Does the mode of exercise influence recovery of functional capacity in the early postoperative period after coronary artery bypass graft surgery? A randomized controlled trial

Effects of early mobilization in elderly patients undergoing cardiac surgery

BACKGROUND

Although early mobilization is associated with improved outcomes in postoperative cardiac patients, implementation of early mobilization in elderly patients is still a challenge.

AIMS

In this study, we aimed to design and assess an early mobilization program for cardiac rehabilitation.

METHODS

We conducted a clinical trial in elderly patients aged over 65 years after coronary artery bypass graft surgery. Patients were randomly assigned to an early mobilization group (Group A) or a routine therapy group (Group B). Short-Form International Physical Activity Questionnaire (SF-IPAQ), to assessment balance Time Up and Go (TUG), to assessment functional capacity the 2-min walking test (2MWT) and the short physical performance battery (SPPB) were used as a reference to formulate and monitor the early mobilization regimen.

RESULTS

A total of 100 patients were enrolled (n = 50 per group). The mean walking distance in Group A was significantly higher at 135.6 ± 9.29 than the mean walking distance in Group B which was lower at 123.4 ± 8.48. Also, the patients in Group B had a mean SF-IPAQ of 389.44 with an SD of 85.7, P < 0.001, whereas the mean SF-IPAQ amount in Group A was 556.16 with an SD of 91.47. In early mobilization group, a strong positive connection was indicated by the correlation coefficient of r = 0.957 between the amount of SF-IPAQ and 2 MWT and there was a significant negative association r =  - 0.768 between 2MWT and TUG.

CONCLUSION

Our study's findings suggest that early mobilization and functional exercises enhanced balance, functionality, and life quality for older cardiac patients.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Efficacy of neuromuscular electrical stimulation for thoracic and abdominal surgery: A systematic review and meta-analysis

This systematic review and meta-analysis examined the efficacy of neuromuscular electrical stimulation (NMES) on lower limb muscle strength and health-related quality of life (HR-QOL) after thoracic and abdominal surgery. We searched the Cochrane Central Register of Controlled Trials, MEDLINE via PubMed, Excerpta Medica Database via Elsevier, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, World Health Organization International Clinical Trials Registry Platform via their dedicated search portal, and ClinicalTrials.gov on November 2021 and updated in April 2023 to identify randomized controlled trials that examined the effects of NMES after thoracic and abdominal surgery. The primary outcomes were lower limb muscle strength, HR-QOL, and adverse events. We used the Cochrane Risk of Bias Tool and the Grading of Recommendations, Assessment, Development, and Evaluation approach to assess the certainty of evidence. A total of 18 randomized control trials involving 915 participants, including 10 on cardiovascular surgery, two on pulmonary surgery, five on digestive system surgery, and one on other surgery, were included. NMES slightly increased lower limb muscle strength and adverse events in cardiovascular surgery. Adverse events (hypotension, pain, and muscle discomfort) occurred in seven patients. HR-QOL was measured in two studies on cardiovascular surgery, but these were not pooled due to concept heterogeneity. Overall, NMES slightly increases lower limb muscle strength after cardiovascular surgery without serious adverse events. However, higher-quality randomized control trials in thoracic and abdominal surgeries are needed.

A randomised controlled, feasibility study to establish the acceptability of early outpatient review and early cardiac rehabilitation compared to standard practice after cardiac surgery and viability of a future large-scale trial (FARSTER)

OBJECTIVE

To determine the acceptability and feasibility of delivering early outpatient review following cardiac surgery and early cardiac rehabilitation (CR), compared to standard practice to establish if a future large-scale trial is achievable.

METHODS

A randomised controlled, feasibility trial with embedded health economic evaluation and qualitative interviews, recruited patients aged 18-80 years from two UK cardiac centres who had undergone elective or urgent cardiac surgery via a median sternotomy. Eligible, consenting participants were randomised 1:1 by a remote, centralised randomisation service to postoperative outpatient review 6 weeks after hospital discharge, followed by CR commencement from 8 weeks (control), or postoperative outpatient review 3 weeks after hospital discharge, followed by commencement of CR from 4 weeks (intervention). The primary outcome measures related to trial feasibility including recruitment, retention, CR adherence, and acceptability to participants/staff. Secondary outcome measures included health-rated quality of life using EQ-5D-5L, NHS resource-use, Incremental Shuttle Walk Test (ISWT) distance, 30- and 90-day mortality, surgical site complications and hospital readmission rates.

RESULTS

Fifty participants were randomised (25 per group) and 92% declared fit for CR. Participant retention at final follow-up was 74%; completion rates for outcome data time points ranged from 28 to 92% for ISWT and 68 to 94% for follow-up questionnaires. At each time point, the mean ISWT distance walked was greater in the intervention group compared to the control. Mean utility scores increased from baseline to final follow-up by 0.202 for the intervention (0.188 control). Total costs were £1519 for the intervention (£2043 control). Fifteen participants and a research nurse were interviewed. Many control participants felt their outpatient review and CR could have happened sooner; intervention participants felt the timing was right. The research nurse found obtaining consent for willing patients challenging due to discharge timings.

CONCLUSION

Recruitment and retention rates showed that it would be feasible to undertake a full-scale trial subject to some modifications to maximise recruitment. Lower than expected recruitment and issues with one of the clinical tests were limitations of the study. Most study procedures proved feasible and acceptable to participants, and professionals delivering early CR.

TRIAL REGISTRATION

ISRCTN80441309 (prospectively registered on 24/01/2019).

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

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.

