European International Journal of Science and Technology Vol. 6 No.

2 March 2017

Pre and post operative physiotherapy for patients after open-heart surgery

Dr. Riaz Fatima

HOD of National Institute of Cardiovascular Diseases,
Karachi, Pakistan
Email: [email protected]

Dr. Syed Abid Mehdi Kazmi

Head of department of Ziauddin Hospitals
Karachi, Pakistan
Email: [email protected]

Dr. Syed Irfan Haider Naqvi

Senior Physiotherapist, Ziauddin Hospitals
Karachi, Pakistan
Email: [email protected]

Dr. Amool Sakeena Rizvi

Physiotherapist in JPMC
Karachi, Pakistan
Email: [email protected]

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European International Journal of Science and Technology ISSN: 2304-9693 www.eijst.org.uk

ABSTRACT
The purpose of this prospective survey was to investigate the pre and postoperative physiotherapy treatment
used on patients undergoing open heart surgery. Survey involved physiotherapists working in
cardiothoracic units throughout Karachi.
METHOD:
A cross-sectional, descriptive study was carried out to know the practice of physiotherapy following routine
open heart surgery in Karachi. Patients having neurological symptoms, restricted lung disease, obstructed
lung disease, cardiac vise unstable (New York association grade iii to grade IV, redo surgeries, emergency
procedure and patients having excesses weight were not considered.
Result: Results showed that 95% of respondents performed routine preoperative physiotherapy; however
100% treat all patients during post-operative period of open heart surgery.
Conclusion: The result of this survey shows that pre and post-operative management of patients undergoing
open heart surgery is done more or less in the same way by physiotherapists throughout Karachi.
Verbal interview with the physiotherapists show that practice is mainly based on personnel preference.
Awareness of recent literature might influence care of postoperative patients and will influence evidence
based practice.

KEY WORDS: Open heart surgery, Physiotherapy, Post-operative management, Awareness, Obstructed
lung disease, Restricted lung disease

INTRODUCTION
Cardiac surgery was started in the year 1893, when Dr Danial Hall Willium from Chicago successfully
operated a patient having stab wound involving the pericardium and the heart (DH, 1897) the first Aortic
surgery was performed by Theodore Tuffier on 13 of July 1912 to open a stenotic valve(T, 1914) ,Initially
clearly documented coronary artery bypass surgery was successfully performed on human being at Ethen
Hospital in the New York City on May 2, 1960 by Dr Robert H Goetz (Konstantinov E, 2000).The evidence
based perioperative physiotherapy treatment and techniques for patient’s care are not well established.
Traditionally, patients have been assessed by physiotherapist before operation, then again assessed in the
immediate post-operative period, while still patient is intubated (Patman S, 2001), (Brasher PA, 2003).
From that period, physiotherapy treatments start and continued after patients was extubated and shifted to
recovery room. Throughout hospital stay patients are treated with deep breathing exercises, incentive
spirometry, and gradual mobilization. Prior to discharge from the hospital proper education regarding sternal
restriction, supported coughing, pain management, posture correction and healthy life style have been given
to the patients. Several studies have challenged the need for this historically protocol, arguing that this
management is not necessary for all patients and thus may not be the best use of physiotherapy resources
(Patman S, 2001) (ThornlowDK, 1995) .in addition to this ,the efficacy of incentive spirometry , (Pasquina,
2003)(Fanning, 2004) (OverendTJ, 2001), deep breathing and coughing (Pasquina, 2003) has not been
found , in term of patients out comes after uncomplicated CABG surgery (Brasher PA, 2003) (Jenkins SC,
1989)(Stiller, 1994).
On the basis of these studies level and type of care provided by physiotherapists to patients undergoing heart
surgery require clarification. physiotherapy is given to reduced post-operative respiratory complications
like arterial hypoxemia, Atelectasis and pulmonary infection .These respiratory complications are main
causes of morbidly and mortality after open heart operation (Crowe JM, 1979)(Matte P, 2000) (OikkenenM,
1991)(Westerdhal E, 2005) .These techniques and treatment are also used to reduced secondary

