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

DEFINITION
Sternotomy: sternotomy (str-nt'-m)

n.

surgical incision through the sternum

STERNAL

PRECAUTIONS

A CONTENTIOUS TOPIC
Therapists Therapists Therapists Therapists

Physicians Nurses Patients Therapists

NO! Shoulder Flexion No more than 90 degrees post-MI

IS ANYONE CONFUSED?

OPINIONS VARY
OhioHealth
MOVEMENT AT THE SHOULDER Do not raise your elbows higher than your shoulders Do not lift greater than 5 to 10 pounds with your affected arm (for 4 weeks) Do not reach behind you when dressing your upper body

The Ohio State Medical Center

You may move your arms within a pain free range Do not lift more than 10 pounds for the 6 weeks after your surgery Avoid reaching backwards

Cleveland Clinic
It is okay to perform activities above shoulder level Do not lift objects greater than 20 pounds for first 6-8 weeks following surgery Not mentioned

LIFTING

REACHING

http://www.ohiohealth.com/documents/orb/Sternal%20precautions.pdf http://medicalcenter.osu.edu/PatientEd/Materials/PDFDocs/surgery/activity-after-chest-surgery.pdf http://my.clevelandclinic.org/heart/disorders/recovery_ohs.aspx

OVERVIEW OF SURGICAL PROCEDURE

Traditional approach: median sternotomy

Minimally invasive approach: partial upper sternotomy

Minimally invasive approach: small right thoracotomy

Sternal Precautions

Literature Review

Tanya LaPier, PT, PhD, CCS

Distinguished Professor

Physical Therapy

Post-surgical Complications
Myocardial Blood

injury 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%)

Sternal instability / dehiscence / mediastinitis: Risk Factors

/ NYHA class transfused units Bilat. IMA grafting Smoking Diabetes Prolonged CPB / Sx time Rethoracotomy Prolonged Post-operative activity level / mechanical arm movements not cited ventilation
COPD # Obesity

/ BMI

CCS

Sternal instability / dehiscence / mediastinitis: Risk Factors-Other

Larger breast size Longer ICU LOS Time of surgery PVD Antibiotic >2 hours pre-sx Staple use for skin closure

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;53:255260

Activity Restrictions
Median
No No

Sternal Precautions
6-12 wks

sternotomy precautions for

lifting, pushing, or pulling > 10 lbs 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 Supra-sternal

with chronic sternal instability skin movement

Patients with chronic sternal instability (ElAnsary D, Ann Thor Surg 2007;83:1513-7)
Sternal Separation

Condition Rest (seated, arms at side) Elevation of both arms Resisted elbow flexion task Pushing up from chair Shoulder protraction Shoulder retraction

Difference

15.4 16.6 17.3 17.4 14.3 17.1

1.2 1.9 2 -1.2 1.7

*measurements in mm

Patients with chronic sternal instability (El-Ansary D, Aust J Physiother 2007;53:255-60) Condition Pain VAS (90100) 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 31 height

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

Condition Lifting 12 oz container Lifting 1 L container Lifting 1 gal container Supine long sitting (push up) Supine short sit (log roll) Sit standing (using arms) Sit standing (without using arms) Skin Mvt
(Microvolts)

180 225 250 360 275 380 310

Effects of Median Sternotomy on PFTs & Chest/Abdominal Movement

Lawrence P. Cahalin PT, PhD, CCS Northeastern University

Effects of Median Sternotomy on PFTs & Chest/Abdominal Movement?

Restrictive Ventilatory Defect

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

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

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

% Change in MIP, MEP, and RR from Pre-Op
% Change from Pre-Op
1 Week Post 40 30 20 10 0 -10 -20 -30 -40 -50 -60 MIP MEP Resp Rate 12 Weeks Post

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

% Change in Pulmonary Function from Pre-Op
% Change from Pre-Op
1 Week Post 0 FEV1 -5 -10 -15 -20 -25 -30 -35 -40 FVC Tidal Volume 12 Weeks Post

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

% Change in Lung Volumes from Pre-Op
% Change from Pre-Op
1 Week Post 10 5 0 TLC -5 -10 -15 -20 -25 FRC RV 12 Weeks Post

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

10

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

% Change in Chest/Abdominal Motion from Pre-Op
% Change from Pre-Op
1 Week Post 0 -10 -20 -30 -40 -50 -60 -70 -80 -90 -100 Sternal Angle Xiphoid Umbilicus Axillary (5th Rib) 12 Weeks Post

Locke TJ et al. Thorax 1990;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

11

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

% Change in Pulmonary Function from Pre-Op
% Change from Pre-Op
1 Week Post 0 FEV1 -5 FVC

-10

-15

-20

-25

-30

*Pre- and Post-Op breathing exercises provided

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

% Change in Chest/Abdominal Motion from Pre-Op*
% Change from Pre-Op
1 Week Post 0 Upper Thoracic -10 Lower Thoracic Umbilicus

