A Mobilization Poster stimulates Early In-Hospital Rehabilitation after Cardiac Surgery: A prospective sequential-group study

doi:10.21203/rs.3.rs-1975144/v1

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Research Article

A Mobilization Poster stimulates Early In-Hospital Rehabilitation after Cardiac Surgery: A prospective sequential-group study

https://doi.org/10.21203/rs.3.rs-1975144/v1

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Journal Publication

published 08 Mar, 2023

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Background

Patients infrequently mobilize at the surgical ward after cardiac surgery. Inactivity results in prolonged hospital stay, readmissions and increased cardiovascular mortality. Next, the course of in-hospital mobilization activities for patients is unclear. The aim was to evaluate early mobilization after heart surgery with a mobilization poster on the Activity Classification Guide for Inpatient Activities score from the American College for Sports Medicine (ACSM). Second, to develop a Thorax Centrum Twente (TCT) score with actual activities.

Methods

A poster was developed for the Moving is Improving! study to stimulate hospital mobilization after heart surgery. In this sequential-group study at a cardiothoracic surgery ward, 32 patients were included in the usual care group and 209 patients in the poster mobilization group. Change of ACSM and TCT scores over time were both defined as primary endpoints. Secondary endpoints included length of stay and survival. A subgroup analysis for coronary artery bypass grafting (CABG) was performed.

Results

ACSM score increased during hospital stay (p < 0.001). No significant increase of ACSM score was observed with a mobilization poster (p = 0.27), nor in the CABG subgroup (p = 0.15). The poster increased mobility to chair, toilet, corridor (all p < 0.01) and home trainer (p = 0.02) as measured by the activity-specific TCT scores, without differences in length of stay or survival.

Conclusions

ACSM score measured day-to-day functional changes, without significant differences between the poster mobilization and usual care group. Actual activities measured with the TCT score did improve. The mobilization poster is now new standard care, and effects in other centers and other departments should be assessed.

Trial registration:

This study does not fall under the ICMJE trial definition and was not registered.

Cardiac Rehabilitation

Early Ambulation

Exercise

Physical Therapy

Thoracic Surgery

Elective cardio-thoracic surgery patients have a hospital stay for 6 to 7 days after surgery in U.S.A. and Europe [1, 2], and a postoperative stay of 9 days in China [3]. Patients often do not know why physical activity and mobilization is important, and stay in bed during hospital stay [4]. This leads to muscle loss and reduced aerobic capacity [5], prolonged hospital stay [6], and readmissions [7]. Hospitalized cardio-thoracic surgery patients spent up to 50% lying in bed during the day [8], despite enhanced recovery after surgery protocols [9]. Rarely patients have their meal outside of bed or walked during hospital admission [10].

Guidelines do describe features of “phase I rehabilitation”, “inpatient” or “early mobilization”, e.g. postoperative mobilization [11, 12], yet focus mainly on outpatient rehabilitation. Almost 20% of postoperative patients do not receive inpatient cardiac rehabilitation, and when utilized less than 30% of the hospital days are covered [13], often without weekend day services [14].

In-hospital exercises include breathing techniques, transfer between bed and chair and walking along the ward [8]. This leads to less pain and depression as well as decreased length of stay [15], and these outcomes are associated with lower mortality, morbidity, and costs [16]. Early mobilization strategies increased 6-minute walking assessment distance from 377m to 444m [17], but did not meet the minimal clinically important difference [18].

Success of mobilization can be assessed with wearable devices [8], and patient-reported or professional scores e.g. the Activity Classification Guide for Inpatient Activities from the American College for Sports Medicine (ACSM) [19]. The latter is a 6-point score that describes activity classes of patients from sitting up in bed with assistance (class I) to doing self-care activities in the bathroom (class III) to independent frequent ambulation (class VI), see Table 1.

However, sensitivity of the ACSM score to measure day-to-day changes for cardio-thoracic surgery patients is unclear. Since the ACSM score aggregates activities in a composite score, it is unclear which individual activities patients perform during early mobilization. A new Thorax Centrum Twente (TCT) score focusing on actual activities might overcome this limitation.

