Early Mobilization Prescription in Patients Undergoing Cardiac Surgery: Systematic Review

Mayara Gabrielle Barbosa Borges Daniel Lago Borges Mariane Oliveira Ribeiro Lara Susan Silva Lima Karolina Carneiro Morais Macedo Vinicius José da Silva Nina About the authors

ABSTRACT

Introduction:

Early mobilization of patients in the postoperative period of cardiac surgery who are hospitalized in the intensive care unit (ICU) is a practice that has a positive impact.

Methods:

This is a systematic review of studies published until September 2020 in the Medical Literature Analysis and Retrieval System Online (or MEDLINE®), Embase, Physiotherapy Evidence Database (or PEDro), Scientific Electronic Library Online (or SciELO), and Latin American and Caribbean Health Sciences Literature (or LILACS) databases. Randomized clinical trials describing mobilization protocols performed early in ICU patients after cardiac surgery were included.

Results:

According to the eligibility criteria, only 14 of the 1,128 articles found were included in the analysis. Early mobilization protocols were initiated in the immediate postoperative period or first postoperative day. The resources and technics used were progressive mobilization, cycle ergometer, early bed activities, walking protocols, resistance exercise, and virtual reality. Intensity of the mobilization activities was determined using the Borg scale and heart rate.

Conclusion:

Early mobilization protocols are generalist (not individual), and low-intensity exercises are used, through progressive mobilization, with two daily physical therapy sessions, during 10 to 30 minutes.

Keywords:
Cardiac Surgical Procedures; Early Ambulation; Resistance Training; Intensive Care Units; Postoperative Period


Abbreviations, Acronyms & Symbols

INTRODUCTION

Cardiac surgery is an option to treat patients with cardiovascular disease, aiming minimize symptoms, optimize cardiac function, and increase survival. Because it is an invasive procedure, it implies numerous functional and systemic consequences in the postoperative period[11 Brick AV, Souza DSR de, Braile DM, Buffolo E, Lucchese FA, Silva FP de V, et al. Diretrizes da cirurgia de revascularização miocárdica valvopatias e doenças da aorta. Arq Bras Cardiol. 2004;82(suppl 5):1-20. doi:10.1590/S0066-782X2004001100001.
https://doi.org/10.1590/S0066-782X200400...

2 Ximenes NN, Borges DL, Lima RO, Barbosa e Silva MG, Silva LN, Costa Mde A, et al. Effects of resistance exercise applied early after coronary artery bypass grafting: a randomized controlled trial. Braz J Cardiovasc Surg. 2015;30(6):620-5. doi:10.5935/1678-9741.20150077.
https://doi.org/10.5935/1678-9741.201500...
-33 Camargo JBG, Cavenaghi OM, Mello JRC, de Brito MVC, Ferreira LL. Mobilidade funcional de pacientes críticos em terapia intensiva: um estudo piloto. Rev Aten Saúde. 2020;18(63):14-20. doi:10.13037/ras.vol18n63.6101.
https://doi.org/10.13037/ras.vol18n63.61...
].

Complications resulting from the surgical procedure may be caused by physiological changes, comorbidities, and previous risk factors. In addition, intraoperative conditions such as mechanical ventilation, cardiopulmonary bypass, surgical time, and anesthesia determine longer hospital stay with negative outcomes[44 Laizo A, Delgado FEF, Rocha GM. Complications that increase the time of hospitalization at ICU of patients submitted to cardiac surgery. Braz. J. Cardiovasc. Surg. 2010; 25(2):166-71. doi:10.1590/S0102-76382010000200007.
https://doi.org/10.1590/S0102-7638201000...
].

Conditions acquired during hospitalization due to immobilization, such as loss of strength and muscle mass, reduction of functional capacity, and physical deconditioning, are common and directly associated with greater disability and need for prolonged rehabilitation[55 da Silva Pissolato J, Fleck CS. Mobilização precoce na unidade de terapia intensiva adulta. Fisioter Bras. 2018;19(3):377-84.].

Early mobilization of patients in the postoperative period of cardiac surgery who are hospitalized in the intensive care unit (ICU) is a practice that has a positive impact on cardiovascular conditioning and ventilatory mechanics, consequently implying improvement of functional capacity, shorter hospitalization time, and lower mortality rate, besides contributing to the prevention of ICU-acquired weakness and to the improvement of muscle strength[44 Laizo A, Delgado FEF, Rocha GM. Complications that increase the time of hospitalization at ICU of patients submitted to cardiac surgery. Braz. J. Cardiovasc. Surg. 2010; 25(2):166-71. doi:10.1590/S0102-76382010000200007.
https://doi.org/10.1590/S0102-7638201000...
,66 Hodgson C, Needham D, Haines K, Bailey M, Ward A, Harrold M, et al. Feasibility and inter-rater reliability of the ICU mobility scale. Heart Lung. 2014;43(1):19-24. Erratum in: Heart Lung. 2014;43(4):388. doi:10.1016/j.hrtlng.2013.11.003.
https://doi.org/10.1016/j.hrtlng.2013.11...
].

Exercises are essential for a quick postoperative recovery. Protocols and resources to assist in cardiovascular rehabilitation have been frequently applied[22 Ximenes NN, Borges DL, Lima RO, Barbosa e Silva MG, Silva LN, Costa Mde A, et al. Effects of resistance exercise applied early after coronary artery bypass grafting: a randomized controlled trial. Braz J Cardiovasc Surg. 2015;30(6):620-5. doi:10.5935/1678-9741.20150077.
https://doi.org/10.5935/1678-9741.201500...
]. Cycle ergometer, neuromuscular electrical stimulation, virtual reality through video games, and protocols of active and resisted mobilization with levels of progression have been increasingly used, presenting positive results in functional capacity[77 Cacau Lde A, Oliveira GU, Maynard LG, Araújo Filho AA, Silva WM Jr, Cerqueria Neto ML, et al. The use of the virtual reality as intervention tool in the postoperative of cardiac surgery. Rev Bras Cir Cardiovasc. 2013;28(2):281-9. doi:10.5935/1678-9741.20130039.
https://doi.org/10.5935/1678-9741.201300...
,88 Fontes Cerqueira TC, Cerqueira Neto ML, Cacau LAP, Oliveira GU, Silva Júnior WMD, Carvalho VO, et al. Ambulation capacity and functional outcome in patients undergoing neuromuscular electrical stimulation after cardiac valve surgery: a randomised clinical trial. Medicine (Baltimore). 2018;97(46):e13012. doi:10.1097/MD.0000000000013012.
https://doi.org/10.1097/MD.0000000000013...
] and motivation[99 Gama Lordello GG, Gonçalves Gama GG, Lago Rosier G, Viana PADC, Correia LC, Fonteles Ritt LE. Effects of cycle ergometer use in early mobilization following cardiac surgery: a randomized controlled trial. Clin Rehabil. 2020;34(4):450-9. doi:10.1177/0269215520901763.
https://doi.org/10.1177/0269215520901763...
] of patients undergoing cardiac surgery.

