Physiotherapy 99 (2013) 187193

Does the addition of deep breathing exercises to physiotherapy-directed

early mobilisation alter patient outcomes following high-risk open upper
abdominal surgery? Cluster randomised controlled trial
Y.R. Silva a, , S.K. Li a , M.J.F.X. Rickard b
b

a Department of Physiotherapy, Concord Repatriation General Hospital, Concord, Australia

Department of Colorectal Surgery, Concord Repatriation General Hospital, Concord, Australia

Abstract
Objective To investigate whether the inclusion of deep breathing exercises in physiotherapy-directed early mobilisation confers any additional
benefit in reducing postoperative pulmonary complications (PPCs) when patients are treated once daily after elective open upper abdominal
surgery. This study also compared postoperative outcomes following early and delayed mobilisation.
Design Cluster randomised controlled trial.
Setting Single-centre study in a teaching hospital.
Participants Eighty-six high-risk patients undergoing elective open upper abdominal surgery.
Intervention Three groups: early mobilisation (Group A), early mobilisation plus breathing exercises (Group B), and delayed mobilisation
(mobilised from third postoperative day) plus breathing exercises (Group C).
Main outcomes PPCs and postoperative outcomes [number of days until discharge from physiotherapy, physiotherapy input and length of
stay (LOS)].
Results There was no significant difference in PPCs between Groups A and B. The LOS for Group A {mean 10.7 [standard deviation (SD)
5.0] days} was significantly shorter than the LOS for Groups B [mean 16.7 (SD 9.7) days] and C [mean 15.2 (SD 9.8) days; P = 0.036]. The
greatest difference was between Groups A and B (mean difference 5.93, 95% confidence interval 10.22 to 1.65; P = 0.008). Group C had
fewer smokers (26%) and patients with chronic obstructive pulmonary disease (0%) compared with Group B (53% and 14%, respectively).
This may have led to fewer PPCs in Group C, but the difference was not significant. Despite Group C having fewer PPCs and less physiotherapy
input, the number of days until discharge from physiotherapy and LOS were similar to Group B.
Conclusions The addition of deep breathing exercises to physiotherapy-directed early mobilisation did not further reduce PPCs compared
with mobility alone. PPCs can be reduced with once-daily physiotherapy if the patients are mobilised to a moderate level of exertion.
Delayed mobilisation tended to increase physiotherapy input and the number of days until discharge from physiotherapy compared with early
mobilisation.
Crown Copyright 2012 Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. All rights reserved.
Keywords: Abdominal surgery; Early mobilisation; Breathing exercises; Postoperative pulmonary complications

Introduction
Postoperative pulmonary complications (PPCs) are a
leading cause of morbidity and mortality following upper
abdominal surgery [1], contributing to prolonged hospital
Corresponding author at: Department of Physiotherapy, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2139, Australia.
Tel.: +61 2 97676101; fax: +61 2 97678448.
E-mail address: yasmin.silva@sswahs.nsw.gov.au (Y.R. Silva).

stay and additional health costs [2]. Physiotherapeutic techniques to increase mean lung volume are of benefit in
preventing PPCs [3], but the effects of mobility alone have
not been evaluated. Mobilisation improves lung volume in
patients after abdominal surgery [4]. However, it is unclear
whether the decrease in PPCs is due to mobilisation alone or
in combination with breathing exercises.
Mackey et al. found that the addition of deep breathing
to physiotherapy-directed early mobilisation did not reduce
PPCs significantly in high-risk patients undergoing open

0031-9406/$ see front matter. Crown Copyright 2012 Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. All rights reserved.
http://dx.doi.org/10.1016/j.physio.2012.09.006

