Received: 31 May 2020

DOI: 10.1002/pri.1882

RESEARCH ARTICLE
- -
Revised: 30 August 2020 Accepted: 12 October 2020

Different physiotherapy protocols after coronary artery

bypass graft surgery: A randomized controlled trial

Breno Caldas Ribeiro1 | Jadson José Guimarães da Poça1 |

Amanda Martins Cavalcante Rocha1 | Clícia Naeli Silva da Cunha1 |
Katiane da Costa Cunha1 | Luiz Fábio Magno Falcão1 |
2
Daniel da Costa Torres | Larissa Salgado de Oliveira Rocha3 |
Rodrigo Santiago Barbosa Rocha1

1
Biological and Health Sciences Center, Para
State University, Belem, Brazil
2
State Public Foundation Gaspar Vianna
Clinical Hospital, Belem, Brazil
3
Universitary Center of Pará, Belem, Brazil
Correspondence
Rodrigo Santiago Barbosa Rocha, Department
of Human Movement Sciences, Biological and
Health Sciences Center, Para State University,
Belem, Brazil.
Email: fisiorocha2000@yahoo.com.br
Abstract
Background and purpose: The aim of this study was to investigate the influence of
different physiotherapy protocols on heart rate variability (HRV) and hospital length
of stay in older adults undergoing coronary artery bypass graft (CABG).
Methods: Randomized controlled trial with allocation and researcher blinding and
intention‐to‐treat analysis. Forty‐eight patients undergoing CABG were randomly
assigned to a control group (CG), early mobilization group (EMG), or virtual reality
group (VRG). CG performed respiratory physiotherapy and metabolic exercises, the
EMG performed cycle ergometer exercises and ambulation, and the VRG performed
the same activities as the EMG, with the addition of two Nintendo Wii games during
3 postoperative days. The variables of heart rate variability on preoperative and
fourth postoperative day, and time of discharge of hospital was analyzed.
Results: The VRG presented a shorter hospital length of stay (p ¼ 0.03). The CG
showed a decline in HRV from the preoperative period to fourth postoperative day
on square root of the mean of the squared differences between successive RR in-
tervals (33.18 � 9.89–9.74 � 6.88, p < 0.05), standard deviation of all RR intervals
(25.48 � 7.50–15.23 � 11.27, p < 0.05), and dispersion of points perpendicular to
identity line (28.26 � 21.6–2.73 � 1.31, p < 0.05). The EMG and VRG presented a
higher cardiac autonomic modulation compared to the CG (p < 0.05), with improved
parasympathetic activity.
Conclusions: Different protocols of physiotherapy intervention affected autonomic
modulation of the heart rate and hospital length of stay in patients undergoing
CABG.

