Cardiac Rehabilitation
Effects of Different Rehabilitation Protocols in Inpatient
Cardiac Rehabilitation After Coronary Artery Bypass
Graft Surgery
A RANDOMIZED CLINICAL TRIAL
Maurice Zanini, ScD, PT; Rosane Maria Nery, ScD; Juliana Beust de Lima, MSc;
Raquel Petry Buhler, MSc, PT; Anderson Donelli da Silveira, MD, ScD; Ricardo Stein, MD, ScD
Purpose: Patients undergoing coronary artery bypass graft
(CABG) surgery typically experience loss of cardiopulmonary
capacity in the post-operative period. The purpose of this study
Downloaded from http://journals.lww.com/jcrjournal by BhDMf5ePHKbH4TTImqenVIu1/FN/J4kOClOdA6CVmrAeaIrtIQcl8AxBvmmmOYZf on 12/09/2019
was to evaluate the effects of different rehabilitation protocols
used in inpatient cardiac rehabilitation on functional capacity
and pulmonary function in patient status post-CABG surgery.
Methods:  This was a single-blind randomized controlled trial. The
primary endpoint of functional capacity and secondary endpoints
of lung capacity and respiratory muscle function were assessed in
patients scheduled to undergo CABG. After surgery, 40 patients
were randomly assigned across 1 of 4 inpatient cardiac rehabilita-
tion groups: G1, inspiratory muscle training, active upper limb and
lower limb exercise training, and early ambulation; G2, same pro-
tocol as G1 without inspiratory muscle training; G3, inspiratory
muscle training alone; and G4, control. All groups received chest
physical therapy and expiratory positive airway pressure. Patients
were reassessed on post-operative day 6 and post-discharge day 30
(including cardiopulmonary exercise testing).
Results:  The 6-min walk distance on post-operative day 6 was
significantly higher in groups that included exercise training (G1
and G2), remaining higher at 30 d post-discharge (P < .001 be-
tween groups). Peak oxygen uptake on day 30 was also higher
in G1 and G2 (P = .005). All groups achieved similar recovery
of lung function.
Conclusion:  Protocols G1 and G2, which included a systematic
plan for early ambulation and upper and lower limb exercise,
attenuated fitness losses while in the hospital and significantly
enhanced recovery 1 mo after CABG.
Key Words:  exercise • functional capacity • lung capacity •
rehabilitation
R eductions in respiratory muscle strength,1,2 oxygenation,3
and pulmonary function1,4,5 are commonly observed in
the post-operative period of on-pump coronary artery bypass
Author Affiliations: Federal University of Rio Grande do Sul, Porto Alegre,
Rio Grande do Sul, Brazil (Drs Zanini, Silveira, and Stein and Mss Lima and
Buhler); and Exercise Cardiology Research Group, Hospital de Clínicas de
Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil (Drs Zanini, Silveira,
Stein, and Nery and Mss Lima and Buhler).
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citation
appears in the printed text and is provided in the HTML and PDF versions of
this article on the journal’s Web site (www.jcrpjournal.com).
Correspondence: Maurice Zanini, ScD, PT, Exercise Cardiology Research
Group, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos, 2350,
Térreo (Serviço de Fisiatria e Reabilitação) 90035-007, Porto Alegre, RS,
Brazil (mauricezanini@gmail.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/HCR.0000000000000431
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graft (CABG) surgery. A marked reduction in functional ca-
pacity also occurs. Within this context, inpatient cardiac re-
habilitation (ICR) consists of a variety of physical therapy
techniques aimed at assisting earlier recovery of function and
reducing the incidence of complications.6-8
Inpatient chest physical therapy (CPT) is provided after
CABG surgery and traditionally includes early mobiliza-
tion, airway clearance techniques, and various respiratory
maneuvers.9 In recent years, however, physical exercise has
been combined with respiratory exercises.10-12 Stein et al13
demonstrated the effects of a 1-wk post-operative cardio-
pulmonary rehabilitation program on inspiratory muscle
strength and its association with submaximal and maximal
functional capacity parameters after CABG. However, ma-
jor knowledge gaps persist regarding ICR, and the evidence
regarding the benefits of specific physiotherapy techniques,
whether isolated or in combination, is scarce.9,14
Therefore, we sought to evaluate the effects of 4 differ-
ent ICR protocols on functional capacity, respiratory mus-
cle strength, and pulmonary function, aiming to identify
which strategy can be more effective, both before hospital
discharge and at 30 d after CABG.
