Surgery To Solve Coronary Artery Disease Biology Essay

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IHD is defined as the acute chronic form of cardiac disability arising from imbalance between myocardial supply and demand for oxygenated blood. Since narrowing or obstruction of the coronary arterial system is the most common cause of myocardial anoxia, it is otherwise termed as CAD - coronary artery disease.

The number of people who are diagnosed as having CAD is increasing all over the world. In CAD, atherosclerotic plaques (inflammed fatty deposits in the blood vessel wall ) obstruct the coronary arteries. When the blockages becomes severe enough, the blood flow to the heart is restricted (cardiac Ischaemia) resulting in angina pectoris.

The acute stage of CAD occurs when one of the plaques ruptures, forming a thrombus and that occludes the whole artery. The portion of the heart muscle supplied by that artery dies and this is known as myocardial Infarction.

The Risk Factors which predispose to disease includes,

Age

High Blood pressure

Diabetes Mellitus

Hypercholesterolemia

Tobacco smoking

Higher fibrinogen and PAI - 1 blood concentration Elevated blood levels of asymmetric dimethyl adrenine.

High levels of environmental noise exposure.

Genetic factors / family history of CAD.

Physical inactivity.

obesity.

Apart from these risk factors, the disease severity is reduced by certain surgical intervention which are indicated to relieve.

Severe blockage in the main artery.

obstruction in several blood vessels.

Persistent chest pain and Ischaemia.

The most commonly performed surgery for the relief of Angina and to improve heart muscle function is CABG (Coronary Artery Bypass Grafting).

MAGNITUDE :

The number of people who is projected with CAD to increase from 10.9 million in 2002. The American Heart Association estimates that 5,73,000 CABG surgeries were performed on 3,63,000 Patients in 1995. 74% of these procedures were performed on men, and 44% on men and women under the age of 65.

CABG- THE SURGERY

Definition:

CABG is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart.

It was invented in Argentina by Rene Favalora

Principle :

To by-pass obstructions in coronary arteries by using venous or arterial conduits taken from upper or lower limbs and inner chest wall.

It re-establishes vascular supply to the distal areas of coronary circulation, previously limited by atheroma.

Precautions:

CABG should be performed in patients only after three months of onset of heart attack.

Patients should be medically stable before the surgery.

Procedure :

The common incision used for CABG is median sternotomy - where the sternum is cut down in the middle with a special bone saw and the chest opened (a procedure known as " cracking the chest") No muscle filers are cut but the sternal attachment of the pectoralis major can be impaired.

Depending on the number of factors it is decided either to place the patient on cardiopulmonary bypass (on pump) or use suction - stabilizing devise to hold the heart still which sewing the anastamoses (off pump). Sometimes artery end branches supplying tissue near the heart are rerouted to create bypass.

CONDUITS USED FOR BYPASS :

Typically the saphenous vein from the leg and the left internal mammary artery ( LIMA ) are used for bypass.

Veins used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft.

LIMA grafts are longer- lasting than vein grafts, both because the artery is more robust than a vein, because, being already connected to the aorta, the LIMA need only be grafted at one end. For this reason, the LIMA is usually grafted to the left anterior descending artery ( LAD ), which supplies the left ventricle, the part of the heart that pumps oxygenated blood around the body

If a leg vein is used, one end is connected to the coronary artery and the other to the aorta.

COMPLICATIONS

 Infections - at the site where graft was harvested

 DVT

 Non Union / malunion of sternum (breast bone)

 Keloid scarring

 Chronic pain - at incision sites

 Stenosis of the graft ( late )

POST - OPERATIVE MORBIDITY:

Though generally considered as the incision with least complications, the immediate post- operative period records morbidity due to splinting.

This restricts the thoracic expansion and thereby affects ventilation resulting in redundant ventilatory status.

Sigh, defined a breath 3 times greater than tidal volume, normally occurs approximately 10 times per hour and helps to maintain lung volume and pulmonary compliance. These efforts are greatly reduced in the post-operative period.

This study tries to bring to the fore the efficacy of

SHUTTLE WALK TEST as a treatment protocol to improve pulmonary functions, there by allowing an optimization of the treatment during the immediate post operative period.

