1. 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

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

3. 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’

4. 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?

5. 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)

6. 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

7. 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

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

9. 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

10. Results: Absolute 6MWA distance (m)

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

12. 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

13. Results: Health-Related QOL
Large standard deviations

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

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

16. 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

17. 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.

18. 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

20. Results: Relative 6MWA distance (m)

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