Accepted Manuscript

Title: Effects of early mobilisation in patients after cardiac

surgery: a systematic review

Author: P.M. Ramos dos Santos N. Aquaroni Ricci É.

Aparecida Bordignon Suster D. de Moraes Paisani L. Dias
Chiavegato

PII: S0031-9406(16)30060-8
DOI: http://dx.doi.org/doi:10.1016/j.physio.2016.08.003
Reference: PHYST 931

To appear in: Physiotherapy

Please cite this article as: Ramos dos Santos PM, Aquaroni Ricci N, Aparecida
Bordignon Suster É, de Moraes Paisani D, Dias Chiavegato L.Effects of early
mobilisation in patients after cardiac surgery: a systematic review.Physiotherapy
http://dx.doi.org/10.1016/j.physio.2016.08.003

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Effects of early mobilisation in patients after cardiac surgery:

a systematic review

P.M. Ramos dos Santosa, N. Aquaroni Riccia, É. Aparecida Bordignon Sustera, D.

de Moraes Paisanib, L. Dias Chiavegatoa,c,*

a
Masters and Doctoral Programmes in Physical Therapy, Universidade Cidade de São Paulo,

São Paulo, Brazil

b
Research Institute, Hospital do Coração, São Paulo, Brazil
c
Pulmonary Division, Universidade Federal de São Paulo, São Paulo, Brazil

*
Corresponding author. Address: Masters and Doctoral Programmes in Physical Therapy, Universidade

Cidade de São Paulo, Rua Cesário Galeno, 448/475, Zip Code 03071-000, Tatuapé, São Paulo, SP,

Brazil. Tel.: +55 11 2178-1565

E-mail address: lu_chiavegato@uol.com.br (L. Dias Chiavegato).

Abstract

Background Early mobilisation is prescribed after cardiac surgery to prevent

postoperative complications, decrease length of hospital stay, and augment return to

daily activities.

Objective To evaluate the evidence for the effects of early mobilisation in patients after

cardiac surgery on length of hospital stay, functional capacity and postoperative

complications.

Data sources The data sources used were Medline, Embase, CINAHL, PEDro, Web of

Science and Cochrane Central Register of Controlled Trials.

Study selection Randomised controlled trials of early mobilisation after cardiac

surgery. Study selection was not restricted by language or publication time.

Study appraisal and synthesis methods The methodological quality of each article

was appraised with the PEDro scale. All review phases (selection, data extraction and

appraisal) were conducted by two investigators, and a third investigator provided

consensus.

Results Nine trials were selected. The PEDro scale showed that the studies had a low

risk of bias (range 5 to 9 points). The trials revealed diversity in techniques used for

mobilisation, as well as periods considered early for the start of the intervention. Early

mobilisation groups had improved outcomes compared with control groups without

treatment. Generally, these advantages did not differ when groups of interventions were

compared.

Limitations It was not possible to perform a meta-analysis due to the variability of the

interventions proposed as early mobilisation.

Conclusions Regardless of the techniques used as mobilisation, the essential point is to

avoid bed rest. Early mobilisation seems to be important to prevent postoperative

2
complications, improve functional capacity and reduce length of hospital stay in

patients after cardiac surgery.

Keywords: Cardiac surgery; Postoperative complications; Randomised control trials;

Early mobilisation

3
<A>Introduction

Cardiovascular diseases rank among the main causes of mortality and hospital

admission [1]. Cardiac surgery stands out from other forms of treatment due to the

advances in techniques and materials that have resulted in safer procedures and lower

perioperative risks [2]. Despite these advances, postoperative complications are

frequent, and are a determinant of length of hospital stay and functional recovery [3]. In

one study, of 204 patients undergoing cardiac diseases, 58% had postoperative

complications, mainly pulmonary (31%), cardiac (15.8%) and neurological (13.9%) [3].

Prolonged bed rest is a well-established contributor to postoperative complications [4].

Bed rest after surgery contributes to dysfunction of multiple organ systems.

Immobility impairs oxygen transport including lung and tissue oxygenation; increases

risk of deep vein thrombosis and pulmonary thromboembolism; and contributes to loss

of muscle mass and strength [5]. Despite its deleterious effects, bed rest after surgery

has been prescribed [4]. For patients undergoing cardiac surgery, mobility restriction

has been indicated to reduce cardiac overload [6–9]. In contrast, recent studies have

emphasised the importance of early mobilisation for enhancing oxygen transport and

functional return, and reducing postoperative complications and length of hospital stay

[4,7,10–13].

Early mobilisation following surgery has multiple benefits including improved

ventilation, ventilation/perfusion matching, muscle strength and functional capacity

[10,14]. A recent systematic review of early mobilisation in intensive care units (ICUs)

analysed 15 randomised clinical trials, and found that early mobilisation is feasible, safe

and has a positive effect on the functional capacity of patients who are critically ill [15].

Another systematic review showed that breathing exercises alone are not sufficient to

prevent postoperative complications in patients after cardiac surgery [16].

4
 Although early mobilisation is prescribed for patients after cardiac surgery, no

consensus exists regarding the best types of mobilisation and their optimal intensities

and durations [17]. Thus, the purpose of this study was to review randomised controlled

trials (RCTs) with respect to elements of early mobilisation in patients after cardiac

surgery, and their effects specifically on postoperative complications, functional return

and length of hospital stay.

