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A periodized model for exercise improves

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 Clinical Rehabilitation
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A periodized model for exercise improves the intra-hospital evolution of patients after
myocardial revascularization: a pilot randomized controlled trial
Rafael Michel de Macedo, José Rocha Faria Neto, Costantino O Costantini, Marcia Olandoski, Dayane
Casali, Ana Carolina Brandt de Macedo, Andrea Muller, Costantino R Costantini, Vivian Ferreria do Amaral,
Katheryne Athayde Teixeira de Carvalho and Luiz César Guarita-Souza
Clin Rehabil 2012 26: 982 originally published online 12 March 2012
DOI: 10.1177/0269215512439727

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439727
2012
CRE261110.1177/0269215512439727de Macedo et al.Clinical Rehabilitation

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

A periodized model for exercise 26(11) 982–989

© The Author(s) 2012
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DOI: 10.1177/0269215512439727

evolution of patients after cre.sagepub.com

myocardial revascularization: a
pilot randomized controlled trial

Rafael Michel de Macedo1,2, José Rocha Faria Neto1,2,

Costantino O Costantini2, Marcia Olandoski1,
Dayane Casali2, Ana Carolina Brandt de Macedo2,
Andrea Muller1,2, Costantino R Costantini2,
Vivian Ferreria do Amaral1, Katheryne Athayde Teixeira de
Carvalho3 and Luiz César Guarita-Souza1,2

Abstract
Objective: To compare models of the postoperative hospital treatment phase after myocardial
revascularization.
Design: A pilot randomized controlled trial.
Setting: Hospital patients in a hospital setting.
Subjects: Thirty-two patients with indications for myocardial revascularization were included between
January 2008 and December 2009, with a left ventricular ejection fraction (LVEF) ≥50%, 1-second forced
expiratory volume (FEV1) ≥60 and forced vital capacity (FVC) ≥60% of predicted value.
Interventions: Patients were randomly placed into two groups: one performed prescribed exercises
according to the model proposed by the American College of Sports Medicine (ACSM) and the other
according to a periodized model.
Main measures: Partial pressure of O2 (Po2) and arterial O2 saturation (Sao2), percentage of predicted
FVC and total distance on the six-minute walking test (6MWT).
Results: Twenty-seven patients were re-evaluated upon release from the hospital (ACSM = 14 and PP
= 13). Five patients extubated for more than 6 hours in the postoperative period were excluded from
the sample. In the preoperative period the variables Po2, Sao2, % FVC and 6MWT were similar. In the
postoperative period, a reduction was observed for all parameters in both groups. Upon comparison of
the groups, a difference was observed in Po2 (ACSM = 68.0 ± 4.3 vs. PP = 75.9 ± 4.8 mmHg; P < 0.001),
Sao2 (ACSM = 93.5 ± 1.4 vs. PP = 94.8 ± 1.2%; P = 0.018) and 6MWT (ACSM = 339.3 ± 41.7 vs. PP =
393.8 ± 25.7 m; P < 0.001). There was no difference in % FVC.
Conclusion: Patients after myocardial revascularization following a periodized model of exercise
presented a better intra-hospital evolution when compared to those using the ACSM model.

1Pontifícia Universidade Católica do Paraná, Brazil Corresponding author:

2Hospital Cardiológico Costantini, Brazil Rafael Michel de Macedo, Rua Aristides Pereira da Cruz, n 1
3Instituto Pequeno Príncipe, Brazil casa 57, Curitiba, Paraná 80330-290, Brazil
Email: rafael.macedo@hospitalcostantini.com.br

