the patient.
Such an idea of the stages of rehabilitation is hardly acceptable to clinicians. The disadvantage is that rehabilitation according to this classification is something independent, in isolation from the treatment process, which is one of the indispensable conditions for successful rehabilitation.
From a clinical point of view, the most acceptable and convenient is the classification of the phases of rehabilitation of patients with myocardial infarction, proposed by the WHO Expert Committee (1968), which distinguishes: 1) the hospital phase, starting from the moment the patient enters the hospital; 2) phase of convalescence (recovery); the program of this phase is carried out in rehabilitation centers or, in extreme cases, at home under the supervision of specialists; in this phase, the patient recovers; 3) the postconvalescence phase (supporting), this phase lasts the rest of the patient's life and is carried out with long-term dispensary observation.
Rehabilitation of patients. Knowledge of the physiological foundations of rehabilitation is one of the key issues in this problem, which determine the correct orientation of doctors in assessing the working capacity and working capacity of patients and adequate control over the implementation of rehabilitation measures.
How, in what way and to what extent physical activity (work) or another type of activity affects the patient's cardiovascular system, what are the mechanisms that ensure the patient's adaptation to physical or other stress, what are the ways to most effectively use the patient's functional reserves and improve the functional state of the heart - vascular and other systems of the body - this is a far from complete list of issues related to the physiological foundations of rehabilitation. Due to the great importance of this aspect of the problem, we consider it necessary to characterize it in more detail.
PHYSIOLOGICAL BASES OF REHABILITATION OF PATIENTS WITH CARDIOVASCULAR DISEASES
Currently, based on data from clinical and epidemiological studies, it is believed that sufficient physical activity can be one of the real means of preventing coronary artery disease. In addition, it has been established that the improvement of the mechanical function of the damaged myocardium, in particular in coronary insufficiency, and, accordingly, the increase in physical activity in general play an important role in the complex of measures for the rehabilitation of patients with coronary artery disease and in the prevention of disease recurrence (Hellerstein, 1969).
This provision contains essentially the main goal pursued by research on the physiological aspects of rehabilitation in IHD.
Rehabilitation of patients. It comes down to studying the effects of physical activity on the functional state of the cardiovascular system.
We fully share the point of view of Varnauskas (1969), which states that, regardless of the methods of restorative treatment and the physiological mechanisms associated with them, the adaptation of the circulatory system to physical (muscular) work, on the one hand, occupies a central position in assessing the effect of restorative treatment, and on the other hand, regular physical activity (training) itself is considered as a valuable means of rehabilitation of patients.
In this regard, it is essential to know what type of physical activity is used, what characterizes the adaptive reactions of the cardiovascular system during physical activity, including in the conditions of previous physical training, what are the fundamental differences in adaptive reactions between healthy people and patients. This should take into account the changes that occur in the respiratory and muscular systems, the nervous system and some types of metabolism.
In the literature, the term "physical tension" is usually used in relation to rhythmic or dynamic muscle tension. In this regard, there are static muscle work with predominant isometric muscle contraction and dynamic muscle work with predominant isotonic contraction. Physiological similarities and differences between them are expressed in the fact that muscle contraction is accompanied in both cases by the expansion of blood vessels, however, with rhythmic contraction, an increase in blood flow through the dilated vessels occurs.
Rehabilitation of patients. During static (isometric) contraction, dilated vessels are subjected to compression by the contracted muscle, which leads to a decrease in blood flow in them.
However, it should be said that during dynamic contraction, mechanical compression of the vessels also occurs, but it is of a transient (rhythmic) nature, while during static contraction, compression extravascular effects on the vessels cause a constant decrease in blood flow through them.
The differentiation of types of muscle contraction is based on the kinetics of oxidative metabolic processes in tissues and is in accordance with predominantly anaerobic, aerobic or mixed types of tissue respiration.
Anaerobic type of respiration is usually present during intense and short-term physical work, in which there is a significant reduction in oxygen debt. The latter is compensated during the rest.
Aerobic type of breathing is typical for work performed for a long time without great physical effort. Under these conditions, a balance is achieved between the needs, delivery and consumption of oxygen. Such a relatively stable state is referred to in the literature as a steady state.
Rehabilitation of patients. Under normal conditions of physical activity, a person has a combination of the above types of work with different levels of oxygen debt, i.e. we are talking about work, the pace and intensity of which can change, but can remain at the level of a steady state.
According to the available observations, the central cardiovascular response to muscle contraction, moderate in strength but reaching the degree of fatigue, is reduced only to a local change in blood flow. Under conditions of muscle fatigue, cardiovascular reactions are characterized by a dramatic increase in systolic and diastolic systemic arterial pressure. At the same time, heart rate and stroke output moderately increase (Andersen, 1970).
We deliberately cited these data, borrowed from the works of Rulli (1969), Bruce (1970), Andersen (1970), as we believe that they are of some importance for practical rehabilitation measures in terms of choosing the most rational forms and degrees of physical training for patients and assessment of their response to physical activity.
The following indicators are currently used as criteria for assessing the functional state of the cardiovascular system, including under conditions of physical activity: stroke volume and heart rate, arterial pressure and peripheral vascular resistance, arteriovenous oxygen difference and distribution of peripheral blood flow.
Rehabilitation of patients. Meanwhile, for a deeper characterization of the functional state of the body, its reserve and compensatory capabilities, along with studies of the main hemodynamic changes, it is equally important to consider the study of the oxygen regime.
The study of the functional state of these systems allows you to get a more complete picture of the participation of cardiac and extracardiac factors in the mechanisms of adaptation of the body of a heart patient to physical activity.
The need to study various indicators characterizing the function of the cardiovascular system and respiration follows from the main purpose of the circulatory system. It consists in creating adequate blood flow through the capillaries, which provides the necessary level of tissue metabolism. This mechanism underlies the adaptation of the peripheral circulation to the metabolic needs of tissues.
Studies have shown that in all healthy individuals during physical activity, an increase in the cardiac index by an average of 63% (with fluctuations from 0.7 to 2.3 l / m 2) of the initial level occurs. In the examined patients, the increase in minute volume was inadequate. Cardiac output was more inert in patients with mitral stenosis and atherosclerotic cardiosclerosis (on average, it increased by 25 and 22%, respectively), in 2 patients with severe postinfarction cardiosclerosis, this figure even slightly decreased. With these diseases, especially with mitral stenosis, the lowest rates of cardiac output were noted at rest. Similar results were obtained in other studies.
Rehabilitation of patients. It can be assumed that a decrease in cardiac output in mitral stenosis is associated with a restriction in blood flow due to the development of a second barrier, blood deposition in some patients.
In atherosclerotic cardiosclerosis, the output is reduced, probably due to a decrease in myocardial contractility, a decrease in coronary reserve, and, possibly, the existence of unloading reflexes on the myocardium. Other authors come to similar conclusions (A. S. Smetnev and I. I. Sivkov, 1965; G. D. Karpova, 1966; S. M. Kamenker, 1966; Donald, 1959; Chapman and Fraser, 1954;: Harvey e. a., 1962). Atrial fibrillation, which was registered in 8 patients with mitral stenosis and 4 with cardiosclerosis, apparently also has a certain value in reducing the cardiac index.
Obviously, these mechanisms become even more important in these diseases under conditions of physical activity.
For comparison, we present the indicators of the cardiac index in patients with hypertension, with cor pulmonale and aortic valve insufficiency. In all these patients, the baseline values were either within the range of values characteristic of healthy individuals, or exceeded them. This concerned, in particular, patients with cor pulmonale and patients with aortic valve insufficiency. During exercise, all patients showed a significant increase in cardiac index: by 54% in cor pulmonale, by 53% in hypertension and by 38% in aortic insufficiency.
Rehabilitation of patients. A significant increase in cardiac output during exercise in hypertensive patients is apparently due to left ventricular hypertrophy and associated myocardial hyperfunction.
However, in cor pulmonale, there are mechanisms that limit blood flow to the heart, in particular intrathoracic pressure. Its increase even at rest can reach significant values, and during exercise it rises even more, which leads to a restriction of blood flow to the heart. Apparently, if this factor were absent, one would expect an even greater increase in minute volume in patients with cor pulmonale.
As for patients with aortic insufficiency, then; despite the relatively high rate of the cardiac index at rest, during exercise, its increase was only 38% of the initial level, i.e., it was significantly less than in healthy people. This may indicate that the mechanisms that ensure a normal level of blood flow at rest (large diastolic volume, hypertrophy and hyperfunction of the myocardium) are not able to maintain the minute volume in these patients at an adequate level during exercise.
An analysis of data on changes in the cardiac index shows that an increase in the minute volume of blood during exercise in healthy people also occurs due to an increase in stroke volume. In patients with heart disease, cardiac output increases mainly due to increased heart rate. Moreover, in a number of patients during exercise, the systolic volume decreased due to a decrease in diastolic filling of the heart due to a sharp tachycardia.
Rehabilitation of patients. Consequently, a characteristic feature of hemodynamics in cardiac patients and in coronary artery disease without signs or with initial signs of heart failure is an inadequate increase in cardiac output, which is realized mainly only due to an increase in heart rate.
The decrease in the minute volume of blood at rest and its inadequate increase during physical activity can be compensated by the mobilization of various systems, in particular respiratory resources (increased ventilation, oxygen uptake, etc.). From this point of view, it is of interest to study the oxygen regime and ventilation under the influence of physical activity. As a result of these studies, carried out using the Belau apparatus, we were able to identify certain differences in the parameters of gas exchange and pulmonary ventilation in different groups of patients.
The minute volume of respiration (MOD) at rest was somewhat higher in patients than in healthy people, and its increase significantly exceeded that in the control. This fact testifies to the compensatory reaction of the respiratory apparatus in case of heart diseases, when the increase in the minute volume of blood becomes inadequate to the degree of physical activity. Thus, the MOD increased in healthy individuals by 70%, with mitral stenosis - by 105%, aortic disease - by 90%, hypertension - by 90%, atherosclerotic cardiosclerosis - by 95% and with cor pulmonale - by 70%.
Differences in changes in MOD are especially significant in patients with mitral stenosis and atherosclerotic cardiosclerosis, in whom, even at rest, the ratio of MOD to minute blood volume is much greater than in healthy people. However, it should be taken into account that increasing the volume of ventilation comes at a high price and requires additional energy consumption.
Rehabilitation of patients. So, if in healthy people an increase in the volume of ventilation by 2 times is accompanied by an increase in the work of breathing by about 2 times, then in patients with heart disease, the increase in the work of breathing is much higher.
In patients, physical activity is accompanied by an increase in oxygen uptake, but due to a decrease in the reserve and adaptive abilities of the circulatory apparatus, this increase occurs in the recovery period, while during physical activity, oxygen consumption is lower than in healthy people. Thus, the ratio of the amount of oxygen consumed during exercise to its level in the recovery period (recovery factor - CV) decreases, and in different ways in different patients. In the control group, the recovery coefficient was 1.88, with mitral stenosis - 1.19, with atherosclerotic cardiosclerosis - 1.08, with aortic disease -1.65, with hypertension - 1.58.
If we compare these figures with the results of hemodynamic studies, we can clearly see that they are in full accordance with the characteristics of hemodynamics in patients of these groups. For example, in mitral stenosis and atherosclerotic cardiosclerosis, as we have already indicated, the lowest rates of cardiac output at rest and during exercise were noted. Naturally, the oxygen debt in these patients was higher.
The energy costs of the body are more fully characterized by indicators of oxygen consumption per unit of work and an indicator of labor efficiency (ET - the ratio of work performed to energy consumption). These indicators characterize the efficiency of labor.
Rehabilitation of patients. In the control group, the indicator is 1.99 ml / kgm, and ET - 23.79%.
In patients, these indicators changed significantly: with mitral stenosis 2.27 ml/kgm and 20.32%, respectively, with atherosclerotic cardiosclerosis 2.28 ml/kgm and 20.76%, with aortic disease 2.41 ml/kgm and 20. 02%, with hypertension 2.46 ml/kgm and 19.80%, with cor pulmonale 2.45 ml/kgm and 20.44%, respectively.
An increase in oxygen consumption per unit of work and a decrease in labor efficiency may indicate that the performance of work in patients required significantly more stress, primarily on the cardiovascular system, than in healthy people.
The given data, based on a comparative study of a number of hemodynamic parameters and oxygen regime in healthy and cardiac patients, indicate significant deviations of the studied parameters in patients with cardiovascular pathology, which are especially clearly detected with the help of physical activity. These deviations are pronounced, in particular, in patients with coronary artery disease (stage III coronary atherosclerosis according to the classification of A. L. Myasnikov) and in patients with mitral stenosis. The results of these studies allow us to recognize that among the mechanisms that ensure the adaptation of the body to physical activity, along with cardiac factors, extracardiac factors play a certain role.
Rehabilitation of patients. The latter, as it were, compensate for the existing disturbances in the functional state of the cardiovascular system, mainly due to the mobilization of respiratory reserves.
The correspondence between changes in parameters characterizing the oxygen regime and pulmonary ventilation revealed by us with hemodynamic shifts observed in patients after exercise gives grounds to use the method of studying the parameters of pulmonary ventilation and gas exchange as an independent and sufficiently informative criterion for assessing the functional state of the body and its reactions to physical load. The value of the spiroergometry method lies, therefore, in the fact that it makes it possible to investigate the integral function of blood circulation and respiration in their interaction.
This conclusion is confirmed by special studies conducted at the Institute of Cardiology of the USSR Academy of Medical Sciences. A. L. Myasnikova (D. M. Aronov and K. A. Memetov), in which gas exchange and pulmonary ventilation under the influence of physical activity in patients with IHD were studied by spiroergometry.
59 men with atherosclerosis of the coronary arteries aged 33 to 65 years were studied. Of these, 35 suffered from atherosclerosis of the coronary arteries of the III stage (according to the classification of A. L. Myasnikov) and had atherosclerotic post-infarction cardiosclerosis with pronounced changes in the myocardium. 24 patients had stage I coronary artery atherosclerosis. As a control, 30 practically healthy individuals of the same age were studied. The research methodology consisted in the study of gas exchange and pulmonary ventilation, first at rest, during exercise in steady state conditions and after it. Spiroergometry was performed on the apparatus "Belau" after preliminary training of patients to breathe through the mouthpiece. Physical activity in the range of 40-60 W was given for 3 minutes in the form of climbing a single-step ladder in a given rhythm.
Rehabilitation of patients. One can see significant differences, identified primarily in terms of the recovery factor (CR).
