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PubMed1986

Exercise program for patients after cardiac surgery.

The effects of an exercise program on patients after cardiac surgery were studied. The physical status and length of hospitalization of 44 patients who were not exposed to the program (group I) were compared with those of 43 program participants (group II). All patients were evaluated preoperatively and before hospital discharge. Whereas 24 of the patients in group I scored lower at discharge than preoperatively on an assessment of functional activity, only 9 from group II did so (p = 0.001). Fewer patients in group I than in group II increased their performance in a test of distance walking. Patients in group I lost significantly more (p = 0.03) range of motion in upper and lower extremities than did patients in group II. The mean length of hospitalization for patients in group II was shorter than for those in group I by 1.9 days (p less than 0.001). In summary, the exercise program reduced the prevalence of activity morbidity incident to hospitalization for cardiac surgery, and was associated with a reduced length of stay.

Adult↗

PubMed1998

Home or supervised rehabilitation following anterior cruciate ligament reconstruction: a randomized controlled trial.

Rehabilitation following anterior cruciate ligament (ACL) reconstruction is varied. Patients are usually prescribed an independent home exercise program, although some patients may attend physical therapy for additional supervised exercise. It is not known whether additional supervised exercise provides any further benefit. The purpose of this study was to compare efficacy for two types of rehabilitation following ACL reconstruction. A randomized controlled trial of 31 ACL-reconstructed patients was used to test the hypothesis that a home program plus supervised rehabilitation (Group S) is more effective than a home program (Group H) alone. Function, activity level, anterior tibial translation, and muscle strength were measured preoperatively and at 3 and 6 months postoperatively. Improvement of function, activity level, muscle strength, and anterior tibial translation was evident in both groups, but no significant differences were found between groups even though the sample size was sufficient to detect small treatment effects. It was concluded that supervised exercise, in addition to a home program, has minimal extra benefit for patients who have undergone ACL reconstruction.

Activities of Daily Living↗

PubMed1980

Physical therapy management of patients with total ankle replacement.

Ankle arthrodesis has been the treatment of choice for patients who have arthritic or degenerative ankly disease with disabling pain and loss of motion. But the results of long-term retrospective studies show a significant percentage of arthrodeses are unacceptable to patients and considered to be clinically poor or failures by the physicians. Therefore, total replacement of the ankle joint is becoming recognized as an alternative to ankle arthrodesis. This procedure eliminates pain and provides suffient ankle motion for resumption of normal activities. Objectives and indications for the procedure, two types of prostheses, and the surgical procedure are discussed. Guidelines are provided for preoperative and postoperative physical therapy for patients having total ankle replacements.

Ankle Joint↗

PubMed1993

Cardiac risk evaluation and management in noncardiac surgery.

A careful history, physical examination, resting electrocardiogram, and chest radiograph are essential for preoperative cardiac assessment of adult patients. The nine individual Goldman indicators of increased perioperative cardiac risk and evidence of an unstable coronary ischemic syndrome should be specifically sought in each patient and treated when possible. After initial assessment, patients who still have a medium level of perioperative risk can usually be accurately assigned to a high- or low-risk category through the use of exercise testing and the selective use of dipyridamole thallium imaging.

Activities of Daily Living↗

PubMed1999

Rest and exercise Doppler hemodynamics of the Medtronic Intact aortic bioprosthesis.

BACKGROUND AND AIMS OF THE STUDY: Exercise treadmill testing was used to evaluate the functional rest and stress hemodynamic profile of the Medtronic Intact aortic bioprosthesis. METHODS: A group of 93 patients (mean age at operation 72.9 years; range: 61-79 years) was studied. Mean time to follow up was 20.8 months. The preoperative diagnosis was aortic stenosis (AS; n = 66), aortic regurgitation (AR; n = 19) or AS/AR (n = 8). Left ventricular function was assessed as normal (n = 78), moderate (n = 14) or poor (n = 1). Patients received a range of valve sizes: 21 mm (n = 7); 23 mm (n = 41); 25 mm (n = 32); 27 mm (n = 7); and 29 mm (n = 6). RESULTS: For all valve sizes, Doppler-derived hemodynamics at rest and peak exercise, respectively were: mean aortic valve gradient (AVG) 13.2 +/- 5.2 mmHg and 22.2 +/- 8.9 mmHg; peak aortic valve gradient (AVG) 24.3 +/- 9.6 mmHg and 39.1 +/- 13.5 mmHg; effective orifice area (EOA) 1.39 +/- 0.49 cm2 and 1.38 +/- 0.5 cm2; and effective orifice area index (EOAI) 0.76 +/- 0.26 cm2/m2 and 0.75 +/- 0.26 cm2/m2. Mean and peak AVG decreased as valve sizes increased, while both EOA and EOAI increased as valve sizes increased. CONCLUSIONS: The Medtronic Intact aortic bioprosthesis provides good hemodynamics both at rest and exercise, across the range of implanted valve sizes.