METHODS
PARTICIPANTS
Patients for this single-blind, single-center randomized con-
trolled trial were recruited systematically from the elective
CABG schedule of a university hospital between 2012 and
2015. The sample consisted of adults aged 18 to 70 yr who
agreed to participate and provided written informed con-
sent. Approval was obtained from the institutional research
ethics committee (Hospital de Clínicas de Porto Alegre,
#09650).
Exclusion criteria were (1) chronic renal failure (creati-
nine clearance <60 mL/min); unstable angina; (2) presence
of symptoms at rest or with minimal exertion; (3) intermit-
tent claudication; moderate or severe heart valve dysfunc-
tion; (4) severe cardiac arrhythmias; (5) history of stroke;
or (6) motor disabilities that would preclude participation
in the study interventions. Patients with chronic obstruc-
tive pulmonary disease who exhibited a >70% reduction
in forced vital capacity or forced expiratory volume in the
first second of expiration on pre-operative spirometry were
also excluded.
INTERVENTION
After inclusion, patients were evaluated by blinded exam-
iners (6-min walk test [6MWT] and pulmonary function
tests using spirometry and respiratory muscle strength test
Inpatient CR After Coronary Artery Bypass Graft Surgery    E19
with a respiratory pressure meter) on the day before surgery
(baseline). Coronary artery bypass graft surgery was then
performed, and patients were randomly allocated to 1 of
the 4 study groups. The group 1 (G1) intervention consist-
ed of active upper limb and lower limb exercise training,
progressive early ambulation, inspiratory muscle training
(IMT) with Threshold IMT (Philips Respironics), and con-
ventional CPT; group 2 (G2) used active upper limb and
lower limb exercise training and progressive early ambu-
lation and conventional CPT; group 3 (G3) patients per-
formed IMT and conventional CPT; and group 4 (G4) was
the control group and received only conventional CPT. The
Appendix (see Supplemental Digital Content 1, available at:
http://links.lww.com/JCRP/A115) has a detailed description
of the interventions for all 4 patient groups.
Patients in all groups received conventional CPT, which
consisted of bronchial hygiene therapy, deep breathing,
and expiratory positive airway pressure (EPAP) provided
through an EPAP device (Vital Signs). All exercises were
planned progressively, according to the principles of speci-
ficity, overload, and individuality.
All patients were encouraged by the care team to get out
of bed and walk starting on post-operative day 2. There
were no restrictions on ambulation during hospital stay or
after discharge. However, only patients in groups 1 and 2
received systematic prescriptions for supervised ambulation
using predetermined distances. After hospital discharge, all
patients received standard guidance on post-CABG care
and ambulation at home.
In all groups, the appropriate protocol was started on the
day after CABG surgery, once patients had been weaned off
invasive mechanical ventilation. Patients were seen twice a
day, by the same physical therapist, for ≥6 d. At the end
of the ICR program, on post-operative day 6 or 7, patients
underwent assessment of respiratory muscle strength, pul-
monary function, and functional capacity (6MWT), and
received guidance on general health and management of
cardiovascular risk factors. On day 30 after discharge, par-
ticipants returned to the hospital as outpatients, completed
a cardiopulmonary exercise test (CPET), and repeated all
tests performed at discharge. After this final evaluation, all
patients were referred to an outpatient cardiac rehabilita-
tion program.
