Effects of Cycle Ergometer Exercise on Functional Capacity and Hospitalization Time of Patients After Open-Heart Surgery: A Systematic Review and Meta-Analysis

Simas, Monielly; Gulart, Aline Almeida; Souza Filho, Vicente Paulo Ponte; Cani, Katerine Cristhine; Campos, Mariana Lanzoni; Matte, Darlan Laurício

doi:10.21470/1678-9741-2024-0437

person Monielly Simas

Substantial contributions to the conception or design of the work · or the acquisition · analysis · or interpretation of data for the work · drafting the work or revising it critically for important intellectual content · agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated · resolved · final approval of the version to be published

* Monielly Simas and Aline Almeida Gulart contributed equally as first authors of this study. schoolPostgraduate Program in Physiotherapy, Universidade do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil

0009-0005-5824-9583

person Aline Almeida Gulart

Substantial contributions to the conception or design of the work · or the acquisition · analysis · or interpretation of data for the work · drafting the work or revising it critically for important intellectual content · agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated · resolved · final approval of the version to be published

* Monielly Simas and Aline Almeida Gulart contributed equally as first authors of this study. schoolPostgraduate Program in Physiotherapy, Universidade do Estado de Santa Catarina, Florianópolis, Santa Catarina, BrazilschoolPhysical Therapy Department, Universidade do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil

0000-0001-9603-320X

person Vicente Paulo Ponte Souza Filho

Substantial contributions to the conception or design of the work · or the acquisition · analysis · or interpretation of data for the work · drafting the work or revising it critically for important intellectual content · agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated · resolved · final approval of the version to be published

schoolPostgraduate Program in Human Movement Sciences, Universidade do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil

0000-0001-6773-8032

person Katerine Cristhine Cani

Substantial contributions to the conception or design of the work · or the acquisition · analysis · or interpretation of data for the work · drafting the work or revising it critically for important intellectual content · final approval of the version to be published

schoolMultiprofessional Unit, Hospital Universitário da Universidade Federal de Santa Catarina, Florianópolis, Santa Catarina, Brazil

0000-0002-8819-3497

person Mariana Lanzoni Campos

Substantial contributions to the conception or design of the work · or the acquisition · analysis · or interpretation of data for the work · drafting the work or revising it critically for important intellectual content · drafting the work or revising it critically for important intellectual content · agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated · resolved · final approval of the version to be published

schoolMultiprofessional Unit, Hospital Universitário da Universidade Federal de Santa Catarina, Florianópolis, Santa Catarina, Brazil

0000-0003-1792-6371

person Darlan Laurício Matte

Drafting the work or revising it critically for important intellectual content · final approval of the version to be published

schoolPostgraduate Program in Physiotherapy, Universidade do Estado de Santa Catarina, Florianópolis, Santa Catarina, BrazilschoolPhysical Therapy Department, Universidade do Estado de Santa Catarina, Florianópolis, Santa Catarina, BrazilschoolPostgraduate Program in Human Movement Sciences, Universidade do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil

0000-0003-4650-3714

*

Monielly Simas and Aline Almeida Gulart contributed equally as first authors of this study.

Editor-in-chief:

Henrique Murad https://orcid.org/0000-0002-9543-7832

Potential Conflict of Interest

The authors declare that there is no conflict of interest in this study.

Correspondence Address: Aline Almeida Gulart, Pascoal Simone, 358, Florianópolis, SC, Brazil, Zip Code: 88080-350, E-mail:
aline.gulart@udesc.br

Abbreviations, Acronyms & Symbols
6MWT	= Six-minute walk test	IV	= Inverse variance
ACSM	= American College of Sports Medicine	LILACS	= Latin American and Caribbean Health Sciences Literature
CG	= Control group	LL	= Lower limbs
CI	= Confidence interval	MRS	= Myocardial revascularization surgery
CINAHL	= Cumulative Index to Nursing & Allied Health Literature	PEDro	= Physiotherapy Evidence Database
CPAP	= Continuous positive airway pressure	PO	= Postoperative
CR	= Cardiac rehabilitation	RPE	= Rate of perceived exertion
HR	= Heart rate	SpO₂	= Pulse oxygen saturation
ICU	= Intensive care unit	UL	= Upper limbs
IG	= Intervention group	VRS	= Valve replacement surgery

