Original ArticleSupervised Moderate Intensity Exercise Improves Distance Walked at Hospital Discharge Following Coronary Artery Bypass Graft Surgery—A Randomised Controlled Trial
Introduction
Traditionally, physiotherapists have employed a variety of respiratory interventions after coronary artery bypass graft surgery (CABG) to reduce the incidence of post-operative pulmonary complications (PPC).1 A recent systematic review provided evidence that such interventions were ineffective at preventing PPC in this population, although it was acknowledged that the component studies were often of low quality, and that further research was indicated.2 Furthermore, the incidence of PPC following cardiac surgery is both small and decreasing,3 a trend which has been attributed in part to current management protocols emphasising early post-operative mobility. Accordingly, physiotherapy during inpatient or Phase 1 cardiac rehabilitation (CR) may be more usefully directed at restoring pre-operative physical functional capacity, through prescription of walking exercise and/or thoracic mobility exercises. Even if such approaches have no impact on PPC rates, early restoration of functional outcomes, e.g. walking ability, may shorten the duration of hospital admission and allow for earlier progression to outpatient CR and return to work.
We searched Medline, CINAHL and PEDro using the search terms ‘cardiac surgery’, ‘coronary artery bypass graft’, ‘CABG’, ‘physiotherapy’, ‘physical therapy’, ‘exercise’ and ‘breathing exercise’. We found no studies of the effect of Phase 1 mobilisation per se on walking ability, respiratory capacity, subjective health or length of hospital stay following CABG. We also failed to find any studies investigating effects of post-CABG upper limb/thoracic mobility exercises or carry-over effects of breathing exercises on walking ability or subjective health. Consequently, we formulated the following research questions:
- 1.
Does a Phase 1, moderate intensity walking exercise program, performed under direct physiotherapy supervision, improve sub-maximal exercise capacity, vital capacity, health-related quality of life or length of hospital stay?
- 2.
Does the addition of specific respiratory and musculoskeletal exercises to such a walking program provide further benefit in respect of these outcomes, compared to the walking program alone?
Section snippets
Patients
A prospective study was performed within the Critical Care Unit and Cardiovascular Ward of Westmead Private Hospital, Sydney, having been approved by the Sydney West Area Health Service Human Research Ethics Committee. Patients awaiting first-time CABG at Westmead Private Hospital between June 2004 and May 2005 were invited to participate in the study, and enrolled after giving written informed consent. Ninety-three patients were enrolled, one of whom did not proceed for operation, yielding a
Results
A flow-chart indicating progression of patients through the study period is shown in Fig. 1.
One patient recruited to the study (standard intervention) was subsequently cleared of significant coronary artery disease and did not proceed for pre-operative assessment or operation. One patient (standard intervention) died on the third post-operative day following an asystolic arrest. Three patients from the standard intervention group and one from the walking exercise group required additional
Discussion
The principal finding of the present study is that, in a population of patients undergoing first-time, non-emergency CABG, a moderate intensity, Phase 1 walking exercise program performed under direct physiotherapy supervision significantly improved sub-maximal exercise capacity at discharge from hospital (as measured by the 6MWA). In the absence of continuing exercise supervision, however, this benefit was not sustained at four-week follow-up. Further, performance of such a walking program
Acknowledgements
The authors would like to acknowledge Dr. Karen Byth-Wilson for her assistance with statistical advice, and all the staff of Westmead Private Hospital who assisted in the study.
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