OUTCOMES
The primary outcome was functional capacity (evaluated by
6MWT). Secondary outcomes were CPET variables, lung
capacity parameters, and respiratory muscle function.
MEASUREMENTS AND INSTRUMENTS
The 6MWT was conducted in a 30-m corridor. Patients
wore a Polar S810i (Polar Electro Oy) heart rate monitor
and sphygmomanometer for measurement of heart rate and
blood pressure, respectively, before and after the test. The
Borg rating of perceived exertion scale was also used.15 The
test was stopped in case of dizziness, palpitations, or abrupt
change in vital signs.16
Pulmonary function tests were performed at rest using
a computer-based spirometry system (Eric Jaeger), follow-
ing European Respiratory Society published standards.17
Forced vital capacity and forced expiratory volume in the
first second of expiration measures were compared to refer-
ence values established by the Brazilian Consensus on Spi-
rometry.18,19
Respiratory muscle strength was measured using the
American Thoracic Society protocol.20 Inspiratory and expi-
ratory muscle strength were evaluated using a measurement
E20    Journal of Cardiopulmonary Rehabilitation and Prevention 2019;39:E19-E25
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circuit composed of a MVD-300 pressure transducer (Mi-
crohard System, Globalmed) with ±300 cm H2O capacity.
Approximately 6 measurements were obtained at 1-min
intervals. The highest value for each parameter was con-
sidered for analysis in the absence of a >10% difference
between the 2 highest values.21
Functional capacity was assessed by means of treadmill
CPET (Inbramed KT 10200, Inbramed) with analysis of ex-
haled gases. A ramp protocol was used, starting at 2.0 km/hr
and 0% grade. Every 10 sec thereafter, speed and grade were
increased in 0.1 to 0.15 km/hr and 0.1% to 0.2% incre-
ments, respectively. Throughout the test, heart rate was
monitored via 12-lead electrocardiogram (Nihon Kohden
Corporation), using the modified Mason-Likar electrocar-
diogram electrode placement method.22 Blood pressure was
measured with a sphygmomanometer every 3 min during
CPET and additionally at the discretion of the physician.
Exhaled gas analysis was performed on a breath-by-breath
basis using a Cortex Metalyzer 3B system (Cortex Medical).
All tests were performed by the same cardiologist, who was
blinded to group allocation on day 30 after discharge.
RANDOMIZATION AND SAMPLE SIZE CALCULATION
The randomization sequence was generated in PASW Statis-
tics, v18.0 (SPSS) by an investigator not otherwise involved
in the study, using a table of random numbers uniformly
distributed and divided into 4 groups. After sequence gen-
eration, values were placed into sequentially numbered,
sealed, opaque envelopes.
These envelopes were given to an investigator who was
not involved in data collection or patient allocation and
whose sole task was patient randomization after CABG.
The only person aware of the group allocation of each pa-
tient was the physical therapist in charge of administering
the corresponding study protocol to the patient. All outcome
assessors remained blinded to intervention group allocation.
On the basis of prior experiments,23 the sample size was
calculated as 7 subjects per group (n = 28 in total) for a
significance level of 5%, a statistical power of 80%, and a
difference in 6-min walking distance (6MWD) of at least
60 m between groups. Anticipating an attrition rate of 20%
and to optimize analysis of results, we chose to enroll 10
participants per group for a total sample size of 40 patients.
STATISTICAL ANALYSIS
All collected data were analyzed in PASW v18.0. Categor-
ical variables were expressed as absolute and relative fre-
quencies. Normally distributed continuous variables were
expressed as mean and standard deviation and asymmet-
rically distributed variables as median and interquartile
range.