NEED AND SIGNIFICANCE OF THE STUDY

Need of the Study :

The use of Anesthesia, blood loss coupled with restricted mobility and pain due to incision primarily affects the oxygen transport. This leads to

 Sub optimal mucocilliary escalation

 Decrease lung volumes & capacities

 Mucus retention

 Increased work of breathing

The ventilation is further affected by pain. Though various modalities and techniques are available but nevertheless none of the techniques so for has been shown improvement. Hence the post - operative treatment still remains to be optimized & lacks the much needed standardization.

SIGNIFICANCE OF THE STUDY :

The SWT and conventional physiotherapy both focus on normalizing respiratory pattern, promoting ventilation, there by clearing the lung from mucus retention and reducing work of breathing. This is important to control the immediate post-operative morbidity.

This study is to evaluate the efficacy of SWT over conventional physiotherapy to improve pulmonary functions in post CABG patients.

STATEMENT OF PROBLEM

To study the effects of SHUTTLE WALK TEST on improving pulmonary functions in post CABG patients.

The study is entitled as "The Efficacy Of SHUTTLE WALK TEST As A Treatment Protocol In Post CABG Patients".

AIMS AND OBJECTIVES

Aims of the Study :

To assess the efficacy of SHUTTLE WALK TEST on pulmonary function in post CABG patients.

Objectives :

 To improve pulmonary function

 To reduce the post-operative morbidity.

 To improve the breathing pattern

 To analyze the effects of SWT

HYPOTHESIS

In the background of ambigious knowledge about the SWT in improving pulmonary functions, it makes the research to be performed under the perspective of[Ho] which could be

Null Hypothesis[Ho]

There is no significant difference between the groups with conventional physiotherapy and conventional physiotherapy with shuttle walking test as a treatment protocol in post CABG patients

Alternate Hypothesis

There is significant difference between the groups with conventional physiotherapy and conventional physiotherapy with shuttle walking test as a treatment protocol in post CABG patients.

REVIEW OF LITERATURE

1. Bojar RM et. At 1992, CABG is performed in patients with CAD to relieve ischaemia and intractable symptoms of angina.

2. Encyclopedia, 2004, coronary artery bypass surgery often is the treatment of choice for than patients with severe coronary artery disease ( 2 to 3 vessel diseased )

3. Richard F.Heitmiller, Glenns, 1996: The development and evolution of thoracic surgical incisions has been closely related to the development in thoracic surgery. The evolution of cardiac surgery has been made the median sternotomy one of the most widely used thoracic incision.

4. American heart association 1992, surgical revascularization of coronary arteries has been performed in this country since the

1960 's. Nearly 4,00,000 patients under go CABG each year in united states.

5. Mark S. Allen and Peter C. Pauolero et al : 1996. The sternal splitting incision that does not cut many muscles. Combined with sternal closure than minimum motion across the splitting is the least descriptive thoracotomy incision.

6. Richard F. Heitmiller, Glenns : 1996, the excellent exposure of heart and great vessels has made the median sternotomy the gold standard incisions for most cardiac surgical procedure especially for CABG.

7. Otto C.W 1990, the risk of respiratory complications increases markedly, when the surgery enters the abdomen or chest and this relative incidence of morbidity is directly related to reduction in vital capacity seen after the surgical incision.

8. Craig.D et al1989, post operative pulmonary complications after Cardiac surgery commonly present as a restrictive pattern with reduced inspiratory capacity, reduced FVC & reduced FRC.

9. Barry A.S Sharprio M.D. et al: Cardiac anesthesia, post-operative respiratory management is an essential component in the case of cardiac surgical patients because the anesthetic, surgical and cardio-pulmonary bypass procedures have transient deleterious effects on pulmonary function.

10. Kaplan et al. the acute restrictive pulmonary deficits resulting from anesthesia and surgical insults are well documented sequalae of cardiac surgery.

11. Christina imle, scott Irwin 1995, post operative pulmonary complications occur in 60% 0f patients who under go cardiac or upper abdomen surgery.

12. Dubach P, Myers j, Wagner D study indicated that early rehabilitation can even improve graft patency after CABG and restoring functional capacity, early return to work and improve psychological status following open heart surgery.