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Y.R. Silva et al. / Physiotherapy 99 (2013) 187193

upper abdominal surgery [5]. However, the frequency of postoperative physiotherapy sessions used by Mackey et al. may
be considered impractical: three times daily on Days 1 and
2, twice daily on Days 3 and 4, and daily thereafter until the
patient was independently mobile with a clear chest assessment on three consecutive days. The frequency of treatment
has implications for resource allocation and cost. The key
concern is whether frequent physiotherapy sessions in the
first four postoperative days ensured that these patients were
upright and mobilised more than normal, and if this influenced the outcomes.
Prophylactic physiotherapy following upper abdominal
surgery is performed once daily at the authors hospital. Therefore, the primary aim was to investigate whether
the addition of deep breathing exercises to physiotherapydirected early mobilisation (once daily) conferred any benefit
in reducing PPCs compared with mobility alone among
high-risk patients following elective open upper abdominal
surgery. The secondary aim of this study was to examine
whether physiotherapy-directed early mobilisation (commencing on the first postoperative day) had a beneficial effect
on postoperative outcomes [PPCs, number of days until discharge from physiotherapy, physiotherapy input and length
of stay (LOS)] compared with delayed mobilisation (commencing on the third postoperative day).
Methods
Participants
Following approval by the Human Research Ethics Committee of Concord Repatriation General Hospital, Sydney,
Australia, patients were recruited from the pre-admission
clinic between March 2006 and March 2008.
The study population consisted of patients undergoing
elective open upper abdominal surgery involving upper or
upper and lower midline abdominal incision. Criteria for classification as high risk for the development of PPCs [6] were:
age >59 years, or age <59 years with a history of one or
more of the following: (1) cigarette smoking (current smokers and those who had ceased smoking less than 6 weeks prior
to surgery) [7]; (2) chronic obstructive pulmonary disease
(COPD); (3) obesity [body mass index (BMI) 27 kg/m2 ];
(4) cardiac disease; and (5) American Society of Anesthesiologists (ASA) score 2. Patients were excluded if they were
undergoing oesophagectomy or abdominal aortic aneurysm
repair due to differences in surgical management, and if they
were immobile due to previous musculoskeletal or neurological conditions.
Study design
Patients who met the study inclusion criteria were given
an information sheet and provided their informed consent.
Eligible patients were allocated to one of three treatment

regimes: early mobilisation (Group A), early mobilisation

plus breathing exercises (Group B), or delayed mobilisation (mobilised from third postoperative day) plus breathing
exercises (Group C) (see Appendix A, supplementary online
material). The Human Research Ethics Committee and surgeons would not allow a control group with mobility delayed
for >3 days. Patients beds were next to each other, and cluster
randomisation to alternate weeks was used to reduce patient
contamination. Previous quality improvement projects at the
hospital demonstrated that 70% of patients were discharged
from physiotherapy by the fifth postoperative day [8]. Elective abdominal procedures are performed from Monday to
Friday in the study hospital. This resulted in the majority
of patients being discharged, or close to being discharged,
from physiotherapy at the end of each week, prior to the
admission of patients the following week, reducing patient
contamination.
Each Monday, an independent investigator selected one
of 105 sealed opaque envelopes with the group allocation for
that week. All patients operated on during that week were
allocated to that group. The patients were blinded to group
allocation as the information sheet did not describe the three
treatment techniques, except for an explanation that all techniques used in the study had been shown to improve outcomes
after surgery.
Basic demographic information and baseline evaluations
including a complete cardiopulmonary assessment were
performed in the pre-admission clinic by the ward physiotherapist. Pulmonary function was assessed using a portable
spirometer with patients seated upright, according to American Thoracic Society Guidelines [9]. The measures were not
repeated following surgery due to a decrease in pulmonary
function after open abdominal surgery [10]. The ASA score
[6], as rated by the assessing anaesthetist in the pre-admission
clinic, was recorded. A higher score indicates more systemic
disorders.
At each postoperative visit, a complete cardiopulmonary
assessment was performed by the ward physiotherapist, who
was not blinded to group allocation. All patients received
education about the effects of abdominal surgery on the
lungs, group-specific benefits of the exercises and a written
instruction sheet of the exercises. Postoperative physiotherapy interventions were administered once daily by the ward
physiotherapist. Medical and nursing staff were not informed
of the group allocation, and their involvements with patients,
including mobilisation, did not change over the course of the
study.
Physiotherapy-directed mobilisation was only implemented if patients met the criteria listed in Table 1 [5]. The
patients were mobilised by the physiotherapist to a moderate
level of exertion, at an intensity of at least 6/10 according to Borgs 10-point scale of perceived exertion, from
either the first or third postoperative day [11]. Patients were
encouraged to mobilise with nurses and relatives if they were
able, and to keep a record of the furthest location/landmark
reached.

