RU2329780C2 - Method of physical rehabilitation of aged patients after cardiac infarction within sanatorium rehabilitation stage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically to cardiology. General clinical and apparatus examination is carried out: rest ECG, veloergometry, echoCG, daily monitoring of BP and Holter's ECG. Medicamentous therapy is accompanied with therapeutic physical exercises, including execise bicycle, graduated walking. Tolerance to physical activity is evaluated by 6-minute test walking and veloergometry. Motion activity stage (MAS) is detected by D. M. Aronov's classifications, yet severity functional class within 1 to 4 depends on period from cardiac infarction, stenocardia attacks, blood circulation insufficiency (BCI), and arrhythmia of the third grade and higher by Lown, aneurysms, ejection fraction of Echo CG. Appropriate therapeutic physical exercise complex (TPE) is prescribed by MAS while TPE are given 2 hours after breakfast within whole rehabilitation period. Based on specified severity functional class lessons are conducted with increase in loading by 25 % for each lesson. Graduated walking is about 0.5 km at speed 70 steps per minute to 2 km at speed 100-110 per minute 2 hours after dinner. Daily walks take 2-3 ways by duration 2-2.5 hours per day for distance 2 to 10 km. 1 hour before dinner bicycle exercises are practiced at intensity 40% of limit loading at duration 10 min for course 10-14 trainings. All the exercises are carried out under haemodynamics control. Offered method allows to lower rate of recurrent cardiovascular accident development, to lower cases of being registered as a disabled person, to raise tolerance to physical activity.

EFFECT: decreased rate of recurrent cardiovascular accident development, increased tolerance to physical activity.

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Description

The method relates to medicine, namely to cardiology.

Physical training is known and widely used in patients who have had myocardial infarction in patients of working age at various stages of rehabilitation (Nikolaeva L.F., Aronov D.M. Rehabilitation of patients with coronary heart disease. - M .: Medicine, 1988). The stationary phase of physical rehabilitation of patients after myocardial infarction is carried out according to a 3-5-week program and aims to restore the patient’s ability to self-care, prevent the deterioration of the cardiovascular system, skeletal muscles and other organs and systems for physical inactivity and physically and psychologically prepare the patient to further expand physical training (Syrkin A.L. Myocardial infarction. - M.: Medicine, 1991). In addition, physical training positively affects the rheological properties of blood, reduce the risk of thromboembolic complications.

It is well known that elderly patients most often experience complications of myocardial infarction such as early post-infarction angina pectoris, cardiac aneurysm, ventricular arrhythmias, and heart failure. There is a close correlation between aging and cardiovascular diseases: disturbances associated with the disease of not only the heart and blood vessels, but also concomitant pathology very often join physiological age-related changes in the elderly and senile. All this, sometimes dramatically, affects the management of patients, often limiting the volume of interventions, sometimes forcing to abandon radical methods of treatment, reducing them to symptomatic therapy. Adequate physical rehabilitation in this category of patients can cause significant difficulties, but classes in these patients are necessary, since even short-term inactivity leads to significant changes in blood circulation in the periphery, the development of dystrophic changes in the muscles and a high risk of thromboembolic complications.

To date, the sanatorium rehabilitation phase after a myocardial infarction has been relatively contraindicated in elderly patients and, as a result, has not been adequately studied.

A known method of training patients with acute myocardial infarction, which consists in conducting a specially designed system of physical exercises, differentiated according to the severity of the condition and the timing of the onset of acute myocardial infarction. (Nikolaeva L.F., Aronov D.M. Rehabilitation of patients with coronary heart disease. - M .: Medicine, 1988).

Along with the undeniable advantages of this method is not indicated for patients with persisting phenomena of left ventricular failure and patients of the older age group.

There is a method of early physical rehabilitation of patients with acute coronary syndrome by training using test static-dynamic exercises for different muscle groups with an increasing degree of burden of 50% of the identified threshold load under the control of hemodynamics (Sumin A.N., Doronin D.V., Varyushkina E.V., Kobyakova O.V. Patent RU 2240152, M. cl. A61N 1/32, published on November 20, 2004, BIMP No. 32).

This method was also not performed in elderly patients who had myocardial infarction in the sanatorium phase of rehabilitation. In addition, an increasing degree of burden of 50% of the identified threshold load is not acceptable for elderly patients.

There is a method of rehabilitation of myocardial infarction at the sanatorium stage, where the leading place is physical rehabilitation of the patient - in the form of therapeutic exercises, dosed walking, training on a treadmill and exercise bike (Barashkova N.L. et al., Clinical sanatorium "Kratovo" FSB of Russia). Application for invention No. 2000101789/14, 01/27/2000, IPC 7 A61M 1/00, Method for the rehabilitation of myocardial infarction, BIMP No. 29, 10/20/2001, pp. 57-58.

This method of rehabilitation was not used in elderly patients. The loads on various stages of motor activity and the degree of increase in the volume of loads depending on the type of physical activity (therapeutic exercises, dosed walking, training on a treadmill and exercise bike) are not defined.

The objective of the invention is to create an effective and safe way of physical rehabilitation of patients who have had myocardial infarction in old age at the sanatorium stage of rehabilitation.

The objective is achieved by the fact that they carry out the method of physical rehabilitation of patients who have had myocardial infarction in old age at the sanatorium stage of rehabilitation. The method includes general clinical and instrumental examination: resting ECG, bicycle ergometric test, echocardiography, daily monitoring of ECG and blood pressure according to Holter. They carry out drug therapy and physical training using physical therapy, exercise on a stationary bike, dosed walking.

Exercise tolerance is determined by a 6-minute walk test and bicycle ergometry test. The degree of motor activity (SDA) is determined according to the classification of D.M. Aronov and the functional class of severity of the patient's condition from 1 to 4.