Thus, considering the various therapeutic proposals, this review aims to describe the prescription of early mobilization in patients undergoing cardiac surgery.

METHODS

This is a systematic review following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (or PRISMA) Statement[1010 Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi:10.1186/2046-4053-4-1.
https://doi.org/10.1186/2046-4053-4-1...
] and registered in the International Prospective Register of Systematic Reviews (or PROSPERO) (CRD42020197787).

Eligibility Criteria

Randomized clinical trials describing early mobilization protocols applied to patients following cardiac surgery were included. Early mobilization has been considered as any mobilization activity that has been carried out as soon as possible during the ICU stay, such as turning, sitting, and orthostatism; passive, assisted, or active exercises; marching on the spot; walking; resistance or aerobic exercise; cycle ergometer; or virtual reality games. The year of publication, as well as the language, were not considered as exclusion criteria.

Search Strategy

The search was conducted in the Medical Literature Analysis and Retrieval System Online (or MEDLINE®) via PubMed®, Embase, Physiotherapy Evidence Database (or PEDro), Latin American and Caribbean Health Sciences Literature (or LILACS), and Scientific Electronic Library Online (or SciELO) databases.

The search strategy comprised the keywords and synonyms for “early mobilization”, and for the study population we searched for “adults undergoing cardiac surgery hospitalized in an intensive care unit”, also including interventions as “marching on the spot”, “walking”, “resistance or aerobic exercise”, “cycle ergometer”, or “virtual reality games”. The search was carried out using terms of Medical Subject Headings (or MeSH) and synonyms, without restriction of date and language, until the period of June 2020, being updated in September 2020. PubMed®'s complete search strategy is described in Table 1. Two studies were manually added after the analysis of Kanejima et al.[1111 Kanejima Y, Shimogai T, Kitamura M, Ishihara K, Izawa KP. Effect of early mobilization on physical function in patients after cardiac surgery: a systematic review and meta-analysis. Int J Environ Res Public Health. 2020;17(19):7091. doi:10.3390/ijerph17197091.
https://doi.org/10.3390/ijerph17197091...
] study.

Table 1
Search strategy used in PubMed®.

Two researchers performed the initial search independently through the evaluation of titles and abstracts. Subsequently, the reviewers assessed the full texts for the independent verification of inclusion and exclusion criteria. In cases of disagreement, a third evaluator was consulted.

Data extraction was performed using a standardized Excel® spreadsheet, with the following information: first author, year of publication, country, number of patients in the study, sample, objective of the study, and, finally, description of the protocol of early mobilization (type of intervention, intensity, frequency, duration, and progression). In cases of incomplete or absent data, the corresponding authors were contacted. Data analysis was performed descriptively.

The assessment of the risk of bias in randomized controlled clinical trials followed the recommendations of the Cochrane Collaboration, using these items: random sequence generation, allocation concealment, blinding (participants, personnel, and outcome assessment), incomplete outcome data, selective reporting, and other sources of bias[1212 Higgins JP, Green S, editors. Cochrane handbook for systematic reviews of interventions. New Jersey: Wiley Online Library; 2008.].

RESULTS

The search identified 1,128 studies, but only 14 controlled and randomized clinical trials, totaling 1,170 patients included in this systematic review (Figure 1). Most studies included only coronary artery bypass grafting procedures. Mean age of patients was 58,67±4,5 years. Study characteristics are summarized in Table 2.

Fig. 1
Flowchart of studies included in this systematic review. ICU=intensive care unit

Table 2
Characteristics of the included studies.

Early mobilization protocols were initiated in the immediate postoperative period or first postoperative day. Different resources and techniques were used to mobilize patients submitted to cardiac surgery: progressive mobilization (four studies), cycle ergometer (three studies), out of bed activities (two studies), walking protocols (three studies), resistance exercise (one study), and virtual reality (one study). The description of the mobilization protocols is shown in Table 3.

Table 3
Early mobilization protocols in patients undergoing cardiac surgery.

The most frequently assessed outcomes in the studies were functional capacity, using the six-minute walk test, and respiratory muscle strength. The main results of the included studies are described in Table 4.

Table 4
Main outcomes of the included studies.

The methodological quality of the studies was evaluated using the Cochrane tool of risk of bias, described in Figure 2. Random sequence generation, allocation concealment, and selective results have a low proportion of risk of bias. On the other hand, a high proportion of high risk of bias for blinding and other types of bias were found.

Fig. 2
Assessment of risk of bias of the included studies.

