Effectiveness of Early Mobilization in Prevention and Rehabilitation of Functional Impairment After Myocardial Revascularization Surgery: A Systematic Review

Judas, Marcia Cristina Lacerda das; Fontes, Rodrigo de Freitas; Moura, Renata de; Santos, Larissa dos; Almeida, Mônica de; Gomes, Vinicius

doi:10.36660/ijcs.20210166

Acessibilidade / Reportar erro

Brasil

International Journal of Cardiovascular Sciences

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

ORIGINAL ARTICLE • Int J Cardiovasc Sci 36 • 2023 • https://doi.org/10.36660/ijcs.20210166 copy

Effectiveness of Early Mobilization in Prevention and Rehabilitation of Functional Impairment After Myocardial Revascularization Surgery: A Systematic Review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction

Myocardial revascularization surgery is associated with high morbidity and mortality, due to factors like the general anesthesia and the surgical procedure itself. Physiotherapy, combined with early mobilization (EM), can provide the patient with better functional parameters.

Objective

To review, identify and describe the effectiveness of EM in the prevention and rehabilitation of functional parameters of coronary artery bypass graft surgery.

Methodology

This is a systematic review conducted between February 2020 and 2021 of randomized clinical trials (RCTs) published in the Cochrane databases Library, LILACS, Scielo and Medline / PubMed. The Physiotherapy Evidence Database (PEDro) scale was used for assessment of the methodological quality of studies included.

Results

Four studies were reviewed. Two articles assessed functional capacity, one using the cycle ergometer and one with inspiratory muscle training (IMT) together with active exercises and early walking. One article reported a reduction in the incidence of atelectasis and pleural effusion with EM and one article reported improvements in the alveolus-artery gradient and inspiratory muscle power using an inspiratory muscle trainer combined with EM.

Conclusion

EM is effective in the prevention and rehabilitation of functional parameters after CABG surgery, by improving functional capacity, respiratory muscle power, quality of life and gas exchange, and reducing the incidence of atelectasis and pleural effusion.

