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1  DOI: https://doi.org/10.47391/JPMA.584
2 

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3  Physiotherapy practices for patients undergoing coronary artery

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4  bypass grafting: a cross- sectional study

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5 

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6  Muhammad Khan, Shaikh Nabi Bukhsh Nazir, Aftab Ahmed Mirza Baig

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7  Department of Physical Therapy, Institute of Physical Medicine Rehabilitation, Dow
8  University of Health Sciences, Karachi, Pakistan

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9  Correspondence: Aftab Ahmed Mirza Baig Email: [email protected]
10 

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11  Abstract

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12  Objective: To evaluate physiotherapy practices in the rehabilitation of patients
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13  undergoing coronary artery bypass grafting.
14  Methods: The cross-sectional study was conducted from October 2016 to
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15  January 2017 in cardiac care units of two private and two government hospitals
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16  in Karachi, and comprised physiotherapists dealing with patients undergoing

17  coronary artery bypass grafting. Data was collected using a modified and
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18  validated version of ‘tucker q’ questionnaire. Data was analysed using SPSS 21.
19  Results: Of the 101 physiotherapists, 60(59.4%) were females and 41(40.6%)
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20  were males. The overall work experience was 4.89+2.08 years. Of the total,
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21  60(59.4%) physiotherapists used air suctioning in preoperative physiotherapy

22  practices. Relaxation techniques were used by 86(85.10%) professionals and
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23  postural drainage by 85(84.20%), while breathing exercises were used by

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24  65(64.4%) subjects in postoperative physiotherapy practices.

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25  Conclusion: Physiotherapists were found to be more or less keeping abreast

26  with advances made regarding managing patients undergoing cardiac artery
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27  bypass grafting.

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28  Key Words: Coronary artery surgery, Heart surgery, Cardiac rehabilitation,
29  Physical therapy, Breathing exercises, Postoperative care.
30 

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31  Introduction

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32  Coronary artery disease (CAD) is a major health problem and attains one of the

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33  highest susceptibilities among the population with Indo-Asian origin,

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34  worldwide. Therefore, it is the foremost cause of death in the subcontinent

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35  currently.1 The higher mortality rate is seen in the developing countries than the

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36  developed countries due to less accuracy of diagnosis, treatment and prevention.
37  The mortality rates of CAD in Georgia and Ukraine are 43% and 45%
38  respectively and it is 20% in Turkey. CAD is more prevalent in Iran 12.7%

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39  among Middle East countries. In Saudi Arabia, its prevalence is 5.5% and in
40  Jordan, it is 5.9%.2 One in five middle-aged individual may have underlying
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41  CAD in urban Pakistan. Females are at greater risk than males in Pakistan1
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42  whereas males have higher chances of developing CAD risk than females
43  worldwide.3 Increased waist circumference (WC) and body mass index (BMI)
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44  are important risk factors for CAD development, whereas the reported risk
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45  factors of CAD are obesity, diabetes, dyslipidaemia, smoking and high blood
46  pressure.1,4 The American College of Cardiology (ACC) regards “aging” to be
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47  an important risk factor for CAD mortality other than the five factors.5
48  There are numerous options for CAD treatment. Cardiac artery bypass grafting
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49  (CABG) has been established as a reliable option for treating patients with
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50  partial or complete blockage of coronary arteries. It has good prognosis,

51  resulting in remission of angina and improved health status of CAD patients. In
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52  spite of its effectiveness, it is a highly invasive method, often entailing

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53  prolonged bed-rest, reduced aerobic capacity, loss of muscle strength and mass,
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54  along with physical de-conditioning. In order to reduce and prevent such
55  damaging effects, cardiopulmonary rehabilitation is essential in the recovery
56  and preventive course, and must be started as soon as possible.6
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57  The role of physiotherapy as cardiopulmonary rehabilitation in the intensive

58  care unit (ICU) has been recently highlighted with its importance in early
59  mobilisation. Thus, pre- and post-operative physiotherapy is beneficial in

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60  reducing and preventing postoperative cardiopulmonary complications. The

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61  physiotherapists use various practice options for this reason with a lack of

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62  standardisation regarding the intensity, type, frequency, and duration of

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63  interventions. The physiotherapist can easily tailor treatment interventions in

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64  cardiopulmonary physiotherapy to the patients’ need.7,8,9 Literature contains

