This Editorial introduces another of Journal of Physiotherapy’s article collections.These are collections of papers on a particular topic, published in the Journal of Physiotherapy within the past decade and compiled to: facilitate access to important recent findings on the topic; highlight trends in research designs, methods, populations and interventions; and suggest avenues for further research. The studies in this article collection relate to physiotherapy management of cardiac conditions

Elkins, Mark R.

Freire, Ana Paula Coelho Figueira

ScholarWorks at Central Washington University

Central Washington University ScholarWorks@CWU All Faculty Scholarship for the College of Education and Professional Studies College of Education and Professional Studies 12-14-2022 Cardiac conditions Ana Paula Coelho Figueira Freire Mark R. Elkins Follow this and additional works at: https://digitalcommons.cwu.edu/cepsfac  Part of the Cardiology Commons, and the Physiotherapy Commons EditorialCardiac conditionsAna Paula Coelho Figueira Freire a, Mark R Elkins b,caDepartment of Health Sciences, Central Washington University, Ellensburg, USA; b Editor, Journal of Physiotherapy; c Faculty of Medicine and Health,University of Sydney, Sydney, AustraliaThis Editorial introduces another of Journal of Physiotherapy’sarticle collections.1,2 These are collections of papers on a particulartopic, published in the Journal of Physiotherapywithin the past decadeand compiled to: facilitate access to important recent findings on thetopic; highlight trends in research designs, methods, populations andinterventions; and suggest avenues for further research. The studiesin this article collection relate to physiotherapy management of car-diac conditions.In 2011, there was a call for physiotherapists to become moreengaged in cardiology research.3 The Editorial highlighted issuesincluding the lack of research in this area being led by physiothera-pists, despite their extensive training in prevention and managementof risk factors for coronary disease. Much important research intophysiotherapy for people with heart conditions has been publishedsince then. This article collection focuses on aspects of cardiac reha-bilitation from both centre-based and home-based perspectives, aswell as reviewing progress in perioperative care, complementing theEditorial on perioperative physiotherapy published in 2022.4 Theimportant advances that have subsequently been published in Journalof Physiotherapy are summarised below and collated as free full-textarticles in the online article collection. Importantly, each paper hasclear implications for clinical physiotherapists, which are identifiablein the paper’s ‘What this study adds’ summary box.Centre-based cardiac rehabilitationClinical guidelines on the management of the most prevalentheart conditions consistently endorse cardiac rehabilitation as anefficient and secure strategy, with exercise identified as a centralelement.5,6 Exercise training has a direct benefit on reducing riskfactors for atherosclerotic disease and also improving heart and cor-onary vasculature.6 Therefore, it is crucial to advance physiothera-pists’ knowledge on the effects of different modalities of exercise. Thefirst and second articles in this collection address investigationsaround the effects of different modalities of exercise-based programsfor patients with coronary heart disease and heart failure.In 2010, Hwang and colleagues7 performed a systematic review toevaluate whether resistance training, alone or as an adjunct to aer-obic training, could improve cardiac function, exercise capacity andquality of life in patients with chronic heart failure. Results from eighttrials involving 241 participants revealed that resistance trainingincreased the 6-minute walk distance (6MWD) by an average of 52 m(95% CI 19 to 85) in comparison with no training. However, whenresistance training was provided either alone or as an addition toaerobic training, no other benefits were seen on cardiac function,peak oxygen consumption or quality of life.A common concern when addressing exercise therapy for patientswith cardiovascular diseases is the high prevalence of morbiditiessuch as overweight, obesity and arthritis.8 These factors can limit theexecution of aerobic and resistance exercise, which are commonlyperformed on treadmills, cycle ergometers and weight machineequipment. Therefore, water-based exercises can be offered as analternative, where the effects of buoyancy reduce the weight-bearingload on the lower limbs and spine.9Scheer et