From randomised trial to national implementation: employment outcomes from individual placement and support in english alcohol and drug treatment services.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of pulmonary embolism characterised by unresolving thromboembolic pulmonary vascular emboli persisting despite medical therapy []. This leads to an increase in pulmonary arterial pressure (PAP). CTEPH is associated with progressive right ventricular dysfunction, leading to reduced exercise tolerance and quality of life, and when untreated, can lead to heart failure and death []. There are limited studies investigating the epidemiology of CTEPH, with an estimated incidence rate ∼2–6% and a prevalence of 26–38 cases per million [, ]. Pulmonary endarterectomy (PEA) is considered to be a curative procedure for patients with CTEPH and remains the gold standard treatment for surgical candidates [, ]. However, there is no consensus in the existing literature as to what constitutes operable disease, with different thresholds for surgery internationally []. Such variations may result in heterogeneous patient cohorts across countries and could influence post-operative outcomes. Many peri-operative complications in patients undergoing PEA are similar to those observed in general cardiac surgery [, ]. However, PEA is also associated with some procedure-specific complications. The most common of these is reperfusion injury, due to high permeability of the pulmonary vasculature which results in oedema accumulating in the airways causing hypoxia []. Reperfusion injury typically occurs within 48 h post-surgery and can often be managed with supplemental oxygen; in severe cases, extracorporeal membrane oxygenation may be required []. It is essential to recognise these factors, as they significantly influence post-operative recovery and affect patient outcomes, including exercise tolerance and quality of life. Physiotherapy plays a critical role in the recovery pathway for patients undergoing PEA surgery for CTEPH. Physiotherapists support early mobilisation, which improves later-stage recovery outcomes. Many surgical specialties use enhanced recovery pathways after surgery, which are evidence-based and patient-centred approaches designed to improve outcomes, decrease costs, reduce post-operative complications and shorten hospital length of stay []. One crucial component of an enhanced recovery pathway is early mobilisation and exercise, which has been shown in general and thoracic surgery to counteract the adverse physiological consequences of immobility and surgical stress []. Exercise training in patients with pulmonary hypertension has been shown to improve exercise capacity and quality of life. Evidence from supervised exercise interventions indicates that such programmes are feasible, safe, and can enhance exercise tolerance, ventilatory efficiency, muscle strength and quality of life, with a low incidence of adverse events when appropriately monitored []. However, in patients recovering from PEA, there is currently no published consensus on safe or optimal exercise parameters in the early post-operative period [].