Aged↗

PubMed1984

Prophylaxis against pulmonary complications in patients undergoing gall-bladder surgery. A comparison between early mobilization, physiotherapy with and without bronchodilatation.

A random comparison of early mobilization and chest physiotherapy (mainly breathing exercises) with or without bronchodilatating inhalations for prophylaxis against pulmonary complications in patients undergoing elective gall-bladder surgery is presented. The operation was performed with a subcostal incision and peroperatively, intercostal nerve block was administered. Preoperative pulmonary status (dynamic volume spirometry, peak expiratory flow rate, arterial blood gas analysis) showed no differences between the groups, and postoperative blood gas analysis and pulmonary X-ray or evident clinical findings did also not show any differences between the groups. Thus early mobilization was as effective in our study as the other prophylactic treatments. In patients without pulmonary disease perhaps early mobilization and efficient analgesia after surgery is as effective as more resource demanding physiotherapy for prophylaxis against postoperative pulmonary complications.

Aged↗

PubMedDate not supplied

Arthroscopic patella realignment: An all-inside technique.

PURPOSE: Many methods of realigning the patella have been described. Most techniques for proximal realignment involve an open medial reefing or advancement of the vastus medialis obliquus. Arthroscopically assisted methods have been described, but these all involve the need for a medial incision to tie sutures. This article describes an entirely arthroscopic technique for proximal realignment that eliminates the need for an incision, and reports the 2-year follow-up results using this technique. TYPE OF STUDY: Retrospective review. METHODS: Over a 5-year period, 26 patients (29 knees) with patellar instability were treated with an outpatient arthroscopic all-inside medial reefing and lateral release. Arthroscopic reefing was performed by percutaneous passage of suture followed by arthroscopic retrieval and knot tying inside the joint. Before knot tying, a healing response was initiated along the medial retinaculum by either gentle shaving with a whisker blade or by radiofrequency thermal response. Rehabilitation consisted of 1 week of immobilization followed by an accelerated program of range of motion exercises and vastus medialis obliquus strengthening. RESULTS: At follow-up, 93% of patients reported significant subjective improvement. The average Lysholm score improved from 41.5 to 79.3 (P <.05). Preoperative and postoperative radiographs were measured for congruence angle, lateral patellofemoral angle, and lateral patella displacement, and all showed significant improvement postoperatively (P <.05). There were no complications and no redislocations. Patients reported a significant improvement in pain, swelling, stair climbing, crepitus, and ability to return to sports (P <.05). CONCLUSIONS: Arthroscopic patella realignment is a viable technique that offers results comparable or superior to published results for open or arthroscopically assisted realignment.

Adolescent↗

PubMed1985

Repair of ventricular septal defect in adults.

