*4.10. Neuromotor Training*

Neuromotor training comprises balance, gait, and coordination exercises. Examples of such training are standing with the feet together or on one leg; displacing the body mass center—e.g., by stepping over an obstacle; or walking with closed eyes in order to limit visual or proprioceptive feedback [12]. It has been demonstrated that neuromotor exercise improves control of posture by challenging the alignment of the body's center of gravity regarding the feet [95]. Such training should be applied to the elderly, as with age changes in the neuromuscular system negatively affect static and dynamic postural control and has also been demonstrated in healthy older adults [96]. Neuromotor training should be performed 2–3 times a week. There is no consensus regarding the optimal duration or number of repetitions; however, a total duration of at least 60 min per week is recommended [12]. A summary of ACSM neuromotor training recommendations is provided in Table 39.


**Table 39.** ACSM neuromotor training recommendations [12].

Abbreviations: ACSM—American College of Sports Medicine. Source: Adapted from [12].

Tai chi is a traditional Chinese mind–body exercise that has been practiced for many centuries; it has been called "meditation in motion" due to its slow movements with simultaneous deep breathing [97–99]. The movements are typically circular and performed during muscle relaxation. Tai chi has emerged as a promising exercise, and, considering recent studies, it has been suggested as a suitable training mode for the elderly. Reductions in the risk of falls, balance improvement, enhancement of range of motion, and improved quality of life following tai chi training have been documented [100]. Tai chi training for older patients entails performing progressively more difficult postures, reducing the base of support (through a semi-tandem stand, tandem stand, one-legged stand), heel stands, toe stands, and standing with closed eyes. Tai chi has been demonstrated to be safe and efficacious in patients following myocardial infarction or coronary artery bypass graft surgery, with in patients with stable heart failure, and following a stroke. Moreover, a reduction in the resting and post-exertional blood pressure and decrease in the blood glucose level following tai chi exercises have also been described [101,102].

### *4.11. Relaxation Training*

Permanent stress negatively affects the cardiovascular system and may be responsible for increased heart rate, elevated blood pressure, increase in respiratory rate, muscle tension, sleeplessness, and emotional problems [103]. These detrimental effects of stress can be counterbalanced by relaxation techniques, such as deep breathing or meditation [104] Relaxation techniques have been proven efficacious in reducing the respiratory rate, heart rate, and blood pressure; alleviating muscular tension; and improving sleep pattern, thus positively affecting well-being [105]. Thus, relaxation techniques have been incorporated in cardiac rehabilitation to induce an effective improvement in mood [106].

The most popular relaxation techniques utilized in cardiac rehabilitation are deep breathing, cardiac yoga, and music therapy.

Indian-origin Yoga is characterized as a combination of specific body postures (so-called asanas) and associated breathing techniques, with almost 100 asanas still being utilized. A deep breathing pattern with the use of the abdominal muscles and the diaphragm is followed by breath hold in full inspiration and is continued as slow and spontaneous exhalation [107]. The efficacy of cardiac yoga in the primary and secondary prevention of ischemic heart disease and post-myocardial infarction rehabilitation has been extensively studied. Interestingly, practicing yoga induces an antihypertensive effect, enhanced heart rate variability, reduction in serum total cholesterol and triglyceride, and significant improvement in cardiovascular fitness [108–110]. There is no consensus regarding the duration and frequency of relaxation techniques; however, most forms of relaxation are practiced for more than 20 min once or twice daily [111]. Yoga appears to be an efficacious alternative technique suitable for patients with cardiovascular disease, especially for those not adhering to conventional exercise. More research is needed to assess the beneficial effects of yoga in the primary and secondary prevention of cardiovascular disease.