Database	Search Strategy
MEDLINE	((Exercise Therapy[MeSH Terms]) OR (Rehabilitation[MeSH Terms]) OR (Early Ambulation[MeSH Terms]) OR (Physical Therapy Modalities[MeSH Terms]) OR (Exercise[MeSH Terms]) OR (Resistance Training[MeSH Terms]) OR (Rehabilitation[MeSH Terms]) OR (Cardiac Rehabilitation[MeSH Terms]) OR (Cycle ergomet^[Text Word]) OR (Bicycle ergomet^[Text Word]) OR (early mobili^[Text Word]) OR (physiotherapy[Text Word]) OR (physical therapy[Text Word])) AND ((Cardiac Surgical Procedures[MeSH Terms]) OR (Coronary Artery Bypass[MeSH Terms]) OR (Myocardial Revascularization[MeSH Terms]) OR (Cardiac Valve Annuloplasty[MeSH Terms]) OR (Heart Bypass, Left[MeSH Terms]) OR (Heart Valve Prosthesis Implantation[MeSH Terms]) OR (Heart Valve Prosthesis[MeSH Terms]) OR ((cardiac[Text Word] OR heart[Text Word] OR cardiovascular[Text Word] OR coronary[Text Word] OR myocardial[Text Word] OR aortic valv^[Text Word] OR mitral valv^[Text Word] OR tricuspid valv^[Text Word] OR pulmonary valv^[Text Word] OR bypass) N1 (operat^[Text Word] OR surg^[Text Word] OR procedure^[Text Word])) OR (CABG[Text Word] OR cardiac valvuloplasty[Text Word] OR heart valvuloplasty[Text Word] OR aortic valvuloplasty[Text Word] OR aortic valvotomy[Text Word] OR mitral valvuloplasty[Text Word] OR tricuspid valvuloplasty[Text Word]) OR ((cardiac[Text Word] OR heart[Text Word] OR cardiovascular[Text Word] OR coronary[Text Word] OR myocardium[Text Word] OR myocardial[Text Word] OR aortocoronary[Text Word] OR cardiopulmonary) N1 (bypass[Text Word] OR anastomosis[Text Word] OR revascularization[Text Word])) OR ((cardiac valv^[Text Word] OR heart valv^[Text Word] OR aortic valv^[Text Word] OR mitral valv^[Text Word] OR tricuspid valv^[Text Word] OR pulmonary valv^) N1 (implant^[Text Word] OR reimplant^[Text Word] OR replac^[Text Word] OR repair^[Text Word] OR reconstruct^[Text Word] OR artificial^[Text Word] OR prosthe^[Text Word] OR valvotom^[Text Word] OR valvulotom^[Text Word] OR annuloplast^[Text Word] OR valvuloplast^[Text Word] OR commissurotom^[Text Word])))
CINAHL - EBSCO	( SU Exercise Therapy OR SU Rehabilitation OR SU Early Ambulation OR SU Physical Therapy Modalities OR SU Exercise OR SU Resistance Training OR SU Rehabilitation OR SU Cardiac Rehabilitation OR TX ( Cycle ergomet^* OR Bicycle ergomet^* OR early mobili^* OR physiotherap^* OR physical therap^* )) AND ( SU Cardiac Surgical Procedures OR SU Coronary Artery Bypass OR SU Myocardial Revascularization OR SU Cardiac Valve Annuloplasty OR SU Heart Bypass, Left OR SU Heart Valve Prosthesis Implantation OR SU Heart Valve Prosthesis OR TX ((cardiac or heart or cardiovascular or coronary or myocardial or aortic valv^* or mitral valv^* or tricuspid valv^* or pulmonary valv^* or bypass) N1 (operat^* or surg^* or procedure^)) OR TX (CABG or cardiac valvuloplasty or heart valvuloplasty or aortic valvuloplasty or aortic valvotomy or mitral valvuloplasty or tricuspid valvuloplasty) OR TX ((cardiac valv^ or heart valv^* or aortic valv^* or mitral valv^* or tricuspid valv^* or pulmonary valv^) N1 (implant^ or reimplant^* or replac^* or repair^* or reconstruct^* or artificial^* or prosthe^* or valvotom^* or valvulotom^* or annuloplast^* or valvuloplast^* or commissurotom^*))
LILACS	((Exercise Therapy) OR (Rehabilitation) OR (Early Ambulation) OR (Physical Therapy) OR (Exercise) OR (Resistance Training) OR (Cardiac Rehabilitation) OR (Cycle) OR (Bicycle) OR (early mobilisation) OR (early mobilization) OR (physiotherapy) OR (physical therapy)) AND ((Cardiac Surgical) OR (Coronary Artery Bypass) OR (Myocardial Revascularization) OR (Cardiac Valve Annuloplasty) OR (Heart Valve Prosthesis) OR (cardiac surgery) OR (heart surgery) OR (coronary surgery) OR (myocardial surgery) OR (valve surgery) OR (CABG) OR (valvuloplasty) OR (valvotomy))
