Physiotherapy Supervised Walking Program Immediately Following CABG Results in Earlier Return of Functional Capacity A Randomized Controlled Trial Andrew Hirschhorn 1,3 David Richards 2 Sean Mungovan 1 Norman Morris 3 Lewis Adams 3 1 Westmead Private Physiotherapy Services, Westmead Private Hospital, Sydney, Australia 2 Westmead Private Cardiology, Westmead Private Hospital, Sydney, Australia 3 School of Physiotherapy and Exercise Science, Griffith University, Gold Coast, Australia

Physical/Clinical Context 140 Bed Private Hospital 4 Cardiac Surgeons Approximately 250 Cardiac Surgeries/Year Represents 1% of CABG Australia-Wide

Research Context Pasquina et al (2003) (Systematic review) ‘Evidence lacking on benefit from any method of prophylactic respiratory physiotherapy after cardiac surgery’ Brasher et al (2003) ‘The removal of a regimen of routine prophylactic deep breathing exercises…has no deleterious effect on patient outcome’ van der Peijl et al (2004) ‘A higher frequency exercise program leads to earlier performance of functional milestones’

Research Questions Does a moderate intensity walking program, performed under direct physiotherapy supervision, improve sub-maximal exercise capacity, vital capacity, self-reported health or length of stay (after elective CABG)? Does the addition of specific respiratory and musculoskeletal exercises provide further benefit as regards these outcomes?

Methods Prospective enrolment of non-emergency CABG (without planned, concomitant surgery) 92 patients (80 men, 12 women), mean age 63 ± 9 Randomized to three physiotherapy treatment protocols: Standard (minimal) intervention (n=31) Walking exercise (n=31) Walking/breathing exercise (n=30)

Intervention Groups Standard intervention (n=31) Pre-operative education Post-operative respiratory assessment (daily) SOOB POD 1 Ambulate 10 metres POD 2 Ambulate 30 metres POD 3 Stairs when appropriate Increase activity per Heart Foundation guidelines

Intervention Groups Walking exercise (n=31) Pre-operative education Post-operative respiratory assessment (daily) Twice daily supervised walking exercise program Walk on spot day one Increase by increments of 2.5 minutes RPE 3-4/10

Intervention Groups Walking/breathing exercise (n=30) Per walking exercise Incentive spirometry Combined upper limb/thoracic mobility and deep breathing exercises

Outcome Measures Primary: Pre-Operative Six-minute walk assessment Vital capacity Health-related quality of life SF-36v2 QoR-40 EQ-5D Secondary: LOS AF PPC markers Pre-Operative Discharge 4/52 Follow-Up

Results: Absolute 6MWA distance (m)

Results: Absolute 6MWA distance (m) Better than ‘Standard’ p = 0.015 p = 0.065

Results: Vital Capacity (L BTPS) No differences between intervention groups* 38% decline in VC from pre-operative to discharge Recovery to 85% pre-operative VC at follow-up

Results: Health-Related QOL Large standard deviations

Results: Health-Related QOL * * * No difference over time

Results: Health-Related QOL * Remained significantly decreased from pre-operative

Results: Complications Prior to Discharge Standard Walking Walking/ breathing Elevated WCC post-operatively 22/30* 21/31 21/30 Tympanic temperature ≥ 38oC post-operatively 16 18 15 Prescription of respiratory antibiotics 1 Requirement of FiO2 > 50% for > 24 hours Post-operative atrial fibrillation 8 9 5 Length of stay (days) (median, IQR) 7, 6-7 6, 6-8 6.5, 6-7

Summary of Key Findings A moderate intensity, walking exercise program, performed under direct physiotherapy supervision, improved sub-maximal exercise capacity at hospital discharge. In the absence of continuing exercise supervision, this benefit was not sustained at four-week follow-up. This program conferred no measurable benefit in terms of health related QOL, VC, PPC markers or LOS. This program did not increase the rate of post-operative atrial fibrillation. Performance of a combination of specific respiratory and musculoskeletal exercises provided no additional measurable benefit.

Conclusions/Clinical Implications Early walking program is beneficial Possible implications for early participation in Phase 2 Cardiac Rehabilitation Further research required to determine optimal level/dosage of aerobic exercise following CABG

Results: Relative 6MWA distance (m)

Results: Relative 6MWA distance (m) no significant change from pre-operative 6MWA