Randomized and Comparative Study Between Two Intra-Hospital Exercise Programs For Heart Transplant Patients

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Kawauchi TS,ORIGINAL

et al. - Randomized and comparative study between two intra-


ARTICLE Rev Bras Cir Cardiovasc 2013;28(3):338-46
hospital exercise programs for heart transplant patients

Randomized and comparative study between


two intra-hospital exercise programs for heart
transplant patients
Estudo randomizado e comparativo entre dois programas de exercícios intra-hospitalares para pacientes
de transplante de coração

Tatiana Satie Kawauchi1; Patricia Oliva de Almeida1; Karen Rodrigues Lucy1; Edimar Alcides
Bocchi1, MD, PhD; Maria Ines Zanetti Feltrim1, PhD; Emilia Nozawa1, PhD

DOI: 10.5935/1678-9741.20130053 RBCCV 44205-1479

Abstract strength by 1RM test, over time, to the muscle groups of the
Objective: To compare the effects of two physical therapy elbow flexors, shoulder flexors, hip abductors and knee flexors.
exercise in-hospital programs in pulmonary function and Conclusion: Heart transplant patients benefit from exercise
functional capacity of patients in the postoperative period of programs in hospital, regardless of the program type applied.
heart transplantation. A new training proposal did not result in superiority compared
Methods: Twenty-two heart transplanted patients were to routine programme applied. Exercise protocols provided
randomized to the control group (CG, n=11) and training group improves in ventilatory variables and functional capacity of this
(TG, n=11). The control group conducted the exercise program population.
adopted as routine in the institution and the training group
has had a protocol consisting of 10 stages, with incremental Descriptors: Heart transplantation. Rehabilitation. Physical
exercises: breathing exercises, resistance training, stretching therapy modalities.
and walking. The programs began on the first day after
extubation and stretched until hospital discharge. Assessed
pulmonary function, distance walked in six minutes walk test Resumo
(6MWT) and peripheral muscle strength by one repetition Objetivo: Comparar os efeitos de dois programas fisiotera-
maximum test (1RM). pêuticos de exercícios intra-hospitalares na função pulmonar e
Results: Similar behavior was observed between the two na capacidade funcional de pacientes no período pós-operatório
groups treated, with statistically significant increases between de transplante cardíaco.
the first and second test of the following variables: FVC (59% Métodos: Vinte e dois transplantados de coração foram
in CG and 35.2% in TG); MIP (8.6% in CG and 53.5% in TG), randomizados em Grupo Controle (GC, n=11) e Grupo de Trei-
MEP (28.8% in CG and 40.7% in TG) and 6MWT (44.5% in namento (GT, n=11). O GC realizou o programa de exercícios
CG and 31.4% in TG). There was an increase of peripheral adotado como rotina na instituição e o GT realizou protocolo

1
Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Correspondence address:
Instituto do Coração, São Paulo, SP, Brazil. Tatiana Satie Kawauchi
Av. Dr. Enéas de Carvalho Aguiar, 44 – Cerqueira César – São Paulo, SP,
Brazil – Zip code: 05403-000
Work carried out at Universidade de São Paulo, Faculdade de Medicina, E-mail: tatikawauchi@gmail.com
Hospital das Clínicas, Instituto do Coração, São Paulo, SP, Brazil.
Article received on February 20th, 2013
Article accepted on July 11th, 2013

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Rev Bras Cir Cardiovasc | Braz J Cardiovasc Surg
Kawauchi TS, et al. - Randomized and comparative study between two intra- Rev Bras Cir Cardiovasc 2013;28(3):338-46
hospital exercise programs for heart transplant patients