13. Ungerman Dement P, Bemis A et .al studied effects of an exercise program on patients after cardiac surgery. The physical status and the length of hospitalization of 44 patients underwent physical training Program and regular follow up at a Post CABG clinic. They conclude that the comprehensive cardiac rehabilitation program offered to patients after CABG will improve the long term goal and reduce the need for hospital care.

14. Rajendran AJ , Panduranji UM, Cherian K.M et.al :The study on short term pulmonary rehabilitation in patient who undergone CABG has been assessed. There is a significant rise in post-Op PEFR and inspiratory capacity. The study concluded that it is feasible and effective in improving pulmonary function before and after surgery and in reducing surgical morbidity.

15. Levensen et al, 1992, Since compressive force to the thorax is greater producing increased chest wall displacement, the stretch to the respiratory muscles may produce increase inspiratory effect.

16. E Dean , Donna frown Felter , 1996 : The general physical therapy interventions frequently used in ICU include those related to mobilization and exercise, body positioning, breathing control and mucus clearance intervention such as Deep breathing, cough maneurs, chest wall mobilization, postural drainage, percussion & vibration, shaking.

17. Burns, Ford, 1991:Postural drainage and percussion has been shown to be effective in some case and detrimental to pulmonary status for some patients.

18. Hall, J.C etal 1996: The regimen consisting of the deep breathing exercise and spirometry is an efficient way of providing prophylaxis against respiratory complication.

19. SA Souter et al 1990 : The addition of breathing exercises or incentive spirometry to a regimen of early mobilization and huffing and coughing confers no extra benefits after the CABG.

20. Jenkins SC,1991:Although chest physical therapy has been used to imprive respiratory function for more than a century; its role in preventing post-operative complications remains conraversial.

21. D.Tobin et al: stated that exercise tolerance expressed as Work load was significantly increased with 10m shuttle Walk test.

22. Sally J Singh,Michael D L Morgan,Shona scott,Denise Walters et al1 992: The shuttle walking test constitutes a Standardized field walking test that provokes a symptom limited maximal performance.it provides an objective measurement of disability and allows direct comparison of patients performance.

23. C A E Dyer,R A Stockley,S J Singh et al:The shuttle walk test is a feasible and reproducible measure of exercise tolerance in elderly people with and without airflow obstruction and correlates with other makers of disability.it is sensitive to change following bronchodilation in subjects with CAL,although the change correlates less well with improvements in FEV1.overall,these results suggests that the SWT might be an appropriate measure to assess interventions in elderly people.

24. Campo LA, Chilingaryan G, Berg K, Paradis, B Mazer B

et al. The modified shuttle walk test is a standardized externally paced submaximal endurance walking test.The results indicate that the MSWT has high concurrent validity and test- retest reliability for patients with chronic obstructive pulmonary disease.

25. Eiser N,wilisher D,Dore C.J et al;Reliability,repeatability and sensitivity to change of externally and self-paced walking tests in chronic obstructive pulmonary disease patients.

26. Payne GE,Skehan JD et al;The SWT is an easy test to administer,requiring little equipment.it produces a symptom limited maximal performance and will be a useful aid to pacemaker programming as it is reproducible and able to show differences in exercise capacity between pacing modes.

27. S.J Fowler,S.J Singh and S.Revill et al;The SWT correlates with VO2 peak and is a reliable measure of cardiorespiratory fitness in this population afterone practice walk.

28. Patrick Pasquina,Martin R,et al 2003;BMJ,The usefulness of respiratory physiotherapy for the prevention of pulmonary complications after cardiac surgery remain unproved.

29. Timothy A.M, C Huter et al.1990,The diaphragmatic breathing and incentive spirometry can be used as a method of prophylaxis against the pulmonary complication.

30. S M Revilla,M D L Morgana,S J Singha,A E Hardmanb

et al. The shuttle walk test was simple to perform,acceptable to all patients and exhibited good repeatability after one practice walk.The test showed major improvement following rehabilitation and was more sensitive to change than the field of maximal capacity.

31. Sherra Solway,Dina Brooks et al,Measurement properties of the shuttle walk test have been the most extensively researched and established.In addition,it is easy to administer,better tolerated, and more reflective of activities of daily living.

32. Mark A Tully,Margaret E Cupples et al,The SWT was developed to measure fitness in patients with respiratory disease.it is used in patients before and after cardiac rehabilitation,either following cardiac surgery or pacemaker insertion.

