sternal precautions

1

Sternal Precautions – What

Do They Mean?

Lawrence P. Cahalin PT, PhD, CCS, FAACVPR

Northeastern University

Tanya Kinney LaPier PT, PhD, CCS

Eastern Washington University

Donald K. Shaw PT, PhD, FAACVPR

Midwestern University

STERNAL PRECAUTIONS

WHAT DO THEY MEAN?

PART 1

http://dictionary.reference.com/browse/Sternotomy

Caduceus072

New Stamp

2

DEFINITION

Sternotomy:

ster·not·o·my (stər-nŏt'ə-mē)n.

“surgical incision through the sternum”

PRECAUTIONS

STERNAL

A CONTENTIOUS TOPIC

Therapists – Physicians

Therapists – Nurses

Therapists – Patients

Therapists – Therapists

http://dictionary.reference.com/browse/Sternotomy

3

Shoulder Flexion

“No more than 90 degrees

post-MI”

NO!

IS ANYONE CONFUSED?

OPINIONS VARY

OhioHealth¹

The Ohio State Medical Center² Cleveland Clinic³

MOVEMENT AT THE

SHOULDER

Do not raise your elbows higher

than your shoulders

You may move your arms within a pain

free range

It is okay to perform activities above shoulder level

LIFTING

Do not lift greater than 5 to 10

pounds with your affected arm (for

4 weeks)

Do not lift more than 10 pounds for the 6 weeks after

your surgery

Do not lift objects greater than 20

pounds for first 6-8 weeks following

surgery

REACHING

Do not reach behind you when

dressing your upper body

Avoid reaching backwards

Not mentioned

¹http://www.ohiohealth.com/documents/orb/Sternal%20precautions.pdf

²http://medicalcenter.osu.edu/PatientEd/Materials/PDFDocs/surgery/activity-after-chest-surgery.pdf

³http://my.clevelandclinic.org/heart/disorders/recovery_ohs.aspx

4

OVERVIEW OF

SURGICAL PROCEDURE

Traditional

approach: median

sternotomy

Minimally invasive

approach: partial

upper sternotomy

Minimally invasive

approach: small

right thoracotomy

Sternal PrecautionsLiterature Review

Tanya LaPier, PT, PhD, CCS

Distinguished Professor

Physical Therapy

5

Post-surgical Complications

Myocardial injury

Blood loss

Superficial incisional infections

Atrial fibrillation

Pneumonia

Memory / cognitive impairment

Subxiphoid incisional hernias

Brachial plexus injury

Complications Associated with Cardiopulmonary Bypass Machine

Immediate surgical outcomes

Atrial fibrillation

Cognition / memory

– Systemic inflammation

– Cerebral hypoperfusion

– Atheromatous debris

– Microemboli

Platelet aggregates

RBC fragments

Air bubbles

Sternal instability / dehiscence / mediastinitis

Definition

Incidence of 0.4 – 5%

Mortality rate of 14 – 47 %

4 year survival rate = 65% (vs. 89%)

6

Sternal instability / dehiscence / mediastinitis: Risk Factors

Obesity / ↑ BMI

COPD

Bilat. IMA grafting

Diabetes

Rethoracotomy

CCS / NYHA class

# transfused units

Smoking

Prolonged CPB / Sx time

Prolonged mechanical ventilation

Post-operative activity level /

arm movements not cited

Larger ♀ breast size

Longer ICU LOS

Time of surgery

PVD

Antibiotic >2 hours pre-sx

Staple use for skin closure

Sternal instability / dehiscence / mediastinitis: Risk Factors-Other

Sternal instability / dehiscence / mediastinitis: Treatment

Surgical debridement / reclosure / lavage

Flap repair

Omentum

Muscle (pectoralis major, rectus abdominis…)

Vacuum-assisted closure therapy

Trunk stabilization exercises

El-Ansary D, Aust J Physiother 2007;53:255-260

7

Activity Restrictions“Sternal Precautions”

Median sternotomy precautions for 6-12 wks

No lifting, pushing, or pulling > 10 lbs

No driving

Avoid (unilateral) shoulder abd / flex > 90 degrees

Ambulatory assistive device use variable

Cough with splinting

What do we actually know about sternal precautions?