Myocardial revascularization; Early mobilization; Rehabilitation

Author and year	Study design	Pedro scale	Sample	Intervention	Control	Analyzed outputs	Main results
Hirschhorn et al .¹¹11. Hirschhorn AD, Richards DA, Mungovan SF, Morris NR, Adams L. Does the Mode of Exercise Influence Recovery of Functional Capacity in the Early Postoperative Period after Coronary Artery Bypass Graft Surgery? A Randomized Controlled Trial. Interact Cardiovasc Thorac Surg. 2012;15(6):995-1003. doi: 10.1093/icvts/ivs403. https://doi.org/10.1093/icvts/ivs403.... 2012	PROSPECTIVE SCREEN	9 /1 0	n = 64 (66 ± 9 years) IG: 32 CG: 32 Post-operative first CABG.	Cycle rgometer (power proportional to the square of the cycling speed) (2x / day) for 10’ with a BORG of 3 and 4 + breathing techniques and standard clinical musculoskeletal movements until hospital discharge.	Walking (2x / day) for 10’ with a BORG of 3 and 4 by the Modified Borg Scale + breathing techniques and standard clinical musculoskeletal movements until hospital discharge.	6MWA, 6MCA and SF-36v2.	There was no statistically significant difference between groups for the 6MWA tests (cyclists: 402 ± 93 m vs walkers: 417 ± 86 m, P = 0.803), 6MCA (cyclists: 15.0 ± 6.4) kJ vs walkers: 14.0 ± 6.3 kJ, P = 0.798) or health-related quality of life.
Moradian et al .¹⁰10. Moradian ST, Najafloo M, Mahmoudi H, Ghiasi MS. Early Mobilization Reduces the Atelectasis and Pleural Effusion in Patients Undergoing Coronary Artery Bypass Graft Surgery: A Randomized Clinical Trial. J Vasc Nurs. 2017;35(3):141-5. doi: 10.1016/j.jvn.2017.02.001. https://doi.org/10.1016/j.jvn.2017.02.00... 2017	RCT	6/10	n = 98 IG: 49 (59 ± 10 years). CG: 49 (60 ± 11.3 years). Patients undergoing CABG.	1^st POD sits in the beside with hangin legs for 15’. 2^nd POD sits in the bedside for 5’ in addition of walk of 10 meters + Night walk of 30 meters. 3^rd POD before and after removal of the chest tube walk 30 meters.	Routine hospital treatment. 3^rd POD: mobilization after removal of the chest tube.	Presence of atelectasis and pleural effusion, SaO₂ and PaO₂.	The PaO₂ in 3DPO and percent SaO₂ in 4DPO were higher in the treatment group (P < 0.05). In general, the incidence of atelectasis and pleural effusion decreased in the treatment group.
Turky and Afify .¹²12. Turky K, Afify AMA. Effect of Preoperative Inspiratory Muscle Training on Alveolar-Arterial Oxygen Gradients after Coronary Artery Bypass Surgery. J Cardiopulm Rehabil Prev. 2017;37(4):290-4. doi: 10.1097/HCR.0000000000000234. https://doi.org/10.1097/HCR.000000000000... 2017	RCT	5/10	n = 40 participants IG: 20 CG: 20 Post-operative CABG	IMT (3x10’ 2x a day with a load of 30% of MIP with a pause of 30 to 60’’ between sets), the resistance was increased incrementally according to BORG. If < 5 the resistance would gradually increase by 2 cmH₂O or half a turn, or reduced 1 to 2cmH₂O BORG case between 9 and 10 + EM (walking around the bed and along the corridors).	Routine respiratory physiotherapy and early mobilization (walking around the bed and through the corridors).	Arterial alveolar gradient and inspiratory muscle power.	The intervention group showed significant improvement (P < 0.05) in the alveolar gradients of arterial oxygen and inspiratory muscle power at all measurement points.
Zanini et al 2019. ¹³13. Zanini M, Nery RM, Lima JB, Buhler RP, Silveira AD, Stein R. Effects of Different Rehabilitation Protocols in Inpatient Cardiac Rehabilitation after Coronary Artery Bypass Graft Surgery: A Randomized Clinical Trial. J Cardiopulm Rehabil Prev. 2019;39(6):E19-E25. doi: 10.1097/HCR.0000000000000431. https://doi.org/10.1097/HCR.000000000000...	RCT	7/10	n = 40 participants divided into: G1 = 10 G2 = 10 G3 = 10 G4 or GC = 10 (18 to 70 years old). Submitted to CABG.	G1:IMT with a load of 20% of the MIP (10 x 10 breath), active training of the upper limbs and lower limbs and early walking (twice a day), conventional pulmonary therapy and Borg 11; G2: Same protocol that without IMT G1 (2x daily), CPT and Borg 11; G3: TMI with a load of 20% of the MIP (10 x 10 breath 2x daily) e CPT.	Conventional pulmonary therapy (THB, deep breathing and EPAP.	Functional capacity (6MWT).	G1 and G2 achieved a more effective recovery of FC on the 6th postoperative day, remaining greater 30 days after discharge. (P < 0.001 between groups).