-20

-30

-40

-50

-60

*Pre- and Post-Op breathing exercises provided

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:

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

Pulmonary Function - seated Chest & Abdominal Motion - supine

Patients were excluded if previous median sternotomy Patients were provided breathing exercises

FEV1 & FVC = 88% predicted values

12

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

% Change in Pulmonary Function from Pre-Op
% Change from Pre-Op
3 Months Post 0 FEV1 -2 -4 -6 -8 -10 -12 -14 -16 FVC 12 Months Post

*Pre- and Post-Op breathing exercises provided

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

% Change in Chest/Abdominal Motion from Pre-Op*
% Change from Pre-Op
3 Months Post 30 12 Months Post

20

10

0 Upper Thoracic -10 Lower Thoracic Umbilicus

-20

-30

*Pre- and Post-Op breathing exercises provided

Summary of the Effects of Median Sternotomy on PFTs & Chest/Abdominal Movement:

Restrictive Ventilatory Defect

1) 2) 3)

With: Altered PFTs and Chest/Abdominal motion up to 1 year post-sternotomy Worsening MIP 12 weeks after sternotomy Worsening Residual Volume 12 weeks after sternotomy Without: A Clear Understanding of PTs Role

13

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 Miltons 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. Cardiologys 10 Greatest Discoveries, Tex Heart Inst J 29 (4):342344, 2002.)

14

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

15

WHERE ARE WE TODAY?

STILL CONFLICTED STILL CONFUSED

16

PERHAPS A VOICE OF REASON

First 5 to 8 weeks:
UE UE

lifting 5-8 pounds 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. ACSMs Guidelines for Exercise Testing and Prescription. Baltimore: Lippincott Williams & Wilkins; 2010; 216.)

A Cardiothoracic Surgeons Perspective on Sternal Precautions: Implications for Rehabilitation Professionals Lawrence P. Cahalin PT, PhD, CCS Northeastern University

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 2009
http://meeting.chestpubs.org/cgi/content/abstract/136/4/98S

17

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 _____________________________________

Sternal Precautions Survey

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 - BILATERAL

1= 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 UNILATERAL

1= 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

18

Sternal Precautions Survey

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

Sternal Precautions Survey

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 (e.g. rolling, supine to sitting, supine use of bed tray=bridging) restrictions 9A. Transfer (e.g. independent bed to chair) restrictions 9B. Transfer (e.g. dependent bed to chair patient requiring assistance) restrictions 10A. Dressing restrictions UPPER BODY 10B. Dressing restrictions LOWER BODY 11. No driving 12A. Sports restrictions (e.g. swimming) BILATERAL 12B. Sports restrictions (e.g. tennis) UNILATERAL 13A. Common lower extremity therapeutic exercise (e.g. knee and hip flexion and extension) restrictions BILATERAL 13B. Common lower extremity therapeutic exercise (e.g. knee and hip flexion and extension) restrictions - UNILATERAL

Sternal Precautions Survey

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 ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

19

Sternal Precautions Survey

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=Dont 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 ,

A=Very Minor

2= Rarely , 3= Sometimes, 4= Most Times, 5=Always , 6=Dont Know B=Minor C=Moderate D=Major E=Severe

Sternal Precautions Survey

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 Unchanged Consists of Greater Abdominal Breathing than Upper Chest Breathing Consists of Greater Upper Chest Breathing than Abdominal Breathing Other (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)_______

Sternal Precautions Survey

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?________________________________________________________

20

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%).

Results
Mean respondent age = 42+25 yrs Mean years of surgical experience = 2018 yrs Mean number of median sternotomies performed per week = 614
Most 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

Sternal Precautions Survey Administered to PTs*

Age

of Respondent__________ of PT Experience__________ Number of Patients with Sternotomies Treated Per Week____________ Most common reason for the Sternotomy and Surgery_________
Years *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.

21

Sternal Precautions Survey Administered to PTs

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

Sternal Precautions Survey Administered to PTs

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=Dont 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 ,

A=Very Minor

2= Rarely , 3= Sometimes , 4= Most Times , 5=Always , 6=Dont Know B=Minor C=Moderate D=Major E=Severe

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

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%).

22

PT Survey Results
Mean respondent age = 43+11 yrs Mean years of PT experience = 1811 yrs Mean number of patients with sternotomies treated per week = 1112
Most 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

PT Survey & PT Facility Results

Top five Sternal Precautions Observed in the PTs 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 PTs & that Observed in PTs 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

Summary

Sternal Precautions reported by:

Surgeons & PTs were very similar Surgeons & PTs were identical in regard to Frequency & Duration of Adherence and Frequency & Magnitude of Complications PTs 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 PTs with greater yrs of experience see fewer patients

23

Functional Status & Quality of Life

Tanya LaPier, PT, PhD, CCS
Distinguished Professor

Sternal Precautions

Physical Therapy

What are outcome measurements?