KEYWORDS
early ambulation, exercise, hospitalization, intensive care units

Physiother Res Int. 2020;e1882. wileyonlinelibrary.com/journal/pri © 2020 John Wiley & Sons Ltd. 1 of 8
https://doi.org/10.1002/pri.1882
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1 | INTRODUCTION
Physical exercise is a major component of physiotherapy following
cardiac surgery, leading to improvements in cardiovascular condi-
tioning and prevention of thromboembolic events (Ennis et al., 2018).
Consequently, it provides greater physical independence and safety
for hospital discharge. Coronary artery bypass grafting (CABG)
surgery may lead to prolonged bed rest, and immobility, that can
result in negative consequences, such as a decrease in functional
capacity, decrease in muscle mass and muscle tone, postural hypo-
tension, and changes in autonomic modulation of the heart rate
(Karapolat et al., 2013; Mendes et al., 2014).
Cardiac autonomic modulation can be evaluated by heart rate
variability (HRV), which involves simple noninvasive measurement
of the oscillations in intervals between consecutive heartbeats (RR
intervals; Kulur, Haleagrahara, Adhikary, & Jeganathan, 2009). A
reduced HRV is associated with cardiac events, such as sudden
death of patients, and an increased HRV is associated with higher
survival rates (Oliveira et al., 2013), patients with cardiac disease
have HRV altered, and exercise can improvement this (Fiogbé
et al., 2018).
Thus, physical exercise in intensive care units (ICUs) may aid in
preventing postoperative complications of cardiac surgery, such as
autonomic dysfunction, by improving the functional status, and
increasing the parasympathetic influence, leading to a decrease in
the hospital length of stay (Pinheiro & Christofoletti, 2012).
Physiotherapy interventions in ICUs include patient positioning,
trunk, and limb exercises (passive, active, or resisted), cycle
ergometer exercises, sitting on the edge of the bed, and/or sitting out
of bed, withdrawal of the bed and early ambulation (Hashem et al.,
2016; Pires‐Neto, Lima, Cardim, Park, & Denehy, 2015). In addition,
virtual reality training is being more used in the intensive care unit to
increase the motor activity; virtual reality training leads to a more
dynamic and less monotonous physiotherapy process in which the
interaction between the individual and the machine allows commu-
nication between computational components and sensory motor
channels (Deutsch et al., 2008).
The aim of this research was to evaluate the effects of different
physiotherapy protocols on the autonomic modulation of the
heart rate and hospital length of stay in older adults undergoing
CABG.
2 | METHODS
2.1 | Study design
A longitudinal and quantitative clinical trial was performed at
the Surgical Ward and Coronary ICU, after approval by the
Ethics Committee with protocol number 2.075.500, and
registered on http://clinicaltrials.gov with registration number
NCT03350971. All volunteers signed the Free and Informed Consent
Form.
ET AL.
2.2 | Subjects
Participants were allocated according to the date of hospital admis-
sion. Participants admitted to the hospital between February 2017
and December 2019 were allocated to the control group (CG), early
mobilization group (EMG), and virtual reality group (VRG), randomly
through lottery by a blinded researcher.
Patients of both genders in the CABG preoperative period were
invited to participate in this study. The inclusion criteria were as
follows: a score of 15 on the Glasgow Coma Scale, musculoskeletal,
and cardiopulmonary conditions suitable for accomplishment of the
proposed activities, and absence of neurological sequelae and/or
neurodegenerative diseases. The exclusion criteria were as follows:
previous cardiac surgeries, hemodynamic instability that prevented
protocol performance, breathing discomfort, invasive ventilatory
support, oxygen saturation below 90% (even with complementary
oxygen therapy), coagulation disorders, infections in any of the
systems, and nonperformance of the whole protocol. Participants
were blinded to the existence of the other groups.
3 | MATERIALS AND PROCEDURE
Different physiotherapy protocols were applied to participants
undergoing CABG from the first to the third postoperative day in the
Coronary ICU by blinded researcher who received the protocols to be
used. Participants allocated to the CG performed respiratory physio-
therapy and foot and ankle exercises for circulation. In addition to these
activities, participants of the EMG also performed cycle ergometer
exercises and ambulation, this protocol was based on the study of da
Costa Torres, Dos Santos, Reis, Paisani, and Chiavegato (2016).
The protocol applied to the VRG was the same of that applied to
the EMG, with the addition of two Nintendo Wii games. A boxing
game was included to increase upper limb strength, and the game
“Basic Run” was included to improve cardiovascular conditioning, as
it requires marching on the spot. Cycle ergometer exercises and the
boxing game were performed with participants sitting up in bed on
the first postoperative day and sitting in a chair on the second and
third postoperative days. The training protocols that used virtual
reality were based on the study by Rocha, De Oliveira Rocha, Pena,
Caldas, and Moreno (2018).
Dosage and the postoperative days on which the activities were
completed are detailed in Table 1. The interventions were stan-
dardized, maintained, and checked by researcher in all groups for all
participants.
The safety of the technique was monitored throughout the
application of the protocol by determining the blood pressure, heart
rate (HR) and peripheral oxygen saturation via a multiparameter
monitor, DX 2022 (Dixtal). Training load was determined by a fatigue
level maintenance of 4 and/or 5 on the modified Borg scale with a
maximum HR elevation of 20%.
Effects on autonomic modulation were determined by changes in
HRV after protocol application. HRV was recorded in the preoperative
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TABLE 1 Physiotherapy protocols applied