At the same time, at the III stage of activity, 1 severity class is established with a period of 14-18 days from the onset of myocardial infarction, no angina attacks or 1-2 fc, circulatory failure (NK) 0-1, no arrhythmias of the third gradation and higher according to Laun, no aneurysm, with an ejection fraction of more than 40% according to Echocardiography, grade 2 severity for a period from the onset of MI 18-20 days, the presence of angina pectoris 1-2 fc, PC 1-2A, the absence of arrhythmias of the third gradation and higher according to Laun, the absence of aneurysm, establish grade 3 severity with a period from the beginning of IM 20-23 days, the presence of angina pectoris 2-3 fc, NK 1-2A, tired pour grade 4 severity with a period from the onset of MI 23-30 days, the presence of angina pectoris 3-4 fc, NK 2-3, the presence of arrhythmias of the third gradation and above Laun, the presence of aneurysm, with an ejection fraction of PV less than 40%.

At the IV stage of activity, 1 severity class is established with a period from the onset of MI 24-28 days, no angina attacks or angina pectoris 1 fc, NK 0-1, no arrhythmia, no aneurysm, with EF more than 40%, 2 severity class is established for a period of from the onset of myocardial infarction 28-30 days, the presence of angina pectoris 1-2 fc, NK 0-1, the absence of arrhythmia, the absence of aneurysm, establish grade 3 severity with a period from the beginning of the IM 30-33 days, the presence of angina pectoris 2-3 fc, NK 1- 2A, establish grade 4 with a period of 33-40 days from the onset of MI, the presence of angina 3-4 fc, NK 2-3, the presence of arrhythmia 3 gra ation and higher Lown, the presence of the aneurysm, at least 40% of the PV.

At the V stage of activity, class 1 is set for severity with a period from the onset of MI 30-34 days, no angina attacks or angina pectoris 1 fc, NK 0-1, no arrhythmia, no aneurysm, with PV more than 40%, class 2 is set for severity from the onset of myocardial infarction 34-36 days, the presence of angina pectoris 1-2 fc, NK 1-2A, the absence of arrhythmia, the absence of aneurysm, establish grade 3 severity with a period from the beginning of myocardial infarction 36-39 days, the presence of angina pectoris 2-3 fk, NK 1- 2A, establish grade 4 with a period from the onset of IM 39-43 days, the presence of angina 3-4 fc, NK 2-3, the presence of arrhythmia 3 gr admission and higher in the Laun, aneurysm, with EF less than 40%.

At the VI stage of activity, grade 1 is established for a period of 36-40 days from the onset of MI, no angina attacks or angina pectoris 1 fc, NK 0-1, no arrhythmia, no aneurysm, with PV more than 40%, grade 2 is established for a period of from the onset of myocardial infarction 40-46 days, the presence of angina pectoris 1-2 fc, NK 1-2A, establish the 3rd severity class with a period from the beginning of myocardial infarction 46-49 days, the presence of angina pectoris 2-3 fk, NK 1-2A, establish the 4th class at the period from the onset of myocardial infarction is 49-54 days, the presence of angina pectoris 3-4 fc, NK 2-3, the presence of arrhythmias of 3 gradations and above Laun, the presence of aneurysm, ri PV less than 40%.

Choose the appropriate set of physical therapy exercises (LFK) according to SDA and conduct LFK classes 2 hours after breakfast during the entire rehabilitation phase. Based on a specific functional class of severity, classes are conducted with an increase in load of 25% for each class. Dosed walking is conducted from 0.5 km at a pace of 70 steps per minute to 2 km at a pace of 100-110 steps per minute 2 hours after lunch. Spend daily walks in 2-3 doses lasting 2-2.5 hours a day at a distance of 2 to 10 km. 1 hour before lunch, exercise is carried out with an intensity of 40% of the threshold load lasting 10 minutes, a course of 10-14 trainings. All classes are carried out under the control of hemodynamics.

The novelty of the invention:

- Determine exercise tolerance by conducting a 6-minute walk test and bicycle ergometry test. This allows you to determine the level of physical activity and choose an adequate level of physical training.

- The degree of motor activity (SDA) is determined according to the classification of D.M. Aronov and the functional class of the severity of the patient’s condition from 1 to 4. This allows taking better into account the complications of acute myocardial infarction and choosing the appropriate mode of expansion of motor rehabilitation.

- Choose the appropriate set of physical therapy exercises (LFK) for SDA and conduct LFK exercises 2 hours after breakfast during the entire rehabilitation phase. With an increase in SDA, the duration and intensity of exercise therapy increases and effects on various muscle groups are performed.

- Based on a specific functional class of severity, classes are conducted with an increase in load of 25% for each class. Such a step load provides timely transfer to the next level of motor activity, and a lower increase in load on the steps ensures the safety of the expansion of the motor regime in elderly patients.

- Perform dosed walking from 0.5 km at a pace of 70 steps per minute to 2 km at a pace of 100-110 steps per minute 2 hours after lunch. Spend daily walks in 2-3 doses lasting 2-2.5 hours a day at a distance of 2 to 10 km. 1 hour before lunch, exercise is carried out with an intensity of 40% of the threshold load lasting 10 minutes, a course of 10-14 trainings. All classes are carried out under the control of hemodynamics. The mode is selected in accordance with the disease, age and the presence of concomitant diseases. Hemodynamic control is necessary to assess the tolerance of the load and the adequacy of the prescribed regimen.

The proposed method allows to reduce the incidence of recurrent cardiovascular catastrophes (recurrent myocardial infarction, acute cerebrovascular accident), reduce the rate of primary disability.

The method is as follows.

Before starting physical rehabilitation, all patients undergo an examination, including clinical and instrumental methods of study: resting ECG, 6-minute walk test, bicycle ergometry test (VEM), daily Holter ECG monitoring. In accordance with the results of the study, the severity class and the level of motor activity are determined (table 1).

