Effect of postoperative high load long duration inspiratory muscle training on pulmonary function and functional capacity after mitral valve replacement surgery: A randomized controlled trial with follow-up

Objectives

Although, pre-operative inspiratory muscle training has been investigated and reported to be an effective strategy to reduce postoperative pulmonary complications, the efficacy of postoperative inspiratory muscle training as well as the proper load, frequency, and duration necessary to reduce the postoperative pulmonary complications has not been fully investigated. This study was designed to investigate the effect of postoperative high-load long-duration inspiratory muscle training on pulmonary function, inspiratory muscle strength, and functional capacity after mitral valve replacement surgeries.

Design

Prospective randomized controlled trial.

Methods

A total of one hundred patients (mean age 38.3±3.29years) underwent mitral valve replacement surgery were randomized into experimental (n = 50) and control (n = 50) groups. The control group received conventional physiotherapy care, while experimental group received conventional care in addition to inspiratory muscle training, with 40% of the baseline maximal inspiratory pressure targeting a load of 80% by the end of the 8 weeks intervention protocol. Inspiratory muscle training started on the patient’s first day in the inpatient ward. Lung functions, inspiratory muscle strength, and functional capacity were evaluated using a computer-based spirometry system, maximal inspiratory pressure measurement and 6MWT respectively at 5 time points and a follow-up assessment was performed 6 months after surgery. Repeated measure ANOVA and post-hoc analyses were used (p <0.05).

Results

Group-time interactions were detected for all the studied variables (p<0.001). Between-group analysis revealed statistically significant postoperative improvements in all studied variables in the experimental group compared to the control group (p <0.001) with large effect size of η² ˃0.14. Within-group analysis indicated substantial improvements in lung function, inspiratory pressure and functional capacity in the experimental group (p <0.05) over time, and these improvements were maintained at follow-up.

Conclusion

High intensity, long-duration postoperative inspiratory muscle training is highly effective in improving lung function, inspiratory muscle strength, and functional capacity after mitral valve replacement surgeries.

[Evaluation of the cardiovascular function in patients with chronic rheumatic heart disease in the practice of medical and social expertise]

Chronic rheumatic heart disease (HRHD) for a long time occupied a prominent position in the structure of the disability population in Ukraine. Aim of the study is to define clinical signs of cardiovascular function in patients with HRHD for disability evaluation in the practice of medical and social expertise. We examined 180 patients with HRHD aged 40-65 years. There were significant differences in patient groups, which allowed us to formulate clinical and functional diagnostic markers of dysfunction of circulation for the objective assessment of the limitations of their life, the definition of disability groups and the development of rehabilitation programs.

[Exercise training of patients in a health resort after surgery for rheumatic heart disease]

We studied the effect of cardiovascular system function on the response to terrain cure in the course of rehabilitation of 88 patients after surgical correction of valvular defects in conditions of low-mountain health resort. We have found that the response to the above exercise depends on functional condition of the cardiovascular system (the degree of correction of hemodynamic disorders related to valvular disease, the degree of myocardial hypertrophy and dilation of the chambers, left ventricular contractility). Terrain cure exercise promotes improvement in regulation of cardiovascular system and mobilization of its reserves.

[Clinical and laboratory support for multiple-modality treatment of rheumatic patients with mitral valve disease]

In 158 rheumatic patients with mitral valvular disease (MVD), clinical-and-laboratory indices were studied together with a possibility for correction of the detected disorders in a multiple-modality staged treatment involving basic drug therapy, EHF-therapy, and sanatorium-health resort stage of rehabilitation. It has been found out that EHF-therapy and sanatorium-health resort treatment have a positive effect on the clinical course of the trouble and on the laboratory indices for the inflammatory process contributing to optimization of medicamentous treatment of rheumatic patients with MVD.