PO1 PO2 PO3

CG Sitting up in bed Sitting up in bed Sitting up in bed

Flow‐oriented incentive spirometer (3 � 15) Flow‐oriented incentive spirometer (X) Flow‐oriented incentive spirometer (3 � 15)

BiPAP (pressure support ¼ 15. PEEP ¼ 8) BiPAP (pressure support ¼ 15. PEEP ¼ 8) BiPAP (pressure support ¼ 15. PEEP ¼ 8)
—20 min —20 min —20 min

Foot and ankle exercises (3 � 15) Foot and ankle exercises (3 � 15) Foot and ankle exercises (3 � 15)

VRG Sitting up in bed Sitting out of bed Sitting out of bed

BiPAP (pressure support ¼ 15. PEEP ¼ 8) BiPAP (pressure support ¼ 15. PEEP ¼ 8) BiPAP (pressure support ¼ 15. PEEP ¼ 8)
—20 min —20 min —20 min

Foot and ankle exercises (3 � 15) Foot and ankle exercises (3 � 15) Foot and ankle exercises (3 � 15)

Wii sports (three rounds of 3 min) Wii sports (three rounds of 3 min) Wii sports (three rounds of 3 min)

Cycle ergometer (3 � 1 min) Cycle ergometer (3 � 2 min) Cycle ergometer (3 � 2 min)

‐ ‐ Ambulation (40 meters)

‐ ‐ Wii fit basic run (5 min)

Abbreviations: BiPAP, bi‐level positive airway pressure; CG, control group; PEEP, positive end expiratory pressure; VRG, virtual reality group.

period and fourth postoperative day (PO4). Participants were posi-
tioned in the supine position and maintained at rest for 10 min to
stabilize the vital signs. After that, HR and RR intervals (iR‐R) were
recorded over a 10‐min period. Participants were instructed not to
move or speak during the data collection period.
HRV data were recorded via a HR sensor, POLAR® RS800C (Polar
Electro TM) in which the HR signal was captured by a strap with a
signal receptor. The strap was positioned on the thorax of the
participant at the level of the xiphoid process of the sternum. Data
recorded via the sensor were transferred to the Polar ProTrainer
Software (Polar Electro OY) via an infrared signal‐emitting interface,
and subsequently stored and exported in txt format. Lastly, data were
sent to a researcher, who was blinded to participants' group allocation,
to analyze HRV in the Kubios HRV 2.2 program (MATLAB).
HRV analysis allows evaluation of HR autonomic modulation by
detecting variations in the intervals between normal heartbeats or
normal R wave peaks. In the time domain, the standard deviation of
all RR intervals (SDNN) and the square root of the mean of the
squared differences between successive RR intervals (RMSSD) are
relevant indices. The time domain parameters are related to each
other and are affected to different degrees by parasympathetic
blockage. Moreover, there is evidence that such parameters are
markers of parasympathetic cardiac modulation.
The secondary outcome of this study was hospital length of stay,
which was measured, in days, from admission to the Coronary ICU to
discharge from the hospital.
3.1 | Statistical analysis
Data analysis was performed using the BioEstat® 5.2 program
(Instituto Mirauá). Chi square test was used for analysis of nominal
variables, and Shapiro–Wilk test was used to analyze data normality.
As data was shown to be nonparametric, Kruskal–Wallis test was
applied for analysis of variance and the Dunn test for multiple
comparisons. A p‐value of <0.05 was regarded as significant.
Cohen's d pooled method was used to generate a suitable effect
size to determine the potential effect of the different types of in-
terventions. This analysis was performed by the “Effect Size Gener-
ator,” version 2.3 (Swinburne University of Technology, Center for
Neuropsychology, Melbourne, Australia). Results were interpreted
according to guidelines proposed by Cohen (1988), with a value less
than 0.3 being considered a small effect, a value between 0.4 and 0.7
being considered a moderate effect, and a value above 0.8 being
considered a great effect.
4 | RESULTS
4.1 | Demographic and clinical characteristics
A total of 75 patients in the CABG preoperative period were
recruited for this study, with five who did not meet the inclusion
criteria being excluded. The remaining 70 participants were enrolled
in the trial and allocated to the three proposed groups. A number of
participants were also excluded in the postoperative period for
several reasons; consequently, a total of 42 participants completed
the whole protocol. The death of the nine volunteers included in the
study occurred before the start of the application of the intervention
protocols, on the intraoperative or in the first 24 after surgery. The
flow of participants through the study is shown in Figure 1.
Clinical and demographic characteristics of participants involved
in this trial are described in Table 2. The variables of demographic
and clinical characteristics indicate homogeneity of groups. The time
of hospital length of stay after surgery is major in CG than EMG and
VRG. The mean age of the study participants was 60.23 � 8.33 years.
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F I G U R E 1 Flowchart of participants through the study. CG, control group; EMG, early mobilization group; IMV, invasive mechanical
ventilation; VRG, virtual reality group

