sexta-feira, 1 de maio de 2015

Physical Therapy Examination for Patients with Cervicogenic Dizziness
1Assistant Professor in Physical Therapy, Physical Therapy Department, Faculty of Applied Medical sciences, King Abdulaziz University, Jeddah, Saudi ArabiaAmer Al-Saif1*, 2Samira Alsenany, PhD, Assistant Professor in Gerontology, Nursing Department, Faculty of Applied Medical science, King Abdulaziz University, Jeddah, Saudi ArabiaHani Al-Nakhli2 and 3Hani Al-Nakhli, Physical Therapy Senior-Specialist, Womens and Maternity Hospital, Al-Madinah Al-Munnawarah, KSASamira Alsenany3


Keywords
Cervicogenic dizziness; Vestibular; Physical therapy; Cervical spine; Rehabilitation
Introduction
Balance is maintained through a complex interaction between the visual, vestibular, and somatosensory systems [1,2]. Within the central nervous system, multimodal sensory integration facilitates motor responses to coordinate head and body orientation, postural stability, and gaze stability during head movements [3]. In the absence of normal sensory integration, imbalance and dizziness often occur [3-6]. Effective clinical management of dizziness is an integral component of improving balance. Dizziness is a nonspecific symptomatic description resulting from numerous pathologies including orthopedic impairments affecting the cervical spine and, in such cases, is referred to as “cervicogenic dizziness” [1,7]. Dizziness is also one of the most common medical problems in many countries, especially in the elderly population [5,6]. Cervicogenic Dizziness (CGD) is a relatively new, emerging area in the medical literature with a growing body of evidence that supports the pathophysiology and physical therapy management of patients with cervicogenic dizziness. Patients with CGD typically describe their dizziness as vertigo, lightheadedness, blurry vision, disequilibrium, and/or nausea. Cervicogenic dizziness has been defined as “a non-specific sensation of altered orientation in space and disequilibrium originating from abnormal afferent activity from the neck” [7]. Physical therapy interventions for CGD include orthopedic and vestibular rehabilitation strategies. There is a growing body of evidence supporting the pathophysiology and physical therapy management of patients with CGD; however, it is still not widely adopted in clinical practice. Therefore, the purpose of this paper is to discuss the etiology of cervicogenic dizziness, describe the proposed pathophysiology, and introduce the physical therapy examination and intervention process for patients with CGD.
Etiology of Cervicogenic Dizziness
There are several proposed mechanisms leading to cervicogenic dizziness including mechanical compression of the vertebral artery system, irritation of the cervical sympathetic nervous system, and abnormal proprioceptive input from the upper cervical spine [1,2,7-9]. The vertebral arteries encounter several soft tissue and bony structures capable of producing mechanical compromise [9]. Muscle tightness in the upper cervical spine can potentially occlude the vertebral arteries reducing brainstem perfusion and causing vertebrobasilar insufficiency (VBI) [7,9,10]. In particular, the vertebral arteries travel between the anterior scalene and longus colli muscles as well as under the inferior capitis oblique and intertransversarius muscles [7]. Cervical spine osteophytes and forward head posture are also potential contributors to vertebral artery compression and VBI [9,10]. Upper cervical spine muscle tightness, bony anomalies, and/or poor cervical spine posture can potentially lead to hypoperfusion of the vertebral and carotid arterial network causing dizziness consistent with cervicogenic dizziness [11-18]. Abnormal proprioceptive input from the vestibular and upper cervical spine can lead to dizziness, unsteadiness, and visual disturbance [1,2,13,17,19]. The somatosensory system detects peripheral stimuli from sensory receptors, including mechanoreceptors located in human skin [1,2]. There are an abundance of mechanoreceptors in the upper cervical spine that primarily transmit impulses through nerve cells originating from C2 dorsal root ganglion [2,16,17]. The upper cervical spine mechanoreceptors also converge in the central cervical nucleus (CCN), which serves as a pathway to the cerebellum for integrating and organizing vestibular, ocular, and proprioceptive sensory input [2,13,16,17]. The CCN also sends coordinated