The effect of a program of combined aerobic physical exercise with exercises of localized muscular resistance in the improvement of systemic and local circulation: a case study

Abstracts

INTRODUÇÃO: A trombofilia, estado que predispõe à ocorrência de trombose, decorre da existência de alterações da hemostasia, podendo ser congênita ou adquirida. A deficiência de proteína S, que ocorre pela falta do co-fator para a proteína C, é uma alteração congênita que pode resultar em trombofilia. A reabilitação física, considerada uma terapêutica eficaz, tem seu papel definido na prevenção e tratamento de doenças cardiovasculares. OBJETIVO: Este estudo se propôs a verificar a influência do exercício físico aeróbio associado aos exercícios de resistência muscular localizada na circulação sistêmica e colateral do membro superior e inferior direito e na redução das conseqüências causadas pelas retrações decorrentes das cirurgias. MATERIAL E MÉTODO: A amostra foi composta por uma paciente do sexo feminino, 19 anos, portadora da síndrome de hipercoagulabilidade (trombofilia) congênita por deficiência da proteína S, com obstrução total na artéria axilar direita e parcial na artéria femoral superficial direita. O programa de exercícios foi dividido em duas fases. Fase I: Atividades para aumento da amplitude de movimentos, em que se realizavam aplicação de calor, alongamentos passivos manuais mantidos, drenagem linfática e manipulações Effleurage. Fase II: Constituída de exercício aeróbio (45 minutos de caminhada, três vezes por semana, intensidade de 60% a 85% da freqüência cardíaca máxima) e exercícios de resistência muscular localizada (contrações dinâmicas, três séries com o máximo de repetições possíveis, baixa intensidade, favorecendo fatores aeróbios). RESULTADOS: 1. Melhora da circulação colateral à artéria axilar, constatada pelo aumento na velocidade de pulso sistólico (verificado através do exame doppler pulsado) - na artéria radial, passou de 3,4cm/s para 16,8cm/s; na artéria braquial, de 8,7cm/s para 45,9cm/s. 2. Melhor tolerância ao exercício aeróbio. 3. Recuperação da capacidade funcional e amplitude de movimento do ombro. 4. Recuperação plena da autonomia para as atividades diárias. CONCLUSÕES: Os resultados obtidos demonstraram que a terapêutica adotada foi eficaz no tratamento dos transtornos provocados pela trombofilia.

Programa de reabilitação; Circulação colateral e sistêmica; Trombose; Exercícios físicos

CASE REPORT

The effect of a program of combined aerobic physical exercise with exercises of localized muscular resistance in the improvement of systemic and local circulation: a case study

El efecto de un programa de ejercício físico aeróbico combinado con los ejercicios de resistencia muscular localizada en la mejora de la circulacion sistemica y local. Estudio de un caso

Ricardo Bosco^I; Amanda Demarchi^I; Fabiana Pereira Vecchio Rebelo^III; Tales de Carvalho^{II, III}

^IAcadêmicos do curso de fisioterapia da Universidade do Estado de Santa Catarina - CEFID/UDESC

^IIProfessor da Universidade do Estado de Santa Catarina - CEFID/UDESC

^IIIClínica CARDIOSPORT de Prevenção e Reabilitação Cardíaca – Florianópolis

^{Correspondence}

ABSTRACT

INTRODUCTION: Thrombophilia, elapses the existence of alterations of the hemostasis, being congenital or to be acquired. The protein S deficiency, occurs for the lack of the cofactor for protein C, is a congenital alteration that can result in thrombophilia. Physical rehabilitation, an efficient therapeutic option, has its paper defined in the prevention and treatment of cardiovascular illnesses.

OBJECTIVE: This study aimed to verify the influence of the associated aerobic physical exercise to the exercises of muscular resistance in the systemic and collateral circulation of the right upper/lower member and in the reduction of the consequences caused for the decurrent retractions of the surgeries.