4.2 | Heart rate variability analysis 4.2.2 | Intergroup analysis

4.2.1 | Intragroup analysis
HRV intragroup analysis data are presented in Table 3. Higher values
of RMSSD, SDNN and SD1 indicate more influence of para-
sympathetic autonomous system in the preoperative period indices
showed greater vagal activity on preoperative period, and SD2 better
autonomic modulation in CG, EMG, and VRG. In EMG, the LF and
SD1 indexes presenting a greater value in the preoperative period
indicating more influence of parasympathetic autonomous system. In
the VRG, the RMSSD, SDNN and SD1 indexes presenting greater
values in the preoperative period indicating more influence of para-
sympathetic autonomous system.
Intergroup data analysis is shown in Table 4. Interpretation of the
intergroup results in the preoperative period showed that only SD1
and SD2 indexes in the preoperative period demonstrated signifi-
cance difference.
In the PO4 period, the RMSSD and SDNN index was greater in
VRG and EMG than CG, demonstrating that physical exercise
increased parasympathetic influence in these groups compared to CG.
The LF values was minor and HF was bigger in the CG, which indicates
worse cardiac autonomic response when compared to EMG. The SD1
and SD2 indexes demonstrating greater values in the EMG and VRG
compared to CG, indicating greater influence of parasympathetic
cardiac autonomic influence and autonomic modulation, respectively.
RIBEIRO ET AL.
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TABLE 2 Demographic and clinical characteristics of participants

CG (n ¼ 16) EMG (n ¼ 15) VRG (n ¼ 17) p‐value

Age (years) 60.3 � 8.3 58.3 � 7.7 62.1 � 9.0 0.6

Male gender (n) 11 13 10 0.75

Female gender (n) 4 2 7 0.50

2
BMI (Kg/m ) 20.5 � 3.5 21.4 � 2.7 21.1 � 2.8 0.15

Left ventricular ejection fraction (%) 60.3 � 8.2 67.4 � 10.2 57.9 � 8.7 0.30

Hospital length of stay before surgery (days) 60 � 13.5 62 � 10.3 65 � 11.6 0.15

Cardiopulmonary bypass duration (min) 65.4 � 18.2 63 � 9.1 67.2 � 12 0.80

IMV duration (hours) 9.3 � 3.1 11.2 � 5.5 10.5 � 4.8 0.10

ICU length of stay (days) 4.1 � 2.3 2.5 � 1.8 4.3 � 1.4 0.25

Hospital length of stay after surgery (days) 16 � 7.3 10.2 � 3.5 8.1 � 1.6 0.03

Pharmacological treatment on PO1

β‐blockers (n) 7 6 8 0.4

Inotropic agents (n) 13 14 15 0.17

Medical history

Hypertension (n) 10 9 11 0.4

Diabetes mellitus (n) 8 10 8 0.3

COPD (n) 2 4 3 0.4

Dyslipidemia (n) 9 10 11 0.4

Congestive heart failure (n) 1 2 2 0.4

Abbreviations: BMI, body mass index; CG, control group; EMG, early mobilization group; ICU, intensive care unit; IMV, invasive mechanical ventilation;
PO1, first postoperative day; VRG, virtual reality group.