information to the cortex for maintenance of postural equilibrium and body orientation [1,2,17,18]. Cervical spine reflexes contribute to head orientation, eye movement control, and postural stability; cervical collic reflex, the cervical ocular reflex, and cervical spinal reflex, respectively [1,2]. These cervical reflexes work in conjunction with vestibular collic reflex, vestibular ocular reflex, and the vestibular spinal reflex [1,2,17,19]. Another potential source of CGD is Irritation of the cervical sympathetic nervous system [3,11]. Abnormal upper cervical spine proprioceptive input, resulting from ischemia, inflammation, or cervical extensor muscle fatigue has also been implicated in patients with imbalance and CGD [3,9,14].
Cervical Spine Trauma
Abnormal cervical somatosensory input can alter somatosensory control and negatively impact postural stability and vision [1]. Cervical spine trauma, such as whiplash-associated disorder (WAD), can impair cervical somatosensory function by causing ischemia, inflammation, and stress [1]. Moreover, evidence suggests that direct trauma to the neck can lead to cervical spine muscle fatigue that ultimately modifies the discharge firing rate of sensory receptors, thus affecting joint position of the head and neck as well as postural stability [3,20-27]. Deficits in oculomotor function have also been described in the literature in patients with WAD [1,28]. Tjell and Rosenhall [27] reported abnormal smooth-pursuit eye movements when the neck was rotated under a stable head in WAD patients. Additionally, greater loss of eye motor control was identified among WAD patients complaining of dizziness [1,28]. Problems of convergence and diplopia have also been associated with WAD patients [1]. It is estimated that approximately 60% of all WAD patients develop dizziness [1]. Abnormalities in motor function of the eyes have also been described in the literature after cervical spine whiplash injuries [1,20]. It is proposed that a sensory mismatch occurs between the multimodal sensory inputs from the upper cervical spine and other systems contributing to postural stability and head orientation. This results in symptoms consistent with CGD [3-5,14-19]. The authors of the current paper also theorize that abnormal sensory input from the upper cervical spine impairs the vestibular ocular reflex, negatively impacting dynamic gaze stability. This theory is made on the basis of existing neural pathways between the upper cervical spine and the vestibular nuclei [1,2,21,22]. Research is in progress to support or refute this theory [21].
Physical Therapy Evaluation
The physical therapy examination process requires clinical decision-making that is based on the best available evidence. The physical therapy evaluation includes subjective and objective components (Tables 1 and 2). Because CGD is one of numerous types of dizziness, the evaluation strategy can be challenging [1,7]. According to Wrisley et al. CGD is a diagnosis of exclusion, meaning that competing causes of dizziness must be ruled out [7]. Physical therapists need to carefully review the past medical history and ask specific questions about the patient’s dizziness in order to determine that the dizziness is Cervicogenic [7]. Episodic dizziness lasting minutes to hours is a common complaint in patients with CGD [7]. They may also report a general sense of disequilibrium or lightheadedness as well as visual disturbances. Vertigo is rarely a chief complaint in CGD patients [1,7]. Circumstances that frequently produce their dizziness include neck pain [1,7]. The physical examination for CGD patients includes a medical screening component that includes three different phases: screening of the (1) cervical spine stability, (2) cervical vascular system, and (3) central nervous system. If any of these medical screening tests produce positive or abnormal results, the physical therapist must refer the patient to a physician for further medical consultation. Otherwise, the physical therapist continues with the physical examination. The vestibular system is examined to determine whether the dizziness is being caused by the peripheral or central vestibular system [7]. Central and peripheral vestibular system testing is performed to determine if the dizziness is being caused by benign paroxysmal position vertigo (BPPV) or vestibuloocular reflex (VOR) hypofunction [9]. If BPPV or VOR hypofunction is found, the appropriate vestibular rehabilitation interventions are implemented [9]. If the peripheral vestibular system examination is positive, appropriate vestibular rehabilitation interventions are implemented. If the central vestibular examination is positive, the physical therapist should refer the patient to a physician for further medical consultation. Otherwise, the physical therapist continues the physical examination [7].
