Gluteus maximus and medius play an important role in the neuromuscular control of dynamic valgus of the knee and, consequently, normal posture and gait patterns. Once the objectives of the protection phase have been achieved, the patient may be progressed to the second phase of cartilage repair rehabilitation. Phase 2: Progressive Joint Loading and Functional Restoration The focus of the second phase is to begin controlled gradual increase of the mechanical stress on the primary repair tissue to stimulate cellular metabolism leading to production of proteoglycans and collagen deposition.
This allows the cartilage repair tissue to strengthen and become more resilient to increasing mechanical stress and more complex joint loading patterns, including both compressive and shear forces. This phase of rehabilitation is, therefore, designed to maintain ROM and flexibility, while restoring neuromuscular control and initiating simple sport-specific movement patterns. Impaired Muscle Performance Emphasis is placed on full restoration of strength and balance to address residual deficiencies.
Strength deficits in the quadriceps and hamstrings, as well as quadriceps-to-hamstrings strength imbalance, should be actively addressed. Testing can be performed with an isokinetic device FIGURE 8 after adequate practice is allowed to ensure maximal effort. For patients who continue to exhibit strength deficits, the use of non-weight-bearing open-chain exercises has been shown to be effective in enhancing muscle strength after knee surgery.
Athletes must be able to decelerate their body or a body segment rapidly to successfully complete sports maneuvers. During deceleration, the lower extremity muscles absorb mechanical work while lengthening. Deficits in hip abduction torques have been associated with excessive lower extremity dynamic valgus and anterior cruciate ligament injuries in female athletes. The entire kinetic chain of the lower extremity hip, thigh, and calf and trunk musculature should be addressed. Proprioception, dynamic joint stability, reactive neuromuscular control, and functional motor patterns are affected by knee injury.
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The inability to maintain postural control may amplify limb-to-limb strength deficits during functional tasks. After adequate strength and postural control have been achieved, the use of perturbation devices is indicated to further enhance neuromuscular control. Perturbation of the support surface by the rehabilitation specialist is performed to alter forces and torques in multiple planes in a systematic progression. A progression in difficulty, similar to the one described above for balance activities, can be followed. Subsequent sessions progress from expected to random directions and timing of the perturbation, increasing intensity and magnitude of the forces, and decreasing verbal cues.
Progression of perturbations is individualized based on the patient's ability to apply appropriate directional and counter-resistive force and muscle activation patterns and reduction in loss of balance. Having the patient perform various functional tasks while standing on an unstable surface should follow and should progress by increasing the difficulty of the tasks.
Providing verbal, tactile, and visual cues is indicated initially but should be strategically and systematically removed when the patient is able to adapt and react to the perturbation. A rehabilitation program augmented with perturbation training has been shown to result in improvements in physical performance measures, self-report outcomes, and biomechanical deficits. Neuromuscular and proprioceptive re-education has important implications for dynamic joint alignment and has been shown to play an important role in preventing injury or reinjury.
Altered Joint Loading Patients who desire to return to a high-level sport or an activity that requires jumping and landing should initiate plyometric activities during this phase. While the effects of plyometric training on patients recovering from knee injuries, especially after articular cartilage repair, are unknown, it may be a critical training method to safely return athletes to full sports participation. Additionally, the clinician should stress that patients maintain proper technique throughout the plyometric training. It is critical to include the work-rest time ratios or recommended during this phase of rehabilitation, and plyometric training should not be performed on successive days.
Chmielewski et al 24 recommended that volume be increased prior to increasing the intensity or frequency of exercise or decreasing rest time. The use of orthotics, bracing, and taping can be helpful during this phase, potentially to reduce the compressive and shear loads in the compartment where the repair has occurred. We recommend that plyometric exercises be performed first in a supine position gravity eliminated , using double-limb landing to initially minimize the stress applied to the joint. The emphasis should be on achieving equal load sharing across the entire joint surface and between limbs.
If poor technique is exhibited by the athlete, such as excessive internal rotation of the femur, external rotation of the tibiofemoral joint, excessive foot pronation, or excessive dynamic knee valgus, it is critical to address the movement dysfunction at this point in time, prior to introducing single-limb landing or exercises against gravity.