… Not very much

Anecdotal / expert opinion

RCT obstacles

Cadaver studies / material engineering approach

Indirect evidence

Patients with chronic sternal instability

Supra-sternal skin movement

Patients with chronic sternal instability (El-

Ansary D, Ann Thor Surg 2007;83:1513-7)

ConditionSternal

Separation Difference

Rest (seated, arms at side) 15.4

Elevation of both arms 16.6 1.2

Resisted elbow flexion task 17.3 1.9

Pushing up from chair 17.4 2

Shoulder protraction 14.3 -1.2

Shoulder retraction 17.1 1.7

*measurements in mm

8

Patients with chronic sternal instability(El-Ansary D, Aust J Physiother 2007;53:255-60)

Condition Pain VAS (90-100)

Rotating trunk 45

Swinging arms 34

Side lying 40

Driving 28

Sitting to standing 38

Supine lying to sitting 51

Suddenly losing footing 53

Coughing 46

Reaching above shoulder height

31

Supra-sternal skin movement(Irion G, et al. Acute Care Perspectives 2007;3:1-5)

Condition Skin Mvt(Microvolts)

Lifting 12 oz container 180

Lifting 1 L container 225

Lifting 1 gal container 250

Supine long sitting (push up)

360

Supine short sit (log roll) 275

Sit standing (using arms) 380

Sit standing (without using arms)

310

Effects of Median Sternotomy

on PFT’s & Chest/Abdominal

Movement

Lawrence P. Cahalin PT, PhD, CCS


9

Restrictive Ventilatory Defect

Effects of Median Sternotomy on PFTs

& Chest/Abdominal Movement?

Locke TJ et al. Thorax 1990;45: 465-468

Before, 1 week, & 12 weeks after median sternotomy for CABG Surgery 16 men underwent measurement of:

Pulmonary Function - seated

Chest & Abdominal Motion - supine

Age range: 47-64 yrs (mean=54 yrs)

Good LVEF

11 patients were ex-smokers

2 had mild airway obstruction

Patients with FEV1/FVC < 60% were excluded


% Change from Pre-Op

-60

-50

-40

-30

-20

-10

0

10

20

30

40

MIP MEP Resp Rate

1 Week Post 12 Weeks Post


% Change in MIP, MEP, and RR from Pre-Op

10



-40

-35

-30

-25

-20

-15

-10

-5

0

FEV1 FVC Tidal Volume


% Change in Pulmonary Function from Pre-Op


-25

-20

-15

-10

-5

0

5

10

TLC FRC RV



% Change in Lung Volumes from Pre-Op


11


-100

-90

-80

-70

-60

-50

-40

-30

-20

-10

0

Sternal Angle Xiphoid Umbilicus Axillary (5th Rib)



% Change in Chest/Abdominal Motion from Pre-Op

Locke TJ et al. Thorax1990;45: 465-468*

*No mention made of Pre- and Post-Op breathing exercises

Ragnarsdottir M et al. Scand Cardiovasc J 2004;38: 46-52

Before and 1 week after median sternotomy for CABG Surgery & Valve Replacement 13 men and 7 women underwent measurement of: Pulmonary Function - seated

Chest & Abdominal Motion - supine

Mean Age = 65+17 yrs

13 patients were ex-smokers FEV1 & FVC = 88% predicted values

Patients were excluded if previous median sternotomy

Patients were provided breathing exercises

12


-30

-25

-20

-15

-10

-5

0

FEV1 FVC

1 Week Post



*Pre- and Post-Op breathing exercises provided


-60

-50

-40

-30

-20

-10

0

Upper Thoracic Lower Thoracic Umbilicus

1 Week Post


% Change in Chest/Abdominal Motion from Pre-Op*


Kristjansdottir A et al. Scand Cardiovasc J 2004;38:98-103

Before, 3 months, and 12 months after median sternotomy for CABG Surgery & Valve Replacement in same 13 men and 7 women underwent measurement of: Pulmonary Function - seated Chest & Abdominal Motion - supine

Mean Age = 65+17 yrs 13 patients were ex-smokers

FEV1 & FVC = 88% predicted values

Patients were excluded if previous median sternotomy

Patients were provided breathing exercises

13


-16

-14

-12

-10

-8

-6

-4

-2

0

FEV1 FVC

3 Months Post 12 Months Post





-30

-20

-10

0

10

20

30

Upper Thoracic Lower Thoracic Umbilicus

3 Months Post 12 Months Post


% Change in Chest/Abdominal Motion from Pre-Op*


Restrictive Ventilatory Defect

Summary of the Effects of Median

Sternotomy on PFTs &

Chest/Abdominal Movement:

Without:

A Clear Understanding of PT’s Role

With:

1) Altered PFT’s and Chest/Abdominal motion up to 1 year post-sternotomy

2) Worsening MIP 12 weeks after sternotomy

3) Worsening Residual Volume 12 weeks after sternotomy

14

STERNAL PRECAUTIONS

WHAT DO THEY MEAN?

