ВВЕДЕНИЕ. Обзор посвящён работам по изучению одного из современных комплексных методов лечения и реабилитации пациентов с сердечно-сосудистыми заболеваниями – терренкуру, включающему элементы дозированной лечебной физкультуры, климатотерапии и предусматривает дозированные физические нагрузки в виде пеших прогулок по пересечённой местности, восхождений в гористой местности по определённым, размеченным маршрутам под наблюдением врача. Является методом тренирующей терапии, способствующим улучшению выносливости, функционирования сердечно-сосудистой, дыхательной и нервной систем, обмена веществ, а также мышц конечностей и туловища. ЦЕЛЬ. Освещение механизмов комплексного действия терренкура, сочетающего в себе элементы климатотерапии и дозированной физической нагрузки, для наиболее оптимального применения у пациентов с патологией сердечно-сосудистой системы, в том числе имеющих избыточную массу тела. МАТЕРИАЛ И МЕТОДЫ. Проведен анализ публикаций в электронных базах «PubMed» и Российского индекса научного цитирования по ключевым словам: «terrencure», «metered physical activity», «climatotherapy», «rehabilitation», «cardiovascular diseases». Дата последнего поиска – 9 августа 2022 г. ЗАКЛЮЧЕНИЕ. Мировой и отечественный научно-практический опыт применения терренкура свидетельствует о его высокой эффективности и повышении адаптационно-компенсаторного потенциала организма пациентов, безопасности использования этого метода как в профилактических, так и в лечебных и реабилитационных программах, обусловленному основными механизмами его реабилитационного действия. Учитывая его широкую доступность, экономичность и дополнительные терапевтические эффекты при контакте с местностью, представляется целесообразным расширение внедрения терренкура и использование его с профилактической целью не только в санаторно-курортных условиях, но и в городской среде – парках и других зонах отдыха горожан.
терренкур, дозированные физические нагрузки, климатолечение, реабилитация, сердечно-сосудистые заболевания
1. World Health Organization. Non-communicable diseases: key facts. 2021. https://www.who.int/news-room/fact-sheets/detail/noncommunicablediseases. Available at: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases (accessed 21.10. 2021).
2. Adam Timmis, Panos Vardas, Nick Townsend, Aleksandra Torbica, Hugo Katus, Delphine De Smedt, Chris P. Gale, Aldo P. Maggioni, Steffen E. Petersen, Radu Huculeci, Dzianis Kazakiewicz, Victor de Benito Rubio, Barbara Ignatiuk, Zahra Raisi-Estabragh, Agnieszka Pawlak, Efstratios Karagiannidis, Roderick Treskes, Dan Gaita, John F. Beltrame, Alex McConnachie, Isabel Bardinet, Ian Graham, Marcus Flather, Perry Elliott, Elias A. Mossialos, Franz Weidinger, Stephan Achenbach, Atlas Writing Group, European Society of Cardiology: cardiovascular disease statistics 2021. European Heart Journal. 2022: 8(43): 716-799. https://doi.org/10.1093/eurheartj/ehab892
3. Go A.S., Mozaffarian D., Roger V. L., Benjamin E. J., Berry D. D., Blaha M. J. et al. Executive Summary: Heart Disease and Stroke Statistics-2014 Update: report of the American Heart Association. Circulation. 2014: 129(3): 399-410. https://doi.org/10.1161/01.cir.0000442015.53336.12
4. Kyu H.H., Bachman V.F., Alexander LT. et al. Physical activity and risk of breast cancer, colon cancer, diabetes, coronary heart disease and isch- emic stroke: a systematic review and dose-response meta-analysis for the 2013 Global Burden of Disease study. The BMJ. 2016; (354): i3857. https://doi.org/10.1136/bmj.i3857
5. Ekelund U., Tarpaulin J., Steen-Johannes J. et al. Dose-response relationships between accelerometry-measured physical activity and sedentary life- style time and all-cause mortality: a systematic review and a consistent meta-analysis. The BMJ. 2019; (366): l4570. https://doi.org/10.1136/bmj.l4570
6. Ming Zhao, Srinivas P. Veranki, Kostan G. Magnussen, Bo Xi. Recommended physical activity and all causes and causes of mortality among adults in the USA: prospective cohort study. The BMJ. 2020: (370): m2031. https://doi.org/10.1136/bmj.m2031
7. Kinoshita M., Yokote K., Arai H. et al. Japan Atherosclerosis Society (JAS) Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases 2017. Journal of Atherosclerosis and Thrombosis. 2018; 25(9): 846-984. https://doi.org/10.5551/jat.GL2017
8. Hansen D., Dendale P., Koninks K., Vanhees L., Piepoli M.F., Niebauer J., Cornelissen V., Pedretti R., Hertz E., Ruiz G.R., Corra Y., Schmid J.P., Greco E., Davos Ch., Edelmann F., Abreu A., Rauch B., Ambrosetti M., Braga S.S., Barna O. et al. The European Association of Preventive Cardiology tool for prescribing exercises in daily practice and rehabilitation training (EXPERT): A digital training and decision support system for optimizing the appointment of exercises in cardiovascular diseases. Concept, definitions and methodology of construction. European Heart Journal to Cardiology. 2017; 24(10): 1017-1031. https://doi.org/10.1177/2047487317702042
9. Bilo G., Villafuerte F.S., Faini A., Anza-Ramirez S., Revera M., Giuliano A., Caravita S., Gregorini F., Lombardi S., Salvioni E. et al. Outpatient blood pressure in untreated and treated patients with hypertension at high altitude: A study of the cardiovascular system at high altitude-Andes study. Journal of Hypertension. 2015 ; (65): 1266-1272.