Once the athlete demonstrates proper technique and is able to tolerate the volume and intensity prescribed without pain or swelling, plyometrics can be performed using a single limb but in a supine, gravity-eliminated position. Plyometric exercises can effectively restore neuromuscular joint control to optimize joint biomechanics and load distribution under higher impact conditions, with the goal of protecting the repair cartilage from overload. Impaired Sport-Specific Movement Patterns The resumption of low-impact activities is recommended based on the athlete's preferred sport and the surgical approach.
Low-load activities produce tibiofemoral joint loads between 1. The ratio of run-to-walk distance is initially gradually increased before increasing the running distance to the patient's preferred or required amount. Joint mobilization of the patella, hip, and tibiofemoral and tibiofibular joints may be indicated at this time. Deyle et al 33 utilized a combined rehabilitation program of manual therapy techniques and standardized knee exercises to improve 6-minute walk time and self-report scores in patients with knee osteoarthritis.
Soft tissue mobilization of the iliotibial band, patellar and quadriceps tendons, popliteal space, and the hip region should be included. A randomized controlled trial in patients with knee osteoarthritis has demonstrated improvements in self-report scores, pain, ROM, and functional performance after an 8-week program of massage therapy.
By using objective criteria rather than fixed time tables, this strategy for progression to on-field rehabilitation follows one of the main principles of sports rehabilitation. As the athlete moves to the next phase of the treatment, on-field rehabilitation, open and continued communication among the rehabilitation team, coaches, and training staff is crucial to achieve the optimal outcome for the athlete. Phase 3: Activity Restoration In addition to the physical criteria listed earlier, cartilage-sensitive MRI evaluation of the graft or repair tissue is routinely recommended to determine the status of the graft before advancing to on-field rehabilitation and high-impact athletic activities.
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MRI is helpful to evaluate the volume of the repair cartilage and can help rule out significant graft hypertrophy or subchondral bone marrow edema, which may indicate risk of graft failure or graft delamination. Increased risk for traumatic graft delamination has been observed in high-impact athletes with graft hypertrophy after first-generation chondrocyte implantation.
On-field rehabilitation is the final and important component of the return-to-sport program following cartilage repair. During this phase, further organization and maturation of the cartilage repair tissue is expected through adaptation to the increasingly more demanding joint stresses associated with impact and pivoting activities. Adaptations include increased rigidity of the matrix due to further proteoglycan deposition and cross-linking, collagen production, and cellular orientation and organization within the neocartilage tissue.
Currently, it is not known how the repair tissue quality affects joint function and ability to return to sport; however, limited repair tissue volume has been associated with a higher failure rate. The final phase is to develop a program that allows for continued recovery while progressively replicating and simulating the complex interaction of tasks during sports.
The goal is to progressively challenge the athlete to allow for full clearance for integration back to physical or sporting activities, while minimizing the risk of reinjury. The primary goal of this last phase of rehabilitation is to address any remaining impairments in muscle power, metabolic capacity, and sport-specific movement patterns, as well as diminished athletic performance. The on-field rehabilitation phase should follow a continuum, building on activities used to simulate athletic movement patterns that were started during the late stages of the second phase of rehabilitation and were taking place in the gym and in the pool.
The last phase of rehabilitation takes place on a specialized rehabilitation field under the supervision of rehabilitation specialists. On-field rehabilitation is designed as a sport-specific progression of exercises that allows gradual functional recovery of sport-specific skills, starting with in-line running and jumping and progressing to acceleration and deceleration drills, pivoting and cutting maneuvers at increasing speeds, and incorporation of sport-specific equipment and movement patterns.
On-field rehabilitation should consist of specific exercises and drills, lasting approximately 90 minutes, performed between 3 and 5 times a week depending on the athlete's activity level for at least 8 weeks. A significant aspect of on-field rehabilitation is dedicated to aerobic conditioning and sport-specific fitness exercises to facilitate the readiness for return to competition at the preinjury level and to reduce the risk of reinjury after successful return. Progression is always criteria-based, requiring the absence of pain and swelling and the maintenance of full ROM with the increasing activity demands.
During this phase, the athlete should continue strengthening and flexibility exercises in the gym. On-field Rehabilitation Stages On-field rehabilitation is divided into 5 stages TABLE 5 , each characterized by well-defined, progressive, sport-specific exercises performed outdoors on a grass field or indoors on a synthetic field.