<A>Methods

<B>Selection and type of study

This systematic review was designed in accordance with the PRISMA statement

[18].

To identify relevant studies for inclusion in the review, the following electronic

databases were searched: Medline, Embase, CINAHL, PEDro, Web of Science and

Cochrane Central Register of Controlled Trials. Searches were conducted between 5 and

17 July 2014, and an update was performed between 1 and 7 December 2015, with no

restrictions in terms of language or date of publication. Four blocks of themes were used

with the keywords ‘cardiac surgery’, ‘early mobilisation’, ‘postoperative’ and

‘randomised control trials’, with their respective synonyms and derivations. In each

block, the words were combined using the Boolean operator OR, and between blocks,

the operator AND. Additional File 1 (see online supplementary material) shows the

search strategy conducted in the Web of Science database. Additionally, a manual

search was undertaken of the references of preselected papers, clinical trial registers,

and investigators who had published extensively in the area.

RCTs were included if the main intervention was early mobilisation of patients

(aged >18 years) who had undergone open cardiac surgery. Early mobilisation was

5
defined a priori as any movement and/or exercise administered within 72 h of surgery.

The experimental group could be compared with a control group that received another

intervention or no treatment. The exclusion criteria were: studies that included patients

after emergency surgery, heart transplants, interventions referred to as ‘early

mobilisation’ but which only focused on chest physiotherapy, including breathing

exercises; and outcomes limited to haemodynamic assessment or respiratory function.

Based on the criteria, two independent investigators assessed the titles and

abstracts of the studies from the search for preselection. The preselected studies were

fully analysed with regard to the eligibility criteria. In case of disagreement between the

investigators, a third investigator provided consensus.

<B>Outcomes evaluated

In this systematic review, the primary outcomes evaluated were postoperative

complications, functional capacity and length of hospital stay. The secondary outcomes

were haemodynamic variables, respiratory function, quality of life, patient satisfaction,

and intervention time and cost.

<B>Data extraction and study assessment

Data from the selected articles were extracted by two investigators using a

structured form with information related to study design, sample characteristics,

outcomes, date of assessment, intervention, definition of early mobilisation, and

results/effects of intervention.

The methodological quality of the studies was assessed using the PEDro scale;

an 11-item scale with a maximum score of 10 [19]. The higher the score, the better the

methodological quality of the study. The first item is not used to calculate the total

6
score. The PEDro database provides the study scores on its website

(www.pedro.org.au). The studies that had not been rated by the PEDro database were

analysed by two investigators. Disagreements were resolved by a third investigator.

The comparison between studies was conducted by means of critical analysis of

their content. It was not possible to conduct a meta-analysis due to the variability of the

interventions used as early mobilisation.

<A>Results

Fig. A (see online supplementary material) shows the flow diagram of the study

selection process. The initial search identified 2857 studies. Twenty-one studies were

selected to be read in full. Of these, 12 studies did not meet the inclusion criteria for this

review (Additional File 2, see online supplementary material). As such, nine studies

[2,13,20–26] were included in this systematic review and their content was analysed

(Table 1).

<insert Table 1 near here>

<B>Sample characteristics

The sample sizes of the selected studies ranged from 56 [21] to 309 [13] patients

(1419 total) allocated randomly to the early mobilisation or control group. Subjects

were predominantly men [2,13,20–24] and ranged in age from 49 [23] to 68 [26] years.

Most studies (n=5) included patients that had undergone coronary artery bypass graft

surgery [2,13,20,21,23], one study included patients who had undergone valve

replacement or repair (aortic, mitral or tricuspid) [26], and the remaining studies

included patients who had undergone a combination of surgeries [22,24,25].

7
<B>Definition of early mobilisation and intervention

Only two studies [23,26], from the same researchers, provided a clear definition

of early mobilisation, i.e. ‘the gradual increase of activity starting on the first

postoperative day until independent ambulation on the fifth postoperative day’. The

remaining studies [2,13,20–22,24,25] did not provide a specific definition for early

mobilisation.

The randomised clinical trials compared an early mobilisation group with a

control group that received no intervention [21,24] or another treatment

[2,13,20,22,23,25,26]. Most studies (n=7) [2,20–23,25,26] included patient education as

part of the intervention. On the first postoperative day, interventions included body

positioning [24], sitting over the edge of the bed [2,13,20,22,25], passive mobilisation

[21], active upper and lower limb exercises [13,20] and ambulation [20]. Cacau et al.

[25] introduced exercises with virtual reality in the experimental group. Six studies

[2,20–22,24,25] added breathing exercises such as incentive spirometry [2,20,23], deep

breathing techniques [2,20,22,24,25] and intermittent positive pressure [21].

Among the studies that compared active treatment protocols, the interventions

differed in terms of exercise technique [2,20,22,23,25,26] and therapy intensity

[13,23,26]. Four studies [2,22,23,26] added various breathing exercises to the early

mobilisation. van der Peijl et al. [13] examined treatment frequency, and Cacau et al.

[25] and Hirschornn et al. [20] compared the effects of various musculoskeletal

approaches.