10. Kanayama H., Kusaka Y., Hirai T., Inoue H., Agis and Y., Shuk A. Climatotherapy in Japan: a pilot study. International Journal of Biometeorology. 2017; 61(12): 2141-2143. https://doi.org/10.1007/s00484-017-1418-x
11. Wang L., Ai D., Zhang N. Dosing and prescribing exercise is a Safe Game: Dangers and Recipes. Advances in Experimental Medicine and Biology. 2017; (1000): 357-387. https://doi.org/10.1007/978-981-10-4304-8_19
12. Лобанов А.А., Бобровницкий И.П., Уянаева А.И., Яковлев М.Ю., Андронов С.В., Гришечкина И. А., Никитин М.В., Фесюн А.Д. Климатотерапия. В книге Научно-практическое руководство для врачей «Санаторно-курортное лечение». Москва. ООО «Реновация». 2022; (1): 83-114.
13. Бокерия Л.А., Аронова Д.М. Коронарное шунтирование больных ишемической болезнью сердца: реабилитация и вторичная профилактика. Российские клинические рекомендации. Москва. 2016.
14. Князева Т.А., Никифорова Т.И., Еремушкин М.А., Стяжкина Е.М., Чукина И.М. Повышение эффективности кардиореабилитации включением методов метаболической адаптации к ишемии миокарда. Вестник восстановительной медицины. 2019; 3(91): 34-39.
15. Sakib Z.A., Dai J., Minhas R., Mahmoud S., Karim M., Sang H., Wang Yu. Physical Activity is a Medicine for Non-Communicable Diseases: A Survey Study Regarding the Perception of Physical Activity Impact on Health Wellbeing. Risk Management and Healthcare Policy. 2020; (13): 2949-2962. https://doi.org/10.2147/RMHP.S280339
16. Nasi M., Patrizi G., Pizzi S., Landolfo M., Boriani G., Dei Cas A., Cicero A.F., Fogacci F., Rapezzi S., Sisca G., Capucci A., Vitolo M., Galie N., Borgi S., Berrettini U., Piepoli M., Mattioli A.V. The role of physical activity in individuals with cardiovascular risk factors: an opinion paper from Italian Society of Cardiology-Emilia Romagna-Marche and SIC-Sport. Journal of Cardiovascular Medicine. 2019; 20(10): 631-639. https://doi.org/10.2459/JCM.0000000000000855
17. Vella K.A., Taylor K., Drummer D. High-intensity interval and moderate-intensity continuous training elicit similar enjoyment and adherence levels in overweight and obese adults. European Journal of Sport Science. 2017; 17(9): 1203-1211. https://doi.org/10.1080/17461391.2017.1359679
18. Барашков Г.Н., Сергеев В.Н., Карамнова Н.С. Терренкуры и физическая тренировка ходьбой: реабилитационно-профилактические аспекты. Профилактическая медицина. 2021; 24(5): 87-93.
