ACPRC scoping review of post-operative physiotherapy in people undergoing cardiac surgery

Introduction

The ACPRC editorial board is comprised of respiratory physiotherapy clinicians and academics. The purpose of the board is to lead scoping, commissioning, co-ordination and delivery of all new ACPRC guidance documents and resources, to facilitate knowledge sharing and drive improvements in the quality of care for people with respiratory conditions. A preliminary scoping day in March 2018 identified surgery as a priority area for guidance. This was subsequently separated into cardiac, thoracic, and upper-gastrointestinal surgery.

For the purpose of this scoping review, cardiac surgery included valve replacements, valve repairs, coronary bypass grafts, and other invasive cardiac procedures requiring a large incision such as median sternotomy. The rationale for this, is that physiotherapy recovery pathways are comparable between surgeries.

There has been a decline in the number of cardiac surgery operations performed in the U.K. This has decreased from 41,586 procedures performed in 2008 and 2009 to 34,000 in 2019. Mortality rates are low at 2.59%, and average post-operative length of stay is 7.8 days (1). During this time there has been an increase in less invasive procedures such as percutaneous coronary interventions. Consequently, patients undergoing surgery have an increased age, co-morbidities and more complex surgery (2).

Systematic reviews have been undertaken for cardiac surgery and physiotherapy, and have either incorporated other types of surgery, for example, thoracic and abdominal surgery (3) or focussed solely on mobilisation after cardiac surgery (4, 5).

The aim was to undertake a scoping review to identify all types of post-operative physiotherapy research, to provide a comprehensive representation of available evidence (6–8).

Objective

The objective of this scoping review is to report the extent and type of evidence, associated with post-operative physiotherapy in people who undergo cardiac surgery.

Scoping review question

The primary scoping review question is:

• What evidence exists for the post-operative physiotherapy management of people who have undergone cardiac surgery that require a hospital stay?

The secondary scoping review questions are:

• What number of studies and research methodologies have been carried out in relation to post-operative physiotherapy, in adults undergoing cardiac surgery?
• What is the quality of the research carried out?
• What are the findings of the studies?

Definition of key terms

Physiotherapy intervention – treatment that is prescribed or carried out by a registered physiotherapist, or an unregistered member of the physiotherapy team.

Surgical intervention – invasive surgery that requires admission to hospital, (not performed as a day case).

Mobilisation – to support and encourage patients to move. This may be to mobilise out-of-bed, to march on the spot or walking.

Respiratory physiotherapy – physiotherapy interventions aimed to mobilise and remove airway secretions, increase lung volume, reduce breathlessness and work of breathing. This may include physical exercise, active cycle of breathing techniques, resistive training, positive and negative pressure devices, and adjuncts.

Eligibility criteria

Participants

Inclusion criteria

• Adult patients undergoing invasive cardiac surgery requiring access through a chest wound, for example, sternotomy, and that requires a post-operative hospital stay.
• Study includes acute post-operative physiotherapy.
• Study published between 2014 and 2021. The start date of 2014 was chosen, as it allowed a slight overlap in studies captured within published systematic reviews identified by the scoping review search.
• Article written in English.

Exclusion criteria

• Animal studies.
• Paediatrics – defined as children less than 18-years-of-age.
• Day case surgery.
• Cardiology interventions such as percutaneous coronary intervention, transcatheter aortic valve implantation.
• Physiotherapy intervention prior to admission, for example prehabilitation and intervention after hospital discharge, for example out-patient follow up.

Concept

Procedures that require post-operative physiotherapy intervention as part of the recovery process.

Context

The context is in-patient, hospital-based surgery, based in any country of origin, within state or privately funded healthcare.

Method

The scoping review objective was developed and agreed by the ACPRC editorial board. The scoping team was formed, and the inclusion criteria agreed by the scoping team.

Search strategy

The search strategy was developed and agreed by the scoping team, with input from local hospital and university library services (Appendix 1). A full search was undertaken of PEDro, CINAHL, EMBASE, MEDLINE, PubMed, and Google Scholar. The Clinical Trials Registry was also searched for any unpublished literature. All articles with search strategy terms contained in the titles and abstracts were shortlisted. The search strategy, including all identified keywords and index terms, were adapted for each database.

