PHYSIOTHERAPY MANAGEMENT AND REHABILITATION FOLLOWING CLOSED-HEART SURGERY
A Comprehensive Evidence-Based Approach to Perioperative Physiotherapy, Early Mobilisation and Functional Recovery
Abstract
Closed-heart cardiac surgery represents an important group of surgical procedures used in the management of congenital and acquired cardiovascular conditions. Although advances in anaesthesia, surgical techniques, intensive care, and perioperative medicine have improved survival and shortened hospitalisation, patients may experience significant postoperative respiratory, cardiovascular, musculoskeletal and functional limitations. These may include reduced lung volumes, impaired airway clearance, pain, muscle weakness, reduced exercise tolerance, impaired mobility, fatigue, anxiety and delayed return to activities of daily living.
Physiotherapy forms an integral component of multidisciplinary cardiac surgical care. Its role extends from preoperative assessment and patient education to postoperative respiratory management, positioning, airway clearance, early mobilisation, exercise therapy, functional retraining and discharge planning. Contemporary enhanced-recovery pathways increasingly emphasise early mobilisation and appropriately prescribed upper- and lower-limb activity as components of recovery following cardiac surgery. The 2024 multidisciplinary ERAS Cardiac/ERAS International Society/Society of Thoracic Surgeons consensus specifically includes early postoperative ambulation and upper-extremity exercise among recommended postoperative care elements. (PubMed)
This thesis examines the theoretical basis, clinical assessment, physiotherapy interventions, safety considerations and rehabilitation principles relevant to patients undergoing closed-heart surgery. Particular attention is given to respiratory physiotherapy, early mobilisation, exercise prescription, functional independence, sternal protection where applicable, patient education and transition from hospital-based rehabilitation to outpatient cardiac rehabilitation.
Keywords: closed-heart surgery, cardiac surgery, physiotherapy, cardiopulmonary physiotherapy, early mobilisation, respiratory physiotherapy, cardiac rehabilitation, exercise therapy, enhanced recovery.
CHAPTER 1: INTRODUCTION
1.1 Background
Cardiac surgery is a complex intervention that produces substantial physiological stress. Improvements in surgical techniques and perioperative management have increased the safety of cardiac procedures; however, surgery may still produce temporary impairments in respiratory function, cardiovascular performance, peripheral muscle strength and functional capacity.
The postoperative period is particularly important from a physiotherapy perspective. Anaesthesia, pain, altered breathing mechanics, immobility, mechanical ventilation and the inflammatory response associated with major surgery may contribute to reduced physical function and pulmonary complications.
Enhanced Recovery After Surgery (ERAS) principles have increasingly incorporated multidisciplinary strategies intended to reduce physiological stress and facilitate functional recovery. Contemporary cardiac-surgery recommendations emphasise coordinated multidisciplinary care, preoperative risk assessment, prehabilitation in selected patients, early postoperative recovery and mobilisation. (Eras Cardiac)
Physiotherapists therefore have an important role within the cardiac surgical team. Their responsibilities include identifying functional and respiratory impairments, selecting appropriate interventions, monitoring physiological responses to activity, progressing mobility and exercise safely, and educating patients regarding recovery.
1.2 Rationale
Postoperative physiotherapy should not be regarded merely as an adjunct to medical treatment. Restoration of movement, ventilation, functional independence and exercise capacity is an essential component of recovery.
Early mobilisation and physiotherapy following cardiac surgery have been associated with improvements in physical function and recovery, while evidence reviewed by ERAS Cardiac supports structured mobility as an important element of enhanced recovery pathways. (Eras Cardiac)
Nevertheless, physiotherapy must be individualised. A patient who is haemodynamically unstable, has significant arrhythmia, uncontrolled pain, active bleeding, severe hypoxaemia or another contraindication requires modification or postponement of mobilisation.
1.3 Aim of the Thesis
The primary aim of this thesis is:
To critically examine the role of physiotherapy in the perioperative and postoperative management of patients undergoing closed-heart cardiac surgery, with particular emphasis on respiratory care, early mobilisation, exercise therapy and restoration of functional independence.
1.4 Objectives
The objectives are to:
Describe the physiological consequences of closed-heart cardiac surgery.
Identify common respiratory and musculoskeletal complications following surgery.
Explain the role of preoperative physiotherapy assessment and education.
Examine postoperative respiratory physiotherapy interventions.
Evaluate the role of early mobilisation.
Describe principles of progressive therapeutic exercise.
Discuss monitoring and safety criteria during mobilisation.