RESULTS

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.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Fit, Female or Fifty–Is Cardiac Rehabilitation “Fit” for Purpose for All? A Systematic Review and Meta-Analysis With Meta-Regression

Aims

Cardiac rehabilitation (CR) is an evidence-based intervention promoting risk factor modification following coronary artery disease events but the relative benefits for patient subgroups is not clear. This review synthesizes the available evidence on the effectiveness of modern CR programs and determines outcomes for age, sex and prior level of fitness.

Methods

MEDLINE, CINAHL, and EMBASE were examined for RCT and cohort studies involving exercise prescription or phase II or III CR following Myocardial Infarction (MI), Percutaneous Coronary Intervention (PCI) and cardiac surgery from January 2010 to February 2021. Outcomes assessed included peakVO2max, 6-min walk test and Metabolic Equivalent of Task. Meta-regression was used to determine CR impact for change in fitness and age and sex influences.

Results

The mean age of study participants was 59.5 years and 82.7% were male. Females, younger people and those of average or above cardiorespiratory fitness were substantially under-represented in data and attendance, with 13% of study groups with a mean age &lt;55 years. At entry, 73% were below average for fitness vs. age-matched normative values. Fitness improved across all groups following CR with no evidence of sex or age independently affecting outcomes.

Conclusions

Modest improvements in fitness in all groups were shown, but the benefits of CR can be far greater. A modern, innovative approach to CR will likely lead to more substantial benefits. This may require a “Precision Medicine” model which tailors exercise prescription to different populations to ensure all CR participant's needs are met. This will ensure that CR is more flexible and accessible for all.

Association of phase angle with hospital-acquired functional decline in older patients undergoing cardiovascular surgery

OBJECTIVE

The aim of this study was to examine whether preoperative phase angle (PhA) measured by bioelectrical impedance analysis was associated with a hospital-acquired functional decline in older patients undergoing cardiovascular surgery.

METHODS

This was an observational study of prospectively collected data of 114 patients (>65 y of age) with cardiovascular disease who underwent elective cardiovascular surgery between September 2019 and August 2020. Patients were classified into tertiles based on PhA levels. Factors associated with the occurrence of hospital-acquired functional decline (postoperative recovery to preoperative physical function was not possible) were analyzed using univariate and multivariate analyses.

RESULTS

Patients in the low PhA group were significantly older than those in the middle and high PhA groups; were predominantly women; had higher New York Heart Association cardiovascular and EuroSCORE severity scores; and had significantly lower levels of body mass index, Geriatric Nutritional Risk Index, hemoglobin, and albumin. There was a significant correlation between PhA and nutrition and physical function. The incidence of hospital-acquired functional decline occurred in 26.3% of all patients, with a significantly higher incidence in patients in the low PhA group. Multivariate analysis showed that PhA was extracted as a factor for the hospital-acquired functional decline in all the models.

CONCLUSIONS

PhA was associated with hospital-acquired functional decline in older patients undergoing cardiovascular surgery. PhA is likely to be a comprehensive indicator of physical health that indicates nutritional status, physical function, and geriatric syndrome (frailty/sarcopenia), and is an important predictor of hospital-acquired functional decline in this group of older patients.

Location and Patterns of Persistent Pain Following Cardiac Surgery

OBJECTIVES

To investigate the specific clinical features of pain following cardiac surgery and evaluate the information derived from different pain measurement tools used to quantify and describe pain in this population.

METHODS

A prospective observational study was undertaken at two tertiary care hospitals in Australia. Seventy-two (72) adults (mean age, 63±11 years) were included following cardiac surgery via a median sternotomy. Participants completed the Patient Identified Cardiac Pain using numeric and visual prompts (PICP), the McGill Pain Questionnaire-Short Form version 2 (MPQ-2) and the Medical Outcome Study 36-item version 2 (SF-36v2) Bodily Pain domain (BP), which were administered prior to hospital discharge, 4 weeks and 3 months postoperatively.

RESULTS

Participants experienced a high incidence of mild (n=45, 63%) to moderate (n=22, 31%) pain prior to discharge, which reduced at 4 weeks postoperatively: mild (n=28, 41%) and moderate (n=5, 7%) pain; at 3 months participants reported mild (n=14, 20%) and moderate (n=2, 3%) pain. The most frequent location of pain was the anterior chest wall, consistent with the location of the surgical incision and graft harvest. Most participants equated "pressure/weight" to "aching" or a "heaviness" in the chest region (based on descriptor of pain in the PICP) and the pain topography was persistent at 4 weeks and 3 months postoperatively. Each pain measurement tool provided different information on pain location, severity and description, with significant change (p<0.005) over time.

CONCLUSION

Mild-to-moderate pain was frequent after sternotomy, improved over time and was mostly located over the incision and mammary (internal thoracic) artery harvest site. Persistent pain at 3 months remained a significant problem in the community within this surgical population.

Alterations in the Properties of Red Blood Cells in Men with Coronary Artery Diseases after Comprehensive Cardiac Rehabilitation

Purpose

Comprehensive cardiac rehabilitation (CCR) is a complex program aimed at improving the health status of patients with coronary artery disease (CAD), especially those who have been subjected to cardiac interventions (PCI and CABG).The aim of this study was to measure the changes in the properties of red blood cells (RBCs) in men with CAD after cardiac intervention and after participation in CCR program.

Methods

In this study, we have investigated the influence of the physical training-based CCR program in 12 men with CAD, after PCI or CABG. The characteristics of RBCs including the basic morphology of RBCs, the conformational state of RBC membrane protein and hemoglobin, acetylcholinesterase activity, membrane fluidity, the osmotic fragility, and thiol concentration in membrane and in hemolysate were measured. Ascorbate concentration and reduced glutathione were also determined. The analysis was performed in men, before and after participation in CCR. The properties of RBCs were observed in connection with the exercise test, and parameters were evaluated before, immediately after, and 1 hour after the exercise test.

