Initiatives to Improve Early Mobilization after Cardiac Surgery: Interim results of the T-REX Twente randomized trial

Nicole Wielens; Kim Roerdink; Winston Lynch; Lauren Esau (Park); F.R. Halfwerk

Abstract

INTRODUCTION / PURPOSE
Sternotomy remains the standard access route for cardiac surgery. Consensus and evidence is lacking regarding post-operative mobilization activities and sternal precautions. The 2024 ERAS Cardiac statement recommends “early
postoperative ambulation” without specifications. The aim of this randomized controlled trial is to investigate whether T-REX Twente sternal precautions impact the modified Quality of Life after Myocardial Infarction questionnaire (MacNew, QLMI-2), and physical activity in patients after full median sternotomy, compared to standard restrictive measures.
MATERIALS AND METHOD
: Adult patients receiving cardiac surgery with full sternotomy were included. Interim analysis was planned after 60/154 recruited patients, and includes patients from June 2024 to February 2025. After applying predefined exclusion criteria
(NCT06115759), 28 patients in the usual care group and 27 patients receiving T-REX Twente guidelines were analysed. T-REX Twente patients keep their elbows at their sides (the "cylinder model") and are allowed to push, lift, and pull based on pain tolerance. Primary endpoints are QLMI-2 score development preoperatively (T0), postoperative day 4 (T2) and cardiac rehabilitation intake after 4 weeks (T4) analysed with linear mixed model, and physical activity increase as determined with accelerometer (not in interim analysis). Secondary endpoints include numerical pain rating scale (NPRS) and Tampa scale for kinesiophobia (TSK-13) changes.
FINDINGS
Quality of life (QLMI-2) increased after surgery (p < 0.001) without additional increase in the T-REX Twente group (p=0.28, Figure 1). Pain as measured with NPRS decreased postoperatively (p < 0.001), without increase in T-REX Twente group (p=0.94, Figure 2). Last, kinesiophobia measured by TSK was lower after surgery (p < 0.001) without differences between groups (p=0.44, Figure 3). Findings are described in Table 1.
DISCUSSION / CONCLUSION
This planned interim analysis of the T-REX Twente trial shows safety of less restrictive sternal precautions, without changes in quality of life, pain or kinesiophobia. Full interpretation and potential benefits should be assessed after trial completion.

Original language	English
Pages	87-88
Number of pages	2
Publication status	Published - 18 Sept 2025
Event	Joint International Meeting on Enhanced Recovery after Surgery, ERAS 2025 - Renaissance Polat Istanbul Hotel, Istanbul, Turkey Duration: 18 Sept 2025 → 20 Sept 2025 https://erasistanbul2025.com/

Conference

Conference	Joint International Meeting on Enhanced Recovery after Surgery, ERAS 2025
Abbreviated title	ERAS 2025
Country/Territory	Turkey
City	Istanbul
Period	18/09/25 → 20/09/25
Internet address	https://erasistanbul2025.com/

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A randomized controlled study on the effects of the T-REX Twente (Thoracic Surgical Rehabilitation Experts Twente) sternal precautions on quality of life and physical activity levels in cardiac surgery patients, compared to standard care in patients following a median sternotomy: The study protocol
Wielens, N., Roerdink, K., Lynch, W., Esau, L., van der Palen, J. & Halfwerk, F. R., 8 Dec 2025, Research Square Publications, 28 p.
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De zorg in beweging - Onderzoek aan beweging (Frank Halfwerk)
Translated title of the contribution: Healthcare in motion - Research into movement (Frank Halfwerk)Halfwerk, F. R. & van der Steen, S. (Producer), 20 Oct 2025
Research output: Non-textual form › Digital or Visual Products › Professional

