Fizičko vežbanje u terapiji gojaznosti kod osoba obolelih od periferne vaskularne bolesti

Abstract

Uvod-Kardiovaskularne bolesti su vodeći uzrok smrti i radne nesposobnosti u Evropi, predstavljaju veliko socijalno i ekonomsko opterećenje. Bolesti periferne arterijske cirkulacije se mogu podeliti u dve celine i to na okluzivne i neokluzivne bolesti, odnosno funkcionalne smetnje. Učestalost arterijske bolesti donjih ekstremiteta snažno je povezana sa godinama starosti. Faktori rizika za perifernu arterijsku bolest su slični onima koji su važni u etiologiji koronarne arterijske bolesti: gojaznost, pušenje, dislipidemija, šećerna bolest, hipertenzija. Najtipičnija prezentacija periferne arterijske bolesti je intermitentna klaudikacija koja se karakteriše bolom u listovima koji se pojačava pri hodanju; bol obično nestaje u miru. Svi gojazni pacijenti sa perifernom arterijskom bolešću donjih ekstremiteta imaju povećan rizik od budućih kardiovaskularnih događaja, te je kod njih obavezna opšta sekundarna prevencija u cilju poboljšanja prognoze. Fizičko vežbanje predstavlja metodu izbora kod obolelih od periferne arterijske bolesti donjih ekstremiteta. Cilj istraživanja: Uporediti efekte programirane fizičke aktivnosti i medikamentozne terapije na hemodinamiku i riziko faktore za kardiovaskularna obolenja kod gojaznih osoba obolelih od periferne arterijske bolesti donjih ekstremiteta. Ispitanici i metode istraživanja: Obavila se retrospektivna-prospektivna, klinički deskriptivna, kontrolisana studija, na ispitanicima Javne Ustanove Domovi Zdravlja Kantona Sarajevo - Specijalističko konsultativna delatnost. OJ Specijalističko konsultativna delatnost predstavlja sekundarni vanbolnički nivo zdravstvene zaštite. Ovom studijom se evaluirao period od 20 nedelja (140 dana). U studiju je uključeno 75 ispitanika. Na početku istraživanja, na osnovu nalaza kolor Doppler sonografije pedalnih arterija, nalaza ejekcione frakcije leve komore, spirometrijskog nalaza, vrednosti pulsnog aortalnog pritiska te utvrđivanja preterane uhranjosti – gojaznosti ispitanici su uključeni u istraživanje. Osim ultrazvučnog nalaza i nalaza spirometrije, pacijenti su dali i iscrpnu anamnezu o prethodnim obolenjima. Uradilo se merenje indeksa telesne težine, obim struka i klaudikacione distance. Lipidogram kao i jutarnji šećer su bili urađeni za svakog pacijenta. Pacijentima je prepisana ili produžena medikamentozna terapija, te data detaljna upustva za svakodnevni program vazoaktivne šetnje. Rezultati istraživanja: Na početku istraživanja prosečna vrednost obima struka ispitanika je iznosila 87,94±3,07cm, nakon dve sedmice prosečan obim struka je iznosio 87,10±2,0 cm, a na kraju istraživanja 84,96±1,98cm. Na početku istraživanja ispitanici ispitivane grupe su imali indeks telesne mase od 28,93±2,10 kg/m2. Nakon dve sedmice istraživanja i provedene terapije indeks telesne mase se smanjio i iznosio 28,36±1,99 kg/m2, da bi na kraju istraživanja prosečna vrednost indeksa telesne mase u ispitivanoj grupi iznosio 27,26±1,87 kg/m2. Prosečna vrednost glukoze u krvi na početku istraživanja je iznosila 5,77±0,96 mmol/L, tokom istraživanja ta vrednost je bila 5,42±0,88 mmol/L, a na kraju istraživanja 5,30±0,92 mmol/L. Postprandijalna