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de Macedo et al.
Keywords
Breathing exercises, cardiac rehabilitation, exercise, physical therapy
Received: 7 September 2011; accepted: 21 January 2011
Introduction
Pulmonary complications in the postoperative
period following myocardial revascularization sur-
gery is the most frequent cause of increased mortal-
ity related to this procedure.1 Approximately 650
000 patients per year undergo myocardial revascu-
larization surgery in the United States,2 and of these,
nearly 13 000 present pulmonary complications
during the postoperative period.1 These complica-
tions can be prevented and/or treated by prescribing
respiratory and motor exercises during hospitaliza-
tion.3,4 However, there is a lack of information
regarding which model of exercise regimen is the
most efficient during the intra-hospital phase.
The existing models of exercise prescribed are
primarily based on individual knowledge of the
physical therapist, without objective methods for
prescription. A prior meta-analysis5 evaluated the
effectiveness of physical therapy interventions with
or without exercise in the reduction of pulmonary
complications. For the 18 studies included in the
analysis (1457 patients), a subjectivity or absence
of method in prescribing exercises was observed.
This could, in essence, compromise the effective-
ness of the therapeutic intervention.6
The exercise model most recognized for applica-
tion during the intra-hospital phase is that proposed
by the American College of Sports Medicine
(ACSM).7 However, this model is also subjective in
that the professional involved defines the parame-
ters for exercise without an objective evaluation.
One way to improve a prescribed exercise regimen
is to use a model of organization or progression of
workload over time, called periodization.8,9
However, we have not encountered other studies
comparing the methodology in prescribed respira-
tory exercises for the postoperative period of myo-
cardial revascularization, or studies comparing
periodic models of prescribed exercise.
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983
Thus, the objective of this study was to compare
a periodized method for respiratory and motor
exercises versus that proposed by the American
College of Sports Medicine prescribed during the
intra-hospital treatment phase after myocardial
revascularization.
Methods
A pilot study was performed to compare the two
methods of exercise prescription during the intra-
hospital period for patients who had undergone
myocardial revascularization.
Sample size was estimated based on the annual
number of surgeries performed in the hospital,
including 30 myocardial revascularization surgeries
in patients with left ventricular ejection fraction of
(LVEF) ≥50%, spirometry results of forced vital
capacity (FVC) ≥60% of predicted and 1-second
forced expiratory volume (FEV1) ≥60% of the pre-
dicted value. This number was attributed to the
available population and utilized for the sample cal-
culation. As such, the sample was estimated at 27
patients with a power of 95% for detecting a differ-
ence of 20% in the 6MWT and an alpha of 0.05.
Patients were included (n = 27) by random sam-
pling using folded papers selected from a non-trans-
parent sack. Each paper indicated either ‘ACSM’ or
‘periodized’. The selection was done by the same
person (RMM), after initial preoperative evaluation
(preoperative period), and the intervention was per-
formed by a team of physical therapists at the
Hospital Cardiológico Costantini (APM, DEC,
RMM). The volunteers were randomized into the
two groups at a 1 : 1 ratio. The patients underwent
two daily exercise sessions with a duration of 30
minutes each supervised by trained physical thera-
pists. As shown in Table 1, the two groups were
given the same respiratory and motor exercises;
 Table 1. Summary of exercises applied during training for both groups, according to the period of hospitalization
984

Group ACSM Periodized ACSM Periodized

Hospitalization
phase Hospitalization in ICU Intensive microcycle Hospitalization in room Microcycle of readaptation
Prescribed Intensity Series × Interval Intensity Series × Interval Intensity Series × Interval Intensity Series × Interval
exercises repetitions repetitions repetitions repetitions
Deep inhalation NAR 3 × 10 Random NAR 3 × 40% Each 1 min NAR 3 × 10 Random NAR 3 × 60% Each 1 min
exercises MNEI MNEI
Fragmented NAR 3 × 10 Random NAR 3 × 40% Each 1 min NAR 3 × 10 Random NAR 3 × 60% Each 1 min
inhalation MNEI MNEI
exercises
(2 times)
Fragmented NAR 3 × 10 Random NAR 3 × 40% Each 1 min NAR 3 × 10 Random NAR 3 × 60% Each 1 min
inhalation MNEI MNEI
exercises
(3 times)
Deep inhalation NAR 3 × 10 Random NAR 3 × 40% Each 1 min NAR 3 × 10 Random NAR 3 × 60% Each 1 min
exercises MNEI MNEI
associated
with LEM
Deep inhalation NAR 3 × 10 Random NAR 3 × 40% Each 1 min x x x x x x
exercises MNEI
associated
with IPPB
Deep inhalation x x x x x x NAR 3 × 10 Random NAR 3 × 60% Each 1 min
exercise MNEI
associated
with FII