Table 1. Activity Classification Guide for Inpatient Activities (ACSM score)
Activity class I	Activity class II	Activity class III
• Sits up in bed with assistance • Does own self-care activities-seated, or may need assistance • Stands at bedside with assistance • Sits up in chair 15-30 minutes, 2-3 times per day	• Sits up in bed independently • Stands independently • Does self-care activities in bathroom-seated • Walks in room and to bathroom (may need assistance)	• Sits and stands independently • Does own self-care activities in bathroom, seated or standing • Walks in halls with assistance short distance (15-30m)^a as tolerated, up to 3 times per day
Activity class IV	Activity class V	Activity class VI
Does own self-care and bathes • Walks in hall short distances (45-60m)^b with minimal assistance, 3-4 times per day	• Walks in halls independently, moderate distances (75-150m)^c, 3-4 times per day	Independent ambulation on unit, 3 to 6 times per day
Table adapted from ACSM’s Guidelines for exercise testing and prescription, 7^th edition [19]. Original text: ^a50-100 ft, ^b150 to 200ft, ^c250 to 500ft

Thus, the aim of the Moving is Improving! study is to evaluate the stimulating effect of early rehabilitation after heart surgery with a mobilization poster on functional independence measured with the ACSM and TCT score. The effects are compared to a usual care group. The hypothesis is that a mobilization poster improves in-hospital mobilization compared to a usual care group.

This study is reported as per the STROBE recommendations on the quality of reporting observational studies [20]. The data presented in this study will be published openly available in 4TU.ResearchData data repository.

Study Design and Study Population

This single center, prospective observational sequential-group study was conducted at Thorax Centrum Twente (Medisch Spectrum Twente, Enschede, The Netherlands), a tertiary non-academic teaching hospital. Adult patients undergoing non-salvage cardiac surgery were included. Patients were excluded with a Katz Index of Independence in Activities of Daily Living ≤ 2 before surgery (i.e. all patients were independent in daily life mobilization) [21] and patients with an intensive care unit (ICU) stay longer than 72 hours.

All patients were admitted to the ICU after surgery. An A1 size mobilization poster for each patient room was developed based on preliminary external work [22].

The “Moving is Improving!” practice improvement initiative recruited from 03 to 20 October 2016 for the usual care group (UCG) and from 31 October 2016 to 22 November 2016 for the poster mobilization group (PMG). This practice improvement was initiated when nurses and physiotherapists observed that patients were not motivated for early mobilization. A best practice unit leadership program was started with the underlying study.

7 dedicated physical therapists trained for cardio-thoracic physiotherapy practice participated in the study. Physical therapists were trained in ACSM and TCT classification and a pocket card was handed out for daily use. Nurses and surgical staff were also educated on the importance of early mobilization. A physiotherapist noted down patient-reported ACSM score daily at each patient room, and was collected after discharge. After interim analysis, the mobilization poster (Translated from Dutch to English, Fig. 1) was implemented as new standard care in the cardio-thoracic surgery ward and patients were also included from 10 September 2017 to 26 March 2018 (PMG).

ACSM score (see Table 1 for definitions) was used to compare UCG to PMG during postoperative hospital stay. No other changes than the poster were implemented during the study.

Change in in-hospital ACSM score and a more detailed Thorax Centrum Twente score (TCT) were defined as primary endpoints. Secondary endpoints included ICU length of stay, surgical ward stay and 30-, 120-day and overall survival. Follow-up on mortality was 100% and ended 1 February 2021. Baseline characteristics were determined based on EuroSCORE II definitions [23]. Rethoracotomy within 30 days, red blood cell transfusions, and rhythm problems were defined according to Netherlands Heart Registry definitions [24]. Temporary pacemaker leads were removed at postoperative day 2 to 5, depending on the type of surgery and underlying rhythm. Having a temporary pacemaker lead was no constraint for mobilization.