If normally it is equal to 1.48, then in patients with IHD with a similar load it is much lower - 1.11 in stage I and 0.82 in stage III coronary atherosclerosis. We attach significant importance to this indicator, since it allows us to more deeply assess the state of the reserve and adaptive capabilities of the circulatory apparatus under load. The decrease in the value of this indicator in patients with coronary atherosclerosis is due to the fact that increased oxygen uptake occurs not during exercise, but mainly in the recovery period, during rest.
This indicates a reduced ability of the cardiovascular system to adapt blood flow in organs and tissues to the loads imposed on the body. In the same figure, it can be seen that as coronary atherosclerosis progresses, oxygen consumption increases per 1 Kgm of work (POg/kgm). If in the control group an average of 2.12 ml of oxygen is consumed per 1 kgm of work, then in patients with atherosclerosis of the coronary arteries of stage I, 2.26 ml of oxygen is needed for the same amount of work, and in patients in stage III of the disease - 2.63 ml of oxygen. It can also be seen that patients have a distinct decrease in labor efficiency (ET). Labor efficiency in the control group, in patients with coronary atherosclerosis stage I and III, respectively, was 22.3%, 20.78% and 18.94%.
Thus, in patients with coronary artery disease, there is an increase in oxygen consumption per unit of work and a decrease in labor efficiency. This indicates that the efficiency of labor in such patients is reduced, the performance of work requires them to use a lot of energy, a lot of tension in the contractile function of the myocardium and pulmonary ventilation.
An analysis of the data obtained as a result of these studies showed that an increase in oxygen consumption per 1 kgm of work in patients with coronary artery disease is accompanied by a decrease in the oxygen utilization factor (CI) compared to the norm, especially during exercise.
Rehabilitation of patients. CI, as is known, is a value that characterizes the effectiveness of pulmonary ventilation, and depends both on the state of the respiratory system and on the stroke volume of the heart, i.e., on myocardial contractility.
What compensatory mechanisms ensure the energy costs of patients during physical activity? Studies show that in patients both at rest and especially during exercise, the minute volume of respiration (MOD) increases. On the other hand, a low increase in oxygen consumption per unit time during exercise was revealed (394 ml in patients versus 509 ml in healthy people). A small increase in oxygen consumption per unit time indicates a reduced ability of the myocardium to increase the minute volume, as evidenced by the data on changes in the cardiac index in patients with coronary artery disease under the influence of physical activity, given above.
The above studies characterize mainly general patterns in changes in the functional state of the circulatory and respiratory apparatus that occur under the influence of physical activity in patients with coronary artery disease and other diseases of the cardiovascular system. Based on these data, it is possible to a certain extent to understand the mechanisms, on the one hand, general, and on the other, specific for each type of pathology, which ensure the adaptation of cardiac patients to physical activity.
Concluding the presentation of this section, we consider it necessary to emphasize that we did not set ourselves the task of discussing all aspects of this complex problem - the problem of adaptation of the cardiovascular system of patients with coronary artery disease to various kinds of loads. The very definition and measurement of optimal performance in diseases of the cardiovascular system is associated with many unresolved issues.
Rehabilitation of patients. These include, in particular, the influence on the process of adaptation of gender, age, degree of physical fitness (training) of a person, his emotional (psychological) mood, etc.
In relation to patients with coronary heart disease, when assessing the adaptive capabilities of the cardiovascular system, of course, it is also necessary to take into account the degree and prevalence of atherosclerotic lesions of the coronary vessels, the possibility of combining coronary vessel lesions with other localizations of atherosclerosis, for example, cerebral, peripheral, etc. In this case, it is necessary to take into account the degree damage to the heart muscle itself, the severity and nature of the clinical manifestations of the disease, the duration of myocardial infarction, the number of heart attacks in the past, the presence of complications, etc. Although these issues are more related to the clinical aspects of rehabilitation, to the assessment of the working capacity and working capacity of patients, to the choice of the most adequate means of rehabilitation Nevertheless, knowledge of them, in our opinion, will allow a deeper understanding of the physiological foundations of rehabilitation.
Particularly little studied is the question of changes in regional blood circulation in both healthy and sick people under conditions of physical activity. This applies, in particular, to such vascular pools as the coronary, cerebral, and renal. The dynamics of changes in blood flow in these organs and the redistribution of blood in atherosclerotic vascular lesions can have a decisive influence on the process of patient adaptation to physical activity. Meanwhile, in this regard, there are only indirect data based on the study of hemodynamic parameters, gas exchange and respiratory function, electrocardiogram, etc.
Earlier, we specifically dwelled on the compensatory-adaptive mechanisms that develop in the coronary circulation system in case of its disturbances, in particular, on the significance of collateral circulation in this case, on the concept of coronary reserve, etc. All these questions, including the question of local mechanisms of self-regulation of coronary blood flow, extravascular effects on coronary blood flow, may be directly related to the study of the physiological foundations of rehabilitation in coronary artery disease, the possibilities and mechanisms of adaptation of patients to physical activity.
Rehabilitation of patients. All the materials and judgments given above concerned the influence of short-term physical activity on the functional systems of the body.
Meanwhile, data characterizing changes in the functional state of the cardiovascular system under the influence of long-term physical training would be of fundamental importance for the problem of rehabilitation.
ADJUSTMENT OF THE CARDIOVASCULAR SYSTEM OF PATIENTS WITH CORONARY HEART DISEASE TO PHYSICAL TRAINING
There are numerous reports in the literature about the beneficial effect of systematic physical training on the clinical condition of patients with coronary artery disease, however, there have been few special studies devoted to the study of the physiological mechanisms that determine the adaptation of the cardiovascular system to physical training.
There are experimental observations on animals, according to which systematic physical activity contributes to the development of collateral circulation and improvement of blood supply to the myocardium.
Of particular interest are the observations of Varnauskas (1960), obtained as a result of contrast angiography of coronary vessels in patients with coronary artery disease before and during acute hypoxia caused by inhalation of a 10% mixture of oxygen with air.
Rehabilitation of patients. The author observed at the same time a noticeable increase in the network of collateral vessels and a visible expansion of the branches of the coronary vessels.
Based on such observations, it is suggested that systematic physical activity or training, causing an increase in myocardial hypoxia under conditions of coronary atherosclerosis, can contribute to the opening and neoplasm of collateral vessels, as well as the expansion of the main branches of the coronary vessels, thereby improving myocardial blood supply.
This assumption is made mainly on the basis of data obtained in the experiment on animals, in which, however, changes in the myocardium, similar to those present in human coronary artery disease, are usually reproduced by stenosis or ligation of one or more branches of the coronary vessels. In general, the coronary system of animals is not affected by a process similar to atherosclerosis, and therefore there are certain limits to the possible use of the results of experiments to understand the processes occurring in the human heart affected by atherosclerosis.
Take, for example, the question of the ability of coronary vessels affected by the atherosclerotic process to expand. Although the general opinion on this matter comes down to the denial of such a possibility, since, as it is assumed, the vessels are already in a state of maximum expansion, we believe that this issue should be considered from the standpoint of the staging of the course of IVS, which was discussed in detail in the section on pathogenesis of coronary heart disease. It can be assumed that in the first period of the disease and in the compensated phase of the second period, coronary vessels, mainly small-caliber vessels, are capable of further expansion, i.e., they retain a constrictor tone, due to which there is a potential for their expansion.
Rehabilitation of patients. We have given a number of arguments in favor of the justification of such an idea, although we consider it necessary to further study this issue.
The possibility of developing collateral circulation in conditions of stenosing coronary atherosclerosis is more documented by actual data. In this regard, a large role belongs, as is well known, to the time factor. On the one hand, this is proved by morphological data indicating the development of an intense network of collateral vessels in stenosing atherosclerosis, especially in the elderly, and the absence of a developed network of collaterals in acute blockage of one of the branches of the coronary arteries with a small degree of atherosclerotic changes in the entire coronary system. .
On the other hand, according to experimental observations, a gradual decrease in myocardial blood supply caused by a dosed narrowing of one of the main trunks of the coronary vessels or sequential ligation of several branches extending from the main trunk of the coronary arteries is accompanied by the opening and formation of collateral vessels.
Although these data do not directly answer the question of the extent to which regular physical training can have a stimulating effect on the development of collaterals, nevertheless, they indicate a large role in the development of collateral circulation of the hypoxic factor. The degree of the latter, on the one hand, should not be so great as to cause damage to the myocardium, on the other hand, it should be sufficient to cause an appropriate vasodilating reaction.
Rehabilitation of patients. A thorough study of the mechanism and features of the development of intercoronary anastomoses in an experiment on dogs with gradual (chronic) occlusion of the coronary artery revealed interesting patterns (Schaper, 1969).
First of all, it was established that the process of neoformation of collateral vessels in response to coronary occlusion occurs due to the mitotic proliferation of endothelial cells, smooth muscle cells and fibroblasts, and the possibility of metaplastic transformation of endothelial cells into smooth muscle cells is also allowed. According to the author of this study, the process of vascular growth is closely related to damage to the artery, i.e., with increased stress on the vascular wall proximal to occlusion and with chemical influences from hypoxic tissue. Under these conditions, the synthesis of all components of the arterial wall is activated, and normal coronary arteries develop in most cases 6 months after coronary occlusion. Initially, many arterioles are involved in the development of collateral circulation, but only some of them are transformed into large coronary arteries, while others completely degenerate over time.
The established patterns in the development of collateral circulation are important from the point of view of studying the factors that create a constant incentive for the preservation and further formation of an additional, roundabout vascular network.
We believe that one of these factors may be adequate long-term physical training, which causes a certain degree of tension in the coronary circulation system and increases the intensity of metabolic processes in the myocardium.
Rehabilitation of patients. In putting forward this proposition, we are aware that it is to some extent hypothetical.
In practice, we often meet with patients with coronary artery disease, in whom the slightest physical effort causes a sharp deterioration in the condition, manifested by an anginal or asthmatic attack, worsening of the coronary circulation and ECG parameters. In such cases, when the coronary reserve is exhausted, one can hardly count on the beneficial effect of physical training, which should give way to the opposite tactics, which involve reducing the work of the heart and its need for oxygen. Mussafia et al. (1969) come to the same conclusion on the basis of a study of 100 patients with coronary artery disease of varying severity, who used tests with dosed physical activity and nitroglycerin.
When analyzing the mechanisms of hemodynamic adaptation to physical training, one should take into account its effect on the regulation of peripheral blood flow and the process of blood redistribution. The same load, but according to the observations of Varnauskas (1966), can cause a noticeable decrease in blood flow in a number of internal organs, primarily in the kidneys, in the group of non-working muscles, etc. As a result, there is a decrease in the ratio of perfusion - oxygen extraction in tissues, which is accompanied by a decrease in the oxygen content in the venous blood and an increase in the arterio-venous oxygen difference. A decrease in the ratio of perfusion - oxygen extraction can also be caused by increasing the ability of tissues to extract oxygen, which is associated with a change in the activity of redox enzymes under the influence of physical training.
Rehabilitation of patients. Thus, the described mechanisms, participating in the adaptation of the cardiovascular system to physical training, allow muscle cells to extract more oxygen.
As a result, one can expect an improvement in the hemodynamic regime, which will first of all be manifested by a decrease in cardiac output. In other words, to perform work with the same load after a long workout, the activity of the heart will be more economical, with less energy.
This position is confirmed by a number of observations available at the Institute of Cardiology named after; A. L. Myasnikova USSR Academy of Medical Sciences. In these studies, an attempt was made to increase the adaptive capacity of the cardiovascular system and the compensatory mechanisms of the apparatus in patients with cardiovascular diseases through the use of systematic physical exercises. Classes consisted of a complex of therapeutic exercises, alternating with relaxation exercises and breathing exercises.
The duration of each complex of therapeutic exercises in accordance with the mode of physical activity was 15-25 minutes. Exercises were performed from the initial sitting or standing position, at a slow and medium pace with a gradual increase in physical activity. Such exercises contribute to a more uniform outflow of blood, prevent a sharp increase in pressure in the pulmonary veins and the left atrium.
Rehabilitation of patients. The results of dynamic observation can, for example, be illustrated in a group of patients with coronary atherosclerosis followed up by DM Aronov and KA Memetov.
After the course of treatment carried out in a sanatorium, an increase in the recovery factor in patients with atherosclerosis of the coronary arteries of stage I was noted by 17.3%, and stage III - by 19.5% compared with the initial level. At the same time, there was a decrease in oxygen consumption per 1 kgm of work, especially pronounced in patients who had myocardial infarction - 2.63 ml of oxygen per 1 kgm of work for treatment and 2.2 ml after. In patients with postinfarction cardiosclerosis, the improvement of the oxygen regime indicators under the influence of systematic physical training went in parallel with the improvement of indicators characterizing the contractile function of the myocardium.
The described data allow us to consider that patients who have had myocardial infarction have the opportunity to restore or improve the contractile function of the heart muscle, implemented under conditions of systematic physical training. It is possible that these changes in the activity of the heart are associated with an improvement in metabolic processes in the myocardium. This assumption is consistent with the observations, according to which physical exercises promote the transition of potassium ions from contracting striated skeletal muscles to the myocardium, where, due to chronic hypoxia developing in connection with coronary atherosclerosis, there is an electrolyte imbalance in the form of a decrease in intracellular potassium concentration.
The beneficial effect of long-term physical training on hemodynamics and spiroergometry in patients with coronary heart disease, including patients with myocardial infarction, is shown in the works of McAlpin and Kattus (1966), Gottheiner (1968), Lachmann et al. (1967), Barry (1966) and etc.
Rehabilitation of patients. Among the factors that are involved in the process of adaptation of the cardiovascular system to physical stress during training, some authors include changes in the venous system.
It is believed that the dysregulation of venous tone may be accompanied by a tendency to develop peripheral venoconstriction, leading to the occurrence of coronary circulation disorders. Elimination or mitigation of this factor improves hemodynamics in general, which has a positive effect on the ability of the cardiovascular system to respond to physical and other stresses (Robinson EA, 1971).
The above studies are an example of how long-term physical training can have a positive effect on the processes of adaptation of the cardiovascular system and other systems of the body of a patient with coronary artery disease to the physiological stress that a person has in life and professional activities.
Above, it was mainly about the mechanisms through which this adaptation is carried out. Meanwhile, it is well known from practice that in some cases physical activity can cause severe, sometimes irreversible disturbances in the activity of the patient's cardiovascular system. So, cases of myocardial infarction and death during physical activity are reported even in practically healthy and relatively young people (Lepeschkin, 1960; Bruce EA, 1968; Naughton EA, 1964, etc.).
The possibility of such incidents is due to the fact that effective loads aimed at promoting the development of collaterals and expansion of the coronary arteries should be close to critical, since it is hypoxia as a result of such a load that acts as an adequate stimulus that can cause the effects listed above.
Rehabilitation of patients. Thus, in relation to patients with IHD, physical activity, depending on its intensity and on the patient's condition, can play the role of both a pathogenic and a therapeutic factor.