PART 2

MEDIAN STERNOTOMY

HISTORY

1897 – Milton – first documented MS procedure Mediastinal cyst removed from a goat Did not enter pleural cavity Artificial respiration via tracheostomy Became known as “Milton’s Procedure”

(Milton H. Mediastinal Surgery, Lancet 1:872-875, 1897. )

1912 – Tuffier – used MS during surgery – aortic stenosis

1923 – Cutler – used MS during surgery – mitral stenosis

1944 – Blalock – performed first subclavian-to-pulmonary artery anastomosis

MEDIAN STERNOTOMY

HISTORY

1957 – Julian – popularized MS use in cardiac surgery General procedure allowed access to intrathoracic

organs Less pain and morbidity than bilateral anterior

thoracotomy

(Julian OC, Lopez-Belio M, Dye WS, Javid H, and Grove WJ. The Median Sternal Incision in Intracardiac Surgery with Extracorporeal Circulation: A General Evaluation of Its Use in Heart Surgery, Surgery 42:753-761, 1957. )

1960 – Goetz – first CABG surgery in United States No heart-lung machine employed LIMA procedure using metal ring Took “only 15 seconds”

(Haller JD, Olearchyk AS. Cardiology’s 10 Greatest Discoveries, Tex Heart Inst J 29 (4):342–344, 2002.)

http://images.google.com/imgres?imgurl=http://howstuffworks.files.wordpress.com/2009/05/goat.jpg&imgrefurl=http://blogs.howstuffworks.com/tag/wind-farms-kill-goats/&usg=__JM6nUoUdvdwCYPmYfdaRk9ELMfU=&h=360&w=360&sz=51&hl=en&start=38&um=1&tbnid=OQtr9FNk8unycM:&tbnh=121&tbnw=121&prev=/images%3Fq%3Dgoat%2Bsurgery%26ndsp%3D20%26hl%3Den%26rlz%3D1W1RNTN_en%26sa%3DN%26start%3D20%26um%3D1

15

CONCERNS ARISE

Sternal infections and dehiscence were reported in approximately 0.5-8.4% of cases

Sternal infections were associated with a mortality rate of between 14% and 50%

www.learningradiology.com/archives2007

www.mclean-academy-publications.co.uk

http://emedicine.medscape.com/article/1278627-overview

BACK OFF!

CONCERNS ARISE

Anecdotal reports of early traumatic sternal separations began to circulate within the medical community

Post-surgical upper extremity exercise was suspected as a possible cause for sternal dehiscence (never clearly proven or documented)

Sternal precautions now morph into accepted physical therapy practice

http://www.google.com/imgres?imgurl=http://zufar.blogs.friendster.com/photos/uncategorized/444814294_2c0fdf82f7_o.gif&imgrefurl=http://zufar.blog.friendster.com/&h=512&w=640&sz=24&tbnid=dtXkeNMqH2Zf4M:&tbnh=110&tbnw=137&prev=/images%3Fq%3Dyosemite%2Bsam&hl=en&usg=__8HOoOjm-jDYTLneXvwtmmtNlwxs=&ei=p8A_S_7DJZDysgPKwJDABA&sa=X&oi=image_result&resnum=1&ct=image&ved=0CAoQ9QEwAA



16

WHERE ARE WE TODAY?

STILL CONFLICTED

STILL CONFUSED

17

PERHAPS A VOICE OF

REASON…

First 5 to 8 weeks:

UE lifting ≤ 5-8 pounds

UE ROM exercise permissible unless there is:

…evidence of sternal instability manifesting as sternum movement, pain, cracking, or popping. Patients should be advised to limit ROM within the onset of feelings of pulling on the incision or mild pain.

(American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. Baltimore: Lippincott Williams & Wilkins; 2010; 216.)

Lawrence P. Cahalin PT, PhD, CCS


A Cardiothoracic SurgeonsPerspective on Sternal Precautions: Implications for Rehabilitation Professionals

Purpose

Discrepancy regarding optimal sternal precautions (SP) exists with many rehabilitation professionals (RP) uncertain about best practice to ensure patient safety and proper progression after a median sternotomy (MS).

Purpose Statement: The purpose of this study was to survey US cardiothoracic surgeons (CTS) about the SP that they provide to patients with a goal of developing universal SP to optimize patient function and decrease secondary impairments after a MS.

Cahalin LP et al. Chest 2009http://meeting.chestpubs.org/cgi/content/abstract/136/4/98S

18

Methods

A survey instrument consisting of 20 questions underwent extensive development and testing (2 pilot runs) prior to the administration of the survey to 1,000 CTS randomly taken from a convenience sample of 3,000 CTS who were members of the American College of Surgeons.

Survey was mailed with return postage rather than being electronically administered in hopes of a greater response rate.

A reminder postcard was sent 2 weeks after the initial mailing.