gramas tiveram início no primeiro dia após a extubação e se


Abbreviations, acronyms & symbols
estenderam até a alta hospitalar. Avaliou-se função pulmonar,
6MWT Six Minute Walk Test distância percorrida no teste de caminhada dos seis minutos
BP Blood pressure (TC6M) e força muscular periférica pelo teste de uma repetição
CG Control group máxima (1RM).
CMV Controled mandatory ventilation mode Resultados: Observou-se comportamento semelhante entre os
FC Functional capacity dois grupos tratados, com aumentos estatisticamente significan-
FVC Forced vital capacity tes entre o primeiro e o segundo teste das variáveis: CVF (59% no
HF Heart failure
GC; 35,2% no GT); PIMax (8,6% no GC; 53,5% no GT, PEMax
HR Heart rate
HT Heart transplantation (28,8% no GC; 40,7% no GT) e TC6M (44,5% no GC; 31,4% no
L Liters GT). Houve aumento de força periférica pelo teste de 1RM para
LL Lower limbs os músculos flexores de cotovelo, flexores de ombro, abdutores de
LVEF Left ventricular ejection fraction quadril e flexores de joelho ao longo do tempo.
MEP Maximal expiratory pressure Conclusão: Pacientes transplantados de coração se benefi-
MIP Maximal inspiratory pressure ciam da aplicação de programas de exercícios no período intra-
PP Postoperative period -hospitalar, independente do tipo de programa aplicado. Uma
PEEP Positive end-expiratory pressure
nova proposta de treinamento não resultou em superioridade
RTG Resistance training group
SpO2 Peripheral oxygen saturation em relação ao programa aplicado de rotina. Os protocolos de
TG Training group exercícios proporcionaram melhora das variáveis ventilatórias
UL Upper limbs e da capacidade funcional dessa população.

constituído de 10 fases, com exercícios incrementais: exercícios Descritores: Transplante de coração. Reabilitação. Modali-
respiratórios, resistidos, alongamentos e caminhada. Os pro- dades de fisioterapia.

INTRODUCTION muscles [6]. Thus, even after HT, the peripheral changes
due to advanced HF remains, resulting in a state of physical
Heart failure (HF) is a clinical syndrome being the final deconditioning. For this reason an exercise program should be
common pathway of heart disease caused by structural or started early, still in the hospital, with a continuing period of
functional abnormalities, acquired or inherited, leading to exercise program after discharge, so that patients can return to
worsening of filling capacity and ventricular ejection. The heart a lifestyle similar to that they had before the illness, allowing
becomes unable to maintain the tissues demands resulting in social interaction and satisfactory return to an active and
symptoms such as fatigue, dyspnea and intolerance to physical productive life [7].
exertion [1,2]. Although widely recommended in the literature, there
In advanced stages of HF (functional classes III and IV), are few studies evaluating the use of exercise protocols
heart transplantation (HT) becomes a treatment able to restore in the postoperative period (PP) of HT in the hospital. In
hemodynamic function, improve quality of life and survival. It our institution, patients undergoing HT perform routinely
is recommended for patients whose symptoms do not respond respiratory therapy and general exercises. We follow a
to drug therapy or other surgical procedures [3]. terapeutic plan tailored to each patient. However, we don´t
Since the first human HT performed in South Africa by have these results controlled and compared to specific
Christiaan Barnard in 1967, HT has improved since its initial protocols applied to HT patients.
experimental stage to devote these days as a treatment of In order to analyze the implementation of a new assistance
choice for patients with end-stage HF, especially after the program based on progression of exercises, we compared
development of immunosuppressive therapy [4]. Actually, the the effects of two programs of physical therapy exercises
survival of patients submitted to HT is 80%, 70% and 60% in on pulmonary function and functional capacity in patients
one, five and 10 years, respectively [3]. undergoing HT during hospitalization.
Most individuals waiting for a HT have prolonged hospital
stay due to prolonged inotropic support or mechanical METHODS
circulatory support [5]. Even after surgery, these individuals
show changes in hemodynamic performance due to central This prospective, randomized and longitudinal follow-
alterations, such as autonomic denervation graft, endothelial up study, was approved by the Hospital das Clinicas Ethics
dysfunction, diastolic dysfunction and accelerated coronary Committee from the University of São Paulo Medical School
atherosclerosis and poor adaptation of the peripheral (HC-FMUSP) under the number 1080/08. The study included

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Kawauchi TS, et al. - Randomized and comparative study between two intra- Rev Bras Cir Cardiovasc 2013;28(3):338-46
hospital exercise programs for heart transplant patients