TABLE 3 Intragroup analysis of heart rate variability indexes

CG (n ¼ 15) EMG (n ¼ 16) VRG (n ¼ 17)

Indexes Pre PO4 Pre PO4 Pre PO4

#
iRR 867 � 157.47 643 � 121.99 981 � 154.58 706 � 159.10 909 � 132.2 694 � 115.64
# #
RMSSD (ms) 33.18 � 9.89 9.74 � 6.88 17.92 � 7.78 20.07 � 36.70 31.9 � 21.86 22.8 � 18.96
# #
SDNN (ms) 25.48 � 7.50 5.23 � 11.2 22.36 � 5.35 18.06 � 31.33 37.53 � 18.4 24.40 � 15.06
# #
LF (un) 47.92 � 13.2 50.25 � 9.82 56.06 � 26.25 30.03 � 23.50 56.25 � 22.33 47.65 � 25.54
#
HF (un) 52.07 � 13.2 49.75 � 9.82 43.93 � 26.25 69.96 � 23.50 43.74 � 22.33 52.34 � 25.54

LF/HF 0.92 � 0.27 1.01 � 1.58 3.1 � 4.46 0.42 � 2.48 2.29 � 2.80 0.91 � 2.34
# # #
SD1 (ms) 28.26 � 21.6 2.73 � 1.31 12.7 � 5.53 6.3 � 4.18 22.60 � 15.5 16.16 � 13.47
#
SD2 (ms) 39.28 � 26.1 7 � 2.85 38.55 � 7.52 19.84 � 16.15 47 � 23.93 30.97 � 18.59

SE 2.89 � 0.55 3.57 � 0.41 2.79 � 1.06 2.80 � 1.62 3.17 � 0.44 3.13 � 0.46

Abbreviations: HF, high frequency; iRR, R‐R intervals; LF, low frequency; PO4, fourth postoperative day; Pre, preoperative period; RMSSD, square root
of the mean of the squared differences between successive RR intervals; SD1, dispersion of points perpendicular to identity line; SD2, measurement of
standard deviation of points of Poincaré plot along R‐R intervals; SDNN, standard deviation of all RR intervals; SE, Shannon's Entropy.
*p < 0.05: Pre versus PO4.

5 | DISCUSSION physiotherapy protocols, including physical exercises, resulted in

improvements to cardiac autonomic modulation and a reduction in
This study evaluated the influence of different physiotherapy pro- hospital length of stay in this population. It is important to note that
tocols on HRV in patients undergoing CABG. It was observed that none of the protocols brought complications to the patients
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TABLE 4 Intergroup analysis of heart rate variability indexes

Pre PO4

Indexes CG EMG VRG CG EMG VRG SE

iRR 867 � 157.4 981 � 154.5 909 � 132.2 643 � 121.9 706 � 159.1 694 � 115.6 0.3
#
RMSSD 33.18 � 9.8 27.92 � 7.7 31.9 � 21.8 9.74 � 6.88 20.07 � 36.70 22.8 � 18.96 1.5
#
SDNN 25.4 � 7.5 22.3 � 5.3 37.5 � 18.4 5.2 � 11.2 18.0 � 31.3 24.4 � 15.0 1.3

LF (un) 47.92 � 13.2 56.06 � 26.25 56.25 � 22.33 50.25 � 9.82* 30.03 � 23.50 47.65 � 25.54 0.5

HF (un) 52.07 � 13.2 43.93 � 26.25 43.74 � 22.33 49.75 � 9.82* 69.96 � 23.50 52.34 � 25.54 0.5

LF/HF 0.92 � 0.27* 3.1 � 4.46 2.29 � 2.80 1.01 � 1.58* 0.42 � 2.48 0.91 � 2.34 0.6
#
SD1 (ms) 28.26 � 21.6* 12.7 � 5.53 22.60 � 15.52 2.73 � 1.31* 6.3 � 4.18 16.16 � 13.47 1.2
§ #
SD2 (ms) 39.28 � 26.1* 38.55 � 7.52 47 � 23.93 7 � 2.85 19.84 � 16.15 30.97 � 18.59 1.1