A 3 week interval of cardio-thoracic surgery determined study size for the usual care group (UCG). A consecutive 3 week interval determined poster mobilization group (PMG) size and was followed by 6 months use of the poster as new standard care (PMG).

The investigation conforms with the principles outlined in the Declaration of Helsinki [25]. This study was exempted from the Medical Research Involving Human Subjects Act by the Medical Ethics Committee Twente (METC Twente: K16-85) and was approved by the local institutional review board. Patients therefore did not sign informed consent.

Development of TCT score

Six functional activities were taken from the ACSM score [19] and Functional Independence Measure dimensions [26]: lying in bed, sitting in a chair, walking to the toilet in the patients’ own hospital room, walking along the ward corridor, cycling at a home trainer and walking the stairs. Four frequency descriptors were added: never, sometimes, often and always. A matrix of functional activities and frequency descriptors is provided in Additional file 1. A patient questionnaire for poster experience was sent by mail to patients after discharge (Additional file 2). In terms of validity, the TCT score was evaluated by calculating two-way mixed, consistency, average-measures intra-class correlation coefficients (ICC) to assess consistency between the ACSM and TCT scores. The inter-rater reliability was qualified as poor for ICC values less than 0.40, fair for values between 0.40 and 0.59, good for values between 0.60 and 0.74, and excellent for values between 0.75 and 1.0 [27].

Exercise program and milestones

Patients received passive mobilization strategies, and potentially sitting on the edge of their bed or chair mobilization starting from the first postoperative day at ICU. Patients received physical therapy twice a day until the 3rd postoperative day and then once a day in both groups, as is standard of care [8]. A standardized program starting at ICU discharge included:

Day 1: Breathing exercises, coughing techniques, control mobilization upper- and lower extremities, transfer from bed to chair with assistance;
Day 2: Exercises as on day 1. Self-transfer from bed to chair with or without assistance, ambulation with assistance for 20m at surgical ward;
Day 3: Exercises as on day 2. Ambulation with increase in distance (± 15m) and frequency (3 times), cycling for 5–10 min with 0–10 Watt depending on hemodynamic stability;
Day 4: Exercises as on day 3. Walking stairs (1 floor) with assistance, information on home mobilization, increase cycling duration (5–10 min) and power (10–15 Watt).

Each patient specific exercise program was based on evaluation findings, comorbidities and patient goals. The poster was discussed during physical therapy sessions, where exercises were shown.

Statistical analysis

Statistical analysis was performed with SPSS 28.0 (SPSS Inc, Chicago, IL). Results were considered statistically significant at the 5% level. Continuous variables were presented as mean with standard deviation (SD) or median with interquartile range (IQR) depending on the distribution. Continuous variables were tested for normality with visual inspection of histograms and skewness and kurtosis measures. Categorical variables were presented as number with corresponding percentages and compared between groups using a Fisher Exact Test. A Kaplan Meier curve with log rank test was used to test for differences in survival between UCG and PMG.

A linear mixed model was used to determine differences in ACSM and TCT scores between groups (UCG and PMG), differences over time (day-to-day scores) and interaction between group and time to study differences in the course of these scores over time between the two groups.

A sex subgroup analysis as encouraged by the Institute of Medicine [28] was performed. Furthermore a subgroup analysis of coronary artery bypass grafting (CABG) patients was planned for all endpoints because of different Dutch guidelines for CABG and non-CABG in-hospital mobilization [29].

Out of 309 patients selected for eligibility, with 37 patients in the UCG (UCG) and 272 patients in the poster group (PMG), in total 59 patients were excluded based on prolonged ICU stay over 72 hours (n=36), salvage surgery (n=11) and absence of major cardiac surgery (n=12) (Figure 2).

Baseline characteristics

Patients had a mean age of 67 years, a BMI of 28 kg/m², over 50% had multivessel disease and 16% a recent myocardial infarction. There were no significant differences between groups for baseline or in-hospital characteristics (Table 2). Median ICU stay was 1.5 [1-2] day in UCG and 1 [1-2] day in PMG (p = 0.92) with a median surgical ward stay of 4 days in both groups (UCG 4 [2.5-4] and PMG 4 [3-5], p = 0.51, Table 3).