DISCUSSION

Cardiac surgery leads to exercise capacity decreases in early stages of rehabilitation programs, when compared to patients undergoing less invasive or non-cardiac interventions[1313 Mendes RG, Simões RP, De Souza Melo Costa F, Pantoni CB, Di Thommazo L, Luzzi S, et al. Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery--a randomised controlled trial. Disabil Rehabil. 2010;32(16):1320-7. doi:10.3109/09638280903483893.
https://doi.org/10.3109/0963828090348389...
,1414 Pantoni CB, Di Thommazo-Luporini L, Mendes RG, Caruso FC, Mezzalira D, Arena R, et al. Continuous positive airway pressure during exercise improves walking time in patients undergoing inpatient cardiac rehabilitation after coronary artery bypass graft surgery: a RANDOMIZED CONTROLLED TRIAL. J Cardiopulm Rehabil Prev. 2016;36(1):20-7. doi:10.1097/HCR.0000000000000144.
https://doi.org/10.1097/HCR.000000000000...
]. Such changes are associated with severity of the disease, high prevalence of comorbidities[1515 Silva LN, Marques MJS, Lima RS, Fortes JVS, Silva MGB, Baldez TEP, et al. Retirada precoce do leito no pós operatório de cirurgia cardíaca: Repercussões cardiorrespiratórias e efeitos na força muscular respiratória e periférica, na capacidade funcional e função pulmonar. ASSOBRAFIR Ciênc. 2017;8(2):25-39. doi:10.47066/2177-9333/ac.27867.
https://doi.org/10.47066/2177-9333/ac.27...
], duration of muscle deconditioning[1616 Stein R, Maia CP, Silveira AD, Chiappa GR, Myers J, Ribeiro JP. Inspiratory muscle strength as a determinant of functional capacity early after coronary artery bypass graft surgery. Arch Phys Med Rehabil. 2009;90(10):1685-91. doi:10.1016/j.apmr.2009.05.010.
https://doi.org/10.1016/j.apmr.2009.05.0...
], incisional pain[1717 Tariq MI, Khan AA, Khalid Z, Farheen H, Siddiqi FA, Amjad I. Effect of early ≤ 3 mets (metabolic equivalent of tasks) of physical activity on patient's outcome after cardiac surgery. J Coll Physicians Surg Pak. 2017;27(8):490-4.], chest drain, and extracorporeal circulation[1818 Hirschhorn AD, Richards D, Mungovan SF, Morris NR, Adams L. Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery--a randomised controlled trial. Heart Lung Circ. 2008;17(2):129-38. doi:10.1016/j.hlc.2007.09.004.
https://doi.org/10.1016/j.hlc.2007.09.00...
].

Therefore, it is common to observe decline in functional performance during the ICU stay[1919 Højskov IE, Moons P, Egerod I, Olsen PS, Thygesen LC, Hansen NV, et al. Early physical and psycho-educational rehabilitation in patients with coronary artery bypass grafting: a randomized controlled trial. J Rehabil Med. 2019;51(2):136-43. doi:10.2340/16501977-2499.
https://doi.org/10.2340/16501977-2499...
]. Functional capacity decrease comparing pre and postoperative periods of cardiac surgery was reported by several studies[22 Ximenes NN, Borges DL, Lima RO, Barbosa e Silva MG, Silva LN, Costa Mde A, et al. Effects of resistance exercise applied early after coronary artery bypass grafting: a randomized controlled trial. Braz J Cardiovasc Surg. 2015;30(6):620-5. doi:10.5935/1678-9741.20150077.
https://doi.org/10.5935/1678-9741.201500...
,2020 Hansen D, Dendale P, Berger J, Meeusen R. Rehabilitation in cardiac patients: what do we know about training modalities? Sports Med. 2005;35(12):1063-84. doi:10.2165/00007256-200535120-00005.
https://doi.org/10.2165/00007256-2005351...

21 Ferrara N, Corbi G, Bosimini E, Cobelli F, Furgi G, Giannuzzi P, et al. Cardiac rehabilitation in the elderly: patient selection and outcomes. Am J Geriatr Cardiol. 2006;15(1):22-7. doi:10.1111/j.1076-7460.2006.05289.x.
https://doi.org/10.1111/j.1076-7460.2006...
-2222 Zanini M, Nery R, Lima J, Buhler R, Silveira R, 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):19-25. http://doi:10.1097/HCR.0000000000000431
http://doi:10.1097/HCR.0000000000000431...
].

Despite this, spontaneous restoration of functional capacity was observed, including in patients who did not participate in any research protocol[2323 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...
]. In specific conditions, such as the elderly, lower training volume and longer recovery periods may be sufficient[2424 Lavie CJ, Milani RV, Marks P, de Gruiter H. Exercise and the heart: risks, benefits, and recommendations for providing exercise prescriptions. Ochsner J. 2001;3(4):207-13.].

Due to individual particularities, a structured therapy including mode, intensity, frequency, and duration based on individualized assessments is fundamental for a proper prescription[2525 Achttien RJ, Staal JB, van der Voort S, Kemps HM, Koers H, et al. Exercise-based cardiac rehabilitation in patients with coronary heart disease: a practice guideline. Neth Heart J. 2013;21(10):429-38. doi:10.1007/s12471-013-0467-y.
https://doi.org/10.1007/s12471-013-0467-...
] and consequently long-term functional outcomes after hospital discharge[2626 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. 2017;103(1):1-12. doi:10.1016/j.physio.2016.08.003.
https://doi.org/10.1016/j.physio.2016.08...
].

Early mobilization in cardiac surgery is performed in the first hours after the surgical procedure as soon as the patient presents clinical conditions for the intervention[2727 Stiller K, Phillips AC, Lambert P. The safety of mobilization and its effect on hemodynamic and respiratory status of intensive care patients. Physiother Theor Pract. 2004;20(3):175-85. doi:10.1080/09593980490487474.
https://doi.org/10.1080/0959398049048747...
]. In the studies included in this review, the time to start mobilization was four hours after extubation to the first postoperative day.