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Active exercises NAW 3 × 10 Random NAW 3 × 10 Each 1 min NAR 3 × 10 Random 10% 3 × 10 Each 1 min
of lower BSW
limbsa
Walking x x x x x x Random 1 × 6 min Continuous 60–80% 1 × 6 min Continuous
MS
ACSM, American College of Sports medicine; ICU, intensive care unit; NAR, no additional resistence; MNEI, maximum number of estimated incursions per minute; IPPB, intermittent
positive pressure breathing; LEM, lung expansion manoeuvre; x, not applied at this phase of treatment; FII, flow inspiratory incentive; NAW, no additional weight; BSW, body segment
weight; MV, mean velocity m/s; MS, maximal speed.
aHip flexion, knee flexion, knee extension, hip extension, ankle plantarflexion, abduction of lower limbs, and adduction of lower limbs.
Clinical Rehabilitation 26(11)
de Macedo et al.
however, they differed with respect to the prescrip-
tion of periodized training.
The primary difference between the two groups
(ACSM versus periodized) was in the individualiza-
tion of the number of sets and weight load pre-
scribed by the physical therapists for those in the
periodized group, as well as the progression of these
exercises during the hospitalization period.
In the ACSM group, all patients performed the
same number of sets and repetitions of respiratory
and lower limb motor exercises (these being pre-
scribed without specific tests for definition of inten-
sity and volume), with no additional load for
movements, and no controlled intervals between
sets (as suggested by the method), walking ran-
domly in the hospital corridors.
In contrast, the periodized group performed a
number of repetitions per minute of respiratory
exercises proportional to their pulmonary capacity,
performed resistance exercises with an additional
load proportional to leg weight, and walked at a pre-
defined speed according to the six-minute walk test,
as shown in Table 1. In addition, two training micro-
cycles were created, the first being the intensive
microcycle (corresponding to the intra-hospital
intensive care unit (ICU) phase) and the second
being the readaptation microcycle (corresponding
to the treatment phase in the hospital room). A tran-
sition between the microcycles (training periods)
occurred upon release from the ICU and the patient
was then presented with a progression of weight
loads for performing the exercises, as shown in
Table 1.
In order to determine the ideal number of repeti-
tions per minute, a MNEI (maximum number of
estimated incursions per minute) variable was cre-
ated for each patient. The MNEI was obtained using
the maximum voluntary ventilation (MVV) test,
calculating the quotient between MVV (1 minute)
and the mean volume inhaled in litres (VI) in the
first three test cycles (MNEI = MVV/VI). The
MNEI expresses the exact number of repetitions per
minute to be executed during the respiratory exer-
cises for each individual.
To determine the ideal additional load for each
patient we utilized a body segment weight table
indicating motor exercise load for the lower limbs,10
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985
adding approximately 10% of the weight of the seg-
ment in motion with the help of leg weights. The
walking speed was prescribed using the mean of the
6MWT in the presurgical evaluation.
The following variables were evaluated to mea-
sure outcomes of the study: arterial Po2, arterial
Sao2, percentage of predicted forced vital capacity
and distance achieved on the 6MWT. Evaluations
were performed by the same person (RMM) one
day prior to surgery and upon discharge from hospi-
tal. In addition, the evaluator knew which group the
patient belonged to. The evaluations included the
following:
• Spirometry: by digital spirometry (Respiradyne
II Plus, Teleflex Medical, IL, USA), with the
patient seated comfortably. In order to evaluate
the FVC and LVEF, patients were initially asked
to exhale rapidly and intensely in intervals of
three after inhaling at maximum lung capacity
(MLC). The best result of the three attempts was
used. Subsequently, the MVV test was per-
formed in which the patient breathed as many
times as possible, deeply and rapidly during 15
minutes, repeating the exercise in intervals of
three. The greatest value obtained (in L/min)
was used.11
• The six-minute walking test (6MWT): The test
was performed in a 30 m corridor, calculating
the total distance and the number of laps
walked by each patient. Walking speed was
determined by the rate of perceived physical
exertion scale (RPE), and every minute the
patient was asked to maintain a slightly greater
intensity (RPE = 13).12
• Arterial gasometry: gasometry data were col-
lected from the patient records during the hospi-
talization period.
Results obtained in the study were expressed as
mean, median, minimum–maximum values and
standard deviation (quantitative variables) or as fre-
quency and percentages (qualitative variables). For
comparison of the two groups, Student’s t-test was
used for independent samples and the non-paramet-
ric Mann–Whitney test was used when appropriate.
For comparison of the groups with respect to
986 Clinical Rehabilitation 26(11)