Physical Therapy Intervention
Physical therapy intervention has been shown to be effective in reducing CGD symptoms (Table 3). According to Wrisley et al. [7], CGD symptoms typically increase with neck pain. Therefore, treating neck pain among this group of patients is one of the main objectives for physical therapists. Intervention strategies may include: (1) orthopedic manual techniques specific to the cervical spine region, (2) head and neck proprioceptive rehabilitation program, and (3) cervical-ocular motor exercises. Cervical spine pain and inflammation can be treated with a variety of physical therapy modalities, including cryotherapy, thermotherapy, ultrasound, and cervical spine traction [1,7]. Cervical spine hypo mobility is common among CGD patients and may increase symptoms of dizziness [1,7]. However, cervical hypo mobility can be treated with joint specific mobilization techniques and tissue/age-specific stretching programs [1,7]. Cervical spine proprioception impairments can be treated with a specific proprioceptive rehabilitation program. The proprioception program includes slow, passive head movements with fixed-target gaze exercises [22,23]. The program can be progressed by doing active head movements rather than passive head movements. Also, the clinician may progress the program by instructing the patient to perform active head movements while maintaining their gaze on a fixed target with their trunk passively or actively moved [23]. Another way of performing the program is to instruct the patient to close their eyes and actively rotate their head, return to the starting position, and open their eyes [23]. If the patient cannot see the target, they can keep their eyes open and continue rotating their head until they can see the target [22,23]. This training provides the patient with information about cervical spine joint position sense and can be performed with restricted peripheral vision using foveal glasses [1,7,22,23]. Input from cervical spine afferent nerves can alter the function of the oculomotor system [1,7,23]. Thus, oculomotor training is important to reduce potential extra ocular muscle weakness [28]. Extraocular motor function can be managed using smooth-pursuit (patient keeps head still while eyes follow a moving target), saccades (patient keeps head still and quickly moves eyes between targets), X1 adaptation exercises (patient moves head from side to side while maintaining the gaze on a stationary target), and X2 adaptation exercises (patient moves head and a hand-held target in opposite directions while maintaining gaze on moving target at all times) [1,22,28]. All extraocular exercises can be progressed by increasing the speed of movement, range, duration, and frequency. Also, the exercises could be progressed by gradually decreasing the stability of support and changing from static to dynamic positions [1,22,28].
Conclusion
Cervicogenic dizziness is often the result of a sensory mismatch between the vestibular, somatosensory, and visual afferent inputs. Physical trauma involving the cervical spine, such as whiplash injury, is a common mechanism of injury in CGD patients. Physical trauma contributes to impairment in the upper cervical spine proprioceptive input leading to symptoms including disequilibrium and dizziness. In order to determine the origin of the patient’s dizziness, the physical therapist must conduct thorough subjective and physical examinations to rule out all competing causes of dizziness. The patient history may include physical trauma involving the head and neck and cervical spine postural faults, which are commonly observed. Once CGD has been confirmed, appropriate interventions are implemented to reduce cervical spine pain and inflammation, improve cervical spine proprioception, improve cervico-ocular function, and restore joint and soft tissue range of motion and mobility.
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Physical Therapy Treatment after Cardiac Surgery : A National Survey of Practice in Greece