Comparison of baseline data across groups was car-
ried out via analysis of variance for normally distributed
quantitative variables or the Kruskal-Wallis test for asym-
metrically distributed variables. Comparative analysis of
CPET-measured outcomes across groups was done by re-
peated-measures analysis of variance or the Kruskal-Wallis
test as appropriate, depending on data distribution, fol-
lowed by the Tukey-Kramer multiple comparisons test. All
other outcomes evaluated by >1 repeated measure over
time were analyzed using a generalized estimating equa-
tions model. When findings were significant, we applied
Bonferroni’s post hoc test. Analyses of outcomes such as
the 6MWD were corrected for age, while maximal inspira-
tory pressure (MIP) and maximal expiratory pressure were
corrected for both age and sex. The significance level was
set at P < .05.
www.jcrpjournal.com
Figure 1. Consolidated Standards of Reporting Trials (CONSORT) flow diagram.
RESULTS
Of the 40 patients randomized, 10 were allocated to each
of the 4 study groups. A flow diagram of participant in-
clusion, allocation, and follow-up, in accordance with the
Consolidated Standards of Reporting Trials (CONSORT)
guidelines, is provided in Figure 1. There was 1 patient lost
to follow-up in the control group (G4) at the last assess-
ment time point.
Descriptive statistics and frequency distributions for clin-
ical, demographic, and anthropometric parameters of all
participants who received the study interventions are listed
in Table 1. All groups were homogeneous in terms of age
and most patients were male. Baseline characteristics were
similar across all groups (P > .05). Table 1 also provides
pre-operative and post-operative data for the study sample.
Mean length of intensive care unit (ICU) stay was longer
in the control group than in the other 3 groups. No such
difference was observed for overall length of hospital stay,
which was similar across all 4 groups (Table 1).
Table 2 presents the primary and secondary outcomes
of interest by group. Analysis of the mean values for the
6MWD shows that the greatest impairment in function-
al capacity from baseline in the immediate post-operative
period was seen in G3 and G4 as compared with G1 and
G2. On analysis of this variable in the late post-operative
period (30 d after hospital discharge), patients in G4 (con-
trol) were found to have experienced the least amount of
recovery. However, despite a lower functional capacity than
patients in other groups, within-group comparison showed
that control-group participants were able to achieve 6MWD
values similar to their pre-operative baseline. In turn, all oth-
er groups experienced a significant improvement in function-
al capacity from baseline, as measured by the 6MWT. The
progression of 6MWD in the 4 study groups at the 3 time
points of assessment is illustrated in Figure 2.
Table 2 also shows lung capacity outcome measures.
All behaved similarly across the groups throughout the
follow-up period, with no significant between-group dif-
ferences for any measure. However, all groups exhibit-
ed a significant decline from baseline in lung capacity
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measures in the immediate post-operative period. In the
late post-operative period (day 30 after hospital discharge),
only group 3 failed to show significant recovery in relation
to the immediate post-operative period (day 6 post-CABG).
Like pulmonary function measures, respiratory muscle
function parameters did not differ across groups. On anal-
ysis of MIP, only group 2 did not exhibit any significant
decline in performance in the immediate post-operative pe-
riod. However, 30 d after hospital discharge, values in all
groups were similar to baseline levels. Regarding maximal
expiratory pressure, all groups exhibited significant loss of
expiratory muscle function in the immediate post-operative
period, but all had returned to baseline levels in the late
post-operative period.
Table 3 shows the main measurements from the CPET.
Notably, both G1 and G2 exhibited significantly higher peak
oxygen uptake (V̇o2) values than G3 and G4.
DISCUSSION
The main finding of this randomized controlled trial is that
groups that received protocols combining active physical
exercise and early ambulation experienced a more effective
recovery of functional capacity, both before hospital dis-
charge and at 30 d after discharge. When implemented as
part of a structured ICR program, such rehabilitation strat-
egies can serve as the cornerstone for the resumption of the
activities of daily living by post-CABG patients.