al10 conducted a randomised controlled trial, publishedin 2021, investigating the effects of 12 weeks of water-based circuittraining exercise on aerobic capacity, strength and body compositionof patients with stable coronary heart disease. The results werecompared with those of a group that performed aerobic andstrengthening exercises at a cardiac rehabilitation outpatient gym.Water-based exercises presented very similar improvements inVO2peak compared with the traditional program. The mean differ-ence between groups was 0.2 ml/kg/min (95% CI –1.5 to 1.9). Addi-tionally, both exercise modalities also showed similar gains in musclestrength and comparable reductions in total body fat.10Home-based cardiac rehabilitationDespite the well-known benefits of exercise-based cardiac reha-bilitation, these programs are not currently being used to their fullpotential. The rates of patients undergoing rehabilitation vary from,20% for heart failure to 40% in those with coronary heart dis-ease.11,12 Therefore, strategies are needed to reduce barriers andwiden access to cardiac rehabilitation programs, such as home-basedexercises.13One of the first randomised controlled trials to compare a home-based video telerehabilitation program with a conventional centre-based program for patients with chronic heart failure was carriedout in 2017 by Hwang et al.7 After 12 weeks of intervention, no sig-nificant between-group differences were observed in 6MWD (MD 15m, 95% CI –28 to 59). In addition, the home-based telerehabilitationgroup had significantly higher attendance rates when compared withthe centre-based group, with a between-group mean difference of sixsessions (95% CI 2 to 9).7Chien et al also reported improvements in 6MWD (MD 21 m, 95%CI 7 to 36) and quality of life by providing home-based exercisesassociated with a daily activity log and telephone monitoring every 1to 2 weeks when compared with a control group that did notexercise.14Another study investigating the effects of home-based trainingwas performed by Jones et al in 2010.15 In this randomised trial, pa-tients with stage I or II hypertension performed slow deep breathingat home, either unloaded or breathing against a load of 20 cmH2Oprovided by a threshold-loaded breathing device for 8 weeks. Bothtraining groups showed significant reductions in systolic and diastolicblood pressure. Additionally, adding an inspiratory load enhanced thedecrease in systolic blood pressure, with a between-group differenceof –5.3 mmHg (95% CI –1.0 to –9.6).Journal of Physiotherapy - (2022) -–-https://doi.org/10.1016/j.jphys.2022.11.0101836-9553/© 2022 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).journal homepage: www.elsev ier.com/locate/ jphysIn the studies discussed above, the 6MWD was one of the mostinvestigated outcomes and is considered an independent predictor ofmortality and cardiovascular hospitalisation in people with heartfailure.16 Wegrzynowska-Teodorczyk performed a prospectiveobservational study and showed that participants with a 6MWD 468 m had a mortality hazard ratio of 3.22 (95% CI 1.17 to 8.86) at 1year and 2.18 (95% CI 1.18 to 4.03) at 3 years of follow-up.16 Therefore,it is important to highlight that the 6-minute walk test should beconsidered an important component of the complex evaluation of thecardiac patient due to its prognostic value.Cardiac surgeryPreoperative and postoperative cardiac rehabilitation havebecome an essential part of care for patients undergoing cardiacsurgery procedures. Such programs can reduce mortality, improvephysical performance and increase quality of life.6,17 Physiotherapistshave an important role in assessing and providing different elementsof these programs, including education, inspiratory muscle trainingand exercise training.4Preoperative care was investigated by Snowdon and colleagues ina systematic review published in 2014.18 The review primarily aimedto analyse whether preoperative intervention in patients undergoingcardiac surgery could reduce pulmonary complications and shortenlength of intensive care unit or hospital stay.18 Their review includeda meta-analysis of data from six trials involving 661 participants; itindicated a worthwhile reduction in the relative risk of developingpostoperative pulmonary complications with preoperative in-terventions (RR 0.39, 95% CI 0.23 to 0.66). Additionally, preoperativeintervention reduced the time to extubation by a pooled mean dif-ference of 0.14 days (95% CI 0.01 to 0.26). The effect on length ofintensive care unit stay was unclear (MD –0.15 days, 95% CI –0.37 to0.08), as was the effect on length of hospital stay (MD –0.55 days, 95%CI –1.32 to 0.23), except among older participants aged . 