Date Presented 04/05/19
Primary Author and Speaker: Dana Grady
Additional Authors and Speakers: Patricia Pierce
PURPOSE: Guidelines for movement following median sternotomy are not universally defined,1 but typically include strict sternal precautions (SP). The SP protocol is not well supported by evidence and is reported to impede functional recovery.2-4 Recently, alternative approaches propose less functional restrictions while avoiding excessive stress to the sternum. The purpose of this study was to determine the effect of a less restrictive (LR) approach after median sternotomy in an acute care hospital. Our hypothesis was that the LR approach group would have no negative change to their sternum, less difficulty during functional mobility and activities of daily living, shorter length of stay, and would discharge to home (vs. rehabilitation), as compared to the SP group.
PARTICIPANTS: 364 (SP: n =172, 66.3 ± 11.2 y; LR: 196, 65.2 ± 11.2 y).
DESIGN AND METHOD: This quasi-experimental design study, ran in 2 consecutive phases, and compared 2 groups post median sternotomy at a community based hospital (March – September 2017). Phase 1 participants and family, the SP group, were instructed to follow SP restrictions. Phase 2 participants and family, the LR group, received instructions on the Keep Your Move in the Tube approach. At 2-3 weeks post discharge, patients completed a self-reported survey and sternal instability was objectively assessed by the surgeons using the Modified Sternal Instability Scale (MSIS). The survey included questions on perceived pain rating and frequency, sternal instability, and functional mobility. Functional mobility was recorded as an average score of the reported level of difficulty (0 = none and 10 = maximum) for getting out of a chair, getting out of bed and putting on a bra or shirt. Chart review provided data on length of stay and discharge disposition (rehabilitation facility vs. home). The 2 groups were compared using the Mann Whitney U test for continuous variables and Chi square test for discharge disposition (P < 0.05).
RESULTS: There were no significant differences between the two groups for all the outcomes, MSIS (SP: 0.02 ± 0.1 vs. LR: 0.02 ± 0.1, P = 0.88), pain rating (SP: 3.4 ± 1.9 vs. LR: 3.4 ± 1.7, P = 0.87), pain frequency (SP:1.7 ± 0.6 vs. LR: 1.6 ± 0.7, P = 0.46), sternal instability (SP: 0.08 ± 0.2 vs. LR: 0.05 ± 0.2, P = 0.24), difficulty with functional mobility (SP: 1.5 ± 2.0 vs. LR: 1.2 ± 1.9, P = 0.09), length of stay (SP: 7.7 ± 5.1 days vs. LR: 8.0 ± 6.1 days, P = 0.56) and discharge disposition (P = 0.09).
CONCLUSIONS: In our study, the implementation of the LR approach, Keep Your Move in the Tube, had no adverse effect on outcomes 2-3 weeks following median sternotomy. Although no statistically significant differences were noted for all outcomes, patients with the LR approach reported less difficulty with functional mobility. The limitations include a short time frame and subjective functional outcomes. Future research with a long term randomized control trial with objective measurements is needed.
IMPACT STATEMENT: This proposal is important to practice as it provides valuable data to clinicians on alternative approaches for mobility and activities of daily living following median sternotomy. It is likely to exert a powerful influence on occupational therapy in regards to treatment following median sternotomy in various settings. Patients report less difficulty in activities of daily living such as donning a shirt or bra as well as functional transfers.
References
1. Tuyl LJ, Mackney JH, Johnston CL. Management of Sternal Precautions Following Median Sternotomy by Physical Therapists in Australia: A Web-Based Survey. Physical Therapy. 2011; 92(1):83-97.
2. Cahalin LP, LaPier TK, Shaw DK. Sternal Precautions: Is It Time for Change? Precautions versus Restrictions – A Review of Literature and Recommendations for Revision. Cardiopulmonary Physical Therapy Journal. 2011; 22(1):5-15.
3. Brocki BC, Thorup CB, Andreasen JJ. Precautions related to midline sternotomy in cardiac surgery: a review of the mechanical stress factors leading to sternal complications. Eur J Cardiovasc Nurs 2010; 9:77–84.
4. Adams, J, Schmid J, Parker RD, et al. Comparison of Force Exerted on the Sternum During a Sneeze Versus During Low-, Moderate-, and High-Intensity Bench Press Resistance Exercise with and without the Valsalva Maneuver in Healthy Volunteers. The American Journal of Cardiology.2014; 113(6):1045-1048.