According to Stiller et al.[2727 Stiller K, Phillips AC, Lambert P. The safety of mobilization and its effect on hemodynamic and respiratory status of intensive care patients. Physiother Theor Pract. 2004;20(3):175-85. doi:10.1080/09593980490487474.
https://doi.org/10.1080/0959398049048747...
] and Bourding et al.[2828 Bourdin G, Barbier J, Burle JF, Durante G, Passant S, Vincent B, et al. The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care. 2010;55(4):400-7.], early mobilization after cardiac surgery promotes several benefits, including improved ventilation, ventilation/perfusion ratio, respiratory muscle strength, and functional capacity. The systematic reviews of Kanejima et al.[1111 Kanejima Y, Shimogai T, Kitamura M, Ishihara K, Izawa KP. Effect of early mobilization on physical function in patients after cardiac surgery: a systematic review and meta-analysis. Int J Environ Res Public Health. 2020;17(19):7091. doi:10.3390/ijerph17197091.
https://doi.org/10.3390/ijerph17197091...
] and Guerra et al.[2929 Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil. 2015;29(9):844-54. doi:10.1177/0269215514558641.
https://doi.org/10.1177/0269215514558641...
] also demonstrated positive effects on functional capacity, being considered safe and feasible in critically ill patients. On the other hand, Santos et al.[2626 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. 2017;103(1):1-12. doi:10.1016/j.physio.2016.08.003.
https://doi.org/10.1016/j.physio.2016.08...
] suggests that early mobilization, evaluated in short term, does not promote significant changes in functional capacity.

Different results may be justified by divergences about early mobilization concepts[2727 Stiller K, Phillips AC, Lambert P. The safety of mobilization and its effect on hemodynamic and respiratory status of intensive care patients. Physiother Theor Pract. 2004;20(3):175-85. doi:10.1080/09593980490487474.
https://doi.org/10.1080/0959398049048747...
]. It is important to highlight that the variety of studies with different starting points difficult the prescription, as it is essential to define the moment of initiation to avoid risks to the patient due to very early or late mobilization[3030 Busch JC, Lillou D, Wittig G, Bartsch P, Willemsen D, Oldridge N, et al. Resistance and balance training improves functional capacity in very old participants attending cardiac rehabilitation after coronary bypass surgery. J Am Geriatr Soc. 2012;60(12):2270-6. Erratum in: J Am Geriatr Soc. 2013;61(3):479. doi:10.1111/jgs.12030.
https://doi.org/10.1111/jgs.12030....
].

Additionally, the term mobilization also covers several therapies. Most types of modalities found were protocols of progressive mobilization, including active exercises, sitting out of bed and walking[3131 Herdy AH, Marcchi PLB, Vila A, Tavares C, Collaco J, Niebauer J, Ribeiro JP: Pre- and postoperative cardiopulmonary rehabilitation in hospitalized patients undergoing coronary artery bypass surgery: a randomized controlled trial. Am J Phys Med Rehabil. 2008;87(9):714-719. https://doi:10.1097/PHM.0b013e3181839152
https://doi:10.1097/PHM.0b013e3181839152...

32 Ades PA, Savage PD, Brawner CA, Lyon CE, Ehrman JK, Bunn JY, et al. Aerobic capacity in patients entering cardiac rehabilitation. Circulation. 2006;113(23):2706-12. doi:10.1161/CIRCULATIONAHA.105.606624.
https://doi.org/10.1161/CIRCULATIONAHA.1...

33 Meyer T, Lucía A, Earnest CP, Kindermann W. A conceptual framework for performance diagnosis and training prescription from submaximal gas exchange parameters--theory and application. Int J Sports Med. 2005;26 Suppl 1:S38-48. doi:10.1055/s-2004-830514.
https://doi.org/10.1055/s-2004-830514...
-3434 Eder B, Hofmann P, von Duvillard SP, Brandt D, Schmid JP, Pokan R, et al. Early 4-week cardiac rehabilitation exercise training in elderly patients after heart surgery. J Cardiopulm Rehabil Prev. 2010;30(2):85-92.], only walking protocols[3535 Mendes RG, Simões RP, De Souza Melo Costa F, Pantoni CB, Di Thommazo L, Luzzi S, et al. Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery--a randomised controlled trial. Disabil Rehabil. 2010;32(16):1320-7. doi:10.3109/09638280903483893.
https://doi.org/10.3109/0963828090348389...
,3636 Ferrara N, Corbi G, Bosimini E, Cobelli F, Furgi G, Giannuzzi P, et al. Cardiac rehabilitation in the elderly: patient selection and outcomes. Am J Geriatr Cardiol. 2006;15(1):22-7. doi:10.1111/j.1076-7460.2006.05289.x.
https://doi.org/10.1111/j.1076-7460.2006...
], and early sitting out of bed[2121 Ferrara N, Corbi G, Bosimini E, Cobelli F, Furgi G, Giannuzzi P, et al. Cardiac rehabilitation in the elderly: patient selection and outcomes. Am J Geriatr Cardiol. 2006;15(1):22-7. doi:10.1111/j.1076-7460.2006.05289.x.
https://doi.org/10.1111/j.1076-7460.2006...
,2222 Zanini M, Nery R, Lima J, Buhler R, Silveira R, 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):19-25. http://doi:10.1097/HCR.0000000000000431
http://doi:10.1097/HCR.0000000000000431...
]. Not all these therapies require instruments for their realization.