For many years, protocols used in clinical studies of
inpatient rehabilitation after cardiac surgery were based
predominantly on respiratory therapy techniques.9,14,24 Ev-
idence shows that the combination of active upper limb or
lower limb exercise and early ambulation can provide ben-
efits beyond prevention of thromboembolism or of range
of motion limitation.25 Early mobilization seems to be im-
portant to prevent post-operative complications, improve
functional capacity, and reduce length of hospital stays in
patients after cardiac surgery.26
In 2008, Hirschhorn et al11 conducted a randomized
controlled trial evaluating the effects of intervention on
Inpatient CR After Coronary Artery Bypass Graft Surgery    E21
 Table 1
Patient Characteristics (Pre-operative, Intraoperative, and Post-operative) in All Groupsa
Group 1 (n = 10) Group 2 (n = 10) Group 3 (n = 10) Group 4 (n = 10)
Anthropometric data
  Age, yr 58 ± 5 56 ± 7 59 ± 8 61 ± 5
  BMI, kg/m2 28 ± 2.9 26 ± 3.8 28 ± 3.7 28 (4.2)
 Male 9 (90) 7 (70) 6 (60) 7 (70)
  Risk factors
  Sedentary lifestyle 7 (70) 8 (80) 7 (70) 9 (90)
  Tobacco smoking 8 (80) 9 (90) 7 (70) 7 (70)
  Diabetes 3 (30) 7 (70) 6 (60) 3 (30)
  Hypertension 8 (80) 8 (80) 9 (90) 7 (70)
Pre-operative data
  Creatinine, mg/dL 0.98 ± 0.19 0.99 ± 0.25 1.1 ± 0.4 0.95 ± 0.34
  Angina class
  I 2 (20) 0 (0) 1 (10) 3 (30)
  II 4 (40) 9 (90) 6 (60) 4 (40)
  III 4 (40) 1 (10) 3 (30) 3 (30)
  NYHA class
  Class 1 2 (20) 1 (10) 1 (10) 0 (0)
  Class 2 4 (40) 7 (70) 7 (70) 5 (50)
  Class 3 4 (40) 2 (20) 2 (20) 5 (50)
  ASA class
  II 1 (10) 3 (30) 3 (30) 3 (30)
  III 8 (80) 5 (50) 6 (60) 4 (40)
  IV 1 (10) 2 (20) 1 (10) 3 (30)
Intraoperative data
  Operative time, min 180 ± 33 158 ± 27 167 ± 42 174 ± 51
  Ischemic time, min 39 ± 13 33 ± 10 40 ± 17 44 ± 16
  On-pump time, min 56 ± 17 50 ± 14 60 ± 24 67 ± 24
  Number of grafts 3 ± 0.9 3 ± 0.9 3 ± 0.8 3 ± 0.5
Post-operative data
  IMV time, hr 8 ± 3.3 9 ± 5.9 11 ± 5.9 11 ± 3.9
  Length of ICU stay, d 3 ± 0.5 3 ± 0.3 3 ± 0.5 4 ± 0.9b
  Length of hospital stay, d 7 ± 0.7 6 ± 0.8 7 ± 0.6 8±3
  Atrial fibrillation 2 (20) 1 (10) 2 (20) 3 (30)
Abbreviations: ASA, American Association of Anesthesiologists; BMI, body mass index; ICU, intensive care unit; IMV, intermittent mandatory ventilation; NYHA, New York Heart Association.
a
Data reported as mean ± standard deviation or number (%).
b
P < .05 compared with the other groups.

functional capacity. In this experiment, the authors as-
sessed moderate-intensity exercise programs, combined or
not with respiratory exercises, and found improvements in
functional capacity as measured by 6MWD at discharge.
However, at 30 d after discharge, there was no significant
difference between groups. This finding differs from that of
the present study at 30 d post-discharge, in which patients
who received conventional CPT alone performed poorly as
compared with the other groups that received active exer-
cise and early ambulation. It is noteworthy that Oliveira
et al27 demonstrated that the type of surgery, cardiopulmo-
nary bypass time, functional independence measure, and
body mass index were determinants of 6MWD at hospi-
tal discharge in patients undergoing cardiac surgery. As
all groups evaluated by us were homogeneous in terms of
clinical and surgical variables, we consider that the impact
observed in the intervention groups is attributable to the
protocols performed.