Prior to the initiation of on-field rehabilitation, the patient performs an aerobic fitness test to identify aerobic and anaerobic thresholds used to personalize the intensity of each training session based on metabolic training loads. During each training session, athletes wear a heart rate monitor to control the metabolic intensity of the training. Periodic reassessment of metabolic training load is performed to adjust the metabolic intensity to improve cardiorespiratory fitness for return to sport. Stage 1.
In the first few sessions, the patient walks along a straight line to gain confidence with the training environment, rehabilitation field, and the ground. Initially, a more compliant surface, such as sand, is used as an effective low-impact method for improving strength and proprioception. Once the athlete has become familiar with the training environment, slow running in a straight line is initiated, as well as global coordination exercises agility drills FIGURE 10A.
Throughout this phase, we recommend that athletes perform the exercises at or below their aerobic threshold. Athletes are progressed to the next phase, when they can perform these drills without pain, swelling, or apprehension. Stage 2. The patient also performs light jumps and soft landing on sand. Proper technique and optimal trunk and lower-limb alignment are emphasized through all exercises, with particular attention to the use of adequate hip and knee flexion and controlling for excessive knee abduction.
Additionally, the metabolic requirements are increased, with athletes performing tasks between their aerobic and anaerobic thresholds. To progress to the next phase, the athlete must demonstrate proper technique during all drills performed at near full speed, without pain, swelling, or apprehension. Stage 3.
The aerobic fitness test is repeated to establish new aerobic and anaerobic thresholds. Additionally, squat and countermovement jump tests are performed to measure jumping performance and lower extremity power. If available, the tests can be performed on a platform connected to a digital timer that records flight and contact time. Markovic et al found that these 2 tests were reliable and valid estimates of lower extremity power in physically active men.
Accurate measurement of these 2 tasks can be useful to monitor progress over time. This stage also includes progressive incorporation of changes in direction and speed, while running along with more intense agility drills and aerobic workouts FIGURE 10C. Patients are allowed to begin practicing sport-specific skills without opponents. Aerobic conditioning is performed at the aerobic threshold for 15 to 20 minutes. Athletes can progress to the next phase when they demonstrate proper technique during all drills and during unopposed practice at near full speed, without pain, swelling, or apprehension.
Stage 4. Technical and sport-specific exercises are initiated, such as kicking or hitting a ball, changing direction and deceleration, and cutting and pivoting maneuvers with the ball or other sport-specific equipment FIGURE 10D. Athletes also start incorporating rotational components to the jumping and landing drills.
Aerobic threshold conditioning is performed for 15 to 20 minutes. Athletes can progress to the next phase when they demonstrate proper technique during all drills performed at full speed, without pain, swelling, or apprehension. Stage 5. During the last stage, the emphasis is on improving and intensifying sport-specific movement patterns, while simulating game-intensive conditions FIGURE 10E. This can be done with controlled introduction of an opponent for one-on-one technical and agility drills.
Aerobic conditioning is also conducted with more intense and prolonged aerobic workouts. Aerobic and anaerobic threshold tests and countermovement and squat jump tests are performed to help confirm progress and determine readiness to return to competition. The progression of exercises during on-field rehabilitation follows the principles of strength training, conditioning, and increased functional demand with respect to the musculoskeletal and neuromuscular components involved in the recovery process.
The criteria required for progression to athletic activity include completion of the sport-specific exercises and one-on-one opposed practice of sport-specific skills 1 without joint pain, swelling, or decreased ROM, 2 with proper coordination and neuromuscular control, and 3 without fear of reinjury.
Articular cartilage repair in athletes requires effective and durable joint surface restoration that can withstand the significant joint stresses generated during athletic activity. Several surgical techniques can successfully restore articular cartilage surfaces and allow for return to high-impact athletics after injury. Postoperative rehabilitation is a quintessential component of the treatment process for cartilage defects in the athlete. To optimize functional outcome and the ability to return to sport, cartilage repair rehabilitation in the athlete has to be adapted to the biology of the surgical repair technique, individual cartilage defect specifications, and each athlete's sport-specific demands.
This can be achieved by a stepwise, phased rehabilitation approach using criteria-based progression of the athlete through the individual rehabilitation phases, based on a thorough understanding of the biomechanics and biology of cartilage injury and repair. Using these principles and close communication between surgical and rehabilitation teams, return to even demanding high-impact sport and continued sports participation can be successfully achieved.