MATERIAL AND METHOD: The sample, composed by a patient of the feminine sex, 19 years, carrier of the syndrome of congenital thrombophilia because of protein S deficiency, with total obstruction of the right axillary artery and partial obstruction of the right superficial femoral artery. The program of exercises were divided in two phases. Phase I: Activities for increase of the amplitude of movements, became fulfilled kept application of heat, manual passive stretching, lymphatic draining and Effleurage manipulations. Phase II: Constituted of aerobic exercise (45 minutes of walked, 3 times per week, intensity of 60% 85% of the maximum cardiac frequency), and exercises of located muscular resistance (dynamic contractions, three series with the maximum of possible repetitions, low intensity, favoring aerobic factors).

RESULT: 1. Improvement of the collateral circulation to the axillary artery, evidenced for the increase in the speed of systolic pulse (verified by pulsed Doppler examination) – in the radial artery passed of 3.4 cm/s for 16.8 cm/s; in the brachial artery, of 8.7 cm/s for 45.9 cm/s. 2. Better tolerance to the aerobic exercise. 3. Recovery of the functional capacity and amplitude of movement of shoulder. 4. Full recovery of the autonomy for the daily activities.

CONCLUSIONS: The gotten results had demonstrated that the adopted therapy was efficient in the treatment of thrombophilia consequences.

Key words: Rehabilitation program. Systemic and collateral circulation. Thrombosis. Physical exercises.

RESUMEN

INTRODUCIÓN: La trombofilia resulta de la existencia de alteraciones de la hemóstasis, pudiendo ser congénita o adquirida. La deficiencia de proteína S ocurre por la falta del cofactor para la proteína C, y una alteración congénita que puede resultar en trombofilia. La reabilitación física, considerada una terapéutica eficaz, tiene su papel definido en la prevención y el tratamiento de enfermedades cardiovasculares.

OBJETIVO: En este estudio se propuso verificar la influencia del ejercicio físico aeróbico asociado a los ejercicios de resistencia muscular localizada en la circulación sistémica y colateral del miembro superior e inferior derecho y en la redución de las consecuencias causadas por las retraciones resultantes de las cirugias.

MATERIAL Y MÉTODO: La muestra fué compuesta por una paciente de sexo femenino, de 19 años, portadora del síndrome de hipercoagulabilidad (trombofilia) congénita por deficiencia de proteína S, con obstrucción total de la arteria axilar derecha y parcial de la arteria femoral superficial derecha. El programa de ejercicios fué dividido en dos fases. Fase I: Actividades para el aumento de la amplitud de movimientos, realizada mediante la aplicación de calor, elongamientos pasivos manuales mantenidos, drenage linfático y manipulaciones Effleurage. Fase II: Constituída de ejercicio aeróbico (45 minutos de caminata, 3 veces por semana, intensidad de 60% a 85% de la frecuencia cardíaca máxima), y ejercicios de resistencia muscular localizada (contraciones dinámicas, tres series con el máximo de repeticiones posibles, baja intensidad, favoreciendo factores aeróbicos).

RESULTADOS: 1. Mejora de la circulación colateral de la arteria axilar, constatada por el aumento de la velocidad de pulso sistólico (verificado a través del examen doppler pulsado) - en la arteria radial paso de 3,4 cm/s a 16,8 cm/s; en la arteria braquial, de 8,7cm/s a 45,9 cm/s. 2. Mejor tolerancia al ejercicio aeróbico. 3. Recuperación de la capacidad funcional y amplitud del movimiento del hombro. 4. Recuperación plena de la autonomía para las actividades diárias.

CONCLUSIONES: Los resultados obtenidos demostraron que la terapéutica adoptada fué eficaz en el tratamiento de los transtornos provocados por la trombofilia.

Palabras clave: Programa de rehabilitación. Circulación colateral y sistémica. Trombosis. Ejercicios físicos.

INTRODUCTION

Thrombophilia is a condition that predisposes the occurrence of thrombosis as a result of the existence of hemostasia alterations¹. The alterations may be either congenital, being established by genetic modifications, inherited by the family members, or situations to be acquired, modifying the hemostasia equilibrium². The inherited thrombophilic disorders, such as the resistance to the activated protein C (factor V Leiden), the lack of protein C, protein S and antithrombin III, are abnormalities related to the quality of activated factors³. The protein S deficiency mechanism is the lack of the cofactor for protein C, where there is no inactivation of the factors Va and VIIIa, as for the deficiency of the protein C². The deficiency of the protein S represents 5-6% of the cases of hereditary thrombophilia³.