To evaluate the outcome of ventricular septal defect (VSD) with long duration of haemodynamic derangement, a retrospective study was made of 42 consecutive patients who underwent closure of VSD as adults (age range 15-48, mean 27 years). The mean systolic pulmonary arterial pressure was 53 mmHg, mean pulmonary vascular resistance 2.5 Wood units and mean pulmonary/systemic flow ratio 2.4. VSD was complicated by aortic regurgitation in 12 cases, mitral regurgitation in 4, and sinus of Valsalva fistula in 6 cases. There were 15 supracristal, 24 infracristal and 3 muscular VSDs. In addition to VSD closure, surgery included aortic valve replacement (7 cases), mitral valve replacement (2), valve repair by suture (7) and repair of Valsalva sinus fistula (6 cases). Two patients died in the early postoperative period and two during follow-up (1-10, mean 4.5 years). The early and the late mortality were related to large infracristal VSD, pulmonary hypertension and irreversible pulmonary vascular changes which could not be anticipated on the basis of high calculated shunt flow at preoperative catheterization. No patient with supracristal VSD died. Recurrent VSD was diagnosed in five patients, three of whom needed reoperation and recovered uneventfully. Reduction of heart size and improved exercise tolerance were the most pertinent follow-up findings. The results suggest that large supracristal VSD with aortic valve involvement can be successfully closed in adults, but that the prospect for large infracristal VSD is less favourable if correction is postponed until adulthood.

Adolescent↗

PubMed1996

[Lung volume reduction surgery in advanced emphysema--results of the Washington University, St. Louis].

The aim of lung volume reduction surgery is to alleviate the symptoms of severe emphysema and to improve the life quality of the patient. The appropriate candidates (approximately 20% of all emphysematic patients examined in our clinic) had considerable dyspnea, an increased lung capacity, and a heterogenous dissemination of the emphysema with regional destruction of the parenchyma, hyperinflation and poor perfusion. After preoperative physiotherapie with a specified rehabilitation aim, a resection of 20 to 30% of the total lung volume was performed via sternotomy. From January 1993 to February 1996, 150 patients underwent bilateral lung volume reduction (age range = 36 to 77 years). The mean forced expiratory volume in 1 s (FEV1) was preoperatively 25% of the predicted value, the total lung capacity (TLC) 142% and the residual volume (RV) 283%, 94% of these patients necessitated oxygen supply at rest or during exercise. The 90-day mortality was 4%. All patients except 1 were extubated immediately after operation. The median hospital stay was 10 days in the first 100 patients and 7 days in the last 50. An increase of the FEV1 by 51% and a decrease of the RV by 28% was observed 6 months after operation. The mean PaO2 was improved by 8 mm Hg while the percentage of oxygen dependent patients went down from 50 to 16%. In addition a raise of the perseverance capacity, a clear decrease of dyspnea and an improvement of the life quality were achieved. These results persist after 1 (n = 56) and 2 (n = 20) years after operation. Lung volume reduction leads to an improvement of the lung function, symptoms and the quality of life, which is superior to that achieved by maximal clinical intervention.

Adult↗

PubMed1997

Expert opinion regarding indications for coronary angiography before noncardiac surgery.

Whether to perform coronary angiography on the basis of preoperative noninvasive cardiac testing remains a difficult decision. We hypothesized that there are noninvasive test results for which experts have general agreement about the indication for preoperative coronary angiography. We asked 30 experts (24 in specific diagnostic tests and six in clinical cardiology) to comment on statements regarding hypothetical noninvasive test results. There was agreement that catheterization should be performed for (1) exercise electrocardiographic ischemia with a blood pressure drop > 10 mm Hg, (2) stress perfusion scan reversibility in one half or more of single-photon emission computed tomographic slices, and (3) stress echo ischemia in more than five segments, two or more coronary artery zones, or four left anterior descending coronary artery segments. Therefore coronary angiography should be performed for results of noninvasive tests that indicate large zones of myocardial ischemia and not for limited ischemia or test abnormalities without other significant findings.

Cardiac Catheterization↗

PubMed1989

Physiotherapy after coronary artery surgery: are breathing exercises necessary?

One hundred and ten men undergoing coronary artery bypass grafting took part in a prospective randomised study comparing three physiotherapy protocols. All patients were taught self supported huffing and coughing by a physiotherapist and encouraged to move about. This comprised the sole treatment for the 37 control patients (group 3). Additional physiotherapy included breathing exercises for the 35 patients in group 1 and use of an incentive spirometer for the 38 patients in group 2. Functional residual capacity (FRC) was measured daily at the bedside until the fifth postoperative day and arterial blood gas tensions were measured on the second and fourth postoperative days. After surgery patients developed a severe restrictive ventilatory defect and profound arterial hypoxaemia. There were no differences between the three groups. Mean FRC on day 2 was 1.90 litres (61% of the preoperative value), increasing to 2.32 1 by day 5 (76% of the preoperative value). The mean arterial oxygen tension was 7.37 kPa on day 2 and 8.58 kPa on day 4. Four patients in group 1, two in group 2, and five in group 3 developed a chest infection. It is concluded that the addition of breathing exercises or incentive spirometry to a regimen of early mobilisation and huffing and coughing confers no extra benefit after uncomplicated coronary artery bypass grafting.