Y.R. Silva et al. / Physiotherapy 99 (2013) 187193

Table 1
Criteria used to assess patient suitability for mobilisation.
Patient awake
Stable blood pressure
Stable heart rate
No dyspnoea at rest
Pain score <8 on visual analogue scale

The deep breathing groups performed four sets of five repetitions of deep breaths, from functional residual capacity to
total lung capacity, with a 3-second inspiratory hold followed
by relaxed expiration. The physiotherapist provided proprioceptive feedback by placing his/her hands bilaterally on the
patients lower ribs. These exercises were completed with the
patient sitting on a chair or on a bed with the head end raised.
Normal breathing was encouraged between the repetitions of
deep breathing exercises. Finally, the patient was educated to
huff and cough, with the wound supported by a towel placed
over the incision. Patients were educated to perform these
exercises every hour while awake.
Patients were discharged from physiotherapy when they
were able to mobilise 100 m independently, had a temperature <38 C, no additional sounds on auscultation, and normal
baseline sputum. The assessor was blinded, as intervention
details and outcome measures were obtained from the medical record after the patient was discharged from hospital.
Outcome measures
For the purpose of the study, the patients were diagnosed
as having PPCs by the ward physiotherapist if they had three
or more of the signs listed in Table 2. Although these criteria
are not validated, they have been used previously in published
work [5]. Chest auscultation findings and sputum production
were recorded daily by the ward physiotherapist and medical staff. Temperature recorded was the patients maximum
documented tympanic temperature prior to physiotherapy
treatment. Chest radiography was performed at the discretion of the medical staff, and was reported by a radiologist
who was blinded to patient allocation. Patients in any group
who developed PPCs were commenced on additional chest
physiotherapy techniques as appropriate for the condition at
the discretion of the ward physiotherapist, and their data were
analysed in an intention-to-treat model.
Pain was measured using a visual analogue scale which
consisted of a standard 10-cm line with verbal anchors
Table 2
Criteria defining postoperative pulmonary complications.
A postoperative pulmonary complication is deemed to have occurred if
three or more of the following signs occur within the same day:
Auscultation changes (decreased breath sounds, crackles, wheezes,
bronchial breath sounds) in addition to those prior to surgery
Otherwise unexplained temperature >38 C
Chest radiography changes (atelectasis, collapse, consolidation)
Changes to sputum (increase in amount and/or change in colour)
compared with what the patient reports is usual for them