Keywords
Breathing exercises; Physical therapy; Postoperative care; Questionnaire; Thoracic surgery

 Introduction
To prevent or diminish postoperative complications, pre- and postoperative physical therapy treatment is often prescribed to cardiac surgery patients during the hospital stay. The physical therapy treatment consists of early mobilization, range of motion exercises, and breathing exercises [1-4]. There is agreement on the value of early mobilization, but there is limited scientific evidence on how the surgery patient actually should be mobilized and exercised during the first days after surgery [4-7]. Different breathing techniques with and without mechanical devices are recommended after cardiac surgery [3,8-11], but there is controversy regarding which breathing techniques are the most effective. Surveys describing chest physical therapy management of patients undergoing cardiac surgery have been carried out in Australia and New Zealand [12], Canada [13] and Brazil [14]. A wide variety of treatments are applied before and after surgery, and there are variations between continents concerning choice of treatment. To date, there are few data available describing physical therapy for cardiac surgery patients in Europe [15,16]. In this national survey current clinical practice of physical therapy for patients undergoing cardiac surgery in Greece was determined.

 Materials and Methods

 Study design
A cross-sectional, descriptive study was carried out to examine the physical therapy management of adult cardiac surgery patients in Greece. The survey applied to chest physical therapy treatment of adult patients undergoing uncomplicated cardiac surgery, including Coronary Artery Bypass Grafting (CABG), mitral, aortic, and tricuspid valve surgery, or a combination of these. A national postal questionnaire survey was sent to all physical therapists working at cardiothoracic centers in Greece, both public and private hospitals. The care of patients developing neurological or circulatory problems or other conditions requiring individualized programs was not considered. Physical therapists that only treated children or patients undergoing other types of cardiac, pulmonary, or thoracic surgery procedures were asked to return the questionnaire unanswered.

 Study population
A sample of physical therapists working at departments of cardiothoracic surgery in public (n=10) and private hospitals (n=6) in Greece were sent a postal questionnaire during January 2009. The questionnaire was addressed personally to the 72 physical therapists thus identified. 14 questionnaires were returned from physical therapists not working with the actual patient group, leaving 58 eligible responders. A cover letter and a prepaid response envelope were included with each questionnaire. After 6 weeks the responders were reminded either by e-mail or phone, if the questionnaires had not been returned. All departments of cardiothoracic surgery in Greece were identified through a private congress consortium (Triaina), which had an updated registry. The total population sample of physical therapists working in these departments was identified through the Panhellenic Physiotherapy Association Registry to ensure that all relevant physical therapists were included in the survey. The names and addresses of the physical therapists had been identified and double-checked via phone or mail by C.L. at each hospital just before the start of the study. Before the questionnaire was sent, written informed consent was obtained from the heads of the clinics granting permission for their physical therapists to participate in the study.
The lead clinician of each cardiothoracic department at the selected hospitals was contacted by e-mail for permission to carry out the study. Informed consent was obtained from physical therapists to participate in the study, but no formal ethical approval from the National Ethical Review Board was considered, since no patients were included. The results from the questionnaire are confidential, and no association between the results and a specific physical therapist is possible.

 Measurements
The questionnaire was developed and constructed following a detailed review of the literature concerning physical therapy treatment after cardiac surgery and has been previously used in a Swedish survey [15,16]. The original questionnaire was translated from Swedish into Greek by a bilingual physical therapist (C.L.), and after that backtranslated by another bilingual health care professional, to ensure correct formulation of the survey questions. Suitable items were modified to Greek conditions as necessary by the physical therapist who conducted the forward translation. The questionnaire consisted of 11 pages of questions on pre- and postoperative physical therapy treatment. Structured and open-ended questions were asked about routine physical therapy care of patients undergoing cardiac surgery. The routine pre- and postoperative care of a hypothetical, “everyday patient” undergoing cardiac surgery was considered to determine the standard clinical practice. The care of patients developing complications or other conditions requiring individualized treatment was not considered.

 Statistical analysis
Data were analyzed using descriptive statistics, and the mean, median, and range were calculated. The SPSS version 15.0 software package (SPSS Inc., Chicago, IL) was used for the statistical analysis.