Results

After CCR, a decrease in the mobility of erythrocyte membrane proteins was observed, which was accompanied by a decrease in lipid fluidity. In addition, immediately after the exercise test and 1 hour later, we measured a decrease in thiol level in hemolysate, but not in the plasma membrane. Unexpectedly, an increase in reduced glutathione concentration one hour after the exercise test after completing comprehensive cardiac rehabilitation was observed.

Conclusion

CCR in men with CAD after cardiac intervention is connected with decreased membrane fluidity and decreased membrane protein mobility, which indicates that reduction of oxidative changes in these components occurs.

Precision implementation of early ambulation in elderly patients undergoing off-pump coronary artery bypass graft surgery: a randomized-controlled clinical trial

Background

Although early ambulation (EA) is associated with improved outcomes in post-operative patients, implementation of EA in elderly patients is still a challenge. In this study, we aimed to design and assess a precision early ambulation program for cardiac rehabilitation.

Methods

We conducted a single-center, randomized and controlled clinical trial in elderly patients aged over 60 years after off-pump coronary artery bypass graft (OPCABG) surgery. Patients were randomly assigned to a precision early ambulation (PEA) group or a routine ambulation (Control) group. Age-predicted maximal heart rate (APMHR) and maximal oxygen uptake (VO_2max) were used as a reference to formulate and monitor the PEA regimen. The primary end-point was the postoperative length of stay in hospital (PLOS). The secondary end-points included 90-day mortality, incidence of early discharge, laboratory tests, length of ICU stay, the incidence of multiple organ complications and post-traumatic stress disorder (PTSD). Ambulation outcomes were also recorded.

Results

In total, 178 patients were enrolled (n = 89 per group). In the intent-to-treat analysis, PLOS in the PEA group was shorter than that in the Control group (9.04 ± 3.08 versus 10.09 ± 3.32 days, respectively. Mean difference 1.045 days; 95% confidence interval [CI] 0.098–1.992; P = 0.031 in the unadjusted model; mean difference 0.957 days; CI 0.007–1.907; P = 0.048 in adjusted model). The incidence of early discharge differed significantly between the PEA and control groups (41[46.1%] versus 24[27.0%] patients, respectively. Odds ratio [OR] 0.432; CI 0.231–0.809; P = 0.009 in unadjusted model; OR 0.466; CI 0.244–0.889, P = 0.02 in adjusted model). The time of first bowel movement, partial pressure O₂ and post-traumatic stress disorder score in the PEA group were better than those in the Control group. Participants walked much longer distances on day 3 in the PEA group than those in the Control group (76.12 ± 29.02 versus 56.80 ± 24.40 m, respectively, P < 0.001).

Conclusion

APMHR and VO_2max are valuable for implementation of PEA according to an established security threshold. PEA after OPCAPG surgery is safe and reliable for elderly patients, not only reducing the hospital stay, but also improving their physiological and psychological symptoms.

Trial registration

This study is a component of a protocol retrospectively registered: Application of ERAS in cardiovascular surgery. Trial registration number: ChiCTR1800018167. Date of registration: 3rd September, 2018. URL of trial registry record: http://www.chictr.org.cn/index.aspx

Preoperative Treatment of Malnutrition and Sarcopenia in Cardiac Surgery: New Frontiers

Cardiac surgery is performed more often in a population with an increasing number of comorbidities. Although these surgeries can be lifesaving, they disturb homeostasis and may induce a temporary overall loss of physiologic function. The required postoperative intensive care unit and hospital stay often lead to a mid- to long-term decline of nutritional and physical status, mental health, and health-related quality of life. Prehabilitation before elective surgery might be an opportunity to optimize the state of the patient. This article discusses current evidence and potential effects of preoperative optimization of nutrition and physical status before cardiac surgery.

The benefit of a preoperative respiratory protocol and musculoskeletal exercise in patients undergoing cardiac surgery

Introduction

Loss of physical activity and pulmonary dysfunction with its associated complications represent two of the most important causes of morbidity and mortality following cardiac surgery.

Aim

To evaluate whether a physiotherapy program based on respiratory training with or without musculoskeletal mobilization, started preoperatively, may provide a significant improvement in pulmonary and musculoskeletal recovery postoperatively in a sufficiently large sample of patients undergoing elective cardiac surgery.

Material and methods

One-hundred and two patients with similar baseline and preoperative characteristics were assigned to a preoperative respiratory physiotherapy protocol (group R, n = 34), a preoperative respiratory and motor physiotherapy protocol (group R + M, n = 34), or no preoperative specific physiotherapy protocol but only a simplified perioperative standard physiotherapy protocol (control group, C, n = 34). Data on 6-minute walking test, peak expiratory flow, and from blood gas analysis were retrospectively analyzed.

Results

As compared with group C, a statistically significant improvement was observed in the two preoperatively treated groups in terms of 1) better pre- (+0.7-0.8 Lt/min, p < 0.05) and postoperative (+1 Lt/min, p < 0.01) peak expiratory flow values; 2) longer pre- (+50-100 m, p < 0.01) and postoperative (+65-170 m, p < 0.01) distance traveled in the 6-minute walking test; 3) better PaO₂, SaO₂, pH value in postoperative blood gas measurements (p < 0.05, for all comparisons); 4) reduction of postoperative length of in-hospital stay (p < 0.05).

Conclusions

A benefit of combined respiratory and motor physiotherapy protocols can be expected in the groups of patients preoperatively treated, especially with the respiratory one, either before or after cardiac surgery with a faster recovery of physical-functional activities. Specifically, the motor protocol is associated with greater autonomy of running before or after cardiac surgery.