Open Access
A mobilization poster stimulates early in-hospital rehabilitation after cardiac surgery: a prospective sequential-group study
Halfwerk, F. R. (Corresponding Author), Wielens, N., Hulskotte, S., Brusse-Keizer, M. & Grandjean, J. G., Dec 2023, In: Journal of Cardiothoracic Surgery. 18, 1, p. 1-11 11 p., 83.
Research output: Contribution to journal › Article › Academic › peer-review

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Cite this

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title = "Initiatives to Improve Early Mobilization after Cardiac Surgery: Interim results of the T-REX Twente randomized trial",

abstract = "INTRODUCTION / PURPOSE Sternotomy remains the standard access route for cardiac surgery. Consensus and evidence is lacking regarding post-operative mobilization activities and sternal precautions. The 2024 ERAS Cardiac statement recommends “early postoperative ambulation” without specifications. The aim of this randomized controlled trial is to investigate whether T-REX Twente sternal precautions impact the modified Quality of Life after Myocardial Infarction questionnaire (MacNew, QLMI-2), and physical activity in patients after full median sternotomy, compared to standard restrictive measures. MATERIALS AND METHOD : Adult patients receiving cardiac surgery with full sternotomy were included. Interim analysis was planned after 60/154 recruited patients, and includes patients from June 2024 to February 2025. After applying predefined exclusion criteria (NCT06115759), 28 patients in the usual care group and 27 patients receiving T-REX Twente guidelines were analysed. T-REX Twente patients keep their elbows at their sides (the {"}cylinder model{"}) and are allowed to push, lift, and pull based on pain tolerance. Primary endpoints are QLMI-2 score development preoperatively (T0), postoperative day 4 (T2) and cardiac rehabilitation intake after 4 weeks (T4) analysed with linear mixed model, and physical activity increase as determined with accelerometer (not in interim analysis). Secondary endpoints include numerical pain rating scale (NPRS) and Tampa scale for kinesiophobia (TSK-13) changes. FINDINGS Quality of life (QLMI-2) increased after surgery (p < 0.001) without additional increase in the T-REX Twente group (p=0.28, Figure 1). Pain as measured with NPRS decreased postoperatively (p < 0.001), without increase in T-REX Twente group (p=0.94, Figure 2). Last, kinesiophobia measured by TSK was lower after surgery (p < 0.001) without differences between groups (p=0.44, Figure 3). Findings are described in Table 1. DISCUSSION / CONCLUSION This planned interim analysis of the T-REX Twente trial shows safety of less restrictive sternal precautions, without changes in quality of life, pain or kinesiophobia. Full interpretation and potential benefits should be assessed after trial completion.",

author = "Nicole Wielens and Kim Roerdink and Winston Lynch and \{Esau (Park)\}, Lauren and F.R. Halfwerk",

year = "2025",

month = sep,

day = "18",

language = "English",

pages = "87--88",

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T1 - Initiatives to Improve Early Mobilization after Cardiac Surgery

T2 - Joint International Meeting on Enhanced Recovery after Surgery, ERAS 2025

AU - Wielens, Nicole

AU - Roerdink, Kim

AU - Lynch, Winston

AU - Esau (Park), Lauren

AU - Halfwerk, F.R.