Table 2. Baseline and procedural characteristics
Variable	Overall (n = 241)	Usual Care Group (n = 32)	Poster Mobilization Group (n = 209)	P value
Baseline characteristics
Age, years	67 ± 11	66 ± 12	68 ± 11	0.32
Sex, male	175 (73%)	24 (75%)	151 (72%)	0.83
Body Mass Index, kg/m²	28 ± 4.2	29 ± 4.5	28 ± 4.1	0.20
Diabetes	66 (27%)	9 (28%)	57 (27%)	0.94
Multivessel disease	138 (69%)	17 (77%)	121 (68%)	0.37
Recent myocardial infarction	39 (16%)	6 (19%)	33 (16%)	0.67
Left Ventricular Function				0.13
Poor, < 30%	8 (3.3%)	2 (6.3%)	6 (2.9%)
Moderate, 30-50%	43 (18%)	2 (6.3%)	41 (20%)
Good, > 50%	190 (79%)	28 (88%)	162 (78%)
COPD	26 (11%)	2 (6.2%)	24 (12%)	0.55
Extracardiac arteriopathy	28 (12%)	1 (3.1%)	27 (13%)	0.14
Neurological dysfunction	6 (2.5%)	0 (0%)	6 (2.9%)	0.99
Previous cardiac surgery	11 (4.6%)	0 (0%)	11 (5.3%)	0.37
NYHA class				0.13
I	171 (71%)	28 (88%)	143 (69%)
II	49 (20%)	4 (13%)	45 (22%)
III	18 (7.5%)	0 (0%)	18 (8.7%)
IV	2 (0.8%)	0 (0%)	2 (1.0%)
Urgency				0.53
Elective	150 (62%)	19 (59%)	131 (63%)
Urgent	85 (35%)	13 (41%)	72 (34%)
Emergency	6 (2.5%)	0 (0%)	6 (2.9%)
Salvage	0 (0%)	0 (0%)	0 (0%)
EuroSCORE I, logistic	3.7 [1.9 – 7.4]	2.8 [1.7 – 5.8]	3.7 [1.9 – 7.5]	0.18
EuroSCORE II	1.3 [0.92 – 2.3]	1.1 [ 0.83 – 1.7]	1.4 [ 0.93 – 2.3]	0.16
Periprocedural characteristics
Type of surgery				0.29
CABG	142 (59%)	19 (59%)	123 (59%)
Valve surgery	55 (23%)	5 (16%)	50 (24%)
CABG + valve surgery	21 (8.7%)	2 (6.3%)	19 (9.1%)
TAVI	12 (5.0%)	3 (9.4%)	9 (4.3%)
Ascending aorta surgery	6 (2.5%)	2 (6.3%)	4 (1.9%)
Other surgery	5 (2.1%)	1 (3.1%)	4 (1.9%)
Cardiopulmonary bypass	162 (71%)	18 (62%)	144 (72%)	0.27
Cardiopulmonary bypass time, min	102 [79 - 128]	97 [62 – 137]	102 [80 - 127]	0.56
Data are means ± SD or Medians [IQR] or numbers (proportions) CABG = Coronary artery bypass grafting, COPD = Chronic obstructive pulmonary disease, NYHA = New York Health Association, PMG = Poster mobilization group, TAVI = Transcatheter aortic valve implantation, UCG = Usual care group.

Median follow-up on mortality was 1574 days in UCG and 1187 days in PMG. There was no difference in mortality at all timepoints (Table 3, Additional file 3). No complications such as wound or sternum dehiscence or ventricular tachycardia related to early mobilization were reported.