Physical exercises form the basis of the entire rehabilitation program for patients with myocardial infarction and include physical therapy, cycling and dosed walking. Physical training is assigned according to the class of severity and level of motor activity.

Table 1 Classification of patients who underwent MI according to severity classes at the sanatorium stage of rehabilitation. Activity level Grade * Dates from the beginning of MI Angina attacks Circulatory failure (NK) Arrhythmias of 3 gradations and above Laun Aneurysm Ejection fraction 40% III one 14-18 No or 1-2 fc 0-1 - - More 2 18-20 1-2 fc 1-2A - - - / + 3 20-23 2-3 fc 1-2A - / + - / + - / + four 23-30 3-4 fc 2-3 + + Smaller IV one 24-28 No or 1 fc 0-1 - - More 2 28-30 1-2 fc 0-1 - - - / + 3 30-33 2-3 fc 1-2A - / + - / + - / + four 33-40 3-4 fc 2-3 + + Smaller V one 30-34 No or 1 fc 0-1 - - More 2 34-36 1-2 fc 1-2A - - - / + 3 36-39 2-3 fc 1-2A - / + - / + - / + four 39-43 3-4 fc 2-3 + + Smaller VI one 36-40 No or 1 fc 0-1 - - More 2 40-46 1-2 fc 1-2A - / + 3 46-49 2-3 fc 1-2A - / + - / + - / + four 49-54 3-4 fc 2-3 + + Smaller * - for patients 60 years and older

In the middle of the course of treatment and before discharge, patients undergo control instrumental studies (ECG, 6-minute walk test, bicycle ergometry, daily monitoring of ECG and blood pressure according to Holter), after which the patient can be transferred to the next level of motor activity and change in severity class, and also correction of drug treatment.

Criteria for transferring patients to the next stage of activity: a satisfactory reaction to the regime of the previous stage, the absence of an increase in angina attacks and the degree of circulatory failure.

LFK classes are recommended to be carried out 2 hours after breakfast. All stages of classes are conducted individually or in small groups (3-5 people). The total duration in the first classes is 15-20 minutes with a gradual increase in duration to 40-45 minutes. Mandatory musical accompaniment.

The training program was carried out only under strict control with a periodic assessment of pulse, blood pressure, respiratory rate, and pain in the chest area during classes. A favorable response to physical activity is considered moderate or severe fatigue, passing within 5 minutes. The adequacy of the response of patients to various forms of exercise therapy is taken into account in terms of heart rate, according to the results of an ECG in dynamics. An adequate response to a standard load (squats, exercises in therapeutic gymnastics) implies an increase in heart rate by 20-30 beats per minute, an increase in blood pressure by 20-30 mm Hg, unchanged or decreased diastolic blood pressure by 5-10 mm Hg. , as well as the restoration of these indicators in the first 3-4 minutes after exercise.

COMPLEX OF EXERCISES FOR PATIENTS WITH III STAGE OF ACTIVITY

1. I.P. Sitting on a chair, lean against the back, hands on his knees. Hands to shoulders, elbows spread apart - inhale, lower your hands to your knees - exhale (4-5 times).

2. I.P. - sitting on a chair. Roll from heels to socks with legs spread to the sides (8-10 times).

3. I.P. - also. Hands forward and up - inhale, lower your hands through the sides down - exhale. (2-3 times).

4. I.P. - also. Gliding the legs on the floor back and forth, without taking your feet off the floor (6-8 times).

5. I.P. - also. To spread your arms to the sides - inhale, hands on your knees, tilt your body forward - exhale (3-5 times).

6. I.P. - also. To put aside the right hand and left foot - inhale. Lower your hand and bend your leg, exhale. Do the same in the other direction (6-8 times).

7. I.P. - also. Lower your arms along the torso. Raising the right shoulder up, at the same time lower the left shoulder down. Then change the position of the shoulders (3-5 times).

8. I.P. is the same. To spread your arms through the sides - inhale, hands pull the right knee to the chest and lower it - exhale. Do the same by pulling the left knee (4-6 times).

9. I.P. - also. Calm breathing.

COMPLEX OF EXERCISES FOR PATIENTS WITH IV STAGE OF ACTIVITY

1. I.P. sitting on a chair, hands on his knees. Inhale - hands to the sides, exhale - hands on your knees (5-6 times).

2. I.P. sitting on the edge of the chair, hands on his knees, legs straightened. Circular movements of the feet, changing the direction of movement, repeat 10-12 times.

3. I.P. sitting on the edge of the chair, put your hands on the back, do not lean against the back. Gliding the legs on the floor, bringing the foot under the chair as far as possible (10-12 times).

4. I.P. sitting on the edge of a chair, feet shoulder width apart, hands on knees. Inhale - take your right hand to the side with a turn of the body, exhale - return to I. p. The same to the left (4-6 times).

5. I.P. - sitting on the edge of the chair, leaning against the back of the chair, rest your hands on your back and straighten your legs. Alternating leg abduction to the side (10-12 times).

6. I.P. - sitting on the edge of the chair, legs bent at the knees. Flexion and extension of the arms and fingers (8-10 times).

7. I.P. - standing behind the back of the chair, legs shoulder-width apart. Inhale - hands behind the head, stretch, bend, exhale - hands down (8-10 times).

8. I.P. - standing behind a chair, hands on the back of a chair, legs together. Alternating abduction of legs to the side (6-8 times).

9. I.P. - feet shoulder width apart, hands on the belt. Inhale - right hand up, exhale tilt the body to the left (10-12 times).

10. I.P. - standing behind the back of the chair, legs the width of the foot. Half-squatting, straightening your arms forward - exhale, while inhaling - return to I.P. (10-12 times).

11. I.P. - the same, hands on the belt. Circular movements of the pelvis, changing the direction of movement (12-16 times).