SE 2.89 � 0.55 2.79 � 1.06 3.17 � 0.44 3.57 � 0.41 2.80 � 1.62 3.13 � 0.46 0.5

Abbreviations: ES, effect size; HF, high frequency; iRR, R‐R intervals; LF, low frequency; PO4, fourth postoperative day; Pre, preoperative period;
RMSSD, square root of the mean of the squared differences between successive RR intervals; SD1, dispersion of points perpendicular to identity line;
SD2, measurement of standard deviation of points of Poincaré plot along R‐R intervals; SDNN, standard deviation of all RR intervals; SE, Shannon's
Entropy.
*p < 0.05: CG versus EMG.
#p < 0.05: CG versus VRG.

involved, and no adverse events such as reduced oxygen saturation,
hypotension or arterial hypertension, syncope or arrhythmia were
observed during protocols application.
Cardiac surgery may alter autonomic modulation of the heart
rate, which is widely investigated by HRV analysis. An increase in
HRV usually indicates a healthy heart and a higher survival rate;
however, a decrease in HRV indicates inability or decrease respon-
siveness of the autonomic nervous system or sinoatrial node to
changes and is associated with high mortality rates among patients
with cardiovascular disease (Routledge, Campbell, McFetridge‐Durdle,
& Bacon, 2010).
Analysis of intragroup results in the CG showed a gradual
decrease in autonomic modulation in the frequency domain from the
preoperative period to PO4. Such a decrease is expected of CABG
surgery; a study conducted by Lakusic et al. reported that HRV
decreases considerably after surgery due to several factors, such as
surgical manipulation of the heart and adjacent structures, anes-
thesia, duration of cardioplegia, and extracorporeal circulation
(Lakusic, Mahovic, Sonicki, Slivnjak, & Baborski, 2013). In addition,
there may be increased levels of noradrenaline during CABG surgery
that may lead to a change in the iR‐R (Hsin, Lee, Lu, Lin, & Shieh,
2017).
However, its significant reduction on PO4, that was more evident
in the CG, suggests that may be related to other factors, such as:
administration of beta‐blocking drugs, which are mainly used for
preventing atrial fibrillation, improving hemodynamics, and reducing
CABG postoperative morbidity and mortality (Krzych, 2012).
This is a known factor that contributes to postoperative
complications, such as dysfunction of multiple organ systems, reduc-
tion of pulmonary and tissue oxygenation, increased risk of deep vein
thrombosis and pulmonary thromboembolism, and a loss of muscle
mass and strength (Santos, Ricci, Suster, Paisani, & Chiavegato, 2017).
With regards to the intragroup data analysis in the EMG, the
reduction of RR intervals on PO4 suggests a decrease in HRV in
relation to the preoperative period. Despite the cardiac function
sustenance in the time domain, analysis of the frequency domain
indexes demonstrated a lower HRV on PO4 (Melenovsky, Simek,
Sperl, Malik, & Wichterle, 2005).
Intergroup analysis of PO4 data showed that the EMG presented
positive results, reflected by the nonlinear SD1 index, which indicates
that the EMG had improved autonomic modulation in comparison to
the group that did not perform any type of physical exercise. This
may have occurred due to an increase in the vagal tone as a result of
exercise.
Physical exercise has multiple benefits, including improvement in
ventilation and ventilation/perfusion ratio, muscle strength, functional
capacity, and vagal activity (Santos et al., 2017). The mechanisms
involved in improving exercise‐related vagal modulation are not fully
understood. However, it is thought that two potential mediators are
involved—nitric oxide and angiotensin II. Nitric oxide improves vagal
activity, whereas angiotensin II has the opposite effect. Thus, physical
exercise leads to increased vagal activity by suppressing angiotensin II
and increasing the bioavailability of nitric oxide (Routledge, 2010).
The VRG showed the greatest autonomic modulation in com-
parison to the CG on PO4, one day after the protocol concluded.
Thus, motor physiotherapy associated with the activities in virtual
reality games was more effective in improving HRV of the
participants. In addition, intergroup analysis demonstrated that the
protocol had a positive effect on the cardiac condition of the VRG
and the EMG. Furthermore, the VRG intragroup analysis indicate that
although the protocol did not affect HRV positively or negatively, it
maintained patients' cardiac function.