only individuals who signed an informed consent form, (MIP) and maximal expiratory pressure (MEP) was obtained
according to Resolution 196/96. by manovacuometry (Marshall Town® model). The patient was
Patients who underwent orthotopic HT at the Heart positioned sitting with a nose clip to allow only oral breathing
Institute, from February 2009 to November 2011, aged over during the test. A maximal inspiratory effort from residual
13 years participated in this study. During this period, 26 volume (RV) was requested through a mouthpiece connected
individuals who initially filled the criteria for hemodynamic to a manometer. We considered the largest deflection obtained
stability and absence of acute or chronic lung disease, in the apparatus for the MIP value. Similarly, the expiratory
neurological and orthopedic complications hindering the effort was requested from the total lung capacity (TLC) to
realization of the proposed protocols were included. Four obtain the MEP value. The measurements were repeated for
individuals were excluded from the program: an individual at least three times for each parameter, accepting less than
due to secondary symptomatic hypertension to cyclosporine 10% difference betwen the measures. The highest value was
therapy, two for neurological complications and one due to considered, since this has not been the last measure [9]. The
death related to acute rejection from the graft. Therefore, values are expressed in cmH2O and percentage of predicted
22 subjects completed the study, 11 patients in the control values, according to Neder [10]. The FVC was measured by
group (CG), which performed the conventional physiotherapy ventilometry (Mark Wright Spirometer 8® model). FVC was
program, and 11 in the training group (TG), which performed obtained in liters (L) through a maximum inspiration followed
a new exercise program (Figure 1). These patients did not by expiration until the maximum RV. The measurement was
perform exercise programs in the preoperative period. performed three times, accepting a difference less than 10%
betwen the measures, considering the highest value obtained,
since it was not the last one. All tests were performed on the
first day after extubation (1st test) and on the day before hospital
discharge (2nd test).
The functional capacity (FC) was assessed using the
Six Minute Walk Test (6MWT) performed according to the
Guidelines of the American Thoracic Society [11], with the
distance measured in meters and percentage of predicted values
and calculated according to the equation proposed by Enright
& Sherrill [12]. The first 6MWT was performed as soon as
the patients had conditions for ambulation, which occurred at
Fig. 1 - Flowchart of studied patients the end of the first week after extubation. The second test was
performed on the day before discharge.
Patients were admitted to the Surgical Intensive Care Unit The dynamics of peripheral muscle strength was assessed
in the immediate PP, in intubation and mechanical ventilation by the One Repetition Maximum Test (1RM), following the
(Hamilton-Switzerland, Galileo ® model), on controled protocol adapted to the Guidelines of the American College
mandatory ventilation mode (CMV), with a tidal volume of 8 of Sports Medicine [13]. Muscle groups responsible for elbow
ml/kg, respiratory rate of 12 breaths/min; fraction of inspired flexion, shoulder flexion, shoulder abduction, elbow extension,
oxygen of 60% and positive end-expiratory pressure (PEEP) knee extension, hip abduction and knee flexion were tested.
of 5 cmH2O, as Unit routine [8]. The first 1RM test was performed at the end of the first week
The study began on the day after extubation, which after extubation and the second, on the day before discharge.
followed institutional protocol [8]. Bedridden patients or Once defined the maximum load reached in the first test, we
patients using vasoactive drugs initiated protocol in phases applied a load for resistance training of 50% 1RM set for each
1 and 2 and continued to phase 3 only when they were muscle group.
hemodynamically stable, with or without vasoactive drugs.
After the withdrawal of ventilatory support, patients Exercise Programs
were randomized to CG or TG. This randomization process CG performed the exercise program adopted as routine in the
was performed by sealed opaque envelopes. An independent institution, composed by series of 10 repetitions of the following
individual generated a sequence of random numbers, putting exercises: (a) diaphragmatic breathing exercises, inspiration in
up one by one in sealed envelopes. Patients were randomly 3 times associated with upper limbs elevation in flexion and in
and consecutively allocated in one of the study groups by the abduction to 90°, (b) general exercises like bending their knees
withdrawal of one envelope for each patient. to hip height, lower limbs abduction to 45°, plantar flexion
Pulmonary function was evalueted in terms of respiratory and dorsiflexion (c) orientation for ambulation without pre-
muscle strength and forced vital capacity (FVC). Respiratory established target distance. The session was conducted once
muscle strength, expressed by maximal inspiratory pressure a day, five times a week, under a physiotherapist supervision.

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Kawauchi TS, et al. - Randomized and comparative study between two intra- Rev Bras Cir Cardiovasc 2013;28(3):338-46
hospital exercise programs for heart transplant patients

Fig. 2 - Intra-hospital exercise program for heart transplant patients

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Kawauchi TS, et al. - Randomized and comparative study between two intra- Rev Bras Cir Cardiovasc 2013;28(3):338-46
hospital exercise programs for heart transplant patients