Explain the role of physiotherapy in functional recovery and discharge planning.
Discuss transition from acute physiotherapy to cardiac rehabilitation.
Identify areas requiring further research.
1.5 Research Questions
What postoperative physiological impairments commonly affect patients following closed-heart cardiac surgery?
What is the role of physiotherapy in preventing and managing these impairments?
How can early mobilisation be implemented safely?
What factors influence functional recovery following cardiac surgery?
How can physiotherapy contribute to enhanced recovery and successful transition to cardiac rehabilitation?
CHAPTER 2: OVERVIEW OF CLOSED-HEART CARDIAC SURGERY
2.1 Definition
The term “closed-heart surgery” traditionally describes cardiac procedures performed without opening the cardiac chambers. Examples may include selected procedures involving the great vessels, congenital cardiovascular abnormalities and other extracardiac structures.
The terminology should be interpreted carefully because modern cardiac surgery includes a wide range of procedures, and the physiological consequences differ considerably according to the surgical approach.
For physiotherapy research, the exact surgical procedure should therefore always be documented rather than assuming that all “closed-heart” operations have identical rehabilitation requirements.
2.2 Physiological Stress of Surgery
Major cardiac surgery can influence multiple physiological systems:
respiratory system;
cardiovascular system;
neuromuscular system;
musculoskeletal system;
metabolic system;
psychological wellbeing;
functional independence.
Pain and altered thoracic mechanics may reduce the patient's willingness or ability to take deep breaths, cough and mobilise.
Prolonged bed rest can further contribute to deconditioning and loss of muscle strength.
2.3 Factors Influencing Recovery
Recovery is influenced by:
age;
preoperative functional capacity;
underlying cardiac disease;
pulmonary disease;
nutritional status;
obesity;
diabetes;
smoking;
frailty;
duration of surgery;
postoperative ventilation;
pain;
postoperative complications;
psychological status;
ICU and hospital length of stay.
Consequently, rehabilitation should be based on individual assessment rather than a rigid postoperative timetable.
CHAPTER 3: ROLE OF THE PHYSIOTHERAPIST
3.1 Multidisciplinary Approach
Cardiac surgical rehabilitation requires collaboration among:
cardiac surgeons;
cardiologists;
anaesthesiologists;
intensivists;
nurses;
physiotherapists;
occupational therapists;
dietitians;
psychologists;
pharmacists;
cardiac rehabilitation specialists.
Current ERAS cardiac recommendations emphasise multidisciplinary care and coordinated perioperative planning. (Eras Cardiac)
The physiotherapist should communicate closely with the medical and nursing team before initiating or progressing activity.
3.2 Physiotherapy Assessment
Assessment should include:
Cardiovascular assessment
heart rate;
blood pressure;
rhythm;
symptoms;
peripheral perfusion;
response to activity.
Respiratory assessment
respiratory rate;
oxygen saturation;
breathing pattern;
chest expansion;
auscultation where clinically appropriate;
secretion load;
cough effectiveness;
oxygen requirement.
Musculoskeletal assessment
muscle strength;
joint range of movement;
posture;
balance;
functional mobility.
Functional assessment
bed mobility;
sit-to-stand;
standing tolerance;
walking ability;
stair negotiation where appropriate;
activities of daily living.
Subjective assessment
pain;
fatigue;
breathlessness;
dizziness;
anxiety;
perceived exertion.
CHAPTER 4: PREOPERATIVE PHYSIOTHERAPY
4.1 Preoperative Education
Preoperative education can reduce uncertainty and prepare patients for postoperative participation.
Education may include:
breathing exercises;
supported coughing;
early mobilisation;
positioning;
transfer techniques;
expectations regarding tubes and monitoring;
pain-management principles;
activity progression;
home exercise principles.
4.2 Prehabilitation
Prehabilitation refers to interventions undertaken before surgery to optimise physical and functional status.
The 2024 ERAS cardiac recommendations state that multicomponent prehabilitation may be considered for selected patients and specifically identify prehabilitation for patients with multiple comorbidities or significant deconditioning. (Eras Cardiac)
Possible components include:
aerobic conditioning;
resistance exercise;
inspiratory muscle training when clinically indicated;
nutritional optimisation;
education;
smoking cessation;
psychological preparation.
CHAPTER 5: POSTOPERATIVE RESPIRATORY PHYSIOTHERAPY
5.1 Respiratory Problems
Following cardiac surgery, patients may develop:
reduced lung volumes;
impaired ventilation;
secretion retention;
atelectatic changes;
reduced cough effectiveness;
hypoxaemia;
dyspnoea;
respiratory muscle weakness.