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European International Journal of Science and Technology Vol. 6 No. 2 March 2017

complications i.e. pain and stiffness, Improve mobility, functions and enhance, postoperative quality of life
(Herdy, 2008)(Peric, 2008). However evidence suggests that some interventions recently used in
physiotherapy may be of no benefit to patients undergoing uncomplicated open heart surgery. Chest
physiotherapy during intubation period following cardiac surgery does not improve pulmonary
complications (Patman S, 2001). Deep breathing exercises (DBEs) has no value to patients following heart
surgery compared early mobilization alone (Brasher PA, 2003)(Jenkins SC, 1989)(Jenkins, 1990)(Johnson,
1995) (Pasquina, 2003) (Stiller, 1994). Percussion, intermittent positive pressure breathing (IPPB), incentive
spirometry and continuous positive airway pressure (CPAP) also has no benefit. (MatteP, 2000). In contrast
positive expiratory pressure (PEP) therapy using blow bottle device reduces atelectasis and improves
pulmonary function compare to controls performing deep breathing with no device or no deep breathing
exercises (Westerdahl, 2001) (Westerdhal E, 2005), but evidence does not support its clinical implications.
Some researchers showed benefits of thoracic and upper limb range of motion (ROM) exercises but results
are not constant across trials. (Aida, 2000)(Shaw, 1989)(Stiller, 1997).Progressive mobilization and walking
training are the strongest suggestion for the management of patients underwent open heart surgery. Patients
who covered longer distance, recover earlier, got greater walking capacity and mentally satisfaction at
discharge from the hospital than their counterpart. (Hirschorn, 2008)(Van, Vilet Vililand TPM, & Versteegh
MIM, 2004).
Researchers suggests that some physiotherapy techniques have no benefit to patients undergoing
uncomplicated cardiac surgery. During intubation period physiotherapy does not alter the rate of respiratory
complications (Patman S, 2001). This was despite available evidence (DullJL, 1983) (Jenkins, 1990)(Stiller,
1994) (CroweJM, 1997) (Brasher PA, 2003)(savci, 2006) that suggested that deep breathing exercises do not
improve clinical outcomes in routine, uncomplicated patients. Tucker(Tucker B, 1996)r et al (1996)
concluded that physiotherapists were “reluctant to change current practice based on research findings.”
Since 1996, the evidence base regarding the benefits of open heart management strategies has grown
considerably (Brasher, McClelland, Denehy, and Story, 2003; Hirschhorn(Hirschorn, 2008) et al, 2008;
Matte, Jacquet, Van Dyck, and Goenen, 2000; Atman, S(McConnell AK, 2004)Anderson, and Blackmore,
2001; Van der Peijl et al, 2004; Westerdahl, Lindmark, Almgren and Tenling, 2001; Westerdahl et al, 2005).
These new findings support the need for a current overview of practices.

Methodology
A questionnaire based survey was done, to identify the physiotherapy management of patients and
mobilization procedures after uncomplicated open heart surgery in Karachi district. Inclusion and exclusion
criteria were verbally explained to all respondents. Inclusion criteria were elective openheart surgeries
(MVR, AVR, DVR, CABG, VSD, ASD, and TC) patients with no lung disease, age limit above 20 year and
below 60 year and physiotherapists having work experience of more than one year in cardiothoracic unit.
The exclusion criteria were patients having restricted or obstructed lung disease, cardiac wise unstable, redo
and emergency surgeries, patients with neurological deficit, circulatory problems, prolonged intubation, or
other conditions calling for personalized treatment. Physiotherapists having work experience less than one
year in cardiothoracic unit. Physiotherapists that cure other varieties of post-operative patients, requested to
precede back the questionnaire unreciprocated. Target population was the cardiothoracic physiotherapists
working in both private and public sectors in Karachi, where open heart surgeries have been performed.
Non- probability convenience sampling technique was used. Sample size was 40 respondents. Open heart
surgery is highly specialized in all large cities of the Pakistan, as in other cities of the developed countries.
In Karachi cardiac surgery is performed in both private and government institutions. This study was

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conducted in four private and two government sector hospitals in Karachi, where cardiothoracic
physiotherapist are performing pre and post-operative physiotherapy regularly.
For this specific study the questionnaire was developed. Previous questionnaire survey performed by
(Tucker B, 1996), (ReeveJ, 2006) and (Westerdahl, 2011) were reviewed to meet the objective of this study
before starting the survey .Questionnaire was designed by the author using expert understanding and
clinical proficiency of almost 30 years in the field of cardiothoracic physical therapy. A range of closed
ended questions about treatments and techniques used in pre and post-operative periods in patients
undergoing coronary artery bypass graft surgery were included in the questionnaire. Duration of the study
was From January 2012 to March 2012. Descriptive statistics were used to analyze the results, means,
medians, standard deviation and ranges were calculated. SPSS 19.0 (IBM) was used for the statistical
analysis.

