Title: A Study to Evaluate the Hemodynamic Effects of Swiss Ball Exercise in Post-Operative Coronary Artery Bypass Graft Patients Introduction: Coronary artery bypass graft (CABG) surgery is a common procedure to restore blood flow to the heart in patients with coronary artery disease. Post-operative cardiac rehabilitation is crucial for optimizing recovery and improving overall cardiovascular health. Swiss ball exercises have gained popularity as a rehabilitation tool due to their potential to improve balance, core stability, and functional capacity. Objective: To assess the hemodynamic effects of Swiss ball exercise in patients undergoing post-operative coronary artery bypass graft surgery. Methods: Study Design: A prospective, randomized controlled trial. Participants: Patients who underwent coronary artery bypass graft surgery and met inclusion criteria. Randomization: Patients will be randomly assigned to either the intervention group (Swiss ball exercise) or the control group (standard cardiac rehabilitation). Intervention: The intervention group will perform supervised Swiss ball exercises as part of their cardiac rehabilitation program. Control Group: The control group will receive standard cardiac rehabilitation without Swiss ball exercises. Outcome Measures: Hemodynamic parameters, including heart rate, blood pressure, cardiac output, stroke volume, and systemic vascular resistance, will be measured at baseline and at specified time intervals during the study period. Data Analysis: Statistical analysis will be performed to compare the hemodynamic parameters between the intervention and control groups. Expected Results: Improved Hemodynamic Parameters: It is hypothesized that the Swiss ball exercise group will exhibit improved hemodynamic parameters compared to the control group. Increased Cardiac Output and Stroke Volume: Swiss ball exercises may enhance cardiac performance, leading to increased cardiac output and stroke volume. Decreased Systemic Vascular Resistance: Swiss ball exercises may result in improved vascular function, leading to reduced systemic vascular resistance. Enhanced Functional Capacity: Patients in the intervention group may experience improved functional capacity, as reflected by increased exercise tolerance and reduced exertional symptoms. Significance: Clinical Application: The findings of this study may provide evidence supporting the inclusion of Swiss ball exercises in post-operative cardiac rehabilitation programs for CABG patients. Rehabilitation Guidelines: The study results may contribute to the development of guidelines for incorporating Swiss ball exercises into standard cardiac rehabilitation protocols. Improved Patient Outcomes: If Swiss ball exercises are found to have positive hemodynamic effects, their implementation in post-operative rehabilitation

1. “A STUDY TO EVALUATE THE
HEMODYNAMIC EFFECT OF SWISS
BALL EXERCISE IN POST
OPERATIVE CORONARYARTERY
BYPASS GRAFT PATIENTS”
Name of researcher – Goldy jain
(MPT)(Cardiopulmonary disorders)
Under the guidance of –Dr. Chirag purbia
(MPT)(Cardiopulmonary disorders)

2. Introduction
Coronary artery disease is the leading cause of cardiovascular
morbidity and mortality worldwide .The burden of coronary artery
disease in India is rising remarkably1.
Fig.a
Relative distribution of cardiac operation by procedure type for calendar
year 2016 2 .

3. Muscle weakness
Increase atrophy
Loss of mass
Decrease protien synthesis
Increase protein degeneration
Excessive unloding
Low muscle activity
Decrease neural drive
Bed rest/ sedation
Fig b
Mechanism pathway involve
in occurance of mucle
weakness in post operative
patients3
Studies of long ago recovery after critical illness demonstrate that some patients
experience profound and prolonged neuromuscular dysfunction. Muscle weakness
and wasting and nerve injury or damage resulting in intense care unit-acquired
weakness (icuaw) appear to start within the first few days of critical illness. As such,
interventions that reduce intense care unit-acquired weakness and improve recovery
after critical illness is of major importance to public health 4

4. Swiss ball exercises
The use of the swiss ball to unload the muscles and
thus provide a more moderate exercise environment
the potential of helping the muscles regain power
and endurance without creating excessive chemical
imbalance5.
Advantages to use swiss ball in ICU early
mobilization is performed in the upright position,
that is the physiologic position whenever possible,
to optimize the effects of being upright on central
and peripheral hemodynamic and fluid shifts.
Thus mobilization is prescribed to elicit both a
gravitational stimulus and an exercise stimulus 6.

5. Need of study
Lack of evidence is the present use of swiss
ball exercises in acute instance care unit
for coronary artery disease whereas
postural drainage, positive expiratory
pressure devices, tricyclic ergometry are
used frequently. So the hemodynamic
effect of swiss ball exercises is yet to be
proven and has vast scope for future
research.

6. Aims and objective
1. To evaluate the hemodynamic effects of conventional
physiotherapy in post operative cardiac surgery patients.
2. To evaluate the hemodynamic effects of Swiss ball exercises
in post operative cardiac surgery patients.
3. To compare the hemodynamic effects of conventional chest
physiotherapy with Swiss ball exercises and conventional
physiotherapy in post operative cardiac surgery patients.