Effects of cycle ergometer use in early mobilization following cardiac surgery: a randomized controlled trial

OBJECTIVE

To evaluate the effect of early use of a cycle ergometer, compared to a standard care protocol, in postoperatory in-hospital mobility following cardiac surgery.

DESIGN

A randomized controlled trial.

SETTING

Tertiary hospital in Salvador, Bahia, Brazil.

SUBJECTS

Patients submitted to elective cardiac surgery (valvular or coronary bypass surgery by sternotomy).

INTERVENTION

Patients were randomly allocated in two groups: (1) cycle ergometer training group (10-minute session) and (2) control group submitted standard physiotherapy protocol (10-minute session). Training was provided twice a day, immediately following extubation and until patient was discharged from the intensive care.

MAIN MEASURES

The primary outcome was the difference in the total number of steps recorded on the pedometer over three days. Secondary outcomes were mobility in different subgroups and the reasons that prevented individuals from walking during early cardiac rehabilitation.

RESULTS

A total of 228 participants completed the study. No significant difference was found in the total number of steps between the groups after intervention: 2183 (range: 1729-2772) in the intervention group versus 2006 (1517-2657) in the control group (P = 0.167). However, self-reports indicated better motivation in the intervention group (P = 0.044). No adverse events occurred during the study.

CONCLUSION

As a strategy for early mobilization following cardiac surgery, the use of a cycle ergometer failed to increase independent physical activity compared to a standard care protocol. Nevertheless, it was safe and could be an alternative to make rehabilitation more attractive and motivational for this patient population.

Preoperative exercise and recovery after cardiac surgery: a meta-analysis

BACKGROUND

To evaluate the association between preoperative exercise and recovery after cardiac surgery.

METHODS

Literature comparing preoperative exercise and the control group for patients receiving cardiac surgery was retrieved in multiple databases. Review Manager 5.2 was adopted for meta-analysis, sensitivity analysis and bias analysis.

RESULTS

Finally, 6 relevant studies satisfied the inclusion criteria. There was significant difference in length of stay in intensive care unit (ICU) (MD- = 1.35, 95%CI [- 2.64, - 0.06], P = 0.04; P for heterogeneity < 0.0001, I2 = 88%) and physical function after operation (P of heterogeneity = 0.32, I2 = 12%, Z = 9.92, P of over effect< 0.00001). The meta-analysis suggested that there was no significant difference in white blood cell count (WBC) at postoperative day 7 and mental health after operation between the exercise group and the control group. Limited publication bias was observed in this study.

CONCLUSION

Preoperative exercise including inhaled muscle training, aerobics, resistance training and stretching could promote recovery after cardiac surgery.

An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy

Cardiac surgery via median sternotomy is performed in over 1 million patients per year worldwide. Despite evidence, sternal precautions in the form of restricted arm and trunk activity are routinely prescribed to patients following surgery to prevent sternal complications. Sternal precautions may exacerbate loss of independence and prevent patients from returning home directly after hospital discharge. In addition, immobility and deconditioning associated with restricting physical activity potentially contribute to the negative sequelae of median sternotomy on patient symptoms, physical and psychosocial function, and quality of life. Interpreting the clinical impact of sternal precautions is challenging due to inconsistent definitions and applications globally. Following median sternotomy, typical guidelines involve limiting arm movement during loaded lifting, pushing, and pulling for 6 to 8 weeks. This perspective paper proposes that there is robust evidence to support early implementation of upper body activity and exercise in patients recovering from median sternotomy while minimizing risk of complications. A clinical paradigm shift is encouraged, one that encourages a greater amount of controlled upper body activity, albeit modified in some situations, and less restrictive sternal precautions. Early screening for sternal complication risk factors and instability followed by individualized progressive functional activity and upper body therapeutic exercise is likely to promote optimal and timely patient recovery. Substantial research documenting current clinical practice of sternal precautions, early physical therapy, and cardiac rehabilitation provides support and the context for understanding why a less restrictive and more active plan of care is warranted and recommended for patients following a median sternotomy.

The challenge of non-adherence to early rehabilitation after coronary artery bypass surgery: Secondary results from the SheppHeartCABG trial

BACKGROUND

Attending and maintaining a cardiac rehabilitation programme is a challenge.

AIMS

The purpose of this study was to explore associations between non-adherence to early coronary artery bypass graft rehabilitation and sociodemographic and clinical baseline data.

METHODS

Coronary artery bypass graft patients were randomised 1:1 to either four weeks of comprehensive early rehabilitation or usual care. Outcomes were assessed at three time-points points: baseline, discharge and four weeks post-coronary artery bypass graft. Differences in sociodemographic and clinical baseline data in adherent versus non-adherent patients were tested using the Pearson χ² test for categorical variables. To test associations between non-adherence to exercise training and sociodemographic and clinical baseline data, multivariate logistic regression was used to estimate the odds ratio for in-hospital training and post-discharge training adjusted for age, sex and left ventricular ejection fraction.

RESULTS

Non-adherence to in-hospital versus post-discharge exercise training was 31% (n=48) versus 53% (n=81). Female non-adherence was 20% versus 70%. Non-adherence to in-hospital versus post-discharge mindfulness was 87% versus 70%. Male non-adherence to mindfulness was 85% versus 70%. Non-adherence to psycho-educational consultations was 3%, most of whom were men. Patients with university level education were more adherent to in-hospital exercise training than patients with lower educational level (odds ratio=3.14 (95% confidence interval; 1.16-8.51), p=0.02). Diabetic patients were more non-adherent to exercise training after discharge (3.74 (1.54-9.08), p=0.004) as were overweight patients (0.37 (0.17-0.80), p=0.01).