Medical
Morbidity Mortality Complication

Rehabilitation
Quality ADL

of life

performance impact

rates Hospital LOS Ejection fraction Quality of life

Symptom Habitual

physical activity level Balance

Functional Limitations & Disability

Inability to maintain healthy lifestyle Activity Restriction

Deconditioning & impaired physical function

Chronic disease associated with sedentary lifestyle

24

Functional Status During Acute Recovery Following Hospitalization for Coronary Heart Disease
N=37: outpt CR new referrals Med vs surg mgt of CHD 6MWT, DASI, & QoL
LaPier T. J Cardiopulm Rehabil 2003;23:203-207.

Surgical vs. Nonsurgical Mgt

Surgical 6MWT (ft) DASI QoL-total QoL-PF QoL-RLPH 853 + 324 14.7 + 7.5 Nonsurgical 965 + 321 18.5 + 7.0

40.0 + 47.2 47.2 + 12.4 34.2 + 19.6 45.0 + 23.2 1.4 + 5.9 12.5 + 25.0

45

Duke Activity Status Index

40 35 30 25 20 15 10 5 0 0

R = 0.56

200

400

600

800

1000

1200

1400

1600

1800

6 Minute Walk Test Distance (feet)

25

Functional Limitations in Patients Recovering From Coronary Artery Bypass: Longitudinal Analysis
N=52; Pre, 2 wk, & 2 mo Self-report outcomes FSI & QoL
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.

Category Mobility

Dimension Assistance Difficulty Pain

Pre-op 8% 58 % 58 % 0% 25 % 21 % 8% 24 % 12 %

2 weeks 17% 59 % 39 % 16%* 32 % 32 % 8% 36 % 12 %

Personal Care

Assistance Difficulty Pain

Hand Activities

Assistance Difficulty Pain

26

RAND 36-Item Health Survey Score

40

RLEP PF Energy RLPH

EW-B

GH

20

SF Pain

-20

-40

-60

Old

Young

Category Mobility

Dimension Assistance Difficulty Pain

Older 13 % 27 % 17 % 17 % 13 % 21 % 0% 16 % 8%

Younger 10 % 48 % 38 % 8% 48 %* 52 %* 25 %* 38 % 42 %*

Personal Care

Assistance Difficulty Pain

Hand Activities

Assistance Difficulty Pain

27

Surgery-specific Symptom Impact on Function: Heart Surgery Symptom Inventory

n=37; pts in outpt CR Disease-specific, self-report 76 Items, 5 subscales
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.

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

30-52%

35-58%

28

5% 10% 20% 10% 15% 20% 10% 10%

10% 10% 10% 15% 30% 5% 5% 0% 0% 5%

5% 10%

5%

15% 10% 5%

20%

5% Uninvolved side

60% Involved side Involved side

15%

5% Uninvolved side

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

n=25; pts in outpt CR Performanced-based & self-report outcomes Multiple domains

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

29

Functional Status Index Results

Need (A)
Mobility Personal Care Hand Activities Home Chores Social Activities

4% 4% 24 % 36 % 4%

Have Experience Difficulty Pain 32 % 40 % 24 % 16 % 40 % 36 % 56 % 20 % 44 % 20 %

Balance Assessment Descriptive Data

Outcome Measure ABC Scale (%) Mean + SD 91.8 10.1 Range > Threshold 37100 5.811.1 47-56 9.441.0 13 % 0% 0% 24 %

Timed-Up-&-Go (sec) 7.8 1.1 Berg Balance Scale Functional Reach (cm) 54 2 30.3 8.6

Correlations between Balance and Aerobic Capacity Outcomes

6 Min Walk Test ABC Scale Timed-Up-&-Go Berg Balance Scale Functional Reach 0.31 -0.61* 0.52* 0.51* Act. Status Index 0.32 -0.38 0.29 0.22

30

Correlations between Balance and Functional Status Outcomes

Physical Physical Function Performance Subscale of Test SF-36 ABC Scale Timed-Up-&-Go Berg Balance Scale Functional Reach 0.43* -0.64* 0.27 0.56* 0.40 -0.52* 0.20 0.23

Functional Deficits at the Time of Hospital Discharge in Patients following CAB Surgery
n=28: <24 hrs D/C HSSI, 2MWT, DASI, Walking speed, & TUG

Wilson B, LaPier T. Cardiopulm Phys Ther J 2006;17:144. (abstract) LaPier T, Wilson B. Heart Lung. (in review)

Correlational Matrix

TUG WS-P WS-F 2MWT STS HG

TUG WS-P WS-F 2MWT STS 1 -0.63 1 -0.66 0.89 1 -0.45 0.47 0.39 1 -0.61 0.45 0.45 0.31 1 -0.22 0.49 0.52 0.58 -0.01

HG

31

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 (cont)

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 Cardiothorac 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 Surg 2007;6:235-237.

32

Additional References (cont)

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;53:25560. El-Ansary D, et al. Measurement of nonphysiological 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. ??

33