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Citation: 5 Contemp. Readings L. & Soc. Just. 177 2013

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ontemporaryReadings nLaw and Social JusticeVolume 5 2), 2013 pp. 177-182 ISSN 1948-9137

PHYSIOTHER PY M N GEMENT ND MOBILIZ TIONROUTINES O C RDI C SURG RY P TIENTS

MIHAI P T HImihai.patachia gmail.comWitting Clinic Hospital Bucharest

ABSTRACT. The purpose of this article is to gain a deeper understanding of therole of sympathetic overactivation in heart failure the use of CPET for the func-tional evaluation of cardiac patients in both clinical and research settings the routinepostoperative physiotherapy management of patients undergoing uncomplicated open-heart surgery and the importance of pre-training cardiovascular risk assessment.My paper contributes to the literature by providing evidence on changes in CPETparameters induced by recent coronary and valvular surgery the role of early mobil-ization of postoperative surgical patients the effect of short-term supervised inpatientphysiotherapy exercise upon cardiac autonomic nervous function the impact ofexercise programs for PAD patients on mortality or incidence of revascularizationand amputations and the postoperative recovery of the cardiac surgery patient.Keywords: physiotherapy management mobilization cardiac surgery patient

1 ntrodu tionThis paper aims to analyze and discuss techniques of respiratory physio-therapy used in the postoperative complications PO) of heart surgery, thepositive effect of physical exercise on cardiac autonomic activity, mobil-ization and exercises usually provided to the patients on the first postoper-ative days after surgery, and the role of mobilization therapy in patients withacute illness requiring high dependency or intensive care. The findings ofthis study have implications for the potential of biofeedback therapies incardiovascular disease, the efficacy of preoperative physiotherapy, physio-therapy-supervised mobilization and exercise after cardiac surgery, and thebenefits derived from participation in exercise-based cardiac rehabilitation.


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2 The Efficacy of Preoperative hysiother pyCardiac patients should attend cardiac rehabilitation programs. Exercise train-ing is associated with more events than exercise testing. The SWT inducespotentially more serious cardiovascular events than exercise training: thepatients eventually achieve exercise at a higher intensity than during circuit-based exercise training. The presence of silent myocardial ischaemia does notnecessarily signify a severe cardiovascular condition. (Pepera et al., 2013)The elderly population represents a perfect population to benefit from for-mal cardiac rehabilitation and exercise training (CRET) programs. Elderlypatients are universally underrepresented in CRET programs. Increased in-flammation is a strong indicator of cardiovascular (CV) health and the riskfor adverse events. (Menezes, 2012)Aerobic exercise training and chest physiotherapy are vital componentsof the rehabilitation program of cystic fibrosis patients. Aerobic exerciseincreases forced expiration and sputum clearance in children with cysticfibrosis. In young children with cystic fibrosis, aerobic exercise programcombined with active cycle of breathing techniques increases strength. Theincreased strength of children with cystic fibrosis following the physio-therapy program is related to the aerobic training provided. Active cycle ofbreathing techniques combined with aerobic training and posture exercisesincrease thoracic mobility and exercise tolerance in clinically stable cysticfibrosis patients. (Elbasan et al., 2012) Exercise may present health risks topatients with certain cardiovascular pulmonary, and metabolic diseases(physical therapists should make sound decisions to identify which exerciseinterventions are appropriate and safe for individual patients). Physical ther-apists have the knowledge to make well-educated decisions (Petersmann,2013) about exercise appropriateness. (Scherer, 2009) Lower heart rate vari-ability (HRV) reflects an intrinsic impairment in the regulation of the heart ssinoatrial node rhythm. An exercise-based rehabilitation program improvescardiac autonomic function assessed by HRV in patients after coronaryartery bypass grafting (CABG) at the time of hospital discharge. The cardiacautonomous neural system (Georgescu, 2012) is related to the functionalproperties of the heart. Early mobilization after CABG is safe and benefi-cial with respect to autonomic modulation. Exercise-based inpatient cardiacrehabilitation (CR) may be an effective non-pharmacological tool to improveautonomic cardiac tone in patient s post-CABG. (Gonc et al., 2010)