189

indicating no pain (0) and severe pain (10 cm) [12]. The
acute pain service assessed patients daily in order to modify
medications to maintain pain at a comfortable level (score of
3 to 5). The VAS score for the first postoperative day was
recorded from the acute pain service records as pain peaks
on the first postoperative day and then decreases over time
[13].
Total distance mobilised daily with physiotherapist,
relatives and nurses was recorded. Each day, the ward physiotherapist and patient discussed the distance mobilised with
nurses and/or relatives, and the furthest location/landmark the
patient had reached in order to calculate the distance.
The day of discharge from physiotherapy and LOS (day
of admission to day of discharge) were recorded. Any
patients re-referred for physiotherapy following discharge
were recorded, along with all treatments provided.
Details of physiotherapy staff time and number of treatments were taken from the Allied Health Information System
(AHIS 1993 Version 2.00, Sydney South Western Area
Health Service: Information Management Service, System
Integration System).
Data analysis
The primary outcome measure was PPCs. Based on a
clinically significant reduction in PPCs of 36% in high-risk
patients after open abdominal surgery [10], a sample size of
16 patients per group was required for 80% confidence to
detect differences with two-tailed tests at an alpha level of
0.05 [14]. Twenty-five subjects per group was considered to
be sufficient to allow for dropouts.
The data were analysed using Statistical Package for
the Social Sciences Version 7 (SPSS, IBM Corporation,
NY, USA). The between-group differences in demographics,
operative data and postoperative outcomes were tested using
analysis of variance. Students two tailed t-test was used to
evaluate differences between the means of the two groups.
A critical probability value of 0.05 or less was deemed to
be significant in all cases. Analyses were conducted on an
intention-to-treat model using all available data.
Results
Ninety patients were invited to participate in the trial. Four
patients declined to participate, and there were no dropouts
(see Appendix A, supplementary online material).
Cluster randomisation yielded three groups that were comparable in most areas, except for a significant difference in
the number of smokers (0.052) (Table 3). There was no significant difference in the number of smokers or patients with
COPD between Groups A and B. However, there were significantly more smokers (P = 0.037) and patients with COPD
(P = 0.032) in Group B compared with Group C. Patients with
multiple comorbidities or complications in surgery, and those

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Y.R. Silva et al. / Physiotherapy 99 (2013) 187193

Table 3
Demographic and operative data.
Data

Group A
Early mobility
(n = 28)

Group B
Early mobility plus deep
breathing
(n = 28)

Group C
Delayed mobility plus deep
breathing
(n = 30)

P-value

Sex ratio M:F, n

Age (years), mean (SD)
BMI (kg/m2 ), mean (SD)
ASA score, n (%)
1
2
3
4
5
FEV1 , mean (SD)
FVC, mean (SD)
COPD, n (%)
Smokers, n (%)
Current smokers
(ceased <6 weeks), n (%)
Cardiac history, n (%)
Cancer history, n (%)
Type of surgery, n (%)
Colorectal
Hepatic/pancreatic
Gastrectomy
Cystectomy with ileal conduit
Division of adhesions
Length of anaesthesia (hours)
ICU/HDU admissions, n (%)
Mean (SD) number of days in ICU/HDU
PCA, n (%)
Epidural, n (%)
Mean (SD) VAS for pain on first postoperative day

12:16
71.1 (7.3)
28.8 (5.8)

16:12
73.1 (8.2)
28.8 (6.6)

17:13
72.1 (9.3)
28.2 (6.7)

0.52
0.90

1 (4)
10 (36)
15 (53)
2 (7)
0
2.18 (0.81)
2.85 (1.02)
1 (4)
9 (32)
3 (11)

2 (7)
10 (36)
16 (57)
0
0
1.78 (0.71)
2.67 (1.0)
4 (14)
15 (53)
4 (14)

1 (3)
19 (63)
9 (30)
1 (4)
0
1.98 (0.54)
2.42 (0.50)
0 (0)
8 (26)
1 (3)

9 (32)
20 (71)

10 (36)
19 (68)

9 (30)
15 (50)

0.70
0.20

21 (75)
2 (7)
1 (4)
4 (14)
0 (0)
4.52 (1.91)
5 (18)
1.6 (0.6)
28 (100)
1 (4)
4.1 (1.5)

21 (75)
2 (7)
4 (14)
1 (4)
0 (0)
4.91 (1.62)
5 (18)
1.2 (0.5)
28 (100)
1 (4)
3.8 (1.3)

20 (67)
4 (1)
2 (7)
2 (7)
2 (7)
4.95 (1.77)
4 (13)
1.3 (0.5)
30 (100)
1 (3)
3.3 (0.9)