Types of sources

The scoping review considered all available evidence using experimental, and quasi­experimental study designs including randomised controlled trials (RCT), observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies. Other designs included systematic reviews, descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies. Qualitative studies that focused on qualitative data, such as phenomenology, grounded theory, ethnography, qualitative description, and action research were considered, as were text and opinion papers.

Source of evidence selection

Following the search of databases and registries, all identified citations were uploaded into web-based Endnote (9). Initially, 2795 articles were retrieved from the database searches (n = 2736) and clinical trial registers (n = 59). Following removal of 53 duplicate records, one reviewer screened the titles and abstracts against the inclusion criteria. This process excluded 2602 studies as they did not fulfil inclusion criteria. Full texts were retrieved for 140 articles, with 19 being unavailable. Each full-text article was screened by two reviewers, and of the 121 full text articles reviewed, 80 were excluded due to a lack of focus on physiotherapy specific treatment, or the intervention was conducted in the pre-operative or post-discharge phases of care. Subsequently, 41 studies were selected for inclusion into the scoping review.

Any ambiguity was discussed with the topic lead. The results are presented in Figure 1 the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Review (PRISMA-ScR) flow diagram (10).

See Figure 1: PRISMA-ScR flow chart.

Data extraction

All articles were reviewed by two independent reviewers and data was extracted and collated. Study quality was assessed using appropriate Critical Appraisal Skills Programme (11) or Joanna Briggs Institute (12) tools. An appraisal tool template was completed for each study, and submitted to the topic lead.

Results

Number of studies and research methodologies

In total, 41 studies researching the post-operative physiotherapy management of people who had undergone cardiac surgery and required a hospital stay were included in this scoping review. This included a total of 7824 participants, ranging from 13 participants (13) to 1419 participants (5). This did not include the number of participants in the systematic review by Sullivan et al. (3) as it was not possible to differentiate participant numbers between cardiac, thoracic and abdominal surgery. The most frequent types of study design were RCTs (n = 21) of which three were pilot RCTs, observational studies (n = 8) and systematic review (n = 3). Two qualitative studies were included for review. The methodology types and number of studies can be seen in Figure 1.

See Figure 2: Methodology types and number of studies included.

The 41 studies were categorised by type of physiotherapy intervention. This included 18 studies (45%) investigating post-operative mobilisation, 12 studies (29%) reviewing respiratory physiotherapy and respiratory interventions, seven studies (17%) exploring sternal wound precautions and associated pain, three studies (7%) investigating staff and patient experience and one study (2%) reporting adverse events during physiotherapy. See Figure 2.

See Figure 3: Methodology types and number of studies included.

Quality of research

Many of the studies (with some exceptions) had small sample sizes and were based in single centres. For the RCTs, blinding was inconsistent across studies resulting in potential risk of bias within the methods. The participants were appropriately selected and accounted for through the pathway of the studies and the study protocols were outlined in nearly all studies. The outcome measures were largely easily replicable and appropriate to the patient groups being investigated, however overall, there was little consideration of cost-benefit analysis.

Study findings

A detailed summary of the studies is presented in the literature review table (Appendix 2).

The themes identified were respiratory physiotherapy, mobilisation and sternal wound precautions.

Respiratory physiotherapy

Research relating to respiratory physiotherapy covered a range of interventions. Three studies (14–16) looked at positive pressure interventions alongside early mobilisation following cardiac surgery. Kamisaka et al. (14) found that delivering pressure support may have a role in improving dyspnoea in early mobilisation. Dholaki et al. (15) compared Bilevel positive airway pressure and high-flow nasal oxygen (HFNO) on ambulation and found both groups doubled the distance mobilised with ventilatory support. Pantoni et al. (16), found continuous positive airway pressure (CPAP) on ambulation demonstrated increased exercise tolerance, tidal volumes, and oxygen saturation, as well as reduced dyspnoea in comparison to the control group.

