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Physiotherapy Management of CABG - Detailed Sequential Guide

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PRE-OPERATIVE PHASE (Prehabilitation)

Goals

• Optimize cardiopulmonary function before surgery
• Teach breathing techniques to be used post-op
• Reduce anxiety and improve psychological readiness
• Reduce post-op complications and hospital stay length

Physiotherapy Interventions

• Explain the surgical procedure, expected recovery timeline, and PT role
• Teach sternal precautions (no pushing/pulling >2-3 kg, no reaching behind head for 6-8 weeks)
• Educate on warning signs: wound infection, chest pain, arrhythmias, leg swelling

• Diaphragmatic breathing: teach before surgery so patient can do it immediately post-op
• Active Cycle of Breathing Technique (ACBT): train the three components - breathing control (BC), thoracic expansion exercises (TEE), forced expiration technique (FET/huff)
• Incentive spirometry: baseline measurement and technique instruction
• Supported cough technique: teach "pillow hug" or sternal support coughing

• Aerobic conditioning: graded walking program, cycling (if tolerated)
• Upper and lower limb strengthening
• Goal: maximize functional reserve before surgery
• Evidence: a 2025 systematic review (PMID 39307000) found prehabilitation reduces post-op complications and hospital stay in CABG patients

• 6-Minute Walk Test (6MWT) for functional capacity baseline
• Spirometry (FEV1, FVC, PEFR)
• Peripheral limb strength, posture assessment
• Psychological screen (anxiety/depression)

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PHASE I - IN-HOSPITAL / ICU PHASE (Days 1-7)

Day 0 (Immediate Post-op, ICU - Still Intubated)

• Passive limb exercises to prevent DVT and maintain circulation
• Ankle pumps and foot circles (can be done immediately)
• Positioning: maintain head-of-bed elevation (30-45°) to aid respiratory function
• Manual chest physiotherapy if indicated (percussion/vibration) for secretion clearance while mechanically ventilated
• Prepare for early extubation (target within 4-6 hours post-op in fast-track protocols, or 24-48 hours in standard)

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Day 1 (Post-extubation, ICU)

• Deep breathing exercises: 10 deep breaths every 1-2 hours while awake
• Diaphragmatic breathing: slow, deep inspirations with abdominal rise
• Incentive spirometry: 10 repetitions/hour, aim for >70% of predicted values
• ACBT: breathing control → 3-4 thoracic expansion exercises → forced expiration (huff) → repeat cycle; perform 2-3 sessions/day
• Supported coughing: patient holds pillow firmly against chest, coughs 2-3 times per session to clear secretions and prevent atelectasis
• Positive Expiratory Pressure (PEP) therapy (if available): improves oxygenation and secretion mobilization post-CABG

• Sitting on edge of bed (dangling): first mobilization milestone - 5-10 minutes
• Passive → active-assisted upper and lower limb exercises in bed
• Ankle pumps continued throughout
• Blood pressure and O2 saturation monitoring throughout

• No mobilization if: HR <40 or >130, SBP <90 or >180, SpO2 <90%, new arrhythmia, active bleeding, chest drain >200 mL/hr

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Day 2 (Step-Down Unit / HDU)

• Continue ACBT 2-3x/day
• Incentive spirometry
• Supported coughing with sternal support (pillow hug)
• Monitor for signs of pulmonary complications: reduced breath sounds, crackles, SpO2 trends

• Transfer from bed to chair: sit out of bed 30-60 minutes, 2-3x/day
• Standing and weight bearing at bedside
• Short-distance ambulation: 10-20 meters with assistance
• Continue ankle pumps and circulation exercises

• No pushing up from bed using arms (use log-roll technique)
• No reaching behind back or above head
• No driving for 4-6 weeks
• No lifting >2-3 kg for 6-8 weeks (until sternal healing confirmed)

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Day 3

• Walking 50-100 meters in corridor with physiotherapist supervision
• Walk 2x/day
• Sit out of bed for meals
• Independent bed-to-chair transfer (with support)

• Active upper limb range of motion: shoulder flexion/abduction (within pain limits)
• Seated lower limb exercises: leg press, knee extensions, hip flexion
• Gradual increase in activity level monitored via Borg RPE scale (target 11-13, "somewhat hard")

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Day 4-5

• Walk 100-200 meters, 2-3x/day, progressing to independent ambulation
• Stair climbing introduced: 1 flight of stairs (essential for discharge readiness)
• Low-level ADLs: dressing upper body, self-hygiene with supervision

• Taper from 3x/day to 2x/day ACBT as lung function improves
• Confirm resolution of atelectasis clinically and on chest X-ray if indicated

• Discharge planning: home exercise program instruction
• Wound care: inspect sternotomy and leg incision sites
• Signs of wound infection, post-pericardiotomy syndrome, deep sternal wound dehiscence

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Day 6-7 (Pre-discharge Assessment)

• Independent ambulation on level ground (>150 meters)
• Stair climbing - 1 flight independently
• Independent ADLs (lower body dressing, basic hygiene)
• O2 saturation >94% on room air at rest and with ambulation
• No respiratory distress
• Understands sternal precautions and home exercise program

• Written home exercise program
• Walking schedule for weeks 1-6
• Sternal precaution reminder card
• Referral to Phase II/III cardiac rehabilitation

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PHASE II - EARLY HOME RECOVERY (Weeks 1-6)

Goals

• Continue gradual activity progression
• Protect healing sternum
• Prevent deconditioning
• Monitor for late complications (pleural effusion, pericardial effusion, post-pericardiotomy syndrome)