63 years(MD –1.32 days, 95% CI –2.36 to –0.28).18 Finally, when evidence forspecific preoperative therapies was taken into account, inspiratorymuscle training promoted significant reductions in postoperativepulmonary complications (RR 0.42, 95% 0.21 to 0.82) and reducedhospital stay (MD –2.1 days, 95% CI –3.41 to –0.76).Significant morbidity and mortality are linked to major surgicalprocedures, including cardiac surgery. One common surgical pro-cedure that physiotherapists often manage in postoperative care ismedian sternotomy.19 A common concern among physiotherapistsand other healthcare providers is whether or not to restrict upperlimb and trunk movements after median sternotomy, due to theconflicting evidence that is available.20The SMART trial explored the effects of an intervention thatincluded less restrictive use of the upper limbs and trunk for patientswho had undergone cardiac surgery via median sternotomy. Theexperimental group was encouraged to use their arms during trans-fers and other tasks, in addition to perform upper limb exercise threetimes daily within the limits of pain and discomfort. The controlgroup was instructed with usual precautions, including to restrict useof the upper limbs for 4 to 6 weeks after surgery.20 After 12 weeks offollow-up, there were negligible between-group differences in theimprovements in physical function as measured by the Short PhysicalPerformance Battery (MD 0.4 points on a 0-to-12 scale, 95% CI –0.9 to1.6).20 Secondary outcomes including pain and kinesiophobia also didnot show important between-group differences. The study alsoshowed that implementation of the modified sternal precautions didnot cause harm or adverse events. Consequently, the authorsconcluded that until further research is performed, modified sternalprecautions might be an equally appropriate option.20Future directionsThis article collection indicated several beneficial physiotherapyinterventions at various phases of cardiac surgery and rehabilitation.Although most studies presented a variety or combination of strate-gies that can be provided, exercise training can be identified as thecornerstone of the interventions for heart conditions. While the roleof physiotherapy interventions for cardiac populations is well estab-lished, several studies have highlighted the need for further in-vestigations in this area. These main aspects for further researchinclude: addressing the effects of rehabilitation programs on sub-groups of patients with heart failure, especially females and moresevere cases of the disease; determining the applicability of tele-rehabilitation in rural and remote locations with variable internetservice; and establishing the effectiveness of preoperative exercisetraining on cost-effectiveness, pulmonary complications, length ofhospitalisation and time to extubation after cardiac surgery.Ethics approval: Not applicable.Competing interest: Nil.Source(s) of support: Nil.Acknowledgements: Nil.Provenance: Invited. Not peer reviewed.Correspondence: Mark Elkins, Centre for Education & WorkforceDevelopment, Sydney Local Health District, Sydney, Australia. Email:mark.elkins@sydney.edu.auReferences1. Dale MT, et al. J Physiother. 2021;67:84–86.2. Reubenson A, et al. J Physiother. 2022;68:153–155.3. Redfern J, et al. J Physiother. 2011;57:209–211.4. Boujibar F, et al. J Physiother. 2022;68:218–219.5. Long L, et al. Cochrane Database Syst Rev. 2019;1:CD003331.6. Dibben G, et al. Cochrane Database Syst Rev. 2021;11:CD001800.7. Hwang R, et al. J Physiother. 2017;63:101–107.8. Sanderson BK, et al. J Cardiopulm Rehabil. 2003;23:281–289.9. Becker BE, et al. PM&R. 2009;1:859–872.10. Scheer A, et al. J Physiother. 2021;67:284–290.11. Golwala H, et al. Am Coll Cardiol. 2015;66:917–926.12. Kotseva K, et al. Eur J Prev Cardiol. 2018;25:1242–1251.13. Neubeck L, et al. Eur J Prev Cardiol. 2012;19:494–503.14. Chien CL, et al. J Physiother. 2011;57:157–163.15. Jones CU, et al. J Physiother. 2010;56:179–186.16. Wegrzynowska-Teodorczyk K, et al. J Physiother. 2013;59:177–187.17. Hulzebos EHJ, et al. Cochrane Database Syst Rev. 2012;11:CD010118.18. Snowdon D, et al. J Physiother. 2014;60:66–77.19. Mekontso Dessap A, et al. Clin Microbiol Infect. 2011;17:292–299.20. Katijjahbe MA, et al. J Physiother. 2018;64:97–106.2 Editorial

Cardiac conditions

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Cardiac conditions

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