SAfety and Feasibility of EArly Resistance Training After Median Sternotomy: The SAFE-ARMS Study.

OBJECTIVE: The purpose of this study was to determine the safety and feasibility of subacute upper limb resistance exercise on sternal micromotion and pain and the reliability of sternal ultrasound assessment following cardiac surgery via median sternotomy. METHODS: This experimental study used a pretest-posttest design to investigate the effects of upper limb resistance exercise on the sternum in patients following their first cardiac surgery via median sternotomy. Six bilateral upper limb machine-based exercises were commenced at a base resistance of 20 lb (9 kg) and progressed for each participant. Sternal micromotion was assessed using ultrasound at the mid and lower sternum at 2, 8, and 14 weeks postsurgery. Intrarater and interrater reliability was calculated using intraclass correlation coefficients (ICCs). Participant-reported pain was recorded at rest and with each exercise using a visual analogue scale. RESULTS: Sixteen adults (n = 15 males; 71.3 [SD = 6.2] years of age) consented to participate. Twelve participants completed the study, 2 withdrew prior to the 8-week assessment, and 2 assessments were not completed at 14 weeks due to assessor unavailability. The highest median micromotion at the sternal edges was observed during the bicep curl (median = 1.33 mm; range = -0.8 to 2.0 mm) in the lateral direction and the shoulder pulldown (median = 0.65 mm; range = -0.8 to 1.6 mm) in the anterior-posterior direction. Furthermore, participants reported no increase in pain when performing any of the 6 upper limb exercises. Interrater reliability was moderate to good for both lateral-posterior (ICC = 0.73; 95% CI = 0.58 to 0.83) and anterior-posterior micromotion (ICC = 0.83; 95% CI = 0.73 to 0.89) of the sternal edges. CONCLUSION: Bilateral upper limb resistance exercises performed on cam-based machines do not result in sternal micromotion exceeding 2.0 mm or an increase in participant-reported pain. IMPACT: Upper limb resistance training commenced as early as 2 weeks following cardiac surgery via median sternotomy and performed within the safe limits of pain and sternal micromotion appears to be safe and may accelerate postoperative recovery rather than muscular deconditioning.

Effects of 12-Week Supervised Early Resistance Training (SEcReT) Versus Aerobic-Based Rehabilitation on Cognitive Recovery Following Cardiac Surgery via Median Sternotomy: A Pilot Randomised Controlled Trial.

AIMS: To investigate the effects of a 12-week early moderate-intensity resistance training program compared to aerobic-based rehabilitation on postoperative cognitive recovery following cardiac surgery via median sternotomy. METHODS: This was a multicentre, prospective, pragmatic, non-blinded, pilot randomised controlled trial (1:1 randomisation) of two parallel groups that compared a 12-week early moderate-intensity resistance training group to a control group, receiving aerobic-based rehabilitation. English-speaking adults (≥18 years) undergoing elective cardiac surgery via median sternotomy were randomised using sealed envelopes, with allocation revealed before surgery. The primary outcome was cognitive function, assessed using the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog), at baseline, 14 weeks and 6 months postoperatively. RESULTS: The ADAS-cog score at 14 weeks was significantly better for the resistance training group (n=14, 7.2±1.4; 95% CI 4.3, 10.2, vs n=17, 9.2±1.3; 95% CI 6.6, 11.9, p=0.010). At 14 weeks postoperatively, 53% of the aerobic-based rehabilitation group (n=9/17) experienced cognitive decline by two points or more from baseline ADAS-cog score, compared to 0% of the resistance training group (n=0/14; p=0.001). CONCLUSION: Early resistance training appears to be safe and may improve cognitive recovery compared to standard, aerobic-based rehabilitation following cardiac surgery via median sternotomy, however as this was a pilot study, the sample size was small and further research is needed to determine a causal relationship.

Effects of Supervised Early Resistance Training versus standard care on cognitive recovery following cardiac surgery via median sternotomy (the SEcReT study): protocol for a randomised controlled pilot study.