[Carbonate mineral baths in the combined treatment at a piedmont health resort of patients operated on for rheumatic heart defects]

The response of the cardiovascular system of 64 patients operated for rheumatic heart disease to mineral carbon dioxide baths was studied in the course of rehabilitation in low-mountain health resort. It was found that the above baths have a training effect on the cardiac muscle, improve myocardial metabolism. They are an essential factor in combined sanatorium treatment of patients after surgical correction of valvular defects. Baths-induced changes in the central and peripheral hemodynamics depend on cardiovascular function. Therefore, they require an individual approach. If the exposition increases to 15 minutes, mineral carbon dioxide baths have more potent training effect on the myocardium and raise effectiveness of the sanatorium treatment.

[The biological rhythms of cardiac activity based on cardiointervalography in children with rheumatism during readaptation after sanatorium treatment]

Heart rate as an integral characteristic of systemic condition in rheumatism was studied in 11-13-year-old children with rheumatic heart disease. The children achieved remission by clinical and laboratory tests and were experiencing postsanatorium readaptation. Pretreatment amplitude of the fluctuations from the mean circadian values were reduced in the patients compared to healthy controls. This shows low compensatory potential of the rheumatic children. Adaptation after sanatorium treatment aggravates the above amplitude diminution, acrophases shifted to later local time.

[Anasarca caused by rheumatic carditis]

Report of a 55-year-old-male patient with most serious anasarca caused by insufficiency right heart. The reason of the heart failure was probably rheumatic carditis caused by streptococcal infections which followed recurrent erysipelas both legs with phleblymphedema. The necessity of consistent antibiotic treatment of the erysipelas, that's the only possibility to avoid more difficult secondary complications like this case of rheumatic carditis showed. The treatment of insufficiency heart was followed by physical decongestive therapy of the phleblymphedema of the legs. After a treatment period of 12 weeks a water loss of 112 kg and reduction of abdominal circumference from 250 cm to 150 cm could be achieved.

[The physiotherapeutic correction of secondary immunodeficiency in the preoperative period in patients with rheumatic heart defects]

Directed correction of immunity by physiotherapeutic methods was used at the period of preoperative preparing 45 patients who needed the operation for rheumatic valvular disease of the heart. The number of purulent complications during the postoperative period in the group of patients subjected to direct correction of the immune status was found to be less than in the control group.

[Psychological characteristics of the personality and the attitude to work of patients subjected to surgery on account of rheumatic heart disease]

The authors studied the psychological peculiarities of personality, attitude towards the disease and orientation for work in 124 patients operated on in connection with rheumatic heart disease. The psychological peculiarities of personality were examined by means of a 16-factor questionnaire suggested by Kettell and the type of attitude towards the disease by a questionnaire prepared by the V. M. Bechterew's Institute, orientation for work--by means of a specially compiled questionnaire. It has been established that the type of attitude towards the disease is determined by psychological peculiarities of personality, it exerts influence on orientation for work. This should be taken into consideration when conducting rehabilitation measures in patients with rheumatic heart disease after the operation on the heart.

Education and employability of young cardiac patients

Between 1966-1980, 136 young cardiac patients were categorized as disabled in accordance with the National Act of Rehabilitation. To study their fate a questionnaire was circulated to them: 96 patients responded, all were 15 years of age or more at the time of the study; 31.2% attended middle or higher school education and 63.3% were employed; 45.9% were skilled and 54.1% unskilled workers; 2.2% were unemployed, which was very close to the general youth unemployment rate. Work was provided for unemployed patients in their homes but they needed additional financial support. The benefits for the young disabled cardiac patients include health insurance, vocational training, payment of boarding school fees and financial support. Nevertheless the focus of the team dealing with these patients should be their preparation for employment.