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65  utilisation of various approaches in physiotherapy practice7-10, but debate is still
66  going on regarding which treatment options are best. The current study was
67  planned to assess pre- and post-operative physiotherapy practices on patients

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68  undergoing CABG.
69 
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70  Subjects and Methods
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71  The cross-sectional study was conducted from October 2016 to January 2017 in
72  cardiac care units of two private and two government hospitals in Karachi, and
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73  comprised physiotherapists dealing with CABG patients. After getting approval
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74  from the ethics review board of Dow University of Health Sciences (DUHS),
75  Karachi, the sample size was calculated using Open-Epi version 3.011 with a
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76  hypothesized frequency of 93% physiotherapists instructing the patients to

77  perform breathing exercises on a regular basis after cardiac surgery, confidence
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78  limit 5%, data effect 1% and confidence level 95%.12 The sample was raised
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79  using non-probability purposive sampling technique. Those included were

80  physiotherapists of either gender working in the cardiothoracic departments of
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81  hospitals for more than one year. Ohysiotherapists not treating CABG patients
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82  were excluded. After taking informed consent, a self-administered modified

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83  validated version of ‘tucker q’ questionnaire was used to collect data after
84  taking permission from the relevant authors.9 The questionnaire comprises
85  closed-ended questions about treatments and techniques used in pre- and post-
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86  operative physiotherapy practice for patients undergoing CABG. Data was
87  analysed using SPSS 21. Frequencies and percentages were used to present
88  baseline parameters, different measures of outcomes used by the

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89  physiotherapists, assessment techniques commonly used in community hospitals

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90  and the sources of information on pre- and post-operative management of

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91  CABG patients. Mean and standard deviation were used for quantitative data.

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92 

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93  Results

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94  Of the 101 physiotherapists, 60(59.4%) were females and 41(40.6%) were
95  males. The overall work experience was 4.89+2.08 years. Air suctioning was
96  the most common practice in pre-operative physiotherapy practices 60(59.4)

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97  (Figure 1). Relaxation techniques and postural drainage were used more often
98  than breathing exercises in post-operative physiotherapy practices (Table;
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99  Figure 2). Peer pressure and preferences of professional colleagues influenced a
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100  physiotherapist’s post-operative practice (Figure 3).
101 
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102  Discussion
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103  Physiotherapists actively participate in the rehabilitation of CABG patients and

104  in identifying post-operative pulmonary complications 13, but the current study
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105  found much less participation in the pre-operative phase. A study suggested that
106  pre-operative physiotherapy decreased pneumonia and length of hospital stay.13
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107  The current study’s findings regarding pre-operative physiotherapy might be

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108  reflective of less awareness of evidence-based physiotherapy for this purpose.

109  CABG is associated with post-operative reductions of functional residual
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110  capacity (FRC). Airway clearance techniques aim at preventing airway plugging
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111  to improve FRC post-surgery.14 An observational study reported decrease in the

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112  incidence of pneumonia among quaternary care cardiac surgical population with
113  airway suctioning15 The current study supported these finding in the manner of
114  response from the physiotherapists. Literature suggests airway suctioning,
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115  hyperinflation and weaning that may result in increased lung compliance in
116  patients. Their clinical implication is still unclear.16 In the current study all
117  physiotherapists showed positive response to airway suctioning,

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118  hyperinflation/bagging and weaning off respirator for patients post-CABG with

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119  majority opting for airway suctioning.

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120  Mostly, physiotherapists treat patients routinely following heart surgery with

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121  one to three sessions per day,17 suggesting different selections of sessions’

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122  number and days. A prospective cross-sectional study found all physiotherapists

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123  offering one to three treatment sessions on post-operative day 1 for all patients
124  undergoing CABG.17 In contrast, the current study showed that half of the
125  physiotherapists provided treatment to only certain patients and half to all

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126  patients in ICU on post-operative day 1. The sample size of current study was
127  comparatively larger, and the results might be due to lack of awareness or weak
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128  decision-making of physiotherapists. Another cross-sectional study found that
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129  Canadian physiotherapists recommended provision of cardiorespiratory
130  treatment on post-operative day 1.18 The study survey was done over the
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131  telephonic, and there might have been limited understanding. The current study
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132  was done face-to-face.