The physiotherapist should first determine whether an intervention is clinically indicated rather than applying respiratory techniques routinely to every patient.
5.2 Breathing Exercises
Breathing exercises may be used to encourage controlled ventilation and improve the patient's confidence in breathing after surgery.
Possible techniques include:
diaphragmatic breathing;
thoracic expansion exercises;
paced breathing;
breathing control;
inspiratory manoeuvres appropriate to the patient's condition.
Exercises should be adjusted according to pain, fatigue, oxygenation and cardiovascular stability.
5.3 Supported Coughing
Pain may cause patients to suppress coughing. Education in supported coughing can help patients clear secretions while minimising discomfort.
Where a sternotomy is present, appropriate support and movement strategies should follow the surgical team's local protocol.
5.4 Positioning
Appropriate positioning can assist ventilation, comfort and mobilisation.
Position changes should be performed according to haemodynamic status, lines, drains, surgical restrictions and patient tolerance.
CHAPTER 6: EARLY MOBILISATION
6.1 Importance
Early mobilisation is a central component of modern cardiac enhanced-recovery pathways. ERAS Cardiac describes early ambulation and physiotherapy as important components of recovery and highlights potential benefits for respiratory function, circulation, muscle strength and functional independence. (Eras Cardiac)
The purpose of early mobilisation is not to make the patient exercise intensely immediately after surgery. Instead, the objective is to restore safe functional movement progressively.
6.2 Staged Mobility
A practical progression may include:
Stage 1
active limb movements;
repositioning;
bed exercises.
Stage 2
sitting at the edge of the bed;
postural control;
seated exercises.
Stage 3
assisted standing;
weight shifting;
marching on the spot.
Stage 4
short-distance walking;
progressive walking duration.
Stage 5
independent or supervised corridor walking;
functional activities;
stairs where appropriate.
Progression should be based on physiological response rather than postoperative day alone.
6.3 Monitoring During Mobilisation
The physiotherapist should monitor:
heart rate;
blood pressure when indicated;
oxygen saturation;
respiratory rate;
symptoms;
level of consciousness;
dizziness;
chest discomfort;
excessive fatigue;
abnormal rhythm where monitoring is available.
Activity should be stopped or modified if clinically significant deterioration occurs.
CHAPTER 7: EXERCISE THERAPY
7.1 Principles
Exercise prescription should follow the principles of:
individualisation;
gradual progression;
appropriate intensity;
adequate recovery;
symptom monitoring;
functional relevance.
The initial emphasis is usually on low-intensity functional activity, followed by progressive aerobic and strengthening exercise as medically appropriate.
7.2 Aerobic Exercise
Walking is often a practical early aerobic activity.
Progression may involve:
increasing duration;
increasing frequency;
reducing assistance;
increasing walking speed;
introducing more demanding functional tasks.
7.3 Resistance Exercise
Resistance exercise may be introduced progressively after appropriate surgical healing and medical clearance.
The programme should account for:
surgical restrictions;
pain;
baseline strength;
age;
frailty;
cardiovascular response;
wound status.
Upper-limb loading requires particular attention when a sternotomy or other chest-wall incision is present.
CHAPTER 8: STERNAL AND SURGICAL PROTECTION
Where median sternotomy has been performed, traditional postoperative practice has often involved restrictions on upper-limb loading and certain movements.
Contemporary practice increasingly emphasises individualised movement strategies rather than unnecessary prolonged immobilisation. ERAS Cardiac recommendations report that early postoperative ambulation and upper-extremity exercise can be well tolerated and associated with faster recovery when appropriately implemented. (Eras Cardiac)
The physiotherapist should therefore follow:
surgeon-specific precautions;
wound status;
pain;
sternal stability;
local hospital protocol;
patient-specific risk factors.
A single universal restriction programme should not be applied to every patient.
CHAPTER 9: FUNCTIONAL RECOVERY
9.1 Activities of Daily Living
Physiotherapy should address functional independence rather than focusing exclusively on physiological parameters.
Important activities include:
rolling;
sitting;
standing;
transferring;
walking;
toileting;
dressing;
stair climbing;
community mobility.
9.2 Fatigue Management
Postoperative fatigue is common and may limit participation.
Patients should be taught:
activity pacing;
appropriate rest;
gradual progression;
prioritisation of important activities;
recognition of excessive symptoms.
CHAPTER 10: DISCHARGE PLANNING
Before discharge, the physiotherapist should assess whether the patient can safely perform essential mobility tasks.