Clinical Commentary. Rehabilitation After Arti Cartilage Surgical Techniques. Restorative Cartilage Repair Techniques. Reparative Cartilage Repair Techniques. Rehabilitation After Articular Cartilage Repair. Factors That Influence Rehabilitation. Weight-bearing progression. Continuous passive motion. Stationary cycling. Schematic drawing illustrating the unsafe range of motion during which the cartilage defect articulates with the opposing joint surface from Mithoefer et al Patellar mobilization.
Neuromuscular electrical stimulation. Isokinetic muscle strength test. Proprioceptive exercises. Gradually increasing on-field rehabilitation exercises. Global coordination A , skipping exercises B and C , sport-specific exercises D , and high-intensity exercises simulating playing situations E. J Orthop Sports Phys Ther ;28 4 J Orthop Sports Phys Ther ;36 10 J Orthop Sports Phys Ther ;42 7 J Orthop Sports Phys Ther ;42 3 Volume 42, Issue 3 March Pages: - Related Articles Articles citing this article: Google Scholar.
Related Articles In: PubMed. Less fear of reinjury and higher self-efficacy are associated with better outcomes. Immediate weight bearing for patellofemoral defect knee brace locked in full extension. Longer recovery if symptoms persist longer than 12 months deconditioning. Modified protocols for anterior cruciate ligament reconstruction, meniscal repair,osteotomy, etc. Slower rehabilitation progression after meniscectomy especially lateral meniscus.
Restoration of symmetry, strength, and flexibility in lower limb Loading program individualized with progression to full resistance over repaired defect in both closed-kinetic-chain and open-kinetic-chain activities Functional sport-specific agility training Presport cardiovascular conditioning Increase intensity and duration of exercise Continue strengthening and flexibility exercises from phase 2 Education and preparation for return to sport.
Phase 1. Aerobic fitness test. Gaining confidence with the environment and the ground Walking in a straight line without shoes Circular walking Slow running in a straight line on rehabilitation field Exercises of mobilization and coordination Sand exercises walking, balancing without jumping. Circular running Skipping exercises Increasing speed of running Light jumps and landings on the sand Advanced proprioceptive exercises Aerobic conditioning. Countermovement jump Squat jump. Running at different speeds with slow changes of direction Slow decelerations Skips different patterns Jumps and landings on the field Aerobic conditioning.
Running with fast changes of direction Decelerations Technical and sport-specific exercises Jumps and landings with rotations Aerobic conditioning Anaerobic-threshold running for 15 min. Aerobic fitness test Countermovement jump Squat jump. Sprinting and fast changes of direction High-intensity exercises in playing situations Aerobic conditioning Anaerobic-threshold running for 20 min.
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Services on Demand Journal. The percentage in Brazil is probably even lower; Relatively few patients are referred to cardiovascular rehabilitation programs by physicians worldwide; There are no specific CVDPR guidelines that contemplate the particularities of Latin American countries; No certification programs for CVDPR services are available in Latin America till date.
A class I indication does not mean that the procedure is the only one acceptable Class II: There is difference of opinion regarding the justification and usefulness of the method or procedure.
It is acceptable, but may be controversial Class IIa: The weight of evidence indicates usefulness or effectiveness Class IIb: The weight of evidence is not very well established regarding the usefulness or efficacy Class III: There is general agreement that the method or procedure is not indicated or justified. In some cases, it may even be dangerous Levels of evidence A: Solid evidence, from multiple randomized clinical trials or meta-analyses with adequate design to reach statistically significant conclusions B: Weak evidence, derived from a simple nonrandomized study or from several nonrandomized studies C: Expert opinion, small studies, or registries.
Patients ineligible for out-of-hospital cardiovascular rehabilitation The contraindications for physical exercise in a cardiovascular rehabilitation program have been modified and are becoming increasingly complex.
Severe symptomatic valvular heart diseases requiring surgery — Rehabilitate only after surgery 4. Uncompensated cardiac failure 6. Serious, complex ventricular arrhythmias 7. Suspected lesion of the left main coronary artery, unstable or severe 8. Infectious endocarditis, myocarditis, pericarditis 9. Severe untreated symptomatic congenital heart diseases Thrombophlebitis and pulmonary embolism — acute phase Aortic dissection — type A or acute phase type B Symptomatic and severe left ventricular outflow tract obstruction with low effort-induced output Uncontrolled diabetes mellitus All acute systemic infections.