Result
A questionnaire was sent to forty physiotherapists working at the cardiothoracic units in the leading
hospitals of Karachi. 13 (33%) were male and 26 (67%) were female. Physiotherapists were aged between
29.6±1.81.Mean experience was 6.2±2 years with standard deviation of 6.46.Results were analyzed using
the statistical package for social sciences (SPSS) Version 19 by IBM.

TABLE I
NUMBER (%) OF RESPONDENT PROVIDING PRE-OPREATIVE INFORMATIONS
REGARDING DEEP BREATHING EXERCISES,COUGHING / HOUFFING & TECHNIQUES
FOR GETTING IN AND OUT OF BED/CHAIR TO THEIR PATIENTS
RESPONSE DEEP BREATHING COUGHING/HUFFING TECHNIQUE FOR GETTING IN
EXCERCISES TECHNIQUES & OUT OF BED/CHAIR

YES 38 ( 95 % ) 33 ( 82.5 % ) 36 ( 90 % )
NO 2(5%) 5 ( 12.5 % ) 3 ( 7.5 % )
NO ------ 2(5%) 1 ( 2.5 % )
RESPONSE

TABLE II
NUMBER (%) OF RESPEONDENTS PROVIDE INFORMATION ABOUT UPPER & LOWER
EXTREMITY EXERCISES, INCENTIVE SPIRRYOMET & USE OF DEVICES TO
STRENGTHEN INSPIRATRY MUSCLES
RESPONSE UPPER & LOWER INCENTIVE USE OF DEVICES TO
EXTREMITY EXERCISES SPIROMETRY STRENGTHEN INSPIRATRY
MUSCLES
YES 35 ( 87.5 % ) 37 ( 92.5 % ) 12 ( 30 % )
NO 3 ( 7.5 % ) 2(5%) 28 ( 70 % )
NO RESPONSE 2(5%) 1 ( 2.5 % ) ------

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European International Journal of Science and Technology Vol. 6 No. 2 March 2017

TABLE III
NUMBER (%) OF RESPONDENT PROVIDING PRE-OPREATIVE INFORMATIONS
REGARDING, EARLY MOBILATION, POST STERNOTOMY RESTRICTION & POST
OPERATIVE PULMONARY COMPLICATIONS.
RESPONSE PRE-OPERATIVE POST STERNOTOMY POST OPERATIVE
INFORMATION REGARDING RESTRICTION. PULMONARY
EARLY MOBILATION COMPLICATIONS
YES 37 ( 9.25 % ) 35 ( 87.5 % ) 35 ( 87.5 % )
NO 2(5%) 5 ( 12.5 % ) 3 ( 7.5 % )
NO 1 ( 2.5 % ) ------ 2(5%)
RESPONSE

TABLE IV
NUMBER (%) OF RESPONDENT PROVIDING INFORMATION ABOUT USE
OF BILATERAL SHOULDER MOVEMENT, STERNAL PRECAUTION AFTER
DISCHARGE & HOME EXERCISES.
RESPONSE USE OF BILATERAL STERNAL PRECAUTION HOME EXERCISES
SHOULDER MOVEMENT AFTER DISCHARGE.
YES 34 ( 85 % ) 30 ( 75 % ) 35 ( 87.5 % )
NO 6 ( 15 % ) 4 ( 10 % ) 5 ( 12.5 % )
NO ------ 6 ( 15 % ) ------
RESPONSE

Table V

NUMBER (%) OF RESPONDENTS PROVIDING A BOOKLET/ WRITTEN

GUIDE TO THE PATIENT AT DISCHARGE
Cumulative
Frequency Percent Valid Percent Percent
Valid Yes 30 75.0 85.7 85.7
No 5 12.5 14.3 100.0
Total 35 87.5 100.0
NO RESPONSE 5 12.5

Total 40 100.0
Table V shows that 75% respondents provide written guide/ booklet to their patients at the time of discharge.