One of the most difficult tasks of rehabilitation in this regard is to establish that limit in the degree of physical activity, the excess of which threatens the patient with serious consequences. This issue, which relates to the clinical aspects of rehabilitation, to the assessment of the working capacity and working capacity of patients, is directly related to the methods of monitoring the functional state of the cardiovascular system of patients.
CLINICAL ASPECTS OF REHABILITATION
An idea of the patient's ability to physical readaptation can be obtained on the basis of a routine clinical study, which involves questioning, examining and monitoring the patient while performing physical exercises. On the basis of clinical criteria, attempts have been made to create various options for the functional classification of patients with coronary artery disease in connection with rehabilitation.
As an example, we can cite the most common classification abroad, based on the criteria developed by the New York Heart Association (1955). This classification provides for four functional groups of patients, depending on the presence and severity of their pain syndrome, shortness of breath and other subjective symptoms during physical exertion, the state of compensation and the degree of circulatory disorders.
Rehabilitation of patients. Group I includes patients who, in an active state, do not experience pain and signs of decompensation.
Even significant physical exercises do not cause any deviations in such patients in comparison with healthy people.
Group II includes patients with minor symptoms of the disease that occur during normal activities, but more intense physical activity is accompanied by shortness of breath, palpitations and angina attacks. These patients have no symptoms of decompensation.
Group III includes patients in whom even moderate physical effort causes angina attacks, shortness of breath, and palpitations. They may develop decompensation, which, however, can be treated.
In patients of group IV, the symptoms of the disease are present even at rest and are difficult to treat or not at all treatable.
However, only one clinical examination without the use of other, in particular instrumental, research methods allows you to get a fairly adequate assessment of the patient's performance in no more than 50-60% of cases (WHO Chronicle, 1969). This partly depends, on the one hand, on the lack of informativeness and objectivity of the anamnestic data, on the other hand, on the fact that the adverse effects of physical stress do not always receive sufficient clinical expression. Due to the low reliability of clinical criteria, they are supplemented by other research methods, most often carried out under conditions of dosed physical activity.
Rehabilitation of patients. Known experience in this regard has been accumulated in the Department of Rehabilitation of the Institute of Cardiology. A. L. Myasnikova USSR Academy of Medical Sciences.
Teleelectrocardiography was used as a method to provide information about the reactions of the cardiovascular system to physical activity in patients with myocardial infarction. These studies were carried out by V. M. Stark using the domestic device TEK-1. The electrocardiogram was recorded in one of the Nab leads on a direct recording electrocardiograph. On the following examples of teleelectrocardiograms relating to three patients with myocardial infarction lasting from 22 to 47 days, one can see that moderate physical activity in the form of walking around the ward, walking along the corridor and climbing stairs does not cause adverse changes in the electrocardiogram, but only leads to a slight increase in heart rate, quite adequate for this type and degree of load.
When evaluating the teleelectrocardiograms of this patient, it can be concluded that the reserves of the coronary circulation allow him to walk long distances at a moderate and even fast pace, to ascend to the 3rd floor, but limit the patient when ascending to the 4th floor.
These examples illustrate the possibilities of teleelectrocardiography, the advantage of which is that it makes it possible to study the response of the cardiovascular system of patients who have had myocardial infarction in natural conditions while performing physical activities habitual for patients.
Rehabilitation of patients. The next method, which was used as a control over the state of the cardiovascular system of patients, is a long-term monitoring electrocardiographic observation.
In the conditions of the rehabilitation department, long-term monitoring of the ECG of patients with myocardial infarction was first carried out at the Institute of Cardiology. A. L. Myasnikova USSR Academy of Medical Sciences. Due to the peculiarities of the method, ECG monitoring was carried out only after exercise. With the help of a monitor device, the reaction of patients to various physical activities of a therapeutic and domestic nature was studied, namely, after performing various complexes of physiotherapy exercises, climbing stairs, walking and dosed walking, eating, etc.
These examples demonstrate the limits of the possibility of monitoring patients. A valuable property of this method is the possibility of signaling in case of sudden deterioration in the patient's condition, as well as the ability to monitor several patients simultaneously. The disadvantage is the impossibility of monitoring the patient at the time of the load, as well as recording only one ECG lead. The last drawback is inherent in teleelectrocardiography.
When only one ECG lead is registered during exercise, pathological changes can be missed that can occur in those leads that are not recorded due to the technical imperfection of the devices. Therefore, when determining the tolerance of patients to various physical activities, it is necessary to take into account changes in the potential of the whole heart.
Rehabilitation of patients. In addition, rehabilitation provides for an accurate quantitative determination of the tolerance of patients suffering from coronary insufficiency to physical activity.
Therefore, of all the existing methods, we consider the most rational and indicative method for determining the individual tolerance of patients to physical activity, which we will dwell on in more detail.
These studies were conducted by D. M. Aronov on 99 patients with various stages of coronary atherosclerosis (according to the classification of A. L. Myasnikov). Of these, there were 32 people with stage I (ischemic), 36 people with stage II (thrombo-necrotic) and 31 people with stage III (sclerotic). Patients with stage II, i.e., with acute myocardial infarction, were examined no earlier than 2 months after the onset of myocardial infarction before being sent to a suburban cardiological sanatorium. By this period, all of them were activated and made independent walks around the territory of the institute.
Approximately one third were young people (up to 39 years old inclusive); the vast majority of patients were male (91 out of 99). Most of the patients were mental workers. However, patients with mental labor under the age of 39, as a rule, systematically went in for sports for many years and had well-developed muscles.
Determination of tolerance to physical activity was carried out on a bicycle ergometer, ECG recording in three leads according to Nab was made on a multichannel mingograph. ECG was recorded in the position of the subject sitting in the saddle of the bucket ergometer before the load, as well as for 10-15 s at the end of each minute of the study and in the recovery period. In addition, continuous visual oscilloscope monitoring of the activity of the heart was carried out. Along with this, blood pressure was measured before, during and after the test.
Rehabilitation of patients. The termination of the test for the reasons listed in paragraphs 7-12 was carried out even in the absence of negative ECG dynamics.
physical activity was given in increasing volume, stepwise. The initial load was 50–90 kgm/min for those with acute myocardial infarction, 100–200 kgm/min for the rest of the patients, and was carried out by the subjects for 5 minutes. In the absence of the signs listed above, the load increased by 100% compared to the original. Each subsequent stage of the load was started with complete recovery of the control ECG, pulse and pressure, but not earlier than 10 minutes after the termination of the previous load.
The level of load at which one of the above signs appeared was considered the limit for this patient.
Careful selection of patients for the exercise test is very important. The latter should not be carried out, in our opinion, in cases of acute myocardial infarction, in the so-called pre-infarction state, in the presence of catarrhal or febrile conditions. Under these conditions, we did not observe any complications in any patient.
In view of the practical significance of the issue, we will specifically dwell on the moments that served as the reason for the termination of further exercise by the patient.
Rehabilitation of patients. The most common reason for this was a horizontal or “trough-shaped” downward displacement of 1 mm or more of the S-G interval in one (21 people) or 2 or more (38 people) leads.
An increase in the S-T interval by 1 mm or more was observed in 17 people, and 16 of them suffered a myocardial infarction 2-3 months ago or in a more remote period. It should be said that the rise of S - T up, as a rule, occurred in those leads where there were deep Q or QS teeth.
T-wave inversion in one or more leads was also relatively common, in 24 of 99 patients.
Sharp fluctuations (mainly upward) of blood pressure were detected only in 2 patients. In no case was a trend towards a decrease in blood pressure observed.
Our experience shows that patients with coronary insufficiency can perform a significant amount of work if the work is done with low power. When the power is exceeded, "ischemic" ECG changes occur with a much smaller amount of work.
As an illustration, we present the following observation.
Patient T., aged 50, suffered a repeated myocardial infarction of the posterior wall of the left ventricle of the heart. Bicycle ergometry was performed 27 years after the acute infarction. Work with a volume of 1000 kgm with a power of 200 kgm/min was performed without any objective and subjective deviations. With an increase in the power of the work performed from 200 to 250 kgm/min, at the 2nd minute of work, the patient developed an "ischemic" decrease in the S-T interval in two leads and an attack of angina pectoris occurred.
Rehabilitation of patients. Given this fact, it is very important to determine not only the total amount of work that a patient with IHD can freely perform, but also the power with which this work is performed.
In this regard, individual indicators of work power in patients with coronary insufficiency deserve attention, which, according to our observations, vary within 50-600 kgm/min.
Thus, the data on the determination of exercise tolerance can significantly complement the ideas about the changes occurring in the condition of patients, about the reserve capabilities of the coronary circulation, and thus allow more accurately determining the degree of working capacity and working capacity of patients. Based on these data, more rational and strictly individual recommendations for each case regarding the physical activity of the patient in everyday and professional terms can be built.
Of interest are the results of a study of the dynamics of heart rate in patients with coronary artery disease when they perform the so-called threshold load, that is, such a load that causes ischemic shifts on the ECG. The data force us to be wary of the WHO recommendations, according to which patients with myocardial infarction during physical training can bring the pulse rate up to 120 per 1 min without the threat of any complications. Therefore, when assessing the patient's physical performance, the method of quantitative determination of the patient's tolerance to physical activity, compared with other methods, is more accurate and safe.
Rehabilitation of patients. For example, the determination of physical performance in healthy people is carried out by calculating the coefficient of maximum oxygen uptake.
To determine it, it is required that the subjects perform maximum work with bringing the pulse rate to 150-200 per minute. Our observations clearly indicate the inapplicability of such tactics in relation to patients with coronary artery disease.
When assessing physical performance and for successful rehabilitation of patients with coronary artery disease, one should take into account the age, nature of the profession and the professional experience of the patient, his living conditions, the degree of his emotionality and psychological state, the characteristics of the reaction to the family and work environment and yar.
The possibility of returning the patient to normal life and to work is also influenced by other factors, in particular, the duration of the forced removal of the patient from professional activities. According to WHO statistics, the probability of a patient returning to work, regardless of the functional state of the cardiovascular system, decreases sharply when the disability continues for more than a year.
Due to the great importance of the psychological aspects of the problem of rehabilitation and, at the same time, their little study, we consider it necessary to characterize them in more detail.
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RUSSIAN STATE SOCIAL UNIVERSITY
therapeutic physical culture in coronary heart disease
MOSCOW 2016
Introduction
1. The concept of coronary heart disease.
2. Contributing factors and causes of the disease.
3. Clinical manifestations of IHD.
4. Features of therapeutic physical culture:
4.1 Periods of exercise therapy
4.2 Tasks of exercise therapy
Introduction
Restorative therapy or rehabilitation of those suffering from coronary heart disease is one of the private sections of rehabilitation in medicine. It originated during the First World War, when the task of restoring the health and working capacity of war invalids first arose and began to be solved. In practice, the problem of rehabilitation arose from the field of traumatology and soon began to spread to other areas: injuries, mental and some somatic diseases. At the same time, one of the important elements of rehabilitation was occupational therapy, first used in English hospitals for the disabled of the First World War and which was carried out under the guidance of skilled workers who retired.
Despite the fact that the rehabilitation of patients with cardiovascular diseases took shape as an independent branch of medicine relatively recently, many elements of it already existed from the very beginning of the development of Soviet healthcare. It is worth emphasizing that social security is a material source that guarantees various forms of manifestation of the state's concern about its citizens who have lost their ability to work. In other words, the system of social security for the disabled is one of the indispensable conditions for the successful functioning of the rehabilitation service.
Therapeutic and rehabilitation measures for coronary heart disease should be in their dialectical unity and close relationship. With myocardial infarction and other forms of coronary heart disease, it is hardly possible to single out purely therapeutic and purely rehabilitation measures.
Rehabilitation started on time and adequately carried out against the background of pathogenetic treatment contributes to an earlier and stable restoration of health and performance in most patients with acute myocardial infarction. At the same time, the later application of rehabilitation measures gives worse results.
The active expansion of the regimen of patients with acute myocardial infarction, of course, belongs to the sphere of the so-called physical aspect of rehabilitation. At the same time, an early expansion of the regimen can also have a purely therapeutic value - with a tendency to circulatory failure, especially of the left ventricular type, a sitting position helps to reduce venous flow to the heart, thereby reducing stroke volume and, consequently, the work of the heart. One of the most serious complications - cardiac asthma and pulmonary edema - is treated in this way.
Chapter 1. The concept of coronary heart disease
Coronary artery disease (CHD) - this term experts combine a group of acute and chronic cardiovascular diseases, which are based, respectively, on acute or chronic circulatory disorders in the coronary (coronary) arteries that provide blood to the heart muscle (myocardium). Ischemic heart disease is a chronic disease caused by insufficient blood supply to the myocardium, in the vast majority of cases is a consequence of atherosclerosis of the coronary arteries of the heart.
Everyone has probably experienced this disease: not at home, but with close relatives.
Ischemic heart disease has several forms:
angina;
myocardial infarction;
Atherosclerotic cardiosclerosis;
Accordingly, the diseases characterized by acute violation of the coronary circulation (acute coronary heart disease) include acute myocardial infarction, sudden coronary death. Chronic coronary circulation disorder (chronic ischemic heart disease) is manifested by angina pectoris, various cardiac arrhythmias and / or heart failure, which may or may not be accompanied by angina pectoris.
They occur in patients both in isolation and in combination, including those with various complications and consequences (heart failure, cardiac arrhythmias and conduction disturbances, thromboembolism).
Ischemic heart disease is a condition in which an imbalance between the heart muscle (myocardium) oxygen demand and its delivery leads to oxygen starvation of the heart muscle (myocardial hypoxia) and the accumulation of toxic metabolic products in the myocardium, which causes pain. The causes of impaired blood flow in the coronary arteries are atherosclerosis and vasospasm.
Among the main factors causing coronary heart disease, in addition to age, are smoking, obesity, high blood pressure (hypertension), uncontrolled medication, etc.
The reason for the lack of oxygen is a blockage of the coronary arteries, which, in turn, can be caused by an atherosclerotic plaque, a thrombus, a temporary spasm of the coronary artery, or a combination of both. Violation of the patency of the coronary arteries and causes myocardial ischemia - insufficient supply of blood and oxygen to the heart muscle.