 Results
In total, 45 physical therapists replied to the 58 questionnaires sent out, giving a response rate of 78%. The physical therapists (female n=26, male n=19) were aged 40 ± 8 years, and the mean work experience as physical therapist at a department of cardiothoracic surgery was 10 ± 6 (range 1-20) years. Twenty-seven (60%) of the respondents had completed specific courses in the cardiopulmonary area. All physical therapists declared that they considered physical therapy necessary after cardiac surgery and 31 (69%) considered the physical therapy treatment offered at their department of cardiothoracic surgery optimal. Reasons given for the treatment not being optimal were lack of resources (personnel), equipment, specialization/education, and collaboration with doctors. Written physical therapy guidelines, protocols or care plans detailing usual physical therapy management of the cardiac surgery patient were available for 5 (11%) of the respondents.

 Preoperative information
Preoperative information was offered to all patients undergoing non-emergency cardiac surgery, according to 24 (53%) of the physical therapists. The following topics were most frequently covered in the preoperative information: breathing exercises (64%), coughing techniques (58%), cardiac surgery procedure/opening of the sternum (58%), early mobilization/techniques for getting in and out of bed (29%), lower limb exercises/thrombosis prophylaxis (27%), and poststernotomy restrictions (27%). Preoperative identification of patients at high risk for postoperative complications was noted by 13 (29%) of the physical therapists. Risk factors mentioned were a history of smoking, COPD, chronic renal failure, severe heart disease, and/or previous unsuccessful cardiac surgery.

 Physical therapy treatment at the intensive care unit
Forty-one of the physical therapists had some experience of working in the thoracic Intensive Care Unit (ICU). Physical therapy treatment at the thoracic ICU, during the first postoperative morning after surgery, was routinely given to all (n=29) or only specified (n=10) patients (two missing values). No written guidelines or protocols for the physical therapy treatment of intubated patients were available (n=45). Twelve (29%) of the 41 physical therapists working in the ICU performed manual hyperinflation/bagging of the lungs: 21 (51%) performed suction of airways via nose, mouth, or tracheotomy: and 16 (39%) actively participated in the procedure for weaning a patient off the respirator.

 Postoperative routine physical therapy treatment
During the first five postoperative days the patients usually received 1 to 6 treatment sessions a day by the physical therapist. Usual physical therapy treatments given to cardiac surgery patients during the first four postoperative days are presented in Tables 1 and 2. In total, 37 respondents indicated that the physical therapist automatically met all patients undergoing cardiac surgery on the ward, while four reported that only certain patients, with special needs, were provided physical therapy postoperatively. During the evenings physical therapy treatment was routinely given on the first and second postoperative day, according to 17 (38%) of the respondents. Seventy-one percent of the physical therapists reported that during the first two postoperative days, physical therapy treatment was routinely given to patients on Saturdays, and the corresponding figure was 58% for Sundays.
Postoperative group training for the patients during the hospital stay was provided by four of the physical therapists. Physical therapysupervised stair climbing prior to discharge was practiced according to 19 (42%) of the physical therapists. Information to the patients about physical activity, exercises, and rehabilitation was provided to the patients, according to 33 (73%), before discharge from the department of cardiothoracic surgery.

 Breathing exercises
Approximately 90% of the physical therapists instructed the patients to perform breathing exercises on a regular basis postoperatively. Breathing exercises usually provided to the patients on the first postoperative days after surgery are presented in Table 3. The two most frequently used breathing techniques were deep breathing exercises (n=37) and incentive spirometry (n=36). The physical therapists instructed the patients to perform the recommended breathing exercises 1-4 times a day during the first two postoperative days. How many breaths the patients were instructed to perform at each training session varied from one to 40 breaths: 1-10 breaths (n=22), 11-30 breaths (n=7), 40 breaths (n=2), missing data (n=13). Ward staff provided assistance to the patients, in performing breathing exercises, according to 19 of the respondents.
Coughing support was provided to the patients, according to 41 (91%) of the physical therapists. Several methods were used: manual support from the physical therapist (n=35), patient performance with a small pillow (n=30) and without a pillow (n=16) and sternal support with a device such as the Heart Hugger harness (n=7) or with the help of a sheet (n=3).
Instructions to the patients to continue breathing exercises after discharge were given by 38 physical therapists, and of these, 36 provided the patient with a device for the home breathing exercises. The patients were advised to continue the breathing exercises for duration of between 3 days and 6 months postoperatively.