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European International Journal of Science and Technology ISSN: 2304-9693 www.eijst.org.uk

FIGURE I

FIGURE II

Figure II shows that If second postoperative day fall on sound, 83.33% respondents visit their patients
regularly.

Discussion
To our knowledge this is a first survey to explore pre and postoperative physiotherapy management
following uncomplicated open heart surgeries in Karachi. These types of survey to know the current
practice among the physiotherapist working in the cardiothoracic unit were also performed by (Tucker B,
1996), (ReeveJ, 2006)and Westerdahl (Westerdahl, 2011).

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In this study 95% respondents informed patients about pre-operative information regarding, deep breathing,
mobilization supported coughing, range of motion exercises and post-operative sternotomy restrictions to
the patient, while 30% respondent use devices to strengthen inspiratory muscle of the patients. Deep
breathing exercises (95%) and incentive spirometry (92.5%) treatment techniques are not supported by
current evidence, (DullJL, 1983), (Jenkins, 1990), (Stiller, 1994) (Brasher PA, 2003) (savci, 2006), continue
to be widely used among cardiothoracic physiotherapist.
Tucker (Tucker B, 1996) described that 34 of 35 respondents (97%) used either cough or deep breathing
exercises, while (Filbay, Hayes, & Holland, 2011) reported that 77% of respondent used this technique
in the management of routine post-operative patients undergoing cardiac surgery. These results suggest
that in the past 14 years implementation of deep breathing exercises has been decrease, on the other hand,
finding of this survey indicates that DBE are the most commonly used technique, as 95% of respondents are
still using deep breathing exercises regardless mounting evidence of no value. Implementation of early
Mobilization (92.5%) was frequently used intervention among cardiothoracic physiotherapists and has sound
evidence supported by recent literature (Hirschorn, 2008).
Manual techniques like percussion and vibration may be harmful to the patients in
Cardiac surgery because of risk of sternum instability and has no positive effects (Jenkins SC, 1989),
(Barerel, 1978),] (Johnson, 1995) , (Matte P, 2000), (OikkenenM, 1991). Literatures mention very little
about this technique (Felcar JM, 2008) had discussed this technique in pediatric cardiac surgery. in this
study 71% respondents, agree that percussion technique used in postoperative period might cause sternal
instability and induce pain so it should be avoided, while 29% respondents agreed that percussion might not
induce pain and sternum harm.
.15% respondents used InspiratoryResistance Positive Expiratory Pressure device (IR-PEP) blow bottle in
the post operative period. Resultsshowed that 95% respondents perform preoperative physiotherapy
,whereas post operative physiotherapy was utilized routinely by all cardiothoracic physiotherapists.Soulder
range of motion exercises are used toprogress blood circulation, reserve thoracic motion and affluence
sternal circulation (Shaw, 1989).Bilateral upper limb movements causes less sternal pain as compared to
unilateral movements (El-Ansary D, 2007). In this study 82% respondents performed bilateral shoulder
movement, 87.5% provided written guide /booklet to the patients. Written guideline about exercise therapy
after cardiac surgery frequently progresses self-confidence, diminishes menace issues, and can upsurge
bodily capability and medical status of the patients.(Graham I, 2007)A recent research report showed that
after cardiac surgery home based cardiac rehabilitation program (HBCR) was realistic and safe compare to
the conservative in hospital rehabilitation. According to this study, large number of individuals, who have
underwent uncomplicated cardiac surgery may benefit from home based cardiac rehabilitation program
using telemedicine.(Scalvini S, 2013)
Post-operative sternal unsteadiness is a main problem, so importance of correct instruction for sternal
precaution is crucial particularly in obese and chronic obstructive pulmonary disease patients (Diez,
2007).85% respondents provide sternal precaution at the time of discharge On Sunday 81.08 % respondent
have managed post-operative patients, 8.11% respondent have attained only if needed while 10.81 % never
give physiotherapy .Physiotherapy interventions routinely performed for patients undergoing uncomplicated
cardiac surgery. It is important to note that this survey data shows only a sample of current physiotherapy
practice in Karachi and might not reflect the ideal care of this patient’s population. Research is needed to
allocate evidence to clarify practice in various areas such as treatment frequency, use of specific treatment
techniques, sternal precaution and lifting restrictions. Tucker made two remarkable points in their
discussion: first, that, in most of the hospitals, treatment of patients after bypass surgery may be more
comprehensive than is supportable by the results of clinical research, and second that “physiotherapists are