CONCLUSIONS

This study demonstrated wide acceptance of psycho-educational consultations in post-coronary artery bypass graft patients. Adherence to physical rehabilitation was low especially after discharge from hospital and the opportunity to attend a mindfulness programme was not used.

Characterizing Patient-Centered Postoperative Recovery After Adult Cardiac Surgery: A Systematic Review

Background

Improving postoperative recovery is important, with a national focus on postacute care, but the volume and quality of evidence in this area are not well characterized. We conducted a systematic review to characterize studies on postoperative recovery after adult cardiac surgery using patient‐reported outcome measures.

Methods and Results

From MEDLINE and Web of Science, studies were included if they prospectively assessed postoperative recovery on adult patients undergoing cardiac surgery using patient‐reported outcome measures. Six recovery domains were defined by prior literature: nociceptive symptoms, mental health, physical function, activities of daily living, sleep, and cognitive function. Of the 3432 studies, 105 articles met the inclusion criteria. The studies were small (median sample size, 119), and mostly conducted in single‐center settings (n=81; 77%). Study participants were predominantly men (71%) and white (88%). Coronary artery bypass graft was included in 93% (n=98). Studies commonly selected for elective cases (n=56; 53%) and patients with less comorbidity (n=67; 64%). Median follow‐up duration was 91 (interquartile range, 42–182) days. Studies most commonly assessed 1 domain (n=42; 40%). The studies also varied in the instruments used and differed in their reporting approach. Studies commonly excluded patients who died during the follow‐up period (n=48; 46%), and 45% (n=47) did not specify how those patients were analyzed.

Conclusions

Studies of postoperative patient‐reported outcome measures are low in volume, most often single site without external validation, varied in their approach to missing data, and narrow in the domains and diversity of patients. The evidence base for postoperative patient‐reported outcome measures needs to be strengthened.

Exercise Parameters and Outcome Measures Used in Cardiac Rehabilitation Programs Following Median Sternotomy in the Elderly: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review was to identify exercise parameters and outcome measures used in cardiac rehabilitation programs following median sternotomy, in the elderly cardiac population.

DATA SOURCES

Five (5) electronic databases were searched for relevant studies published in English after 1997.

STUDY SELECTION

The screening process was completed by two independent researchers, with a third independent reviewer for overall agreement. Studies were selected if they included only cardiac patients aged ≥65 years who had undergone valve surgery and/or coronary artery bypass grafting via median sternotomy, and who had undertaken a postoperative cardiac rehabilitation exercise intervention assessing physical function and/or cognitive recovery as outcomes.

DATA EXTRACTION

Two researchers independently completed the data extraction and quality assessment. Quality was assessed using a modified Downs and Black tool.

DATA SYNTHESIS

In total, 11 articles were included for appraisal with respect to the quality of the study. Only two randomised controlled trials were suitable for meta-analysis. A higher volume of exercise was shown to have a positive effect on functional recovery, assessed using the 6-minute walk test (6MWT) (mean difference=26.97m; 95% confidence interval [CI], 6.96-46.97; p=0.008; I²=0%). No significant improvement was shown between additional exercise compared to standard care in improving VO_2peak, maximal power output or quality of life. No studies evaluated the effect of exercise on cognitive recovery.

CONCLUSIONS

Exercise significantly improves functional recovery in the post-surgical elderly cardiac population, however uncertainty still exists with regard to which modes of exercise and their specific parameters are most effective in improving cognitive recovery.

Longitudinal Changes of Handgrip, Knee Extensor Muscle Strength, and the Disability of the Arm, Shoulder and Hand Score in Cardiac Patients During Phase II Cardiac Rehabilitation

Handgrip strength (HS) and knee extensor muscle strength (KEMS) showed a negative correlation with the Disabilities of the Arm, Shoulder, and Hand (DASH) score at one month following cardiac surgery. We performed a longitudinal study to examine changes in HS/KEMS and DASH score during phase II cardiac rehabilitation (CR) in patients after cardiac surgery. We measured and assessed HS, KEMS, and DASH score in 41 consecutive patients at one and three months following cardiac surgery and examined the relation between these factors at three months following cardiac surgery. Wilcoxon signed-rank test and Spearman correlation coefficients were used to analyze the results. Finally, 26 patients (63.2 years, 73.1% male) were analyzed. There were significant differences from one month to three months following cardiac surgery in HS (26.78 ± 8.26 to 31.35 ± 9.41 kgf, p < 0.001), KEMS (1.53 ± 0.42 to 1.72 ± 0.46 Nm/kg, p = 0.001), and DASH score (14.76 ± 12.58 to 7.62 ± 9.29, p < 0.001). DASH score correlated negatively with HS (r = −0.41, p = 0.01) but not with KEMS (r = −0.32, p = 0.09) after three months of phase II CR. Although HS, KEMS, and DASH scores changed significantly from one to three months following cardiac surgery during phase II CR, only HS correlated negatively with DASH score at three months following cardiac surgery.