19. Schobersberger W., Leichtfried V., Mueck-Weyman M., Humpeler E. Austrian Moderate Altitude Studies (AMAS): benefits of exposure to moderate altitudes (1,500-2,500 m). Sleep and Breathing. 2010; (14): 201-207. https://doi.org/10.1007/s11325-009-0286-y
20. Faulhaber M., Flatz M., Gatterer H., Shobersberger W., Burtscher M. Prevalence of Cardiovascular Diseases Among Alpine Skiers and Hikers in the Austrian Alps. High Altitude Medicine & Biology. 2007; (8): 245-252. https://doi.org/10.1089/ham.2007.1005
21. Faulhaber M., Gatterer H., Bertscher M. Preexisting Cardiovascular Diseases Among High-Altitude Mountaineers in the Alps. Journal of Travel Medi- cine. 2011; (18): 355-357. https://doi.org/10.1111/j.1708-8305.2011.00536.x
22. Bercher M. Risk of cardiovascular events during mountain activities. Advances in Experimental Medicine and Biology. 2007; (618): 1-11.
23. Stoltzfus K.B., Naylor D., Cattermole T., Ankeny A., Mount R., Chang R., Gibson C.A. Blood Pressure Changes While Hiking at Moderate Altitudes: A Pro- spective Cohort Study. International Journal of Environmental Research and Public Health. 2020; 17(21): 7978. https://doi.org/10.3390/ijerph17217978
24. Parati G., Agostoni P., Basnyat B., Bilo G., Brugger H., Coca A., Festi L., Giardini G., Lironcurti A., Luks A.M. et al. Clinical recommendations for high altitude exposure of individuals with pre-existing cardiovascular conditions: A joint statement by the European Society of Cardiology, the Council on Hypertension of the European Society of Cardiology, the European Society of Hypertension, the International Society of Mountain Medicine, the Italian Society of Hypertension and the Italian Society of Mountain Medicine. European Heart Journal. 2018; 39(17): 1546-1554. https://doi.org/10.1093/eurheartj/ehx720
25. Festa A., D'Agostino R., Howard G., Mykkänen L., Tracy R.P., Haffner S.M. Chronic Subclinical Inflammation as Part of the Insulin Resistance Syndrome. The Insulin Resistance Atherosclerosis Study (IRAS). Circulation. 2000; (102): 42-47.
26. Schlaich M., Straznicky N., Lambert E., Lambert G. Metabolic syndrome: a sympathetic disease? The Lancet Diabetes & Endocrinology. 2015; (3): 148-157.
27. Carnagarin R., Mathews V., Zaldivia M.T.K., Peter K. and Schleich M.P. The bidirectional interaction between the sympathetic nervous system and immune mechanisms in the pathogenesis of hypertension. British Journal of Pharmacology. 2019; 176(12): 1839-1852. https://doi.org/10.1111/bph.14481
28. Li G., Liu J.Y., Zhang H.X., Li Q., Zhang S.W. Exercise training attenuates sympathetic activation and oxidative stress in diet-induced obesity. Physiological Research. 2015; (64): 355-367.
29. Peichenen-Alkho M.K., Mankhem K., Katsman P., Kibarskis A., Antikainen R.L., Erkkola R.U. et al. Central sympatholytic therapy has anti-inflammatory properties in postmenopausal women with hypertension. Journal of Hypertension. 2008; (26): 2445-2449.
30. Chazova I., Almazov V.A., Shlyakhto E. Moxonidine improves glycaemic control in mildly hypertensive, overweight patients: a comparison with metformin. Diabetes, Obesity and Metabolism. 2006; 8(4): 456-465.
31. Panchapakesan U., Pegg K., Gross S., Komala M.G., Mudaliar X., Forbes J., Pollock C., Mather A. Effects of SGLT2 inhibition in human kidney proximal tubular cells--renoprotection in diabetic nephropathy? PLoS One. 2013; 8(2): e54442.
32. Matthews V.B., Elliot R.H., Rudnicka C., Hricova J., Herat L., Schlaich M.P. Role of the sympathetic nervous system in regulation of the sodium glucose cotransporter 2. Journal of Hypertension. 2017; 35(10): 2059-2068.