0.61

0.03*
0.40

0.10

0.15

0.11
0.24
0.06
0.05*
0.12

BMI, body mass index; ASA, American Society of Anesthesiologists classification of comorbidity; FEV1 , forced expiratory volume in 1 second, FVC, forced
vital capacity; COPD, chronic obstructive pulmonary disease; colorectal surgery, hemicolectomy, Hartmanns, transverse colectomy, proctocolectomy, anterior
resections, abdominoperineal resection and small bowel resection; ICU/HDU, intensive care unit/high dependency unit; PCA, patient-controlled analgesia;
VAS, visual analogue scale; SD, standard deviation.
* p value 0.05.

who remained intubated after surgery were admitted to the

intensive care unit (ICU) or high dependency unit (HDU) at
the discretion of the anaesthetists or surgeons. The numbers of
patients admitted to ICU and HDU was comparable between
the three groups. The majority of the intubated patients were
extubated the day after surgery and discharged to the ward.
There was a significant difference in the number of days spent
in ICU/HDU between the groups (P = 0.030). However, this
significant difference only occurred between Groups B and
C (P = 0.013), as Group B spent 1 day longer in ICU which
was not clinically significant.

There was no significant difference in PPCs between the

groups (Table 4). Clinically significant PPCs were often
diagnosed on the first postoperative day. However, PPCs
developed in one patient on the second postoperative day,
four patients on the third postoperative day and one patient
on the fifth postoperative day. Except for two patients, PPCs
that developed after the second postoperative day tended to
develop as secondary consequences of being unwell from
postoperative complications such as an anastomotic leak,
confusion, cardiac problems, pulmonary oedema and gastrointestinal problems.

Table 4
Incidence of postoperative pulmonary complications.
Group A
Early mobility
(n = 28)

Group B
Early mobility
plus deep
breathing
(n = 28)

Group C
Delayed
mobility plus
deep breathing
(n = 30)

P-value

6 (21%)

7 (25%)

3 (10%)

0.20

CI, confidence interval.

Groups A and B

Groups B and C

Groups A and C

Absolute risk
reduction
(95% CI)

P-value

Absolute risk
reduction
(95% CI)

P-value

Absolute risk
reduction
(95% CI)

P-value

4%
(6 to 2)

0.6

14%
(12 to 16)

0.07

10%
(8 to 12)

0.21

Table 5
Results of postoperative outcomes for distance mobilised on third and fifth postoperative days, number of days until discharge from physiotherapy, length of stay, treatment duration and number of physiotherapy
treatments.
Group B
Early mobility
plus deep
breathing

Group C
Delayed
mobility plus
deep breathing

Mean (SD)

Mean (SD)

Mean (SD)

111.7 (96.5)

105.6 (81.2)

72.6 (70.5)

118.9 (54.5)

104.0 (65.3)

5.4 (2.2)
10.7 (5.0)
1.9 (1.0)
5.2 (2.1)

P-value

Groups A and B

Groups B and C

Groups A and C

Mean difference
(95% CI)

P-value

Mean difference
(95% CI)

P-value

Mean difference
(95% CI)

P-value

0.19

6.1 (44.5 to 56.7)

0.80

33.0 (44.5 to 56.7)

0.12

39.11 (8.1 to 86.3)

0.10

97.6 (61.1)

0.60

14.9 (31.1 to 61.0)

0.51

6.38 (36.8 to 49.6)

0.8

21.3 (19.8 to 62.5)

0.3

7.6 (7.2)

8.3 (8.2)

0.24

2.2 (5.2 to 0.7)

0.14

0.7 (6.3 to 0.4)

0.09

2.9 (5.2 to 0.7)

0.09

16.7 (9.7)
2.8 (2.0)
7.2 (5.0)

15.2 (9.8)
2.2 (1.6)
6.8 (4.6)

