Physiotherapy After Heart Surgery

Globally Heart disease is the leading cause of death. Due to the unchecked rise in risk factors like obesity, smoking, cholesterol etc the fury of heart disease continues to wreak havoc worldwide.

The problems arising from heart disease are corrected through lifestyle modification, pharmacological management ,surgical procedures and cardiac rehabilitation.

The primary goal of surgery is healing the affected area of heart and ensuring blood flow. Some surgical procedures that help improve heart health are- 

1. PTCA- Percutaneous Transluminous Coronary Angioplasty.
2. Coronary Artery Bypass Graft.
3. Valve replacement or repairs.
4. Insertion of ventricular assistive devices (LVAD).
5. Heart transplants.

What happens during a heart surgery?

Globally, CABG or bypass surgery is the most frequently performed heart surgery. It's a complicated surgery involving the following steps -

• The patient is put on a ventilator to help them breathe.
• IV lines are put in to administer medications directly.
• A catheter is inserted in the bladder to drain out urine.
• Sometimes a heart lung bypass machine is used to take over the job of pumping oxygenated blood.
• An Incision is done on the midline of the chest.
• The Breastbone(sternum) is split.
• The rib cage is spread out to access the heart.
• One or more veins from the leg or arm are harvested to act as the bypass for the blocked vessels.
• After completion of all steps patients rib cage is lowered and incision is closed using sutures or staples.

What problems can arise after heart surgery? 

Some of the Problems that can arise after heart surgery are as follows-

1. Surgical Complications(Graft related)

• Thrombosis
• Graft damage, infection, kinking or malposition

2. Surgical Complications (Not Graft related)

• Bleeding.
• Blood clots 
• Delayed wound healing
• Embolism.
• Pneumonia.
• Breathing issues.
• Arrhythmia.

To know more regarding this, stay updated through Truepal.

What is Cardiac Rehabilitation? Who can be a part of cardiac rehabilitation?

Cardiac rehabilitation (cardiac rehab) is a multidisciplinary approach to treat individuals with heart disease. The team includes cardiologists, surgeons,physical therapists, nurses ,nutritionists etc. 

The people with following conditions can be included in cardiac rehabilitation-

• Coronary artery disease
• Heart attack
• Congestive heart failure
• Post heart surgery- CABG,valve repairs, LVAD placements,transplants etc.

The anticipated goals and outcomes of cardiac rehabilitation are: 

1. Increase the patient's aerobic capacity.
2. Improve the patient’s response to increased oxygen demand during daily activities.
3. Improve patient’s, strength,power and endurance.
4. Reduce risk of future occurrence of heart problems.
5. Identify warning signs .
6. Keep family and caregivers updated about necessary post surgical precautions and expected recovery timelines. 

Why is physiotherapy after heart surgery important?

Physical therapy plays a vital role in patient recovery after heart surgery. The goals of physical therapy after heart surgery are:

• Document

The physiotherapist documents all tests,expected goals and progress of the patient. Any complications or difficulty related or unrelated to the sessions are also documented. Any environmental barriers are identified

• Prevent post surgical complications.

Gentle physiotherapy and guided exercises prevent postoperative complications like blood clots and circulation issues, maintain lung health and prevent damage at the harvest site.

Prolonged positioning during surgery sometimes results in an injury to the brachial plexus. The role of a physiotherapist is to rule out and formulate a plan for any such injuries with gentle assessment after medical clearance.

• Educate about lifestyle modification.

Physiotherapists help address modifiable risk factors and improve resulting poor health outcomes. 

Some modifiable risk factors that can result in major health issues are high blood pressure,cholesterol,diabetes, smoking, excessive alcohol and obesity.

Patients are also taught about the importance of leading an active lifestyle

• Help set recovery goals.

Recovery from heart surgery is complex and can be very overwhelming. A physiotherapist helps you through guided protocols, safety instructions and recovery timelines.