TG performed exercise program consisted in 10 phases of corresponding Mann-Whitney, presented as median and
increasing complexity, including breathing exercises, active, interquartile ranges. To test the homogeneity between the
resistance and aerobic exercises and stretching, as shown in proportions we used the chi-square test or Fisher’s exact
Figure 2. The phases were established in order to promote test. The variables were subjected to analysis of variance
incremental effort; progression to a new phase depended for repeated measures ANOVA and when the normality
on the patient’s clinical response and ability to perform the assumption was rejected we used the Friedman test [15]. The
proposed activities at each phase without compensation and level of statistical significance was 5%.
independently; progression was also based on the perception
effort assessed by the modified Borg scale [14] which consists RESULTS
in a score of 0 to 10 grades, using descriptive terms. Patients
were instructed to maintain a score of 4 (somewhat severe) The general anthropometric characteristics and left ventricular
to 6 (severe). When the score reached 7 (very severe) the ejection fraction (LVEF) values had no statistically significant
patient was oriented to regress one phase of the protocol. The difference between the groups, as shown in Table 1. There was
progression phases were suspended or had regression when it a prevalence of 63.64% males in the population studied, with an
was necessary to remain at rest, for medical request, or when equal proportion in both groups.
the patient was unable to carry out the activities by side effects Chagas cardiomyopathy was the etiology of HF in 28%
of immunosuppressive therapy. During the exercise sessions, of patients in the CG and 55% in TG; idiopathic dilated
heart rate (HR), blood pressure (BP) and peripheral oxygen cardiomyopathy in 45% of CG and 18% in TG; ischemic
saturation (SpO2) from the TG patients were monitored at the cardiomyopathy in 9% in both groups and other causes 9%
beginning, during the activity, at the end of the sessions and in both groups.
5 minutes after the sessions, in order to evaluate the safety of Mechanical ventilation time was 11.83 hours (7.85 - 21.17)
the proposed protocol. in CG and 8.33 hours (4.93 - 10.94) in TG, with no statistically
The statistical analysis used to compare the groups significant difference between groups (P=0.094). The length of
consisted on Student t test for normally distributed data hospital stay in the postoperative period was 34 days (26 - 48)
which are presented as mean and standard deviation, or its in CG and 32 days (21 - 46) in TG (P=0.768). The application
period of the protocols was 26 ± 12 sessions in CG and 18 ±
Table 1. Anthropometric data and left ventricular ejection fraction
6 sessions in TG, with no statistically significant difference
Control Training P-value between groups (P=0.074).
(n=11) (n=11) When comparing the responses against exercise programs
Age (years) 42.0 ± 16.46 39.0 ± 17.54 0.613 applied, we had a statistically significant increase in MIP,
Weight (Kg) 60.0 ± 10.72 59.2 ± 9.03 0.725 MEP and FVC variables in both groups, as shown in Table 2.
Height (m) 1.68 ± 8.74 1.66 ± 6.3 0.582 The same was observed in the 6MWT (Table 3) and in 1RM
BMI (Kg/m2) 21.38 ± 2.74 21.45 ± 3.26 0.956 test for the movements of elbow flexion, shoulder flexion,
LVEF (%) 18 (16-20) 20 (20-20) 0.278 hip abduction and knee flexion (Table 4). Although the TG
BMI = body mass index; LVEF (%) = left ventricular ejection values were higher than those of the CG, they did not reach
fraction. Kg = kilograms; m2 = square meter statistical significance.

Table 2. Lung function variables before and after the implementation of training programs
Control Training P P
Group Time
1st Test 2nd Test 1st Test 2nd Test
MIP 58 ± 30 63 ± 29* 52 ± 23 80 ± 31* 0.619 0.007
MIP% pred 53 57* 50 73* 0.616 0.009
MEP 59 ± 30 76 ± 34* 59 ± 33 83 ± 27* 0.828 0.001
MEP% pred 50 65* 54 73* 0.684 0.002
FVC (L) 1.84 ± 0.87 2.93±1.31* 1.96±0.45 2.65 ± 1.04* 0.785 0.002
FVC% pred 45 ± 25 67 ± 26* 48 ± 11 67 ± 29* 0.878 0.003
MIP = maximum inspiratory pressure, MIP% pred = maximum inspiratory pressure in
percentage of predicted, MEP= maximum expiratory pressure and MEP%pred = maximum
expiratory pressure in percentage of predicted, FVC = forced vital capacity, FVC% pred
= forced vital capacity in percentage of predicted.
* P<0.05 when compared with the value obtained in 1st intra-group test

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Kawauchi TS, et al. - Randomized and comparative study between two intra- Rev Bras Cir Cardiovasc 2013;28(3):338-46
hospital exercise programs for heart transplant patients