Sternal Precautions Survey

Age of Respondent__________ Years of Surgical Experience__________ Number of Sternotomies Performed Per Week____________ Most common reason for the Sternotomy and Surgery_________

What percentage of the surgical sternal procedure(s) listed below do you perform?

Median Sternotomy ____ Paramedian Sternotomy ____ Manubrium-Sparing Median Sternotomy ____ Inferior Sternotomy ____ Limited Sternotomy ____ Other _____________________________________

What percentage of the surgical sternal closure(s) listed below do you perform?

Figure-of-Eight Stainless-Steel Wires ____ Pectofix Dynamic Sternal Fixation ____ Figure-of-Eight Stainless-Steel Cables ____ Other _____________________________________

Having provided the percentages for the above sternotomy and closure technique(s) please circle the appropriate response for each of the following potential sternal precautions that are utilized in your practice with respect to the frequency (1 – 5) and duration (A –E). Please answer based on your response to the above two questions and the procedures representing the greatest percentage of your practice.

1A. Active shoulder flexion no greater than 90 degrees - BILATERAL1= Never 2= Rarely 3= Sometimes 4= Most Times 5=Always

A=2-4 Wks, B=5-8 Wks, C=9-12 Wks, D=13-16 Wks, E=> 16 Wks

1B. Active shoulder flexion no > 90 degrees – UNILATERAL1= Never 2= Rarely 3= Sometimes 4= Most Times 5=Always

A=2-4 Wks, B=5-8 Wks, C=9-12 Wks, D=13-16 Wks, E=> 16 Wks


19

2A. Active shoulder abduction no greater than 90 degrees –BILATERAL

2B. Active shoulder abduction no greater than 90 degrees –UNILATERAL

3A. Active shoulder external rotation restrictions – WITH SHOULDERS IN NEUTRAL

3B. Active shoulder external rotation restrictions – WITH SHOULDERS IN FLEXION AND ABDUCTION

4A. Active horizontal shoulder adduction restrictions –BILATERAL

4B. Active horizontal shoulder adduction restrictions –UNILATERAL

5A. No hand over head activities (e.g. brushing hair, placing glasses in cupboard) – BILATERAL

5B. No hand over head activities (e.g. brushing hair, placing glasses in cupboard) – UNILATERAL

6A. No upper extremity work or activities of daily living (ADL) using the arms - BILATERALLY

6B. No upper extremity work or activities of daily living (ADL) using the arms - UNILATERALLY


7A. Lifting no more than 5 pounds of weight – BILATERALLY7B. Lifting no more than 5 pounds of weight – UNILATERALLY7C. Lifting no more than 10 pounds of weight – BILATERALLY7D. Lifting no more than 10 pounds of weight – UNILATERALLY8. Bed mobility (e.g. rolling, supine to sitting, supine use of bed

tray=bridging) restrictions9A. Transfer (e.g. independent bed to chair) restrictions9B. Transfer (e.g. dependent bed to chair – patient requiring

assistance) restrictions10A. Dressing restrictions – UPPER BODY10B. Dressing restrictions – LOWER BODY11. No driving12A. Sports restrictions (e.g. swimming) – BILATERAL12B. Sports restrictions (e.g. tennis) – UNILATERAL13A. Common lower extremity therapeutic exercise (e.g. knee

and hip flexion and extension) restrictions – BILATERAL13B. Common lower extremity therapeutic exercise (e.g. knee

and hip flexion and extension) restrictions - UNILATERAL


14A. Common upper extremity therapeutic exercise (e.g. elbow and shoulder flexion and extension) restrictions – BILATERAL

14B. Common upper extremity therapeutic exercise (e.g. elbow and shoulder flexion and extension) restrictions – UNILATERAL

15. Please rank the top 5 sternal precautions (previous #’s 1-14) which you believe to be most important following a sternotomy – in descending order.

1A. Active shoulder flexion no greater than 90 degrees - Bilateral ____1B. Active shoulder flexion no greater than 90 degrees – Unilateral ____2A. Active shoulder abduction no greater than 90 degrees - Bilateral ____2B. Active shoulder abduction no greater than 90 degrees – Unilateral ____3A. Active shoulder external rotation restrictions – Shoulders in neutral ____3B. Active shoulder external rotation restrictions – Shoulders flexed & abducted ____4A. Active horizontal shoulder adduction restrictions – Bilateral ____4B. Active horizontal shoulder adduction restrictions – Unilateral ____5A. No hand over head activities - Bilateral ____5B. No hand over head activities - Unilateral ____6A. No upper extremity work or activities of daily living using the arms – Bilateral ____6B. No upper extremity work or activities of daily living using the arms – Unilateral ____7A. Lifting no more than 5 pounds of weight - Bilaterally ____7B. Lifting no more than 5 pounds of weight - Unilaterally ____7C. Lifting no more than 10 pounds of weight - Bilaterally ____7D. Lifting no more than 10 pounds of weight - Unilaterally ____8. Bed mobility restrictions ____9A. Transfer restrictions – patient independent ____9B. Transfer restrictions – patient dependent and requiring assistance ____10A. Dressing restrictions – Upper body ____10B. Dressing restrictions – Lower body ____11. No driving ____12A.Sports restrictions - Bilateral ____12B.Sports restrictions - Unilateral ____13A.Common lower extremity therapeutic exercise restrictions - Bilateral ____13B.Common lower extremity therapeutic exercise restrictions - Unilateral ____14A.Upper extremity therapeutic exercise restrictions - Bilateral ____14B.Upper extremity therapeutic exercise restrictions - Unilateral ____