Three studies (17–19) investigated positive expiratory pressure (PEP) devices. They found no benefit of PEP (17) or Acapella® (18) over conventional physiotherapy on pulmonary function, post-operative pulmonary complications (PPCs), radiological changes or length of hospital stay (17–18). Petterson et al. (19) found deep breathing exercises performed with bubble PEP demonstrated significantly higher SpO2 in standing versus sitting.

Incentive spirometry has been investigated with mixed results. In a systematic review, Sullivan et al. (3) reported that incentive spirometry alone did reduce PPCs. However, a pilot RCT concluded that there was no statistically significant difference in lung function tests, at post-operative day (POD) seven or on six-minute walk distance (6MWD) in incentive spirometry versus diaphragmatic breathing (20).

Wu et al. (21) found the use of mechanical insufflation:exsufflation post-operatively, had significantly improved lung function, but patients reported significantly more pain compared with the Intermittent Positive Pressure Breathing Group. There was no difference in PPCs between groups.

Zochios et al. (22) found that prophylactic use of HFNO in patients with pre-existing respiratory conditions resulted in lower hospital length of stay and reduced intensive care unit (ICU) readmissions in comparison to a standard care control group.

Cargnin et al. (23) found the use of post-operative inspiratory muscle training demonstrated significant improvement in maximal inspiratory pressure and non-significant improvement in 6MWD, with no difference in length of stay, lung function or quality of life. Another study found that ACBT did not lead to physiological improvements compared to routine physiotherapy (24).

Mobilisation

Studies have established that early mobilisation is beneficial compared to bedrest, but there was no evidence of the optimal exercise prescription, or definition of early mobilisation (5, 25).

Early mobilisation significantly reduced hospital length of stay (LOS) in five studies (26–30), but not in other studies that reported no significant difference in LOS (4, 31–32). Intensive care LOS was shown to have been significantly reduced by Afxonidis et al. (26), and was also reported to be reduced, but not significantly by Chen et al. (4).

Four studies (29, 31, 33–34) all found no significant difference in 6MWD between control and intervention groups whereas one study (35) showed a significant improvement in 6MWD in their small sample intervention groups. Kubitz et al. (36) reported that 80% of patients fully adhered to their post-operative mobility protocol. Outcomes of supervised exercise are variable, with one study showing a significant increase in step count when supervised by physiotherapists (37), but another showed no significant difference between orderly led ambulation (31).

Physiological measures showed no significant differences following the interventions of cycle ergometry (34). However, Tariq et al. (28) showed a significant improvement in SpO2 following mobilisation and respiratory physiotherapy within four hours of extubation. Studies found no significant difference in left ventricular ejection function (29), respiratory muscle strength (35) or lung function (35, 38) between an exercising intervention group and the control group.

Miwa et al. (30) and Floyd et al. (32) showed no differences between control and intervention groups, and the incidence of adverse events. Takei et al. (39) reported an incidence of 18% of physiological abnormalities or potential safety events during physiotherapy, but only 2% requiring treatment. The main adverse effects reported were altered blood pressure and vertigo. The study by Sousa et al. (40) found the majority of physiological abnormalities or adverse events were mild or near misses occurring more so with mechanically ventilated patients.

Other interventions reporting positive impact on recovery are targeted exercise and education (41) and distance walked based on wall art (42). There was a significant reduction in costs in an early rehabilitation (<8 days) intervention group compared to the control or delayed (>8 days) intervention group (29).

Sternal wound precautions

Work reviewing the long-established practice of strict sternal wound precautions has been compared to modified sternal precautions, such as Keep your Move in the Tube (KYMITT) (43–45). KYMITT is a post-sternotomy protocol that allows load bearing movement through the upper-limbs whilst avoiding excessive stress to the sternal wound. This is achieved by keeping upper-limbs at close range to the trunk, or as if you were placed in a tube. Both Gach et al. (43) and Radfar et al. (44) found that implementing KYMITT was associated with an increased proportion of cardiac surgery patients discharged home, opposed to inpatient rehabilitation or nursing facilities. The use of KYMITT did not increase wound complication or readmission rates. Katjjahbe et al. (45) study showed substantial improvement with KYMITT, but no significant difference at weeks four and 12. LaPier et al. (46) found the majority of physiotherapists would implement wound support immediately after median sternotomy to reduce pain and to protect sternal healing. Restrictions related to the arms lifting weights and heights were commonly employed but varied greatly in degree and duration.