EMBASE	('exercise therapy'/exp OR 'rehabilitation'/exp OR 'physical therapy modalities'/exp OR 'exercise'/exp OR 'cardiac rehabilitation'/exp OR 'cycle ergometer':ab,ti OR 'bicycle ergometer':ab,ti OR 'cycle ergometry':ab,ti OR 'bicycle ergometry':ab,ti OR 'early mobilisation':ab,ti OR 'early mobilization':ab,ti OR 'physiotherapy':ab,ti OR 'physical therapy':ab,ti) AND ('cardiac surgical procedures'/exp OR 'coronary artery bypass'/exp OR 'myocardial revascularization'/exp OR 'cardiac valve annuloplasty'/exp OR 'heart bypass, left'/exp OR 'heart valve prosthesis implantation'/exp OR 'heart valve prosthesis'/exp OR 'cardiac surgery':ab,ti OR 'heart surgery':ab,ti OR 'coronary surgery':ab,ti OR 'myocardial surgery':ab,ti OR 'valve surgery':ab,ti OR 'cabg':ab,ti OR 'valvuloplasty':ab,ti OR 'valvotomy':ab,ti)
Web of Science	#1: TS=("Exercise Therapy” OR “Rehabilitation” OR “Early Ambulation” OR “Physical Therapy Modalities” OR “Exercise” OR “Resistance Training” OR “Rehabilitation” OR “Cardiac Rehabilitation")
	#2: Ab=("cycle ergomet^” OR “bicycle ergomet^” OR “early mobili^*” OR “physiotherapy” OR “physical therapy"))
	#3: #2 or #3
	#4: TS=("Cardiac Surgical Procedures” OR “Coronary Artery Bypass” OR “Myocardial Revascularization” OR “Cardiac Valve Annuloplasty” OR “Heart Bypass, Left” OR “Heart Valve Prosthesis Implantation” OR “Heart Valve Prosthesis")
	#5 AB=("cardiac surgery” OR “heart surgery” OR “coronary surgery” OR “myocardial surgery” OR “valve surgery” OR “cabg” OR “valvuloplasty” OR “valvotomy"))
	#6: #4 or #5
	#7: #3 and #6
SCOPUS	(TITLE-ABS-KEY ("Exercise") OR ("Rehabilitation") OR ("Cycle ergomet^") OR ("Bicycle ergomet^") OR ("early mobili^*") ("physiotherapy") OR ("physical therapy") ) AND ( TITLE-ABS-KEY ("Cardiac Surgical") OR ("Coronary Artery Bypass") OR ("Myocardial Revascularization") OR ("Cardiac Valve Annuloplasty") OR ("Heart Valve Prosthesis") OR ("cardiac surgery") OR ("heart surgery") OR ("coronary surgery") OR ("myocardial surgery") OR ("valve surgery") OR ("CABG") OR ("valvuloplasty") OR ("valvotomy") )
Cochrane	#1: MeSH descriptor: [Exercise therapy] explode all trees
	#2: MeSH descriptor: [Rehabilitation] explode all trees
	#3: MeSH descriptor: [Physical therapy modalities] explode all trees
	#4: MeSH descriptor: [Exercise] explode all trees
	#5: MeSH descriptor: [Cardiac rehabilitation] explode all trees
	#6: (cycle ergomet^*)
	#7: (bicycle ergomet^*)
	#8: #1 or #2 or #3 or #4 or #5 or #6 or #7
	#9: MeSH descriptor: [Cardiac surgical procedures] explode all trees
	#10: MeSH descriptor: [Coronary artery bypass] explode all trees
	#11: MeSH descriptor: [Myocardial revascularization] explode all trees
	#12: MeSH descriptor: [Cardiac valve annuloplasty] explode all trees
	#13: MeSH descriptor: [Heart bypass, left] explode all trees
	#14: MeSH descriptor: [Heart valve prosthesis implantation] explode all trees
	#15: MeSH descriptor: [Heart valve prosthesis] explode all trees
	#16: (cardiac surgery)
	#17: (heart surgery)
	#18: (valve surgery)
	#19: #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18
	#20: #8 and #19
PEDro	Strategy 1: 3326
	Title & abstract field: Exercise
	Subdiscipline: cardiothoracics
	Method: Clinical trial
	Terms were reached in association (“AND”)
	Strategy 2: 181
	Title & abstract field: cycle ergomet^*
	Subdiscipline: cardiothoracics
	Method: Clinical trial
	Terms were reached in association (“AND”)
	Strategy 3: 78
	Title & abstract field: bicycle ergomet^*
	Subdiscipline: cardiothoracics
	Method: Clinical trial
	Terms were reached in association (“AND”)
	Strategy 4: 90
	Title & abstract field: Early mobili^*
	Subdiscipline: cardiothoracics
	Method: Clinical trial
	Terms were reached in association (“AND”)
	Strategy 5: 1482
	Title & abstract field: Rehabilitation
	Subdiscipline: cardiothoracics
	Method: Clinical trial
	Terms were reached in association (“AND”)
	Strategy 6: 348
	Title & abstract field: Physical therapy
	Subdiscipline: cardiothoracics
	Method: Clinical trial
	Terms were reached in association (“AND”)
	Strategy 7: 492
	Title & abstract field: Physiotherapy
	Subdiscipline: cardiothoracics
	Method: Clinical trial
	Terms were reached in association (“AND”)
CINAHL=Cumulative Index to Nursing & Allied Health Literature; LILACS=Latin American and Caribbean Health Sciences Literature; PEDro=Physiotherapy Evidence Database