The fact is that over time, the deposits of cholesterol and calcium, as well as the growth of connective tissue in the walls of the coronary vessels, thicken their inner shell and lead to a narrowing of the lumen. Partial narrowing of the coronary arteries, which limits the blood supply to the heart muscle, can cause angina pectoris (angina pectoris) - constricting pain behind the sternum, the attacks of which most often occur with an increase in the workload on the heart and, accordingly, its oxygen demand. The narrowing of the lumen of the coronary arteries also contributes to the formation of thrombosis in them. Coronary thrombosis usually leads to myocardial infarction (necrosis and subsequent scarring of a portion of the heart tissue), accompanied by a violation of the rhythm of heart contractions (arrhythmia) or, in the worst case, heart block. The "gold standard" in the diagnosis of coronary heart disease has become catheterization of its cavities. Long flexible tubes (catheters) are passed through the veins and arteries into the chambers of the heart. The movement of the catheters is monitored on a TV screen and any abnormal connections (shunts) are noted. After the introduction of a special contrast agent into the heart, a moving image is obtained, which shows the places of narrowing of the coronary arteries, valve leaks and malfunctions of the heart muscle. In addition, the echocardiography technique is also used - an ultrasound method that gives an image of the heart muscle and valves in motion, as well as isotope scanning, which makes it possible to obtain an image of the heart chambers using small doses of radioactive isotopes. Since the narrowed coronary arteries are not able to satisfy the oxygen demand of the heart muscle that increases during physical exertion, stress tests are often used for diagnosis with simultaneous recording of an electrocardiogram and ECG Holter monitoring. The treatment of coronary heart disease is based on the use of medications that, according to the indications of a cardiologist, either reduce the workload on the heart by lowering blood pressure and equalizing the heart rate, or cause the coronary arteries themselves to dilate. By the way, narrowed arteries can also be expanded mechanically - using the method of coronary angioplasty. When such treatment is unsuccessful, usually cardiac surgeons resort to bypass surgery, the essence of which is to direct blood from the aorta through a venous graft to a normal section of the coronary artery, bypassing its narrowed section.
Angina pectoris is an attack of sudden pain in the chest, which always responds to the following signs: it has a clearly defined time of onset and cessation, it appears under certain circumstances (when walking normally, after eating or with a heavy burden, when accelerating, climbing uphill, a sharp headwind, other physical effort); the pain begins to subside or completely stops under the influence of nitroglycerin (1-3 minutes after taking the pill under the tongue). The pain is located behind the sternum (most typically), sometimes in the neck, lower jaw, teeth, arms, shoulder girdle, in the region of the heart. Its character is pressing, squeezing, less often burning or painfully felt behind the sternum. At the same time, blood pressure may rise, the skin turns pale, covered with perspiration, the pulse rate fluctuates, and extrasystoles are possible.
Chapter 2
coronary disease heart gymnastics
The cause of myocardial ischemia may be blockage of the vessel by an atherosclerotic plaque, the process of thrombus formation, or vasospasm. Gradually increasing blockage of the vessel usually leads to chronic insufficiency of blood supply to the myocardium, which manifests itself as stable exertional angina. The formation of a thrombus or spasm of the vessel leads to acute insufficiency of blood supply to the myocardium, that is, to myocardial infarction.
In 95-97% of cases, atherosclerosis becomes the cause of coronary heart disease. The process of blockage of the lumen of the vessel with atherosclerotic plaques, if it develops in the coronary arteries, causes malnutrition of the heart, that is, ischemia. However, in fairness it should be noted that atherosclerosis is not the only cause of coronary artery disease. Malnutrition of the heart can be caused, for example, by an increase in the mass (hypertrophy) of the heart in hypertension, in physically hard workers or athletes. There are some other reasons for the development of coronary artery disease. Sometimes IHD is observed with abnormal development of the coronary arteries, with inflammatory vascular diseases, with infectious processes, etc.
However, the percentage of cases of CHD for reasons not related to atherosclerotic processes is rather insignificant. In any case, myocardial ischemia is associated with a decrease in the diameter of the vessel, regardless of the reasons that caused this decrease.
Of great importance in the development of IHD are the so-called risk factors for IHD, which contribute to the occurrence of IHD and pose a threat to its further development. Conventionally, they can be divided into two large groups: modifiable and non-modifiable risk factors for coronary artery disease.
Various models have been proposed in epidemiological studies to classify the many risk factors associated with cardiovascular disease. Alternatively, risk indicators can be classified as follows.
Biological determinants or factors:
Elderly age;
Male gender;
Genetic factors contributing to dyslipidemia, hypertension, glucose tolerance, diabetes mellitus and obesity. ischemic physical culture therapeutic
Anatomical, physiological and metabolic (biochemical) features:
Dyslipidemia;
Arterial hypertension (AH);
Obesity and the nature of the distribution of fat in the body;
Diabetes.
Behavioral (behavioral) factors:
Eating habits;
Smoking;
Physical activity;
alcohol consumption;
Behavior that contributes to coronary artery disease.
The likelihood of developing coronary heart disease and other cardiovascular diseases increases synergistically with an increase in the number and "power" of these risk factors.
Consideration of individual factors.
Age: it is known that the atherosclerotic process begins in childhood. The results of autopsy studies confirm that atherosclerosis progresses with age. The prevalence of stroke is even more related to age. With each decade after reaching the age of 55, the number of strokes doubles.
Observations show that the degree of risk increases with age, even if other risk factors remain in the "normal" range. However, it is clear that a significant increase in the risk of coronary heart disease and stroke with age is associated with those risk factors that can be influenced. Modification of the main risk factors at any age reduces the likelihood of the spread of diseases and mortality due to initial or recurrent cardiovascular diseases. Recently, much attention has been paid to the impact on risk factors in childhood in order to minimize the early development of atherosclerosis, as well as to reduce the "transition" of risk factors with age.
Gender: among the many conflicting provisions regarding coronary artery disease, one is beyond doubt - the predominance of male patients among patients. In women, the number of diseases slowly increases between the ages of 40 and 70 years. In menstruating women, IHD is rare, and usually in the presence of risk factors, smoking, arterial hypertension, diabetes mellitus, hypercholestremia, and diseases of the genital area. Sex differences are especially pronounced at a young age, and over the years they begin to decrease, and in old age both sexes suffer from coronary artery disease equally often.
Genetic factors: The importance of genetic factors in the development of coronary heart disease is well known, and people whose parents or other family members have symptomatic coronary heart disease are at an increased risk of developing the disease. The associated increase in relative risk is highly variable and can be up to 5 times higher than in individuals whose parents and close relatives did not suffer from cardiovascular disease. The excess risk is especially high if the development of coronary heart disease in parents or other family members occurred before the age of 55. Hereditary factors contribute to the development of dyslipidemia, hypertension, diabetes mellitus, obesity, and possibly certain behaviors that lead to the development of heart disease.
Poor nutrition: most of the risk factors for developing coronary artery disease are associated with lifestyle, one of the important components of which is nutrition. Due to the need for daily food intake and the huge role of this process in the life of our body, it is important to know and follow the optimal diet. It has long been noted that a high-calorie diet with a high content of animal fats in the diet is the most important risk factor for atherosclerosis.
Diabetes mellitus: Both types of diabetes markedly increase the risk of coronary artery disease and peripheral vascular disease, more so in women than in men. The increased risk is associated both with diabetes itself and with the greater prevalence of other risk factors in these patients (dyslipidemia, arterial hypertension). Increased prevalence occurs already in carbohydrate intolerance, as detected by carbohydrate loading. The “insulin resistance syndrome” or “metabolic syndrome” is being carefully studied: a combination of impaired carbohydrate tolerance with dyslipidemia, hypertension and obesity, in which the risk of developing coronary artery disease is high. To reduce the risk of developing vascular complications in diabetic patients, normalization of carbohydrate metabolism and correction of other risk factors are necessary. Persons with stable type I and type II diabetes are shown physical activity that improves functional ability.
Overweight (Obesity): Obesity is one of the most significant and at the same time the most easily modifiable risk factors for coronary artery disease. There is now convincing evidence that obesity is not only an independent risk factor for cardiovascular disease, but also one of the links - perhaps a trigger - of other factors. Thus, a number of studies have revealed a direct relationship between mortality from cardiovascular diseases and body weight. More dangerous is the so-called abdominal obesity (male type), when fat is deposited on the abdomen.
Lack of physical activity: Individuals with low physical activity develop coronary artery disease more frequently than individuals leading a physically active lifestyle. When choosing a program of physical exercises, it is necessary to take into account 4 points: the type of physical exercises, their frequency, duration and intensity. For the purposes of CHD prevention and health promotion, physical exercises are most suitable, which involve regular rhythmic contractions of large muscle groups, brisk walking, jogging, cycling, swimming, skiing, etc.
Smoking: Smoking affects both the development of atherosclerosis and the processes of thrombosis. Cigarette smoke contains over 4,000 chemical compounds. Of these, nicotine and carbon monoxide are the main elements that have a negative effect on the activity of the cardiovascular system.
Alcohol consumption: The relationship between alcohol consumption and CHD mortality is as follows: non-drinkers and heavy drinkers have a higher risk of death than moderate drinkers (up to 30 g per day in terms of pure ethanol). Despite the fact that moderate doses of alcohol reduce the risk of CHD, other health effects of alcohol (increased blood pressure, risk of sudden death, effects on psychosocial status) do not allow alcohol to be recommended for the prevention of CHD.
Psychosocial factors: Individuals with higher levels of education and socioeconomic status are known to have a lower risk of developing coronary artery disease than those with lower levels. This pattern can only partly be explained by differences in the levels of commonly recognized risk factors. It is difficult to determine the independent role of psychosocial factors in the development of coronary artery disease, since their quantitative measurement is very difficult. In practice, individuals with the so-called type “A” behavior are often identified. Work with them is aimed at changing their behavioral reactions, in particular, at reducing the component of hostility characteristic of them.
The greatest success in the prevention of coronary artery disease can be achieved by following two main strategic directions. The first of them - population - consists in changing the lifestyle of large groups of the population and their environment in order to reduce the influence of factors contributing to the CHD epidemic. The second is to identify individuals at high risk for the development and progression of coronary artery disease for its subsequent reduction.
Modifiable risk factors for CHD include:
Arterial hypertension (that is, high blood pressure),
Smoking,
overweight,
Disorders of carbohydrate metabolism (in particular diabetes mellitus),
Sedentary lifestyle (lack of exercise),
Irrational nutrition,
Increased blood cholesterol, etc.
The most dangerous from the point of view of the possible development of coronary artery disease are arterial hypertension, diabetes, smoking and obesity.
The immutable risk factors for coronary artery disease, as the name implies, include those from which, as they say, you can’t get anywhere. These are factors such as:
Age (over 50-60 years old);
Male gender;
Burdened heredity, that is, cases of coronary artery disease in close relatives.
In some sources, you can find another classification of CHD risk factors, according to which they are divided into socio-cultural (exogenous) and internal (endogenous) CHD risk factors. Socio-cultural risk factors for coronary artery disease are those that are caused by the human environment. Among these risk factors for coronary artery disease, the most common are:
Improper nutrition (excessive consumption of high-calorie foods saturated with fats and cholesterol);
Hypodynamia;
Neuropsychic overstrain;
Smoking;
Alcoholism;
The risk of coronary heart disease in women will increase with prolonged use of hormonal contraceptives.
Internal risk factors are those that are caused by the state of the patient's body. Among them:
Hypercholesterolemia, that is, high levels of cholesterol in the blood;
Arterial hypertension;
Obesity;
Metabolic disease;
Cholelithiasis;
Some features of personality and behavior;
Heredity;
Age and gender factors.
A noticeable impact on the risk of developing coronary artery disease is exerted by factors that at first glance are not related to the blood supply to the heart, such as frequent stressful situations, mental overstrain, and mental overwork.
However, most often it is not the stresses themselves that are “to blame”, but their influence on the characteristics of a person’s personality. In medicine, two behavioral types of people are distinguished, they are usually called type A and type B. Type A includes people with an excitable nervous system, most often of a choleric temperament. A distinctive feature of this type is the desire to compete with everyone and win at all costs. Such a person is prone to inflated ambitions, vain, constantly dissatisfied with what has been achieved, is in eternal tension. Cardiologists say that it is this type of personality that is least able to adapt to a stressful situation, and people of this type of coronary artery disease develop much more often (at a young age - 6.5 times) than people of the so-called type B, balanced, phlegmatic, benevolent .
Chapter 3. Clinical manifestations of coronary artery disease
The first signs of IHD, as a rule, are painful sensations - that is, the signs are purely subjective. The sooner the patient focuses on them, the better. The reason for contacting a cardiologist should be any unpleasant sensation in the region of the heart, especially if it is unfamiliar to the patient and has not been experienced by him before. However, the same applies to "familiar" sensations that have changed their character or conditions of occurrence. Suspicion of coronary artery disease should arise in a patient even if pain in the retrosternal region occurs during physical or emotional stress and passes at rest, they have the nature of an attack. In addition, any retrosternal pain of a monotonous nature also requires an immediate appeal to a cardiologist, regardless of either the strength of the pain, or the young age of the patient, or his well-being the rest of the time.
As already mentioned, IHD usually proceeds in waves: periods of calm without the manifestation of pronounced symptoms are replaced by episodes of exacerbation of the disease. The development of coronary artery disease lasts for decades, during the progression of the disease, its forms and, accordingly, the clinical manifestations and symptoms may change. It turns out that the symptoms and signs of IHD are the symptoms and signs of one of its forms, each of which has its own characteristics and course. Therefore, we will consider the most common symptoms of IHD in the same sequence in which we considered its main forms in the "Classification of IHD" section. However, it should be noted that about one third of patients with coronary artery disease may not experience any symptoms of the disease at all, and may not even be aware of its existence. This is especially true for patients with painless myocardial ischemia. Others may experience CAD symptoms such as chest pain, arm pain, lower jaw pain, back pain, shortness of breath, nausea, excessive sweating, palpitations, or abnormal heart rhythms.
As for the symptoms of such a form of IHD as sudden cardiac death, very little can be said about them: a few days before an attack, a person has paroxysmal discomfort in the retrosternal region, psycho-emotional disorders, and fear of imminent death are often observed. Symptoms of sudden cardiac death: loss of consciousness, respiratory arrest, lack of pulse on large arteries (carotid and femoral); absence of heart sounds; pupil dilation; the appearance of a pale gray skin tone. During an attack, which often occurs at night in a dream, 120 seconds after it begins, brain cells begin to die. After 4-6 minutes, irreversible changes in the central nervous system occur. After about 8-20 minutes, the heart stops and death occurs.
The most typical and common manifestation of coronary artery disease is angina pectoris (or angina pectoris). The main symptom of this form of coronary heart disease is pain. Pain during an angina attack is most often localized in the retrosternal region, usually on the left side, in the region of the heart. The pain can spread to the shoulder, arm, neck, sometimes to the back. With an attack of angina pectoris, not only pain is possible, but also a feeling of squeezing, heaviness, burning behind the sternum. The intensity of the pain can also be different - from mild to unbearably strong. The pain is often accompanied by a feeling of fear of death, anxiety, general weakness, excessive sweating, nausea. The patient is pale, his body temperature decreases, the skin becomes moist, breathing is frequent and shallow, the heartbeat quickens.