0.036*
0.10
0.17

5.9 (10.2 to 1.7)

0.9 (1.8 to 0.6)
2.0 (4.2 to 0.1)

0.008*
0.037*
0.61

1.5 (3.9 to 7.0)

0.7 (0.3 to 1.7)
0.4 (2.24 to 3.1)

0.57
0.18
0.75

4.4 (8.8 to 0.3)

0.3 (1.0 to 0.5)
1.6 (3.6 to 0.4)

0.049*
0.50
0.11

Y.R. Silva et al. / Physiotherapy 99 (2013) 187193

Distance mobilised on third

postoperative day (m)
Distance mobilised on fifth
postoperative day (m)
Number of days until discharge
from physiotherapy
Length of stay (number of days)
Treatment duration (hours)
Number of physiotherapy
treatments

Group A
Early mobility

SD, standard deviation; CI, confidence interval.

* p value 0.05.

191

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Y.R. Silva et al. / Physiotherapy 99 (2013) 187193

There was no significant difference in the distances

mobilised on the third and fifth postoperative day, or the number of days until discharge from physiotherapy between the
three groups (Table 5). However, the distances mobilised by
Group C on the third and fifth postoperative days were less
than those for the other groups. For the first three postoperative days, patients did not mobilise with relatives. Nurses
usually walked patients from all three groups very short
distances to promote independence of activities of daily living (toileting or showering), as per normal practice at the
hospital.
The number of days until discharge from physiotherapy was not significantly different between the three groups
(Table 5). Group A had a significantly lower LOS than the
other two groups (P = 0.036).
There was no significant difference in the total duration or
the frequency of physiotherapy treatments between the three
groups. However, Group B had a significantly longer total
duration of physiotherapy treatment (P = 0.037) compared
with Group A (Table 5).
Seven patients were re-referred to physiotherapy (two
from Groups A and B and three from Group C) due
to deconditioning caused by other postoperative medical
complications such as emphyema, low albumin and gastrointestinal problems that occurred after discharge from
physiotherapy. One patient in each group died due to postoperative complications. The trend observed did not show any
differences in the LOS between the groups.

Discussion
The primary aim of this research was to determine whether
the addition of deep breathing exercises to physiotherapydirected early mobilisation of high-risk patients undergoing
elective open upper abdominal surgery would further reduce
PPCs compared with mobility alone. Treatment was given
once daily post surgery until discharge from physiotherapy. A
group of Australian cardiopulmonary physiotherapists previously indicated that, for a therapy to be clinically worthwhile,
one PPC should be prevented in every 20 treatments [15]. This
corresponds to an absolute risk reduction of PPCs between
interventions of 5%. In the current study, Group B had more
PPCs due to the greater number of smokers and patients with
COPD compared with Group A. However, the increase in
PPCs for Group B was not significant. As such, it appears
that the addition of breathing exercises to early mobilisation
is not essential for all patients following elective open upper
abdominal surgery. This finding supports previous research
[5].
When patients are moved from a supine position to an
upright position, there is a significant increase in minute ventilation [4]. However, ambulation did not appear to increase
minute ventilation significantly once the effect of position was taken into consideration. It could be assumed that
patients are not being exercised at a sufficiently high intensity.

