Physical Rehabilitation (Treatment Strategies in Cardiac Transplantation) Part 3

Flexibility exercises

Stretching exercises should be conducted to promote gains on range of motion, balance, to stretch the muscles of the neck, lower back, upper and lower limbs. Exercise with elastic can be performed in small series of ten repetitions for each muscle prioritizing posterior trunk and involving large joints of hip, knee, elbow and shoulder.

Aquatic exercise

Physical activity in aquatic environment is little reported after cardiac transplantation. However, a case report demonstrated potential benefits of training in heated swimming pool at 30-31°C, 1.40 meters of depth, with sessions of 40 minutes of exercise: 5-minute warm up, 15 minutes of walking on water, 15-minute workout with weights involving large joints and 5 minutes of relaxation. Physical activity in aquatic environment is a well established method of rehabilitation for patients with significant functional limitations and has proven to be effective in cases of obesity after transplantation.

Implication of drug therapy in exercise

During the last 25 years there has been a significant increase in survival of patients undergoing heart transplantation (Guba, 2002), generally, as a result of advanced immunosuppressive therapy to control organ rejection since the transplanted heart originates from another organism, and the recipient’s immune system attempt to reject it.

But the most widely used therapy is the combination of several drugs that have different modes of action and potential. Some side effects of the use of immunosuppressive medication may appear early in the drug treatment and can be minimized with appropriate modifications and adjustments of schedules and doses (Chart 1, 2 and 3).


Since the late onset side effects must be controlled with the inclusion of specific drugs to control the clinical signs and symptoms of the patient. The latter is represented by corticosteroids, calcineurin inhibitors and TOR inhibitors.

Corticosteroids (Prednisone) act as a nonspecific anti-inflammatory, so the rejection process suffers a direct influence of the recruitment and activation of T-helper lymphocytes. The TOR inhibitors: Tacrolimus (also known as FK-506 or Fujimycin) has a similar action to cyclosporine and is used as a second option to cyclosporine, and Sirolimus, also known as rapamycin, has an inhibitory effect on activation and proliferation of T cells. So, these immunosupressive drugs reduce the infection risk, but may have some undesirable adverse effects (Bortolotto, 1997; Fiorelli, 1996), such as nephrotoxic effects, artery damage and narrowing, left ventricle hypertrophy, increased likelihood of bone fractures and infections. These entire side effects contribute to related health problems over time, so it makes professional responsible for their physical rehabilitation more attempted to effects during exercise as increased blood pressure, transient ischemic attack (TIA).

Moreover, there has been growing clinical consensus that specific training regimens (endurance and resistance) in heart transplant recipients can be efficacious adjunctive therapies in the prevention of immunosuppression-induced side effects and may be an effective countermeasure for corticosteroid-induced osteoporosis and skeletal muscle myopathy.

In contrast, those who do not participate in resistance training lose approximately 15% BMD from the lumbar spine early in the postoperative period and experience further gradual reductions in BMD and muscle mass late after transplantation. (Braith, 2000) Chart 3. Side effects and mainly antiproliferative agents interferences.

Medicine

Side Effects

Exercise limitations

Corticosteroids (Prednisone)

Hypertention

Left ventricle hypertrophy, damage to the arteries, brain, heart, kidney and even sudden death.

Hyperglycemia

Damage to the arteries, brain, heart, and kidney.

Hyperlipidemia

Damage to the arteries, brain, heart, and kidney.

Diabetes

Damage to the arteries, brain, heart, and kidney, peripheral neuropathy, loss of balance and falls.

Weight gain

Gallstones and Diabetes.

Osteoporosis

Bone fracture


Cushingoid appearance

NA

Mood changes

Not adherence to an exercise protocol

Cataract

Incoordination and loss of balance

Calcineurin

inhibitors

(Cyclosporine)

Kidney

vasoconstriction

Nephrotoxicity and sodium retention (which contribute to body plasma volume)

Hyperkalemia

Cardiopulmonary arrest

Hypertension

Left ventricle hypertrophy, damage to the arteries, brain, heart, kidney and even death.

Venous thrombosis

Pulmonary thromboembolism

Migraine

Not adherence to an exercise protocol

Tremor

Incoordination

Paresthesia

Loss of balance and falls

Gout

Pain and ROM limitation

Gum hyperplasia

NA

Hepatotoxicity

NA

Chart 1. Side effects and mainly corticosteroids and calcineurin inhibitor interferences. NA: not applicable. ROM: range of motion.

Medicine

Side Effects

Exercise limitations

Tacrolimus

Kidney

vasoconstriction

Nephrotoxicity (similar to cyclosporine)

Hypertension*

Left ventricle hypertrophy, damage to the arteries, brain, heart, kidney and even sudden death.

Hyperlipidemia*

Damage to the arteries, brain, heart, and kidney.

Diabetes #

Damage to the arteries, brain, heart, and kidney, peripheral neuropathy, loss of balance and falls.

Sirolimus

Bone marrow aplasia

Thrombocytopenia, anemia and leukopenia

Hyperlipidemia

Damage to the arteries, brain, heart, and kidney.

Peripheral edema

Difficulty on progressing ROM, loss of balance and falls.

Wound healing impairment.

Incapacity of moving the affected area, not adherence to an exercise protocol.

Chart 2. Side effects and mainly TOR inhibitors interferences. * fewer than cyclosporine’s side-effect; # greater than cyclosporine’s side-effect;

Medicine

Side Effects

Exercise limitations

Azathioprine

Neutropenia and thrombocytopenia

Increased risk of infections, venous thrombosis, pulmonary thromboembolism anemia, and bleeding.

Nausea, vomit

Not adherence to an exercise protocol

Pancreatitis,

hepatotoxicity and cancer.

NA

Mycophenolate

Neutropenia

Increased risk of infections

Nausea, vomit

Not adherence to an exercise protocol

Final comments

Heart transplantation is indicated as therapy for patients in the end stage of heart failure. These patients, despite the fact they trade their damaged hearts for functional ones, they remain with several impairments, as muscle weakness, and develop some other disabilities because of the transplantation procedure itself and due to the use of required drugs to control rejection.

Regular physical activity in general has shown potential benefits for the control and reduction of chronic degenerative diseases, which should be incorporated as a therapeutic agent after cardiac transplantation. However, studies on cardiac rehabilitation in transplanted patients are isolated and inconclusive regarding the answer in the long term effect on the immune system, neurohormonal, musculoskeletal and adherence to the program. Furthermore, these studies refer only to cardiovascular training, leaving aside structural and postural changes, such as rotations, shoulder girdle and pelvic misalignments-scapular of the patient, which can be found in the majority who have some functional deviation as stiffed vertebral joints and shorten muscle. Another important aspect that we consider is the socio-cultural reference of transplant patients, which can often limit or even refuse to participate on a physical training program.

The effect of physical conditioning after transplantation is mainly attributed to higher peripheral efficiency, but there has also been found a degree of cardiac adaptation.

In current practice of heart transplant recipients’ therapy, further studies are needed to elucidate the role of physical activity on the interaction of physiological and clinical responses in this group of patients.

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