12. I.P. - standing, hands along the body. At the expense of 1 - hands behind the head, bend the right leg at the knee. To account 2 - return to I.P. At the expense of 3 - hands behind the head, bend the left leg at the knee. Keep balance for 2-3 seconds.

13. I.P. - Walking at a pace of 80-90 steps per minute, performing exercises on the go (arms to the sides, up, to the waist). - 3-4 minutes

14. I.P. - sitting on the edge of the chair, arms to the sides. Circular movements of the hands, changing the direction of movement (10-12 times).

15. I.P. - sitting on the edge of the chair, lean against the back, the emphasis with his hands behind, legs straightened. Imitation of cycling (10-12 times).

16. I.P. - sitting on the edge of the chair, legs shoulder-width apart, arms to shoulders. Stand on account 1, sit on account 2 (6-8 times).

17. I.P. - sitting on the edge of the chair, legs shoulder-width apart, arms to shoulders. At the expense of 1, tilt the body forward, with the body turning, with the right elbow touch the left knee, at the expense of 2 - straighten up (8-12 times).

18. Relaxation of the muscles of the arms and legs - 1 minute.

COMPLEX OF EXERCISES FOR PATIENTS WITH V STAGE OF ACTIVITY

1. I.P. sitting on a chair. At the expense of 1-2 raise your left hand up - inhale; 3-4 - lower your hand - exhale. The same with the right hand (5-6 times).

2. I.P. - also. Alternating flexion and extension of the feet (10-12 times).

3. I.P. - also. Alternating bending of the legs without taking the feet off the floor (by sliding) (10-12 times).

4. I.P. - also. Hands to the side; at the expense of 1 - bend your arms to your shoulders, at the expense of 2 - arms to the sides, the same at the expense of 3-4 (6-8 times).

5. I.P. sitting on a chair. At the expense of 1 - raise the left straight leg, at the expense of 2 - return to ip; at the expense of 3-4 - the same with the right foot (8-10 times).

6. I.P. also. At the expense of 1-2 - raise your hands up, unclench your fingers - inhale, at the expense of 3-4 - clenching your fingers into a fist, lower your hands - exhale (6-8 times).

7. I.P. - also. At the expense of 1-2-3-4 - circular movements with the left foot, without taking the feet off the floor, in one or the other direction, then the same with the right foot (6-8 times).

8. I.P. also. Hands to shoulders, fingers touching shoulders. Circular movements in the shoulder joints. At the expense of 1-2-3-4 - forward, at the expense of 5-6-7-8 - backward (8-12 times).

9. I.P. - standing. At the expense of 1-2 - raise your hands, take your right leg to the side, stretch - inhale, at the expense of 3-4 - lower your hands - exhale (8-10 times).

10. I.P. standing behind a chair, holding on to its back, rolls from heel to toes (10-12 times).

11. I.P. - standing, hands on the belt. Circular motion of the pelvis. At the expense of 1-2-3-4 - in one direction, 5-6-7-8 - in the other direction (10-12 times).

12. I.P. - standing to the left of the chair. The right hand on the belt, the left - on the back of the chair. At the expense of 1 - the right leg forward, at the expense of 2 - back. The same, standing at the chair with the other leg (10-12 times).

13. I.P. - standing, hands along the body. At the expense of 1 - tilt to the left, the right hand up along the body, at the expense of 2 - return to I. p. At the expense of 3-4 - the same in the other direction (8-10 times).

14. I.P. - Walking at a pace of 70-80 steps per minute.

15. I.P. - standing, hands on the belt. On account 1 - turn left, left hand to the side - inhale, on account 2 - return to I. p. - exhale, at the expense of 3 - turn right, right hand to the side - inhale; to account 4 - return to ip - exhale.

16. I.P. - sitting on a chair. At the expense of 1 - get up - inhale, at the expense of 2 - sit down - exhale (6-8 times).

17. I.P. - the same, hands on his knees. On account 1 - bend the left hand at the elbow, touch the shoulder, on account 2 - return to I. p. At the expense of 3-4 - the same with the right hand (5-6 times).

18. I.P. - also. On account 1 - turn your head to the left; to account 2 - return to ip On account 3 - turn your head to the right, on account 4 - return to I.P. On the same account, tilt your head back and forth (6-8 times).

19. I.P. - the same, hands down. Relaxation of the muscles of the arms and legs (1 min).

COMPLEX OF EXERCISES FOR PATIENTS WITH VI STAGE OF ACTIVITY

1. I.P. - sitting on a chair. Hands to shoulders - inhale, lower hands - exhale (4-5 times)

2. I.P. - also. Rolling the feet from the heel to the toe with legs spread to the sides, simultaneously clenching the fingers into fists, performing these movements, bending the arms alternately in the elbow joints (15-20 times).

3. I.P. same, hands in the castle. Arms up, legs straighten (do not lift up!) - inhale. Hands lower, legs bend - exhale (4-5 times).

4. I.P. - sitting on the edge of the chair, sliding the legs along the floor with the movement of the hands, as when walking (10-12 times). The breath is arbitrary.

5. I.P. - also. To reach up, to get up from a chair is a breath. Sit down - exhale (6-8 times).

6. I.P. standing behind the back of a chair, legs shoulder-width apart, arms to shoulders. Rotation in the shoulder joints in one and the other direction (10-13 times).

7. I.P. - the same, hands on the belt. Right hand forward, up - inhale, hands back, down - exhale (4-6 times).

8. I.P. standing behind the back of the chair, legs wider than shoulders, arms on the back of the chair. Transfer of body weight from one foot to another, bending the legs alternately at the knees (6-8 times).

9. I.P. standing sideways to the back of a chair. Swing movements of the foot back and forth (8-10 times)

10. I.P. standing behind the chair, hands on the back of the chair. Roll from heel to toe, bending down and arching the back during the transition to the heels, do not bend your arms (8-10 times). The breath is arbitrary.