The average duration of an angina attack is usually short, it rarely exceeds 10 minutes. Another hallmark of angina pectoris is that an attack is quite easily stopped with nitroglycerin. The development of angina pectoris is possible in two versions: stable or unstable. Stable angina is characterized by pain only during exertion, physical or neuropsychic. At rest, the pain quickly disappears on its own or after taking nitroglycerin, which dilates blood vessels and helps to establish a normal blood supply. With unstable angina, retrosternal pain occurs at rest or at the slightest exertion, shortness of breath appears. This is a very dangerous condition that can last for several hours and often leads to the development of a myocardial infarction.
According to the symptoms, an attack of myocardial infarction can be confused with an attack of angina pectoris, but only at its initial stage. Later, a heart attack develops quite differently: it is an attack of retrosternal pain that does not subside within a few hours and is not stopped by taking nitroglycerin, which, as we said, was a characteristic feature of an angina attack. During an attack of myocardial infarction, pressure often rises significantly, body temperature rises, a state of suffocation, interruptions in the heart rhythm (arrhythmia) may occur.
The main manifestations of cardiosclerosis are signs of heart failure and arrhythmia. The most noticeable symptom of heart failure is pathological dyspnea that occurs with minimal exertion, and sometimes even at rest. In addition, signs of heart failure can include increased heart rate, increased fatigue, and swelling caused by excess fluid retention in the body. Symptoms of arrhythmias can be different, because this is a common name for completely different conditions, which are united only by the fact that they are associated with interruptions in the rhythm of heart contractions. A symptom that unites various types of arrhythmias is the unpleasant sensations associated with the fact that the patient feels how his heart beats “wrongly”. In this case, the heartbeat may be rapid (tachycardia), slowed down (bradycardia), the heart may beat intermittently, etc.
It should be recalled once again that, like most cardiovascular diseases, coronary disease develops in a patient over many years, and the sooner a correct diagnosis is made and appropriate treatment is started, the greater the patient's chances for a full life in the future.
Chapter 4. Features of therapeutic physical culture
4.1 Periods of exercise therapy
The method of therapeutic exercises is developed, depending on the patient's belonging to one of the three groups, according to the classification of the World Health Organization.
Group I includes patients with angina pectoris without myocardial infarction;
Group II - with postinfarction cardiosclerosis;
Group III - with post-infarction aneurysm of the left ventricle.
Physical activity is dosed on the basis of determining the stage of the disease:
I (initial) - clinical signs of coronary insufficiency are observed after significant physical and neuropsychic stress;
II (typical) - coronary insufficiency occurs after exercise (fast walking, climbing stairs, negative emotions, and so on);
III (sharply pronounced) - the clinical symptoms of the pathology are noted with slight physical exertion.
In the preoperative period, dosed tests with physical activity are used to determine exercise tolerance (bicycle ergometry, double Master's test, etc.).
In patients of group I, hemodynamic parameters after exercise are higher than in patients of other groups.
The motor mode allows the inclusion of physical exercises for all muscle groups performed with full amplitude. Breathing exercises are mostly dynamic in nature.
Long-term immobilization (in patients with chronic coronary heart disease) after surgery negatively affects the function of the cardiovascular system, causes a violation of the trophism of the central nervous system, increases the total resistance in the peripheral vessels, which adversely affects the work of the heart. Dosed physical exercises stimulate metabolic processes in the myocardium, reduce the sensitivity of the coronary arteries to humoral antispasmodic effects, increase the energy capacity of the myocardium.
After surgical treatment of patients with chronic coronary heart disease, early therapeutic exercises (on the first day) and a gradual expansion of motor activity are provided, and before the end of the stay in the hospital, a transition to active training loads. With each change in the complex of physical exercises, it is necessary to obtain a summary of the patient's reaction to exercise, which in the future is the basis for increasing the load, increasing activity, and leading to a reduction in the duration of inpatient treatment.
After surgery, for the selection of physical exercises, patients are divided into 2 groups: with uncomplicated and complicated course of the postoperative period (myocardial ischemia, pulmonary complications). With an uncomplicated postoperative course, 5 periods of patient management are distinguished:
I - early (1-3rd day);
II - ward (4-6th day);
III - small training loads (7-15th day);
IV - average training loads (16-25th day);
V - increased training loads (from the 26th-30th day until discharge from the hospital).
The duration of the periods is different, because the postoperative course often has a number of features that require a change in the nature of physical activity.
4.2 Tasks of exercise therapy
The tasks of exercise therapy for coronary heart disease include:
ѕ contributing to the regulation of the coordinated activity of all parts of the blood circulation;
* development of reserve capabilities of the human cardiovascular system;
* improvement of coronary and peripheral blood circulation;
* improvement of the patient's emotional state;
* increasing and maintaining physical performance;
* secondary prevention of coronary artery disease.
4.3 Methodological features of exercise therapy
The use of physical exercises in cardiovascular diseases allows using all the mechanisms of their therapeutic action: tonic effect, trophic effect, formation of compensation and normalization of functions.
In many diseases of the cardiovascular system, the patient's motor mode is limited. The patient is depressed, “immersed in the disease”, inhibitory processes predominate in the central nervous system. In this case, physical exercises become important for providing a general tonic effect. Improving the functions of all organs and systems under the influence of physical exercise prevents complications, activates the body's defenses and speeds up recovery. The psycho-emotional state of the patient improves, which, of course, also has a positive effect on the processes of sanogenesis. Physical exercise improves trophic processes in the heart and throughout the body. They increase the blood supply to the heart by increasing coronary blood flow, opening reserve capillaries and developing collaterals, and activate metabolism. All this stimulates the recovery processes in the myocardium, increases its contractility. Physical exercise also improves the overall metabolism in the body, lowers cholesterol in the blood, delaying the development of atherosclerosis. A very important mechanism is the formation of compensation. In many diseases of the cardiovascular system, especially in a serious condition of the patient, physical exercises are used that have an effect through extracardiac (extracardiac) circulatory factors. So, exercises for small muscle groups promote the movement of blood through the veins, acting as a muscle pump and causing the expansion of arterioles, reduce peripheral resistance to arterial blood flow. Breathing exercises contribute to the flow of venous blood to the heart due to the rhythmic change in intra-abdominal and intrathoracic pressure. During inhalation, the negative pressure in the chest cavity has a suction effect, and the rising intra-abdominal pressure, as it were, squeezes blood from the abdominal cavity into the chest cavity. During expiration, the movement of venous blood from the lower extremities is facilitated, since intra-abdominal pressure is reduced.
Normalization of functions is achieved by gradual and careful training, which strengthens the myocardium and improves its contractility, restores vascular responses to muscle work and changes in body position. Physical exercise normalizes the function of regulatory systems, their ability to coordinate the work of the cardiovascular, respiratory and other body systems during physical exertion. Thus, the ability to perform more work is increased. Systematic exercise has an impact on blood pressure through many parts of the long-term regulatory systems. So, under the influence of a gradual dosed training, the tone of the vagus nerve and the production of hormones (for example, prostaglandins) that reduce blood pressure increase. As a result, resting heart rate slows down and blood pressure drops.
Special attention should be paid to special exercises, which, having an effect mainly through neuro-reflex mechanisms, reduce blood pressure. So, breathing exercises with lengthening the exhalation and slowing down the breath reduce the heart rate. Exercises in muscle relaxation and for small muscle groups lower the tone of arterioles and reduce peripheral resistance to blood flow. In diseases of the heart and blood vessels, physical exercises improve (normalize) the adaptive processes of the cardiovascular system, which consist in strengthening the energy and regenerative mechanisms that restore functions and disturbed structures. Physical culture is of great importance for the prevention of diseases of the cardiovascular system, as it compensates for the lack of physical activity of a modern person. Physical exercises increase the general adaptive (adaptive) capabilities of the body, its resistance to various stressful influences, giving mental relaxation and improving the emotional state.
Physical training develops physiological functions and motor qualities, increasing mental and physical performance. Activation of the motor mode by various physical exercises improves the functions of systems that regulate blood circulation, improves myocardial contractility and blood circulation, reduces the content of lipids and cholesterol in the blood, increases the activity of the anticoagulant blood system, promotes the development of collateral vessels, reduces hypoxia, i.e., prevents and eliminates manifestations most risk factors for major diseases of the cardiovascular system.
Thus, physical culture is shown to all healthy people not only as a health-improving, but also as a prophylactic. It is especially necessary for those individuals who are currently healthy, but have any risk factors for cardiovascular disease. For people suffering from cardiovascular diseases, physical exercise is the most important rehabilitation tool and a means of secondary prevention.
Indications and contraindications for the use of physiotherapy exercises. Physical exercises as a means of treatment and rehabilitation are indicated for all diseases of the cardiovascular system. Contraindications are only temporary. Therapeutic exercise is contraindicated in the acute stage of the disease (myocarditis, endocarditis, angina pectoris and myocardial infarction during the period of frequent and intense attacks of pain in the heart, severe cardiac arrhythmias), with an increase in heart failure, the addition of severe complications from other organs. With the removal of acute phenomena and the cessation of the increase in heart failure, the improvement of the general condition should begin to exercise.
4.4 Complex of therapeutic exercises
An effective method of preventing coronary artery disease, in addition to rational nutrition, is moderate physical education (walking, jogging, skiing, hiking, cycling, swimming) and hardening of the body. At the same time, you should not get carried away with lifting weights (weights, large dumbbells, etc.) and perform long (more than an hour) runs that cause severe fatigue.
Very useful daily morning exercises, including the following set of exercises:
Exercise 1: Starting position (ip) - standing, hands on the belt. Take your hands to the sides - inhale; hands on the belt - exhale. 4-6 times. Breathing is even.
Exercise 2: I.p. -- Same. Hands up - inhale; bend forward - exhale. 5-7 times. The pace is average (t.s.).
Exercise 3: I.p. - standing, hands in front of the chest. Take your hands to the sides - inhale; return to i.p. - exhale. 4-6 times. The pace is slow (t.m.).
Exercise 4: I.p. - sitting. Bend the right leg - cotton; return to i.p. The same with the other leg. 3-5 times. T.s.
Exercise 5: I.p. - standing by the chair. Sit down - exhale; get up - inhale. 5-7 times. T.m.
Exercise 6: I.p. - Sitting on a chair. Squat in front of a chair; return to i.p. Don't hold your breath. 5-7 times. T.m.
Exercise 7: I.p. - the same, legs straightened, arms forward. Bend your knees, hands on your belt; return to i.p. 4-6 times. T.s.
Exercise 8: I.p. - standing, take your right leg back, arms up - inhale; return to i.p. - exhale. The same with the left leg. 4-6 times. T.m.
Exercise 9: I.p. - standing, hands on the belt. Tilts left and right. 3-5 times. T.m.
Exercise 10: I.p. - standing, hands in front of the chest. Take your hands to the sides - inhale; return to i.p. - exhale. 4-6 times. T.s.
Exercise 11: I.p. - standing. Take your right leg and arm forward. The same with the left leg. 3-5 times. T.s.
Exercise 12: I.p. standing, arms up. sit down; return to i.p. 5-7 times. T.s. Breathing is even.
Exercise 13: I.p. - the same, hands up, brushes "in the castle." Body rotation. 3-5 times. T.m. Don't hold your breath.
Exercise 14: I.p. - standing. Step from the left foot forward - arms up; return to i.p. The same with the right leg. 5-7 times. T.s.
Exercise 15: I.p. - standing, hands in front of the chest. Turns left-right with the breeding of hands. 4-5 times. T.m.
Exercise 16: I.p. - standing, hands to shoulders. Straighten your arms one by one. 6-7 times. T.s.
Exercise 17: Walking in place or around the room - 30 s. Breathing is even.
List of used literature
1. Heart disease and rehabilitation / M. L. Pollock, D. H. Schmidt. -- Kyiv. Olympic Literature, 2000. - 408 p.
2. Ischemic heart disease / A. N. Inkov. - Rostov n / a: Phoenix, 2000. - 96 p.
3. Therapeutic physical culture: a Handbook / V. A. Epifanova. - M.: Medicine, 1987. - 528 p.
4. General physiotherapy. Textbook for medical students / V. M. Bogolyubov, G. N. Ponomarenko. - M.: Medicine, 1999. - 430 p.
5. Polyclinic stage of rehabilitation of patients with myocardial infarction / V. S. Gasilin, N. M. Kulikova. - M.: Medicine, 1984. - 174 p.
6. Prevention of heart disease / N. S. Molchanov. - M.: "Knowledge", 1970. - 95 p.
7. http://www.cardiodoctor.narod.ru/heart.html
8. http://www.diainfo2tip.com/rea/ibs.html
9. http://www.jenessi.net/fizicheskaya_reabilitaciya/47-3.3.- fizicheskaya-reabilitaciya-pri.html
10. http://www.jenessi.net/fizicheskaya_reabilitaciya/49-3.3.2.-metodika-fizicheskojj.html
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With coronary heart disease, conservative treatment methods are not effective enough, therefore it is often necessary to resort to surgery. Surgical intervention is carried out according to certain indications. A suitable variant of surgical treatment is chosen individually, taking into account a number of criteria, the characteristics of the course of the disease and the state of the patient's body.
Indications for surgical treatment
Surgical intervention for coronary artery disease is carried out for the purpose of myocardial revascularization. This means that the operation restores the vascular blood supply to the heart muscle and blood flow through the arteries of the heart, including their branches, when the lumen of the vessels is narrowed by more than 50%.
The main goal of surgery is to eliminate atherosclerotic changes leading to coronary insufficiency. This pathology is a common cause of death (10% of the total population).
If surgical intervention is necessary, the degree of damage to the coronary arteries, the presence of concomitant diseases, and the technical capabilities of the medical institution are taken into account.
The operation is necessary in the presence of the following factors:
- pathology of the carotid artery;
- reduced contractile function of the myocardium;
- acute heart failure;
- atherosclerosis of the coronary arteries;
- multiple lesions of the coronary arteries.
All these pathologies can accompany ischemic heart disease. Surgical intervention is necessary to improve the quality of life, reduce the risk of complications, get rid of some manifestations of the disease or reduce them.
Surgery is not performed in the early stages after myocardial infarction, as well as in case of severe heart failure (stage III, stage II is considered individually).
All operations for IHD are divided into 2 large groups - direct and indirect.
Direct operations for coronary artery disease
The most common and effective methods of direct revascularization. Such an intervention requires long-term rehabilitation, subsequent drug therapy, but in most cases restores blood flow and improves the condition of the heart muscle.