Timing of the initiation of early mobilisation varied between studies.

Mobilisation was initiated during the period of intubation [24], post extubation [21], on

the first postoperative day [2,13,20,22,25] and up to 48 h [23] or 72 h post extubation

[26].

8
<B>Outcome measures

Length of hospital stay was the only outcome measure evaluated in all studies

[2,13,20–26]. Other outcomes included functional capacity {measured by the Functional

Independence Measure (FIM) [13,25] and the 6-minute walk test (6MWT) [2,20,21,25]}

and postoperative complications (atelectasis, pneumonia, pleural effusion and atrial

flutter [2,21–23,26]).

The secondary outcomes evaluated were: lung function [forced vital capacity

(FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF)]

[2,21,22,26], quality of life (Short Form 36 [2,20], Nottingham Health Profile [25]),

patient satisfaction [13], and the time and cost of the intervention [22–24].

The outcomes were assessed pre-operatively [2,20,21,25], on the first

postoperative day [13,22,23,26], at discharge [2,13,20,21,23–26] and at follow-up

[2,13,20]. The endpoints evaluated at follow-up were patient satisfaction after 3 weeks

[13], vital capacity, quality of life at 4 weeks [2] and mortality at 6 months [20].

<B>Methodological quality

Regarding methodological quality, five [2,20,22–24] of the nine studies scored

≥6 on the PEDro scale (Table A, see online supplementary material). The main

limitation of these studies [2,20,22–24] was blinding of patients and therapists. In

studies with scores <6 [13,21,25,26], the main methodological biases were absence of

concealed allocation [13,21,25,26], blinding of therapists and patients [13,21,25,26],

and intention-to-treat analysis [13,25,26].

<B>Effects of early mobilisation

9
 The average length of hospital stay ranged from 5.9 [21] to 12.2 [25] days, and

the average length of ICU stay ranged from 1.5 [24] to 2.3 [26] days. Between-group

comparisons of length of hospital and ICU stay are shown in Table 2.

<insert Table 2 near here>

<B>Early mobilisation group vs control group without intervention

Two studies [21,24] compared the effects of early mobilisation with a control

group without intervention. Patman et al. [24] did not find any difference between the

intervention and control groups in any of the outcomes measured. In contrast, Herdy et

al. [21] found favourable results for the early mobilisation group compared with the

control group without intervention with regard to extubation time, incidence of

postoperative complications, functional capacity according to the 6MWT and length of

hospital stay.

<B>Comparison between groups with interventions

Among the seven studies [2,13,20,22,23,25,26] that compared different

interventions, only two [23,25] found a shorter hospital stay in one of the active groups

(control groups that received any treatment). In the study by Johnson et al. [23], this

result may have been influenced by group allocation according to atelectasis, which

would explain the longer hospital stays of the more severe cases. Cacau et al. [25]

verified a shorter hospital stay for the group receiving early mobilisation by virtual

reality compared with the control group. Length of ICU stay was assessed in two studies

[23,26]. Only the study by Johnson et al. [23], which divided the groups by severity of

atelectasis, showed differences in the lengths of ICU and hospital stay. The groups with

10
extensive atelectasis had longer stays than the groups with minimal atelectasis. Both

studies [13,25] that assessed functional capacity using the FIM found no significant

difference between interventions. Among those that assessed functional capacity using

the 6MWT [2,20,21,25], only the study by Hirschornn et al. [20] did not find a

difference between treatments when comparing the cycle ergometer group and the

ambulation group.

Among the four studies [2,22,25,26] that assessed postoperative

complications, none reported differences between the intervention groups. The only

study [20] that evaluated mortality did not verify the difference in mortality rate 6

months after surgery between active groups.

With respect to secondary outcomes, no differences were found between the

groups for pulmonary function [2,22,26] and quality of life [2,20,25]. Johnson et al.

[23,26] showed greater time and cost of physical therapy in the groups with a high-

intensity exercise load compared with the groups with a low-intensity exercise load. van

der Peijl et al. [13] verified that patients who received physical therapy more frequently

were more satisfied than those who received physical therapy less frequently.

<A>Discussion

This review found that, despite growing interest in the use of early mobilisation

in the hospital setting, there remains a lack of evidence on this topic in patients who

have undergone open cardiac surgery. The absence of a definition, the variety of

physiotherapeutic techniques, and the different starting points for the intervention

described in the studies show that ‘early mobilisation’ is a complex intervention.

According to the results of this systematic review, early mobilisation is beneficial in

patients after cardiac surgery compared with bed rest. Nevertheless, when different

11
techniques and periods of mobilisation are compared, there is no evidence for an

optimal prescription. It seems that the essential element for patient recovery after

cardiac surgery is not the type of early mobilisation, but the best intervention starting at

the best time according to the patient’s condition to prevent the harmful effects of bed

rest [27].

The characteristics of the study samples included in this review were consistent

with heart disease and related surgery being predominant in older men [28–30]. With

age, the cardiovascular system undergoes structural and functional modifications, and

combined with factors such as smoking, physical inactivity and obesity, these

modifications can lead to cardiovascular events [30].