This significant improvement in cardiac autonomic modulation
observed in the VRG may be associated with increased motivation
RIBEIRO ET AL.
and a decrease in pain promoted by the virtual reality training, which
increased the commitment of the patient to the therapy. The use of
virtual reality increases motivation by providing external feedback on
motor performance (Zimmerli, Jacky, Lünenburger, Riener, & Bolliger,
2013). Another advantage attributed to this type of therapy is the
decrease in the pain intensity. Patients undergoing CABG surgery
report a high degree of pain, which may impair patient compliance
with the therapy (Sethares, Chin, & Costa, 2013). The use of virtual
reality for therapeutic purposes may facilitate improved patient
commitment to treatment (Schmitt, 2011). Although virtual reality
training has been used in intensive care, its effect on cardiac auto-
nomic modulation of patients undergoing CABG is unknown. How-
ever, it seems that the protocol applied in this study enhanced this
modulation.
Research conducted by Mendes et al. (2014) applied the same
protocol in groups with different clinical characteristics. Researchers
found that patients with minor cardiovascular impairments show less
significant changes, whereas patients with more severe impairments
are more affected by the protocol. This study allowed us to identify
that different exercise programs elicit different responses when
applied to groups with the same characteristics. Mendes also hy-
pothesized that more stringent protocols may lead to further positive
effects, which may explain the significant improvement of the VRG in
comparison with both, the EMG and the CG, when participants from
VRG performed several exercises that were more extensive.
The hospital length of stay after surgery was significantly shorter
for the VRG. This finding was similar to that of a study conducted by
Cacau et al. (2013) on 60 volunteers, who compared an early mobi-
lization group using virtual reality training and a control group. It was
concluded that patients in the virtual reality group had a reduced
length of hospital stay due to improvements in functional capacity
recovery as a result of pain attenuation and increased energy levels.
There were a number of limitations to this study. The autonomic
modulation of HR may be impaired even before the surgical procedure
due to the long waiting time between hospital admission and the day of
surgery, which may have influenced the HRV results in the post-
operative period. Another limiting factor was the lack of published
studies regarding the virtual reality training influence on autonomic
modulation of HR, which prevented comparison between the results
obtained and previous studies. This study provides important tools for
cardiac physiotherapy in the postoperative period of myocardial
revascularization, demonstrating that early intervention protocols
reduce hospitalization time and can reduce the mortality rate and the
cost of hospitalizations.
Different protocols of physiotherapy intervention affected
autonomic modulation of the heart rate and length of hospitalization
in patients undergoing CABG. To our knowledge, this is the first
clinical trial to evaluate the effect of virtual reality training on cardiac
autonomic modulation in older adults after CABG. It was shown that
physiotherapy protocols, including exercise, improved HRV and in
combination with virtual reality training, led to an improvement in a
higher number of indicator indices and a shorter hospital stay after
surgery. Moreover, the improved outcome of the VRG showed that
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more intense physiotherapy protocols may be used safely and
effectively in the ICU.
CO N F L I C T O F I N T E R E S T
The authors declare no conflict of interest.
OR CI D
Katiane da Costa Cunha https://orcid.org/0000-0001-5361-5090
Luiz Fábio Magno Falcão https://orcid.org/0000-0001-8391-2694
Daniel da Costa Torres https://orcid.org/0000-0002-8820-1645
Larissa Salgado de Oliveira Rocha https://orcid.org/0000-0002-
6919-4160
Rodrigo Santiago Barbosa Rocha https://orcid.org/0000-0001-
5964-946X
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How to cite this article: Ribeiro BC, Poça JJGda, Rocha AMC,
et al. Different physiotherapy protocols after coronary artery
bypass graft surgery: A randomized controlled trial. Physiother
Res Int. 2020;e1882. https://doi.org/10.1002/pri.1882