20

16A. Please indicate the frequency and duration that you believe patients adhere to your sternal precautions instructions?

1= Never , 2= Rarely , 3= Sometimes , 4= Most Times,5=Always , 6=Don’t Know

A=2-4 Wks , B=5-8 Wks , C=9-12 Wks , D=13-16 Wks, E=greater than 16 Wks

16B. Please indicate the frequency and magnitude of complications that you believe occur from patients not adhering to your sternal precautions instructions

1= Never , 2= Rarely , 3= Sometimes, 4= Most Times,5=Always , 6=Don’t Know

A=Very Minor B=Minor C=Moderate D=Major E=Severe


17A. How often do you examine breathing patterns before and after a sternotomy?

1= Never , 2= Rarely , 3= Sometimes , 4= Most Times , 5=Always

17B. If you answered that you examine breathing patterns more than rarely, have you observed a breathing pattern after a sternotomy that (please circle the breathing pattern you observe most often after a sternotomy):

Is UnchangedConsists of Greater Abdominal Breathing than Upper Chest BreathingConsists of Greater Upper Chest Breathing than Abdominal BreathingOther (please describe the “other” breathing pattern you have

observed)_________________________________________________

17C. Are your patients instructed on proper breathing patterns after a sternotomy?

1= Never , 2= Rarely , 3= Sometimes , 4= Most Times , 5=Always

17D. Who instructs patients on proper breathing patters after a sternotomy (Please check all that apply)?

MD____ RN____ PT____ OT____ Health Care Aide____Other____(please describe the “other” instructor of proper breathing)_______


18A. Do you provide patient education material about sternal precautions to your patients?Yes ____ No ____

18B. If you answered yes to the above question, please indicate which methods you use to provide your patients education about sternal precautions from the list below (with a percentage summing to 100%).

Verbal instruction ____ VHS video instruction ____Written instruction ____ CD-ROM/DVD instruction ____Other________________ Classroom instruction ____

19. If you modify your sternal precautions depending on particular patient characteristics please identify which characteristics you use (no response indicates that you do not modify your sternal precautions)?

Smoking ____ Repeat Sternotomy ____ Older Age ____Diabetes ____ Spinal Cord Injury ____ Frailty ____Obesity ____ Recent Sternal Infection____ Sternectomy ____Please quantify/qualify patient characteristics and modifications if

possible_____________________________________________________________

20. Are there any other sternal precautions not covered in the survey that you provide to your patients?________________________________________________________


21

Results

Despite the response rate being surprisingly low (10%), the survey results were very consistent among the respondents. The greatest percentage of respondents was from the Northeast and Southeast regions of the US (33%).

ResultsMean respondent age = 42+25 yrs

Mean years of surgical experience = 20±18 yrs

Mean number of median sternotomies performed per week = 6±14Most common reason was bypass graft surgery (60%)

Top five Sternal Precautions in descending order were:(1) Lifting no more than 10 pounds of weight bilaterally(2) Lifting no more than 10 pounds of weight unilaterally(3) Bilateral sports restrictions(4) No driving(5) Unilateral sports restrictions

95 percent of Surgeons provide patients education materials on Sternal Precautions

Frequency & duration patients adhere to Sternal Precautions:Most Times patients adhere for 5-8 Weeks

Frequency & magnitude of complications if Sternal Precautions are not followed:Rarely occurring complications with Moderate Magnitude

Age of Respondent__________

Years of PT Experience__________

Number of Patients with Sternotomies Treated Per Week____________

Most common reason for the Sternotomy and Surgery_________

Sternal Precautions SurveyAdministered to PT’s*

*Survey was administered electronically to 640 Cardiovascular and

Pulmonary Section members using the apta.org website. Several repeat e-mails were sent to encourage recipients to complete the survey.

22

Please rank the top 5 sternal precautions which YOU believe to be most important following a sternotomy (in descending order) AND those YOU HAVE OBSERVEDto be implemented IN YOUR FACILITY (also in descending order).