Two other randomized controlled trials13,28 that also
employed ICR protocols of progressive walking plus ac-
tive exercise, with usual care as a comparator, validate
our findings. In these studies, patients exhibited improve-
ment in functional capacity both before discharge and on
day 30 after discharge. Stein et al13 found that 30 d after
discharge, V̇o2 peak was higher in the intervention group
(CPT with EPAP plus active upper and lower limb exercise
plus ambulation) than in the control group (no physical
therapy). In this study, the authors postulated that phys-
iological adaptations induced by exercise might relieve
pain in the saphenous vein donor limb and thus facilitate
improved performance on functional tests.13 Furthermore,
the superior performance of such rehabilitation protocols
may also be attributed to optimization of oxygen trans-
port secondary to increased ventilation and improved ven-
tilation/perfusion ratio. In this context, ambulation would
serve as a gravitational stimulus capable of restoring the
normal distribution of extravascular fluid, thus mitigating
the effects of immobility.29 It is entirely plausible that a
combination of such effects would have a positive impact
on functional capacity.
Impaired lung function is a frequent occurrence after
CABG surgery and, throughout the present study, outcome
measures of lung capacity and respiratory muscle function
did not differ across groups. All groups derived benefit
from the physical therapy protocols administered during
the intervention, including the control group, which also

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Table 2
Measures of Functional Capacity (6MWD) and Lung Capacity for Patients in All Groupsa
Group 1 Group 2 Group 3 Group 4 P Value (G)b P Value (T)b P Value (G  T)b
6MWD, m <.001 <.001 <.001
  Pre-operative baseline 398 (21)A 419 (20)A 384 (22)A 423 (17)A
 PO6 365 (23)A,ce 401 (20)A,c 275 (23)B,d 291 (22)B,de
 PD30 531 (23)B,de 531 (16)B,e 471 (14)C,cd 433 (14)A,c
FVC, % predicted .85 <.001 .18
  Pre-operative baseline 90.4 (3.7)A 94.8 (3.3)A 96.8 (5.0)A 100.4 (3.6)A
 PO6 65.8 (3.6)B 67.6 (2.6)B 73.2 (5.2)B 61.8 (5.6)B
 PD30 82.6 (4.0)C 83.5 (2.7)C 82.6 (4.5)B 85.3 (4.6)C
FEV1, % predicted .99 <.001 .055
  Pre-operative baseline 91.3 (2.9)A 94.7 (3.2)A 93.5 (5.1)A 97.7 (3.7)A
 PO6 67.0 (3.1)B 65.0 (2.6)B 68.9 (5.0)B 59.3 (5.9)B
 PD30 82.1 (4.4)C 80.8 (3.2)C 75.9 (4.1)B 80.7 (4.5)C
MIP, cm H2O .90 <.001 .29
  Pre-operative baseline 91.7 (11.2)A 88.8 (8.9)AB 89.5 (8.5)A 87.1 (4.4)A
 PO6 62.8 (8.6)B 68.2 (11.1)A 68.0 (6.7)B 65.7 (7.3)B
 PD30 87.5 (8.6)A 92.4 (10.8)B 85.3 (9.3)A 76.0 (5.9)AB
MEP, cm H2O .68 <.001 .02
  Pre-operative baseline 124.9 (14.0)A 105.2 (12.8)A 123.0 (13.9)A 114.4 (11.3)A
 PO6 89.2 (10.7)B 83.6 (14.4)B 100.1 (13.2)B 92.3 (12.2)B
 PD30 121.8 (11.1)A 113.5 (9.5)A 115.3 (10.6)AB 98.8 (12.6)AB
Abbreviations: FEV1, forced expiratory volume in the first second of expiration; FVC, forced vital capacity; G, group; MEP, maximal expiratory pressure; MIP, maximal inspiratory pressure; PD30,
post-discharge day 30; PO6, post-operative day 6; 6MWD, 6-min walk distance; T, time points.