The lack of consensus regarding the definition and use of the term ‘early

mobilisation’ has been described in the literature [31–33], and corroborates with the

findings of this review. The meaning of ‘early’, when applied for the beginning of

mobilisation in hospital, can vary according to the surgical procedure and the type of

pathology. In a systematic review of the effects of early mobilisation in patients after

hip or knee replacement, the investigators reported positive results when mobilisation

had occurred within 24 hours of surgery [33]. However, no consensus was found among

stroke care professionals with regard to the ideal time to begin mobilisation [31].

Although 40% of professionals believed that mobilisation should begin within 24 hours

of stroke onset, 41% considered it safer and more appropriate to begin the intervention

after 24 hours [31]. A systematic review on brief vs prolonged bed rest after acute

myocardial infarction without complications concluded that there is no evidence to

support bed rest lasting more than 2 days [27]. In the present systematic review, the

studies also differed in terms of the ideal time to begin mobilisation, which varied from

12
intubation until 72 hours post extubation. It is essential to identify the starting time to

avoid risk to the patient due to mobilisation being administered too early or too late [4].

In addition to the variety of start times, the term ‘mobilisation’ also encompasses

a range of therapies. In the ICU, early mobilisation is defined as ‘the application of

traditional modes of physical therapy at an earlier stage then delivered more regularly

than conventional practice and/or the early use of novel mobilisation techniques (for

example, cycle ergometer and transcutaneous electrical muscle stimulation)’ [32]. In

patients admitted to hospital, mobilisation is defined as ‘walking, standing, and sitting

on a chair with or without assistance’ [34] and ‘getting a patient out of bed (e.g. sitting

out of bed, toileting at bedside or to a bathroom, standing, and ambulation)’ [35]. In the

present review, mobilisation varied from bed positioning [22,24] to unassisted walking,

[23,26] as well as more sophisticated technologies, i.e. virtual reality [25]. Therefore,

early mobilisation constitutes a continuum of care and multiple therapy techniques.

However, the similar results of the studies that compared active treatments with

different complexities or intensities (as in the case of assisted walking vs cycle

ergometer [20]) suggest that traditional mobilisation is just as effective as sophisticated

interventions. Therefore, traditional mobilisation should be implemented during hospital

stay because it is inexpensive, easy to perform and does not require equipment.

Breathing exercises were the most commonly performed element of the early

mobilisation protocols. From 18 Canadian hospitals, 89% used respiratory techniques

for patients after cardiac surgery on the first postoperative day, with deep breathing and

coughing as the most common exercises [36]. In this review, only one [13] of the nine

trials did not include breathing exercises. Anaesthesia, type of surgery, surgical trauma

and the patient’s pre-existing health problems contribute to reduced lung volume and

compliance, decreased effectiveness of cough, and respiratory muscle fatigue [37].

13
These changes in pulmonary function can lead to complications, such as atelectasis,

which are commonly treated and prevented with various chest physiotherapy techniques

[37]. However, there is no evidence that one respiratory intervention is superior to

another [37,38], and no scientific evidence to support the effectiveness of these

exercises [16,39]. Studies with patients after cardiac [22,40] and abdominal [41]

surgeries did not report additional benefits from the use of respiratory techniques

combined with mobilisation compared with mobilisation alone. These results are similar

to those found in the present review, in that none of the trials reported significant

benefits with the additional use of breathing exercises [2,13,20–26]. Therefore,

mobilisation alone at moderate intensity is sufficient to stimulate the respiratory system

by increasing ventilation, while the breathing exercises alone do not impose a sufficient

load for patients without risk of cardiopulmonary complications [41,42].

Most studies in this review included patient education in their interventions

[2,13,20,22–24]. In hospital, the education of patients after cardiac surgery includes

orientations of breathing exercises, pain management, postoperative precautions and

treatment progress [36]. The amount of supervised therapy at hospital is limited, and

aside from the therapy period, most patients do not undertake any activities [39]. A

study of hospitalised elderly patients reported that patients spent, on average, 83.3% of

their time lying in bed, 12.9% of the time seated, and 3.8% of the time walking [43].

Therefore, instructions regarding movements and activities that can be performed safely

and without therapist assistance are crucial to accelerating the process of postoperative

rehabilitation and reducing the cost of hospital stay [44].

Finally, another important factor regarding early mobilisation is intensity, i.e. the

number of sessions per day, the duration of physical therapy, and the exercise load. In

the present review, the trials that compared groups with different intensity [13,23,26]

14
did not report any differences for the primary outcomes. Thus, low-frequency exercises

can be sufficiently beneficial in patients who are not at risk for complications, while

also reducing time and costs by allowing the therapist to focus on more debilitated

patients [26].

Prolonged hospital stay after surgery predisposes patients to clinical

complications and increases medical costs [45]. Therefore, it is understandable that the

length of hospital stay is the most frequently used outcome to assess the effectiveness of

early mobilisation in patients following cardiac surgery. In this review, most trials

reported an average hospital stay of 8 days. An analysis of the medical records of

496,797 patients who underwent coronary artery bypass graft surgery revealed that 53%

had early discharge (i.e. within 5 days of surgery) and 5% had prolonged hospital stay

(i.e. >14 days) [46]. Hence, the studies included in this review corroborate with the

statistics of length of hospital stay for patients following cardiac surgery. One of the

factors that could delay hospital discharge is the occurrence of postoperative

complications. In this review, only the trial that compared mobilisation with no

treatment [21] found a significant reduction in postoperative complications in the

intervention group, which indicated that early mobilisation is an option to help prevent

complications in patients following cardiac surgery. The advances in cardiac surgery

techniques and the pre-operative screening/risk assessment can contribute to the

reduction of these complications [44,47]. In spite of this, therapists must keep in mind

that pre-operative preparation and the patient’s previous clinical conditions are of

fundamental importance to prognosis, hospital discharge and occurrence of

complications [48].