133  Breathing exercises, postural drainage and relaxation techniques are the most
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134  suitable choices of treatment provided to patients on the first four post-operative
135  days9, whereas different modes of these interventions are used on the basis of
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136  patients’ needs. Westerdel et al in 2015 collected 29 Swedish physiotherapists’

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137  responses in a cross-sectional study, and showed that all the physiotherapists
138  instructed breathing post-operatively. All physiotherapists reported frequency
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139  and duration of the exercises which varied from 4 to 30 breaths hourly during
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140  the daytime on the first post-operative day.9 The current study suggested that
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141  half of the physiotherapists instructed all their patients to breathe 20-25 breaths
142  per session, and the other half instructed less than 20 breaths per session on a
143  regular basis. Moreover, findings suggest that more than half of the
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144  physiotherapists recommended breathing exercises with device for home

145  programme to certain patients in the post-operative phase.
146  A study used ventilator response as outcome measure for peak oxygen uptake in

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147  patients suffering with cardiac disease before and after completion of 8-week

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148  cardiac rehabilitation. It recommended the measure.19

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149  To the best of our knowledge, the current studyis the first to assess practice in

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150  physiotherapy outcome measures for patients undergoing CABG, and has given

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151  additional results for outcome measures used by the physiotherapists.

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152  The current study is limited to the current practice for patients undergoing
153  CABG in Karachi only. Its findings cannot be generalised. The questionnaire
154  was self-reported and there is a possibility of respondent’s wrong understanding

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155  to the question or misconception regarding their practice.
156 
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157  Conclusion
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158  The current physiotherapy practices in patients undergoing CABG were found
159  to be relatively updated with the available evidence on their expected role.
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160 
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161  Disclaimer: None.

162  Conflict of interest: None.
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163  Source of Funding: None.

164 
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165  References
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166  1. Jafar TH, Qadri Z, Chaturvedi N. Coronary artery disease epidemic in

167  Pakistan: more electrocardiographic evidence of ischaemia in women
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168  than in men. Heart. 2008; 94(4):408-13.

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169  2. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A.

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170  Growing epidemic of coronary heart disease in low-and-middle-income

171  countries. Curr Probl Cardiol .2010; 35:72-115.
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172  3. Yahagi K, Davis HR, Arbustini E, Virmani R. Sex differences in

173  coronary artery disease: pathological observations. Atherosclerosis. 2015;
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175  4. Yusuf S, Reddy S, Ôunpuu S, Anand S. Global burden of cardiovascular

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176  diseases part I: general considerations, the epidemiologic transition, risk

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177  factors, and impact of urbanization. Circulation. 2001; 104:2746-53

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178  5. Barengo NC, Antikainen R, Borodulin K, Harald K, Jousilahti P.

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179  Leisure‐time physical activity reduces total and cardiovascular mortality

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180  and cardiovascular disease incidence in older adults. J Am Geriatr Soc.
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183  al. Coronary-artery bypass surgery in patients with ischemic
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185  7. Stammers AN, Kehler DS, Afilalo J, Avery LJ, Bagshaw SM, Grocott HP
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186  et al. Protocol for the PREHAB study—Pre-operative Rehabilitation for
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188  a randomized controlled trial. BMJ. 2015; 5(3):1-9.

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189  8. Da Costa Torres D, dos Santos PM, Reis HJ, Paisani DM, Chiavegato
190  LD. Effectiveness of an early mobilization program on functional
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191  capacity after coronary artery bypass surgery: A randomized controlled

192  trial protocol. SAGE Open Med. 2016; 4:1-8.
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193  9. Westerdahl E, Olsén MF. Chest physiotherapy and breathing exercises

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194  for cardiac surgery patients in Sweden-a national survey of practice.

195  Monaldi Arch Chest Dis. 2015; 75(2):112-19.
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196  10. Fiore JF, Chiavegato LD, Paisani DM, Colucci DB. Utilization of
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197  positive-pressure devices for breathing exercises in the hospital setting: A

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198  regional survey in Sao Paulo, Brazil Respir Care. 2010; 55: 719-24.
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199  11. Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic
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202  12. Lomi C, Westerdahl E. Physical therapy treatment after cardiac surgery: a

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203  national survey of practice in Greece. J Clin Exp Cardiolog S. 2013; 7: 1-

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204  5.

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205  13. Valkenet K, Trappenburg JC, Hulzebos EH, van Meeteren NL, Backx FJ.