Objectives of cardiovascular rehabilitation The pillars of cardiovascular rehabilitation and secondary prevention are as follows: lifestyle modifications with an emphasis on regular physical activity, adoption of healthy feeding habits, smoking and drug use cessation, and stress managing strategies. No complex arrhythmias, both at rest or exercise induced 3. Uncomplicated myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty 4. Asymptomatic, including absence of angina with effort or in the recovery period 6. Survivors of cardiac arrest or sudden death 3.
Complex ventricular arrhythmias at rest or with exercise 4. Abnormal hemodynamics with exercise especially depressed curve or drop in systolic blood pressure, or chronotropic incompetence not related to medication with increasing load 6. Patient safety and monitoring Potential cardiac complications during cardiovascular rehabilitation programs are as follows: cardiac arrest, arrhythmias, and AMI, among others Table 4. Conducts the stress test. Competencies of the Rehabilitation Staff A CVDPR program is integrated by a multidisciplinary team Table 6 , which requires the following competencies: basic knowledge in the cardiovascular, pulmonary, and musculoskeletal areas, ECG analysis, medical emergency management, and theoretical and practical knowledge regarding physical exercise.
Initial patient evaluation At the start of a rehabilitation program, the initial assessment of the patient must include obtaining an exhaustive and thorough medical history, which includes details regarding previous surgical procedures and comorbidities, such as cardiovascular, renal, pulmonary, and musculoskeletal diseases, as well as depression and other relevant information.
Exercise prescription Exercise prescription should always be considered individually in accordance with each phase, taking into account individual limitations and comorbidities musculoskeletal, neurological, respiratory, renal, and among others. Phase 1 During phase 1, in hospital, is a moment when patients are very receptive. Exercises can be started immediately after disease stabilization: In cases of ACS, after the first h, in the absence of symptoms; In cases of heart failure, after dyspnea improvement, gentle stretching and movement exercises can also be started as soon as the patient can ambulate; In cases of cardiac surgery, especially in the days prior to the intervention, a program comprising breathing exercises, stretching, and progressive movement, followed by physical therapy after surgery, provides a significant reduction in respiratory complications, arrhythmias, and length of hospitalization 19 - Phase 2 In this phase, the patient needs supervision and individualized care, because this is the convalescence phase and the patient often has not had any previous contact with formal physical activities.
Phases 3 and 4 These phases have an indefinite duration Components of each session a Warm-up period: a moment in which muscle groups are incorporated gradually; starting with small groups and then progressing to larger muscle groups. Types of exercise The exercises can be divided into isotonic or dynamic and isometric or static: Isotonic or dynamic exercises change muscle length with rhythmic contractions, joint movements, and limited strength development. Education As previously mentioned, a multidisciplinary CVDPR program includes not only the scheduled exercise plan but also the education provide to the patient, about CVD and the appropriate management of risk factors Obesity and overweight Definition and facts The incidence and prevalence of overweight and obesity have increased globally to alarming levels.
Special recommendations Feeding habits education is paramount, with emphasis on decreasing caloric intake and drastically decreasing the intake of fats and simple carbohydrates. Special recommendations To collect a complete medical history; To determine the CVD risk individually; To prescribe physical activity aerobic, resistance, and flexibility ; To supervise the physical activity practice according to the risks and prescriptions.
Challenges and goals It is important to know the degree of stress and depression of patients seeking a CVDPR program; the use of standardized questionnaires is recommended, such as the PHQ-9 depression questionnaire, which is free and available online. Special recommendations The recommendations focus on the identification of these groups of patients to allow early intervention, through psychotherapy and lifestyle changes, not only aimed specifically at the individual but also at the family members. Smoking Definition and facts Smoking is a chronic addiction caused by the excessive tobacco smoking, which is triggered by its main component, nicotine.
Challenges and goals The overall goal is to achieve complete cessation of cigarette smoking 59 , Specific recommendations Every clinical history must include questions regarding smoking history, so as to diagnose smokers according to the above definition. Dyslipidemia Definitions and facts Dyslipidemia is a major risk factor for developing atherosclerosis.
Special considerations As previously mentioned, the overall risk stratification defines each patient's LDL-C targets according to the risk category. The therapeutic options are as follows: Nonpharmacological measures: decreased intake of simple carbohydrates and of saturated and trans fats in general; weight loss in individuals with obesity; and increased physical activity class I, level of evidence B. Arterial hypertension Definitions and facts One of the most common problems in primary care is the lack of detection, treatment, and control of hypertension, which is undoubtedly a risk factor with the highest impact in CVD.