[Evaluation of patient rehabilitation effectiveness after aortic valve prosthesis based on spiroergometric study data]

Patients after surgery introducing aortal valve prosthesis in cases of rheumatic aortal defect or defect due to bacterial endocarditis were examined using spiro- and bicycle ergometry. Two groups of patients were compared: those subjected to rehabilitation procedures and a control group undergoing no rehabilitation program. Functional results were better in post-rehabilitation patients. By the end of the rehabilitation program, the examined spiroergometric parameters were significantly closer to those of normal subjects, as compared to the controls. Spiroergometric investigation in patients with newly applied aortal valve prostheses supplements clinical data in providing a more profound functional evaluation of surgical results and rehabilitation efficiency.

[Problems of rehabilitating patients who have undergone a mitral commissurotomy]

The article analyses the course of the rheumatic process in 241 patients who underwent mitral commissurotomy. Study was conducted at the same time of the volume of antirecurrence antirheumatic treatment applied before and after operation and its importance in the prevention of exacerbations of rheumatism in late postoperative periods. Analysis was made of the working capacity of 241 patients in follow-up periods of one to 20 years after operation and the individual tolerance to physical exertion was determined in 52 patients. It was found that the maximum number of individuals in occupation (62.3%) is encountered in the period from 5 to 11--12 years.

[Sanatorium stage in the rehabilitation of patients with rheumatic defects after heart valve prosthesis]

In 93.2% of 104 patients treated at a cardiological sanatorium after heart valve prosthetics the condition had improved by the time of discharge and only in 2.9% (3 patients) it had grown worse. The measures of rehabilitation comprised curative, physical, and psychologic aspects. The improvement in the condition of patients who had been operated on was attested by the results of ECG, polycardiography, and external respiration tests. The increased tolerance to physical load and the improved ability for coping with the tasks of every-day life are also objective indicators of the effectiveness of the stage of sanatorium treatment in the general complex of rehabilitation of patients who had been subjected to heart valve prosthetics.

[Physical work capacity in rheumatic heart defects in children]

Physical performance of children with rheumatic heart diseases depends upon the activity of rheumatism (rheumatism carditis) and specificity distinguishing the given disease. Spiroergometric examinations under a load of 1 w/kg is a highly informative method of evaluating the physical performance capacity of children with rheumatic heart diseases. By using this method it is possible to obtain quantitative and qualitative functional characteristics of their cardiopulmonary system, to disclose latent cardiac insufficiency. The data obtained help improve the rehabilitation of rheumatic patients.

Myocardial performance of disabled patients in a rehabilitation program

Thirty-two patients with heart disease in addition to another disability were monitored continuously with the ten-hour electrocardiographic (ECG) tape. Eighteen of the 32 patients manifested abnormalities of rate, rhythm or ST-segment depression. Patients with arrhythmia eventually did better than those with other ECG abnormalities because drug therapy was successful in abolishing the abnormal rhythm in most cases. Those patients with excessive tachycardia did poorly as a group in so far as their rehabilitation program was concerned. This technique of continuous ECG monitoring may be helpful in assessing myocardial performance in these patients and in defining the prescription for rehabilitation therapy.

Rehabilitation following cardiac surgery

Of 120 vocational rehabilitation clients having cardiac surgery between July, 1966 and December, 1968, seven were lost to follow-up, and the operative and late mortality totaled 14%. Ninety-six patients were seen for voluntary outpatient evaluation with a mean postoperative evaluation time of 22 months. Two-thirds of the patients had acquired heart disease and were in functional class III or IV preoperatively. After surgery 76 were in functional class I or II with 20 in functional class III. The electrocardiogram and radiographic heart size had returned toward normal in over 50%, and 76% of those having preoperative exercise tests demonstrated improved exercise capacity postoperatively.

The rehabilitation effort was successful in 83% of those surviving surgery and 77% of the entire series. Medical and surgical physical factors were found to be more important than psychosocial factors in determining the vocational outcome after surgery. The duration of unemployment was the most important preoperative variable in predicting the rehabilitation result. The importance of medical follow-up after cardiac surgery is emphasized by the detection of a significant number of residual medical problems.