3. The Positive Effect of Physical Exercise on CardiacAutonomic ActivityPhysiotherapy procedures provide stability ofhemodynamic variables. Physio-therapy treatment improves newborns hemodynamic parameters, diminishing


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cardiovascular instability. Chronic chest and motor physiotherapy helps tostabilize cardiovascular parameters in SDR newborns. Chronic physiotherapymaneuvers such as clapping or vibration followed by suction and posturaldrainage and/or vacuum improve cardiovascular variables in newborns withSDR. Chest and motor physiotherapy treatment can improve basal cardio-vascular parameters in newborns with respiratory distress syndrome newborns.(de Abreu et al., 2011 Physiotherapy following cardiac surgery prevents andtreats postoperative complications (Toader, 2013), improving pulmonaryfunction and promoting physical activity. The routine use of early mobil-ization and upper extremity exercises is common during the first postoper-ative days. The individual strength (Trofin and Tomescu, 2011 and cardio-vascular status of the patient (David, 2012) decides the level and intensityof mobilization. There are only small variations in physiotherapy-supervisedexercise and mobilization following cardiac surgery. (Westerdahl and Mbller,2010) Physiotherapists can facilitate cardiorespiratory function through avariety of interventions. A recognized process of cardiorespiratory continuingeducation (Peters, 2012) should be developed to provide a vehicle for main-taining (Preduca, 2011 and upgrading competency. Detection of hyperten-sion and identification of risk factors are not firmly entrenched as traditionalphysiotherapy practice. (Reid et al., 2008)

Regular physical activity contributes to primary prevention of cardiovas-cular disease. Exercise therapy may not improve aerobic fitness as facilitaterehabilitation (Pdrlea-Buzatu, 2011) after an episode of illness and neuro-muscular deconditioning. Specific types of mobilization therapy (Pera, 2013)are tailored to patient needs. Early mobilization therapy for patients withacute illness has a positive effect on rate of recovery. The data in support ofmobilization therapy for perioperative and critically ill patients justify aparadigm shift in attitudes towards physiotherapy and the prevention ofcritical illness weakness. (O Connor and Walsham, 2009) Cardiovasculardiseases are among the main causes of death in developed countries. Heartsurgery (HS) commonly causes changes in lung function and the use of re-spiratory physiotherapy intervention in reversing such changes. (Renault, 2009)

4. The se of Biofeedback to Control ctivation ofthe Sympathetic and Parasympathetic Nervous Systems

Cardiovascular diseases cause high mortality rates worldwide. Peripheralartery disease (PAD) is partial or total obstruction of the peripheral arteriescaused by atherosclerosis. Patients suffering from limited exercise capacityare predisposed to PAD progression and are at greater risk of cardiovas-cular and cerebrovascular disease. PAD provokes high morbidity and is anindependent predictor of mortality resulting from cardiovascular causes (Sales