Cui et al .¹⁴14. Cui Z, Li N, Gao C, Fan Y, Zhuang X, Liu J, et al. Precision Implementation of Early Ambulation in Elderly Patients Undergoing Off-Pump Coronary Artery Bypass Graft Surgery: A Randomized-Controlled Clinical Trial. BMC Geriatr. 2020;20(1):404. doi: 10.1186/s12877-020-01823-1. https://doi.org/10.1186/s12877-020-01823... 2020	RCT	8/10	n = 194 participants GI = 89 GC = 89	Intervention – 1^st POD transition sitting on the bed → chair at the bedside with hanging legs + 10'and can stand 3'-5' repeating 5x. 2POD equal to 1POD + minimum 20’ walk with incentive to ↑ intensity and ↑ frequency up to 5x. 3POD sit out of bed + 10', stand 5’ and walk minimum 20’ with help and incentive for ↑ intensity and ↑ frequency up to 5x. Turn back the lifestyle with walking + distant independently.	Walking on the second or third day after surgery	Post-operative hospital stay, postoperative complications and physiological and psychological functional return.	IG had ↓ postoperative hospital stay significantly compared to the CG (P = 0.031), with no significant difference in atelectasis and pulmonary infection (P > 0.05) between the two groups. Return physiological functional function + rapid evacuation to the IG compared to the CG P < 0.001 in addition to better PO₂ values between GI and GC P = 0.001. PTSD in the GI was ↓ than GC P < 0.001.
Steinmetz et al. ¹⁵15. Steinmetz C, Bjarnason-Wehrens B, Baumgarten H, Walther T, Mengden T, Walther C. Prehabilitation in Patients Awaiting Elective Coronary Artery Bypass Graft Surgery - Effects on Functional Capacity and Quality of Life: A Randomized Controlled Trial. Clin Rehabil. 2020;34(10):1256-67. doi: 10.1177/0269215520933950. https://doi.org/10.1177/0269215520933950... 2020 .	RCT	6/10	230 patients GI = 115 CG = 115 (age between 67.1 ± 8.4).	2 weeks of supervised preoperative exercise in exercise bike 3x weekly, with 70% of VO₂peak. Each session of training included 2 aerobic exercises and 15’ of light gymnastics between them. Start: 2 cycling sessions of 10'(1st session) up to 2 cycling sessions of 25' (6th session); (2nd and 3rd session: 2 × 15’, 4th and 5th session: 2 × 20’). Light gymnastics included breathing techniques and chair coordination exercises.	GC without preoperative training or additional information. Usual care provided by the patient's general practitioner. IG and GC participated in a 3-week post-cardiac rehabilitation program operative.	Baseline (T1), 1 day before surgery (T2), onset (T3) and end of cardiac rehabilitation (T4): cardiopulmonary exercise test, 6 'walk test (6MWT), timed - Up-and-Go (TUG) and QoL test (MacNew questionnaire ).	171 patients (IG, n = 81; CG, n = 90) completed the study. Preoperative FC (6MWTIG: 443.0 ± 80.1 m to 493.5 ± 75.5 m, P = 0.003; TUGIG: 6.9 ± 2.0 s to 6.1 ± 1.8 s, P = 0.018) and QoL (IG: 5.1 ± 0.9 to 5.4 ± 0.9, P & lt ; 0.001) improved significantly more in the IG than in the CG. In addition to postoperative also in FC (6MWDIG: Δ-64.7 m, pT1 - T3 = 0.013; Δ + 47.2 m , pT1 - T4 & lt; 0.001; TUGIG: Δ + 1.4 s, pT1 - T3 = 0.003).
Windmoller et al. ¹⁶16. Windmöller P, Bodnar ET, Casagrande J, Dallazen F, Schneider J, Berwanger SA, et al. Physical Exercise Combined with CPAP in Subjects who Underwent Surgical Myocardial Revascularization: A Randomized Clinical Trial. Respir Care. 2020;65(2):150-7. doi: 10.4187/respcare.06919. https://doi.org/10.4187/respcare.06919.... 2020	RCT	6/10	n = 31 (40-75 years). GI = 15 GC = 16	Exercise bike + PEPPA (10cmH2O pressure), session single daily in 2POD (maximum length 20’), and 3POD 4POD (maximum 30’ each). Intensity estimated at up to 30 bpm of HRR; SpO2 up to 90% without oxygen therapy; and MBS between mild and moderate.	7 steps immediately for each POD gradually, with exercises between MI and MS. Evolution of positions: 1^st POD lying down; 2^nd POD sitting; 3^rd POD to the 7^th POD ambulation (between 35 and 200m). Stretches: 2^nd POD (passive); 3^rd POD to 7^th POD (active). Up and down stairs: 4^th POD and 7^th POD (between 1 and 3 levels). Breathing exercises and flow stimulation: between 1^st POD and 7^th POD.	FC (6MWT); respiratory muscle strength and 1 ' test to get up and sit down; length of ICU stay.	FC ↓ in both groups, but IG was not significant (P = . 11); respiratory muscle strength and 1 'stand up and sit ↓ test on both the groups. Hospitalization time was ↓ in the IG (P = 0.50).