33. Nigel Hart et al,The SWT is easy to administer,requires little equipment and only one member of staff to run.This makes the shuttle walk test an attractive option when considering possible fitness tests for use in general practice.

34. Heppner PS,Morgan C,Kaplan RM,Ries AL et al:suggests that participation in regular exercise such as walking after rehabilitation is associated with slower declines in overall health-related quality of life and walking self-efficacy as well as self progression of dyspnea during activities of daily living.Regular exercise after rehabilitation may be protective against increases in dyspnea symptoms and perceived limitations in walking which are both characteristic of progressive chronic lung disease.

35. Eiser N,Willsher D,et al:Self-paced walks are as useful as externally paced shuttles.

36. Stewart Taylor,Helen Frost et al:The SWT is a relable and responsive test within a group pf patients with low back pain,with or without sciatica.it is simple to administer and provides a quickmethod of measuring one aspect of a patient's physical function.

37. Booth S,Adams L et al:The SWT is a reproducible test of functional capacity in ambulant patients with advanced cancer,WHO performance status 1 or 2.The data indicate that a practice session is needed.It is easy to carry out and acceptable for patients with advanced cancer.

38. K.Woolf-May and D Ferrett et al;states it would appear that for asymptomatic individuals it is appropriate to apply established METs for flat walking to the SWT.However,the significantly higher METs for the post-MI compared with the non-cardiac subjects indicates the need for caution when using METs derived from healthy subjects in the prescription of exercise for myocardial patients.

MATERIALS AND METHODOLOGY

MATERIALS

OUTCOME MEASURES

Chest expansion was measured using inch tape.

RPE - Modified Borg's scale for Dyspnoea.

Peak expiratory flow rate was measured using peak expiratory flow meter.

MATERIALS USED

 INCH tape for chest expansion

Peak expiratory flow meter

 Assessment performa

 Data collection sheet

 Modified Borg's scale chart

 Daily assessment chart.

METHODOLOGY

RESEARCH APPROACH :

This study experiments the efficacy of shuttle walk test as a treatment protocol to improve pulmonary endurance and to reduce the post operative pulmonary complication in post CABG patients. The research approach adopted for the study was an experimental approach.

STUDY DESIGN :

This will be an experimental study with 2 groups, one control group and other experimental group. The results of these were compared.

STUDY SETTING

The study was carried out in the department of cardio thoracic surgery, Sri Ramakrishna hospital, coimbatore. The subjects will be obtained from the patients referred for physical therapy.

POPULATION STUDIED :

The population studied was 20 post operative CABG patients with medication.

SAMPLING :

The subjects were selected from patients referred to physical therapy through convenient sampling.this includes 2 groups of 10 subjects each. They are

Group A : This group will under go purely conventional physiotherapy & devoid of SHUTTLE WALKING TEST.

Group B : This group will under go conventional physiotherapy with SHUTTLE WALKING TEST .

TYPE OF SAMPLING :

 Convenient sampling.

Inclusion Criteria

 Age limit 50 - 65 years

 Patients who had undergone median sternotomy incision for CABG from 3rd day onwards.

 Both sexes were taken for the study.

 Patients willing to participate on a voluntary basis

Exclusion Criteria

 Age below 50 and above 65 years

 Presence of pre and post operative wound complication

 Unstable vital signs and wound infection

 Unspecified pulmonary diagnosis

 Smokers are excluded

 Presence of infectious disease.

 Other valvular heart disease and CABG with valvular disease / closure are excluded .

 Asthma, other COPD's any other lung pathology are excluded.

 Other joint involvements like shoulder etc are excluded.

 Other neurological conditions that affect the respiratory muscles are excluded.

DURATION OF A STUDY

The study was conducted for a period of three months.

Treatment session: The patients were treated in 2 sessions per day, at 30 minutes per sessions.

DATA COLLECTION PROCEDURE

Patients were divided into two groups with simple random sampling to group 'A' and group 'B'. Group A will under go conventional therapy and group B will undergo conventional physiotherapy along with SWT. The treatment program is started from the 3rd post operative day and the results are recorded in the patient's assessment chart.