The main objectives of physiotherapy with early mobilisation are prevention of

deconditioning, promotion of independence in daily activities, and return to work

15
[17,49,50]. These outcomes should be included more often in the assessment protocol of

trials in order to verify the effects of early mobilisation [31]. In the present review, the

studies assessed functional capacity using the 6MWT [13,25] and the FIM [2,20,21,25].

However, the results of this review show that, in the short term, early mobilisation does

not promote significant changes in functional capacity. Therefore, other outcomes, such

as muscle strength and level of assistance, can be more relevant in assessments during

hospital stay [32].

The trials included in this review had satisfactory methodological quality

according to the PEDro scale. However, all studies had limitations related to blinding

criteria. It is difficult to blind therapists and/or patients in interventions involving

exercises. Therefore, it is common in rehabilitation research that these criteria have the

lowest PEDro score [51]. Despite the high scores on the PEDro scale, the lack of sample

size calculation as well as a clear definition of the control group may result in a low

quality of evidence overall.

The lack of homogeneity between early mobilisation protocols precluded the

meta-analysis. The absence of a meta-analysis hinders an effective conclusion regarding

the evidence of this therapy in patients after cardiac surgery, and could be a limitation of

this review. However, the lack of homogeneity regarding early mobilisation

interventions shows that a unique protocol in acute care settings (e.g. hospital) may not

be appropriate, as seen in RCTs conducted in more controlled settings (e.g. clinic). The

intervention under study in an acute care setting is affected by many variables such as

patient status (which changes rapidly), different professionals involved in treatment,

other interventions needed, and resources available.

The trials included in this review were published between 1995 and 2013.

Thus, even after 20 years, this topic remains current and has not been fully elucidated,

16
and research is still required to determine the most adequate dose, frequency and

optimal timing to begin intervention. The ordinary RCT design can be restricted to

examine a complex intervention such as early mobilisation. Therefore, qualitative

studies and process evaluation design could add more information regarding

organisation barriers to early mobilisation implementation, patient satisfaction and

difficulties with treatment, patient progress within the early mobilisation spectrum of

techniques, and hospital staff knowledge of when and how to use early mobilisation.

<A>Conclusion

The trials revealed diversity in techniques used as mobilisation, as well as the

period considered ‘early’. This review concluded that early mobilisation was beneficial

in terms of length of hospital stay, functional capacity and prevention of postoperative

complications compared with no treatment [21,24]; and found no difference between

traditional therapies [2,20,22,23,25] and less-intensity exercise load [13,23,26].

Ethical approval: None required.

Conflict of interest: None declared.

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23
 Table 1

Data summary of randomised clinical trials using early mobilisation for patients after
cardiac surgery

Early
Study Sample mobilization Outcomes Intervention Results
definition
Johnson et Surgery: Study defines 1) Pneumonia IG1: Education, - Chest x-ray
al. [23] CABG in all early incidence early mobilisation atelectasis scores
groups. mobilisation 2) Length of (graded increases did not improve
as a gradual hospital stay in activity over a significantly from
n=251 increase in 3) Length of 5-day period until extubation to
(sample activity ICU stay independent hospital discharge.
loss=27) beginning on 3) Respiratory unassisted
the first PO function ambulation) and - Length of hospital
IG1, IG2: day over 5 4) Personal deep breathing stay and ICU stay
minimal days, until costs (five deep breaths were higher in IG3
atelectasis independent 5) Presence of hourly). and IG4 compared
IG1: n=48 unassisted atelectasis with IG1 and IG2.
60 ± 10 years ambulation is 6) Pain IG2: IG2 training
IG2: n=49 achieved. was the same as - No differences in
64 ± 11 years Date of IG1 with the the incidence of
assessment: addition of pneumonia, pain
IG3, IG4: - Pre-operative sustained maximal and respiratory
extensive day inspirations function between
atelectasis - Daily (series of stacked groups.
IG3: n=64 evaluation after inhalations from
66 ± 8 years surgery until 5th FRC to TLC with - Physical therapy
IG4=n=63 PO day a 5-second breath time and costs were
64 ± 11 years - Discharge hold at TLC for a superior for IG4
from hospital total of five compared with
repetitions). The IG1, IG2 and IG3.
manoeuvres were
performed hourly
in supine, upright
and lateral
positions.

IG3: IG3 training

was the same as
IG2.

IG4: IG4 training

was the same as
IG3 with the
addition of single-
handed percussion
(administration of
cupped-hand
percussions to the
chest wall, applied
at a frequency of 1
to 2 seconds and
given at TLC
during a complete
sustained maximal

24
 inspiration
manoeuvre).