Table 3. Postoperative characteristics and survival
Variable	Overall (n = 241)	Usual Care Group (n = 32)	Poster Mobilization Group (n = 209)	P value
Intensive care unit stay, days	1 [1 – 2]	1.5 [1 – 2]	1 [1 – 2]	0.92
Surgical ward stay, days	4 [3 – 5]	4 [2.5 – 4.5]	4 [3 – 5]	0.51
Rethoracotomy within 30 days	13 (6.4%)	0 (0%)	13 (7.1%)	0.75
Red blood cell transfusion	35 (15%)	4 (14%)	31 (16%)	0.99
Rhythm problems (atrial fibrillation and resuscitation)	56 (25%)	4 (14%)	52 (26%)	0.17
Discharge to:				0.36
Home	154 (64%)	24 (75%)	130 (62%)
Referring hospital	86 (36%)	8 (25%)	78 (37%)
Other	1 (0.4%)	0 (0%)	1 (0.47%)
Survival
30-day survival	241 (100%)	32 (100%)	209 (100%)	0.99
120-day survival	240 (99.6%)	32 (100%)	208 (99.5%)	0.70
365-day survival	237 (98%)	31 (97%)	206 (99%)	0.48
* 28 patients from PMG had incomplete data-collection for one of more days Data are Medians [IQR] or numbers (proportions) ACSM = Activity Classification Guide for Inpatient Activities score from the American College for Sports Medicine, TCT = Thorax Centrum Twente score

American College of Sports Medicine (ACSM) Functional Score

Median ACSM score one day after ICU discharge was 1 [1-1] in UCG and 1 [1-2] in PMG (day-to-day boxplot, see Additional file 4). Overall, ACSM scores increased significantly from postoperative admission to the surgical ward and discharge (p < 0.001), with a plateau phase starting from day 4 (Figure 3). ACSM score was not significantly affected by the mobilization poster (p = 0.27), see Additional Tables 5.3 and 5.4.

TCT Descriptive Score with Actual Activities

Incomplete data collection for one or multiple days resulted in exclusion from analysis for 28 patients. In total 32 UCG-patients and 188 PMG-patients were included in TCT score analysis. Overall, TCT scores increased significantly from postoperative admission to the surgical ward and discharge (p < 0.001).

Every individual TCT score, bed, chair, toilet, corridor, home trainer and stairs was significantly different over time as determined in a linear mixed model (p < 0.001). TCT scores for chair, toilet, corridor and home trainer were significantly higher in the poster mobilization group (see Figure 4 and Additional Tables 5.3 and 5.4).

Subgroup analysis for sex, and CABG

Men had an overall significant higher median ACSM score of 4 [2 to 5] throughout the stay compared to women, 3 [2 to 4] (p < 0.001). Furthermore, there was a significant difference in the course of the ACSM score over time between men and women (p < 0.001, Additional file 4). There was no difference in ACSM score for sex between UCG and PMG (p = 0.23).

A subgroup analysis for CABG patients included 21 patients in UCG and 142 patients in PMG. There were no differences in baseline or periprocedural characteristics (see Additional Tables 5.1 and 5.2). ACSM was significantly different over time (p < 0.001). No significant effect of the mobilization poster was observed (p = 0.15) in the CABG subgroup (Additional Table 5.3). In the CABG subgroup TCT scores for bed, chair, toilet, corridor and home trainer were significantly higher in the poster group (Additional Table 5.3).

The Moving is Improving! study evaluated the stimulating effect of a mobilization poster on early mobilization after heart surgery, as measured with the ACSM and TCT scores.

Measuring ACSM Functional Score for cardiac surgery patients

ACSM score was sensitive to measure daily improvement of patient functional activities after heart surgery. A stabilization pattern was observed 4 to 5 days after ICU discharge. This is in line with accelerometer data obtained at our surgical ward [8]. The mobilization poster did not increase ACSM score in the overall group (p = 0.27) or CABG subgroup (p = 0.15).