• Administer & educate about wound care precautions

The incision sites at the sternum and the sites from where the vein or artery is harvested are at risk of infection. Patients and family are instructed to report any discharge,foul smell, increase in temperature or pain around the scar or an unhealing wound.

‘Sternal precautions’ are used by physical therapists to prevent scar adhesion.Scar adhesions over the chest wall can reduce mobility and make breathing difficult and energy consuming. The sternal incision takes 6 to 8 weeks for healing. Patients are not allowed to push or pull objects during this time or lift objects heavier than 5 to 8 lbs.

• Educate patients about warning signs ..

Any sudden or gradual experience of blurred vision, breathlessness, inability to move facial muscles ,confusion ,dizziness ,fever ,bleeding,unbearable pain or ache even on medications are all emergency signs requiring immediate medical attention. Patients are also taught to stop or modify exercise routines if these signs are noticed.

The role of a physical therapy is to reinforce awareness of these indicators in the patient and family members. 

• Educate about the importance of stress management.

Due to the overwhelming nature of the condition and its complex treatment ,patients can get easily overwhelmed .The role of physiotherapist includes identifying stressors for the patient and finding solutions for them.

The physiotherapist also teaches relaxation techniques such as Pranayama, diaphragmatic breathing exercises and guided sensory imagery.

Guided sensory imagery uses sensory feedback such as images, sounds to help patients visualise a different, more relaxed environment e.g. sounds of waterfall, birds chirping etc.

• Alert about fall risk

Patient’s are attached to many drains ,wires and IV’s after surgery. Also the patient can easily overestimate their abilities according to their pre surgery status.This can lead to an increased risk of fall.

Due to this patient is advised on the hazards of self mobilizing especially in the inpatient stage of recovery.

The role of physiotherapist is to emphasize the need for assisted mobility and careful ambulation in the early stages of recovery.

• Monitor vitals during ADLs

The physiotherapist monitors baselines such as heart rate , respiratory and pulse rate along with oxygen saturation.

The patient is also taught to self monitor during daily activities once discharged from the hospital

• Improve aerobic capacity through safe and effective exercises.

The Clinical Practice Guidelines For Cardiac Rehabilitation agree that guided exercises improve exercise tolerance for patients with heart disease. These guidelines form the baseline for physical therapy after heart surgery.

• Exercise training for at least  3-5 days for 12 weeks after heart surgery.
• Duration approximately 30-40 minutes aerobic exercise, with 5 to 10 minutes warmup and 5 minutes rest after each set.
• Exercise heart rate should be around 70 to 85 %.
• Exercise intensity is assessed using a patient rated scale called RPE scale( rating of perceived exertion)- all symptoms such as fatigue ,muscle cramps , breathlessness etc are identified with this scale.
• Exercise tolerance test- A physiotherapist performed test to assess the ability( of the heart) to tolerate increasing activity load. This test assists to create safe activity guidelines on discharge.
• Heart rate max- If the above test cannot be safely performed 60 to 85 % of patients maximum heart rate is calculated.

Phases of Cardiac Rehabilitation

To ensure patient safety and standardize treatment , cardiac rehabilitation or physiotherapy after heart issues is divided into four phases:-

• Acute/ Inpatient Phase (Phase I)

The goals in this phase are to prevent complications,improve circulation, strengthen lungs and resume gentle and safe movements. Patients are discharged by day 5 if there are no complications.

• Day 1-2

# incentive spirometry and diaphragmatic breathing.

#Coughing technique i.e to either hug a pillow or use a binder when coughing, sneezing or when abdominal pressure is increased.

# Assisted sitting on the edge of bed with feet supported.

# Walk to a chair near the bedside with assistance.

# Only sitting on a supported chair , 30 minutes a few times a day.

• Day 3-5

# Hallway walking progressed gradually.

# Education on sternal precaution is given .

# Gentle limb movements are started with clearance from the surgeon.

# Breathing exercises continued.

# Stair climbing commences after medical clearance.

• Subacute/ Early Outpatient( Phase II)

Phase II begins after discharge. It lasts from week 2 to week 8 depending on the surgeon's recommendation and patient's recovery.