INTRODUCTION: Mild cognitive impairment is considered a precursor to dementia and significantly impacts upon quality of life. The prevalence of mild cognitive impairment is higher in the post-surgical cardiac population than in the general population, with older age and comorbidities further increasing the risk of cognitive decline. Exercise improves neurogenesis, synaptic plasticity and inflammatory and neurotrophic factor pathways, which may help to augment the effects of cognitive decline. However, the effects of resistance training on cognitive, functional and overall patient-reported recovery have not been investigated in the surgical cardiac population. This study aims to determine the effect of early moderate-intensity resistance training, compared to standard care, on cognitive recovery following cardiac surgery via a median sternotomy. The safety, feasibility and effect on functional recovery will also be examined. METHODS: This study will be a prospective, pragmatic, pilot randomised controlled trial comparing a standard care group (low-intensity aerobic exercise) and a moderate-intensity resistance training group. Participants aged 18 years and older with coronary artery and/or valve disease requiring surgical intervention will be recruited pre-operatively and randomised 1:1 to either the resistance training or standard care group post-operatively. The primary outcome, cognitive function, will be assessed using the Alzheimer's Disease Assessment Scale and cognitive subscale. Secondary measures include safety, feasibility, muscular strength, physical function, multiple-domain quality of recovery, dynamic balance and patient satisfaction. Assessments will be conducted at baseline (pre-operatively) and post-operatively at 2 weeks, 8 weeks, 14 weeks and 6 months. DISCUSSION: The results of this pilot study will be used to determine the feasibility of a future large-scale randomised controlled trial that promotes the integration of early resistance training into existing aerobic-based cardiac rehabilitation programs in Australia. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001430325p . Registered on 9 October 2017. Universal Trial Number (UTN): U1111-1203-2131.

Exercise Parameters and Outcome Measures Used in Cardiac Rehabilitation Programs Following Median Sternotomy in the Elderly: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this systematic review was to identify exercise parameters and outcome measures used in cardiac rehabilitation programs following median sternotomy, in the elderly cardiac population. DATA SOURCES: Five (5) electronic databases were searched for relevant studies published in English after 1997. STUDY SELECTION: The screening process was completed by two independent researchers, with a third independent reviewer for overall agreement. Studies were selected if they included only cardiac patients aged ≥65 years who had undergone valve surgery and/or coronary artery bypass grafting via median sternotomy, and who had undertaken a postoperative cardiac rehabilitation exercise intervention assessing physical function and/or cognitive recovery as outcomes. DATA EXTRACTION: Two researchers independently completed the data extraction and quality assessment. Quality was assessed using a modified Downs and Black tool. DATA SYNTHESIS: In total, 11 articles were included for appraisal with respect to the quality of the study. Only two randomised controlled trials were suitable for meta-analysis. A higher volume of exercise was shown to have a positive effect on functional recovery, assessed using the 6-minute walk test (6MWT) (mean difference=26.97m; 95% confidence interval [CI], 6.96-46.97; p=0.008; I2=0%). No significant improvement was shown between additional exercise compared to standard care in improving VO2peak, maximal power output or quality of life. No studies evaluated the effect of exercise on cognitive recovery. CONCLUSIONS: Exercise significantly improves functional recovery in the post-surgical elderly cardiac population, however uncertainty still exists with regard to which modes of exercise and their specific parameters are most effective in improving cognitive recovery.

Resistance Training Following Median Sternotomy: A Systematic Review and Meta-Analysis.

OBJECTIVE: Despite no evidence to support weight limitations following median sternotomy, sternal precautions continue to be routinely prescribed. Moreover, international cardiac rehabilitation guidelines lack sufficient detail for the implementation of resistance training. This systematic review and meta-analysis aimed to determine what the literature defines as resistance training; how resistance training is applied, progressed and evaluated; and, whether resistance training improves physical and functional recovery postoperatively in the cardiac surgical population. DATA SOURCES: Five (5) electronic databases were searched from inception to 28 September 2018 for studies published in English that investigated the effects of a resistance training intervention on physical and functional recovery following median sternotomy. RESULTS: Eighteen (18) trials (n=3,462) met eligibility criteria and were included in the analysis. Seven (7) randomised controlled trials shared common outcome measures, allowing meta-analysis. The performance of resistance training appears to be safe and feasible, and resulted in similar improvements in both cardiopulmonary capacity and anthropometry, when compared to aerobic training alone. However, the definition and application of resistance training is frequently a lower intensity and volume than recommended by the American College of Sports Medicine. Furthermore, sternal precautions are not reflective of the kinematics and weights used when performing many activities of daily living. For this reason, resistance training needs to be task-specific, reflecting functional tasks to promote recovery. CONCLUSION: Resistance training, in isolation or when combined with aerobic training, may lead to greater improvements in physical and functional recovery following cardiac surgery via median sternotomy; however, further research is required to inform clinical guidelines.