Thoracic exercises showed a significant reduction in early (0–6 weeks) sternal pain post cardiac surgery. However, there was no difference at three months (47). A systematic review of continuous local anaesthetic in post-cardiac surgery patients (48) found no significant differences in pain scores, distance walked, or for time to physiotherapy discharge.

Boitor et al. (49) found hand massage in the critically ill cardiac surgery patients significantly reduced pain immediately post intervention compared to active and passive control groups, but they were unable to assess longer term benefit.

The qualitative studies explored patient’s experiences following cardiac surgery (13, 50). They concluded that cardiac surgery causes both physical and emotional disturbance. Relationships developed with healthcare professionals built safe spaces for discussion, to prepare patients and families adequately for discharge.

Discussion

This scoping review outlines research published in key areas of physiotherapy and post cardiac surgery management. There is a variety of respiratory treatment techniques and interventions studied which makes concluding the impact of respiratory physiotherapy more difficult. There is some evidence that initiating positive pressure such as CPAP or HFNO in the early phase of care does positively impact patient recovery. However, physiotherapy delivered pressure treatment such as PEP and incentive spirometry are less likely to improve outcome in the absence of PPCs. In patients who do not develop PPCs or have pre-operative respiratory conditions, physiotherapy adjuncts do not expedite recovery and that these treatment options should not be routinely delivered.

Research supports that mobility provides a multi-faceted impact on recovery including enhancing re-ambulation, cardiovascular improvement and contributes towards prevention of PPCs.

There is strong evidence for early mobilisation, in reducing ICU and hospital LOS. However, the optimal timings and frequency of mobility remains unanswered. There is evidence to support that staff and a culture dedicated to mobilisation impacts step count and frequency of mobility. These findings support the more holistic post-operative recovery approach, involving patient experience and patient accountability for their care, in addition to physiological recovery.

The pioneering work around sternal precautions has been a significant change in post-operative cardiac care, over the past few years. Due to the increasing age and frailty of patients, the inability to use the upper-limbs to facilitate bed transfers, and aid sit-to-stand has an impact on recovery, hospital length of stay and ongoing care needs on discharge. Evidence provides assurance that the KYMITT approach does not lead to an increase in sternal wound breakdown, infection or pain (51). It would be interesting to assess adoption of this practice in cardiac centres.

The literature includes mainly quantitative research, however qualitative consideration of the impact of staff and patient experience in recovery after cardiac surgery was included. Additional consideration for further research would be multi-centred trials to enable greater sample sizes, and cost-benefit analysis in terms of both hospital and patient benefit would allow for greater weight for supporting change in practice.

A limitation to this scoping review was that the search criteria excluded prehabilitation and post-discharge exercise prescription such as cardiac rehabilitation programmes. Further scoping reviews would be beneficial to identify studies relating to these areas.

Conclusion

In conclusion, the objective of this scoping review was to report the extent and methodological type of evidence associated with post-operative physiotherapy in people who undergo cardiac surgery.

The initial search returned 2795 articles and following screening 41 studies were included in the scoping review. A variety of different research methodologies were included in the review which demonstrates diversity of evidence available.

The literature showed positive outcomes for physiotherapy interventions involving early mobility, a culture that supports holistic post-operative recovery and allowing increased use of the upper-limbs. It is more difficult to conclude which respiratory intervention provides the most benefit, and targeted use in patients with respiratory compromise appears to be better than routine application. Cost effectiveness analysis needs to be undertaken. There is scope for an increase in qualitative studies to be undertaken to focus on patient experience and reported outcomes.

In addition to this cardiac scoping review, the editorial board has published separate gastrointestinal and thoracic scoping reviews and plan to publish a combined ACPRC surgical position statement.

Acknowledgements

Thanks to Becky Scott, Royal Papworth Hospital library services, and Rebecca Rowe, Royal Papworth Hospital library services.

Funding

There was no funding provided in this scoping review. All participants gave their time voluntarily.

Conflicts of interest

There are no conflicts of interest with the authors listed on this manuscript.

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