Coronary artery bypass grafting
The technique is microsurgical and involves the use of artificial vessels - shunts. They allow you to restore normal blood flow from the aorta to the coronary arteries. Instead of the affected area of the vessels, the blood will move along the shunt, that is, a new bypass is created.
How the operation goes, you can understand by watching this animated video:
Coronary artery bypass surgery can be performed on a beating or non-working heart. The first technique is more difficult to perform, but reduces the risk of complications and speeds up recovery. During surgery on a non-working heart, a heart-lung machine is used, which will temporarily perform the functions of an organ.
The operation can also be performed endoscopically. In this case, the incisions are made minimal.
Coronary artery bypass grafting can be mammary-coronary, auto-arterial or auto-venous. This division is based on the type of shunts used.
With a successful operation, the prognosis is favorable. This approach has certain attractive advantages:
- restoration of blood flow;
- the ability to replace several affected areas;
- a significant improvement in the quality of life;
- increase in life expectancy;
- cessation of angina attacks;
- reduced risk of myocardial infarction.
Coronary artery bypass grafting is attractive due to the possibility of using several arteries in stenosis at once, which most other methods do not allow. This technique is indicated for patients with a high risk group, that is, with heart failure, diabetes mellitus, over the age of 65 years.
Perhaps the use of coronary artery bypass grafting in a complicated form of coronary heart disease. It implies a reduced left ventricular ejection fraction, left ventricular aneurysm, mitral insufficiency, atrial fibrillation.
The disadvantages of coronary artery bypass grafting include possible complications. During or after surgery, there is a risk of:
- bleeding;
- heart attack;
- thrombosis;
- shunt narrowing;
- wound infection;
- mediastenitis.
Coronary artery bypass grafting does not provide a permanent effect. Shunts typically last 5 years.
This technique is also called the Demikhov-Kolesov operation and is considered the gold standard for coronary bypass surgery. Its main difference lies in the use of the internal mammary artery, which serves as a natural bypass. A bypass for blood flow in this case is created from this artery to the coronary. The connection is made below the site of stenosis.
Access to the heart is provided by a median sternotomy; simultaneously with such manipulations, an autovenous graft is taken.
The main advantages of this operation are as follows:
- mammary artery resistance to atherosclerosis;
- durability of the mammary artery as a bypass (versus a vein);
- the absence of varicose veins and valves in the internal mammary artery;
- reducing the risk of recurrence of angina pectoris, heart attack, heart failure, the need for reoperation;
- improvement of the left ventricle;
- the ability of the mammary artery to increase in diameter.
The main disadvantage of mammary-coronary bypass surgery is the complexity of the technique. Isolation of the internal mammary artery is difficult, in addition, it has a small diameter and a thin wall.
With mammary coronary artery bypass grafting, the possibility of revascularization of several arteries is limited, since there are only 2 internal mammary arteries.
Stenting of the coronary arteries
This technique is called intravascular prosthetics. For the purpose of the operation, a stent is used, which is a metal mesh frame.
The operation is performed through the femoral artery. A puncture is made in it and a special balloon with a stent is inserted through a guide catheter. The balloon expands the stent, and the lumen of the artery is restored. A stent is placed opposite the atherosclerotic plaque.
How the stent is installed is clearly shown in this animated video:
Due to the use of a balloon during the operation, this technique is often called balloon angioplasty. The use of a balloon is optional. Some types of stents expand on their own.
The most modern option is scaffolds. Such walls have a biosoluble coating. The drug is released within a few months. It heals the inner shell of the vessel and prevents its pathological growth.
This technique is attractive with minimal trauma. Other benefits of stenting include:
- the risk of re-stenosis is significantly reduced (especially with drug-eluting stents);
- the body recovers much faster;
- restoration of the normal diameter of the affected artery;
- no general anesthesia required;
- the number of possible complications is minimal.
There are some disadvantages of coronary stenting. They relate to the presence of contraindications to the operation and the complexity of its implementation in the case of calcium deposits in the vessels. The risk of re-stenosis is not completely excluded, so the patient needs to take prophylactic agents.
The use of stenting is not justified in the stable course of coronary heart disease, but is indicated when it progresses or myocardial infarction is suspected.
Autoplasty of the coronary arteries
This technique is relatively young in medicine. It involves the use of the tissues of one's own body. Veins are the source.
This operation is also called autovenous shunting. A portion of the superficial vein is used as a shunt. The source can be a shin or a thigh. The saphenous vein of the leg is the most effective for coronary vessel replacement.
Carrying out such an operation implies the conditions of artificial circulation. After cardiac arrest, a revision of the coronary bed is carried out and a distal anastomosis is applied. Then, cardiac activity is restored and a proximal anastomosis of the shunt with the aorta is performed, while its lateral squeezing is performed.
This technique is attractive because of its low traumatism relative to the stitched ends of the vessels. The wall of the used vein is gradually rebuilt, which ensures the maximum similarity between the graft and the artery.
The disadvantage of the method is that if it is necessary to replace a large portion of the vessel, the lumen of the ends of the insert differs in diameter. Features of the technique of the operation in this case can lead to the occurrence of turbulent blood flows and vascular thrombosis.
Balloon dilatation of the coronary arteries
This method is based on the expansion of a narrowed artery with a special balloon. It is inserted into the desired area using a catheter. There, the balloon is inflated, eliminating the stenosis. This technique is usually used for lesions of 1-2 vessels. If there are more areas of stenosis, then coronary bypass surgery is more appropriate.
The whole procedure takes place under x-ray control. The bottle can be filled multiple times. For the degree of residual stenosis, angiographic control is performed. After the operation, anticoagulants and antiplatelet agents are prescribed without fail to avoid thrombosis in the dilated vessel.
First, coronary angiography is performed in the standard way using an angiographic catheter. For subsequent manipulations, a guide catheter is used, which is necessary for conducting a dilatation catheter.
Balloon angioplasty is the main treatment for advanced coronary heart disease and is effective in 8 out of 10 cases. This operation is especially appropriate when the stenosis occurs in small areas of the artery, and calcium deposits are insignificant.
Surgical intervention does not always allow you to get rid of the stenosis completely. If the vessel has a diameter of more than 3 mm, then in addition to balloon dilatation, coronary stenting can be performed.
Watch the animation of balloon angioplasty with stenting:
In 80% of cases, angina pectoris disappears completely or its attacks appear much less frequently. In almost all patients (more than 90%), exercise tolerance increases. Improves perfusion and contractility of the myocardium.
The main disadvantage of the technique is the risk of occlusion and perforation of the vessel. In this case, urgent coronary artery bypass grafting may be necessary. There is a risk of other complications - acute myocardial infarction, spasm of the coronary artery, ventricular fibrillation.
Anastomosis with gastroepiploic artery
This technique means the need to open the abdominal cavity. The gastroepiploic artery is isolated in adipose tissue and its lateral branches are clipped. The distal part of the artery is cut off and carried into the pericardial cavity to the desired site.
The advantage of this technique lies in the similar biological features of the gastroepiploic and internal mammary arteries.
Today, this technique is less in demand, as it carries the risk of complications associated with additional opening of the abdominal cavity.
At present, this technique is rarely used. The main indication for it is widespread atherosclerosis.
The operation can be performed by an open or closed method. In the first case, endarterectomy is performed from the anterior interventricular branch, which ensures the release of the lateral arteries. The maximum incision is made and the atheromatous intima is removed. A defect is formed, which is closed with a patch from the autovein, and the internal thoracic artery is sewn into it (end to side).
The object of the closed technique is usually the right coronary artery. An incision is made, the plaque is peeled off and removed from the lumen of the vessel. Then a shunt is sewn into this area.
The success of the operation directly depends on the diameter of the coronary artery - the larger it is, the more favorable the prognosis.
The disadvantages of this technique include technical complexity and a high risk of coronary artery thrombosis. Re-occlusion of the vessel is also likely.
Indirect operations for coronary artery disease
Indirect revascularization increases blood flow to the heart muscle. For this, mechanical means and chemicals are used.
The main goal of surgery is to create an additional source of blood supply. With the help of indirect revascularization, blood circulation is restored in small arteries.
Such an operation is performed to stop the transmission of a nerve impulse and relieve arterial spasm. To do this, clip or destroy the nerve fibers in the sympathetic trunk. With the clipping technique, it is possible to restore the patency of the nerve fiber.
A radical technique is the destruction of the nerve fiber by electrical action. In this case, the operation is highly effective, but its results are irreversible.
Modern sympathectomy is an endoscopic technique. It is performed under general anesthesia and is completely safe.
The advantages of such an intervention are in the effect obtained - the removal of vascular spasm, the subsidence of edema, the disappearance of pain.
Sympathectomy is inappropriate for severe heart failure. Among the contraindications are also a number of other diseases.
Cardiopexy
This technique is also called cardiopericardopexy. The pericardium is used as an additional source of blood supply.
During the operation, extrapleural access to the anterior surface of the pericardium is obtained. It is opened, the liquid is sucked out of the cavity and sterile talc is sprayed. This approach is called the Thompson method (modification).
The operation leads to the development of an aseptic inflammatory process on the surface of the heart. As a result, the pericardium and epicardium are closely fused, intracoronary anastomoses open and extracoronary anastomoses develop. This provides additional myocardial revascularization.
There is also omentocardiopexy. An additional source of blood supply in this case is created from a flap of the greater omentum.
Other materials can also serve as a source of blood supply. With pneumocardiopexy, this is the lung, with cardiomyopexy, the pectoral muscle, with diaphragmatic cardiopexy, the diaphragm.
Operation Weinberg
This technique is intermediate between direct and indirect surgical interventions for coronary heart disease.
Improving the blood supply to the myocardium is performed by implanting the internal thoracic artery into it. The bleeding distal end of the vessel is used. It is implanted in the thickness of the myocardium. First, an intramyocardial hematoma is formed, and then anastomoses develop between the internal thoracic artery and the branches of the coronary arteries.
Today, such surgery is often carried out bilaterally. To do this, resort to transsternal access, that is, the mobilization of the internal thoracic artery throughout.
The main disadvantage of this technique is that it does not provide an immediate effect.
Operation Fieschi
This technique allows you to increase the collateral blood supply to the heart, which is necessary for chronic coronary insufficiency. The technique consists in bilateral ligation of the internal thoracic arteries.
Ligation is performed in the area below the pericardial diaphragmatic branch. This approach increases blood flow throughout the artery. This effect is provided by an increase in the discharge of blood into the coronary arteries, which is explained by an increase in pressure in the pericardial-diaphragmatic branches.
Laser revascularization
This technique is considered experimental, but quite common. The patient is made an incision on the chest to bring a special conductor to the heart.
The laser is used to make holes in the myocardium and create channels for blood to enter. Within a few months, these channels are closed, but the effect persists for years.
Thanks to the creation of temporary channels, the formation of a new network of vessels is stimulated. This allows compensating for myocardial perfusion and eliminating ischemia.
Laser revascularization is attractive in that it can be performed in patients with contraindications for coronary artery bypass grafting. Typically, this approach is required for atherosclerotic lesions of small vessels.
Laser technique can be used in combination with coronary artery bypass grafting.
The advantage of laser revascularization is that it is carried out on a beating heart, that is, a heart-lung machine is not required. The laser technique is also attractive due to minimal trauma, low risk of complications and a short recovery period. The use of this technique eliminates the pain impulse.
Rehabilitation after surgical treatment of IHD
After any type of surgery, lifestyle changes are necessary. It is aimed at nutrition, physical activity, rest and work regime, getting rid of bad habits. Such measures are necessary to accelerate rehabilitation, reduce the risk of recurrence of the disease and the development of comorbidities.
Surgery for coronary heart disease is performed according to certain indications. There are several surgical techniques, when choosing the appropriate option, the clinical picture of the disease and the anatomy of the lesion are taken into account. Surgery does not mean the abolition of drug therapy - both methods are used in combination and complement each other.
Chapter 2.0. Physical rehabilitation in atherosclerosis, coronary heart disease and myocardial infarction.2.1 Atherosclerosis.
Atherosclerosis is a chronic pathological process that causes a change in the walls of the arteries as a result of lipid deposition, the subsequent formation of fibrous tissue and the formation of plaques that narrow the lumen of the vessels.
Atherosclerosis is not considered an independent disease, since it is clinically manifested by general and local circulatory disorders, some of which are independent nosological forms (diseases). Atherosclerosis is the deposition of cholesterol and triglycerides in the walls of the arteries. In plasma, they are associated with proteins and are called lipoproteins. There are high density lipoproteins (HDL) and low density lipoproteins (LDL). As a rule, HDL does not contribute to the development of atherosclerosis and related diseases. On the other hand, there is a direct relationship between LDL levels in the blood and the development of diseases such as coronary heart disease and others.
Etiology and pathogenesis. The disease develops slowly, initially asymptomatically, goes through several stages, in which there is a gradual narrowing of the lumen of the vessels.
Causes of atherosclerosis include:
unhealthy diet containing excess fats and carbohydrates and lack of vitamin C;
psycho-emotional stress;
diseases such as diabetes, obesity, decreased thyroid function;
violation of the nervous regulation of blood vessels associated with infectious and allergic diseases;
hypodynamia;
smoking, etc.
With atherosclerosis, the blood circulation of various organs is disturbed, depending on the localization of the process. When the coronary (coronary) arteries of the heart are affected, pains appear in the region of the heart and the function of the heart is disturbed (for more details, see the section "Ischemic heart disease"). Atherosclerosis of the aorta causes pain behind the sternum. Atherosclerosis of the cerebral vessels causes a decrease in efficiency, headaches, heaviness in the head, dizziness, memory impairment, hearing loss. Atherosclerosis of the renal arteries leads to sclerotic changes in the kidneys and to an increase in blood pressure. When the arteries of the lower extremities are affected, pain in the legs occurs when walking (for more details, see the section on obliterating endarteritis).
Sclerotic vessels with reduced elasticity are more easily ruptured (especially with an increase in blood pressure due to hypertension) and bleed. The loss of smoothness of the inner lining of the artery and ulceration of the plaques, combined with bleeding disorders, can cause the formation of a blood clot, which makes the vessel obstructed. Therefore, atherosclerosis can be accompanied by a number of complications: myocardial infarction, cerebral hemorrhage, gangrene of the lower extremities, etc.
Severe complications and lesions caused by atherosclerosis are difficult to treat. Therefore, it is desirable to start treatment as early as possible with the initial manifestations of the disease. Moreover, atherosclerosis usually develops gradually and can be almost asymptomatic for a long time, without causing a deterioration in performance and well-being.