vrednost glukoze u krvi je na početku istraživanja iznosila7,48±0,85 mmol/L, tokom istraživanja ta vrednost je bila 6,82±0,62 mmol/L, a na kraju istraživanja 6,44±0,64 mmol/L. Na početku istraživanja vrednost HbA1c je iznosila 5,52±0,91%, tokom istraživanja 5,32±0,97%, a na kraju istraživanja 5,09±0,73%.Prosečna vrednost CRP-a na početku istraživanja je iznosila 3,77±1,12mg/L, tokom istraživanja vrednost je iznosila 3,66±1,36mg/L, da bi na kraju istraživanja ta vrednost iznosila 3,61±1,21mg/L. Uparenim t-testom nije ustanovljeno statistički značajno smanjenje ili povečanje CRP-a tokom istraživanja. Prosečna vrednost holestarola u krvi ispitanika na početku istraživanja je bila iznad referentnih vrednosti i iznosila 6,58±0,90 mmol/L. Nakon dve sedmice istraživanja i provedene terapije vrednost je iznosila 4,96±0,46 mmol/L, da bi na kraju istraživanja vrednost iznosila 4,15±0,54 mmol/L. Prosečne vrednosti triglicerida na početku i tokom istraživanja su bile povišene, da bi na kraju istraživanja bile u okvirima referentnih vrednosti. Razlika između VI vrednosti leptina kod muškaraca na početku i kraju istraživanja je iznosila 2,66±1,52 ng/ml (t=3,024; p=0,094) dok kod ispitanica ženskog pola nije došlo do statistički značajne razlike. Prosečne vrednosti viskoznosti plazme su na početku i tokom istraživanja bile iznad referentnih vrednosti da bi na kraju istraživanja ta vrednost bila u granicama fizioloških vrednosti. Prosečne vrednosti PSV na početku i tokom istraživanja su bile u granicama patoloških vrednosti da bi na kraju istraživanja vrednost bila u granicma fizioloških vrednosti. Na početku istraživanja prosečna vrednost PSV-a je bila 25,64±5,38 cm/s, tokom istraživanja 26,94±5,31 cm/s, da bi na kraju istraživanja iznosila 35,84±5,73 cm/s. Tokom sva tri merenja došlo je do statistički značajnog poboljšanja. Na početku i tokom istraživanja ispitanici ispitivane grupe su imali patološke vrednosti klaudikacione distance, da bi na kraju istraživanja ta vrednost bila u fiziološkim granicama. Ustanovljeno je statistički značajno smanjenje pulsa tokom istraživanja i to u fiziološkim okvirima. Iako je došlo do statistički značajnog poboljšanja EFLV ipak su vrednosti na kraju istraživanja bile na donjim granicama fizioloških vrednosti. U toku istraživanja dobilo se i statistički značajno poboljšanje vrednosti pulsnog aortalnog pritiska. Iako je došlo do statistički značajnog poboljšanja FEV1 ipak su vrednosti na kraju istraživanja bile na donjim granicama fizioloških vrednosti. Zaključak - Vrednosti indeksa telesne mase ispitanika na kraju istraživanja su se statistički značajno smanjile. Prosečna vrednost holesterola i triglicerida, kao i prosečna vrednost PSV-a, BMI, EFLV, FEV1, kao i svih ostali poređenih parametara značajno se smanjila nakon oba tretmana. Na osnovu dobijenih rezultata ustanovljeno je da je klaudikaciona distanca statistički značajno manja u odnosu na početne vrednosti. Poredeći efekte medikamentoznog tretmana sa efektima kombinovanog terapijskog pristupa dolazi se do zaključka da su svi poređeni parametri, izuzev C-reaktivnog proteina u krvi, statistički značajno poboljšani na kraju kombinovanog tretmana u odnosu na vrednosti na kraju medikamentoznog tretmana.