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et al. 2012) Patients undergoing cardiac surgery are at risk of postoperativepulmonary complications. Increased physical activity can improve the func-tional capacity of a number of organ systems. Breathing exercises compen-sate for and normalize abnormal breathing patterns. Regular exercise andphysical conditioning cause positive changes in cardiorespiratory function.A distinction between postoperative pulmonary dysfunction and a postoper-ative pulmonary complication is necessary. Preoperative physical therapyreduces postoperative pulmonary complications and length of hospital stayin patients undergoing elective cardiac surgery. Hulzebos et al., 2012)Cardiopulmonary exercise testing CPET) has profoundly changed theapproach to patients functional evaluation. CPET can be useful to detectexercise-induced myocardial ischemia. Most pathophysiological factors linkedto exercise-induced ischemia can be reliably measured by CPET. The fullpotentialities of CPET in the clinical and research setting remain largelyunderused. Systolic blood pressure and mean arterial pressure should in-crease in parallel during exercise. Systolic blood pressure measurement ismore reliable than mean blood pressure in a noninvasive laboratory setting.Narrowing of the great epicardial coronary arteries does not let adequateblood flow to the myocardium during effort. Early after coronary and espe-cially valvular heart surgery, the spontaneous exercise capacity improvementis weak. Improvements in the exercise capacity after exercise tr ining inmost heart transplant HTx) recipients are correlated with improvements inskeletal muscle endothelial function. Mezzani et al., 2009)Many diseases of the heart and vasculature involve inappropriate regulationof the autonomic nervous system. The sympathetic branch of the autonomicnervous system serves to augment cardiac function in times of stress. Theparasympathetic branch of the autonomic nervous system exerts a calminginfluence on cardiovascular function. Heart rate is governed by the para-sympathetic nervous system under resting conditions. In heart failure, over-activation of the sympathetic nervous system results in many of the phenotypicchanges in the myocardium. Biofeedback therapy may teach patients a skillthat may allow them to decrease activation of their autonomic nervous system.The input of the autonomic nervous system to the heart can be regulated bybiofeedback techniques. In cardiovascular disease, stress management is fre-quently a component of cardiac rehabilitation programs. Heart rate variabilityreflects the balance between sympathetic and parasympathetic input to theheart. Heart rate variability biofeedback trains patients to increase the vari-ability in their heart rate. Biofeedback improves overall cardiovascular reac-tivity and gives the patient a great sense of control over his or her physicalwell-being. The most effective interventions for hypertension are individ-ualized for the patient. In patients with heart failure, the sympathetic nervoussystem is overactivated. Decreasing activation of the sympathetic nervous


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system improves both symptoms and prognosis. Among diseases of the car-diovascular system, biofeedback has been used most frequently in hyper-tension. Biofeedback can serve as a component of stress management pro-grams, teaching the subject to control physiologic reactions that are part ofthe stress response. Biofeedback-mediated stress management may be themost practical use of biofeedback in the setting of cardiovascular disease.Mental stress is a significant risk factor Kenagy et al., 2012) for manyforms of cardiovascular disease. Patients who exhibit ischemia in responseto a mental stress test have increased mortality from cardiovascular disease.Many cardiovascular diseases involve inappropriate regulation of the auton-omic nervous system. Moravec, 2008)

5 ConclusionsThis research makes conceptual and methodological contributions to therole of autonomic nervous system dysregulation in cardiovascular diseases,the opportunities that CPET offers for the functional evaluation of cardiacpatients, the value of postoperative chest physiotherapy, and the use andsafety of CRET among older patients. My analysis complements the growingliterature on the use of biofeedback to control activation of the sympatheticand parasympathetic nervous systems, the scope of cardiorespiratory practiceexpanding to more diverse interventions and patients with multiple comor-bidities, the supervised exercise/rehabilitation program for PAD, and themanagement of cardiovascular disease.

REFERENCESElbasan, Bulent, et al. (2012), Effects of Chest Physiotherapy and Aerobic ExerciseTraining on Physical Fitness in Young Children with Cystic Fibrosis, Italian

Journal of Pediatrics38: 2.David, Bogdan (2012), The Legal Construction of the Ethical Character of Society,nalysis and Metaphysics : 161-166.Georgescu, Matei (2012), The Phenomenological Texture of Desire, Contemporary

Readings in aw andSocial Justice4(1): 51-56.Gone, Renata, et al. (2010), Short-term Supervised Inpatient Physiotherapy ExerciseProtocol Improves Cardiac Autonomic Function after Coronary Artery BypassGraft Surgery A Randomised Controlled Trial, Disabilityand Rehabilitation32(16): 1320-1327.Hulzebos, Erik H. J. et al. (2012), -Preoperative Physical Therapy for Elective CardiacSurgery Patients, CochraneDatabaseof Systematic Reviews 11: CDO 10118.Kenagy, Robert, David Vollrath, and Mark Fox (2012), Tests of Deceptive Adver-tising Used by the Federal Trade Commission with an Application to AlternativeMedicine, ContemporaryReadings in aw andSocialJustice 4(1): 11-24.