YOU/Facility1A. Active shoulder flexion no greater than 90 degrees - Bilateral ____/____1B. Active shoulder flexion no greater than 90 degrees – Unilateral ____/____2A. Active shoulder abduction no greater than 90 degrees - Bilateral ____/____2B. Active shoulder abduction no greater than 90 degrees – Unilateral ____/____3A. Active shoulder external rotation restrictions – Shoulders in neutral ____/____3B. Active shoulder external rotation restrictions – Shoulders flexed & abducted ____/____4A. Active horizontal shoulder adduction restrictions – Bilateral ____/____4B. Active horizontal shoulder adduction restrictions – Unilateral ____/____5A. No hand over head activities - Bilateral ____/____5B. No hand over head activities - Unilateral ____/____6A. No upper extremity work or activities of daily living using the arms – Bilateral ____/____6B. No upper extremity work or activities of daily living using the arms- Unilateral ____/____7A. Lifting no more than 5 pounds of weight - Bilaterally ____/____7B. Lifting no more than 5 pounds of weight - Unilaterally ____/____7C. Lifting no more than 10 pounds of weight - Bilaterally ____/____7D. Lifting no more than 10 pounds of weight - Unilaterally ____/____8. Bed mobility restrictions ____/____9A. Transfer restrictions – patient independent ____/____9B. Transfer restrictions – patient dependent and requiring assistance ____/____10A. Dressing restrictions – Upper body ____/____10B. Dressing restrictions – Lower body ____/____11. No driving ____/____12A.Sports restrictions - Bilateral ____/____12B.Sports restrictions - Unilateral ____/____13A.Common lower extremity therapeutic exercise restrictions - Bilateral ____/____13B.Common lower extremity therapeutic exercise restrictions - Unilateral ____/____14A.Upper extremity therapeutic exercise restrictions - Bilateral ____/____14B.Upper extremity therapeutic exercise restrictions - Unilateral ____/____

Sternal Precautions SurveyAdministered to PT’s

15A. Please indicate the frequency and duration that you believe patients adhere to the sternal precautions instructions in your facility.

1= Never , 2= Rarely , 3= Sometimes , 4= Most Times ,5=Always , 6=Don’t Know

A=2-4 Wks , B=5-8 Wks , C=9-12 Wks , D=13-16 Wks , E=greater than 16 Wks

15B. Please indicate the frequency and magnitude of complications that you believe occur from patients not adhering to sternal precautions instructions in your facility.

1= Never , 2= Rarely , 3= Sometimes , 4= Most Times ,5=Always , 6=Don’t Know

A=Very Minor B=Minor C=Moderate D=Major E=Severe

16. Please list patient characteristics you use to modify sternal precautions (e.g. infection)

Sternal Precautions SurveyAdministered to PT’s

PT Survey Results

The response rate was also surprisingly low (12.5%) and the survey results were less consistent among the PT respondents. The greatest percentage of respondents was from the Midwest and Southwest regions of the US (50%).

23

PT Survey ResultsMean respondent age = 43+11 yrs

Mean years of PT experience = 18±11 yrs

Mean number of patients with sternotomies treated per week = 11±12Most common reason was bypass graft surgery (76%)

Top five Sternal Precautions in descending order were:(1) Lifting no more than 10 pounds of weight bilaterally(2) No hand over head activities bilaterally(3) Bilateral sports restrictions(4) No driving(5) Active bilateral shoulder flexion no greater than 90 degrees

Frequency & duration patients adhere to Sternal Precautions:Most Times patients adhere for 5-8 Weeks

Frequency & magnitude of complications if Sternal Precautions are not followed:Rarely occurring complications with Moderate Magnitude

Top five Sternal Precautions Observed in the PT’s Facility in descending order were:

(1) Lifting no more than 10 pounds of weight bilaterally(2) Active bilateral shoulder flexion no greater than 90 degrees(3) No driving(4) Active bilateral shoulder abduction not > 90 degrees(5) No hand over head activities bilaterally

The Relationship between the Top Sternal Precaution of PT’s & that Observed in PT’s Facility was strong: r=0.67; p<0.0001

The Relationship between # of Patients with sternotomy seen per week and PT age as well as PT years of experience was negative:

# Patients seen per week and PT age: r= - 0.22; p=0.06# Patients seen per week and PT yrs Experience: r= - 0.21; p=0.07

PT Survey & PT Facility Results

Summary

Sternal Precautions reported by: Surgeons & PT’s were very similar

Surgeons & PT’s were identical in regard to Frequency & Duration of Adherence and Frequency & Magnitude of Complications