STATISTICAL ANALYSIS

Pre test and post test values of the study were collected and assessed for variations in improvement and their results are analyzed using independent 't' test.

t =

Where,

S =

S = Combined standard deviation

d1 and d2 = Difference between initial and final readings in group A and B respectively.

n1 and n2 = No. of patients in Group A and Group B respectively

= Mean of Group A and Group B respectively

PNF TECHNIQUES

SHUTTLE WALKING TEST

The SHUTTLE WALK TEST was developed to stimulate a cardiopulmonary test using a field walking test.The 10-Meter shuttle test(10-m shuttle) is a walking protocol that uses a recorded audio signal to dictate incremental walking speeds on a level 10-meter field.

Protocol

 Each subject should be screened by a member of the Pulmonary Rehabilitation team for any exclusion criteria before proceeding

 Place two cones exactly 9 metres apart, thus allowing the subjects to walk 10 metres when they go round the cone at the end of each shuttle.

 Subjects then listen to the instructions on the audio cassette. These should be repeated verbally to ensure that they understand what is expected during the test.

 Subjects walk around the 10 metre course aiming to be turning at the first marker cone when the first audio signal is given, and turning at the second cone at the next audio signal.

 Subjects should be accompanied around the first level of the test to help them keep pace with the audio signals. Thereafter the operator stands mid way between the two marker cones offering advice on completion of a level: 'Walk a bit faster now if you can'.

 Progression to the next level of difficulty is indicated by a triple bleep which lets the subject know that an increase in walking speed is required.

 The full test comprises 12 levels each of one minute duration with walking speeds that rise incrementally from 1.2 miles per hour (1.9 km per hour) to 5.3 miles per hour (8.5 km per hour).

 The test is completed at 12 minutes or if one of the termination criteria are met.

STANDARDISATION

Standardisation of the SWT is very important for obtaining meaningful outcomes.The SWT must be measured on two occasions to account for a learning effect.i.e

The best result is recorded.

If the repeat test is performed on the same day,30 minutes rest should be allow between tests.

Debilitated individuals may require tests to be performed on separate days, but a tests to be less than one week apart.

Onlt standardized instructions from the CD should be used.

A comfortable ambient temperature and humidity should be maintained for all the tests.

The walking track must be same for all tests for a patient:

- Cones are placed nine meters apart

- The distance walked around the cones is 10 meters.

SHUTTLE WALK TEST EQUIPMENT:

The equipment needed to conduct the SWT is identified in the attached checklist.

10 meters

BEFORE THE SWT:

Ensure that you have obtained a medical history for the patient and have taken if account any precautions or contraindications to exercise testing.

Instruct the patient to dress comfortably and to wear appropriate footwear.

Any prescribed medication should be taken within one hour testing or when the patient arrives for testing.

The patient should rest for atleast 15 minutes before beginning the SWT.

Record:

- Blood pressure

- Heart rate

- Oxygen saturation

- Dyspnoea score

DURING THE SWT:

Follow the instructions on the CD,and use the following standard prompts:

Each time the beep sounds:"Increase your speed now"

Use the following prompt if the patient is less than 0.5m away from the cone when sounds."you're not going fast enough;try to make up the speed this time".

Record each shuttle that is completed on the swt recording sheet.

Monitor the patient for untoward signs and symptoms.

ENDING THE SWT:

The swt ends if any one of the following occur:

The patient is more than 0.5m away from the cone when th beep sounds(allow to catch up)

The patient reports that they are too breathless to continue.

The patient reaches 85% of predicted maximum heart rate(maximum heart rate 0.65xage)

The patient exhibits any of the following signs and symtoms:

- chest pain that is suspicious of /for angina.

- evolving mental confusion or lack of coordination.

- evolving light-headedness

- intolerable dyspnea

- leg cramps or extreme leg muscle fatigue

- Any other clinically warranted reason.

AT THE END OF THE SWT:

Seat the patient or,if the patient prefers,allow to the patient to the patient to stand.

Immediately record oxygen saturation(Spo2)%,heart rate and dyspnea rating.

Two minutes later,record spo2% and heart rate to assess the recovery rate.

Record the total number of shuttles.

Record the reason for terminating the test.

SWT AS AN OUTCOME MEASURE:

The change in the distance walked in the SWT can be used to evaluate the efficacy of exercise training program and or to track the change in exercise capacity over time.