Other studies included instruments, such as the cycle ergometer[99 Gama Lordello GG, Gonçalves Gama GG, Lago Rosier G, Viana PADC, Correia LC, Fonteles Ritt LE. Effects of cycle ergometer use in early mobilization following cardiac surgery: a randomized controlled trial. Clin Rehabil. 2020;34(4):450-9. doi:10.1177/0269215520901763.
https://doi.org/10.1177/0269215520901763...
,1313 Mendes RG, Simões RP, De Souza Melo Costa F, Pantoni CB, Di Thommazo L, Luzzi S, et al. Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery--a randomised controlled trial. Disabil Rehabil. 2010;32(16):1320-7. doi:10.3109/09638280903483893.
https://doi.org/10.3109/0963828090348389...
,2323 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...
], virtual reality[77 Cacau Lde A, Oliveira GU, Maynard LG, Araújo Filho AA, Silva WM Jr, Cerqueria Neto ML, et al. The use of the virtual reality as intervention tool in the postoperative of cardiac surgery. Rev Bras Cir Cardiovasc. 2013;28(2):281-9. doi:10.5935/1678-9741.20130039.
https://doi.org/10.5935/1678-9741.201300...
], and resistance exercises with shin pads and dumbbells[22 Ximenes NN, Borges DL, Lima RO, Barbosa e Silva MG, Silva LN, Costa Mde A, et al. Effects of resistance exercise applied early after coronary artery bypass grafting: a randomized controlled trial. Braz J Cardiovasc Surg. 2015;30(6):620-5. doi:10.5935/1678-9741.20150077.
https://doi.org/10.5935/1678-9741.201500...
]. The cycle ergometer is considered a viable strategy for those with restriction to walk[1212 Higgins JP, Green S, editors. Cochrane handbook for systematic reviews of interventions. New Jersey: Wiley Online Library; 2008.]. The practice of resistance exercises in this population is restricted due to incisional precautions, but it is known that this modality optimizes cardiovascular function and peripheral muscle strength[22 Ximenes NN, Borges DL, Lima RO, Barbosa e Silva MG, Silva LN, Costa Mde A, et al. Effects of resistance exercise applied early after coronary artery bypass grafting: a randomized controlled trial. Braz J Cardiovasc Surg. 2015;30(6):620-5. doi:10.5935/1678-9741.20150077.
https://doi.org/10.5935/1678-9741.201500...
,2929 Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil. 2015;29(9):844-54. doi:10.1177/0269215514558641.
https://doi.org/10.1177/0269215514558641...
] and promotes reduction of inflammation, cognitive dysfunction, and sarcopenia[3737 Borges DL, Silva MG, Silva LN, Fortes JV, Costa ET, Assunção RP, et al. Effects of aerobic exercise applied early after coronary artery bypass grafting on pulmonary function, respiratory muscle strength, and functional capacity: a randomized controlled trial. J Phys Act Health. 2016;13(9):946-51. doi:10.1123/jpah.2015-0614.
https://doi.org/10.1123/jpah.2015-0614...
].

In a systematic review, Ramos dos Santos et al.[2626 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. 2017;103(1):1-12. doi:10.1016/j.physio.2016.08.003.
https://doi.org/10.1016/j.physio.2016.08...
] observed that the groups submitted to early mobilization presented lower rates of postoperative complications, improvement of functional capacity, and reduction of hospital stay in comparison with control groups without treatment. However, when comparing different mobilization protocols, there was no superiority of any intervention.

Regarding intensity, most studies[22 Ximenes NN, Borges DL, Lima RO, Barbosa e Silva MG, Silva LN, Costa Mde A, et al. Effects of resistance exercise applied early after coronary artery bypass grafting: a randomized controlled trial. Braz J Cardiovasc Surg. 2015;30(6):620-5. doi:10.5935/1678-9741.20150077.
https://doi.org/10.5935/1678-9741.201500...
,77 Cacau Lde A, Oliveira GU, Maynard LG, Araújo Filho AA, Silva WM Jr, Cerqueria Neto ML, et al. The use of the virtual reality as intervention tool in the postoperative of cardiac surgery. Rev Bras Cir Cardiovasc. 2013;28(2):281-9. doi:10.5935/1678-9741.20130039.
https://doi.org/10.5935/1678-9741.201300...
,99 Gama Lordello GG, Gonçalves Gama GG, Lago Rosier G, Viana PADC, Correia LC, Fonteles Ritt LE. Effects of cycle ergometer use in early mobilization following cardiac surgery: a randomized controlled trial. Clin Rehabil. 2020;34(4):450-9. doi:10.1177/0269215520901763.
https://doi.org/10.1177/0269215520901763...
,1313 Mendes RG, Simões RP, De Souza Melo Costa F, Pantoni CB, Di Thommazo L, Luzzi S, et al. Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery--a randomised controlled trial. Disabil Rehabil. 2010;32(16):1320-7. doi:10.3109/09638280903483893.
https://doi.org/10.3109/0963828090348389...
,1616 Stein R, Maia CP, Silveira AD, Chiappa GR, Myers J, Ribeiro JP. Inspiratory muscle strength as a determinant of functional capacity early after coronary artery bypass graft surgery. Arch Phys Med Rehabil. 2009;90(10):1685-91. doi:10.1016/j.apmr.2009.05.010.
https://doi.org/10.1016/j.apmr.2009.05.0...
,1919 Højskov IE, Moons P, Egerod I, Olsen PS, Thygesen LC, Hansen NV, et al. Early physical and psycho-educational rehabilitation in patients with coronary artery bypass grafting: a randomized controlled trial. J Rehabil Med. 2019;51(2):136-43. doi:10.2340/16501977-2499.
https://doi.org/10.2340/16501977-2499...

20 Hansen D, Dendale P, Berger J, Meeusen R. Rehabilitation in cardiac patients: what do we know about training modalities? Sports Med. 2005;35(12):1063-84. doi:10.2165/00007256-200535120-00005.
https://doi.org/10.2165/00007256-2005351...
-2121 Ferrara N, Corbi G, Bosimini E, Cobelli F, Furgi G, Giannuzzi P, et al. Cardiac rehabilitation in the elderly: patient selection and outcomes. Am J Geriatr Cardiol. 2006;15(1):22-7. doi:10.1111/j.1076-7460.2006.05289.x.
https://doi.org/10.1111/j.1076-7460.2006...
] did not use objective criteria. Hirschhorn et al.[1818 Hirschhorn AD, Richards D, Mungovan SF, Morris NR, Adams L. Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery--a randomised controlled trial. Heart Lung Circ. 2008;17(2):129-38. doi:10.1016/j.hlc.2007.09.004.
https://doi.org/10.1016/j.hlc.2007.09.00...
] applied the modified Borg scale with target of three to four points, equivalent to moderate to low exercise intensity[3838 Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet. 1999;354:1229-33. https://doi:10.1016/s0140-6736(98)10063-6
https://doi:10.1016/s0140-6736(98)10063-...
], while Zanini et al.[2222 Zanini M, Nery R, Lima J, Buhler R, Silveira R, 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):19-25. http://doi:10.1097/HCR.0000000000000431
http://doi:10.1097/HCR.0000000000000431...
] performed exercises aiming level 11 on the Borg scale from six to 20 points. This intensity corresponds to light exercises, in which participants feel that the effort is “very light”[3939 Burneto AF, Paulin E, Yamaguti WPS. Comparação entre a escala modificada de Borg e a escala de Borg modificada análago visual aplicadas em pacientes com dispnéia. Rev Bras Ciênc Mov. 1989;3(1):34-40.].