The cardiovascular rehabilitation has been currently widely employed and supported by the medical and scientific community. Once physical exercises play a well-defined role on the primary and secondary prevention not only of cardiovascular illness but of other illnesses as well, in other words, the prescription of physical exercises is a therapeutics^4-7.

The movement amplitude gain is administered in order to provide mobility and flexibility to the soft tissues around the articulation (muscles, connective tissue and skin)⁹, as well as to revert the existing contractive status, giving back to the articulation its regular movement amplitude^9,10.

The physical exercise has beneficial effects that seem to result from complex interactions of psychological and physiological effects. Furthermore, it is worthy emphasizing the stress reduction, the improvement of the cardiorespiratory function, the removal of factors such as the smoking habit and the alimentary reeducation^5,7,11.

The improvement of the systemic circulation occurs, among other factors, since exercise contributes for the hematocrit reduction (as plasma volume is increased) and causes increase on the erythrocyte plasticity, furthering an increase on the blood flow and a better distribution of the oxygen on the cell-capillary interface¹². However, both anatomical and physiological significant modifications of the cardiovascular system may yet occur with improvement of the oxygen transport, extraction and utilization systems¹³.

Studies demonstrate that the exercises of localized muscular resistance may contribute for the increase of the collateral blood circulation^14-17. However, the theory that regular exercises further the development of the collateral arteries in human beings requires a more conclusive evidence¹³. Studies in animals that had their coronaries arteries artificially blocked submitted to controlled regular exercises, demonstrated that the coronary vascularization had improved¹⁵, what led to the conclusion that the moderate and severe arterial narrowing result in the development of collateral arteries proportionally to the obstruction degree¹⁴.

The aim of this study was to verify the influence of the physical exercise combined with exercises of localized muscular resistance on the improvement of the systemic and local circulation in a female patient, with deficiency of protein S with total thromboembolic obstruction in the right axillary artery and partial obstruction in the right superficial femoral artery.

MATERIAL AND METHODS

This research deals about a singular case study of a patient, carrier of congenital thrombophilia for deficiency of protein S; white, female, 19 years of age, from the city of Florianópolis, previously submitted to three angioplasties at the right axillary artery, with re-thrombosis occurrence with one-centimeter total obstruction at the right axillary artery and partial obstruction at the right superficial femoral artery.

The time elapsed between surgeries and the beginning of the physical rehabilitation was of seven days, where the patient performed clinical treatment with anticoagulating sodic heparin (application of 12/12 hours, daily dosage of 15,000 U, subcutaneous way) during the seven first days of rehabilitation. Oral anticoagulating coumarins derivate (warfarin) with folic acid was progressively administered and maintained until the end of the therapeutics.

Data were obtained through interviews, method used when one intends to complement data extracted from other sources or when there are no safe sources for the attainment of the desired information. Other facilities for obtaining data were the measuring the cardiac frequency at the moment of limping of the right lower member and the distance elapsed in a 30-minutes period.

The performance of the colored arterial Doppler Echo complementary examination of the right upper member in order to verify the fluxometry in color, the peak systolic velocity, the peak diastolic velocity and the presence of stenosis in both the pre and post therapeutics, is required in order to verify the treatment efficiency, being a non-invasive and quite effective intervention.

The materials used during the therapeutics were: mattresses, towels, elastic materials for the resistance exercises, label Mercur, model Thera-band, cardiac frequency monitor label Polar model A1, stethoscope, sphygmomanometer label Glicomed model Premium and chronometer label Casio.

Rehabilitation program

The rehabilitation program was performed during 15 weeks, with three weekly sessions, being divided in two phases:

1. Activities in order to increase the movement amplitude – This phase lasted four weeks and occurred due to the patient had been submitted to three angioplasties (two of them with incision in the right ulnar cavity and one at the axillary region) what made the shoulder and elbow articulations of the right upper member to be contractive due to scar adhesions, what resulted in limitations in the articular mobility.