PT’s were more “functionally inclusive” than the Surgeons

The “PT” and “PT Facility” were similar, but had different priorities

Negative Relationships between: # of Patients seen and PT Age & Years of Experience

is concerning and warrants further investigation• Older PT’s with greater yrs of experience see fewer patients

24

Sternal PrecautionsFunctional Status & Quality of Life

Tanya LaPier, PT, PhD, CCS

Distinguished Professor

Physical Therapy

What are outcome measurements?Medical

Morbidity

Mortality

Complication rates

Hospital LOS

Ejection fraction

Quality of life

Rehabilitation

Quality of life

ADL performance

Symptom impact

Habitual physical activity level

Balance

Functional Limitations & Disability

Inability to maintain

healthy lifestyle

Activity Restriction

Chronic disease associated

with sedentary lifestyle

Deconditioning & impaired

physical function

25

Functional Status During Acute Recovery Following Hospitalization for Coronary Heart Disease

LaPier T. J Cardiopulm Rehabil 2003;23:203-207.

N=37: outpt CR new referrals

Med vs surg mgt of CHD

6MWT, DASI, & QoL

Surgical vs. Nonsurgical Mgt

Surgical Nonsurgical

6MWT (ft) 853 + 324 965 + 321

DASI 14.7 + 7.5 18.5 + 7.0

QoL-total 40.0 + 47.2 47.2 + 12.4

QoL-PF 34.2 + 19.6 45.0 + 23.2

QoL-RLPH 1.4 + 5.9 12.5 + 25.0

0

5

10

15

20

25

30

35

40

45

0 200 400 600 800 1000 1200 1400 1600 1800

6 Minute Walk Test Distance (feet)

Du

ke A

cti

vit

y S

tatu

s I

nd

ex

R = 0.56

26

Functional Limitations in Patients Recovering From Coronary Artery Bypass: Longitudinal Analysis

LaPier T, Howell. Cardiopulm Phys Ther 2003;14:9-12

Wintz G, LaPier TL. Cardiopulm Phys Ther J. 18(2):13-20.

LaPier TL. J Cardiopulm Rehabil Prevent. 2007;27:161-165.

N=52; Pre, 2 wk, & 2 mo

Self-report outcomes

FSI & QoL

Category

Dimension

Pre-op

2 weeks

Mobility

Assistance

8 %

17%

Difficulty

58 %

59 %

Pain

58 %

39 %

Personal Care

Assistance

0 %

16%*

Difficulty

25 %

32 %

Pain

21 %

32 %

Hand Activities

Assistance

8 %

8 %

Difficulty

24 %

36 %

Pain

12 %

12 %

27

-60

-40

-20

0

20

40

RA

ND

36

-Ite

m H

ea

lth

Su

rv

ey

Sco

re

Old Young

PF

RLPH

RLEP

Energy

EW-B

SFPain

GH

* *

Category

Dimension

Older

Younger

Mobility

Assistance

13 %

10 %

Difficulty

27 %

48 %

Pain

17 %

38 %

Personal Care

Assistance

17 %

8 %

Difficulty

13 %

48 %*

Pain

21 %

52 %*

Hand Activities

Assistance

0 %

25 %*

Difficulty

16 %

38 %

Pain

8 %

42 %*

28

Surgery-specific Symptom Impact on Function: Heart Surgery

Symptom Inventory

LaPier T, Wilson B. Acute Care Pers 2007;16(3):10-15.

LaPier T. J Cardiopulm Rehabil. 2006;26:101-106.

LaPier T, Wilson B. Cardiopulm Phys Ther J. 2006;17(2):77-83.

LaPier T, Jung C. Acute Care Perspectives. 2002;11(2):5-12.

n=37; pts in outpt CR

Disease-specific, self-report

76 Items, 5 subscales

During the past week, how much have you been bothered by:

30-52%

35-58%

29

20%

10% 10%

5%

20%

15%10%

10%15%

5%

5%

20%

60%

10% 10%

10%

10% 15%

30%

0% 0%

15% 5%

Uninvolved

side

Involved

side

Involved

side

Uninvolved

side

10% 5% 5% 5%

5% 5%

Greater than half of patients reported

the following symptoms:

• Worrying about heart problems (50%)

• General fatigue (78%)

• Whole body weakness (53%)

• Difficulty falling asleep (65%)

• Waking multiple times at night (75%)

• Feeling sleepy / tired (81%)

• Needing to take daytime nights (66%)

• Difficulty remembering things (59%)

• Shoulder pain / soreness (53%)

• Chest incision tenderness / irritation (69%)

• Chest incision numbness / tingling (50%)

• Leg incision tenderness / irritation (75%)

• Swelling in a leg (56%)

Functional Status of Patients During Subacute Recovery from CAB

Surgery

LaPier T. Heart Lung 2007; 36(2):114-24.

