Supervised Moderate Intensity Exercise Improves Distance Walked at Hospital Discharge Following Coronary Artery Bypass Graft Surgery—A Randomised Controlled Trial

doi:10.1016/j.hlc.2007.09.004

Heart, Lung and Circulation

Volume 17, Issue 2, April 2008, Pages 129-138

https://doi.org/10.1016/j.hlc.2007.09.004 Get rights and content

Background

This study aimed to determine whether a structured, inpatient (or Phase 1 cardiac rehabilitation), physiotherapy-supervised walking program, with or without musculoskeletal and respiratory exercises, might improve walking capacity and other parameters for patients undergoing coronary artery bypass graft surgery (CABG).

Methods

Ninety-three patients awaiting first-time CABG over a 12-month period were randomised to one of three post-operative physiotherapy regimens: ‘standard intervention’, consisting of gentle mobilisation; ‘walking exercise’, consisting of a physiotherapy-supervised, moderate intensity walking program; and ‘walking/breathing exercise’, consisting of the same moderate intensity walking program, musculoskeletal exercises and respiratory exercises. Primary outcomes; six-minute walking assessment (6MWA) distance, vital capacity and health-related quality of life, were measured pre-operatively, at discharge from hospital and at four weeks following discharge.

Results

Walking and walking/breathing exercise groups had significantly higher 6MWA distance (444 ± 84 m, 431 ± 98 m, respectively) than the standard intervention group (377 ± 90 m) at discharge from hospital. There was no significant difference between intervention groups for 6MWA distance at four-week follow-up. There was no significant difference between intervention groups in terms of vital capacity and health-related quality of life.

Conclusions

A physiotherapy-supervised, moderate intensity walking program in the inpatient phase following CABG improves walking capacity at discharge from hospital. The performance of respiratory and musculoskeletal exercises confers no additional benefit to the measured outcomes.

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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Citation Excerpt :
Patients in the intensive mobilisation group, however, more rapidly achieved the functional objectives and showed a higher degree of satisfaction compared to those in the simple mobilisation group [275]. Regarding other postoperative complications, such as atrial fibrillation or renal failure, the evidence is scarce [274,276,277]. Doyle et al. [278] evaluated, in a meta-analysis, the effect of early exercise (bicycling or walking once or twice a day with a physiotherapist’s supervision) prior to hospital discharge.
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Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.
The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1−); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2−); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.
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To update a previous review on whether additional physical therapy services reduce length of stay, improve health outcomes, and are safe and cost-effective for patients with acute or subacute conditions.
Electronic database (AMED, CINAHL, EMBASE, MEDLINE, Physiotherapy Evidence Database [PEDro], PubMed) searches were updated from 2010 through June 2017.
Randomized controlled trials evaluating additional physical therapy services on patient health outcomes, length of stay, or cost-effectiveness were eligible. Searching identified 1524 potentially relevant articles, of which 11 new articles from 8 new randomized controlled trials with 1563 participants were selected. In total, 24 randomized controlled trials with 3262 participants are included in this review.
Data were extracted using the form used in the original systematic review. Methodological quality was assessed using the PEDro scale, and the Grading of Recommendation Assessment, Development, and Evaluation approach was applied to each meta-analysis.
Postintervention data were pooled with an inverse variance, random-effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). There is moderate-quality evidence that additional physical therapy services reduced length of stay by 3 days in subacute settings (mean difference [MD]=–2.8; 95% CI, –4.6 to –0.9; I²=0%), and low-quality evidence that it reduced length of stay by 0.6 days in acute settings (MD=–0.6; 95% CI, –1.1 to 0.0; I²=65%). Additional physical therapy led to small improvements in self-care (SMD=.11; 95% CI, .03–.19; I²=0%), activities of daily living (SMD=.13; 95% CI, .02–.25; I²=15%), and health-related quality of life (SMD=.12; 95% CI, .03–.21; I²=0%), with no increases in adverse events. There was no significant change in walking ability. One trial reported that additional physical therapy was likely to be cost-effective in subacute rehabilitation.
Additional physical therapy services improve patient activity and participation outcomes while reducing hospital length of stay for adults. These benefits are likely safe, and there is preliminary evidence to suggest they may be cost-effective.
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Original ArticleSupervised Moderate Intensity Exercise Improves Distance Walked at Hospital Discharge Following Coronary Artery Bypass Graft Surgery—A Randomised Controlled Trial

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Acknowledgements

Aust J Physiother

Aust J Physiother

Heart Lung

Ann Thorac Surg

Am Heart J

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Chest

Chest

J Thorac Cardiovasc Surg

Prophylactic respiratory physiotherapy after cardiac surgery: systematic review

BMJ

Original Article
Supervised Moderate Intensity Exercise Improves Distance Walked at Hospital Discharge Following Coronary Artery Bypass Graft Surgery—A Randomised Controlled Trial