In other studies, heart rate (HR) change from 20 to 30 bpm above baseline HR was used to determine exercise intensity according to guidelines from the American College of Sports Medicine (or ACSM) for patients who do not have a stress test performed. Increased exercise intensity considered the patient’s perceived effort, signs and symptoms, and normal physiological response[4040 Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377-81.].

Another way to determine the exercise intensity is the reserve HR (maximum HR - resting HR)[4141 Santos PMR, Ricci NA, Suster ÉAB, Paisani DM, Chiavegato LD. Effects of early mobilisation in patients after cardiac surgery: a systematic review. Physiotherapy. 2017;103(1):1-12. https://doi:10.1016/j.physio.2016.08.003
https://doi:10.1016/j.physio.2016.08.003...
]. However, this is based on the maximum HR achieved in an effort test that can quantify the anaerobic thresholds and thus determine the prescription of adequate exercise. This type of test is not performed in early postoperative period.

Subjectively, one can also consider the speech test or Talk Test, with the perception of the ventilation itself, that is, the exercises are performed in intensity that feels the most panting breath, however, without a degree of tachypnea that prevents the patient from completing a phrase[4242 Royse CF, Saager L, Whitlock R, Ou-Young J, Royse A, Vincent J, et al. Impact of methylprednisolone on postoperative quality of recovery and delirium in the steroids in cardiac surgery trial: a randomized, doubleblind, placebo-controlled substudy. Anesthesiology. 2017;126(2):223-33. https://doi:10.1097/ALN.0000000000001433
https://doi:10.1097/ALN.0000000000001433...
]. None of the studies analyzed used this way of determining intensity.

The definition of intensity is fundamental to determine the continuity or suspension of therapy. In phase I of the cardiac rehabilitation, low-intensity exercises should predominate, aiming the best possible physical and psychological conditions to patient hospital discharge[4343 Sebastian LA, Reeder S, Williams M. Determining target heart rate for exercising in a cardiac rehabilitation program: a retrospective study. J Cardiovasc Nurs. 2015;30(2):164-71. Erratum in: J Cardiovasc Nurs. 2015;30(3):221. doi:10.1097/JCN.0000000000000154.
https://doi.org/10.1097/JCN.000000000000...
,4444 Herdy AH, López-Jiménez F, Terzic CP, Milani M, Stein R, Carvalho T, et al; Diretriz Sul Americana de prevenção e reabilitação cardiovascular. Arq Bras Cardiol. 2014;103(2Supl1):1-31. doi:10.36660/abc.20200407.
https://doi.org/10.36660/abc.20200407...
]. However, it is important to highlight that the increase in exercise intensity is associated with enhanced cardiac output and oxygen consumption, resulting from increased muscle oxygen consumption. Thus, such physiological changes may be associated with greater gains in peripheral muscle strength[4545 Dehart-Beverley M, Foster C, Porcari JP, Fater DCW, Mikat RP. Relationship between the talk test and ventilatory threshold. Clin Exerc Physiol. 2000;2(1):34-8.].

The frequency of interventions found was once to twice daily, lasting 10 to 30 minutes. The South American Guidelines for Cardiovascular Prevention and Rehabilitation[4646 Castro CLB, Araujo CGS. Princípios da prescrição do exercício físico e critérios para realização sob supervisão médica. Rev SOCERJ. 2000;3(4):198-200.] recommended duration between 40 and 60 minutes daily. However, there is no consensus about the appropriate duration of therapy during phase I of cardiovascular rehabilitation.

Another important point in the prescription is the criteria for progression. There are protocols that demonstrate progression in steps that evolve according to patient recovery[4747 Forton K, Motoji Y, Deboeck G, Faoro V, Naeije R. Effects of body position on exercise capacity and pulmonary vascular pressure-flow relationships. J Appl Physiol (1985). 2016;121(5):1145-50. doi:10.1152/japplphysiol.00372.2016.
https://doi.org/10.1152/japplphysiol.003...
,4848 Regenga MM. Fisioterapia em Cardiologia: da Unidade de Terapia Intensiva à Reabilitação. São Paulo: Roca; 2000. 417p.] and others with progressive therapeutic strategies[4949 Umeda IIK. Manual de Fisioterapia na Reabilitação Cardiovascular. São Paulo: Manole, 2005.