33. Arita Y., Kihara S., Ouchi N., Takahashi M., Maeda K., Miyagawa J. et al. Paradoxical Decrease of an Adipose-Specific Protein, Adiponectin, in Obesity. Biochemical and Biophysical Research Communications. 1999; 257(1): 79-83. https://doi.org/10.1006/bbrc.1999.0255
34. Qiao L., Zou C., van der Westhuizen D.R., Shao J. Adiponectin Reduces Plasma Triglyceride by Increasing VLDL Triglyceride Catabolism. Diabetes. 2008; 57(7): 1824-33. https://doi.org/10.2337/db07-0435
35. Matsuura F., Oku H., Koseki M., Sandoval J.C., Yuasa-Kawase M., Tsubakio-Yamamoto K. et al. Adiponectin accelerates reverse cholesterol transport by increasing high density lipoprotein assembly in the liver. Biochemical and Biophysical Research Communications. 2007; 358(4): 1091-1095. https://doi.org/10.1016/j.bbrc.2007.05.040
36. Oku H., Matsuura F., Koseki M., Sandoval J.C., Yuasa-Kawase M., Tsubakio-Yamamoto K. et al. Adiponectin deficiency suppresses ABCA1 expression and ApoA-I synthesis in the liver. FEBS Letters. 2007; 581(26): 5029-5033. https://doi.org/10.1016/j.febslet.2007.09.038 37.
37. Ryo M., Nakamura T., Kihara S., Kumada M., Shibazaki S., Takahashi M. et al. Adiponectin as a biomarker of metabolic syndrome. Circulation Journal. 2004; 68(11): 975-81. https://doi.org/10.1253/circj.68.975
38. Mattu H.S., Randeva H.S. Role of adipokines in cardiovascular disease. Journal of Endocrinology. 2013; 216(1): T17-36. https://doi.org/10.1530/JOE-12-0232
39. Schindlert T.H., Cardenas J., Pryor J.O., Fact A.D., Kreissl M.C., Zhang X.L. et al. Relationship Between Increasing Body Weight, Insulin Resistance, Inflammation, Adipocytokine Leptin, and Coronary Circulatory Function. Journal of the American College of Cardiology. 2006; (47): 1188-95. https://doi.org/10.1016/j.jacc.2005.10.062
40. Gruzdeva O., Uchasova E., Belik E., Dyleva Y., Shurygina E., Barbarash O. Lipid, adipokine and ghrelin levels in myocardial infarction patients with insulin resistance. BMC Cardiovascular Disorders. 2014; 14(7). https://doi.org/10.1186/1471-2261-14-7
41. Vissers D., Hens W., Taeymans J., Baeyens J.P., Poortmans J., Van Gaal L. The effect of exercise on visceral adipose tissue in overweight adults: a systematic review and meta-analysis. PloS One. 2013; 8(2): e56415.
42. Pattyn N., Cornelissen V.A., Eshghi S.R.T., Vanhees L. The effect of exercise on the cardiovascular risk factors constituting the metabolic syndrome: a meta-analysis of controlled trials. Sports Medicine. 2013; 43(2): 121-33. https://doi.org/10.1007/s40279-012-0003-z
43. Gruzdeva O., Uchasova E., Belik E., Dyleva Yu., Shurygina E., Barbarash O. Lipid, adipokine and ghrelin levels in myocardial infarction patients with insulin resistance. BMC Cardiovascular Disorders. 2014; (14): 7. https://doi.org/10.1186/1471-2261-14-7
44. Golbidi S., Laher I. Exercise Induced Adipokine Changes and the Metabolic Syndrome. Journal of Diabetes Research. 2014; (2014): 726861. https://doi.org/10.1155/2014/726861
45. Pattin N., Kornelissen V.A., Eshgi S.R., Vanhis L. The Effect of Exercise on the Cardiovascular Risk Factors Constituting the Metabolic Syndrome. Sports Medicine. 2013; (43): 121-33. https://doi.org/10.1007/s40279-012-0003-z
46. Pescatello L.S., Blanchard B.E., Van Hist J.L., Marech K.M., Gordisch-Dressman H., Thompson P.D. The Metabolic Syndrome and the immediate antihypertensive effects of aerobic exercise: a randomized control design. BMC Cardiovascular Disorders. 2008; (8): 12. https://doi.org/10.1186/1471-2261-8-12
47. Boyer S.J., Blum F D. Weight loss and changes in body composition at high altitude. Journal of Applied Physiology. 1984; (57): 1580-5.
48. Wu T-Y., Ding Q., Liu J.L., Yu M.T., Jia J.H., Chai Z.C. et al. Who Should Not Go High: Chronic Disease and Work at Altitude During Construction of the Qinghai-Tibet Railroad. High Altitude Medicine & Biology. 2007; 8(2): 88-107. https://doi.org/10.1089/ham.2007.1015
49. Ri-Li G., Chase P.J., Witkowski S., Wyrick B.L., Stone J.A., Levine B.D., Babb G.T. Obesity: Associations with Acute Mountain Sickness. Annals of Internal Medicine. 2003; (139): 253-7. https://doi.org/10.7326/0003-4819-139-4-200308190-00007
50. Zheqing Cai, Weibo Luo, Huiwang Zhan, Gregg L. Semenza. Hypoxia-inducible factor 1 is required for remote ischemic preconditioning of the heart. PNAS. 2013; (110): 17462-7. https://doi.org/10.1073/pnas.1317158110 51.