n=25; pts in outpt CR

Performanced-based &

self-report outcomes

Multiple domains

30

Need (A) Have

Difficulty

Experience

Pain

Mobility 4 % 32 % 40 %

Personal Care 4 % 24 % 16 %

Hand Activities

24 % 40 % 36 %

Home Chores 36 % 56 % 44 %

Social Activities

4 % 20 % 20 %

Functional Status Index Results

Outcome Measure Mean + SD Range > Threshold

ABC Scale (%)91.8 ±

10.137-100

13 %

Timed-Up-&-Go (sec) 7.8 ± 1.15.8-11.1

0 %

Berg Balance Scale 54 ± 2 47-56 0 %

Functional Reach

(cm)30.3 ±

8.69.4-41.0

24 %

Balance Assessment Descriptive Data

Correlations between Balance and Aerobic Capacity Outcomes

6 Min Walk Test Act. Status Index

ABC Scale 0.31 0.32

Timed-Up-&-Go -0.61* -0.38

Berg Balance Scale 0.52* 0.29

Functional Reach 0.51* 0.22

31

Physical Performance

Test

Physical Function Subscale of

SF-36

ABC Scale 0.43* 0.40

Timed-Up-&-Go -0.64* -0.52*

Berg Balance Scale 0.27 0.20

Functional Reach 0.56* 0.23

Correlations between Balance and Functional Status Outcomes

Functional Deficits at the Time of Hospital Discharge in Patients

following CAB Surgery

Wilson B, LaPier T. Cardiopulm Phys Ther J2006;17:144. (abstract)

LaPier T, Wilson B. Heart Lung. (in review)

n=28: <24 hrs D/C

HSSI, 2MWT, DASI, Walking

speed, & TUG

Correlational Matrix

TUG WS-P WS-F 2MWT STS HG

TUG 1

WS-P -0.63 1

WS-F -0.66 0.89 1

2MWT -0.45 0.47 0.39 1

STS -0.61 0.45 0.45 0.31 1

HG -0.22 0.49 0.52 0.58 -0.01 1

32

Comparison of Results

Timed up and Go (TUG) = 16.0 7.5 sec (<13.5)

Preferred and Fast Walking Speeds (~50%)

Preferred Walking Speed = 2.5 0.8 ft/sec

Fast Walking Speed = 3.1 0.9 ft/sec

2 minute walk test (2MWT) = 220 83.7 ft (540)

Hand grip strength (HG)

Males = 31.5 6.9 lbs (93.5)

Female: 21.2 7.2 lbs (52.2)

Timed Sit-to-stand = 6 + 1 rep (11-18)

Additional References

Savage B, et al. Use of both internal thoracic arteries in diabetic patients increases deep sternal wound infection. Ann Thorac Surg 2007;83:002-7.

Crabtree TD, et al. Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center. Sem Thorac Cardiovasc Surg 2004;16:53-61.

Trick WE, et al. Modifiable risk factors associated with deep sternal site infections after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000;119:108-14.

Olbrecht VA, et al. Clinical outcomes of noninfectious sternal dehiscence after median sternotomy. Ann Thorac Surg 2006;82:902-8.

Lu JCY, et al. Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery. Euro J Cardio-thorac Surg 2003;23:943-9.

Additional References (con’t)

Strecker T, et al. Sternal wound infections following cardiac surgery: risk factor analysis and interdisciplinary treatment. Heart Surg Forum 2007;10: E366-71.

Diez C, et al. Risk factors for mediastinitis after cardiac surgery – a retrospective analysis of 1700 patients. J Cardiothorac Surg 2007;2:23-30.

Losanoff JE, et al. Disruption and infection of median sternotomy: a comprehensive review. Euro J Cardio-thorac Surg 2002;21:831-839.

Mackey RA et al. Subxiphoid incisional hernias after median sternotomy. J Am Coll Surg 2005;201:71-6.

Unlu Y, et al. Brachial plexus injury following median sternotomy. Interactive Cardiovasc Thorac Surg2007;6:235-237.

33

Additional References (con’t)

El-Ansary D, et al. Trunk stabilization exercises reduce sternal separation in chronic sternal instability after cardiac surgery: a randomised cross-over trial. Aust J Physiother 2007;53:255-60.

El-Ansary D, et al. Measurement of non-physiological movement in sternal instability by ultrasound. Ann Thorac Surg 2007;83:1513-7.

Irion GL et al. Sternal skin stress produced by functional upper extremity movements. Acute Care Perspectives 2007;16:1-5. ??

Irion GL et al. effect of upper extremity movement on sternal skin stress. Acute Care Perspectives 2007;16:1-5. ??

sternal precautions

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