they represent a large social and economic burden. Diseases of peripheral arterial circulation can be divided into two groups - the occlusive and non-occlusive disease, or functional impairment. Incidence of arterial disease of the lower extremities is strongly associated with age. Risk factors for peripheral arterial disease are similar to those that are important in the etiology of coronary artery disease: obesity, smoking, dyslipidaemia, diabetes and hypertension. The most typical presentation of peripheral arterial disease is intermittent claudication, which is characterized with pain in the leaves, which increases during walking; the pain usually goes away in peace. All obese patients with peripheral arterial disease of the lower extremities have an increased risk of future cardiovascular incidents, and they require general secondary prevention in order to improve their health forecasts. Physical activity represents the method of choice in patients with peripheral arterial disease of the lower extremities. Aim of the research: Compare the effects of programmed physical activity and medical therapy on hemodynamic and risk factors for cardiovascular diseases in patients with peripheral arterial diseases of the lower extremities. Subjects and methods of research: A retrospective-prospective, clinically descriptive, controlled study was conducted on subjects of the Public Institution Health Care Centre of Sarajevo Canton– Specialist-consultative unit. Specialist-consultative unit represents secondary outpatient level of health care. This study evaluated a period of 20 weeks (140 days). The study involved 75 subjects. At the beginning of the study, based on the findings of colour Doppler sonography of the pedal arteries, the findings of ejection fraction of the left ventricle, spirometry findings, values of pulmonary aortic pressure and the determination of overweight - obesity subjects were included in the research. In addition to ultrasound findings and spirometry findings, patients provided an exhaustive history of previous illnesses. Measurement of the body weight index, waist circumference and claudication distance were performed. Lipid status and morning blood glucose level were performed for each patient. Prescribed or prolonged medicinal therapy was performed for patients, and detailed instructions for everyday vasoactive walking program were given. Research resultsAt the beginning of the study, the average volume of the subjects' waist circumference was 87.94 ± 3.07cm, after two weeks the average volume of the waist was 87.10 ± 2.0 cm, and at the end of the study 84.96 ± 1.98cm. At the beginning of the study, subjects of the tested group had a body mass index of 28.93 ± 2.10 kg / m2. After two weeks of research and performed therapy, the body mass index decreased and amounted to 28.36 ± 1.99 kg / m2, so that at the end of the study, the average body mass index in the tested group was 27.26 ± 1.87 kg / m2. The mean blood glucose level at the beginning of the study was 5.77 ± 0.96 mmol / L, during the study this value was 5.42 ± 0.88 mmol / L, and at the end of the study, 5.30 ± 0.92 mmol / L. The postprandial blood glucose level at the beginning of the study was 7,48 ± 0,85 mmol / L, during the study, this value was 6.82 ± 0.62 mmol / L, and at the end of the study, 6.44 ± 0.64 mmol / L. At the beginning of the study, the HbA1c value was 5.52 ± 0.91%, during the study 5.32 ± 0.97%, and at the end of the study, 5.09 ± 0.73%. The C-reactive protein (CRP) mean at the beginning of the study was 3.77 ± 1.12mg / L, during the study, the value was 3.66 ± 1.36mg / L, and at the end of the study, this value was 3.61 ± 1.21mg / L. Paired t-test did not show a statistically significant reduction or an increase in CRP during the study. The average blood cholesterol of the subjects at the beginning of the study was above the reference values and amounted to 6.58 ± 0.90 mmol / L. After two weeks of research and therapy, the value was 4.96 ± 0.46 mmol / L, and at the end of the study the value was 4.15 ± 0.54 mmol / L. The average triglyceride values at the beginning and during the study were elevated so that at the end of the study they were within the reference values. VIII The difference between the values of leptin in male subjects at the beginning and at the end of the study were 2.66 ± 1.52 ng / ml (t = 3.024; p = 0.094) while there was no statistically significant difference in female subjects. The average values of plasma viscosity were initially and during the study above the reference values, and at the end of the study this value was within the limits of physiological values. The mean values of PSV at the beginning and during the study were within the limits of pathological values, and at the end of the study the value was within the physiological limits. At the beginning of the study, the mean PSV value was 25.64 ± 5.38 cm / s, during the study 26.94 ± 5.31 cm / s, and at the end of the study it was 35.84 ± 5.73 cm / s. During all three measurements statistically significant improvement was observed. At the beginning and during the study, the subjects of the tested group had pathological values of claudication distance, and at the end of the study this value was within the physiological limits. A statistically significant reduction in pulse was observed during the study, in physiological frameworks. Although there was statistically significant improvement in EFLV, however, the values at the end of the study were at the lower limits of physiological values. During the study, statistically significant improvement in the value of pulmonary aortic pressure was obtained. Although there was statistically significant improvement in FEV1, the values at the end of the study were at the lower limits of physiological values. Conclusion - The values of the body mass index of subjects involved at the end of the study were statistically significantly reduced. The average value of cholesterol and triglycerides, as well as the average value of PSV, BMI, EFLV, FEV1 as well as all other comparable parameters, decreased significantly after both treatments. Based on the obtained results it was found that the claudication distance was statistically significantly lower than the baseline values. Comparing the effects of medicinal treatment with the effects of the combined therapeutic approach, it is concluded that all the compared parameters, other than C-reactive protein in the blood, were statistically significantly improved at the end of the combined treatment compared to the values at the end of the medicinal treatment.