In this phase, the session was initiated by a previous application of heat on the area surrounding the articulations to be elongated, once the heating of the soft tissue and muscles before elongation increases the extensibility of the shortened tissue^8,10,18. Following, a manual passive elongation was performed in which the therapist applies an extreme power and controls direction, velocity, intensity and duration of the elongation (four repetitions of 30 seconds on average)¹⁷.

For the application of the elongation techniques, the movement functional and anatomical levels were considered, being the shoulder emphasized regarding flexion, hyperextension, abduction, external and internal rotation and horizontal abduction, extension, supination and pronation for the elbow^10,19.

As the elongation was carried out, the lymphatic drainage of the member was performed for the solution of the lymphedema as well as the Effleurage manipulations through the slow smoothing out movement, performed with progressive pressure, towards the venous and lymphatic flow, for the pain releif²⁰.

2. Anaerobic exercises and exercises of localized muscular resistance – This phase lasted 11 weeks and attempted to verify whether such therapeutic modality would further a better blood flow in the effected members through the improvement of the collateral circulation to the right axillary artery. In this phase, the session was composed of two periods:

2.1. Aerobic exercise

The aerobic exercise was performed three times per week with 45-minutes duration each period in which the 7 first minutes applied to the warming up, 3 minutes applied to elongate the main muscular groups in order to reduce the probability of injuring a muscle or conjunctive tissue; 4 minutes of low intensity walking recommended to increase the muscular temperature and to accelerate the blood flow^4,21.

The aerobic training was performed for 30 minutes with the target cardiac frequency established between 60% and 85% from the maximal cardiac frequency observed in a conventional effort test^11,22-24. Within these values, it was attempted to maintain the patient in activity, even though before the limping symptoms/signals and the discomfort in the right lower member, in the attempt to improve the collateral circulation of the superficial femoral artery^23,25.

The slowing down exercises (cooling) were performed for 8 minutes as follows: 5 minutes of low intensity walking, used in order to prevent blood stagnation at extremities, especially at legs; 3 minutes of static elongation in order to prevent the appearance of muscular lesions^4,5,21.

2.2. Exercises of localized muscular resistance

The exercises of localized muscular resistance were performed shortly after the aerobic exercise⁵ and were composed of dynamic contractions performed in three series with the maximal possible repetitions, with or without low resistance, low intensity and long duration, where the aerobic factor was preponderant, once those exercises did not aim at the muscular hypertrophy, but rather the increase on the local blood flow and the vascular improvement or neo-formation^5,17.

In the resistance exercises program, the anatomical, kinetics and functional features of the upper member as well as the functional limitation imposed by the problem were taken into consideration^10,19. The techniques used were: shoulder horizontal abduction, internal and external rotation, elbow flexion and extension, wrist flexion and fingers and thumb flexion and extension^8,19.

At the end of this period, elongations were performed as well as muscular relaxation through massage, avoiding muscular lesions and blood stagnation^4,5.

It is worthy emphasizing that at the beginning and at the end of each session, the diastolic and systolic arterial pressure, the cardiac frequency, the respiratory frequency and the presence of right and left radial pulse were measured.

RESULTS AND DISCUSSION

The return to the productive life was one of the therapy results applied to the patient. Significant data were reported, such as the simple act of pulling the blanket at night with the right upper member, the school activities (writing and carrying the books), the hygiene habits, the act of eating and the act of changing clothes, impracticable at the beginning of the therapy, progressively started being performed and at the end of treatment, limitations were not found (table 1). The rehabilitation enabled an improvement of the life quality through the evolution in the functional capacity furthering higher independence in the daily life activities^5,11,19.

Aerobic exercises

The graphic 1 shows the progressive increase of the distance elapsed during the 30-minutes aerobic training, which at the beginning of the treatment was of 2,400 meters and, at the end, 4,000 meters, an increase of 66.6% in relation to the initial distance.