Relationship between Daytime Sleepiness and Health Utility in Patients after Cardiac Surgery: A Preliminary Study

Background Daytime sleepiness can be assessed by the Epworth Sleepiness Scale (ESS), which is widely used in the field of sleep medicine as a subjective measure of a patient's sleepiness. Also, health utility assessed by the mean Short-Form Six-Dimension (SF-6D) score, one of several preference-based utility measures, is an important measure in health care. We aimed to examine age-related differences in daytime sleepiness and health utility and their relationship in patients 5 months after cardiac surgery. Methods; This cross-sectional study assessed 51 consecutive cardiac surgery patients who were divided into a middle-aged (<65 years, n = 29) and older-age group (≥65 years, n = 22). The mean ESS and SF-6D utility scores were measured at 5 months after cardiac surgery and compared. In addition, the relationship between ESS and SF-6D utility scores were assessed. Results; There were no significant differences between the middle-aged and older-aged groups in either the mean ESS (5.14 ± 2.96 vs. 4.05 ± 3.23, p = 0.22) or SF-6D utility (0.72 ± 0.14 vs. 0.71 ± 0.10, p = 0.76) scores. However, there was a negative correlation between both values in all of the patients after cardiac surgery (r = -0.41, p = 0.003). Conclusions; Although there were no age-related differences in the ESS and SF-6D utility values between the two groups, there was a negative correlation between these values in all patients at 5 months after cardiac surgery. This suggested that sleepiness is associated with decreased utility scores in patients at 5 months after cardiac surgery.

Safety and efficacy of aerobic exercise commenced early after cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Aerobic exercise is a critical component of cardiac rehabilitation following cardiac surgery. Aerobic exercise is traditionally commenced 2-6 weeks following hospital discharge and most commonly includes stationary cycling or treadmill walking. The initiation of aerobic exercise within this early postoperative period not only introduces the benefits associated with aerobic activity sooner, but also ameliorates the negative effects of immobilization associated with the early postoperative period.

METHODS

A systematic review identified all studies reporting safety and efficacy outcomes of aerobic exercise commenced within two weeks of cardiac surgery. A meta-analysis was performed comparing functional, aerobic and safety outcomes in patients receiving early postoperative aerobic exercise compared with usual postoperative care.

RESULTS

Six-minute walk test distance at hospital discharge was 419 ± 88 m in early aerobic exercise patients versus 341 ± 81 m in those receiving usual care (mean difference 69.5 m, 95% confidence interval (CI) 39.2-99.7 m, p < 0.00001). Peak aerobic power was 18.6 ± 3.8 ml·kg^-1·min^-1 in those receiving early exercise versus 15.0 ± 2.1 ml·kg^-1·min^-1 in usual care (mean difference 3.20 ml·kg^-1·min^-1, 95% CI 1.45-4.95, p = 0.0003). There was no significant difference in adverse events rates between the two groups (odds ratio 0.41, 95% CI 0.12-1.42, p = 0.16).

CONCLUSION

Aerobic exercise commenced early after cardiac surgery significantly improves functional and aerobic capacity following cardiac surgery. While adverse event rates did not differ significantly, patients included were very low risk. Further studies are required to adequately assess safety outcomes of aerobic exercise commenced early after cardiac surgery.

Early initiation of post-sternotomy cardiac rehabilitation exercise training (SCAR): study protocol for a randomised controlled trial and economic evaluation

INTRODUCTION

Current guidelines recommend abstinence from supervised cardiac rehabilitation (CR) exercise training for 6 weeks post-sternotomy. This practice is not based on empirical evidence, thus imposing potentially unnecessary activity restrictions. Delayed participation in CR exercise training promotes muscle atrophy, reduces cardiovascular fitness and prolongs recovery. Limited data suggest no detrimental effect of beginning CR exercise training as early as 2 weeks post-surgery, but randomised controlled trials are yet to confirm this. The purpose of this trial is to compare CR exercise training commenced early (2 weeks post-surgery) with current usual care (6 weeks post-surgery) with a view to informing future CR guidelines for patients recovering from sternotomy.

METHODS AND ANALYSIS

In this assessor-blind randomised controlled trial, 140 cardiac surgery patients, recovering from sternotomy, will be assigned to 8 weeks of twice-weekly supervised CR exercise training commencing at either 2 weeks (early CR) or 6 weeks (usual care CR) post-surgery. Usual care exercise training will adhere to current UK recommendations. Participants in the early CR group will undertake a highly individualised 2-3 week programme of functional mobility, strength and cardiovascular exercise before progressing to a usual care CR programme. Outcomes will be assessed at baseline (inpatient), pre-CR (2 or 6 weeks post-surgery), post-CR (10 or 14 weeks post-surgery) and 12 months. The primary outcome will be change in 6 min walk distance. Secondary outcomes will include measures of functional fitness, quality of life and cost-effectiveness.

ETHICS AND DISSEMINATION

Recruitment commenced on July 2017 and will complete by December 2019. Results will be disseminated via national governing bodies, scientific meetings and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03223558; Pre-results.

Advances in cardiorespiratory physiotherapy and their clinical impact

INTRODUCTION

Cardiorespiratory physiotherapy is an evidence-based practice that has evolved alongside changes in medical and surgical management, analgesia, the ageing society and increasing comorbidities of our patient populations. Continued research provides the profession with the ability to adapt to meet the changing patient and community needs. Areas covered: This review focuses on surgical, respiratory and critical care settings discussing the most significant changes over the past decade with an increased focus on rehabilitation across the care continuum and a shift away from providing predominately airway clearance in established disease populations but also providing this in emerging groups. Further important changes are identification and emphases on patient self-management including changing their behaviour to more positively embrace wellness, particularly increasing physical activity levels. This paper outlines these changes and offers speculation on factors that may impact the profession in the future. Expert commentary: The increasing focus on new technologies, physical activity levels, changes to the health systems in different countries and an increasingly comorbid and ageing society will shape the next steps in the evolution of cardiorespiratory physiotherapy. Continued research is vital to keep pace with these changes so that physiotherapists can provide the most effective treatments to improve patient outcomes.