7. Hypothesis
 NULL HYPOTHESIS:
There is no significance in hemodynamic
changes in response to Swiss ball
exercises with post coronary bypass graft
patients.
 ALTERNATE HYPOTHESIS:
There is significance in hemodynamic
changes in response to Swiss ball
exercises with post coronary bypass graft
patients.

8. Review of litratures
 Patrícia Alcântara Vianna(2020)- This is a randomized-controlled study that
included patients undergoing valve heart surgery or coronary artery bypass grafting.
Patients initiate the exercise with cycle ergometer or received the usual treatment
(assisted active exercise) on the first day after surgery. Both interventions were
performed twice a day, without imposing a load, and a mean duration of 15 minutes,
while the patients remained in the intensive care unit (ICU). The primary outcome
was defined as walking speed, assessed after discharge from the ICU, measured by a
blind evaluator for the patient’s allocation group. Conclusion is the use of cycle
ergometer during the early mobilization in the ICU does not promote an increase in
functional capacity when compared to active assisted exercise in patients’
underground cardiac surgery.
 Bruno Bavaresco Gambassi (2019)- Conduct a sample consisted of eight patients
(age: 58.6±7.7 years; body mass index: 26.7±3.5 kg.m2) who underwent a successful
CABG (no complications during surgery and/or in the following weeks). To assess
heart rate variability (HRV), participants remained in a supine position with a 30-
degree head elevation for 20 minutes. This assessment was performed before, after
one hour and after 24 hours of the exercise session. All patients underwent a 35
minutes aerobic exercise session (AES) (low-moderate intensity) on the cycle
ergometer. Conclusion: The practice of (acute) aerobic exercise improved autonomic
cardiac control in patients undergoing CABG.

9.  Ahmad Osailan (2019)- Fifteen CABG (51.4 þ 6.4 years, 14 male, 1 female) patients without
altering their medication were enrolled in a hospital-based cardiac rehabilitation program. .
Patients performed two Incremental Shuttle Walking Test and one before exercise training
program and one after, during which resting systolic blood pressure (SBP) and diastolic blood
pressure (DBP), post- Incremental Shuttle Walking Test SBP and DBP, resting HR, peak HR,
HRR (which was defined as the absolute change from peak HR to 1-minute post peak HR), and
RPP at rest and at the end of the Incremental Shuttle Walking Test were measured. Exercise
training sessions included both aerobic and resistance exercises, which were preceded by a
cooling down period and followed by a recovery period . conclusion there was a significant
increase in the speed and distance achieved on Incremental Shuttle Walking Test 2 after the
training program
 Michelle E. Kho(2016)- conducted a 33-patient prospective cohort study in a 21-bed adult
academic medicalsurgical intensive care unit (ICU) in Hamilton, ON, Canada. We included adult
patients ( 18 years) receiving MV who walked independently pre-ICU. Our intervention was 30
minutes of in-bed supine cycling 6 days/week in the ICU. Our primary outcome was Safety
(termination), measured as events prompting cycling termination; secondary Safety
(disconnection or dislodgement) outcomes included catheter/tube dislodgements. Feasibility was
measured as consent rate and fidelity to intervention. For our primary outcome, we calculated the
binary proportion and 95% confidence interval . Conclusions Early cycling within the first 4 days
of MV among hemodynamically stable patients is safe and feasible. Research to evaluate the
effect of early cycling on patient function is warranted
 Beate Carriere The Swiss Ball(1997) - The Swiss ball reduces the weight of the limbs when the
patient is actively exercising. The Swiss ball can enable the patient to exercise without straining
himself by reducing the weight of the limbs while exercising. Exercises can be performing with
active assisted. The critical care and acute care units present the therapist with numerous
possibilities for using the Swiss ball to help manage the very ill patient and allow for a slow
progression to increase weight bearing and early active movement. Use of the Swiss ball does
not exclude conventional exercising or helping the patient progress to resistive exercises.

10. Methodology
 STUDY DESIGN:
 A comparative study design was identified as appropriate to carry out A study to evaluate the
hemodynamic effects of swiss ball exercises in post operative coronary artery bypass graft
patients
 SOURCE OF DATA: A sample were taken from Geetanjali Medical College and Hospital;
Cardio Thoracic Vascular Surgery Instance Care Unit which are eligible as per inclusion and
exclusion criteria.
 SAMPLE: A total of 124 individuals both males and females were selected for the study.
 SAMPLING TECHNIQUE: A Convenient random sampling technique is used for data
collection.
 SAMPLE SIZE: 62 subjects. Each group
 Duration 7 days