PY - 2025/9/18

Y1 - 2025/9/18

N2 - INTRODUCTION / PURPOSE Sternotomy remains the standard access route for cardiac surgery. Consensus and evidence is lacking regarding post-operative mobilization activities and sternal precautions. The 2024 ERAS Cardiac statement recommends “early postoperative ambulation” without specifications. The aim of this randomized controlled trial is to investigate whether T-REX Twente sternal precautions impact the modified Quality of Life after Myocardial Infarction questionnaire (MacNew, QLMI-2), and physical activity in patients after full median sternotomy, compared to standard restrictive measures. MATERIALS AND METHOD : Adult patients receiving cardiac surgery with full sternotomy were included. Interim analysis was planned after 60/154 recruited patients, and includes patients from June 2024 to February 2025. After applying predefined exclusion criteria (NCT06115759), 28 patients in the usual care group and 27 patients receiving T-REX Twente guidelines were analysed. T-REX Twente patients keep their elbows at their sides (the "cylinder model") and are allowed to push, lift, and pull based on pain tolerance. Primary endpoints are QLMI-2 score development preoperatively (T0), postoperative day 4 (T2) and cardiac rehabilitation intake after 4 weeks (T4) analysed with linear mixed model, and physical activity increase as determined with accelerometer (not in interim analysis). Secondary endpoints include numerical pain rating scale (NPRS) and Tampa scale for kinesiophobia (TSK-13) changes. FINDINGS Quality of life (QLMI-2) increased after surgery (p < 0.001) without additional increase in the T-REX Twente group (p=0.28, Figure 1). Pain as measured with NPRS decreased postoperatively (p < 0.001), without increase in T-REX Twente group (p=0.94, Figure 2). Last, kinesiophobia measured by TSK was lower after surgery (p < 0.001) without differences between groups (p=0.44, Figure 3). Findings are described in Table 1. DISCUSSION / CONCLUSION This planned interim analysis of the T-REX Twente trial shows safety of less restrictive sternal precautions, without changes in quality of life, pain or kinesiophobia. Full interpretation and potential benefits should be assessed after trial completion.

AB - INTRODUCTION / PURPOSE Sternotomy remains the standard access route for cardiac surgery. Consensus and evidence is lacking regarding post-operative mobilization activities and sternal precautions. The 2024 ERAS Cardiac statement recommends “early postoperative ambulation” without specifications. The aim of this randomized controlled trial is to investigate whether T-REX Twente sternal precautions impact the modified Quality of Life after Myocardial Infarction questionnaire (MacNew, QLMI-2), and physical activity in patients after full median sternotomy, compared to standard restrictive measures. MATERIALS AND METHOD : Adult patients receiving cardiac surgery with full sternotomy were included. Interim analysis was planned after 60/154 recruited patients, and includes patients from June 2024 to February 2025. After applying predefined exclusion criteria (NCT06115759), 28 patients in the usual care group and 27 patients receiving T-REX Twente guidelines were analysed. T-REX Twente patients keep their elbows at their sides (the "cylinder model") and are allowed to push, lift, and pull based on pain tolerance. Primary endpoints are QLMI-2 score development preoperatively (T0), postoperative day 4 (T2) and cardiac rehabilitation intake after 4 weeks (T4) analysed with linear mixed model, and physical activity increase as determined with accelerometer (not in interim analysis). Secondary endpoints include numerical pain rating scale (NPRS) and Tampa scale for kinesiophobia (TSK-13) changes. FINDINGS Quality of life (QLMI-2) increased after surgery (p < 0.001) without additional increase in the T-REX Twente group (p=0.28, Figure 1). Pain as measured with NPRS decreased postoperatively (p < 0.001), without increase in T-REX Twente group (p=0.94, Figure 2). Last, kinesiophobia measured by TSK was lower after surgery (p < 0.001) without differences between groups (p=0.44, Figure 3). Findings are described in Table 1. DISCUSSION / CONCLUSION This planned interim analysis of the T-REX Twente trial shows safety of less restrictive sternal precautions, without changes in quality of life, pain or kinesiophobia. Full interpretation and potential benefits should be assessed after trial completion.

M3 - Abstract

SP - 87

EP - 88

Y2 - 18 September 2025 through 20 September 2025

ER -

Initiatives to Improve Early Mobilization after Cardiac Surgery: Interim results of the T-REX Twente randomized trial

Abstract

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Research output

A randomized controlled study on the effects of the T-REX Twente (Thoracic Surgical Rehabilitation Experts Twente) sternal precautions on quality of life and physical activity levels in cardiac surgery patients, compared to standard care in patients following a median sternotomy: The study protocol

De zorg in beweging - Onderzoek aan beweging (Frank Halfwerk)

A mobilization poster stimulates early in-hospital rehabilitation after cardiac surgery: a prospective sequential-group study

Cite this