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206  Effects of a pre-operative home-based inspiratory muscle training

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207  programme on perceived health-related quality of life in patients
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209  103(3):276-82..

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210  14. Paulus F, Veelo DP, de Nijs SB, Beenen LF, Bresser P, de Mol BA et al.
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213  Care. 2011; 15(4):187-92.
214  15. Hudson JK, McDonald BJ, MacDonald JC, Ruel MA, Hudson CC.
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215  Impact of subglottic suctioning on the incidence of pneumonia after

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216  cardiac surgery: a retrospective observational study. J Cardiothorac Vasc

217  Anesth. 2015; 29(1):59-63.
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218  16. Overend TJ, Anderson CM, Brooks D, Cicutto L, Keim M, McAuslan D
219  et al. Updating the evidence base for suctioning adult patients: a
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220  systematic review. Can Respir J. 2009; 16(3): 6-17.

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221  17. Westerdahl E, Möller M. Physiotherapy-supervised mobilization and

222  exercise following cardiac surgery: a national questionnaire survey in
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223  Sweden. J Cardiothorac Surg. 2010; 5(1):67-70.

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224  18. Overend TJ, Anderson CM, Jackson J, Lucy SD, Prendergast M, Sinclair
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225  S. Physical therapy management for adult patients undergoing cardiac

226  surgery: a Canadian practice survey. Physiother Can. 2010; 62(3):215-21.
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227  19. Andersen KS, Laustsen S, Petersen AK. Correlation between exercise
228  capacity and quality of life in patients with cardiac disease. J Cardiopulm
229  Rehabil Prev. 2018; 38(5):297-303.

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231  ----------------------------------------------------
232 
233  Table 1: Physiotherapists’ responses for post-operative practice of cardiac patients.

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Serial Multiple option questions Frequency Percentage

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.No (n=101) (%)
1. Days of physiotherapy after surgery.

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a. Routinely 75 74.3%
b. If needed 25 24.7%

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c. Never 1 01.0%
2. Physiotherapy sessions per day.

a. One per day 18 17.8%

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b. Two per day 46 45.5%
c. Three per day 37 36.7%
3. Physiotherapy on day 1’
a. No
ed 1 1.0%
b. Only certain cases 55 54.5%
c. Yes to all patients 45 44.5%
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4. Breathing exercises on regular basis.
a. No 32 31.7%
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b. Only certain cases 43 42.6%

c. Yes to all patients 26 25.7%
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6 Breaths per session during breathing exercise.

a. < 20 46 45.4%
b. 20-25 49 48.6%
c. >25 6 6.0%
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7 Recommendation to performing breathing exercises at home

after discharge.
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a. Only certain patients 46 45.5%

b. Yes to all patients 55 54.5%
234 
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235  -----------------------------------------------
236 
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100.00%

90.00%

80.00% 40.60%
50.50%

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70.00%
71.30%

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60.00%

50.00% No

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40.00% Yes

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30.00% 59.40%
49.50%

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20.00%
28.70%
10.00%

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0.00%
Manual Suction of airways Weaning off respirator
hyperinflation/bagging
237 

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238  Figure 1: Physiotherapists’ approach towards patients undergoing coronary artery

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239  bypass grafting (CABG) pre-operatively
240 
241 
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------------------------------------------------------
242 
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14.90%
Relaxation technique
85.10%
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15.80%
Postural drainage
84.20%
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34.70%
Positioning
65.30%
40.60%
Percussion
59.40%
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31.70%
Cough/huff
68.30%
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35.60%
Breathing exercise
64.40%
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0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%

NO YES
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243 
244  Figure 2: Physiotherapy techniques administered post-operatively.
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245 
246  ------------------------------------------------
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60.00% 55.40% 56.40%

49.50%
50.00% 46.50% 47.50%
45.50% 45.50% 45.60% 44.60%
43.60% 43.60% 42.60%
40.60%

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40.00%
34.70%
31.50% 31.70%

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29.70% 30.80%
30.00%
23.70% 22.80%

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20.00% 15.80%
14.90%

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9.90% 10.90%
8.90% 8.90%
10.00% 5% 5%
4%

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2.00% 1% 1%
0 0 0% 0%
0.00%

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No influence Somewhat influence Moderately influence Very influence

248  Figure 3: Physiotherapists’ responses for influences on their post-operative practice.

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249 
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