11. Outcome measurements
Primary
 Blood pressure systolic and diastolic
.(SBP and DBP)
 Heart rate ( HR)
Secondary
 Oxygen saturation ( spo2)
 Respiratory rate (RR)

12. Criteria of selection
 INCLUSION
CRITERIA:
 Age group: - >18
years.
 Gender :- both
male and female
 Hemodynamic
stable
 Patient with
CAB)
 More than 40 %
LVEF
EXCLUSION CRITERIA:
•Those who are not fulfilling
the criteria
•Those who refuse for the
consent form
•Other Cardiac surgery (except
CABG)
•Pre-existing Respiratory
condition (COPD, asthmatic,)
•Patient those who are on
ventilator
•Unstable angina pectoris
Renal complications

13. Total no. Participants from
inform consent {n=124}
Allocated traditional
physiotherapy +swiss ball
exercises {n=62}
Pre intervention
Parameters
HR,RR,SBP,DBP
Post intervention
parameters
HR,RR,SBP,DBP
Follow up
Post Op
Day 2
Day 4
Day 6
Allocated traditional
physiotherapy {n=62}
Pre intervention
parameters
HR,RR,SBP,DBP
Post intervention
parameters
HR,RR,SBP,DBP
Follow up
Post Op
Day 2
Day 4
Day 6

14. Exercise Protocol for coronary artery bypass graft
patients
Warm-up (10 mints.)
 Breathing exercises - 10 repetitions (deep breathing exercise, inspiration hold )
 Spirometer – 5 repetitions ( inspiration and expiration)
 Ankle toe movements 10 repetitions
 Wrist pump movements 10 repetitions
 Workout (20 mints )
(A) Swiss ball exercises for group A – 5 repetitions
 Ankle toe movement with lower limb elevation in supine or sitting.
 Shoulder flexion –extension with breathing control
 Posterior support for anterior basal expansion.
 Relaxed shoulder breathing control
 Side rolling lateral basal expansion
 Bed side sitting knee movement
 Shoulder movement with chair sitting
 Shoulder movement with standing
(B) Conventional exercises for group B – 5 Repetitions
 Chest expansion exercises
 Chest mobility exercises
 Walking with support (2 round )
According to patient condition
 Force expiratory techniques ( huffing and coughing) (3 to 5 repetition )
 Postural drainage (vibration and percussion )
Cool down (10 mints)
 Relaxation position (on day 3 in supine and on day 5 in sitting )
 Deep breathing exercise

15. Pre and post leg elevation
Shoulder flextion

16. Age and Gender Wise Distribution in percentage
of sample
Gender 40-50 50-60 60-70 ≥80
Total number
out of (124)
In present
%
Male 10 37 43 1 91 73.40%
Female 4 20 8 1 33 26.6%
total 14 57 51 2 124 100%
0
20
40
60
80
100
120
140
40-50 50-60 60-70 ≥80 Total
number out
of (124)
In present
%
Male
Female
total

17. Male-female Ratio with mean and
SD score in Swiss ball exercise
Variables Group N Mean SD t df P
HR PRE AND
POST
M 45 74.17 5.206 5.096 88 0.0001
M 45 79.4 4.504
F 17 73.58 4.316 4.229 32 0.0002
F 17 80.17 4.759
SBP PRE AND
POST
M 45 132.6 13.7 2.42 88 0.017
M 45 126.3 10.82
F 17 124.7 15.64 0.261 32 0.795
F 17 126 13.28
DBP PRE AND
POST
M 45 76.88 9.672 0.4617 88 0.6454
M 45 77.82 9.641
F 17 74.82 7.518 0.19 32 0.845
F 17 74.17 11.35

18. Male-female Ratio with mean
score in swiss ball exercise
M M F F M M F F M M F F
74.17
79.4
73.58
80.17
132.6
126.3 124.7 126
76.88 77.82
74.82 74.17
HR PRE
AND
POST
SBP PRE
AND
POST
DBP PRE
AND
POST
Mean

19. Pre and post exercise Mean , t, SD score and p
value in Swiss ball exercises
VARIABLES N Mean SD t df P
HR
PRE EXERCISE 62 70.62 8.924 2.884 122 0.004
POST EXERCISE 62 74.61 6.244
SBP
PRE EXERCISE 62 125.4 9.056 2.513 122 0.013
POST EXERCISE 62 129.4 8.658
DBP
PRE EXERCISE 62 75.24 15.94 1.144 122 0.254
POST EXERCISE 62 77.96 9.668

20. Pre and post exercise Mean score
in Swiss ball exercises
70.62
74.61
125.4
129.4
75.24
77.96
Mean
HR PRE EXERCISE POST EXERCISE
SBP PRE EXERCISE POST EXERCISE
DBP PRE EXERCISE POST EXERCISE
: p value of HR (p<0.001) are statistically significant but DBP (0.013) and
SBP (0.254) are consider to be not statistically significant.