However, in this study, patients were mobilised to a moderate level of intensity to challenge the respiratory system. A
systematic review reported that no physiotherapy technique
is superior to others in reducing PPCs, and combined modalities did not lead to additional risk reduction [3]. Therefore,
mobility alone, to a moderate level of exertion, may have
provided adequate prophylaxis to reduce PPCs. The addition
of deep breathing exercises did not further reduce prophylaxis for the development of PPCs compared with mobility
alone.
The total physiotherapy time was significantly greater in
Group B, given the breathing exercises they performed and as
a result of PPCs they developed, compared with Group A. A
study has shown that patients with PPCs tend to mobilise less
than patients without PPCs [13]. Therefore, physiotherapist
may have spent more time with these patients.
This study also compared postoperative outcomes following early and delayed mobilisation. Group C had significantly
fewer smokers and patients with COPD compared with Group
B, leading to fewer PPCs. However, it was surprising that the
total distances mobilised by Group C were less than those
for the other groups. Also, the total physiotherapy treatment
time and number of days until discharge from physiotherapy was similar to Group B. The role of the physiotherapist
in mobilising patients can be somewhat controversial. At
this hospital, mobilisation is performed by both physiotherapists and nurses. Data demonstrated that patients were only
mobilised short distances by nurses. Physiotherapists tend
to increase walking intensity within a structured, graduated
exercise programme to challenge the patients cardiopulmonary system, promoting rapid return of physical fitness
and normal pulmonary function. A sudden increase in pace
to a moderate level of exertion for the first time on the
third postoperative day may have resulted in Group C having a shorter mean mobility distance. After surgery, many
patients experience a high level of dependency [16] due to
postoperative fatigue, described as sleeping more due to
tiredness [17]. Therefore, when mobilised from the third postoperative day onwards, the physiotherapist may have spent
more time with these patients in an attempt to achieve the
hospital abdominal surgery indicator (discharged from physiotherapy by the fifth postoperative day with a clear chest
on auscultation and able to mobilise 100 m independently)
[8].
The greater number of PPCs in Group B and delayed
physiotherapy-directed mobility in Group C may have contributed to the significantly shorter LOS in Group A. LOS
can be affected by many barriers to discahrge such as PPCs
and learning to use colostomy bag. While physiotherapy may
not have a direct effect on LOS, it allows comparison with
previous studies on abdominal surgery. The LOS in this study
was comparable to other studies [5,18].
This study had several limitations:
(1) Patient numbers were small compared with previous
studies, despite the sample size calculation showing

Y.R. Silva et al. / Physiotherapy 99 (2013) 187193

(2)

(3)

(4)
(5)

that patient numbers were adequate. Only those patients

who would gain the greatest benefit from physiotherapy treatment were selected for inclusion. This increased
the possibility of detecting any treatment effect from
the techniques used, thus increasing the power of the
study.
With cluster randomisation, it is unclear whether there
was some contamination with patients undergoing
surgery at the end of the week and those undergoing
surgery at the beginning of the following week.
Despite being blinded to patient allocation, medical and
nursing staff may have encouraged deep breathing exercises because these exercises are routine in postoperative
management.
Patient adherence to deep breathing exercises and length
of time sat out of bed were not measured.
The assessor was not involved in group allocation or
treatment of the study patients. However, the group allocation would have been evident during data collection
(post discharge).

Conclusions
Mobility alone can reduce PPCs in high risk patients following elective open upper abdominal surgery without the
addition of deep breathing exercises. Reduction in PPCs can
be achieved when patients are treated once daily if mobilised
to a moderate level of exertion. This is cost beneficial and
allows allocation of physiotherapy to patients with PPCs
to be commenced on breathing and other physiotherapy
techniques. Early mobilisation may improve postoperative
outcomes compared with delayed mobilisation. However, the
authors believe that delaying physiotherapy-directed mobilisation until the third postoperative day may not result in
clinically significant differences compared with mobilisation on the first postoperative day. If patients are unable to
mobilise during the initial stages after surgery, it may be
important to continue breathing exercises until they are able
to mobilise.
Acknowledgements
The authors wish to thank the Physiotherapy Department
of Concord Repatriation General Hospital, NSW, Australia
for their assistance in conducting this investigation.
Ethical approval: Human Research Ethics Committee of
Concord Repatriation General Hospital, Sydney, Australia
(CH62/6/2005-023-Y Silva).
Conflict of interest: None declared.

193

Appendix A. Supplementary data

Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.physio.2012.09.006.
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