DATA PRESENTATION, ANALYSIS & INTERPRETATION DATA PRESENTATION

DEMOGRAPHIC DATA

GROUP-A ( CONTROL GROUP )

Age in yrs

No. of Patients

Males

Females

45 - 55

2

0

50 - 65

2

1

56 - 65

4

1

Total = 10

GROUP- B (EXPERIMENTAL GROUP)

Age in yrs

No. of Patients

Males

Females

45 - 55

2

0

50 - 65

2

1

56 - 65

4

1

Total = 10

CHEST EXPANSION

GROUP- A (CONTROL GROUP)

Pre-test

Post-test

d1

2.3

2.7

0.4

2.1

2.11

0.01

2.8

3.11

0.31

2.5

3.0

0.5

2.7

3.1

0.4

2.4

2.6

0.2

2.1

2.3

0.2

2.6

2.9

0.3

1

1.5

0.5

2

2.2

0.2

Mean = 2.25

Mean = 2.55

Mean = 0.302

GROUP - B (EXPERIMENTAL GROUP)

Pre-test

Post-test

d2

2.5

3.0

0.5

2.4

2.7

0.3

2.1

2.5

0.4

2.7

3.1

0.4

2.2

2.6

0.4

1.8

2.2

0.4

1.5

1.9

0.4

1.7

2.2

0.5

1.6

2.6

1

1.6

2.0

0.4

Mean = 2.01

Mean = 2.48

Mean = 0.470

CHEST EXPANSION IN CONTROL GROUP

CHEST EXPANSION IN EXPERIMENTAL GROUP

MODIFIED BORG'S SCALE

GROUP - A (CONTROL GROUP)

Pre-test

Post-test

d1

5

2

3

6

2

4

8

6

2

7

6

1

9

5

4

2

1

1

7

1.5

5.5

4

2

2

6

2

4

7

4

3

Mean = 0.61

Mean = 3.15

Mean = 2.95

GROUP - B (EXPERIMENTAL GROUP)

Pre-test

Post-test

D2

5

2.5

2.5

8

4.5

3.5

9

6

3

4

2

2

2

1.5

0.5

7

5

2

2

1

1

3

2

1

3

2.5

0.5

3

2.5

0.5

Mean = 4.6

Mean = 2.95

Mean = 1.65

MODIFIED BORG'S SCALE IN CONTROL GROUP

MODIFIED BORG'S SCALE IN EXPERIMENTAL GROUP

PEAK EXPIRATORY FLOW RATE

GROUP-A(CONTROL GROUP)

Pre-test

Post-test

D2

2.9

8.2

5.3

3

8.1

5.1

2.8

7.4

4.6

2.5

8.5

6

2

8.7

6.7

3

7.6

4.6

2

7.3

5.3

2.8

7.9

5.1

2

8.6

6.6

3

8.4

5.4

Mean=2.6

Mean=8.07

Mean=5.47

GROUP-B(EXPERIMENTAL GROUP)

Pre-test

Post-test

d2

3

8.5

5.5

2.8

8.8

6

2

8

6

3

9

6

2.5

9.2

6.7

2.3

9

6.7

2.8

8.7

5.9

2

9

7

3

9.5

6.5

2.9

9.2

6.5

Mean=2.63

Mean=8.89

Mean=6.26

PEAK EXPIRATORY FLOW RATE

GROUP-A (CONTROL GROUP)

PEAK EXPIRATORY FLOW RATE IN EXPERIMENTAL GROUP

DATA ANALYSIS & INTERPRETATION

Independent 't' test is used to compare the significance in the improvements shown between the Group A and B using the following formula,

t =

CHEST EXPANSION

CHEST EXPANSION SCALE

Group

Mean value

Calculated 't' value

Pre-test

Post-test

SD

Group A

2.25

2.55

0.176

2.14

Group B

2.09

2.48

The difference between the post-test and pre-test values of Group A & Group B regarding chest expansion is 2.14. The calculated 't' value is greater than the critical 't' value showing that there is a significant difference between the Groups A & B.

Hence the alternate hypothesis is accepted which states that there is a significant difference between control group and experimental group in post CABG patients.