21. Comparative Mean, Sd, t score And P
Value of Swiss Ball And Conventional
Exercises
Variables swiss ball conventional t p
HR
Mean 79.32 76.22
2.079 0.039
Sd 8.2 8.4
SBP
Mean 135.5 130.3
2.506 0.013
SD 11.4 11.7
DBP
Mean 82.43 77.84
2.284 0.0241
SD 12 10.31

22. Comparative Mean score of Swiss Ball and Conventional Exercises
(Systolic Blood Pressure),(heart rate )and (distolic blood presssure)
79.32
76.22
swissball conventional
HR
135.5
130.3
swissball conventional
SBP
82.43
77.84
swissball conventional
DBP

23. Pre and post exercises Mean score of oxygen
saturation in Swiss ball exercises
95.5
98.33
PRE
POST
MEAN
MEAN SD t p
PRE 95.5 2.762
8.3073 0.001
POST 98.33 0.676
(p<0.001) by conventional
criteria this difference is
consider to be extremely
statistically significant.
Comparison of pre and post
mean SPO2 shown that there
is significant improvement in
SPO2 in patients. (P<0.001)

24. Pre and post exercises Mean score of respiratory
rate in Swiss ball exercises.
Variables MEAN SD t p
PRE 23.45 3.814
5.2016 0.00
POST 20.35 2.734
23.45
20.35
PRE
POST
MEAN
(p<0.001) by
conventional criteria this
difference is consider to
be extremely statistically
significant.

25. Group A (Swiss ball individuals) experienced
more cardiovascular demand increased then
the intervention has cardiovascular effects on
GROUP B (conventional individual)
In Swiss ball exercises HR value 80.95+5 beat
per mints (on day 4th p<0.001, day 6th
p<0.001), SBP value 138+5mmHg (on day
4th p<0.001, day 6th p<0.001), DBP value
75+5 mmHg (on day 4th p<0.20, on day 6th
p<0.25).

26. Discussion
VARIABLE CONVENTIONAL SWISS BALL
N 62 62
AGE (YEAR) 56+5 60+5
MEN 45(36%) 45(36%)
BMI (KG/M2) 23.5+5 24.1+5
HEIGHT(M) 153+5 152+5
WEIGHT(KG) 60+5 60+5

27. Conclusion
 This were study demonstrated that swiss ball
exercises effective in promoting increased
SBP & HR in Hemodynamic effects in
CABG patient who underwent physical
therapy rehabilitation.
 Swiss ball exercises show more stability in
Hemodynamic effect. As per result Swiss
ball is safer exercise as well as effective
treatment to prevent atrophy, maintain
peripheral circulation mobility in limbs this
intervention could be the part of routine care
in CABG.

28. Referance
 Donna Frownfelter, Elizabeth Dean Principle and practice of
Cardiopulmonary physiotherapy, 3rd Edition, Mosby, 1996.
 W. Larry Kenney, Jack H. Wilmore, Austin David L. Costill Physiology of
Sport and Exercise 5th Edition Human kinetics, 2012.
 B.D. Chaurasia et al. Human Anatomy, Vol. 1: 6th Edition; CBS Publishers
and Distributors Pvt. Ltd.
 Susan standing gray`s anatomy, 9th Edition; Elsevir Churchill Livingstone;
2005.
 Carrière, B. et al. ‘The Swiss ball: An effective physiotherapy tool for patients,
families and physiotherapists’, Physiotherapy, (1999). 85, 10, 552-561.
 ACSM’s Guidelines for Exercise Testing and Prescription; 10th Edition;
American College of Sports Medicine 2018.
 Vivian H. Heyward; Advanced Fitness Assessment Exercise Prescription;
Seventh Edition; Human Kinetic; 2014.
 Beate Carriere; The Swiss Ball Theory, Basic Exercises and Clinical
Application; Springer-Verlag Berlin Heidelberg 1998.
 Frank H. Netter; Atlas of Human Anatomy, 7th Edition, Elsevier; Philadelphia;
2019.

29. LIMITATION AND RECOMMENDATION
 LIMITATIONS OF THE STUDY
1. The information on the safety and injury risk of the training protocol in the general
population was not known.
2. Influence of drug, climate and psychological factors cannot be controlled.
3. Only subjects with coronary artery bypass graft were taken for the study.
4. Psychological status was not evaluated.
 FUTURE RECOMMENDATION
1. The study can be done with other critical acute steups .
2. Large age group can be considered.
3. The VO2 max recovery can also be measured.
4. The work and rest ratio can be changed as 1:2, 1:4, etc.
5. The swiss ball exercise can be compared with other training.
6. Patients who underwent treatment with percutaneous Transluminal Angioplasty, Stent
placement or other interventions for coronary artery disease can be included for the future
study.

30. Thank you