11. I.P. standing behind the back of a chair. Hands up - inhale. Leaning forward, arms on the chair seat - exhale (6-8 times).

12. I.P. standing with your back to the back of the chair half a step away. Turns the body to the right and left with the hands touching the back of the chair. (8-10 times).

13. I.P. standing in front of the chair seat. Put your straight leg on the seat. Hands up - inhale. Bend the leg at the knee, forward, hands on the knee - exhale. Also with the other leg (6-10 times).

14. I.P. standing behind the chair, legs together, hands on the belt. Take the right leg to the side on the toe, the left arm up - inhale. Tilt to the right - exhale. The same in the other direction (6-8 times).

15. I.P. also. To rise on socks is a breath. Sit down and straighten up - exhale (5-6 times).

16. I.P. standing, legs together, arms along the torso. Hands through the sides up - inhale. Hands through the sides down - exhale (3-4 times).

17. I.P. same, hands on the belt. The rotation of the body clockwise and counterclockwise (8-10 times).

18. I.P. also. Free abduction of arms to the right - to the left (6-8 times).

19. I.P. sit astride a chair, hands on the back of a chair. Alternately raising the legs forward - up, not leaning back (6-8 times). The breath is arbitrary.

20. I.P. also. Hands up - inhale. Put your hands on the back of the chair, relax the muscles of the body - exhale (2-3 times).

21. The same. Torso rotation. The breath is arbitrary. Change the direction of movement (4-6 times).

22. I.P. sitting on the edge of a chair. Hands to hand - inhale. Pull the knee to the chest - exhale. The same pulling up the other knee (6-8 times).

23. I.P. also. Lean against the back of a chair, spread your arms and legs to the sides - a breath. Sit straight - exhale (6-8 times).

24. I.P. sitting, hands on your knees. Hands slide on the body - inhale, return to I.P. - exhale (2-3 times).

25. I.P. also. Tilting the head to the right, left, forward, backward - rotation of the head (8-10 times). Relaxation.

After carrying out bicycle ergometry (VEM) and determining an individual threshold load and a training pulse, bicycle trainings are carried out for 10 minutes with an intensity of 40% of the threshold load.

From the first days of stay in the sanatorium, patients are prescribed dosed walking, the rate increases gradually: from 70 steps in 1 minute at III SDA to 100-110 steps in 1 minute on V and VI SDA (table 1).

The load during dosed walking is increased by increasing the pace, lengthening the path and reducing the number of stops. Starting from V SDA, the interval walking method is used: changing the pace using pauses.

In addition to dosed walking, patients are recommended daily walks in 2-3 doses up to 2-2.5 hours a day. Walking volume gradually increases from 2 to 7-10 km per day. The walking speed also increases during walks, but it remains less than with dosed walking, about 10 steps per minute.

Patients belonging to grades 1 and 2 of severity have no contraindications to the expansion of the motor regime and easily master the rehabilitation program from III to VI SDA. Patients of grades 3 and 4 due to the presence of serious complications need a careful, gradual expansion of motor activity.

The effectiveness of the sanatorium rehabilitation phase is evaluated according to the following criteria:

1. improving the well-being of the patient, reducing the frequency of development of repeated cardiovascular disasters

2. dose reduction of coronary drugs

3. reduction or disappearance of angina attacks

4. positive ECG dynamics, lowering blood pressure

5. increased exercise tolerance

6. The transition from a lower to a higher functional class.

The study included 68 people aged 60 to 77 years (68.5 ± 4.5 years) who had primary myocardial infarction. MI was diagnosed according to WHO criteria (1970), based on a characteristic attack of anginal pain lasting more than 30 minutes, with typical ECG changes.

Patients are divided into two groups. Patients of the main group (n = 51) received physical rehabilitation at the sanatorium stage of rehabilitation treatment according to the proposed method, patients of the control group (n = 17) did not receive the sanatorium stage of rehabilitation, without any medical contraindications. The studied groups of patients were comparable by sex, age, and localization of primary MI. Comparative clinical characteristics of patients are presented in table 2.

table 2 Clinical characteristics of patients Clinical data Main group Control group Abs. Number % Abs. Number % Front IM 39 76.5 9 53 Rear IM 10 19.5 8 52 Circular IM 2 four 0 0 Large focal MI 27 53 8 52 Small focal IM 24 52 9 53 Heart Failure (by Killip) I class 43 84.3 12 71 II class 8 15.7 5 29th The presence of aneurysm of the heart eleven 21.6 0 0

In addition, in the main group, ventricular arrhythmias were observed in 19% of cases, while in the control group their frequency was 6%.

The presence of heart aneurysm was detected only in the main group and amounted to 21.6%.

The presence of angina attacks of the II-III functional class amounted to 35% of patients in the main group and 52.9% in the control group. Severe left ventricular dysfunction (PV 40%) was detected in 7.8% of patients in the main group and 11.8% in the control group.

The duration of the stationary phase is the same in both groups and averaged 19.5 bed days. Analysis of outpatient records of patients showed that the average number of days of disability in the main group was 129.5 and 106 in the control group. 76.5% of patients in both groups returned to work; the frequency of repeated myocardial infarction over two years of observation in the main group was 9.8% and 11.8% in the control group. Over 70% of the patients of the main group in the first year did not have a single re-hospitalization due to exacerbation of coronary heart disease, while in the control group in the first year each of the patients had re-hospitalization.

Thus, in our study, it was shown that in a homogeneous group of elderly patients who underwent primary myocardial infarction, relatively the same in severity, the inclusion of physical rehabilitation methods at the sanatorium stage in the program proved its effectiveness. Despite the increase in the period of incapacity for work in the long-term period, the risk of developing repeated MI is significantly reduced, and the frequency of repeated hospitalizations is significantly reduced.