Specific recommendations To achieve the treatment goals, it is crucial to implement lifestyle changes Table Challenges and goals Strict glycemic control class I, level of evidence A Table 14 is recommended. Specific recommendations DM treatment includes pharmacological and nonpharmacological measures. Metabolic syndrome Definition and facts Metabolic syndrome is a cluster of risk factors that include central obesity, elevated BP, elevated levels of triglycerides and blood glucose, and low HDL-C Table Challenges and goals To achieve the proposed goals for each component of the syndrome; To measure waist circumference in all patients; To educate the patient about the strong influence that a lifestyle change can have on this syndrome.
Recommendations on restarting sexual activity after cardiovascular events Lack of confidence to perform sexual activity, decreased libido, erectile dysfunction, and ejaculation disorders are important points to consider after a cardiovascular event. Some practical recommendations 82 : If the patient is able to achieve 6 METs of physical exertion in a stress test, or the equivalent in daily life tasks, sexual activity should not be restricted, because neither the duration nor the intensity of physical effort during sexual activity are risky enough to cause cardiovascular complications.
Counseling is key in restoring the patient's confidence.
Challenges and goals Decrease the access barriers to CVDPR programs; Promote and encourage strategies that improve CVDPR program adherence; Implement strategies that educate the patients regarding healthy habits, exercise prescription, and the importance of medication 12 , Challenges and goals Encourage the referral of the elderly to CVDPR programs; Minimize barriers to inclusion and adherence to the program; Manage comorbidities in a comprehensive manner; Achieve a higher level of independence, self-care, and social adaptation; Stimulate the practice of resistance exercises to prevent or reverse sarcopenia; Consider the possibility of some cognitive deterioration that can represent a challenge in learning exercise techniques, diet, and other principles included in the CVDPR program.
Specific recommendations Encourage learning motivation, not only in the context of exercise but also regarding information related to their illness; Consider whether orders, indications, and precautions should be repeated; Include exercises that promote self-care; Combine aerobic exercise with individualized exercise program and stretching, flexibility, coordination, and balance exercises.
Rehabilitation in children and adolescents Definitions and facts Pathologies with CVDPR indication in this population derive from congenital heart disease, with or without heart failure, as well as neurocardiogenic syncope. Challenges and goals Minimize barriers to inclusion for this group of patients; Consider the educational component related to healthy habits; Achieve the highest level of patient's self-care and adaptation to the family and social context. Specific recommendations Guide and motivate patients to perform their preferred recreational physical activity that meets the specific recommendations for each pathology and clinical status; Dietary recommendations should consider the patient's age and developmental stage, as well as the underlying disease; thus, it is very important to include consulting and monitoring by nutrition experts.
Rehabilitation in women Definition and facts There is limited specific information on women, because they are under-represented in clinical trials. Furthermore, it is important to: Adjust the exercise prescription to the comorbidities of the patient; Include the patient in a compatible physical activity group; Consider the atypical symptoms that may be present; During the sessions, determine the patient's preferred type of aerobic exercise walking, dancing, cycling, swimming, or other , thereby favoring its performance as a part of the patient's routine, independently of the program Rehabilitation in patients with DM Definition and facts Proper diagnosis and treatment of DM are associated with decreased mortality.
Special recommendations Exercise prescription: The exercise must comply with the following goals: Short term: change the sedentary habits through daily walks at the patient's pace. In case of hypoglycemia: Administer 15 g of carbohydrates to the patient e. Individuals with diabetes are times more likely to have a CVD than those without.
In addition, CVD occurs at a younger age in individuals with diabetes, who tend to develop morediffuse lesions. Therefore, tailoring training exercises that allow the recognition of symptoms of myocardial infarction in this type of patients is not easy. Rehabilitation in patients with heart failure Definition and facts Heart failure is a major health problem, especially in the elderly population Challenges and goals Despite the known benefits derived from physical exercise, few patients with heart failure enter CVDPR programs.
Special recommendations In this type of patients, predominantly aerobic exercises are recommended; they can be performed either continuously or at intervals, with small and gradual increases in frequency and intensity, returning to the previous level when there is decreased tolerance. Rehabilitation in patients with valvular heart disease Definition and facts The prevalence of valvular heart disease has been changing in our setting in recent decades.