IG1, IG2, IG3,

IG4: pre-operative
education.
Intervention
started on the 1st
PO day -
extubated within
48 hours.
IG4: 3x/day.
Johnson et Surgery: Study defines 1) Extent of Intervention - Length of ICU
al. [26] cardiac valve early atelectasis received by both stay and the length
surgery mobilisation 2) Pulmonary groups: pre- of hospital stay did
(mitral valve as a gradual function (FVC, operative not differ between
replacement, increase in FEV1, MIP, education, early groups.
aortic valve activity MEP) mobilisation
replacement, beginning on 3) (active movement - Values of
mitral valve the first PO Complications – upper extremity pulmonary function
repair, aortic day over 5 4) Pain flexion, extension were reduced to a
and both days, until 5) Hand grip exercises, and similar extent in
valves). independent strength dangling legs over both groups.
unassisted 6) Length of the side of the
n=78 ambulation is ICU stay bed) and deep- - At discharge,
(sample achieved. 7) Length of breathing atelectasis scores
loss=3) hospital stay exercise. and improvement
8) Personal in chest
IG1: n=41 costs IG1 (lower- radiographs were
63 ± 12 years intensity treatment similar between
*statistically Date of regimen): groups.
younger than assessment: conventional
IG2 - Pre-operative therapy with the - IG1 reported
day addition of slightly more pain
IG2: n=34 - Daily sustained maximal than IG2 (P<0.05).
68 ± 10 years evaluation after inspiration
surgery until 5th manoeuvres - There were no
PO day (series of stacked differences in hand
- Discharge inhalations from grip and PO
from hospital FRC to TLC with complications
5-second breath between groups.
hold at TLC for a
total of five - IG2 received
repetitions). The more treatment
manoeuvres were from the physical
performed hourly therapist and had
in supine, upright higher treatment
and lateral costs (P<0.05) than
positions. IG1.

IG2 (higher-
intensity treatment
regimen): IG2
training was the
same as IG1 with
the addition of
single-handed
percussion
(administrationof
cupped-hand

25
 percussions to the
chest wall, applied
at a frequency of 1
to 2 seconds and
given at TLC
during a complete
sustained maximal
inspiration
manoeuvre).

IG1, IG2: pre-

operative
education.
Intervention
started on the 1st
PO day -
extubated within
72 hours.
IG2: 2x/day.
Patmam et Surgery: No specific 1) Length of CG: no - No significant
al. [24] elective or definition of intubation period physiotherapy difference between
semi-urgent early 2) Length of intervention groups in level of
cardiac mobilisation. ICU stay during the physiotherapy
surgery 3) Length of PO intubation period. intervention.
(coronary hospital stay
artery surgery, 4) Incidence of IG: positioning, - There were no
aortic valve PO pulmonary manual differences
replacement, complications hyperinflation, between groups in
Bentall 5) Daily records endotracheal length of intubation
surgery, of maximal suctioning, (hours), length of
mitral valve incentive thoracic exercises ICU stay and PO
replacement spirometry and upper limb hospital stay.
or values exercises during
combination). the intubation - There was no
Date of period. difference between
n=236 assessment: groups in the
- Daily After extubation, incidence of PO
CG: n=128 evaluation until there is no pulmonary
(sample discharge difference complications.
loss=19) between groups
63.9 ± 14.4 regarding - No differences
years physiotherapy were found
treatment. between groups for
IG: n=108 *Incentive daily maximal
(sample loss spirometry was incentive
=7) only performed spirometry values.
62.8 ± 12.2 post extubation
years for all subjects. *Five patients in
the control group
IG: intervention received physical
started in the therapy after
immediate PO surgery, as
period. No prescribed by the
information on the medical staff, but
number of all the analyses are
sessions per day. reported on
intention-to-treat
basis.

Brasher et Surgery: open No specific 1) SpO2 Pre-operative - No significant

26
al. [22] heart surgery definition of 2) Pulmonary education for differences
with early complications both groups: between groups in
sternotomy mobilisation. 3) Length of effects of surgery, SpO2, pulmonary
incision hospital stay positions to complications,
(CABG, 4) Pulmonary improve lung pulmonary function
CAGS function tests function, tests and length of
without (FVC and supported cough hospital stay.
bypass, FEV1) and progression of
CABG + 5) Pain mobility. - There was a
valve (Monash Pre-operative significant increase
replacement, Medial Centre education for in SpO2 over time
valve acute pain CG: deep from surgery in
surgery). service breathing both groups.
observation exercises.
n=230 sheet) - The groups
6) CG: breathing presented a
CG: n=115 Physiotherapy exercise significant decrease
(sample treatment time treatment. in the verbal pain
loss=18) Training was the score over time
60.7 ±10.9 Date of same as the IG after surgery
years assessment: with breathing (P<0.001). No
-Two times on exercises (four significant
IG: n=115 the 1st and 2nd sets of five deep difference between
(sample PO day breaths from FRC groups in verbal
loss=14) - Once on the to TLC) in pain score.
63.3 ± 10.8 3rd PO day upright, sitting or
years flat side lying - Physiotherapy
positions. time was
IG: Position to significantly
improve lung different between
function, groups (P<0.001).
supported cough, The CG spent more
sit out of bed, time doing
ambulation physiotherapy than
(minimum 10 m the IG.
increasing to
minimum of 30
m).