a
Data reported as mean (standard error of the mean). Superscript capital letters indicate that Bvalues are significantly different based on the effect of time versus Avalues and/or Cvalues;
A
values are significantly different based on the effect of time versus Bvalues and/or Cvalues; Cvalues are significantly different based on the effect of time versus Avalues and/or Bvalues.
b
Generalized estimating equation models: P (G), significance between groups; P (T), significance between time points; and P (G × T), significance of group × time interaction.
c
Values are significantly different based on group effects versus dvalues and/or evalues; dvalues are significantly different based on group effects versus cvalues and/or evalues; and evalues
are significantly different based on group effects versus dvalues and/or evalues.

exhibited recovery of lung capacity at 30 d post-discharge.
Therefore, it is important to note that all patients, even
controls, received CPT consisting of respiratory exercises
and use of an EPAP device. According to Borghi et al,30 the
combination of positive pressure and physical therapy in-
terventions was more effective than physical therapy alone
at minimizing lung flow and volume alterations. Optimized
thoracoabdominal motion mechanics and, consequently, in-
creased respiratory movement amplitude facilitate pulmo-
nary re-expansion and improvement of pulmonary function
parameters.29
Unlike the present study, some investigations8,13 have
found between-group differences in pulmonary variables
during post-operative follow-up. However, in these studies,
controls did not receive progressive, supervised CPT and
exhibited marked declines in performance in the imme-
diate post-operative period, as well as a more protracted
recovery, differing even from the control group in the pres-
ent study. Haeffener et al31 evaluated pulmonary function
in the post-operative period. Corroborating our findings,
the authors also identified a decline in performance in the
immediate post-operative period with recovery at the 30-d

Figure 2. 6MWD by groups at 3 time periods. aP < .05 between G2 and G3, G4. bP < .05 between G1 and G3. cP < .05 between G1 and G4. G
indicates group.

www.jcrpjournal.com Inpatient CR After Coronary Artery Bypass Graft Surgery    E23

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 Table 3
Cardiopulmonary Exercise Test Measures at 30 d Post-discharge for Patients in All Groupsa
Group 1 (n = 10) Group 2 (n = 10) Group 3 (n = 10) Group 4 (n = 9) P Value
V̇o2 peak, mL/kg/min 21.4 ± 3.1b 21.4 ± 2.8b 17.7 ± 3.2c 17.3 ± 3.2c .005
V̇e peak, L/min 74.6 ± 19.0 67.9 ± 14.2 55.8 ± 17.2 65.5 ± 18.7 .130
V̇e/V̇o2 43.5 ± 7.4 44.3 ± 8.1 38.8 ± 10.6 46.3 ± 10.7 .349
V̇e/V̇co2 slope 33.7 ± 5.6 39.2 ± 7.6 38.5 ± 9.4 41.3 ± 9.7 .239
V̇co2 peak, mL/kg/min 27.8 ± 4.1b 26.4 ± 4.3b 20.5 ± 4.2c 20.7 ± 3.7c .001
RQ peak 1.3 ± 0.1b 1.2 ± 0.1c 1.2 ± 0.1c 1.2 ± 0.1c .008
V̇o2/HR, mL/beat 13 ± 3 11 ± 3 10 ± 2.33 9.4 ± 2.6 .053
HR peak, beats/min 129 ± 11 136 ± 21 129 ± 20 137 ± 20 .627
SBP peak, mm Hg 168 ± 22 176 ± 14 176 ± 15 163 ± 25 .370
DBP peak, mm Hg 74 ± 7 78 ± 6 74 ± 8 74 ± 9 .583
Abbreviations: DBP, diastolic blood pressure; HR, heart rate; RQ, respiratory quotient; SBP, systolic blood pressure; V̇ co2, carbon dioxide production; V̇ e, minute ventilation; V̇ e/V̇ co2, ventilatory
equivalent for carbon dioxide; V̇ e/V̇ co2 slope, minute ventilation/carbon dioxide production slope; V̇ e/ V̇ o2, ventilatory equivalent for oxygen; V̇ o2/HR, oxygen pulse.