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reluctant to change current practice based on research findings.” (Tucker B, 1996). Reeve and Ewan also
concluded that many physiotherapists are unwilling to change practice based on the available evidence on
treatment techniques in this patient population (Reeve & Evan, 2005). While all aspects of the routine
physical therapy administration of patients following heart surgery not yet conducted in any systematic
review, evidence has arose to suggest that use of at least some traditional treatment techniques and practices
should be reconsidered (Patman S, 2001), (Jenkins SC, 1989), (Pasquina, 2003), (Stiller, 1994),
(OverendTJ, 2001) (Parker RD A. J., 2008)In this study the treatment choice was mainly influence on
personal choice, experience, surgeon recommendations and hospital policy. Recent literature influence was
not reflected in practice as most patient were treated with deep breathing exercises (95%), despite literature
consistently proving that deep breathing has no benefit. A recent study ( (Filbay, Hayes, & Holland, 2011)
shows that respondents with a bachelor or diploma in physiotherapy were more likely to used breathing
techniques or coughing than physiotherapist with a post graduate degree. physiotherapists with more
advance education may be more inclined to use evidence-based practice, which may interconnected to their
extended understanding in their field obtained by extensive research skills achieved while obtaining a
postgraduate degree. Davidson (IlesR, 2006) study showed that physiotherapists with advanced levels of
training were more confident in their ability to search databases and did so more frequently than
physiotherapists with lower levels of education.
Eduardo and Weiner P also studied efficacies of inspiratory muscle training in patients undergoing heart
surgery. (Hulzebos, 2006) In a specific type of scientific experiment, of patients experiencing cardiac
surgery concluded as rigorous workout of muscles of inhalation (7 episodes weekly for minimum fifteen
days) former to surgery decreases occurrence of respiratory complications and hospital stay in high risk
population of patients after surgery). Endurance and strengthening training of inspiratory muscle in
preoperative period causes increased resistance to fatigue and enhanced respiratory function by decreasing
the work of breathing and increasing pulmonary reserve (Enright SJ, 2006), (McConnell AK, 2004)in this
study 30% respondent used inspiratory muscle training device. It means that use of this device is
uncommon in this population of cardiothoracic physiotherapist. A recent study showed that inspiratory
muscle training device can be used in the high risk patients to prevent postoperative pneumonia, but results
of the study were questionable to support the proof for inspiratory muscle training in tumbling the
occurrence of this post-operative pulmonary complication, so more investigations are needed to know its
effect in regular care of patients.(Valkenet K, 2013)

Conclusion
It is concluded that, to augment evidence based practice, physiotherapists working in cardiac surgery unit
should rationalize and validate their treatments and techniques and conduct new research. Cardiothoracic
physiotherapists may benefit by means of proper evidence- based guidelines for use on routine,
uncomplicated open heart cardiac patients. These guidelines would make specific recommendations
regarding physiotherapy management and the evidence on which they are based.

Limitation of Study
Since many questions were not answered, so author only considered those questions, which were commonly
attained by the respondents. As this study collected information’s regarding self –reported physiotherapy
practice for treatment of patients undergoing open heart surgeries. It may be possible that physiotherapists’
response in a manner they thought represented acceptable practice, and thus may be our result may not
reflect the actual management provided by respondents.

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Abbreviations
CABG :Coronary Artery Bypass Graft Surgery
CPR: Cardiopumonary resuscitation
DBE : Deep Breathing Exercises
SpO2 : Oxyhaemoglobinsaturation
LOS: Length of Stay
IS: Incentive spirometry
SP: Sternal Precaution
MI: Myocardial Infarction
MIP: Maximal Inspiratory Pressure
MEP: Maximal Expiratory Pressure
IPPB: Intermittent Positive Pressure Breathing
IR-PEP: Inspiratory Resistance Positive Expiratory Pressure
PPCs: Post-Operative Pulmonary Complication’s
PVD: Peripheral Vascular Disease
AVR: Aortic Valve Replacement
MVR: Mitral Valve Replacement
DVR: Double Valve Replacement
TC: Total Correction
ASD: Atrial Septal Defect
(savci, 2006)(Scalvini S, 2013)VSD: Ventricular Septal Defect
HBCR: Home Based Cardiac Rehabilitation

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