CG, IG1: pre-

operative
education.
Intervention
started on the 1st
PO day.
2x/day.
van der Surgery: No specific 1) Functional CG (low- - IG achieved
Peijl et al. CABG in both definition of level: frequency functional
[13] groups. early - Ward treatment): CG milestones faster
mobilisation. walking; group training was the than CG
n=309 exercise same as the IG, (P=0.007).
therapy; and but with a lower
CG: n=143 climbing stairs. frequency of - No significant
(sample - FIM subscales sessions. differences
loss=31) (self-care, Intervention between groups in
62.0 ± 10.2 transfers, started on the first FIM subscale
years locomotion). weekday after scores.
- Amount of surgery.
IG: n=166 daily physical 1x/day not - No significant
(sample activity including differences

27
 loss=32) measured by weekends until between groups in
63.2 ± 10.2 portable discharge. length of hospital
years activity stay and extubation
monitor- IG (high- day.
Dynaport. frequency
2) Extubation treatment): - Satisfaction with
day active ROM and treatment was
3) Length of muscle strength superior in the IG
hospital stay exercises for (P=0.032).
4) Patient upper and lower
satisfaction extremities,
(self-developed coordination
questionnaire) exercises,
transferences,
Date of walking, and stair
assessment: climbing.
- Pre-operative Intensity increased
day from 1.0 MET
- Functional initially to a
level variables: maximum of 3.5
6th PO day MET at discharge.
- Patient Intervention
satisfaction: started on the 1st
within 3 weeks PO day,
after discharge regardless of the
day of the week.
2x/day including
weekends until
discharge.

Herdy et al. Surgery: No specific 1) Length of CG: no physical - The length of ICU
[21] CABG in all definition of ICU stay therapy treatment, stay was not altered
groups. early 2) Days on the unless prescribed significantly by
mobilisation. ward (after ICU by medical staff. rehabilitation.
n=56 until hospital
discharge) IG: pre-operative - There was a
CG: n=27 3) Time until exercise significant
58 ± 9 years orotracheal tube programme. reduction in the
removal Progressed from length of ward stay
IG: n=29 4) passive (P=0.01) and time
61 ± 10 years Complications: movements to of extubation
pneumonia with walking and (P=0.04) for the IG
the need for climbing two compared with the
antibiotic flights of stairs. CG.
treatment, atrial Additional
fibrillation or respiratory - The incidence of
flutter, pleural exercises all types of
effusion and (spirometer complications was
atelectasis. training and lower in the IG
5) Peak flow intermittent compared with the
6) 6MWT positive pressure CG.
breathing).
Date of Exercise starts - Both
assessment: with interventions groups
- Pre-operative that elicited presented
day energy significant
- Immediate PO expenditures of reduction
- After 2METS and in peak
orotracheal tube progressed to 4 flow after
removal METS. extubation

28
 - Discharge Intervention . At
from hospital started pre- discharge,
operatively (at peak flow
least 5 days) - values
paused for surgery returned
- continued after to baseline
extubation until values in
the day of hospital the IG, but
discharge. not in the
CG.

- Patients in the CG
showed a
significant decrease
in the distance
walked in the
6MWT at
discharge.
Hirschhorn Surgery: No specific 1) 6MWT IG1 (standard - IG2 and IG3 had
et al. [2] CABG in all definition of 2) Vital intervention): significantly higher
groups. early capacity education and 6MWT than IG1
mobilisation. 3) Quality of body positioning, (P=0.012). No
n=93 life (SF36) sitting out of bed, between-group
62.9±8.9 4) Length of walking increased differences were
years hospital stay by distance, ascent found for this test
5) Pulmonary and descent of at follow-up.
IG1: n=32 PO stairs.
(sample complications - All groups
loss=3) indicators. IG2 (walking presented
63.6 ± 8.5 exercise): IG2 improvement over
years Date of training was the time for vital
assessment: same as IG1 with capacity and SF36.
IG2: n=31 - Pre-operative walking exercise No significant
(sample day started on the spot differences
loss=1) - Discharge and increased by between
63.2 ± 10.8 from hospital distance, time and intervention groups
years - Follow-up: rating of for these tests.
approximately perceived
IG3: n=30 4 weeks after exertion. - No significant
(sample the day of between-group
loss=1) discharge. IG3 (walking and differences in
61.8 ± 7.2 breathing hospital stay.
years exercise): IG3
training was the - There were no
same as IG2 with significant
respiratory differences
exercises. Use of between
an incentive intervention groups
spirometer; and for any pulmonary
combined deep PO complications
breathing indicators.
exercises and
upper
limb/thoracic
spine range of
motion exercises.

IG1, IG2, IG3:

pre-operative
education.