In graphic 2, one may observe that the cardiac frequency the patient presented at the moment of limping increased from 108 at the beginning of the therapy up to 146 beatings per minute at the end of treatment, showing an increase on the intensity in order to lead the patient to limping. It is worthy emphasizing that during the 30-minutes aerobic training (walking), the patient was led to limp the right lower member twice.

It is interesting observing that the evolution of the distance elapsed is coincident with the increase on the cardiac frequency that elevates limping, what corroborates that the tolerance to the aerobic training has improved; recent studies have demonstrated that walking may increase significantly the distance elapsed (150%)²⁶ or to generate an increase of 122% on the distance²⁴, in individuals who feel limping in the lower members by arterial obstructions. This increase on the walking capacity is associated with significant changes on distance and velocity¹¹, or with the functioning of the member free of pain^11,24; such evolution is related to the regression of the partial obstruction of the superficial femoral artery^27,28, and to the improvement of the collateral circulation^14,16,24.

Exercises of localized muscular resistance

The table 2 shows the muscular groups trained, the number of repetitions and the load during the 2^nd phase of the employed treatment. One may observe that at the beginning of the therapy, the right upper member showed cyanotic and cold, and it became necessary to cover it with a cotton band in the attempt of maintaining it at a given temperature. As the treatment was carried out, the cotton band had been put away once the member improved its color and temperature, being with normal appearance from the ninth week of treatment. Researches verify that exercises mostly aerobical improve the blood circulation of the member to be exercised^11,17, as well as the skeletal muscle metabolism, enabling the oxygen utilization²⁹.

The figures 1 and 2 illustrate the pre- and post-therapy pulse velocity (verified through pulsed Doppler). One may observe that the improvement on the systolic pulse velocity was significant. The pulse velocity in the right brachial artery, which was of 8.7 cm/s before therapy (figure 1B), increased up to 45.9 cm/s at the end of the treatment (figure 2B), showing an increase of 427.9%. The same effect occurred to the pulse velocity of the right radial artery, which increased from 3.4 cm/s (figure 1A) to 16.8 cm/s (figure 2A) of systolic pulse, what evidences an improvement of 394.12%. This increase on the systolic pulse velocity may occur due to a favorable potential of the fibrinolytic activity due to training with aerobic predominance^14,27,28, associated to a change on the blood flow of the collateral circulation^11,16, or to a vasodilatation as result of the treatment¹⁴. Thus, it is verified that the employed treatment does not seem to be worse than interventionist therapeutic procedures employed to similar cases⁷.

CONCLUSION

Through the therapy employed, a significant improvement of the patient's life quality was observed with return to the productive life and higher independence in the daily activities such as the act of writing and the hygiene habits.

It was also verified a remarkable reduction on the limitation caused by the circulatory dysfunction, verified by the increase on the limping threshold of the right lower member, in other words, higher tolerance to the aerobic exercise and by the increase on the velocity of the systolic pulse in the brachial and radial artery of the right upper member.

This study suggests that the treatment established for this patient may be considered for similar cases; such procedures could yet reduce some cardiovascular risk factors as well as the symptoms of the own disease.

All the authors declared there is not any potential conflict of interests regarding this article.