Important considerations include:
independent or appropriate assisted transfers;
safe walking;
stair ability where necessary;
adequate exercise tolerance;
understanding of prescribed activity;
appropriate family support;
knowledge of warning symptoms.
The patient should receive clear written and verbal instructions consistent with the surgical and cardiac team's recommendations.
CHAPTER 11: TRANSITION TO CARDIAC REHABILITATION
Hospital physiotherapy represents only the early stage of recovery.
Following medical clearance, appropriate patients may progress to structured outpatient cardiac rehabilitation.
Cardiac rehabilitation may incorporate:
aerobic exercise;
resistance training;
education;
cardiovascular risk-factor modification;
nutritional counselling;
psychosocial support;
long-term physical-activity planning.
The transition should be individualised according to diagnosis, operation, complications, functional capacity and medical status.
CHAPTER 12: SAFETY CONSIDERATIONS
Physiotherapy following cardiac surgery must prioritise safety.
Potential reasons to delay or modify mobilisation include:
haemodynamic instability;
significant uncontrolled arrhythmia;
active bleeding;
severe hypoxaemia;
acute clinical deterioration;
uncontrolled pain;
altered consciousness;
significant dizziness or syncope;
unstable surgical or wound-related problems.
These criteria should be interpreted in conjunction with the patient's medical status and local ICU/cardiac-surgery protocol.
CHAPTER 13: DISCUSSION
The evidence increasingly supports a shift from prolonged postoperative inactivity toward structured, monitored recovery. Contemporary ERAS cardiac pathways place physiotherapy within a broader multidisciplinary programme rather than treating it as an isolated postoperative service. (PubMed)
Early mobilisation may provide several clinically relevant advantages, including preservation of functional capacity, reduction of deconditioning and earlier return to independence. However, early does not mean indiscriminate. Appropriate timing, monitoring and progression are essential.
An important principle for modern cardiac physiotherapy is therefore:
“Mobilise early when clinically appropriate, monitor continuously, and progress according to the patient's physiological and functional response.”
Another important development is the movement away from purely impairment-based treatment toward patient-centred functional goals. The ultimate outcome is not simply improved oxygen saturation or chest expansion; it is the patient's ability to breathe effectively, move safely, perform daily activities and return progressively to meaningful life roles.
The 2024 ERAS consensus supports this broader perioperative model, incorporating patient engagement, prehabilitation in selected patients, early recovery strategies and postoperative mobilisation. (PubMed)
CHAPTER 14: CONCLUSION
Physiotherapy is an important component of multidisciplinary recovery following closed-heart cardiac surgery. The physiotherapist contributes throughout the perioperative pathway, beginning with assessment and education and continuing through respiratory management, early mobilisation, exercise progression, functional retraining and discharge planning.
Modern cardiac enhanced-recovery principles support early, appropriately monitored mobilisation and progressive physical activity rather than unnecessary postoperative inactivity. (Eras Cardiac)
The optimal physiotherapy programme should nevertheless be individualised according to the type of operation, surgical approach, medical stability, respiratory status, pain, functional capacity and postoperative complications.
Future research should focus on standardising physiotherapy pathways, identifying patient-specific predictors of recovery, determining optimal exercise dosing, and evaluating long-term functional outcomes after different types of cardiac surgery.
REFERENCES
Grant MC, Crisafi C, Alvarez A, et al. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Annals of Thoracic Surgery. 2024;117(4):669–689. (PubMed)
Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surgery. 2019;154(8):755–766. (PubMed)
ERAS Cardiac Society. Expert Recommendations for Cardiac Surgery: 2024 ERAS Cardiac recommendations. (Eras Cardiac)
ERAS Cardiac Society. Ambulation and Physiotherapy: Enhanced Recovery After Cardiac Surgery. (Eras Cardiac)
ERAS Cardiac Society. Early Ambulation and Physiotherapy: Patient Education Resource. (Eras Cardiac)
Ramos dos Santos PM, Aquaroni Ricci N, Aparecida Bordignon Suster É, de Moraes Paisani D, Dias Chiavegato L. Effects of early mobilisation in patients after cardiac surgery: a systematic review. Physiotherapy. 2017;103:1–12. (Eras Cardiac)
Doyle MP, Indraratna P, Tardo DT, Peeceeyen SC, Peoples GE. Safety and efficacy of aerobic exercise commenced early after cardiac surgery: a systematic review and meta-analysis. European Journal of Preventive Cardiology. 2019;26:36–45. (Eras Cardiac)