Patients undergo Exercise Tolerance Test (ETT) around 4 to 6 weeks after surgery or as advised by the surgeon. If this is not achievable, 65 to 80 % of patients' maximum heart rate calculated and exercises are prescribed safely.

A combination of rest and gentle mobility exercises for upper limb and lower limb are done in this phase.

Patients are encouraged to change positions every 1 to 2 hours.

Strength training begins 8 weeks after cardiac surgery with around 12 to 15 repetitions. 

• Outpatient (Phase III)

This phase starts after 8 to 12 weeks. Regular self directed exercises are encouraged with supervision. A structured supervised aerobic and strength training routine is prescribed to the patient.

Stress management techniques and self monitoring for warning signs are reemphasised for the patient.

• Long Term Maintenance (Phase IV)

Community ,home or gym based rehabilitation is continued for life.

Patients are encouraged to resume recreational activities . Patients continue with routine follow ups with the cardiac rehab team.

Emphasis is placed on maintaining a healthy lifestyle and eliminating modifiable risk factors.

Tips & Tricks for fast recovery

The best way to speed up recovery after heart surgery is to use Energy Conservation Techniques.

Energy conservation techniques, as the name suggests, are tricks that help complete tasks faster with optimal or less effort.

The techniques are-

• Pacing- break tasks into smaller steps, rest at intervals before fatigue sets and alternate between heavy and light tasks.
• Prioritizing- Most important task first. Use to do list. Delegate non essential tasks.
• Planning- plan your tasks when your mind is awake and fresh.
• Positioning- keep all things ready prior to an activity. Running back and forth to get things causes fatigue and delays task completion.
• Use Adaptive equipment- shower railings,shower chairs,wheel cart to carry heavy objects ,long handled tools to reduce strain and use lift where available .
• Work Simplification- Make use of appliances like microwave, dishwasher ,washing machine etc to simplify daily living.
• Good Body ergonomics- Do not hunch or strain during activities.Keep items closer to you during lifting . 
• Environmental modification- Organize work space and reduce clutter.Keep frequently used items closer to you.

Final thoughts 

A determined and compliant patient along with a cardio specialised physical therapist can easily scale the challenge of heart surgery recovery. 

A standardized treatment protocol helps patients not just survive but thrive after heart surgery.

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FAQs

1. When should I start physiotherapy after heart surgery?

A medically stable patient is referred for physiotherapy as early as 24 to 48 hours after surgery.

2. Is physiotherapy safe after heart surgery?

Yes, physiotherapy is absolutely safe after a heart surgery. Physiotherapy done by a qualified cardio respiratory physiotherapist will improve the chances of fast recovery.

3. How long does cardiac rehabilitation take?

Cardiac rehabilitation lasts for around 8 to 12 weeks . However maintenance therapy and followup visits will continue lifelong.

4. Can I do physiotherapy after heart surgery at home? 

Yes.If visiting hospital regularly is difficult and you have access to a qualified homecare physiotherapist ,then it can be done. Home physiotherapy or visiting a clinic, whichever ensures compliance should be the location of choice for therapy.

5. What precautions should I take during post surgery    physiotherapy?

Learn to self monitor vitals, know when to stop and seek help and do not be in a rush. 

6. Can online videos and brochures alone help my recovery?

No, due to the complicated nature of the surgery and heart disease itself it is recommended that any protocols followed should be only under the guidance of a qualified healthcare professional. 

Online resources should only be treated as informative adjuncts.

7. What signs indicate I should stop or adjust my physiotherapy routine?

Dizziness, breathing difficulty, blackouts, blurred vision, vomiting, high BP , fever and chills are some of the reasons to stop physiotherapy at least until evaluated further.