Author	1	2	4	3	5	6	7	8	9	10	11	Score 0/10
Hirschhorn et al. ¹¹11. Hirschhorn AD, Richards DA, Mungovan SF, Morris NR, Adams L. Does the Mode of Exercise Influence Recovery of Functional Capacity in the Early Postoperative Period after Coronary Artery Bypass Graft Surgery? A Randomized Controlled Trial. Interact Cardiovasc Thorac Surg. 2012;15(6):995-1003. doi: 10.1093/icvts/ivs403. https://doi.org/10.1093/icvts/ivs403.... 2012	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	9
Turky et al. ¹²12. Turky K, Afify AMA. Effect of Preoperative Inspiratory Muscle Training on Alveolar-Arterial Oxygen Gradients after Coronary Artery Bypass Surgery. J Cardiopulm Rehabil Prev. 2017;37(4):290-4. doi: 10.1097/HCR.0000000000000234. https://doi.org/10.1097/HCR.000000000000... 2017	Yes	Yes	Yes	Yes	No	No	No	No	No	Yes	Yes	5
Moradian et al. ¹⁰10. Moradian ST, Najafloo M, Mahmoudi H, Ghiasi MS. Early Mobilization Reduces the Atelectasis and Pleural Effusion in Patients Undergoing Coronary Artery Bypass Graft Surgery: A Randomized Clinical Trial. J Vasc Nurs. 2017;35(3):141-5. doi: 10.1016/j.jvn.2017.02.001. https://doi.org/10.1016/j.jvn.2017.02.00... 2017	Yes	Yes	Yes	Yes	No	No	No	No	Yes	Yes	Yes	6
Zanini et al. ¹³13. Zanini M, Nery RM, Lima JB, Buhler RP, Silveira AD, Stein R. Effects of Different Rehabilitation Protocols in Inpatient Cardiac Rehabilitation after Coronary Artery Bypass Graft Surgery: A Randomized Clinical Trial. J Cardiopulm Rehabil Prev. 2019;39(6):E19-E25. doi: 10.1097/HCR.0000000000000431. https://doi.org/10.1097/HCR.000000000000... 2019	Yes	Yes	Yes	Yes	No	No	Yes	Yes	No	Yes	Yes	7
Cui *et al.* ¹⁴14. Cui Z, Li N, Gao C, Fan Y, Zhuang X, Liu J, et al. Precision Implementation of Early Ambulation in Elderly Patients Undergoing Off-Pump Coronary Artery Bypass Graft Surgery: A Randomized-Controlled Clinical Trial. BMC Geriatr. 2020;20(1):404. doi: 10.1186/s12877-020-01823-1. https://doi.org/10.1186/s12877-020-01823... *2020*	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes	Yes	8
Windmoller et al. ¹⁶16. Windmöller P, Bodnar ET, Casagrande J, Dallazen F, Schneider J, Berwanger SA, et al. Physical Exercise Combined with CPAP in Subjects who Underwent Surgical Myocardial Revascularization: A Randomized Clinical Trial. Respir Care. 2020;65(2):150-7. doi: 10.4187/respcare.06919. https://doi.org/10.4187/respcare.06919.... 2020	No	Yes	Yes	Yes	No	No	Yes	No	No	Yes	Yes	6
Steinmetz et al. ¹⁵15. Steinmetz C, Bjarnason-Wehrens B, Baumgarten H, Walther T, Mengden T, Walther C. Prehabilitation in Patients Awaiting Elective Coronary Artery Bypass Graft Surgery - Effects on Functional Capacity and Quality of Life: A Randomized Controlled Trial. Clin Rehabil. 2020;34(10):1256-67. doi: 10.1177/0269215520933950. https://doi.org/10.1177/0269215520933950... 2020	Yes	Yes	Yes	Yes	No	No	No	Yes	No	Yes	Yes	6

Sociedade Brasileira de Cardiologia Avenida Marechal Câmara, 160, sala: 330, Centro, CEP: 20020-907, (21) 3478-2700 - Rio de Janeiro - RJ - Brazil
E-mail: revistaijcs@cardiol.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Mailing Address: Rodrigo de Freitas Fontes Centro Universitário Social da Bahia. Av. Oceânica, 2717. Postal code: 40170-010. Ondina, Salvador, BA – Brazil E-mail: rodrigodefreitasfontes@gmail.com