We are the first to report results of an “aggressive phase I mobilization” strategy [31]. Our study shows that early mobilization is safe and results in increased activity levels without compromising safety. The early mobilization protocol is comparable in physical activity to other published protocols [32]. Afxonidis et al. intensified early postoperative physiotherapy sessions after cardiac surgery starting at the ICU, and reached milestones during hospital stay compared to our Day 2 protocol [15]. Physical therapists in Australia and New Zealand reported in a national survey that all patients are sitting out of bed at first postoperative day and 20% completed one flight of stairs on day 4 after uncomplicated CABG [14]. In our study, 88 to 96% sat on a chair at first postoperative day, 36 to 48% cycled at a home trainer on day 3 and 45 to 75% walked the stairs on day 4 (see Additional file 7).

The ACSM score increased drastically in this study from day 1 to day 4. That means that implementation of this poster in more conservative mobilization programs focusing on lower metabolic equivalents of physical activity [15] are likely to observe an increase in ACSM score during hospital stay as well.

Higher ACSM scores were observed in men who might have a more competitive attitude to mobilization or overestimate self-reported activities. Self-reported patient activities were aligned with nursing records and with activities performed during physical therapy sessions. Most of these activities were unsupervised, and self-reported activities could therefore shift a borderline score towards a higher level. Also, women might be more hesitant to mobilize after surgery. This finding is in line with a study on postoperative mobilization after total hip arthroplasty [33]. No differences in in-hospital mobilization after cardiac surgery were observed between men and women in another study where accelerometers were used [8]. Further research should quantify this difference using objective data from activity trackers in a larger study. If the difference between men and women persists in future studies, physical therapists should develop motivational interviewing strategies to reduce women patients’ hesitance to mobilization.

TCT descriptive score

The mobilization poster had a significant impact on sitting in a chair, walking to the toilet and along the corridor and cycling at a home trainer. No difference in TCT score for bed and stairs was found. Patients generally only lay in bed at day 1 after ICU discharge and this did not change between UCG and PMG. Walking the stairs is a discharge target and thus did not change. These TCT scores might be removed in future studies to reduce administrative load for physical therapists.

Classification of patient mobility with the TCT scores had an overall high agreement with the ACSM score, with ICCs in the good to excellent range for bed, chair, toilet and corridor. There was poor agreement for home trainer and stairs, which was no surprise because these activities are not described in the ACSM score at all. Last, TCT score was planned as an individual score per activity. Future studies might include a cumulative day score for comparison and for potentially clinical cut-off selection.

Study Limitations

Scoring was based on self-reported activities and was not blinded, potentially introducing bias. A study in our center used accelerometer measurements for objective qualification of activities, and found similar results [8].

Next, our prospective sequential-group study might include bias compared to a randomized controlled trial, and did not allow for extension of the control group, resulting in unequal group sizes. After the initial PMG group and extensive analysis, poster mobilization was continued as new standard. In this study, baseline characteristics were balanced between both groups (Table 2). Furthermore, a parallel randomized design would allow for informal cross-over as patients might see or discuss the poster at the surgical ward. Last, type I error might have been introduced with 7 primary endpoints (1 ACSM score and 6 TCT scores). With a Holm-Bonferroni correction for our primary endpoints, we still find significant results in our mixed model analysis (Additional Table 5.3) for chair (p = 0.007), toilet (p = 0.012), corridor (p = 0.025), and not home trainer (p = 0.08).

A linear mixed model was used as length of stay differed between patients and repeated ACSM or TCT measures from the same patient are more similar than responses from other patients. A sample size of 32 patients in the control group might be too small to find a significant effect of a mobilization poster for a composite measure such as ACSM score. Contrarily, the TCT scores focusing on one activity only were able to find an improved effect of the mobilization poster in this study population.

ACSM and TCT scores sitting, and walking to the toilet and corridor were higher in the PMG at the first postoperative day. Preoperative ACSM and TCT scores were not collected the day before surgery. All patients were independent in daily life mobilization, as determined with the Katz Index of Independence in Activities of Daily Living [21]. It is unclear if the poster benefits patients as early as day one, or alternatively, that the patient groups differed already at ICU discharge. As there was no patient selection, and both cohorts were in a short time span, we do not expect preoperative differences and address this increase to be the poster effect.