quantitative variables evaluated in the postoperative

Elegible pa!ents (n=51)
phase, or regarding the difference between the pre
and post evaluations, the analysis of covariance Pa!ent recruitment (n=32) Pa!ents who fulfilled
model (ANCOVA) was applied and the preopera- inclusion criteria (n=32)

tive evaluation was considered a covariant. With Randomiza!on (n=32)

respect to dichotomous nominal variables, the
groups were compared using Fisher’s exact test. A
P-value <0.05 was considered to be statistically Pa!ents allocated to Pa!ents allocated to
ACSM group (n=17) periodized group (n=15)
significant.
All patients were contacted, informed and evalu-
Pa!ents excluded in post- Pa!ents excluded in post-
ated during the presurgical period at the Costantini opera!ve phase: opera!ve phase:
extuba!on at +6 hours
Cardiological Hospital (HCC). The study was (n=3).
extuba!on at +6 hours
(n=2)
approved by the referred institution and the patients
were included after signing an informed consent.
Pa!ents without follow-up (n=0) Pa!ents without follow-up (n=0)
Discon!nued (n=0) Discon!nued (n=0)

Results Pa!ents re-evaluated (n=14) Pa!ents re-evaluated (n=13)

Fifty-one patients were recruited from January 2008

to December 2009. Of these, 32 met the inclusion
criteria and thus participated in the study (Figure 1).
However, 5 of these patients were later excluded
due to late extubation, leaving a total of 27 patients
treated during 7 ± 1.5 days of hospitalization. Figure
1 shows the patient flow of the study. Selected
patients included those with indication for myocar-
dial revascularization surgery with a LVEF ≥50%,
FEV1 ≥60% of the predicted, and FVC ≥60% of the
predicted value. Patients extubated for more than 6
hours in the postoperative period were excluded
from the sample.
As shown in Table 2, we can see that the groups
did not present a difference in age, weight, height,
body mass index (BMI) or number of bypasses for
myocardial revascularization.
Both groups showed a decrease in 6MWT, how-
ever, the groups using the periodized model showed
a smaller decrease than the ACSM group (Figure 2).
Figure 1. Flowchart for study patients.
The groups also presented a decrease in arterial
Po2 (P < 0.05), Sao2 (P < 0.05), % predicted FVC (P
< 0.05), the periodized group presenting a smaller
decrease in the first two variables (Table 3). Upon
comparison of the pre and post differences between
the groups there was a difference between the vari-
ables Po2 (P < 0.05) and Sao2 (P < 0.05).
Discussion
To the best of our knowledge, this is the first study
to present a periodized model of exercise prescribed
during the intra-hospital treatment phase of patients
after myocardial revascularization. In our study,

Table 2. Base characteristics of the ACSM and periodized groups

Variable ACSM (M ± DP) (n = 14) Periodized (M ± DP) (n = 13) P-value

Age (years) 65.64 ± 7.39 59.54 ± 8.16 0.09
Weight (kg) 76.93 ± 10.89 81.69 ± 9.34 0.23
Height (m) 1.71 ± 0.09 1.72 ± 0.08 0.88
BMI (kg/m2) 26.22 ± 1.87 27.70 ± 3.54 0.43
No. of bypasses 2.86 ± 0.53 3.08 ± 0.64 0.43