The therapeutic effect of physical exercise, first of all, is manifested in their positive effect on metabolism. Physiotherapy exercises stimulate the activity of the nervous and endocrine systems that regulate all types of metabolism. Animal studies convincingly prove that systematic exercise has a normalizing effect on blood lipids. Numerous observations of patients with atherosclerosis and the elderly also indicate the beneficial effect of various muscle activities. So, with an increase in cholesterol in the blood, a course of physiotherapy exercises often lowers it to normal values. The use of physical exercises that have a special therapeutic effect, for example, improves peripheral circulation, helps to restore motor-visceral connections that have been disturbed due to the disease. As a result, the responses of the cardiovascular system become adequate, the number of perverted reactions decreases. Special physical exercises improve blood circulation in the area or organ, the nutrition of which is impaired due to vascular damage. Systematic exercises develop collateral (roundabout) blood circulation. Under the influence of physical activity, excess weight is normalized.
With the initial signs of atherosclerosis and the presence of risk factors for the prevention of the further development of the disease, it is necessary to eliminate those that can be affected. Therefore, physical exercises, a diet with a decrease in foods rich in fat (cholesterol) and carbohydrates, and smoking cessation are effective.
The main tasks of physiotherapy exercises are: activation of metabolism, improvement of the nervous and endocrine regulation of metabolic processes, increase in the functionality of the cardiovascular and other body systems.
The exercise therapy methodology includes most physical exercises: long walks, gymnastic exercises, swimming, skiing, running, rowing, sports games. Especially useful are physical exercises that are performed in an aerobic mode, when the need of working muscles for oxygen is fully satisfied.
Physical activity is dosed depending on the functional state of the patient. Usually, they initially correspond to the physical loads used for patients assigned to functional class I (see coronary heart disease). Then classes should be continued in the Health group, in a fitness center, in a jogging club or on your own. Such classes are held 3-4 times a week for 1-2 hours. They must continue constantly, since atherosclerosis proceeds as a chronic disease, and physical exercises prevent its further development.
With a pronounced manifestation of atherosclerosis, exercises for all muscle groups are included in the classes of a therapeutic gymnast. Exercises of a general tonic nature alternate with exercises for small muscle groups and respiratory ones. In case of insufficiency of blood circulation of the brain, movements associated with a sharp change in the position of the head (rapid tilts and turns of the torso and head) are limited.
2.2. Ischemic heart disease (CHD).
Cardiac ischemia – acute or chronic damage to the heart muscle due to circulatory failure of the myocardiumdue to pathological processes in the coronary arteries. Clinical forms of IHD: atherosclerotic cardiosclerosis, angina pectoris and myocardial infarction.
IHD among diseases of the cardiovascular system is the most common, accompanied by a large disability and high mortality.
The occurrence of this disease is promoted by risk factors (see section "Atherosclerosis"). The presence of several risk factors at the same time is especially unfavorable. For example, a sedentary lifestyle and smoking increase the possibility of the disease by 2-3 times. Atherosclerotic changes in the coronary arteries of the heart impair blood flow, which causes the growth of connective tissue and a decrease in the amount of muscle, since the latter is very sensitive to lack of nutrition. Partial replacement of the muscle tissue of the heart with connective tissue in the form of scars is called cardiosclerosis. Atherosclerosis of the coronary arteries, atherosclerotic cardiosclerosis reduce the contractile function of the heart, cause rapid fatigue during physical work, shortness of breath, and palpitations. There are pains behind the sternum and in the left half of the chest. The performance goes down.
angina pectoris – a clinical form of ischemic disease in which attacks of sudden chest pain occur due to acute circulatory failure of the heart muscle.
In most cases, angina pectoris is a consequence of atherosclerosis of the coronary arteries. The pains are localized behind the sternum or to the left of it, spread to the left arm, left shoulder blade, neck and are compressive, pressing or burning in nature.
Distinguish exertional angina when attacks of pain occur during physical exertion (walking, climbing stairs, carrying heavy loads), and rest angina, in which an attack occurs without connection with physical effort, for example, during sleep.
Downstream, there are several variants (forms) of angina pectoris: rare angina attacks, stable angina pectoris (attacks under the same conditions), unstable angina pectoris (more frequent attacks that occur at lower stresses than before), pre-infarction state (attacks increase in frequency, intensity and duration, rest angina appears).
In the treatment of angina pectoris, the regulation of the motor regimen is important: it is necessary to avoid physical exertion leading to an attack, with unstable and pre-infarction angina, the regimen is limited up to bed.
The diet should be limited in volume and caloric content of food. Medications are needed to improve coronary circulation and eliminate emotional stress.
Tasks of exercise therapy for angina pectoris: stimulate neurohumoral regulatory mechanisms to restore normal vascular reactions during muscular work and improve the function of the cardiovascular system, activate metabolism (fight against atherosclerotic processes), improve emotional and mental state, ensure adaptation to physical exertion.
In the conditions of inpatient treatment with unstable angina and pre-infarction, therapeutic exercises are started after the cessation of severe attacks on bed rest, with other variants of angina on the ward. A gradual expansion of motor activity and the passage of all subsequent modes are carried out.
The technique of exercise therapy is the same as for myocardial infarction. Transfer from regime to regime is carried out at an earlier date. New initial positions (sitting, standing) are included in the classes immediately, without prior careful adaptation. Walking in the ward mode starts from 30-50 m and is brought up to 200-300 m, in the free mode the walking distance increases to 1-1.5 km. The pace of walking is slow with rest breaks.
At the sanatorium or polyclinic stage of rehabilitation treatment, the motor regimen is prescribed depending on the functional class to which the patient is assigned. Therefore, it is advisable to consider a method for determining the functional class based on the assessment of patients' tolerance to physical activity.
Determination of exercise tolerance (ET) and the functional class of a patient with coronary artery disease.
The study is carried out on a bicycle ergometer in a sitting position under electrocardiographic control. The patient performs 3-5-minute incremental physical activity, starting from 150 kgm/min: stage II - 300 kgm/min, stage III - 450 kgm/min, etc. - before determining the maximum load tolerated by the patient.
When determining TFN, clinical and electrocardiographic criteria for terminating the load are used.
TO clinical criteria include: achievement of submaximal (75-80%) age-related heart rate, an attack of angina pectoris, a decrease in blood pressure by 20-30% or the absence of its increase with increasing load, a significant increase in blood pressure (230-130 mm Hg), an asthma attack, severe shortness of breath, a sharp weakness, refusal of the patient from further testing.
TO electrocardiographic criteria include: a decrease or rise in the ST segment of the electrocardiogram by 1 mm or more, frequent electrosystoles and other disorders of myocardial excitability (paroxysmal tachycardia, atrial fibrillation), impaired atrioventricular or intraventricular conduction, a sharp decrease in R wave values. The test is stopped when at least one of the above signs.
Termination of the test at its very beginning (1st - 2nd minute of the first step of the load) indicates an extremely low functional reserve of the coronary circulation, it is characteristic of patients with functional class IV (150 kgm / min or less). The termination of the test within the range of 300-450 G kgm/min also indicates low reserves of coronary circulation - III functional class. Appearance of criteria for termination of the sample within 600 kgm/min - functional class II, 750 kgm/min and more - functional class I.
In addition to TFN, clinical data are also important in determining the functional class.
TO Ifunctional class include patients with rare angina attacks that occur during excessive physical exertion with a well-compensated state of blood circulation and above the specified TFN.
Co. second functional class include patients with rare attacks of angina pectoris (for example, when climbing uphill, stairs), with shortness of breath when walking fast and TFN 600.
TO IIIfunctional class include patients with frequent attacks of angina pectoris that occur during normal exertion (walking on level ground), circulatory failure of I and II A degrees, cardiac arrhythmias, TFN - 300-450 kgm / min.
TO IVfunctional class include patients with frequent attacks of angina at rest or exertion, with circulatory failure II B degree, TFN - 150 kgm / min or less.
Patients of the IV functional class are not subject to rehabilitation in a sanatorium or clinic, they are shown treatment and rehabilitation in a hospital.
The method of exercise therapy for patients with coronary artery disease at the sanatorium stage.
SickIfunctional class are engaged in the program of the training mode. In physiotherapy exercises, in addition to exercises of moderate intensity, 2-3 short-term loads of high intensity are allowed. Training in dosed walking begins with walking 5 km, the distance gradually increases and is brought up to 8-10 km, at a walking speed of 4-5 km/h. While walking, accelerations are performed, sections of the route may have a rise of 10-15. After the patients master the distance of 10 km well, they can start training by jogging in alternation with walking. If there is a pool, classes are held in the pool, their duration gradually increases from 30 minutes to 45-60 minutes. Outdoor and sports games are also used - volleyball, table tennis, etc.
Heart rate during exercise can reach 140 beats per minute.
Patients of the II functional class are engaged in a program of sparing training regimen. In physiotherapy exercises, loads of moderate intensity are used, although short-term physical loads of high intensity are allowed.
Dosed walking begins with a distance of 3 km and is gradually brought to 5-6 km. Walking speed at first 3 km/h, then 4 km/h. Part of the route may have an elevation of 5-10.
When exercising in the pool, the time spent in the water gradually increases, the duration of the entire lesson is brought to 30-45 minutes.
Skiing is carried out at a slow pace.
The maximum heart rate shifts are up to 130 beats per minute.
Patients of the III functional class are engaged in the sparing program of the sanatorium. Training in dosed walking begins with a distance of 500 m and increases daily by 200-500 m and is gradually brought up to 3 km, at a speed of 2-3 km/h.
When swimming, the breaststroke method is used. Proper breathing is taught with lengthening the exhalation into the water. The duration of the lesson is 30 min. In any form of training, only low-intensity physical activity is used.
The maximum shifts in heart rate during classes are up to 110 beats / min.
It should be noted that the means and methods of physical exercises in sanatoriums can differ significantly due to the peculiarities of the conditions, equipment, and preparedness of the methodologists.
Many sanatoriums now have various simulators, primarily bicycle ergometers, treadmills, on which it is very easy to accurately dose loads with electrocardiographic control. The presence of a reservoir and boats allows you to successfully use dosed rowing. In winter, if you have skis and ski boots, skiing, strictly dosed, is an excellent means of rehabilitation.
Until recently, patients with IHD class IV were practically not prescribed exercise therapy, since it was believed that it could cause complications. However, the success of drug therapy and rehabilitation of patients with coronary artery disease has made it possible to develop a special technique for this severe contingent of patients.
Therapeutic physical culture for patients with coronary artery disease IV functional class.
The tasks of rehabilitation of patients with IHD of the IV functional class are as follows:
to achieve full self-service of patients;
adapt patients to household loads of low and moderate intensity (washing dishes, cooking, walking on level ground, carrying small loads, climbing one floor);
reduce medication;
improve mental state.
The training methodology is as follows. First, an individual TFN is determined. Usually in patients with functional class IV, it does not exceed 200 kgm/min. Set the load level to 50%, i.e. in this case - 100 kgm / min. This load is training, the duration of work at the beginning is 3 minutes. It is carried out under the supervision of an instructor 5 times a week.
With a consistently adequate response to this load, it lengthens by 2-3 minutes and is brought up to 30 minutes in one lesson for a more or less long period.
After 4 weeks, the TFN is re-determined. When it increases, a new 50% level is determined. Duration of training up to 8 weeks. Before training on an exercise bike or after it, the patient is engaged in therapeutic exercises in I.P. sitting. The lesson includes exercises for small and medium muscle groups with the number of repetitions of 10-12 and 4-6 times, respectively. The total number of exercises is 13-14.
Classes on an exercise bike are stopped when one of the signs of deterioration of the coronary circulation, which was mentioned above, occurs.
To consolidate the achieved effect of stationary training, patients are recommended home training in an accessible form.
In persons who have stopped training at home, after 1-2 months, a worsening of the condition is observed.
At the outpatient stage of rehabilitation, the training program for patients with coronary artery disease is very similar to the outpatient training program for patients after myocardial infarction, but with a bolder increase in the volume and intensity of loads.
2.3 Myocardial infarction.
(Myocardial infarction (MI) is an ischemic necrosis of the heart muscle due to coronary insufficiency. In most cases, the leading etiological cause of myocardial infarction is coronary atherosclerosis.
Along with the main factors of acute insufficiency of the coronary circulation (thrombosis, spasm, narrowing of the lumen, atherosclerotic changes in the coronary arteries), a large role in the development of myocardial infarction is played by the insufficiency of collateral circulation in the coronary arteries, prolonged hypoxia, excess catecholamines, lack of potassium ions and excess sodium, which cause long-term cell ischemia.
Myocardial infarction is a polyetiological disease. In its occurrence, an undoubted role is played by risk factors: physical inactivity, excessive nutrition and increased weight, stress, etc.
The size and location of myocardial infarction depend on the caliber and typography of the blocked or narrowed artery.
Distinguish:
A) extensive myocardial infarction- macrofocal, capturing the wall, septum, apex of the heart;
b) small focal infarction, striking parts of the wall;
V) microinfarction, in which the foci of infarction are visible only under a microscope.
With intramural MI, necrosis affects the inner part of the muscle wall, and with transmural MI, the entire thickness of its wall. Necrotic muscle masses are resorbed and replaced by granulation connective tissue, which gradually turns into scar tissue. The resorption of necrotic masses and the formation of scar tissue lasts 1.5-3 months.
The disease usually begins with the appearance of intense pain behind the sternum and in the region of the heart; pains last for hours, and sometimes 1-3 days, subside slowly and turn into a long dull pain. They are compressive, pressing, tearing in nature and are sometimes so intense that they cause shock, accompanied by a drop in blood pressure, a sharp pallor of the face, cold sweat and loss of consciousness. Following pain within half an hour (maximum 1-2 hours), acute cardiovascular failure develops. On the 2-3rd day, there is an increase in temperature, neutrophilic leukocytosis develops, and the erythrocyte sedimentation rate (ESR) increases. Already in the first hours of the development of myocardial infarction, characteristic changes in the electrocardiogram appear, which make it possible to clarify the diagnosis and localization of the infarction.
Drug treatment during this period is directed primarily against pain, to combat cardiovascular insufficiency, as well as to prevent recurrent coronary thrombosis (anticoagulants are used - drugs that reduce blood clotting).
Early motor activation of patients contributes to the development of collateral circulation, has a beneficial effect on the physical and mental state of patients, shortens the period of hospitalization and does not increase the risk of death.
Treatment and rehabilitation of patients with MI is carried out in three stages: inpatient (hospital), sanatorium (or rehabilitation cardiological center) and polyclinic.
2.3.1 Therapeutic exercise for MI at the stationary stage of rehabilitation .
Physical exercises at this stage are of great importance not only for restoring the physical capabilities of patients with MI, but also largely important as a means of psychological impact, instilling in the patient faith in recovery and the ability to return to work and society.
Therefore, the sooner, but taking into account the individual characteristics of the disease, therapeutic exercises will be started, the better the overall effect will be.