Table 3. Functional capacity variables before and after the implementation of the training
programs
Control Training P P
Group Time
1st Test 2nd Test 1st Test 2nd Test
6MWT 272 ± 168 393 ± 155* 322 ± 83 423 ± 70* 0.430 0.001
6MWT%pred 41 60* 50 66* 0.323 0.001
6MWT = six minute walk test, 6MWT% pred = six-minute walk test in percentage of
predicted values.
* P<0.05 when compared with the value obtained in the 1st test, intra-group test

Table 4. Test of 1RM values before and after implementation of the training programs
Training Control P P
Group Time
1st Test 2nd Test 1st Test 2nd Test
Elbow flexion 3.91 4.45* 3.36 4.45* 0.38 0.009
Shoulder flexion 2.18 2.82* 1.73 2.0* 0.22 0.024
Shoulder abduction 2.09 2.36 1.45 2.0 0.257 0.055
Elbow extension 1.91 2.54 1.82 1.82 0.353 0.132
Knee extension 6.0 7.0 4.54 5.73 0.361 0.054
Hip abduction 3.64 4.86* 3.18 3.91* 0.438 0.015
Knee flexion 3.27 4.86* 3.0 4.45* 0.749 0.005
1RM= one repetition maximum test.
* P<0.05 when compared with the value obtained in the 1st intra-group test

Fig. 3 - Values of maximal inspiratory pressure expressed as Fig. 4 - Distance in the Six Minute Walk Test before and after the
percentage of predicted values training programs

The mean MIP, expressed as percentage of predicted Peripheral muscle strength increased significantly in the second
values , in CG was 53% and 57% in the first and second tests test compared to the first test for the following muscle groups:
respectively and in TG was 50% and 73%, respectively. There elbow flexion (P=0.009), shoulder flexion (P=0.024), hip abduction
was no statistically significant difference between groups (P=0.015) and knee flexion (P=0.005), as shown in Table 4.
(P=0.616), but over time, the patients showed significant gains
(P=0.009) (Figure 3). DISCUSSION
6MWT mean values were 272m in the first test and 393m
in the second test for CG, and 322m and 423m, respectively, in Exercise programs are important for HT patients and
TG. The performance of the groups was similar (P=0.430), with should be started as early as possible to restore their FC after
significant improvement in the second test (P=0.001) (Figure 4). the surgical procedure, but also to recover part of the muscle

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Kawauchi TS, et al. - Randomized and comparative study between two intra- Rev Bras Cir Cardiovasc 2013;28(3):338-46
hospital exercise programs for heart transplant patients