50 Babu AS, Noone MS, Haneef M, Naryanan SM. Protocol-guided phase-1 cardiac rehabilitation in patients with ST-elevation myocardial infarction in a rural hospital. Heart Views. 2010;11(2):52-6. doi:10.4103/1995-705X.73209.
https://doi.org/10.4103/1995-705X.73209...
-5151 Dias CM, Vieira Rde O, Oliveira JF, Lopes AJ, Menezes SL, Guimarães FS. Three physiotherapy protocols: effects on pulmonary volumes after cardiac surgery. J Bras Pneumol. 2011;37(1):54-60.]. Winkelman et al.[5252 Winkelmann ER, Dallazen F, Bronzatti AB, Lorenzoni JC, Windmöller P. Analysis of steps adapted protocol in cardiac rehabilitation in the hospital phase. Rev Bras Cir Cardiovasc. 2015;30(1):40-8. doi:10.5935/1678-9741.20140048.
https://doi.org/10.5935/1678-9741.201400...
] described a protocol in which each step is determined by activities with frequency and intensity corresponding to a given energy expenditure (2 to 4 metabolic equivalents of task) until hospital discharge. This form of progression was also used in several studies[77 Cacau Lde A, Oliveira GU, Maynard LG, Araújo Filho AA, Silva WM Jr, Cerqueria Neto ML, et al. The use of the virtual reality as intervention tool in the postoperative of cardiac surgery. Rev Bras Cir Cardiovasc. 2013;28(2):281-9. doi:10.5935/1678-9741.20130039.
https://doi.org/10.5935/1678-9741.201300...
,1414 Pantoni CB, Di Thommazo-Luporini L, Mendes RG, Caruso FC, Mezzalira D, Arena R, et al. Continuous positive airway pressure during exercise improves walking time in patients undergoing inpatient cardiac rehabilitation after coronary artery bypass graft surgery: a RANDOMIZED CONTROLLED TRIAL. J Cardiopulm Rehabil Prev. 2016;36(1):20-7. doi:10.1097/HCR.0000000000000144.
https://doi.org/10.1097/HCR.000000000000...
,1717 Tariq MI, Khan AA, Khalid Z, Farheen H, Siddiqi FA, Amjad I. Effect of early ≤ 3 mets (metabolic equivalent of tasks) of physical activity on patient's outcome after cardiac surgery. J Coll Physicians Surg Pak. 2017;27(8):490-4.,1818 Hirschhorn AD, Richards D, Mungovan SF, Morris NR, Adams L. Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery--a randomised controlled trial. Heart Lung Circ. 2008;17(2):129-38. doi:10.1016/j.hlc.2007.09.004.
https://doi.org/10.1016/j.hlc.2007.09.00...
,2121 Ferrara N, Corbi G, Bosimini E, Cobelli F, Furgi G, Giannuzzi P, et al. Cardiac rehabilitation in the elderly: patient selection and outcomes. Am J Geriatr Cardiol. 2006;15(1):22-7. doi:10.1111/j.1076-7460.2006.05289.x.
https://doi.org/10.1111/j.1076-7460.2006...
,2222 Zanini M, Nery R, Lima J, Buhler R, Silveira R, 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):19-25. http://doi:10.1097/HCR.0000000000000431
http://doi:10.1097/HCR.0000000000000431...
].

The volume of therapy[1515 Silva LN, Marques MJS, Lima RS, Fortes JVS, Silva MGB, Baldez TEP, et al. Retirada precoce do leito no pós operatório de cirurgia cardíaca: Repercussões cardiorrespiratórias e efeitos na força muscular respiratória e periférica, na capacidade funcional e função pulmonar. ASSOBRAFIR Ciênc. 2017;8(2):25-39. doi:10.47066/2177-9333/ac.27867.
https://doi.org/10.47066/2177-9333/ac.27...
,2323 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...
], time[1313 Mendes RG, Simões RP, De Souza Melo Costa F, Pantoni CB, Di Thommazo L, Luzzi S, et al. Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery--a randomised controlled trial. Disabil Rehabil. 2010;32(16):1320-7. doi:10.3109/09638280903483893.
https://doi.org/10.3109/0963828090348389...
], or evolution in positioning were identified as determining factors for progression. Regardless of the form of progression, it is important to consider the functional capacity, clinical condition, use of medications, age, and objectives of the program. Moreover, in the early periods it is essential to respect the adaptation to exercise and later evolve with progression, especially in those who are reestablishing themselves from an acute event, such as cardiac surgery[4545 Dehart-Beverley M, Foster C, Porcari JP, Fater DCW, Mikat RP. Relationship between the talk test and ventilatory threshold. Clin Exerc Physiol. 2000;2(1):34-8.].

In general, the therapy prescription is not clearly defined for patients in phase I of cardiac rehabilitation, as there is no standardization on the “dosage” of the therapy. According to the South American Guidelines for Cardiovascular Rehabilitation[4343 Sebastian LA, Reeder S, Williams M. Determining target heart rate for exercising in a cardiac rehabilitation program: a retrospective study. J Cardiovasc Nurs. 2015;30(2):164-71. Erratum in: J Cardiovasc Nurs. 2015;30(3):221. doi:10.1097/JCN.0000000000000154.
https://doi.org/10.1097/JCN.000000000000...
], in this phase, the focus is patient education and low-intensity exercises, which include from passive mobilization to light walks with individual progressions. However, although the intensity is mild, it is important to respect the criteria of the prescription to guarantee reproducibility and efficacy of therapy, thus respecting the bases of exercise physiology.

In addition, in most of the protocols studied, it is common to perceive the same therapy for all patients. However, it is important to highlight that physical exercise, as well as drug prescription, should be individualized, aiming to maximize the benefits and minimize risks[4545 Dehart-Beverley M, Foster C, Porcari JP, Fater DCW, Mikat RP. Relationship between the talk test and ventilatory threshold. Clin Exerc Physiol. 2000;2(1):34-8.].

