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Sternal Precautions

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by

Lisa Boester

on 10 December 2013

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Transcript of Sternal Precautions

Optimize return to functional activities, prevent progression of disability, and facilitate appropriate levels of physical activity
1. AAROM ankle/wrists 5x10 bed inclined at 45
2. AAROM in sitting
flex/ext shldr, elbow, wrist, ankle; ABD/ADD hips 2x15 & amb 5 min
3. Active #2 3x15, amb 5 mins
4. #3 and amb 10 min
5. #3 in standing & amb 10 mins & 4 steps
References
Forces on the Sternum
Pushing up from chair in sit>stand caused greatest sternal separation
Reaching arms overhead caused least separation
Some of the greatest forces occur with opening and closing doors
Many ADLs require 12.5 lb or more of force
Performing tasks at slower than normal speeds reduces the peak force that occurs
Typical Precautions
Restrict weight during UE lifting to 5-8 lbs
No unilateral UE pushing/pulling
Avoid abduction or flexion > 90 degrees
No reaching behind with arms
Avoid driving
No pushing up with arms during transfers
Sternal Precautions
Force of Coughing
Coughing is encouraged, but how much force does it place on the sternum?
Loaded arm movements
LaPier TK, et al. Analysis of activities of daily living performance in patients recovering from coronary artery bypass surgery. Physical & Occupational Therapy in Geriatrics. 2008; 27(1): 16-35.
Irion FL, Gamble J, Harmon C, Jones E, Vaccarella A. Effects of upper extremity movements on sternal skin stress. JACPT. 2013; 4(1): 34-40.
Parker R, et al. Current activity guidelines for CABG patients are too restrictive: comparison of the forces exerted on the median sternotomy during a cough vs lifting activities combined with Valsalva Maneuver. Thorac Cardiov Surg. 2008; 56: 190-194.
Brocki BC, Thorup CB, Andreasen JJ. Precautions related to midline sternotomy in cardiac surgery: a review of mechanical stress factors leading to sternal precautions. Eur J Cardiovasc Nurs. 2010; 9(77): 78-82.
Variations of SP
Avoid elbows higher than shoulders
May move arms in a pain-free range
Limit ROM if patient feels pulling on incision or has mild pain with motion
Water immersion (more than 2 wks)
No activities involving vigorous UE/trunk rotation (more than 3 mos)
Advise patient to not sit behind air bags in cars

Compared 5 typically contraindicated ADLs to coughing:
5lb wgt
milk to counter
20lb suitcase
2x20lb wgts
25lb grandchild
Coughing exerted largest mean total force on the sternotomy at 27.5kg = 60.5 lbs
Mendes RG, et al. Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery – a randomized controlled trial. Disability and Rehabilitation. 2010; 32(16): 1320-1327.
Tuyl LJ, Mackney JH, Johnston CL. Management of sternal precautions following median sternotomy by physical therapists in Australia: a web-based survey. Physical Therapy. 2012; 92(1): 83-97.
Cahalin LP, LaPier TK, Shaw DK. Sternal precautions: is it time for change? Precautions versus restrictions – a review of literature and recommendations for revision. Cardiopulmonary Physical Therapy Journal. 2011; 22(1): 5-15.
LaPier RK, Schenk R. Thoracic musculoskeletal considerations following open heart surgery. Cardiopulmonary Physical Therapy Journal. 2002; 13(2): 16-20.
Swanson L, LaPier T, Chatellier M. Upper extremity forces generated during activities of daily living: pilot data and implications for patients following sternotomy. Cardiopulmonary Physical Therapy Journal. 2012; 23(4): 41-42.

Patient risk factors
Sternal dehiscence is multifactorial
Optimal degree and duration of activity restriction should be based on patient’s characteristics
Progression of activity should be based on patient characteristics
Common risk factors: COPD, macromastia, obesity, suboptimal sternal closure, early surgical chest reoperation, prolonged postop vent, and premature overexertion
Six mechanisms that may provoke sternal dehiscence, instability, and incisional pain
Frequent coughing
places significant strain on sternal closure site
Patients should cross their arms in a “self-hugging” posture while turning or sitting up
to take stress off sternal incision line
(case series)
Obesity
(expert opinion)
create constant peak force equal to that of coughing
sternal reinforcement of patient with a BMI >35 during 6-8 wks postop
(expert opinion)
Movements with elbows kept close to thorax do not cause excessive strain on sternum and should be allowed, regardless of workload
Sternal strain highest when moving both arms sideways or upwards
Bilateral movements
of arms
(case series)
Directions of horizontal level, backwards, and overhead should be in pain-free limits until wound is healed within first 10 days
Well-endowed women
(cohort)
Pain and wound complications are reduced with use of supportive bra
Recruit abdominal muscles during supine to sit
(expert opinion)
Poor technique is use of both arms and simultaneous activation of abdominals
Use elbow method with log rolling
Consequences of restrictive SP
physiological decline during a time that they need to gain strength
Restrictive guidelines
Reinforce patient’s fear of injuring themselves
inactivity
No scientific evidence
to support weight limitation regarding activity as long as the arms are kept close to the body and activity is within a pain-free range
Conclusions of previous literature search on SP were
inconclusive

No direct evidence
linking activity level or arm movement to increased risk for complications
Very little literature available
to either support or refute the usefulness of SP
Evidence
"In my practice many people who do not follow sternal precautions ended with wound dehiscence and non union" -KG
Professional Opinion
Not necessarily a risk of having sternum pop open, but more that the motions cause pain and with that, typically inflammation. If SP prevent this, then they promote healing. -KL
Post polio patient- would not be able to follow SP; patient was able to lift himself within days of surgery and had no problem -Ken L
Illogical and too restrictive
Incidence of postop complications (sternal dehiscence, infection, sternal instability) is reported to be 1-5%
Based only on proposed
theoretical rationale
Exercises that can be done
Protocol
Perform 3 breathing and coughing exercises qh awake (40 deep breaths 4x10 c 5 sec hold followed by coughs)
Program significantly improved cardiac autonomic function assessed by heart rate variability in patients after CABG at D/C
UE exs during recovery process provide benefits: enhance circulation of chest wall mm and shoulder girdle
BUEs produces symmetrical loads on the sternum, which may be beneficial for sternal healing rather than unilateral which causes shearing forces on sternum
-Important to prevent general physiological decline
(each one is POD #)
Force of a cough > lifting 40lb weights
SP
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