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Luiz Carlos de Abreu, et al. (2011), Chest Associated to Motor Physiotherapy Im-proves Cardiovascular Variables in Newborns with Respiratory Distress Syn-drome, InternationalArchives of Medicine 4: 37.

Menezes, Arthur R., et al. (2012), Cardiac Rehabilitation and Exercise Therapy inthe Elderly' Journalo GeriatricCardiology9: 68-75.Mezzani, Alessandro, et al. (2009), Standards for the Use of Cardiopulmonary

Exercise Testing for the Functional Evaluation of Cardiac Patients, EuropeanJournalof CardiovascularPrevention and Rehabilitation16: 249-267.

Moravec, Christine S. (2008), Biofeedback Therapy in Cardiovascular Disease:Rationale and Research Overview, Cleveland ClinicJournal o Medicine 7(Supplement 2): 35-38.

O'Connor, Enda D., and James Walsham (2009), Should We Mobilise CriticallyIll Patients? A Review, CriticalCare and Resuscitation : 290-300.

Pdrlea-Buzatu, Daniela (2011), On the Process of Implementing Change within Orga-nizations, ContemporaryReadings in Law and SocialJustice 3(2): 212-217.

Pepera, Garyfallia, Paul D. Bromley, and Gavin R. H. Sandercock (2013), A PilotStudy to Investigate the Safety of Exercise Training and Testing in CardiacRehabilitation Patients, BritishJournalo Cardiology20: 78.

Pera, Aurel (2013), The Social Aspects of Technology-enhanced Learning Situations,Geopolitics History andInternationalRelations 5(2): 118-123.

Peters, Michael A. (2012), Inventing Human Rights: A Social Theory of Right andthe Juridical Construction of the Subject, ContemporaryReadings in Law andSocialJustice 4(2): 47-64.

Petersmann, Ernst-Ulrich (2013), Human Rights Require *Cosmopolitan Constitu-tionalism' and Cosmopolitan Law for Democratic Governance of Public Goods,ContemporaryReadings in Law and SocialJustice 5(2): 90-119.

Preduca, Grigoriana (2011), Religious Liberty and Human Rights, ContemporaryReadings in Law andSocial Justice3(2): 230-235.

Reid, W. Darlene, Susan J. Stanton, and L. Cheryle Kelm (2008), Factors Associ-ated with Physiotherapists' Interest in Cardiorespiratory Continuing EducationUsing Computer-Assisted Learning: A Survey, PhysiotherapyCanada60: 80-91.

Renault, Julia Alencar, Ricardo Costa-Val, and Mfircia Braz Rossetti (2008), Res-piratory Physiotherapy in the Pulmonary Dysfunction after Cardiac Surgery,Revista Brasileira e CirurgiaCardiovascular23(4): 562-569.

Sales, Ana Tereza, Cibele Dias Ribeiro, and Fernando Lavezzo Dias (2012), LowerExtremity Peripheral Artery Disease: Implications for Physiotherapy, Journalo Respiratoryand CardiovascularPhysical Therapy 1 1): 23-33.

Scherer, Susan (2009), Addressing Cardiovascular Risk as Part of Physical Ther-apist Practice What about Practice Recommendations for Physical Therapists?,CardiopulmonaryPhysical TherapyJournal20(3): 27-29.

Toader, Elena (2013), Ethical Issues in Public Health Management, JournalofSelf-Governance andManagement Economics 1 1): 106-112.

Trofin, Liliana, and Mgdlina Tomescu (2011), Solidarity and Society in the Era ofGlobalization, ContemporaryReadings in Law andSocialJustice 3(2): 236-241.

Westerdahl, Elisabeth, and Margareta M611er (2010), Physiotherapy-supervised Mobil-ization and Exercise Following Cardiac Surgery: A National QuestionnaireSurvey in Sweden, Journalof Cardiothoracic urgery : 67.

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