Future work

Other patient groups with intermediate to long hospital stay might benefit from early mobilization. At the cardiology ward and other wards early mobilization for patients with or without a mobilization poster should be evaluated using the ACSM or TCT score. Effects of prehabilitation for frail patients [34], or patients with high BMI and estimated long cardiopulmonary bypass times [35] can also be studied with these measures.

The poster group used an A1 size poster during ward stay. Patients found this poster to be clear, motivating and not pushy (Additional file 2). Functional activities might increase faster with digital persuasive technology focusing on the current activity level. Future work should focus on patient-specific information and exercises that match the current functional level of patients recovering from cardiac surgery based on self-reported or wearable device measurements [6, 8].

ACSM functional score showed to be sensitive to measure day-to-day changes of patients at a surgical ward after cardiac surgery, yet no difference in effects between the mobilization poster and usual care group was observed. Higher ACSM scores were found for men. An early mobilization strategy using a mobilization poster however significantly increased sitting in a chair, walking to the toilet and corridor and cycling at a home trainer as measured with the TCT score.

Implementation of a mobilization poster to promote a more mobile behavior after cardiothoracic surgery is a low-cost approach and should be implemented in other hospitals. Both the ACSM or TCT score can be used for evaluation of postoperative mobilization.

ACSM

American College for Sports Medicine

BMI

body mass index

CABG

coronary artery bypass grafting

COPD

chronic obstructive pulmonary disease

ICC

intra-class correlation coefficient

ICU

intensive care unit

NYHA

New York Health Association

PMG

poster mobilization group

TAVI

transcathether aortic valve implantation

TCT

Thorax Centrum Twente

UCG

usual care group

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki. This study was exempted from the Dutch Medical Research Involving Human Subjects Act by the Medical Ethics Committee Twente (METC Twente: K16-85, October 2016) and approved by the Institutional Review Board of Medisch Spectrum Twente. Patient consent was waived by the Ethical Committee due to the more observational design of this study. Therefore, this research does not fall under the ICMJE definition of a clinical trial (patients were not assigned to a medical intervention by the investigator) and was therefore not registered.

Consent for publication

Not applicable

Availability of data and materials

The data presented in this study are openly available in 4TU.ResearchData after publication of this manuscript.

Competing interests

The authors declare that they have no competing interests.

Funding

This research received no external funding.

Authors’ contributions

Conceptualization, F.H., N.W., S.H. and J.G., methodology, F.H., N.W., S.H., M.B. and J.G., validation, F.H. and M.B., formal analysis, F.H., investigation, N.W. and S.H., resources, F.H. and J.G., data curation, F.H., writing—original draft preparation, F.H., writing—review and editing, F.H., N.W., S.H. and J.G., visualization, F.H., supervision, F.H and J.G., project administration, F.H. All authors read and approved the final manuscript.

Acknowledgements

The authors acknowledge prof. Bart Koopman PhD for his valuable comments to the manuscript. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ information

Dr Frank R. Halfwerk is Assistant Professor and Principle Investigator of the Cardiac Surgery Innovations Lab at the University of Twente and is Technical Physician in cardiothoracic surgery at Thoraxcentrum Twente, Medisch Spectrum in Enschede, the Netherlands. His focus is on personalized treatment and rehabilitation for cardiothoracic surgery patients with predictable surgical outcomes.

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No competing interests reported.

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A Mobilization Poster stimulates Early In-Hospital Rehabilitation after Cardiac Surgery: A prospective sequential-group study

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Journal Publication

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Abstract

Background

Methods

Results

Conclusions

Trial registration:

Figures

Background

Methods

Study Design and Study Population

Development of TCT score

Exercise program and milestones

Statistical analysis

Results

Baseline characteristics

American College of Sports Medicine (ACSM) Functional Score

TCT Descriptive Score with Actual Activities

Subgroup analysis for sex, and CABG

Discussion

Measuring ACSM Functional Score for cardiac surgery patients

TCT descriptive score

Study Limitations

Future work

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors’ contributions

Acknowledgements

Authors’ information

References

Additional Declarations

Supplementary Files

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