Preoperative Physical Therapy in the Elective Cardiac Surgery Patient: Good Move

In 2010, approximately 7.5 million American underwent 7,588,000 inpatient cardiovascular operations and procedures, an increase of 28% over the year 2000. Overall postoperative mortality has fallen, which is good news. Evidence indicates that risk of pulmonary complications increases morbidity and mortality. Most surgeons refer patients for postoperative physical rehabilitation, but little evidence prompts them to start physical therapy before surgery. An article in the February 2015 issue of Physical Therapy looked at employing physical therapy earlier to prevent complications.

A 2011 Cochrane concluded that current evidence was incomplete for different risk groups (low versus high risk of pulmonary complications) or different types of physical therapy with an exercise component. The authors noted that regardless, it was clear that preoperative physical therapy reduced atelectasis, pneumonia and postoperative length of stay (LOS) for patients undergoing elective cardiac surgery. They reported that postoperative pneumothorax, prolonged (>48 hours) mechanical ventilation, and all-cause mortality did not seem to be affected by preoperative physical therapy.

The authors revisited the Cochrane review and looked at additional information from other studies. They conclude that:

• A pre-rehabilitation program employing multiple interventions may reduce postoperative pulmonary complications and shorten LOS for patients awaiting cardiac surgery.
• A reasonable care plan should include aerobic and functional training with and individualized exercise prescription (eg, exercise intensity of 40%-70% of heart rate reserve with a target duration of 30 minutes).
• Although physical therapists often ignore inspiratory muscle training (IMT), evidence supports including therapeutic exercises (eg, breathing retraining and strength or endurance IMT) in the care plan.

Patients with known cardiac and pulmonary diseases can safely perform these interventions.

The authors suggest additional research on prerehabilitation programs and IMT. Studies might focus on identifying patients who are appropriate candidates, exploring interventions necessary for an optimal plan of care, clarifying the optimal IMT prescription, and identifying the optimal setting (ie, outpatient versus home care). They indicate that prerehabilitation programs offer significant promise for improving outcomes for patients after elective CABG.