Age-Related Differences of Maximum Phonation Time in Patients after Cardiac Surgery

Background and aims: Maximum phonation time (MPT), which is related to respiratory function, is widely used to evaluate maximum vocal capabilities, because its use is non-invasive, quick, and inexpensive. We aimed to examine differences in MPT by age, following recovery phase II cardiac rehabilitation (CR). Methods: This longitudinal observational study assessed 50 consecutive cardiac patients who were divided into the middle-aged group (<65 years, n = 29) and older-aged group (≥65 years, n = 21). MPTs were measured at 1 and 3 months after cardiac surgery, and were compared. Results: The duration of MPT increased more significantly from month 1 to month 3 in the middle-aged group (19.2 ± 7.8 to 27.1 ± 11.6 s, p < 0.001) than in the older-aged group (12.6 ± 3.5 to 17.9 ± 6.0 s, p < 0.001). However, no statistically significant difference occurred in the % change of MPT from 1 month to 3 months after cardiac surgery between the middle-aged group and older-aged group, respectively (41.1% vs. 42.1%). In addition, there were no significant interactions of MPT in the two groups for 1 versus 3 months (F = 1.65, p = 0.20). Conclusion: Following phase II, CR improved MPT for all cardiac surgery patients.

Relation between the Disability of the Arm, Shoulder and Hand Score and Muscle Strength in Post-Cardiac Surgery Patients

Background: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a valid and reliable patient-reported outcome measure. DASH can be assessed by self-reported upper extremity disability and symptoms. We aimed to examine the relationship between the physiological outcome of muscle strength and the DASH score after cardiac surgery. Methods: This cross-sectional study assessed 50 consecutive cardiac patients that were undergoing cardiac surgery. Physiological outcomes of handgrip strength and knee extensor muscle strength and the DASH score were measured at one month after cardiac surgery and were assessed. Results were analyzed using Spearman correlation coefficients. Results: The final analysis comprised 43 patients (men: 32, women: 11; age: 62.1 ± 9.1 years; body mass index: 22.1 ± 4.7 kg/m²; left ventricular ejection fraction: 53.5 ± 13.7%). Respective handgrip strength, knee extensor muscle strength, and DASH score were 27.4 ± 8.3 kgf, 1.6 ± 0.4 Nm/kg, and 13.3 ± 12.3, respectively. The DASH score correlated negatively with handgrip strength (r = -0.38, p = 0.01) and with knee extensor muscle strength (r = -0.32, p = 0.04). Conclusion: Physiological outcomes of both handgrip strength and knee extensor muscle strength correlated negatively with the DASH score. The DASH score appears to be a valuable tool with which to assess cardiac patients with poor physiological outcomes, particularly handgrip strength as a measure of upper extremity function, which is probably easier to follow over time than lower extremity function after patients complete cardiac rehabilitation.

SheppHeartCABG trial-comprehensive early rehabilitation after coronary artery bypass grafting: a protocol for a randomised clinical trial

INTRODUCTION

Patients undergoing coronary artery bypass graft surgery often experience a range of symptoms. Studies indicate that non-pharmacological interventions such as exercise training and psychoeducation have a positive physiological and psychological effect in early outpatient rehabilitation. The SheppHeartCABG trial will investigate the effect of early comprehensive rehabilitation in early phase rehabilitation versus usual care. The aim of this paper is to present the protocol for the SheppHeartCABG trial.

METHODS/ANALYSIS

SheppHeartCABG is an investigator-initiated randomised clinical superiority trial with blinded outcome assessment, employing 1:1 central randomisation to rehabilitation plus usual care versus usual care alone. On the basis of a sample size calculation, 326 patients undergoing coronary artery bypass grafting will be included from two clinical sites. All patients receive usual care and patients allocated to the experimental intervention follow 4 weeks rehabilitation consisting of an exercise programme, psycho-educative consultations and a compact mindfulness programme. The primary outcome is physical function measured by the 6-min walk test. The secondary outcomes are mental health and physical activity measured by the Medical Outcome Study Short Form (SF-12), anxiety and depression measured by the Hospital Anxiety and Depression Scale questionnaire, physical, emotional and global scores by the HeartQoL questionnaire, sleep measured by the Pittsburgh Sleep Quality Index, pain measured by the Örebro Musculoskeletal Screening Questionnaire and muscle endurance measured by the sit-to-stand test. A number of explorative analyses will also be conducted.

ETHICS AND DISSEMINATION

SheppHeartCABG is approved by the regional ethics committee (no. H-4-2014-109) and the Danish Data Protection Agency (no. 30-1309) and is performed in accordance with good clinical practice and the Declaration of Helsinki in its latest form. Positive, neutral and negative results of the trial will be submitted to international peer-reviewed journals. Furthermore, results will be presented at national and international conferences relevant to the subject fields.

TRIAL REGISTRATION NUMBER

NCT02290262; pre-results.

Effect of bed exercises and gum chewing on abdominal sounds, flatulence and early discharge in the early period after caesarean section

AIMS AND OBJECTIVES

The purpose of this study was to determine the effects of bed exercises and gum chewing on abdominal sounds, flatulence and early discharge on women who have given birth at the Cengiz Gökçek Gynecology and Obstetrics Hospital surgery services in Gaziantep city centre.

BACKGROUND

Caesarean operation is the most significant surgical intervention that affects central nervous system and decelerates bowel movements in the postoperative period. Conducted studies show that practices such as gum chewing ensure that bowel functions start in a short time through early feeding and mobilisation and shorten the duration of hospital stay.

DESIGN

A randomised controlled experimental was used.

