Physiotherapy intervention in community-dwelling adults post-CABG: What is effective intervention to improve exercise tolerance?
Date First Published:
October 31, 2012
Last Updated:
June 10, 2013
Report by:
Hospital & Community Team, Physio (CMFT)
Search checked by:
Hospital & Community Team, CMFT
Three-Part Question:
In [community-dwelling adults 2-6 weeks post-CABG], what [physiotherapy intervention] is most effective in improving [exercise tolerance]?
Clinical Scenario:
A multidisciplinary supported discharge team (Physiotherapists, Occupational Therapist, Rehabilitation Assistants) notice an increase in referrals for patients in the early post-op phase (2-6 weeks) following CABG. The team provide short-term rehab (up to 6 weeks) to patients in their own homes.
Team physiotherapists are unsure what form of intervention is most effective at improving exercise tolerance in this patient group.
Team physiotherapists are unsure what form of intervention is most effective at improving exercise tolerance in this patient group.
Search Strategy:
AMED, EMBASE, CINAHL databases were searched on 30.08.12
Search terms in Title & Abstract: Coronary AND Artery AND Bypass AND Graft (15672);Physio*(618450);Exercis*(275190);Community OR domiciliary(382814);Combined all(0);Combined 1,2 and 3
Medline and Cochrane databases were searched on 14.08.12
Search terms in Title & Abstract: Coronary AND Artery AND Bypass AND Graft; physiothera*; community; domiciliary; home; exercise; rehabilitation.
PEDro database searched 18/10/12: [coronary AND artery AND bypass AND graft] 17 results (One 7/10).
Date of search 18/1012: [coronary AND artery AND bypass AND graft AND exercise] 6 results, (One 7/10)
Search terms in Title & Abstract: Coronary AND Artery AND Bypass AND Graft (15672);Physio*(618450);Exercis*(275190);Community OR domiciliary(382814);Combined all(0);Combined 1,2 and 3
Medline and Cochrane databases were searched on 14.08.12
Search terms in Title & Abstract: Coronary AND Artery AND Bypass AND Graft; physiothera*; community; domiciliary; home; exercise; rehabilitation.
PEDro database searched 18/10/12: [coronary AND artery AND bypass AND graft] 17 results (One 7/10).
Date of search 18/1012: [coronary AND artery AND bypass AND graft AND exercise] 6 results, (One 7/10)
Search Details:
AMED, CINAHL, Embase: 35 results
Medline and Cochrane: 54 results
PEDro: 6 results
From AMED, CINAHL, Embase, Medline, PEDro and Cochrane databases 54 articles were found of which 2 articles were felt to be relevant
Medline and Cochrane: 54 results
PEDro: 6 results
From AMED, CINAHL, Embase, Medline, PEDro and Cochrane databases 54 articles were found of which 2 articles were felt to be relevant
Outcome:
2 papars;
Hirschhorn, A.D., Richards, D. Mungovan, S.F., Morris, N.R., Adams, L., (2008). Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery – a randomised controlled trial, Heart, Lung and Circulation, 17, 129-138.
Van der Peijl, I.D., Vliet Vlieland, T.P.M., Versteegh, M.I.M., Lok, J.J., Munneke, M., Dion, R.A.E. (2004) Exercise therapy after coronary artery bypass graft surgery: a randomized comparison of a high and low frequency exercise therapy program, Annals of Thoracic Surgery, 77, 1535-1541.
Hirschhorn, A.D., Richards, D. Mungovan, S.F., Morris, N.R., Adams, L., (2008). Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery – a randomised controlled trial, Heart, Lung and Circulation, 17, 129-138.
Van der Peijl, I.D., Vliet Vlieland, T.P.M., Versteegh, M.I.M., Lok, J.J., Munneke, M., Dion, R.A.E. (2004) Exercise therapy after coronary artery bypass graft surgery: a randomized comparison of a high and low frequency exercise therapy program, Annals of Thoracic Surgery, 77, 1535-1541.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery – a randomised controlled trial Hirschhorn, A.D., Richards, D. Mungovan, S.F., Morris, N.R., and Adams, L., 2007 Australia | 93 awaiting 1st time CABG. Inpatient population Exclusions; planned concomitant surgery, msk or neuro impairment r/o walking Ax, inability to complete questionnaires, emergency CABG |
Prospective, randomised trial comparing ‘standard’ post-op intervention, ‘walking exercise’ and ‘walking/breathing exercise’ | Primary measures: 6MWA, Vital Capacity, HRQoL (SF-36). Secondary Measures 1. Length of Stay 2. PPC 3. Atrial Fibrillation | No significant difference in 6MWA pre-op, but significant diffrence at discharge between standard group vs. other 2 groups. No significant difference between other 2 groups. Difference not sustained at follow up. No significant diffrences in any other outcomes | Small sample size Only included elective CABG patients Physiotherapists were not blinded to group allocation – attempted to reduce bias via stringent assessment procedures |
| Exercise therapy after coronary artery bypass graft surgery: a randomized comparison of a high and low frequency exercise therapy program Van der Peijl, I.D., Vliet Vlieland, T.P.M., Versteegh, M.I.M., Lok, J.J., Munneke, M., Dion, R.A.E 2004 Netherlands | 246 undergoing uncomplicated CABG. Inpatient population. Exclusions; concomitant surgery, severe comorbidity, non-Dutch speaking, mental disorders |
Prospective, single-blinded, randomised trial comparing high intensity (twice daily, every day) to low intensity physio (once a day, mon-fri) | 1. Five functional milestones 2. Level of dependence 3. RPE 4. FIM scores for self care, transfers and locomotion 5 Quanitity of physical activity 6. Patient Satisfaction | 1. High intensity group reached 4/5 functional milestones quicker. 3. No difference in RPE 4. No significant difference between groups 5. No significant difference between groups 6. High intensity group more satisfied but low intensity group not dissatisfied. | Only “uncomplicated” CABG pt’s. No power calculation for sample size Data not analysed with intention to treat ?Sensitivity of FIM |
Author Commentary:
No papers were found that answered the 3 part question in full. Two papers were found that were considered to have a degree of relevance to the question as they look at early-phase intervention after Coronary Bypass Graft, however intervention was hospital based.
The articles suggest there is some benefit of high intensity exercise intervention in the early stage post CABG in reaching functional milestones quicker and improving exercise tolerance. The two studies reviewed were both hospital based and immediate post operation phase. The evidence did not suggest recommendations for continuation of Physiotherapy input post discharge in the early stages of recovery (2 to 4 weeks).
The articles suggest there is some benefit of high intensity exercise intervention in the early stage post CABG in reaching functional milestones quicker and improving exercise tolerance. The two studies reviewed were both hospital based and immediate post operation phase. The evidence did not suggest recommendations for continuation of Physiotherapy input post discharge in the early stages of recovery (2 to 4 weeks).
Bottom Line:
There is no current evidence available to suggest what type and intensity of Physiotherapy intervention is most effective in improving exercise tolerance in the early phase post CABG following discharge from hospital.
References:
- Hirschhorn, A.D., Richards, D. Mungovan, S.F., Morris, N.R., and Adams, L., . Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery – a randomised controlled trial
- Van der Peijl, I.D., Vliet Vlieland, T.P.M., Versteegh, M.I.M., Lok, J.J., Munneke, M., Dion, R.A.E. Exercise therapy after coronary artery bypass graft surgery: a randomized comparison of a high and low frequency exercise therapy program