REFERENCES

Received in 12/1/04

Approved in 21/1/04

• 1. Lourenço DM. Trombofilia. In: Pitta GBB, Castro AA, Buriham E, editores. Angioplastia e cirurgia vascular: guia ilustrado. Maceió: UNCISAL/ECMAL, 2000;1-9.
• 2. Orúe MT. Thrombophilia and stroke. Anales Sis San Navarra 2000;23:39-46.
• 3. Hambleton J, Leung L, Levi M. Coagulation: consultative hemostasis. American Society of Hematology 2002;335-53.
• 4. American College of Sports Medicine. Exercise for patients with coronary artery disease. Med Sci Sports Exerc 1994;26:i-v.
• 5. Benetti M, Nahas M. Alterações na qualidade de vida em coronariopatas acometidos de infarto agudo do miocárdio, submetidos a diferentes tipos de tratamentos. Rev Bras Atividade Física e Saúde 2000;6:27-33.
• 6. Stadler E, Leite N. Reabilitação cardiovascular, custo-benefício. Rev Bras Med Esporte 2000;6:96-106.
• 7. Carvalho T. Reabilitação cardíaca em portadores de cardiopatia isquêmica com obstruções coronárias passíveis de tratamento intervencionista. São Paulo, 2001. Tese (doutorado) - faculdade de medicina, Universidade de São Paulo.
• 8. Kisner C, Colby L. Exercícios terapêuticos, fundamentos e técnicas. São Paulo: Manole, 1998;25-54.
• 9. Regenga M. Fisioterapia em cardiologia da UTI à reabilitação. São Paulo: Roca, 2000;248-60.
• 10. Bath P, Less K. A B C of arterial and venous disease. Acute stroke. BMJ 2000;320:920-4.
• 11. Silva DK, Nahas MV. Prescrição de exercícios físicos para pessoas com doença vascular periférica. Rev Bras Cien Mov 2002;10:55-61.
• 12. Foss M, Keteyian S. Bases fisiológicas do exercício e do esporte. 6^a ed., Rio de Janeiro: Guanabara Koogan, 2000;178-94.
• 13. Froelicher V, Myers J. Exercício e o coração. 3^a ed., Rio de Janeiro: Revinter, 1999;361-73.
• 14. Hambrecht R, Wolf A. Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med 2000;342:454-61.
• 15. Froelicher V, Jensen D. Cardiac rehabilitation: evidence for improvement in myocardial perfusion and function. Arch Phys Med Rehabil 1980; 61:517-22.
• 16. Eckstein RW. Effect of exercise and coronary artery narrowing on coronary collateral circulation. Circ Res 1957;5:230.
• 17. Bruton A. Muscle plasticity: response to training detraining. Physiotherapy 2002;88:398-409.
• 18. Pickering J. Tratamento das doenças vasculares periféricas. In: Downie P. Fisioterapia nas enfermidades cardíacas, torácicas e vasculares. 3^a ed., São Paulo: Panamericana, 1987;335-44.
• 19. Matheson LM, Isernhagen SJ, Hart DL. Relationships among lifting ability, grip force, and return to work. Phys Ther 2002;82:249-56.
• 20. Domenico G, Wood E. Técnicas de massagem de Beard. 4^a ed., São Paulo: Manole, 1998;55-71.
• 21. American College of Sports Medicine. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exerc 1990;22:265-74.
• 22. Benetti M. Condicionamento físico aplicado a doenças cardiovasculares. Rev Bras Med Esporte 1997;3:22-6.
• 23. Hiatt WR, Wolfel EE, Meier RH, Regensteiner JG. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease: implications for mechanism of training response. Circulation 1994;90:1866-74.
• 24. Thompson PD, Buchner D, Pina IL, Balady GJ, Willians MA, Marcus BH, et al. Exercise and physical activity in prevention and treatment of atherosclerotic cardiovascular disease. Arterioscler Thromb Vasc Biol 2003;23:E42-51.
• 25. McDermott MM, Greenland P, Liu K, Guralnik JM, Celic L, Criqui M, et al. The ankle brachial index is associated with leg function and physical activity: the walking and leg circulation study. Ann Intern Med 2002; 136:873-83.
• 26. Burns P, Gough S, Bradbury A. Management of peripheral arterial disease in primary care. BMJ 2003;326:584-9.
• 27. Lakka T, Laukkanen J, Rauramaa R. Cardiorespiratory fitness and progression of carotid atherosclerosis in middle-aged men. Ann Intern Med 2001;134:12-20.
• 28. Chandler WL, Schwartz RS, Stratton IR, Vitiello MV. Effects of endurance training on the circadian rhythm of fibrinolysis in mem and women. Med Sci Sports Exerc 1996;28:647-58.
• 29. Jen C, Chan H, Chen H. Chronic exercise improves endothelial calcium signaling and vasodilatation in hypercholesterolemic rabbit femoral artery. Arterioscler Thromb Vasc Biol 2002;22:1219-24.

Publication Dates

• Publication in this collection
  05 May 2004
• Date of issue
  Feb 2004

History

• Received
  12 Jan 2004
• Accepted
  21 Jan 2004