Example 1

Patient E., 65 years old, was transferred to the cardiology department of the Prokopyevsky sanatorium on the 22nd day from the onset of acute myocardial infarction.

Ds: IHD: primary small focal (m / o) myocardial infarction of the septum, apex, side wall. KhKN 2 tbsp; CHF 1 tbsp. Fc 2

Hypertension of the III degree, risk 4.

CVB: recurrent thromboembolism in the vessels of the brain (in the MCA on the left in 2004 and January 2006)

Diabetes mellitus type 2 moderate, subcompensation, in the framework of the metabolic syndrome.

From the anamnesis.

Two years ago, he suffered an ischemic stroke in the MCA pool on the left. When hospitalized in the neurological department, hypertension and diabetes were first detected.

Five months ago, he suffered a recurrent ischemic stroke in SMA with right-sided hemiparesis of stage 2. After the sanatorium rehabilitation, a complete restoration of the function of the limbs took place and after 3 months I started working in the specialty.

Against the background of regular medical treatment (enap, verapamil, cardiomagnyl, diabetes MB, vasilip), an attack of pressing-burning chest pain at rest lasted about 30 minutes for the first time, stopped with nitrosorbide and was hospitalized in the cardiology department. In the dynamics of the ECG, signs of m / v of anterior myocardial infarction formed.

When examined in a hospital:

General blood test (OAK) - no features (b / o), general urine analysis (OAM) - b / o.

Blood sugar 13.06 mmol / L. Glycemic profile: 9.8-6.7-6.5-10.7 mmol / L.

R-graphy of the chest organs (OGK): no infiltrative changes. Violations of hemodynamics of the small circle were not detected.

Echo-KG: the cavities of the left ventricle, right ventricle, left atrium are enlarged. Aorta 3.2 cm, the walls are sealed. Valves b / o. There are no zones of myocardial hypokinesia. PV 50%.

In the hospital, coronary pains were repeated often during the week, then 0-1 times a day. At the time of transfer to the sanatorium, he mastered the third stage of motor activity.

Upon admission to the sanatorium, angina attacks persisted within the 2 functional class, circulatory failure stage 2A. An objective examination of the general condition is satisfactory. The physique is hypersthenic. Subcutaneous fatty tissue is excessive. The skin is normal in color. No swelling. Pulse 92 beats per minute, rhythmic. Heart sounds are muffled, heart murmurs are absent. HELL 130/90 mm Hg The respiratory rate (BH) is 21 per minute, with percussion of the lungs, the sound is pulmonary with a box tint, vesicular breathing, no wheezing. The tongue is wet, coated with a white coating. The abdomen is soft, painless. The liver is not enlarged.

When examined in a sanatorium:

In OAK, - without features, in OAM sugar 2%, blood sugar 15.0 mmol / L. According to the ECG - sinus tachycardia of 96 beats per minute, single and paired ventricular extrasystoles, left ventricular myocardial hypertrophy with signs of systolic overload. M / o apical and lateral myocardial infarction, in the stage of scarring.

According to the daily monitoring of ECG and blood pressure, tachycardia was registered during the day (max 127 beats per min), a single ventricular extrasystole 33 per hour in the afternoon, 15 per hour at night; paired ventricular extrasystole about 1 per hour; episode of group ventricular extrasystole in the daytime. Violation of the rhythm corresponds to IV B class according to Laun. 3 episodes of depression ST≥1 mm when walking (heart rate> 120 beats per min) were detected, were accompanied by coronary pains, against the background of blood pressure> 160/110 mm Hg. The dynamics of blood pressure per day is characteristic of moderate arterial hypertension.

Given the results of the study, the patient was assigned grade 3 severity, SDA III, according to which physiotherapy exercises were prescribed with the appropriate set of exercises 2 hours after breakfast and dosed walking at 500 m at a pace of 70 steps per minute 2 hours after lunch. Coronary and hypoglycemic therapy has been strengthened (the dose of nitrates, BAB, diabetes, diuretics has been increased).

Against the background of the treatment, the patient retained coronary pains within 2 FC, signs of heart failure decreased. According to the ECG - sinus rhythm of 76 per min, extrasystoles were not recorded, in the state of the myocardium positive dynamics due to a decrease in signs of systolic overload of the left ventricle.

The 24-hour monitoring of ECG and blood pressure recorded a sinus rhythm of 56-98 beats per minute, single rare ventricular extrasystoles, and no ischemic changes were detected.

With bicycle ergometry, a threshold load of 50 W with ECG signs of myocardial ischemia with a heart rate of 108 beats per minute, a training pulse of 92 beats per minute.

Blood sugar in dynamics decreased to 8.6 mmol / L.

The patient was prescribed physiotherapy exercises according to IV mode, dosed walking 600 m per day at a pace of 80-90 steps per minute, cycling intensity of 20 W for 10 minutes. A course of 10 workouts. Daily walks in 3 receptions with a total duration of 2 hours at a distance of 2 km.

By the time of discharge from the sanatorium, the patient had no signs of heart failure, rare episodes of coronary pain remained within 1 fc, ECG showed positive dynamics, single ventricular extrasystoles corresponding to Graduation I according to Laun were recorded by daily monitoring of ECG and blood pressure. Thus, at the time of discharge, the patient mastered IV SDA and corresponded to grade 1 severity according to the proposed classification.

Example 2

Patient A., 67 years old, was transferred to the cardiology department of the Prokopyevsky sanatorium on the 24th day from the onset of myocardial infarction.

Ds: IHD: primary m / o myocardial infarction of the septum, apex, side wall. HKN 1 tbsp., CHF 1 tbsp. FC 1

Hypertension of the III degree, risk 4.

From the anamnesis.

Hypertension 10 years, did not receive continuous antihypertensive therapy, was not observed by a cardiologist.