Challenges and goals Increasing the participation of patients with valvular heart disease in CVDPR programs is challenging. Specific recommendations The guidelines or recommendations about exercise in this group of patients are directed primarily to lesions that have a moderate or severe degree, because patients with mild and asymptomatic lesions without hemodynamic repercussion have no restriction to the practice of noncompetitive physical activity Table 18 29 , Specific recommendations One of the most frequent mistakes in this group of patients is pushing them to walk at a pace close to the maximum pain of claudication.
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The correct recommendations regarding scheduled walks for patients with claudication are as follows : Intensity: moderate and gradual. Rehabilitation in post-heart transplantation patients Definition and facts Despite receiving a heart with normal systolic function, the transplanted patient experiences exercise intolerance after surgery. Specific recommendations An echocardiogram can be used by a physician to discard pericardial effusion and evaluate ventricular function, as well as to provide information to the patient and family about changes in vital functions derived because of transplantation.
Exercise should be stopped during steroid pulse therapy Rehabilitation in patients with pacemakers and cardiac defibrillators Definitions and facts The benefit of these devices in decreasing episodes of sudden death and improving quality of life has already been demonstrated; however, a significant incidence of depression, anxiety, and phobias has been described.
Challenges and goals Because physiological changes of exercise can increase the likelihood of the defibrillator implantable cardioverter-defibrillator [ICD ] being triggered, both the medical team and the patient fear the practice of physical activities. The following must be known prior to physical activity initiation: Patient's pathology; Basic information of the pacemaker, such as type of sensor that adjusts HR, as this will determine, in some patients, the HR response to exercise, especially in those without adequate chronotropic response.
Special recommendations They will depend on the type of pacemakers implanted: Unicameral VVI without adaptive response, but with good chronotropic response: the physician should treat the patient in a similar way to individuals without CVD. Rehabilitation in patients with chronic obstructive pulmonary disease Definition and facts Patients with pulmonary disease associated with stable cardiac disease should not be excluded from a CVDPR program; it is only required that they are stable and properly medicated.
Challenges and goals Get the patient to tolerate the prescribed exercise program; Conduct a joint assessment with the pulmonologist to establish an adequate medication regime to allow for the performance of an exercise program; Adequately quantify the level of inability to prescribe the appropriate exercise load; Control the CVD risk factors; Control the depression and anxiety produced by the sensation of dyspnea; Improve muscle strength and decrease muscle atrophy; Improve the quality of life of patients by improving their functional capacity with exercise; Decrease the rest period between each exercise period.
Specific recommendations It is important to evaluate the respiratory and cardiovascular parameters before starting the program. Rehabilitation in coronary artery disease patients after MI, percutaneous coronary revascularization, or after CABG Definition and facts After an acute coronary event, patients should start a physical activity that is compatible with their tolerance walking, cycle ergometer, etc. Special recommendations A stress test and a neuromusculoskeletal assessment should be performed when patients start the CVDPR program.
Cost effectiveness of a cardiovascular rehabilitation program Cost effectiveness measures the years and quality of life gained; it is usually expressed in monetary terms over the years gained. References Brown RA. How to cite this article. Class I: There is a general agreement that the method or procedure is beneficial, useful, and effective. A class I indication does not mean that the procedure is the only one acceptable. Class II: There is difference of opinion regarding the justification and usefulness of the method or procedure. It is acceptable, but may be controversial. Class IIa: The weight of evidence indicates usefulness or effectiveness.
Class IIb: The weight of evidence is not very well established regarding the usefulness or efficacy. Class III: There is general agreement that the method or procedure is not indicated or justified. In some cases, it may even be dangerous. A: Solid evidence, from multiple randomized clinical trials or meta-analyses with adequate design to reach statistically significant conclusions.
B: Weak evidence, derived from a simple nonrandomized study or from several nonrandomized studies. Severe symptomatic valvular heart diseases requiring surgery — Rehabilitate only after surgery. Suspected lesion of the left main coronary artery, unstable or severe. Symptomatic and severe left ventricular outflow tract obstruction with low effort-induced output. Uncomplicated myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty. Asymptomatic, including absence of angina with effort or in the recovery period.
Abnormal hemodynamics with exercise especially depressed curve or drop in systolic blood pressure, or chronotropic incompetence not related to medication with increasing load. The presence of some of the risk factors included in this category is considered as high risk. Myocardial infarction rate of 1 per , patient hours.
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