51. Netzer N.C., Chytra R., Küpper T. Low intense physical exercise in normobaric hypoxia leads to more weight loss in obese people than low intense physical exercise in normobaric sham hypoxia. Sleep and Breathing. 2008; (12): 129-34. https://doi.org/10.1007/s11325-007-0149-3
52. Workman C., Basset F.A. Post-metabolic response to passive normobaric hypoxic exposure in sedendary overweight males: a pilot study. Nutrition & Metabolism. 2012; (9): 103. https://doi.org/10.1186/1743-7075-9-103
53. Anne-Christin Stöwhas, Tsogyal D. Latshang, Christian M. Lo Cascio, Sina Lautwein, Katrin Stadelmann, Noemi Tesler, Lisa Ayers, Kaspar Berneis, Philipp A. Gerber, Reto Huber, Peter Achermann, Konrad E. Bloch, Malcolm Kohler. Effects of Acute Exposure to Moderate Altitude on Vascular Function, Metabolism and Systemic Inflammation. PLoS One. 2013; (8): e70081. https://doi.org/10.1371/journal.pone.0070081
54. Kiave Yune Howangyin, Jean-Sébastien Silvestre. Diabetes Mellitus and Ischemic Diseases Molecular Mechanisms of Vascular Repair Dysfunction. Arteriosclerosis, Thrombosis, and Vascular Biology. 2014; (34): 1126-35. https://doi.org/10.1161/ATVBAHA.114.303090
55. Martin Burtscher. Effects of Living at Higher Altitudes on Mortality: A Narrative Review. Aging and Disease. 2014; (5): 274-80. https://doi.org/10.14336/AD.2014.0500274
56. Wolfgang Schobersberger, Peter Schmid, Monika Lechleitner, Serge P. von Duvillard, Helmut Hörtnagl, Hanns-Christian Gunga, Anton Klingler, Dietmar Fries, Karl Kirsch, Reinhard Spiesberger, Rochus Pokan, Peter Hofmann, Fritz Hoppichler, Gebhard Riedmann, Holger Baumgartner, Egon Humpeler. Austrian Moderate Altitude Study 2000 (AMAS 2000). The effects of moderate altitude (1,700 m) on cardiovascular and metabolic variables in patients with metabolic syndrome. European Journal of Applied Physiology. 2003; 88(6): 506-14. https://doi.org/10.1007/s00421-002-0736-8
57. Greie S., Humpeler E., Gunga H.C., Koralewski E., Klingler A., Mittermayr M., Fries D., Lechleitner M., Hoertnagl H., Hoffmann G., Strauss-Blasche G., Schobersberger W. Improvement of metabolic syndrome markers through altitude specific hiking vacations. Journal of Endocrinological Investigation. 2006; 29:497-504. https://doi.org/10.1007/BF03344138
58. Johannes Mair, Angelika Hammerer-Lercher, Markus Mittermayr, Anton Klingler, Egon Humpelere, Otmar Pachinger, Wolfgang Schobersberger. 3-week hiking holidays at moderate altitude do not impair cardiac function in individuals with metabolic syndrome. International Journal of Cardiology. 2008; (123): 186-8. https://doi.org/10.1016/j.ijcard.2006.11.127 59.
59. Tobias Dünnwald, Hannes Gatterer, Martin Faulhaber, Marjan Arvandi, Wolfgang Schobersberger. Body Composition and Body Weight Changes at Different Altitude Levels: A Systematic Review and Meta-Analysis. Frontiers in Physiology. 2019; (10): 430. https://doi.org/10.3389/fphys.2019.00430
60. Chacaroun S., Borowik A., Vega-Escamilla Y. Gonzalez I., Doutreleau S., Wuyam B., Belaidi E., Tamisier R., Pepin J-L., Flore P., Verges S. Hypoxic Exercise Training to Improve Exercise Capacity in Obese Individuals. Medicine & Science in Sports & Exercise. 2020; 52(8): 1641-1649. https://doi.org/10.1249/mss.0000000000002322