Study	Participants	Control	Intervention	Outcomes
Trevisan et al. 2015	N = 24 CG = 10 / IG = 14 Male: CG = 80% / IG = 71% PO of MRS Average age: CG = 63.2 ± 11.1 years IG = 58.0 ± 8.1 years	3^rd PO day: changes in bed position and secretion removal techniques when necessary; 4^th - 7^th PO days: pulmonary reexpansion techniques, specific physical exercises and progressive walking; From the 5^th PO day: up and down the stairs with supervision. Frequency: 2 times a day; Duration: 20 min.	Similar to the CG protocol, except by replacing walking and stair exercises for cycle ergometer exercise since 3^rd PO day. Frequency: 2 times a day; Duration: 20 minutes. HR tolerated was up to 30 bpm above the resting HR.	6MWT: CG: 212 ± 69.6 m 3^rd PO vs. 250 ± 61.4 m 6^st PO or discharge (P < .001); IG: 208 ± 71.4 m preoperative 3^rd PO vs. 312 ± 80.6 m 6^rd PO or discharge (P < .001); Comparison: there was no significant difference between the groups.
Borges et al. 2016	N = 34 CG = 15 / IG = 19 Male: CG = 52.6% / IG = 80% PO of MRS Average age: CG = 62.8 ± 42.0 years IG = 62.5 ± 7.1 years	From 1^st PO day to hospital discharge: Secretion removal techniques, diaphragmatic breathing exercises, assisted and active exercises for UL and LL, and progressive walking. Frequency: 2 times a day in the ICU and 1 time a day in the ward until hospital discharge; Duration: Not clear.	Protocol similar to the CG, with an additional exercise with cycle ergometer, without load, initiating from 1^st PO day to hospital discharge. Frequency: 2 times a day in the ICU and 1 time a day in the ward until hospital discharge. Duration in the ICU: 5 minutes. Duration in the ward: 1^st-2^nd PO days: 10 minutes. From 3^rd PO day to discharge: 20 min. Patients were instructed to pedal as fast as possible, maintaining the same pace used during the intervention period.	6MWT: CG: 320 (288 - 393 m) preoperative vs. 292 (237 - 336 m) PO (P = .01); IG: 364 (324 - 428 m) preoperative vs. 348 (301 - 414 m) PO (P = .06); Comparison: The distance in the 6MWT was kept in the IG but significantly decreased in CG patients. A significant difference was observed in the intergroup analysis of hospital discharge (P = .03). ICU length of stay: CG: 3.6 ± 1.4 days; IG: 3.2 ± 1.4 days; Comparison: there was no significant difference between the groups (3.4 ± 1.4 days; P = .31). Hospital length of stay: CG: 8.3 ± 2.2 days; IG: 8.1 ± 0.9 days; Comparison: there was no significant difference between the groups (8.2 ± 1.7 days; P = .53).
Gama Lordello et al. 2020	N = 228 CG = 117 / IG = 111 Male: CG = 57% / IG = 59% PO of MRS, VRS, and/or combined Average age: CG = 58.2 ± 12.9 years IG = 57.2 ± 13.2 years	From 6 h - 8 h post-extubation to ICU discharge: 10 active exercises repetitions for LL (straight leg raise, hip flexion-extension, knee flexion-extension, and ankle flexion-extension) and UL (diagonal movements). Frequency: 2 times a day; Duration: 10 min.	From 6 h - 8 h of extubation to ICU discharge: only the cycle ergometer was used for both LL and UL. The individuals were instructed to pedal continuously without any additional load. For LL, the headboard was declined to a 30° to provide better access to the pedals and prevent compensatory hip movements. For UL, individuals were positioned with the headboard elevated to 60° horizontally. After drain removal, physical activity progressed to standing, sitting in a chair and walking in the ICU hall. Frequency: 2 times a day; Duration: 10 min (5 min. for UL and 5 min. for LL).	ICU length of stay: CG: 2 (2 - 4 days). IG: 2 (2 - 3 days). Comparison: there was no significant difference between the groups (P = .09). Hospital length of stay: CG: 8 (7-14 days). IG: 8 (7-11 days). Comparison: there was no significant difference between the groups (P = .28).