Physical rehabilitation at the stationary stage is aimed at achieving such a level of physical activity of the patient, at which he could serve himself, climb one floor up the stairs and take walks up to 2-3 km in 2-3 doses during the day without significant negative reactions. .
The tasks of exercise therapy at the first stage are aimed at:
Prevention of complications associated with bed rest (thromboembolism, congestive pneumonia, intestinal atony, etc.)
Improving the functional state of the cardiovascular system (first of all, training the peripheral circulation with a sparing load on the myocardium);
Creating positive emotions and providing a tonic effect on the body;
Training of orthostatic stability and restoration of simple motor skills.
At the stationary stage of rehabilitation, depending on the severity of the course of the disease, all patients with a heart attack are divided into 4 classes. This division of patients is based on various types of combinations, such main indicators of the course of the disease as the extent and depth of MI, the presence and nature of complications, the severity of coronary insufficiency (see Table 2.1)
Table 2.1.
Classes of severity of patients with myocardial infarction.
The activation of motor activity and the nature of exercise therapy depend on the class of severity of the disease.
The program of physical rehabilitation of patients with MI in the hospital phase is built taking into account the patient's belonging to one of the 4 classes of severity of the condition.
The severity class is determined on the 2-3rd day of illness after the elimination of pain and complications such as cardiogenic shock, pulmonary edema, severe arrhythmias.
This program provides for the assignment to the patient of this or that nature of household loads, the method of practicing therapeutic exercises and the acceptable form of leisure activities.
Depending on the severity of MI, the hospital stage of rehabilitation is carried out within a period of three (for small-focal uncomplicated MI) to six (for extensive, transmural MI) weeks.
Numerous studies have shown that the best treatment results are achieved if therapeutic exercises begin early. Therapeutic exercises are prescribed after the cessation of the pain attack and the elimination of severe complications (heart failure, significant cardiac arrhythmias, etc.) on the 2nd-4th day of illness, when the patient is on bed rest.
On bed rest, in the first lesson in the prone position, active movements are used in the small and medium joints of the limbs, static tension in the muscles of the legs, exercises in muscle relaxation, exercises with the help of an exercise therapy instructor for large joints of the limbs, breathing exercises without deepening breathing, elements of massage (stroking) lower extremities and back with passive turns of the patient to the right side. In the second lesson, active movements are added in the large joints of the limbs. Leg movements are performed alternately, sliding movements along the bed. The patient is taught an economical, effortless turn to the right side and raising the pelvis. After that, it is allowed to independently turn to the right side. All exercises are performed at a slow pace, the number of repetitions of exercises for small muscle groups is 4-6 times, for large muscle groups - 2-4 times. There are rest breaks between exercises. The duration of classes is up to 10-15 minutes.
After 1-2 days, during LH classes, the patient is seated with dangling legs with the help of an exercise therapy instructor or a nurse for 5-10 minutes, it is repeated 1-2 more times during the day.
LH classes are performed in the initial positions lying on the back, on the right side and sitting. The number of exercises for small, medium and large muscle groups is increasing. Leg exercises with lifting them above the bed are performed alternately with the right and left legs. The range of motion gradually increases. Breathing exercises are carried out with deepening and lengthening of the exhalation. The pace of exercise is slow and medium. The duration of the lesson is 15-17 minutes.
The criteria for the adequacy of physical activity is an increase in heart rate at first by 10-12 beats / min., And then up to 15-20 beats / min. If the pulse quickens more, then you need to pause for rest, perform static breathing exercises. An increase in systolic pressure by 20-40 mm Hg is acceptable, and diastolic pressure by 10 mm Hg.
3-4 days after MI with MI severity class 1 and 2 and 5-6 and 7-8 days with MI severity class 3 and 4, the patient is transferred to the ward.
The objectives of this regimen are: prevention of the consequences of hypodynamia, sparing training of the cardiorespiratory wall, preparing the patient for walking along the corridor and everyday activities, climbing stairs.
LH is carried out in the initial positions lying, sitting and standing, the number of exercises for the trunk and legs increases and decreases for small muscle groups. Breathing exercises and muscle relaxation exercises are used to relax after difficult exercises. At the end of the main part of the lesson, the development of walking is carried out. On the first day, the patient is raised with insurance and limited to his adaptation to a vertical position. From the second day they are allowed to walk 5-10 meters, then every day they increase the walking distance by 5-10 meters. In the first part of the lesson, the initial positions are used lying and sitting, in the second part of the lesson - sitting and standing, in the third part of the lesson - sitting. The duration of the lesson is 15-20 minutes.
When the patient masters walking for 20-30 meters, they begin to use a special activity of dosed walking. The dosage of walking is small, but daily increases by 5-10 meters and is brought up to 50 meters.
In addition, patients do UGG, including individual exercises from the LH complex. Patients spend 30-50% of their time sitting and standing.
6-10 days after MI with MI severity class 1, 8-13 days - with MI severity 2, 9-15 days - with MI 3 and individually with MI 4, patients are transferred to a free mode.
The tasks of exercise therapy in this motor mode are as follows: preparing the patient for complete self-service and going for a walk outside, for dosed walking in the training mode.
The following forms of exercise therapy are used: UGG, LH, dosed walking, stair climbing training.
In the classes of therapeutic exercises and morning hygienic gymnastics, active physical exercises are used for all muscle groups. Exercises with light objects (gymnastic stick, maces, ball) are included, which are more difficult in terms of coordination of movements. Just like in the previous mode, breathing exercises and muscle relaxation exercises are used. The number of exercises performed in a standing position is increasing. The duration of the lesson is 20-25 minutes.
Dosed walking, first along the corridor, starts from 50 meters, the pace is 50-60 steps per minute. The walking distance is increased daily so that the patient can walk along the corridor 150-200 meters. Then the patient goes out for a walk on the street. By the end of his stay in the hospital, he should walk 2-3 km per day in 2-3 doses. The pace of walking gradually increases, first 70-80 steps per minute, and then 90-100 steps per minute.
Stair climbing is done very carefully. For the first time, an ascent of 5-6 steps is made with a rest on each. During rest, inhale, while lifting - exhale. In the second lesson, during exhalation, the patient passes 2 steps, while inhaling, he rests. In subsequent classes, they switch to normal walking up the stairs with rest after passing the flight of stairs. By the end of the regimen, the patient masters the rise to one floor.
The adequacy of physical activity to the capabilities of the patient is controlled by the response of the heart rate. On bed rest, the increase in heart rate should not exceed 10-12 beats / min, and on the ward and free heart rate should not exceed 100 beats / min.
2.3.2 Therapeutic exercise for MI at the sanatorium stage of rehabilitation.
The tasks of exercise therapy at this stage are: the restoration of the physical performance of patients, the psychological readaptation of patients, the preparation of patients for independent living and production activities.
Physical therapy classes begin with a sparing regimen, which largely repeats the free regimen program in the hospital and lasts 1-2 days if the patient completed it in the hospital. In the case when the patient did not complete this program in the hospital or a lot of time passed after discharge from the hospital, this regimen lasts 5-7 days.
Forms of exercise therapy on a sparing regimen: UGG, LH, training walking, walking, training in climbing stairs. The technique of LH differs little from the technique used in the free mode of the hospital. In the classroom, the number of exercises and the number of their repetitions gradually increase. The duration of LH classes increases from 20 to 40 minutes. The LH lesson includes simple and complicated walking (on socks with high knees), various throwing. Training walking is carried out along a specially equipped route, starting from 500 m with a rest (3-5 minutes) in the middle, the pace of walking is 70-90 steps per minute. The walking distance increases daily by 100-200 m and is brought up to 1 km.
Walks start at 2 km and go up to 4 km at a very calm, accessible pace of steps. Daily training is held in climbing stairs, and climbing 2 floors is mastered.
When mastering this program, the patient is transferred to a sparing training mode. Forms of exercise therapy are expanding by including games, lengthening the training walk up to 2 km per day and increasing the pace to 100-110 steps / min. Walking is 4-6 km per day and its pace increases from 60-70 to 80-90 steps / min. Climbing stairs to 2-3 floors.
A variety of exercises without objects and with objects, as well as exercises on gymnastic apparatus and short-term running, are used in the LH classes.
Only patients of I and II severity classes of MI are transferred to the training regimen of exercise therapy. In this mode, in the LH classes, the difficulty of performing exercises increases (the use of weights, exercises with resistance, etc.), the number of repetitions of exercises and the duration of the entire lesson increases to 35-45 minutes. The training effect is achieved by performing long-term work of moderate intensity. Training walking 2-3 km at a pace of 110-120 steps / min, walking 7-10 km per day, climbing stairs 4-5 floors.
The program of exercise therapy in the sanatorium largely depends on its conditions and equipment. Now many sanatoriums are well equipped with simulators: bicycle ergometers, treadmills, various power simulators that allow you to monitor heart rate (ECG, blood pressure) during physical activity. In addition, it is possible to use skiing in winter and rowing in summer.
You should only focus on the allowable shifts in heart rate: in a sparing mode, the peak heart rate is 100-110 beats / min; duration 2-3 min. on a gentle training peak, heart rate is 110-110 beats / min, the duration of the peak is up to 3-6 minutes. 4-6 times a day; in the training mode, the peak heart rate is 110-120 beats / min, the duration of the peak is 3-6 minutes 4-6 times a day.
2.3.3 Therapeutic exercise for MI at the outpatient stage.
Patients who have undergone myocardial infarction, at the outpatient stage, are persons suffering from chronic coronary artery disease with postinfarction cardiosclerosis. The tasks of the exercise therapy at this stage are as follows:
Restoration of the function of the cardiovascular system by switching on the mechanisms of compensation of the cardiac and extracardiac nature;
Increasing tolerance to physical activity;
Secondary prevention of coronary artery disease;
Restoration of ability to work and return to professional work, preservation of restored ability to work;
Possibility of partial or complete refusal of medicines;
Improving the quality of life of the patient.
At the outpatient stage, rehabilitation by a number of authors is divided into 3 periods: sparing, sparing-training and training. Some add a fourth - supportive.
The best form is long training loads. They are contraindicated only in case of: left ventricular aneurysm, frequent attacks of angina pectoris of low effort and rest, serious cardiac arrhythmias (atrial fibrillation, frequent polytopic or group extrasystole, paroxysmal tachycardia, arterial hypertension with stably elevated diastolic pressure (above 110 mm Hg. ), tendencies to thromboembolic complications.
With myocardial infarction, long-term physical activity is allowed to start 3-4 months after MI.
According to functional capabilities, determined using bicycle ergometry, spiroergometry or clinical data, patients belong to functional classes 1-P - "strong group", or to functional class III - "weak" group. If classes (group, individual) are conducted under the supervision of an exercise therapy instructor, medical personnel, then they are called controlled or partially controlled, conducted at home according to an individual plan.
Good results of physical rehabilitation after myocardial infarction at the outpatient stage are given by the technique developed by L.F. Nikolaev, YES. Aronov and N.A. White. The course of long-term controlled training is divided into 2 periods: preparatory, lasting 2-2.5 months and main, lasting 9-10 months. The latter is subdivided into 3 sub-periods.
In the preparatory period, classes are held by the group method in the hall 3 times a week for 30-60 minutes. The optimal number of patients in the group is 12-15 people. In the process of training, the methodologist should monitor the condition of the trainees: by external signs of fatigue, by subjective sensations, heart rate, respiratory rate, etc.
With positive reactions to the load of the preparatory period, patients are transferred to the main period, lasting 9-10 months. It consists of 3 stages.
The first stage of the main period lasts 2-2.5 months. The lessons at this stage include:
1. Exercises in the training mode with the number of repetitions of individual exercises 6-8 times, performed at an average pace.
2. Complicated walking (on toes, heels, on the inside and outside of the foot for 15-20 s).
3. Dosed walking at an average pace in the introductory and final parts of the lesson; at a fast pace (120 steps per minute), twice in the main part (4 min).
4. Dosed running at a pace of 120-130 steps per minute. (1 min.) or complicated walking (“ski step”, walking with high knees for 1 min.).
5. Training on a bicycle ergometer with physical load dosing in time (5-10 minutes) and power (75% of the individual threshold power). In the absence of a bicycle ergometer, you can assign an ascent to a step of the same duration.
6. Elements of sports games.
Heart rate during exercise can be 55-60% of the threshold in patients with functional class III ("weak group") and 65-70% in patients with functional class I ("strong group"). At the same time, the "peak" heart rate can reach 135 beats/min., with fluctuations from 120 to 155 beats/min.,
During classes, the heart rate of the "plateau" type can reach 100-105 per minute in the "weak" and 105-110 - in the "strong" subgroups. The duration of the load on this pulse is 7-10 minutes.
At the second stage, lasting 5 months, the training program becomes more complicated, the severity and duration of the loads increase. Dosed running is used at a slow and medium pace (up to 3 minutes), work on a bicycle ergometer (up to 10 minutes) with a power of up to 90% of the individual threshold level, playing volleyball over a net (8-12 minutes) with a ban on jumping and a one-minute rest after every 4 min.
Heart rate during "plateau" type loads reaches 75% of the threshold in the "weak" group and 85% in the "strong" group. "Peak" heart rate reaches 130-140 beats / min.
The role of LH decreases and the value of cyclic exercises and games increases.
At the third stage, lasting 3 months, the intensification of loads occurs not so much due to an increase in "peak" loads, but due to the lengthening of physical loads of the "plateau" type (up to 15-20 minutes). Heart rate at the peak of the load reaches 135 beats / min in the "weak" and 145 - in the "strong" subgroups; the increase in heart rate in this case is more than 90% in relation to the resting heart rate and 95-100% in relation to the threshold heart rate.
Control questions and tasks
1. Give an idea about atherosclerosis and its factors
callers.
2. Diseases and complications in atherosclerosis.
3. Mechanisms of the therapeutic effect of physical exercises in
atherosclerosis.
4. Methods of physical exercises during
early stages of atherosclerosis.
5. Define coronary artery disease and the factors that cause it.
Name its clinical forms.
6. What is angina pectoris and its types, course options
angina?
7. Tasks and methods of exercise therapy for angina on stationary and
outpatient stages?
8. Determination of exercise tolerance and
functional class of the patient. Characteristics of functional
classes?
9. Physical rehabilitation of patients with IHD IV functional
class?
10. The concept of myocardial infarction, its etiology and pathogenesis.
11. Types and classes of severity of myocardial infarctions.
12. Describe the clinical picture of myocardial infarction.
13. Tasks and methods of physical rehabilitation in MI on
stationary stage.
14. Tasks and methods of physical rehabilitation in case of myocardial infarction
sanatorium stage.
15. Tasks and methods of physical rehabilitation in case of myocardial infarction
outpatient stage.
