sternal precautions
TRANSCRIPT
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
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
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
Northeastern University
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
Locke TJ et al. Thorax 1990;45: 465-468
% 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
Locke TJ et al. Thorax 1990;45: 465-468
% Change in MIP, MEP, and RR from Pre-Op
10
Locke TJ et al. Thorax 1990;45: 465-468
% Change from Pre-Op
-40
-35
-30
-25
-20
-15
-10
-5
0
FEV1 FVC Tidal Volume
1 Week Post 12 Weeks Post
% Change in Pulmonary Function from Pre-Op
% Change from Pre-Op
-25
-20
-15
-10
-5
0
5
10
TLC FRC RV
1 Week Post 12 Weeks Post
Locke TJ et al. Thorax 1990;45: 465-468
% Change in Lung Volumes from Pre-Op
Locke TJ et al. Thorax 1990;45: 465-468
11
% Change from Pre-Op
-100
-90
-80
-70
-60
-50
-40
-30
-20
-10
0
Sternal Angle Xiphoid Umbilicus Axillary (5th Rib)
1 Week Post 12 Weeks Post
Locke TJ et al. Thorax 1990;45: 465-468
% 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
% Change from Pre-Op
-30
-25
-20
-15
-10
-5
0
FEV1 FVC
1 Week Post
Ragnarsdottir M et al. Scand Cardiovasc J 2004;38: 46-52
% Change in Pulmonary Function from Pre-Op
*Pre- and Post-Op breathing exercises provided
% Change from Pre-Op
-60
-50
-40
-30
-20
-10
0
Upper Thoracic Lower Thoracic Umbilicus
1 Week Post
Ragnarsdottir M et al. Scand Cardiovasc J 2004;38: 46-52
% Change in Chest/Abdominal Motion from Pre-Op*
*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: 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
% Change from Pre-Op
-16
-14
-12
-10
-8
-6
-4
-2
0
FEV1 FVC
3 Months Post 12 Months Post
Kristjansdottir A et al. Scand Cardiovasc J 2004;38:98-103
% Change in Pulmonary Function from Pre-Op
*Pre- and Post-Op breathing exercises provided
% Change from Pre-Op
-30
-20
-10
0
10
20
30
Upper Thoracic Lower Thoracic Umbilicus
3 Months Post 12 Months Post
Kristjansdottir A et al. Scand Cardiovasc J 2004;38:98-103
% Change in Chest/Abdominal Motion from Pre-Op*
*Pre- and Post-Op breathing exercises provided
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.)
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
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
Northeastern University
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
Sternal Precautions Survey
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
Sternal Precautions Survey
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
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 ____
Sternal Precautions Survey
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
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 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)_______
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?________________________________________________________
Sternal Precautions Survey
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. ??