IJCS | Volume 32, Nº6, November / December 2019

648 Figure 1 - Skin ulceration before and after the CMR. favors the entire tissue healing process. Additionally, CMR resulted in improved glycemia and lipid control, a condition that favors the ulceration healing and controls the evolution of the atherosclerotic disease. 7 Strongly corroborating this hypothesis, Murphy et al., 5 carried out a study in which 111 subjects with lower-limb PAOD were randomized into three groups. A group received only pharmacological treatment, a group underwent coronary artery bypass grafting in the region affected by PAODplus pharmacological treatment and a group that underwent a supervised walking training plus pharmacological treatment. The authors found that after a six-month period, the exercise group increased walking tolerance more than the CABG group and themedication group. The same result was identified in the questionnaire that was applied in this study and investigated the limitation that claudication brings to activities of daily living. It was concluded that, of the three treatments, the supervisedwalking exercise was the best treatment option, considering the cost-benefit ratio. However, despite evidence such as this and cases such as the one reported herein, there are few patients with lower-limb PAOD who are referred to CMR services to undergo a specific and supervised treatment. A study carried out in 2002 by Nunes et al., 3 reported that more than 180 people a year are amputated because of lower-PAOD in the city of Salvador, state of Bahia, Brazil. There are reports in the literature that support the idea that a CMR program could in many cases avoid amputation. A study published in 2011 1 reports the case of a patient with lower-limb PAOD that avoided amputation after undergoing a supervised treadmill walking program. Such evidence suggests that other patients with lower-limb PAODmay benefit fromCMR. It is also interesting to note that in the case reported herein, before the patient underwent the CMR, she had already undergone unsuccessful physical therapy with laser, ultrasound and microcurrent sessions for the ulceration healing. She had also been undergoing two years of topical pharmacological treatmentwithnopositive response. However, when the pharmacological treatment was associated with CMR and physical therapy, the ulceration healing was attained. It should be noted in this case the fact that theCMRprogram, using treadmillwalking as the main exercise type, was crucial for the patient’s clinical and functional improvement andulcerationhealing and how the interdisciplinary interaction is essential to optimize the treatment of lower-limb PAOD. Physical exercise is fundamental for the control of two of themainmodifiable risk factors for the development of lower-limb PAOD - diabetes mellitus and dyslipidemia. According to Conte et al., 6 the main modifiable risk factors for PAOD are dyslipidemia, diabetes mellitus and smoking. Therefore, the visible metabolic improvement in this case, both in triglyceride and plasma lipoprotein levels, as well as glycemia, also favored the patient’s clinical and functional improvement. Brandão et al., 2 reported that each 10% reduction in total cholesterol Petto et al. Physical exercise for skin ulceration secondary to peripheral disease Int J Cardiovasc Sci. 2019;32(6):645-649 Case Report