Against the background of intense physical conditions, an attack of pressing-burning chest pain at rest lasted about 30 minutes for the first time, and therefore he was hospitalized in the cardiology department for emergency treatment. In the dynamics of the ECG, signs of m / v of anterior myocardial infarction formed.

When examined in a hospital:

OAK - n / a, OAM - n / a.

OGK R-graph: no infiltrative changes. Violations of hemodynamics of the small circle were not detected.

Echo-KG: the cavity of the left ventricle of the Aorta is expanded 3.2 cm, the walls are sealed. Valves b / o. There are no zones of myocardial hypokinesia. PV 45%.

In the hospital, coronary pains did not recur. At the time of transfer to the sanatorium, he mastered the 4th SDA.

When entering the sanatorium no complaints.

An objective examination of the general condition is satisfactory. The physique is normosthenic. The skin is normal in color. No swelling. The pulse is 76 beats per minute, rhythmic. Heart sounds are muffled, heart murmurs are absent. HELL 130/90 mm Hg BH 18 per minute, with percussion of the lungs, the sound is pulmonary, vesicular breathing, no wheezing. The tongue is wet, clean. The abdomen is soft, painless. The liver is not enlarged

Prescribed medication selected in a hospital (nitrates, BAB, and PF, antiplatelet agents, statins).

When examined in a sanatorium:

At OAK, OAM is without features. On an ECG - sinus rhythm of 68 beats per minute, left ventricular myocardial hypertrophy. M / o apical and lateral myocardial infarction, in the stage of scarring.

According to the daily monitoring of ECG and blood pressure, a sinus rhythm of 52-98 beats per min, a single ventricular ekstasistoliya was registered. Violation of the rhythm corresponds to class I according to Laun. No ischemic changes were detected. The dynamics of blood pressure per day is characteristic of moderate arterial hypertension.

By VEM, the threshold load of 100 watts upon reaching submaximal heart rate without ischemic changes. Training pulse 100 beats per min.

Given the results of the study - SDA IV, Grade 1. IV exercise was prescribed for IV mode, dosed walking at 1 km per day at a pace of 70 steps per minute 2 hours after lunch, cycling with an intensity of 40 watts for 10 minutes 1 hour before lunch with a course of 14 workouts. Daily walks in 2 receptions lasting 2 hours at a distance of 5 km.

Against the background of the treatment, the patient showed no signs of coronary and heart failure.

On an ECG - positive dynamics. The results of daily monitoring of ECG and blood pressure and the threshold load for VEM remained the same. The patient was transferred to V SDA, severity class 1. He continued exercise therapy according to V mode, dosed walking at 1.25 km at a pace of 80-90 steps per minute, cycling with 40 W intensity lasting 10 minutes was continued. Walks daily in 2 receptions lasting 2.5 hours at a distance of 7 km

By the time of discharge from the sanatorium, the patient had no signs of cardiac and coronary insufficiency, ECG showed positive dynamics, single ventricular extrasystoles, corresponding to Grad I according to Laun, were recorded by daily monitoring of ECG and blood pressure.

Thus, at the time of discharge, the patient mastered V SDA and corresponded to grade 1 severity according to the proposed classification.

Example 3

Patient M., 64 years old, was transferred to the cardiology department of the Prokopyevsky sanatorium on 21 days from the onset of myocardial infarction.

Ds: coronary heart disease: primary large focal (c / o) anterior-widespread myocardial infarction. Aneurysm of the anterior wall of the left ventricle, ventricular extrasystole NK 0-1 tbsp. Arterial hypertension III, risk 4, decompensation.

From the anamnesis.

Hypertension 10 years, did not receive continuous antihypertensive therapy, was not observed by a cardiologist.

Against the background of intense physical conditions, an attack of pressing-burning chest pain at rest lasted about 30 minutes for the first time, and therefore he was hospitalized in the cardiology department for emergency treatment. In the dynamics according to the ECG, signs of c / o anterior myocardial infarction formed.

When examined in a hospital:

OAK - n / a, OAM - n / a.

OGK R-graph: no infiltrative changes. Violations of hemodynamics of the small circle were not detected.

Echo-KG: the cavity of the left ventricle of the Aorta is expanded 3.2 cm, the walls are sealed. Valves b / o. Akinesia of the anterior wall of the left ventricle and interventricular septum. Aneurysm in the apex. PV 34%.

In the hospital, coronary pains did not recur. At the time of transfer to the sanatorium, he mastered the 3rd SDA.

When entering the sanatorium no complaints.

An objective examination of the general condition is satisfactory. The physique is normosthenic. The skin is normal in color. No swelling. Pulse 63 beats per minute, rhythmic. Heart sounds are muffled, heart murmurs are absent. HELL 130/90 mm Hg BH 18 per minute, with percussion of the lungs, the sound is pulmonary, vesicular breathing, no wheezing. The tongue is wet, clean. The abdomen is soft, painless. The liver is not enlarged

Prescribed medication selected in a hospital (nitrates, BAB, ACE inhibitors, antiplatelet agents, statins).

When examined in a sanatorium:

In OAK, OAM - without features. On an ECG - sinus rhythm of 60 beats per minute, left ventricular myocardial hypertrophy. To / about anterior myocardial infarction, in the stage of scarring. The aneurysm of the apex.

According to the daily monitoring of ECG and blood pressure, a sinus rhythm of 52-90 beats per minute, a single ventricular extrasystole, were recorded. Violation of the rhythm corresponds to class I according to Laun. No ischemic changes were detected. The dynamics of blood pressure per day is characteristic of moderate arterial hypertension.

According to VEM, a threshold load of 50 W without ischemic changes. Training pulse 88 beats per min.

Given the results of the study - SDA III, grade 3 severity. Exercise therapy was assigned according to mode III, dosed walking at 500 m at a pace of 70 steps per minute, 2 hours after lunch, cycling with an intensity of 20 W for 10 minutes 1 hour before lunch.