 Sternal precautions
Sternal precautions recommended for the healing period during the first postoperative weeks are presented in Table 4. Recommendations for how long after surgery the patients should avoid weight bearing varied between 1 and 18 weeks (mean 7 weeks). How much weight the patients were allowed to lift while the sternum was healing varied between 1 and 5 kg (mean 2 kg).
In total, 27 physical therapists gave individually adapted instructions for getting in, and out of bed, while 12 reported that the patients were instructed using a “standard technique.” The two most commonly used techniques for getting out of bed was turning to the side, or moving the legs out of the bed and leaning forward up to a sitting position.
Discussion
This survey provides an illustration of how chest physical therapy treatment of cardiac surgery patients is carried out in Greece. Most of the physical therapists, 82%, declared that they routinely met all patients undergoing cardiac surgery. During the first five postoperative days the patients usually received 1 to 6 treatment sessions a day by the physical therapist.
To our knowledge previous surveys of physical therapy management of patients undergoing cardiac surgery has been performed in Australia and New Zealand [12], Canada [13] and Sweden [15,16]. The clinical practice in these countries seems to be similar to that in the present study in terms of frequency of assessment, even if choices of treatment techniques differ.
Only 53% of the physical therapists reported that preoperative information was offered to all patients undergoing non-emergency cardiac surgery. This is less than reported in other countries, Australia and New Zealand (94%) [12] and Sweden (88%) [16]. The educational content of the preoperative information was similar, though.
All physical therapists in the present study declared that they considered physical therapy necessary after cardiac surgery. In total, 31% considered that the physical therapy treatment offered at their department of cardiothoracic surgery was not optimal. Reasons given were lack of personnel, equipment, education, and collaboration with doctors. Written physical therapy guidelines, protocols or care plans detailing usual physical therapy management of the cardiac surgery patient at the cardiothoracic surgery ward were only available according to 11% of the physical therapists and no written guidelines for intubated patients were available. This is in accordance with Swedish conditions [16].
Today there is agreement as to the value of early mobilization after cardiac surgery [17,18]. After cardiac surgery the cardiovascular status of the patient is one factor that helps decide the intensity of mobilization. Almost all physical therapists in our study mobilized the patients to sitting and standing in the first postoperative days. The patients’ actual mobilization rate would have been interesting to investigate, but this aspect was not covered in this survey, since the routine followed by the physical therapists was the routine determined for a hypothetical “everyday” patient. Positioning to side-lying was used by approximately 50% of the physical therapists, which is more frequently than described in earlier surveys [15]. Positive effects of side lying on lung volumes [19] and oxygenation [20] have been described.
Besides early mobilization, several breathing exercises were applied. In the present study, 93% of the physical therapists instructed the patients to perform breathing exercises on a regular basis postoperatively. Deep breathing was the first choice of breathing technique, and this is in agreement with previous studies [12,13,16]. Incentive spirometry was the second most frequently used breathing technique. The incentive spirometry device is often recommended postoperatively [12,13], but has not been proven to show effect after cardiac surgery [21].
The use of breathing exercises with positive expiratory pressure (PEP) devices has been described as being extensively used in clinical practice postoperatively in Sweden [16] and Brazil [14], despite the lack of evidence of benefit compared with that for conventional deep breathing exercises [22,23]. However, in the present survey no physical therapists used the PEP technique. It is unknown whether the technique is widespread in other parts of the world, and there is currently no evidence to support one breathing technique over another [9,22,24,25].
The physical therapists recommended that patients should perform the breathing exercises 1 to 4 times a day during the first two postoperative days. There is currently no scientific evidence on how often breathing exercises should be performed, but the most commonly suggested frequency is hourly treatment during the first postoperative days after cardiac surgery [1,16,26,27]. Patients were instructed to perform 1 to 40 breaths during each training session, and this is a somewhat larger variation than described in clinical practice in Sweden [16].