Breathing Exercises↗

PubMed2005

Changes in pulmonary function test and cardio-pulmonary exercise capacity in COPD patients after lobar pulmonary resection.

OBJECTIVE: Pulmonary Function Tests (PFT) and Cardio-Pulmonary Exercise Testing (C-PET) are useful to evaluate operability in functionally compromised patients. Although modifications of PFT and C-PET after lung surgery have been widely explored, little information exists as to modifications of exercise capacity in COPD patients undergoing lung resection. We prospectively analyzed the changes in PFT and C-PET in patients with COPD after a pulmonary lobar resection. METHODS: From January 2003 to March 2004 all patients scheduled for lung resection were considered for participation in the study protocol. Those patients with a preoperative diagnosis of COPD on PFT were explored through a C-PET. Only patients who had undergone a lobar pulmonary resection were subsequently considered; these patients had a new complete cardio-respiratory evaluation 3 months after surgery. The pre- and postoperative values compared were those of FEV1, TLC, DLCO, VO2max, and VE/VCO2. Data are expressed as mean +/- standard deviation (SD). Statistic evaluation was made using the Wilcoxon test. RESULTS: During this period 11 patients completed the study protocol. Ten patients underwent surgery for NSCLC and one for a pulmonary aspergilloma. Nine lobectomies and two bilobectomies were performed. In the study population, the preoperative mean value of FEV1 resulted as being 53% (SD+/-20) of the predicted mean value, that of TLC 120% (SD+/-35) and that of DLCO 65% (SD+/-27). The preoperative mean value of VO2max resulted as being 17.8 ml/Kg/min (SD+/-3.25) and mean VE/VCO2 resulted as being 35.7 (SD+/-4). Three months after surgery the measured mean value of FEV1 was 53% (SD+/-18), that of TLC was 99% (SD+/-24) and that of DLCO 52% (SD+/-18). The mean value of VO2max resulted as being 14.1 ml/Kg/min (SD+/-3.04) and that of VE/VCO2 was 42.5 (SD+/-12.8). Statistical analysis of PFT values showed that FEV1 and DLCO were not significantly modified (P > 0.05); in contrast, TLC had significantly decreased (P = 0.008). VO2max had significantly decreased (P = 0.004) and VE/VCO2 had significantly increased (P = 0.018). CONCLUSIONS: Three months after a lobar pulmonary resection, patients with COPD were found to have a significant decrease in exercise tolerance. PFT alone can underestimate the postoperative loss of exercise capacity through exercise.

Aged↗

PubMedDate not supplied

Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study.

We conducted a prospective, randomized study of open and closed kinetic chain exercises during accelerated rehabilitation after anterior cruciate ligament reconstruction to determine if closed kinetic chain exercises are safe and if they offer any advantages over conventional rehabilitation. The closed kinetic chain group used a length of elastic tubing, the Sport Cord, to perform weightbearing exercises and the open kinetic chain group used conventional physical therapy equipment. Results are reported with a minimum 1-year followup (mean, 19 months). Pre- and postoperative evaluation included the Lysholm knee function scoring scale, Tegner activity rating scale and KT-1000 arthrometer measurements. Overall, stability was restored in over 90% of the knees. Preoperative patellofemoral pain was reduced significantly; 95% of the patients had a full range of motion. The closed kinetic chain group had lower mean KT-1000 arthrometer side-to-side differences, less patellofemoral pain, was generally more satisfied with the end result, and more often thought they returned to normal daily activities and sports sooner than expected. We concluded that closed kinetic chain exercises are safe and effective and offer some important advantages over open kinetic chain exercises. As a result of this study, we now use the closed kinetic chain protocol exclusively after anterior cruciate ligament reconstruction.