dysfunction due to the long period of deconditioning in the functional rehabilitation a good therapeutic strategy for the
preoperative phase and to the effects of immunosuppressive treatment of advanced HF patients.
therapy in skeletal muscle [16]. In relation to the MIP, both groups were lower than 70%
Our study evaluated the effects of exercise programs of predicted values at the beginning of the programs adopted
immediately after HT still in hospital phase. The literature is in our study and only the TG reached average values above
rich in studies that evaluate the effectiveness of programs in post this threshold in the second test. According to Borges [21],
discharge phases (II and III). However, studies addressing phase respiratory muscle weakness, characterized by MIP less
I are scarce, probably due to the diversity in patient outcomes. than 70% of predicted values, is one of the risk factors for
Protocols assistance are applied by different transplant centers, but the development of postoperative pulmonary complications
there is little information on the impact of such assistance [17]. in patients undergoing cardiac surgery. Thus, programs
In our institution, the exercise program is performed tailored to that contribute to the improvement of muscle strength are
each patient. To compare this program with a new proposal that beneficial, regardless the association of specific inspiratory
includes exercise progression based on the complexity execution muscle training, thus minimizing the risk of complications.
and resistance exercises, was the aim of this study. The improvement of FC in our study, 44.5% in CG and
Two programs of therapeutic exercise have been 31.4% in TG, was more expressive than in the study of Coronel
applied to patients in the PP of heart transplantation. The et al. [20], where FC improved only 11.2% between tests.
CG performed exercises according to a protocol routinely We believe that this result is due to the stimulus given to the
practiced in the institution and TG performed a new exercise patient to walk in the PP in our institution, either randomly
protocol based on incremental workloads. Our data show (CG) or standardized by the proposed protocol (TG), where
that the implementation of both protocols contributed to the at the final phase, phase 10, the patients walked at least 900m
improvement in lung function, in peripheral muscle strength per day and went up and down a flight of stairs. In the PP of
and physical performance over time, with no differences coronary artery bypass surgery, we have demonstrated that a
between the protocols. moderate supervised walking program during hospitalization
Lung function may change in heart transplant in the PP, improves walking ability at hospital discharge [22]. Thus,
as well as in other cardio-thoracic surgery [18]. Ferreira et the inclusion of hiking seems an important feature in phase I
al. [19] observed a reduction in vital capacity 40%-50% cardiac rehabilitation programs for improvement in FC patients
compared to preoperative values for at least 10-14 days after in the PP of cardiac surgery, as well as in HT surgery.
cardiac surgery and abdominal surgery. It is believed that Although the early indication of exercise in the PP of HT
factors such as pain, abnormal respiratory mechanics due to the is a consensus, there are few publications that describe the
sternotomy and the deleterious effects of general anesthesia on protocols implemented in this population in the hospital phase.
pulmonary function, contributes to these findings. In HT, poor According to the Brazilian Cardiology Guidelines for Heart
preoperative condition and the surgical procedure itself favor Transplantation [23], general exercises should be started in the
the reduced respiratory capacity and increased pulmonary immediate postoperative period, increased gradually until the
secretions, which can be minimized through breathing patient develops muscle strength and adequate endurance to
exercises, bronchial hygiene and cough stimuli. restore a level of fitness. The ambulation should be started as
Coronel et al. [20], in a retrospective cohort study evaluated soon as possible and after discharge, the supervised program
21 patients undergoing HT. The authors observed a volume should include stretching, aerobic and endurance exercises.
and lung capacity reduction and a respiratory muscle strength The intensity of aerobic activity can be prescribed between
decrease on the first postoperative day compared to the the anaerobic threshold and respiratory compensation point
preoperative period and recovery of these values on the 14th obtained in the cardiopulmonary exercise test, or 60%-85%
postoperative day. The improvement of FVC, MIP and MEP of maximum HR achieved in the testing effort. Increased
between the first and 14th postoperative day was 70.1%, 75.1% intensity during the program should be done gradually, taking
and 62.8%, respectively. into account the HR, BP, Borg scale and rejection episodes.
In our study, there was an improvement in ventilatory Squires [24] recommend performing passive mobility
variables between the first and second tests but our medium exercises for upper limbs (UL) and lower limbs (LL), exercises
datas are lower than those observed by Coronel et al. [20] (59% to get up and sit in the chair and ambulation prescribed after
in the CG versus 35.2% in TG for FVC, 8.6% in CG versus extubation of the HT patient, which in general occurs within
53.5% in TG for MIP and 28.8% in the CG versus 40.7% in TG the first 24 hours after surgery. A walk or aerobic exercises
for MEP). Our results corroborate the finding that changes in on a stationary bicycle for 20 to 30 minutes can be tolerated
ventilatory function in patients undergoing HT are predictable, using prescription based on the Borg scale between 11 and 13.
but these recover the expression of respiratory muscle strength Training for strength gain is indicated for the first six months
and lung capacity within two weeks, besides improving FC, after HT, when the authors recommend a maximum weight of
considering the association between the HT surgery and 5 kg for bilateral UL exercises, to avoid complications with the

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Kawauchi TS, et al. - Randomized and comparative study between two intra- Rev Bras Cir Cardiovasc 2013;28(3):338-46
hospital exercise programs for heart transplant patients

surgical incision, as sternal instability. Our patients underwent


Authors' roles & responsibilities
resistance training with a maximum of 2 kg to 3 kg for UL and
LL, considered safe within the exercise protocol proposed. TSK Conception and design of the study, implementation of
The use of resistance exercises during exercise programs in projects and /or experiments, data analysis, writing of the
the PP of HT is being increasingly used, since this method manuscript
POA Conception and design of the study, implementation of
helps to minimize the deleterious effects of corticosteroids and projects and/or experiments
immunosuppressants. It is common to skeletal muscle atrophy KRL Implementation of projects and or experiments
and weakness in addition to osteoporosis in recipients of organ EAB Final approval of manuscript
transplantation as a side effect of this drug therapy. In this MIZF Critical review and final approval of the manuscript
EN Critical review and final approval of the manuscript
context, resistance exercise have osteogenic effect, since during
its execution leads to bone deformation, generating cellular
responses that determine the release of bone growth factors [16].
Braith et al. [25], in 2005, evaluated 15 HT patients who
were randomized into CG, who performed a walking program
(n=7), and a resistance training group (RTG), who performed

walking and resistance exercise (n=8). Both programs began
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