During weekends routine physical therapy for patients on their first postoperative day was given more often (Saturdays 71% and Sundays 58%) in the present survey in than in Sweden, (Saturdays 59% and Sundays 31%) [16]. During the evenings physical therapy treatment was routinely given on the first and second postoperative day, according to 38% of the respondents, while in Sweden no evening physical therapy treatment is available. Considering that patients are undergoing surgery on all weekdays, there is a discrepancy in physical therapy treatment accessible to patients, depending on the weekday on which they have their surgery. Patients undergoing surgery in Greece seem to have access to more comprehensive physical therapy than those in Sweden. However, postoperative care is an interdisciplinary activity, and different hospital policies dictate how clinical practice should be performed, making comparisons of treatment between countries difficult. As well, many therapies are applied by other staff members; however, other professional categories were not the focus in this survey.
Shoulder range of motion exercises are intended to improve ventilation, preserve thorax mobility, and ease sternal circulation and healing, even if the efficacy after cardiac surgery has been questioned [5]. In the present survey, mostly bilateral upper extremity exercises were prescribed, rather than unilateral range of motion exercises, in accordance with the results from El Ansaray [28], showing that bilateral upper limb movement was significantly less associated with sternal pain.
Due to sternal precautions, some activities are discouraged after cardiac surgery. Recommendations for how long after surgery the patients should avoid weight bearing varied between 1 and 18 weeks, and the weight allowed to be lifted varied between 1 and 5 kg. It has been suggested that current activity guidelines for CABG patients are too restrictive [29,30]; however, considering that postoperative sternal instability is a serious complication, the importance of correct instructions is essential.
There are some study limitations that need to be mentioned. In total, 45 physical therapists replied to the questionnaires sent out, giving a response rate of 78%. Considering that all cardiac surgical units in Greece were represented, this could be an acceptable response rate. Various strategies were used to achieve a high response rate, though. The questionnaires were accompanied with self-addressed, stamped envelopes, and the responders were reminded 6 weeks later in cases where the questionnaires had not been returned [31]. Access to a list of all physical therapists identified through a physical therapy association registry ensured that all relevant physical therapists were included in the survey. There is a risk of selection bias, since it is possible that only the most motivated physical therapists responded. Some issues may have been overlooked in the questionnaire, but an exact description of the actual clinical practice is difficult to capture, even with other study designs, such as observational studies. Despite these limitations, we believe that the results from this survey could reflect current clinical practice in Greece, and because a total population sample was surveyed, the external validity of the study is fairly good. This survey provides information that may be useful in the development and implementation of clinical practice guidelines for cardiac surgery patients.

 Conclusions
This survey provides an overview of current physical therapy practice for cardiac surgery patients in Greece. The routine use of breathing exercises, coughing techniques, chest wall vibrations, and mobilization is common during the first postoperative days. During the first five postoperative days the patients usually received 1 to 6 treatment sessions a day by the physical therapist. Almost all physical therapists regularly recommended postoperative breathing exercises and coughing techniques. Deep breathing exercises and incentive spirometry were the two most frequently used techniques. Sternal precautions were given routinely, but the advice given varied as to how long after surgery the patients should avoid weight bearing.
In several countries, physical therapy is routinely offered after cardiac surgery. There are various treatment options and opinions about the best way to treat the patients, and this survey provides an insight into the physical therapy practice in Greece. Further comparisons between countries and development of international physical therapy guidelines are warranted to establish the optimal physical therapy practice for cardiac surgery patients.

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