Adolescent↗

PubMed1990

Thallium-201 perfusion imaging with atrial pacing or dipyridamole stress testing for evaluation of cardiac risk prior to nonvascular surgery.

Preoperative assessment of cardiac risk using thallium-201 scintigraphy and atrial pacing (n = 42) or dipyridamole stress testing (n = 35) was performed in 77 patients (mean age 65 +/- 7 years), who subsequently underwent elective nonvascular surgery. All patients were at low cardiac risk by clinical criteria; none could perform exercise stress testing due to physical limitations. ST depression consistent with ischemia occurred in 11 patients during atrial pacing and in 1 patient during dipyridamole stress testing (p less than 0.01). Nine patients had reversible perfusion defects with atrial pacing, and 10 patients with dipyridamole stress testing; fixed defects were present in 15 and 8 patients, respectively. Only one patient (fixed perfusion defect with atrial pacing, left main disease on coronary angiography) underwent preoperative coronary revascularization. Two patients subsequently had postoperative cardiac events. One patient (reversible perfusion defect with dipyridamole stress testing) experienced sudden death after a nonvascular procedure, while a second patient (normal thallium images with dipyridamole testing) had a nonfatal myocardial infarction. In patients having atrial pacing or dipyridamole stress testing, thallium-201 scans that are normal or show only a fixed perfusion defect confirm a low risk of cardiac complications following nonvascular surgery. The presence of a reversible perfusion defect does not preclude a postoperative course free of cardiac complications in patients at low cardiac risk by clinical criteria.

Aged↗

PubMed2003

A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery.

OBJECTIVE: To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery. DESIGN: Meta-analysis of published reports. METHODS: Eight studies on ambulatory electrocardiography, seven on exercise electrocardiography, eight on radionuclide ventriculography, 23 on myocardial perfusion scintigraphy, eight on dobutamine stress echocardiography, and four on dipyridamole stress echocardiography were selected, using a systematic review of published reports on preoperative non-invasive tests from the Medline database (January 1975 and April 2001). Random effects models were used to calculate weighted sensitivity and specificity from the published results. Summary receiver operating characteristic (SROC) curve analysis was used to evaluate and compare the prognostic accuracy of each test. The relative diagnostic odds ratio was used to study the differences in diagnostic performance of the tests. RESULTS: In all, 8119 patients participated in the studies selected. Dobutamine stress echocardiography had the highest weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and a reasonable specificity of 70% (95% CI 62% to 79%) for predicting perioperative cardiac death and non-fatal myocardial infarction. On SROC analysis, there was a trend for dobutamine stress echocardiography to perform better than the other tests, but this only reached significance against myocardial perfusion scintigraphy (relative diagnostic odds ratio 5.5, 95% CI 2.0 to 14.9). CONCLUSIONS: On meta-analysis of six non-invasive tests, dobutamine stress echocardiography showed a positive trend towards better diagnostic performance than the other tests, but this was only significant in the comparison with myocardial perfusion scintigraphy. However, dobutamine stress echocardiography may be the favoured test in situations where there is valvar or left ventricular dysfunction.

Cardiotonic Agents↗

PubMed2000

Recent advances in dobutamine stress echocardiography.

Dobutamine stress echocardiography (DSE) is a reliable cardiac risk stratifier that has widespread applicability because of its clinical accuracy and cost effectiveness. Dobutamine has positive inotropic and chronotropic effects and is commonly used in patients who cannot exercise or achieve an adequate heart rate response with exercise. Recently available long-term results from several independent clinical trials, combined with enhancements in image quality, have improved the ability to detect significant coronary artery disease and determine myocardial viability. Dobutamine stress echocardiography has an excellent safety profile with clinical results superior to regular exercise electrocardiography and comparable with exercise echocardiography and radionucleotide perfusion stress imaging. Low-dose dobutamine response can accurately predict dysfunctional yet viable myocardial regions that may improve with revascularization. Clinical studies are now available refining the common use of DSE preoperatively in female patients with valvular disease, as well as in the emergency department. Dobutamine stress echocardiography does have some limitations in discriminating particular regions of ischemia when multiple ventricular segments are involved and when the imaging is suboptimal. It can be applied using minimal additional resources in an otherwise functioning echocardiography laboratory and, with appropriate training, can result in clinical results comparable with those of large-scale multicenter trials. Ongoing improvements in technology and the development of new reagents such as myocardial contrast agents hold promise for further advancement in the near future.

