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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.

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)


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

Search 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.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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
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

Comment(s)

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).

Clinical 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

1. 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 Heart, Lung and Circulation, 2007: (17) 129-138
2. 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 Annals of Thoracic Surgery 2004: (77) pp1535-1541