Against the background of the treatment, the patient showed no signs of coronary and heart failure.

On an ECG - positive dynamics. The results of daily monitoring of ECG and blood pressure and the threshold load for VEM remained the same. The patient was transferred to IV SDA, severity class 3. He continued exercise therapy according to IV mode, dosed walking at 700 m per day at a pace of 80 steps per minute, cycling with an intensity of 20 W for 10 minutes, course 14. Daily walks up to 4 km in two doses lasting 2 hours a day.

By the time of discharge from the sanatorium, the patient had no signs of cardiac and coronary insufficiency, ECG showed positive dynamics, single ventricular extrasystoles, corresponding to Grad I according to Laun, were recorded by daily monitoring of ECG and blood pressure. Thus, at the time of discharge, the patient mastered IV SDA and corresponded to grade 3

From the above data it is seen that the proposed method used in the rehabilitation department of patients who have suffered myocardial infarction of the Sanatorium Prokopyevsky OJSC allows to reduce the incidence of recurrent cardiovascular catastrophes (recurrent myocardial infarction, acute cerebrovascular accident), reduce the rate of primary disability, increase exercise tolerance.

Claims (1)

A method of physical rehabilitation of patients who have had myocardial infarction (MI) in old age at the sanatorium stage of rehabilitation, including general clinical and instrumental examination: resting ECG, bicycle ergometry test, echocardiography, 24-hour monitoring of blood pressure and ECG by Holter, drug therapy and physical training using physiotherapy exercises , exercises on a stationary bike, dosed walking, characterized in that they determine exercise tolerance by conducting a 6-minute walk test and bicycle ergometry tests, determine the level of motor activity (SDA) according to the classification of D.M. Aronov and the functional severity class of the patient’s condition from 1 to 4, while at the III stage of activity, class 1 severity is established with a period from the onset of MI 14-18 days, no attacks angina pectoris or 1-2 fc, circulatory failure (NK) 0-1, the absence of arrhythmias of the third gradation and higher according to Laun, the absence of aneurysm, with an ejection fraction of more than 40% by echocardiography, grade 2 severity with a period from the start of MI 18-20 days , the presence of angina 1-2 fc, NK 1-2A, the absence of arrhythmia third gradations and higher according to Laun, the absence of aneurysm, establish grade 3 severity with a period from the start of MI 20-23 days, the presence of angina pectoris 2-3 fc, NK 1-2A, set grade 4 severity with a period from the start of MI 23-30 days, availability angina pectoris 3-4 fc, NK 2-3, the presence of arrhythmias of the third gradation and higher according to Laun, the presence of aneurysm, when the ejection fraction of the PV is less than 40%, grade 1 severity is established at the IV stage of activity with a period from the onset of MI 24-28 days, absence angina attacks or the presence of angina pectoris 1 fc, NK 0-1, the absence of arrhythmia, the absence of aneurysm, with EF more than 40%, establish grade 2 severity with a period from the onset of MI 28-30 days, the presence of angina pectoris 1-2 fc, NK 0-1, the absence of arrhythmia, the absence of aneurysm, establish grade 3 severity with a period from the start of MI 30-33 days, the presence of angina 2- 3 fc, NK 1-2A, establish grade 4 with a period of 33-40 days from the onset of myocardial infarction, presence of angina pectoris 3-4 fc, NK 2-3, presence of arrhythmia of 3 gradations and higher in Laun, aneurysm, with EF less than 40% , at the V stage of activity, 1 severity class is established with a period from the onset of MI 30-34 days, absence of angina attacks or the presence of angina pectoris 1 fc, NK 0-1, from the absence of arrhythmia, the absence of aneurysm, with an EF of more than 40%, establish a grade 2 severity with a period from the onset of MI 34-36 days, the presence of angina pectoris 1-2 fc, NK 1-2A, the absence of arrhythmia, the absence of aneurysm, establish grade 3 severity from the onset of myocardial infarction 36-39 days, the presence of angina pectoris 2-3 fc, NK 1-2A, establish grade 4 with a period from the beginning of myocardial infarction 39-43 days, the presence of angina pectoris 3-4 fc, NK 2-3, the presence of arrhythmia 3 gradations and above Laun, the presence of aneurysm, with PV less than 40%, at the VI stage of activity, class 1 severity is established with a period of 36-40 days from the onset of MI, the absence of angina pectoris or the presence of angina pectoris 1 fc, NK 0-1, the absence of arrhythmia, the absence of aneurysm, with EF more than 40%, establish grade 2 severity with a period from the beginning of myocardial infarction 40-46 days, the presence of angina pectoris 1-2 fc, NK 1-2A establish grade 3 severity with a period from the onset of MI 46-49 days, the presence of angina 2-3 fc, NK 1-2A, establish grade 4 with a period from the beginning of IM 49-54 days, the presence of angina 3-4 fc, NK 2- 3, the presence of arrhythmias of 3 gradations and higher according to Laun, the presence of aneurysm, with EF less than 40%; they choose the appropriate set of physical therapy exercises (LFK) according to SDA and conduct LFK classes 2 hours after breakfast during the entire rehabilitation phase, on the basis of a certain functional class of severity, conduct classes with an increase in load of 25% for each class, dosed walking from 0.5 km at a pace of 70 steps per minute to 2 km at a pace of 100-110 steps per minute 2 hours after lunch, daily walks in 2-3 steps lasting 2-2.5 hours per day for a distance of 2 to 10 km, per 1 h before lunch carry out bicycle training with an intensity of 40% of the threshold load narrow duration of 10 minutes, the course of 10-14 training sessions all conducted under the supervision of hemodynamics, with the results of the control of instrumental studies possible transfer of the patient to the next level of physical activity