MODIFIED BORG's SCALE

Modified Borg's scale

Group

Mean value

Calculated

't' value

Pre-test

Post-test

SD

Group A

0.61

4.6

1.30

2.24

Group B

3.15

2.95

The difference between the post test and pretest values group A and group B regarding BORG's Scale is 2.24. The calculated 't' values greater than critical value 't' value showing that there is a significant between the Groups A & B.

Hence the alternate hypothesis is accepted which states that there is significant difference between control and experimental group in post CABG patients.

PEAK EXPIRATORY FLOW RATE

Peak Expiratory Flow Rate

Group

Mean value

Calculated

't' value

Pre-test

Post-test

SD

Group A

2.6

8.07

0.616

2.87

Group B

2.63

8.89

The difference between the post test and pretest values group A and group B regarding Peak expiratory flow rate is 2.87. The calculated 't' values greater than critical value 't' value showing that there is a significant between the Groups A & B.

Hence the alternate hypothesis is accepted which states that there is significant difference between control and experimental group in post CABG patients.

DISCUSSION

This study is an experimental comparative study in which the objective is to determine "The Efficacy of SHUTTLE WALK TEST as a treatment protocol in post CABG patients "

The study consists of two individual groups. One control group and one experimental group with the inclusion of 10 immediate post CABG patients in each group. On the basis of treatment protocol control group received conventional physiotherapy, and experimental group received conventional physiotherapy along with SWT to improve pulmonary functions after CABG.

The subjects in the individual groups are given the respective mode of treatment from the 3rd post operative day to the 7th post operative day.

The chest expansion at xiphisternum level and Modified Borg's scale for RPE,Peak expiratory flow rate are used to measure the outcome.

All the subjects were assessed on the 3rd post-operative day and 7th post-operative day to record the outcome measures.

Where SWT test were administered there was significant improvement in chest expansion of these patients.On statistical analysis using independent t-test between group A and group B,group B showed significant difference in chest expansion.

Modified Borg's scale is a simple and frequently used method for assessment of variants in the rate of perceived exertion.The rate of perceived exertion assessed by Modified Borg's scale is often considered as a measure of the efficacy of treatment.On statistical analysis using independent t-test between group A and group B showed significant reduction in RPE.

PEFR,this parameter which gives an idea about the airway resistance,is decreased not only due to pain but also cental depression produced by anaesthesia.it recorded mean improvement from the baseline values on the preopearative day.This gives us an insight into the speedy recovery to normal and also reduce the dyspnea perception. On Statistical analysis using independent "t"- test showed significant difference when the pre- test and post test value are compared to each other. This shows all the treatment protocols were effective in improving the pulmonary hygiene of the patient.

From this we infer that SWT can be used as an efficient treatment protocol for improving pulmonary functions and thereby it allows and optimization of the treatment during the immediate post -operative period.

LIMITATIONS

Though carried out with the best of efforts,the study has the following limitations:

The sample studied was small and very stipulated.

The study was short term study.

The criterion for patient selection was much stipulated and only the CABG patients without any pulmonary pathology were selected are very constrained.

For SWT test, the active participation of the patient is needed.

CONCLUSION

Physiotherapists commonly use conventional methods of treatment following CABG in order to reduce the post-operative morbidity. The statistical analysis of the mean improvements recorded between the two group of patients have clearly demonstrated that the improvements produced by inclusion of SHUTTLE WALK TEST treatment in the immediate post-operative period of cardiac CABG patients arguments the conventional physiotherapy. In that regard we should understand that all parameters show greater improvements though not significant enough from the magnitude point of view. This may require further analysis through prolonged follow up. May be a greater sample size might also influence those factors.

Hence the null hypothesis of this study is rejected and alternate hypothesis is accepted , which could be stated that there is a significant difference between conventional physiotherapy and SWT to improve pulmonary functions on post CABG patients.

This study proposes and provides the evidence that SHUTTLE WALK TEST are very effective in improving the pulmonary functions in post CABG patients. This technique is simple, beneficial but needs and allows active participation of patients in the treatment session.

SUGGESTIONS

The further studies could be modified to accommodate the following changes:

Study with higher population is recommended.

Study with long term follow is suggested.

Study can also be conducted in patients with lung pathology.

Study with thoracic incisions other than median sternotomy can be done.

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