IJCS | Volume 32, Nº6, November / December 2019

647 Table 1 - Evolution of laboratory variables pre- and post-cardiovascular rehabilitation (six months) Variables Pre-CR Post-CR Normal values Triglycerides (mg/dL) 276 119 < 150 mg/dL HDL (mg/dL) 41 51 > 50 mg/dL LDL (mg/dL) 58 39 < 130 mg/dL Total cholesterol (mg/dL) 154 114 < 200 mg/dL Glycemia (mg/dL) 172 130 < 100 mg/dL Glycated hemoglobin (%) 9.8 7.8 Between 4.0 and 5.6% Creatinine (mg/dL) 1.5 1.5 Between 0.6 and 1.1 mg/dL HDL: high-density lipoprotein; LDL: low-density lipoprotein; CR: cardiovascular rehabilitation. treatment. For the treadmill use, a maximum walking tolerance test, described by Petto et al., was applied at a velocity of 1.5 km/h on a treadmill without inclination. The maximum walking tolerance road was reached at 280 seconds (4 minutes and 7 seconds). The trainingwas prescribed based on this test. The first two sets were performedwith 60%and, the last four, with 80% of the maximum walking tolerance obtained at the test (280 seconds) at a speed of 1.5 km/h, the same speed used in the test. This totaled 1,232 seconds of walking, approximately 4.5 times the total time obtained at the walk tolerance test. The test was performed monthly for the increase in time and speed employed for the training, which lasted three months. Therefore, the total time of CMRwas six months, with the first three months being dedicated to neuromuscular exercises for upper and lower limbs, arm cycle ergometer and IMT, twice a week. In the last three months, the cycle ergometer was replaced by the ergometric treadmill and CMR started to be performed three times a week. It is important to note that the pharmacological treatment, laser therapy, ultrasound and microcurrent for the ulceration healing were maintained from the beginning to the end of the CMR. Results Table 1 shows the evolution of the metabolic variables after the CMR. The great improvement in the patient’s lipid profile and fasting glycemia can be observed, factors that positively contribute to the clinical and functional improvement of patients with PAOD. The reduction in the glycated hemoglobin levels demonstrates the glycemic control improvement throughout the CMR program. This figure shows that the heel ulceration was healed, after the three-month treadmill training. No ulceration improvement was seen in the first three months of CMR. In addition to the ulceration healing, the patient improved her treadmill performance, being able to carry out uninterrupted walks at a speed of 5.5 km/h for 30 minutes. It is worth emphasizing that this gain probably occurred due to the blood flow improvement in the affected limb, caused by the opening of the collateral circulation and angiogenesis (formation of new capillaries), therefore promoting ulceration healing and walking performance improvement. In addition to these improvements, the patient after six months of treatment was able to reduce drug dose for hypertension (Manidipine), diabetes mellitus (NPH and metformin) and dyslipidemia (atorvastatin). Discussion Physical exercise has been increasingly becoming significant in the treatment of peripheral vascular diseases because it is a non-invasive method, it has a positive impact on the quality of life and functional status, in addition to being a low-cost and high- effectiveness treatment. 7 Locatelli et al., 8 report that a physical exercise program that combines treadmill walking with neuromuscular exercises (resistance exercises with weights) is the one that significantly increases the maximum pain-free walking distance in patients with lower-limb PAOD and intermittent claudication. That occurs because walking training stimulates the opening of collateral circulation and also angiogenesis. 9 These two mechanisms are the main responsible ones for the improvement in the perfusion of the affected region, reducing ischemia and its consequences. Specifically in this reported case, the ulceration healing was due mainly to the improved blood irrigation, which Petto et al. Physical exercise for skin ulceration secondary to peripheral disease Int J Cardiovasc Sci. 2019;32(6):645-649 Case Report