29
 Intervention
started on the 1st
PO day.
2x/day.
Hirschhorn Surgery type: No specific 1) 6MWT Both groups: - No significant
et al. [20] CABG in all definition of 2) 6MCA - Pre-operative differences
groups. early 3) Quality of education. between
mobilisation. life (SF36) - 1st PO and 2nd intervention groups
n=64 5) Mortality PO day: sitting at hospital
65.6 ± 9.2 rate out of bed, discharge for
years 6) Length of walking increased 6MWT, 6MCA and
hospital stay by distance, SF36.
IG1: n=32 respiratory
(sample Date of techniques, - There was a
loss=2) assessment: shoulder and significant decrease
65.3 ± 9.8 - Pre-operative thoracic spine in both 6MWT and
years day ROM movements. 6MCA from pre-
- Discharge operative to
IG2: n=32 from hospital IG1 (stationary discharge for the
(sample - 6 months after cycling): whole sample.
loss=2) surgery to respiratory and
65.9 ± 8.7 assess mortality ROM exercises. - No significant
years rate Stationary cycling difference between
(10 minutes) groups in mortality
based on rating of rate.
perceived
exertion. - No significant
Ascent/descent of difference between
stairs. groups in hospital
stay.
IG2 (walking
exercise):
respiratory and
ROM exercises.
Walking (10
minutes) based on
rating of
perceived
exertion.
Ascent/descent of
stairs

IG1, IG2: same

intervention as the
1st PO day.
Different
protocols on the
3rd PO day.
2x/day.
Cacau et al. Surgery: No specific 1) Functional CG (conventional - After surgery,
[25] CABG and/or definition of capacity (FIM) physiotherapy): both groups
valve early 2) Quality of breathing presented a
replacement mobilisation. life (NHP) exercises, airway significant decrease
in both 3) Length of clearance in FIM score, with
groups. hospital stay techniques, this loss even
4) 6MWT metabolic greater in the CG.
n=102 exercises and No difference
Date of motor exercises between groups in
CG: n=55 assessment: (upper and lower FIM at discharge.
(sample - Pre-operative limbs), up and - There was a

30
 loss=25) day downstairs, significant decrease
52 ± 2.4 years - On the 1st and ambulation. in the NHP pain
3rd PO day score at third
IG: n=47 - Discharge IG (virtual reality assessment
(sample from hospital training): IG (P<0.05) and a
loss=17) training was the higher energy level
49 ± 2.6years same as the CG in the first
with the motor evaluation
exercise (P<0.05) for the IG
performed using compared with the
virtual reality. The CG.
exercises were - Both treatments
performed in proved effective in
accordance with optimising
energy recovery on
expenditure emotional reaction,
(MET). sleep, physical
abilities and social
CG, IG: interaction
intervention domains, evaluated
started on the 1st by NHP (P<0.05),
PO day. with no significant
2x/day. differences
between groups.
- Length of hospital
stay was
significantly
shorter (P<0.05) in
the IG compared
with the CG.
- At discharge, the
IG had a better
performance on the
6MWT than the
CG (P<0.05).
CABG, coronary artery bypass graft; CAGS, coronary artery surgery; CG, control group; FEV1, forced expiratory
volume in 1 second; FIM, functional independence measures; FRC, functional residual capacity; FVC, forced vital
capacity; ICU, intensive care unit; IG, intervention group; MEP, maximum expiratory pressure; MET, metabolic
equivalent; MIP, maximum inspiratory pressure; PO, postoperative; NPH, Nottingham Health Profile; ROM, range of
motion; SF36, Short Form 36 health survey; SpO2, oxygen saturation; TLC, total lung capacity; 6MWT, 6-minute walk
test; 6MCA, 6-minute cycle work.

31
 Length of hospital stay (days) Length of ICU stay (days)
Study
Mean (SD) Median (IQR) P-value Mean (SD) P-value

IG1 8 (1.5) P<0.05 2 (0.5)

P<0.05
Johnson et al. IG2 8 (1.6) between 2.1 (0.5) between IG1–
[23] IG1–IG2
IG3 9 (2.7) 2.3 (0.8) IG2 and IG3–
and IG3–
IG4
IG4 10 (8.5) IG4 2.3 (0.6)
Comparison between groups with different interventions

Johnson et al. IG1 8.3 (1.3) 2.3 (1.2)

NS
[26] IG2 8.3 (2.8) 2.1 (0.3)

Brasher et al. CG 8 (6.3)

NS
[22] IG 8.2 (8.7)

van der Peijl et CG 7 (3 to 18)

NS
al. [13] IG 7 (4 to 15)

IG1 7 (6 to 7)
Hirschhorn et al. NS
IG2 6 (6 to 8)
[2]
IG3 6.5 (6 to 7)

Hirschhorn et al. IG1 7.9 (1.7) 7 (7 to 8.5)

NS
[20] IG2 7.7 (2.7) 7 (7 to 8)

CG 12.2 (0.9)
Cacau et al. [25] P<0.05
IG 9.4 (0.5)
Early mobilisation

CG 9.6 (6.7) 1.5 (1.1)

vs control group

Patman et al. [24] NS NS

intervention

IG 9.2 (4.5) 1.8 (1.8)

without

CG 10.3 (4.6) 2.15 (0.84)

Herdy et al. [21] P=0.01 NS
IG 5.9 (1.1) 1.98 (0.44)
CG, control group; IG, intervention group; ICU, intensive care unit; IQR, interquartile range; NS, non-significant; SD,
standard deviation.

Table 2 Effects of early mobilization on length of hospital and intensive care unit stay of the
clinical trials included in the systematic review

32