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de Macedo et al.
Figure 2. Results of the distance walked in the six-
minute walking test (6MWT) in the ACSM group and
the periodized group, comparing pre and post treatment.
*Significant difference intra-group; †significant difference
inter-groups (P < 0.05).
patients that received periodized exercise therapy
were released from the hospital in better physical
condition than patients treated using the model pro-
posed by the American College of Sports Medicine
(ACSM). The periodized groups presented a smaller
decrease (post/pre difference) in the final distance
of the 6MWT, Po2 and Sao2 when comparing preop-
erative results with those upon release. However,
the %FVC did not present a difference (pre–post)
between the two groups.
The distance walked in the 6MWT decreased in
both groups when comparing the pretreatment eval-
uation with that performed on the day of release
from the hospital. This was expected, since patients
Table 3. Comparisons between the ACSM and periodized groups, pre and post treatment, for Po2, Sao2 and %FVC
and total distance walked in the six-minute walking test (6MWT) variables
Group ACSM
Pre
Po2 87.20 ± 6.59
Sao2 96.14 ± 1.06
% FVC 95.73 ± 10.69
TDW6 399.29 ± 31.25
*Significant difference intra-group P < 0.05.
†Significant difference between groups P < 0.05.
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987
have been found to show reduced total distance
walked during the postoperative phase.12 However,
those in the periodized group presented a smaller
difference (pre–post) in final distance walked when
compared to the ACSM group. This improvement in
the evolution of patients in the periodized group can
be attributed to the objectivity and individualized
prescription of the exercises in this model. The peri-
odized group was given a prescribed distance to be
achieved daily for the 6MWT. This corroborates
with the findings of Van Der Peijil et al.,13 who
demonstrated the benefits of prescribing exercises
with increasing load for hospitalized patients,
including better physical condition upon release
when compared to those who were not given
increasing load. In the present study, the periodized
group followed localized training with a load that
was increasing and proportional to the weight of the
body segment involved in the motion. Po2 and Sao2
also presented a similar pattern to that observed in
the 6MWT. A drop in arterial Po2 (hypoxaemia) and
in Sao2 are pulmonary dysfunctions frequently
encountered in the postoperative period following
myocardial revascularization, and are associated
with an increase in morbidity and mortality of these
patients.1 These respiratory dysfunctions, however,
can be prevented. The periodized group was given
an individualized prescription of respiratory exer-
cises using the MNEI and presented a better intra-
hospital evolution of Po2 and Sao2. A smaller
decrease in hypoxaemia in the periodized group
may have been the result of a better and quicker
Periodized
Post Pre Post
68.00 ± 4.32*† 82.46 ± 5.75 75.95 ± 4.78*†
93.54 ± 1.40*† 95.59 ± 0.99 94.79 ± 1.17*†
69.77 ± 9.72* 96.98 ± 15.41 78.55 ± 13.75*
339.93 ± 41.71*† 421.54 ± 23.40 393.85 ± 25.67*†
988
learning of lung expansion promoted by the use of
the MNEI in prescribing a number of repetitions for
each exercise. Accordingly, the periodized model
for respiratory exercises was shown to be more
effective than the subjective model of the American
College of Sports Medicine. This raises the ques-
tion of whether or not results such as those described
by Pasquina et al.5 in which physical therapy inter-
vention was not beneficial to patients,14–17 occurred
because an objective prescription model of respira-
tory exercises was not used.
The %FVC showed a significant drop for both
groups when comparing the pre- and posttreatment
phases, however, without a significant difference
between the groups. This is confirmed by the find-
ings of Guizilini et al.18 who demonstrated a sig-
nificant drop in %FVC as a result of a reduction in
dynamic complacency. In the present study, the
prescription model did not influence the evolution
of %FVC. This may have occurred because this
variable is a function of maximum inhalation.
Inhalation is limited by dependent ventilatory pain
resulting from the sternotomy performed in myo-
cardial revascularization surgery.19,20 Consequently,
the restriction in thoracic expansion could limit the
inspiratory capacity in both groups, independent of
the model applied.
The small sample size of the present study may
have influenced the results; however, considering
the difficulty of inclusion for studies such as these
and the originality of the proposed concept, the
results are, indeed, promising. Furthermore, an ade-
quate and rigorous statistical analysis was applied
in order to minimize errors in interpretation of the
results.
In summary, the present study concludes that in
comparison with the model proposed by the
American College of Sports Medicine, a peri-
odized model of exercise prescription for the inter-
hospital postoperative treatment phase was shown
to be superior. In addition, considering that the
periodized model of exercise prescription is sim-
ple and low cost in its application, the results of
this study could be applied to the daily clinical
practice and could contribute to the improvement
of the professional evidence-based practice of
physical therapists.
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Clinical Rehabilitation 26(11)
Clinical messages
• The prescribed periodized model pre-
sented better results than the American
College of Sports Medicine model.
• Accordingly, physical therapists could
consider this model for daily practice and
patient care following myocardial revas-
cularization surgery.
Funding
This work was supported by CAPES.
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