Cardiotonic Agents↗

PubMed1997

Is preoperative cardiac evaluation for abdominal aortic aneurysm repair necessary?

PURPOSE: It is reported that 25% to 50% of patients with abdominal aortic aneurysms (AAA) have severe coronary artery disease (CAD) and should undergo an aggressive cardiac workup before AAA repair. In contrast, it has been our policy that patients referred for AAA repairs undergo no cardiac testing before surgery. METHODS: This report reviews the last 113 consecutive patients who underwent elective AAA repair by the senior author using this policy. Seventy-four patients (group A) had only an electrocardiogram before surgery. The remaining 39 patients (group B) were referred having already had additional testing that included a thallium stress test (n = 20), echocardiogram (n = 18), multiple gated acquisition (MUGA) scan (n = 3), cardiac catheterization (n = 8), or some combination of these. RESULTS: There was no statistical difference between group A and group B with regard to age, sex, tobacco use or history of coronary artery disease, diabetes mellitus, stroke (CVA), hypertension, peripheral vascular disease, or chronic obstructive pulmonary disease. Group B more commonly had a history of myocardial infarction (41% vs 19%, p < 0.03) and congestive heart failure (23% vs 7%, p < 0.03). During surgery there was no significant differences in blood loss, transfusion requirements, or operative times. There were no myocardial infarctions in group A and two (5.1%) in group B, which was not significantly different. Other complications, such as CVA, renal failure, pulmonary failure, pneumonia, wound infection, and hemorrhage, were not significantly different between the two groups. Postoperative hospital stay was not significantly different. There were three deaths in the entire series (2.7%), and only one in group B was cardiac-related in a patient with known end-stage cardiac disease and a symptomatic 8 cm AAA. CONCLUSIONS: These data indicate that most patients with AAA can safely undergo repair with no cardiac workup and that cardiac workup before AAA repair contributes little information that impacts on treatment or final clinical outcome. We conclude that cardiac testing in preparation for AAA repair is not usually necessary and that intraoperative hemodynamic management may be the most important variable in determining outcome.

Aged↗

PubMed2002

Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients.

PURPOSE: The aim of this study is to review the new technical modifications and results of 303 patients who have had pectus excavatum repair utilizing the minimally invasive technique. METHODS: A retrospective chart review was conducted of 303 patients undergoing minimally invasive pectus repair from 1987 through August 2000. Since 1997, a standardized treatment pathway was implemented, and 261 of the 303 patients have been treated on this pathway. Preoperative evaluation included computed tomography (CT) scan, pulmonary function tests (PFT), and cardiac evaluations with electrocardiogram (EKG) and echocardiogram. Indications for operation included at least 2 of the following: progression of the deformity, exercise intolerance or restrictive disease on PFT, Haller CT index greater than 3.2, mitral valve prolapse (MVP), or cardiac compression. Technical and design modifications since 1998 have included routine thoracoscopy, the use of an introducer/dissector for creating the substernal tunnel and elevating the sternum, and routine use of a wired lateral stabilizer to prevent bar displacement. The bar is removed as an outpatient procedure in 2 to 4 years. RESULTS: In 303 patients undergoing minimally invasive pectus repairs, single bars were used in 87% and double in 13%. Lateral stabilizers were applied in 70% of patients and were wired for further stability in 65%. Bar shifts before the use of stabilizers were 15%, which decreased to 6% after stabilizers were placed and 5% with a wired stabilizer. Excellent results were noted in 85% with failure in only 1 patient. Complications included pneumothorax with spontaneous resolution in half of the patients and pericarditis in 7. CONCLUSIONS: The minimally invasive technique has evolved into an effective method of pectus excavatum repair. Modifications of the technique have reduced complications. Long-term results continue to be excellent.

Adolescent↗