IJCS | Volume 32, Nº6, November / December 2019

646 Rehabilitation Service of the URMEC Clinic in Santo Antônio de Jesus, BA, Brazil inDecember 2014, diagnosed with PAOD. The arteriography disclosed 100% of occlusion in the popliteal, anterior and posterior tibial arteries of the right lower limb. According to the medical report, the patient was submitted to coronary artery bypass grafting (CABG) with three grafts: distal third of the posterior descending artery, proximal third of anterior descending artery and circumflex artery. She had been diagnosed with systemic arterial hypertension 15 years ago and type II diabetes mellitus for 8 years, with both conditions under pharmacological treatment. She had osteopenia in the pelvic region and in the head of the femur. She reported symptoms of chronic fatigue at moderate exertion, compatible with functional class II heart failure during the anamnesis. The physical examination disclosed diffuse sarcopenia, mainly in the upper and lower limbs, blood pressure of 180/100 mmHg. She had an ulceration in the posterior side of the right heel in progress for 24 months, undergoing topical pharmacological treatment (Papain and Chlorhexidine). For the skin ulcer treatment, the patient also reported that she had undergone physical therapy sessions (32 sessions) with laser, microcurrent and 3MHZ ultrasound. She did not show any signs of pulmonary congestion and cyanosis of the extremities. These findings corroborated the idea of a good prognosis for the heart failure, since it was characterized as non- congestive and warm. The 24-hour ambulatory blood pressure monitoring (ABPM) showed mean BP of 160/90 mmHg with absence of nocturnal dipping. The fasting laboratory tests showed: triglycerides 276 mg/dL, high-density lipoprotein (HDL) of 41 mg/dL, low-density lipoprotein (LDL) of 58 mg/dL, total cholesterol of 154 mg/dL and glycemia of 172 mg/dL. At the end of the evaluation, the patient’s main complaint was ambulation difficulty, due to the heel ulceration and the difficulties caused by this condition when performing the activities of daily living. She was receiving treatment with the following drugs: NPH insulin, 25 IU/mL at 8 AM and 20 IU/mL at 8 PM; Metformin, 500 mg at 8 AM and 12 PM; Olmesartan, 40 mg at 8 AM; Indapamide, 1.5 mg at 8 AM, Manidipine, 20 mg at 8 AM; Atorvastatin, 80 mg at 7 PM; Clopidogrel, 75 mg at 7 PM; and Vitamin D, 1,200 IU twice a week. Based on the patient’s complaints and the possibilities of the exercise program, the aims of the study were: 10-20% reduction in the fasting glycemia and glycated hemoglobin values; normalization of fasting triglyceride values; reduction of 5 to 10mmHg in SBP and 5mmHg in DBP; increase in functional capacity by at least 20%; skin ulceration healing; increased tolerance to walking. An eight-month projection was estimated to reach the goals. Cardiovascular and Metabolic Rehabilitation Protocol The patient started the CMR by performing neuromuscular exercises for the upper and lower limbs, arm cycle ergometer for upper body training and inspiratory muscle training (IMT). In the first month, the neuromuscular exercises were performed twice a week on alternate days (Mondays and Wednesdays), with the exercises for upper limbs being performed on the first day and those for lower limbs on the second day. The exercises comprised two sets of 20 repetitions with a 2-minute interval between sets, with loads based on Borg’s rating of perceived exertion (RPE) scale between 9 and 11. After the first month, the neuromuscular exercise schedule was readjusted to two sets of 12 repetitions with loads that stimulated a Borg scale score between 12 and 15. The load progression occurred monthly until the end of the treatment, which lasted six months. At the same session, after the neuromuscular exercises, the arm cycle ergometer training was performed for 20 minutes using a passive interval approach (active for five minutes followed by two minutes of passive rest). The load was also based on the Borg scale, being the first and second sets performed with Borg score between 9 to 11 and the last 3 with Borg between 12 and 14. The arm cycle ergometer was used until the third month of treatment. The IMT was performed at home with 30% of PImax in 30 daily repetitions carried out in sets of 10 repetitions, seven days a week. The IMT loadwas readjustedweekly, which persisted until the end of the first three months of treatment. After the thirdmonth, the IMTwas performed with no more progressive loads. After three months, a gel insole was manufactured for the ulcerated heel, which contained an orifice at the ulceration site allowing the treadmill training. Therefore, the arm cycle ergometer training was replaced by the treadmill at the beginning of the fourth month of Petto et al. Physical exercise for skin ulceration secondary to peripheral disease Int J Cardiovasc Sci. 2019;32(6):645-649 Case Report