Hirschhorn et al. 2012	N = 64 CG = 32 / IG = 32 Male: CG = 88.2% / IG = 70.4% PO of MRS Average age: CG = 65.9 ± 8.7 years IG = 65.3 ± 9.8 years	1^st and 2^nd PO days: motor and breathing exercises, transfers, and walking. From the 3^rd PO day until hospital discharge: walking progression (BORG Modified 3 - 4/10). Before discharge, the patient went up and down the stairs with supervision. Guidance was given about the exercise progression after the hospital discharge and forwarded referred to CR ambulatory. Frequency: 2 times a day; Duration: 10 min.	Protocol similar to the CG, except for from 3^rd PO day to discharge, walking was replaced by exercise using the cycle ergometer. Frequency: 2 times a day; Duration: 10 min. Patients were instructed to maintain the pace that results in 3 - 4/10 BORG rating.	6MWT: CG: 484 ± 86.0 m preoperative vs. 417 ± 86.0 m PO; IG: 450 ± 76.0 m preoperative vs. 401 ± 93.0 m PO; Comparison: both groups reduced the distance covered (P < .001), with no significant difference between the groups (P = .80). Hospital length of stay: CG: 7.7 ± 2.7 days / 7.0 (7 - 8 days); IG: 7.9 ± 1.7 / 7.0 (7 - 8.5 days); Comparison: there was no significant difference between the groups (P = .34).
Windmöller et al. 2020	N = 31 CG = 16 / IG = 15 Male: CG = 62.5% / IG = 80% PO of MRS Average age: CG = 62 ± 6.0 years IG = 57 ± 8.0 years	From immediate PO to hospital discharge: exercise program in seven progressive stages. The exercises began in bed progressing to sitting position with subsequent walking (initiating in 35 m, progressing to 200 m through the days) and up and down the stairs (starting with down 1 level to up and down 3 levels), plus stretches. In all stages, if necessary, CPAP was used. Frequency: 2 times a day; Duration: average of 25 min. HR tolerated was up to 30 bpm above resting HR.	Protocol similar to that of the CG, including the cycle ergometer and CPAP from the 2^nd to the 4^th PO day. On the 4^th PO day, the intervention was done in the morning and was measured in the afternoon. Frequency: 1 time a day (cycle ergometer + CPAP) + 2 times a day (conventional protocol); Duration: 20 min. on the 2^nd PO day and 30 min. on the other days. HR tolerated was up to 30 bpm of the resting value, SpO₂ up to 90% and BORG 2 - 3/10.	6MWT: CG: 290 ± 86.1 m preoperative vs. 181 ± 60.5 m PO (P < .001); IG: 264 ± 132.0 m preoperative vs. 216 ± 75.1 m PO (P =.11); Comparison: there was no significant difference between the groups in the preoperative (P = .52) and PO (P = .16) periods. Length of stay in the ICU: CG: 2.9 ± 0.7 days; IG: 2.5 ± 0.5 days; Comparison: there was no significant difference between the groups (P = .05). Length of hospital stay: CG: 7.3 ± 1.2 days; IG: 7.1 ± 1.1 days; Comparison: there was no significant difference between the groups (P = .69).
6MWT=six-minute walk test; CG=control group; CPAP=continuous positive airway pressure; CR=cardiac rehabilitation; HR=heart rate; ICU=intensive care unit; IG=intervention group; LL=lower limbs; MRS=myocardial revascularization surgery; PO=postoperative; SpO₂=pulse oxygen saturation; UL=upper limbs; VRS=valve replacement surgery Data was presented as median (interquartile range) and mean ± standard deviation