METHOD

A total of 120 women participated in the study in three groups of 40 for gum, exercise and control groups. Gum was given to the groups in the gum section two hours after the ceasarean, the women chewed gum for the first eight hours until flatulence for 15 minutes every two hours. However, the women in the exercise group started moving two hours after the caesarean for the first eight hours until flatulence for five minutes every two hours. The control group consisted of women under routine treatment and care of the hospital. All women were hourly evaluated in terms of abdominal sounds, flatulence and defaecation.

RESULTS

It was determined that following caesarean, bowel functions started in three groups at the same time, there was no significant difference between three groups. It was determined that the gum group, exercise group and the control group were discharged earlier, there was no significant difference between three groups

CONCLUSION

The study results show that spinal anaesthesia have positive effects on discharge time after caesarean section operation.

RELEVANCE TO CLINICAL PRACTICE

This study provides useful information to clinician and researchers when determining practices such as postoperative standing up in early period, gum chewing and early liquid intake related to postoperative bowel functions after abdominal operations.

ICU Blood Pressure Variability May Predict Nadir of Respiratory Depression After Coronary Artery Bypass Surgery

Objectives: Surgical stress induces alterations on sympathovagal balance that can be determined through assessment of blood pressure variability. Coronary artery bypass graft surgery (CABG) is associated with postoperative respiratory depression. In this study we aimed at investigating ICU blood pressure variability and other perioperative parameters that could predict the nadir of postoperative respiratory function impairment.

Methods: This prospective observational study evaluated 44 coronary artery disease patients subjected to coronary artery bypass surgery (CABG) with cardiopulmonary bypass (CPB). At the ICU, mean arterial pressure (MAP) was monitored every 30 min for 3 days. MAP variability was evaluated through: standard deviation (SD), coefficient of variation (CV), variation independent of mean (VIM), and average successive variability (ASV). Respiratory function was assessed through maximal inspiratory (MIP) and expiratory (MEP) pressures and peak expiratory flow (PEF) determined 1 day before surgery and on the postoperative days 3rd to 7th. Intraoperative parameters (volume of cardioplegia, CPB duration, aortic cross-clamp time, number of grafts) were also monitored.

Results: Since, we aimed at studying patients without confounding effects of postoperative complications on respiratory function, we had enrolled a cohort of low risk EuroSCORE (European System for Cardiac Operative Risk Evaluation) with < 2. Respiratory parameters MIP, MEP, and PEF were significantly depressed for 4–5 days postoperatively. Of all MAP variability parameters, the ASV had a significant good positive Spearman correlation (rho coefficients ranging from 0.45 to 0.65, p < 0.01) with the 3-day nadir of PEF after cardiac surgery. Also, CV and VIM of MAP were significantly associated with nadir days of MEP and PEF. None of the intraoperative parameters had any correlation with the postoperative respiratory depression.

Conclusions: Variability parameters ASV, CV, and VIM of the MAP monitored at ICU may have predictive value for the depression of respiratory function after cardiac surgery as determined by peak expiratory flow and maximal expiratory pressure.

ClinicalTrials.gov Identifier: NCT02074371.

Sub-xyphoid pleural drain as a determinant of functional capacity and clinical results after off-pump coronary artery bypass surgery: a randomized clinical trial

OBJECTIVES

The aim of this trial was to compare functional capacity, pulmonary shunt fraction and clinical outcomes between patients undergoing pleurotomy with a pleural drain inserted in the sub-xyphoid position and patients with a pleural drain placed in the intercostal position after off-pump coronary artery bypass surgery.

METHODS

Patients were randomized into two groups according to the pleural drain site: Group II (n = 33 intercostal pleural drain); and Group SI (n = 35 sub-xyphoid pleural drain). Functional capacity was assessed by the distance covered on the 6-min walking test performed preoperatively and on postoperative day (POD) 5; in addition, pulmonary function test was determined preoperatively and on POD 1 and 5. Pulmonary shunt fraction was evaluated preoperatively and on POD 1, and clinical outcomes were recorded throughout the study.

RESULTS

Group SI had better preservation of lung volumes and capacities in POD compared with Group II (P <0.05). Pulmonary shunt fraction increased in both groups postoperatively; however, Group SI showed a smaller pulmonary shunt fraction (0.26 ± 0.04 vs 0.21 ± 0.04%; P = 0.0014). Functional capacity was significantly reduced in both groups on POD 5; however, Group SI showed better preservation of functional capacity (P = 0.0001). Group SI had better postoperative clinical results, with lower incidence of atelectasis and pleural effusion (P <0.05), lower pain scores (P <0.0001), and shorter orotracheal intubation and hospitalization lengths (P <0.001).

CONCLUSIONS

Sub-xyphoid pleural drain determined better functional capacity and exercise tolerance with a smaller pulmonary shunt fraction and improved clinical outcomes compared with intercostal pleural drainage after off-pump coronary artery bypass surgery.

Peri-operative physiotherapy

Postoperative pulmonary complications (PPC) are a major cause of morbidity, mortality, prolonged hospital stay, and increased cost of care. Physiotherapy (PT) programs in post-surgical and critical area patients are aimed to reduce the risks of PPC due to long-term bed-rest, to improve the patient's quality of life and residual function, and to avoid new hospitalizations. At this purpose, PT programs apply advanced cost-effective therapeutic modalities to decrease complications and patient's ventilator-dependency. Strategies to reduce PPC include monitoring and reduction of risk factors, improving preoperative status, patient education, smoking cessation, intra-operative and postoperative pulmonary care. Different PT techniques, as a part of the comprehensive management of patients undergoing cardiac, upper abdominal, and thoracic surgery, may prevent and treat PPC such as secretion retention, atelectasis, and pneumonia.