Functional loss in the postoperative period is an expected complication if no therapeutic intervention is performed. So, interventions performed in this period aim to maintain functionality during the hospital stay. Divergent data were observed in the studies included in this review. Maintenance of the functional capacity in the intervention group, comparing post and preoperative periods, was found in several studies[22 Ximenes NN, Borges DL, Lima RO, Barbosa e Silva MG, Silva LN, Costa Mde A, et al. Effects of resistance exercise applied early after coronary artery bypass grafting: a randomized controlled trial. Braz J Cardiovasc Surg. 2015;30(6):620-5. doi:10.5935/1678-9741.20150077.
https://doi.org/10.5935/1678-9741.201500...
,77 Cacau Lde A, Oliveira GU, Maynard LG, Araújo Filho AA, Silva WM Jr, Cerqueria Neto ML, et al. The use of the virtual reality as intervention tool in the postoperative of cardiac surgery. Rev Bras Cir Cardiovasc. 2013;28(2):281-9. doi:10.5935/1678-9741.20130039.
https://doi.org/10.5935/1678-9741.201300...
,1313 Mendes RG, Simões RP, De Souza Melo Costa F, Pantoni CB, Di Thommazo L, Luzzi S, et al. Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery--a randomised controlled trial. Disabil Rehabil. 2010;32(16):1320-7. doi:10.3109/09638280903483893.
https://doi.org/10.3109/0963828090348389...
,1515 Silva LN, Marques MJS, Lima RS, Fortes JVS, Silva MGB, Baldez TEP, et al. Retirada precoce do leito no pós operatório de cirurgia cardíaca: Repercussões cardiorrespiratórias e efeitos na força muscular respiratória e periférica, na capacidade funcional e função pulmonar. ASSOBRAFIR Ciênc. 2017;8(2):25-39. doi:10.47066/2177-9333/ac.27867.
https://doi.org/10.47066/2177-9333/ac.27...
,2323 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...
], while others found decrease[1616 Stein R, Maia CP, Silveira AD, Chiappa GR, Myers J, Ribeiro JP. Inspiratory muscle strength as a determinant of functional capacity early after coronary artery bypass graft surgery. Arch Phys Med Rehabil. 2009;90(10):1685-91. doi:10.1016/j.apmr.2009.05.010.
https://doi.org/10.1016/j.apmr.2009.05.0...
,2222 Zanini M, Nery R, Lima J, Buhler R, Silveira R, 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):19-25. http://doi:10.1097/HCR.0000000000000431
http://doi:10.1097/HCR.0000000000000431...
] or similar values[99 Gama Lordello GG, Gonçalves Gama GG, Lago Rosier G, Viana PADC, Correia LC, Fonteles Ritt LE. Effects of cycle ergometer use in early mobilization following cardiac surgery: a randomized controlled trial. Clin Rehabil. 2020;34(4):450-9. doi:10.1177/0269215520901763.
https://doi.org/10.1177/0269215520901763...
]. Concerning to respiratory function, respiratory muscle strength was decreased[1313 Mendes RG, Simões RP, De Souza Melo Costa F, Pantoni CB, Di Thommazo L, Luzzi S, et al. Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery--a randomised controlled trial. Disabil Rehabil. 2010;32(16):1320-7. doi:10.3109/09638280903483893.
https://doi.org/10.3109/0963828090348389...
,2222 Zanini M, Nery R, Lima J, Buhler R, Silveira R, 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):19-25. http://doi:10.1097/HCR.0000000000000431
http://doi:10.1097/HCR.0000000000000431...
] or maintained[1919 Højskov IE, Moons P, Egerod I, Olsen PS, Thygesen LC, Hansen NV, et al. Early physical and psycho-educational rehabilitation in patients with coronary artery bypass grafting: a randomized controlled trial. J Rehabil Med. 2019;51(2):136-43. doi:10.2340/16501977-2499.
https://doi.org/10.2340/16501977-2499...
,2020 Hansen D, Dendale P, Berger J, Meeusen R. Rehabilitation in cardiac patients: what do we know about training modalities? Sports Med. 2005;35(12):1063-84. doi:10.2165/00007256-200535120-00005.
https://doi.org/10.2165/00007256-2005351...
] in both intervention and control groups, while lower incidence of respiratory complications[1414 Pantoni CB, Di Thommazo-Luporini L, Mendes RG, Caruso FC, Mezzalira D, Arena R, et al. Continuous positive airway pressure during exercise improves walking time in patients undergoing inpatient cardiac rehabilitation after coronary artery bypass graft surgery: a RANDOMIZED CONTROLLED TRIAL. J Cardiopulm Rehabil Prev. 2016;36(1):20-7. doi:10.1097/HCR.0000000000000144.
https://doi.org/10.1097/HCR.000000000000...
] was found in the intervention group . The protocols presented by Ximenes et al.[22 Ximenes NN, Borges DL, Lima RO, Barbosa e Silva MG, Silva LN, Costa Mde A, et al. Effects of resistance exercise applied early after coronary artery bypass grafting: a randomized controlled trial. Braz J Cardiovasc Surg. 2015;30(6):620-5. doi:10.5935/1678-9741.20150077.
https://doi.org/10.5935/1678-9741.201500...
], Cacau et al.[77 Cacau Lde A, Oliveira GU, Maynard LG, Araújo Filho AA, Silva WM Jr, Cerqueria Neto ML, et al. The use of the virtual reality as intervention tool in the postoperative of cardiac surgery. Rev Bras Cir Cardiovasc. 2013;28(2):281-9. doi:10.5935/1678-9741.20130039.
https://doi.org/10.5935/1678-9741.201300...
], Borges et al.[3636 Ferrara N, Corbi G, Bosimini E, Cobelli F, Furgi G, Giannuzzi P, et al. Cardiac rehabilitation in the elderly: patient selection and outcomes. Am J Geriatr Cardiol. 2006;15(1):22-7. doi:10.1111/j.1076-7460.2006.05289.x.
https://doi.org/10.1111/j.1076-7460.2006...
], Stein et al.[1616 Stein R, Maia CP, Silveira AD, Chiappa GR, Myers J, Ribeiro JP. Inspiratory muscle strength as a determinant of functional capacity early after coronary artery bypass graft surgery. Arch Phys Med Rehabil. 2009;90(10):1685-91. doi:10.1016/j.apmr.2009.05.010.
https://doi.org/10.1016/j.apmr.2009.05.0...
], and Zanini et al.[2222 Zanini M, Nery R, Lima J, Buhler R, Silveira R, 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):19-25. http://doi:10.1097/HCR.0000000000000431
http://doi:10.1097/HCR.0000000000000431...
] presented the best results in the most relevant outcomes.

Despite all the restrictions of the prescription of early mobilization in the postoperative period of cardiac surgery, due to the severity of the patient in phase I of cardiovascular rehabilitation, its benefits in this population are known. Thus, the question arises: would a mobilization program carefully prescribed for patients in the postoperative period of cardiac surgery be able to optimize outcomes?

CONCLUSION

During the hospitalization phase, the prescription of early mobilization is not a frequent concern, since there are few studies specifically targeting the most appropriate type, intensity, frequency, duration, and progression. In addition, the protocols are generalist and not individual, as recommended by the physiological bases of exercise prescription. As for the studies included in the review, low-intensity exercises are used, through progressive mobilization, once to twice daily, during 10 to 30 minutes.


Authors' roles & responsibilities

  • No financial support.

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Publication Dates

  • Publication in this collection
    14 Mar 2022
  • Date of issue
    Mar-Apr 2022

History

  • Received
    04 Mar 2021
  • Accepted
    15 July 2021
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