PT Interventions

• Continue diaphragmatic breathing exercises and ACBT once daily until lung function normalizes
• Supported coughing as needed

• Flat surfaces initially; avoid inclines until week 3-4
• Target heart rate: Resting HR + 20-30 bpm, or Borg RPE 11-13
• Stop and rest if: chest pain, dizziness, excessive dyspnea, palpitations

• Weeks 1-6: No lifting >2-3 kg
• Range of motion exercises permitted: gentle shoulder circles, pendulum exercises, neck stretches
• No overhead activities or pushing/pulling movements

• Chair stands (sit-to-stand)
• Heel and toe raises
• Seated knee extensions
• Wall slides for gluteal strengthening
• Step-ups on low platforms (week 3+)

• Once sutures/staples removed and wound closed (typically week 2-3)
• Gentle scar massage to prevent adhesions: circular and transverse movements
• Desensitization exercises for sternotomy and leg harvest sites

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PHASE III - STRUCTURED CARDIAC REHABILITATION (Weeks 6-12)

Goals

• Improve cardiorespiratory fitness (VO2 max)
• Reduce cardiovascular risk factors
• Psychosocial recovery
• Return to work and social activities

Initial Assessment (Week 6)

• Repeat 6MWT or graded exercise test (GXT/stress test if cleared by cardiologist)
• Echocardiogram review
• Risk factor profiling: lipids, HbA1c, BP, BMI
• Psychological assessment: HAD scale for anxiety/depression
• Physical assessment: posture, shoulder mobility, incision healing

Exercise Prescription (FITT Principle)

1. Warm-up (10 min): slow walking, gentle stretching, range of motion
2. Aerobic component (20-40 min): treadmill, cycle ergometer, rowing
3. Resistance training (10-15 min): begin after sternal clearance (week 6-8), start with resistance bands and light weights (1-2 kg)
4. Cool-down (10 min): slow walking, flexibility exercises

• Evidence supports IMT in Phase I and Phase II post-CABG (PMID 38624192, 2024 systematic review and meta-analysis)
• Device: threshold loading device at 30-60% maximal inspiratory pressure (MIP)
• 30 breaths/session, once daily or 2x/day
• Improves inspiratory muscle strength, reduces dyspnea, improves 6MWT distance

• Upper body: resistance bands → 1-2 kg dumbbells → progressive loading
• Lower body: chair squats, leg press, step-ups
• Core stabilization (protecting sternum): pelvic floor, transverse abdominus activation, modified bridging
• NO heavy Valsalva-type maneuvers

Behavioral/Education Components (Multidisciplinary)

• Dietary counseling: Mediterranean diet, reduced saturated fat, salt restriction
• Smoking cessation (if applicable)
• Medication adherence: antiplatelet therapy (aspirin ± clopidogrel), statins, beta-blockers, ACE inhibitors
• Stress management: relaxation techniques, mindfulness
• Sexual activity counseling: typically safe when patient can climb 2 flights of stairs without symptoms
• Driving: cleared at 4-6 weeks if sternal healing confirmed (varies by country/policy)

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PHASE IV - LONG-TERM MAINTENANCE (3+ Months)

Goals

• Maintain gains from Phase III
• Prevent future cardiac events
• Optimize quality of life and independent function

PT Role

• Transition to independent community exercise program
• Periodic reassessment every 3-6 months
• Goal: 150-300 min/week moderate-intensity aerobic activity (per cardiac guidelines)
• Resistance training 2x/week, full program
• Ongoing lifestyle modification support
• Return to sport/occupational activities as appropriate
• Monitoring for late complications: graft failure, restenosis (angina symptoms)

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KEY PT MONITORING PARAMETERS (All Phases)

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SPECIAL CONSIDERATIONS

• Incisional leg pain limits early ambulation - key barrier to PT
• Compression stockings (thigh-high TED stockings) from Day 1 post-op
• Limb elevation when sitting/lying to reduce edema
• Gentle ankle pumps and walking are therapeutic

• 57-89% of patients develop pleural effusion post-CABG
• Usually left-sided or bilateral (Murray & Nadel's)
• PT role: breathing exercises to maintain lung expansion; thoracentesis by medical team if >25% hemithorax

• Use "sternal support" during coughing at all times for 6-8 weeks
• Log-roll technique for bed mobility
• No activities that cause sternal clicking/pain

• Fever, pleuritic chest pain, pericardial rub (weeks 2-6 post-op)
• Managed medically (NSAIDs, colchicine)
• PT: gentle breathing and mobility, avoid vigorous exercise until resolved

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SUMMARY TABLE

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• ACBT is safe and effective post-CABG, improving oxygenation, lung volumes, and functional capacity - typically applied 2-3x/day over 2-5 days post-op (PMID 40917540, 2025 review)
• Inspiratory muscle training in Phase I and II significantly improves respiratory outcomes post-CABG (PMID 38624192, 2024 systematic review and meta-analysis in Physical Therapy)
• Early mobilization after cardiac surgery improves physical function (PMID 32998202, systematic review and meta-analysis)
• Exercise prehabilitation before CABG reduces post-op complications (PMID 39307000, 2025 systematic review)
• Miller's Anesthesia 10e - sternotomy pain management essential for enabling deep breathing and preventing lobar collapse and pneumonia
• Murray & Nadel's Respiratory Medicine - pleural effusion in 57-89% of CABG patients by ultrasound at 7 days post-op; breathing exercises central to prevention