a
Data reported as mean ± standard deviation.
b
Values are significantly different based on group effects versus values marked with superscript letter c.

follow-up, likely due to reduced alveolar recruitment and
pulmonary re-expansion in the immediate post-operative
period, followed by recovery due to the study intervention.
Respiratory muscle performance is also impaired after
CABG, the result of a multifactorial phenomenon. In this
sample, MIP and maximal expiratory pressure were re-
duced on post-operative day 6 but had recovered substan-
tially (to pre-operative baseline levels) at 30 d after hospital
discharge. In this study, use of the Threshold IMT trainer,
which was utilized in only 2 of the groups, did not appear to
influence variability in MIP values in these groups as com-
pared with the groups that did not use the device. Notably,
other studies13,31,32 that did not employ this device in their
ICR protocols reported results similar to ours for respirato-
ry pressure variables measured at similar time points. Re-
versal of loss of respiratory muscle performance may be at
least partly attributable to an additional effect of EPAP.30
The MIP has also been associated with V̇o2 peak in the
literature13; however, our findings do not suggest that the
increase observed in V̇o2 peak could be attributed to IMT.
Physiotherapist-supervised activity fosters improvements
in post-operative physiological functional capacity and re-
duces length of stay in hospital following cardiac surgery.33
Length of ICU stay and overall length of hospital stay have
been reported in 2 prior studies of ICR.28,31 Both of these
studies reported differences in overall length of hospital
stay between groups. On the contrary, length of ICU stay
did not differ between groups. In our study, overall length
of hospital stay was similar in all 4 rehabilitation groups,
whereas ICU stay was longer in the control group.
The clinical relevance of our findings lies in the identifi-
cation of which post-CABG physical therapy protocols can
provide a significant increase in functional capacity and,
thus, aid in the early recovery of patients whose autonomy
for physical activities is greatly limited. This gives patients
greater potential to resume their activities of daily living as
soon as they are discharged from hospital. Both the pres-
ent experiment and data from previously published stud-
ies11,13,28 strengthen the evidence for optimized management
of this patient population by rehabilitation teams, which
should include active exercise as part of routine ICR in the
post-operative period of patients with ischemic heart disease.
LIMITATIONS
The protocols used in this study were developed for reha-
bilitation of patients who are status post-CABG. Therefore,
other studies should be conducted to evaluate the effects in
different types of cardiac surgery patients. A second limita-
tion was that the patients and the physiotherapist were not
blind to study groups. In our study, pulmonary function pa-
rameters were assessed as secondary outcomes. New studies
designed to consider these parameters as primary outcomes
are warranted. Finally, this study was not designed or pow-
ered to look for differences regarding cardiac and/or pul-
monary complications.
CONCLUSION
Protocols combining early implementation of active upper
limb and lower limb exercise with progressive ambulation
were associated with superior recovery of functional capac-
ity in patients who underwent CABG surgery.
ACKNOWLEDGMENTS
This study was supported by grants from Coordenação de
Aperfeiçoamento de Pessoal de Nível Superior and Con-
selho Nacional de Desenvolvimento Científico Tecnológi-
co, Brasília, Brazil, and Fundo de Incentivo a Pesquisa e
Eventos—Hospital de Clínicas de Porto Alegre, Brazil.
This study was registered at clinicaltrials.gov (identifier
NCT01410253).
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