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Hathorn B, Adams J. Return of a flight attendant to full duty following myocardial infarction and subsequent coronary artery bypass grafting through a high-intensity occupation-specific cardiovascular rehabilitation program. Proc AMIA Symp 2023; 37:165-168. [PMID: 38173993 PMCID: PMC10761117 DOI: 10.1080/08998280.2023.2259762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/10/2023] [Indexed: 01/05/2024] Open
Abstract
Flight attendants play a vital role in the safety and security of air passengers during emergencies. A 61-year-old flight attendant who endured myocardial infarction and coronary artery bypass graft surgery wanted to return to full duty. To meet airline requirements, he chose to participate in our occupation-specific, high-intensity performance training program. This patient returned to full duty as a flight attendant upon completion of this specialized cardiac rehabilitation program.
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Affiliation(s)
- Brandon Hathorn
- Cardiac Rehabilitation Department, Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas, USA
- Department of Kinesiology, University of Texas at Arlington, Arlington, Texas, USA
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2
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Giardini M, Guenzi M, Arcolin I, Godi M, Pistono M, Caligari M. Comparison of Two Techniques Performing the Supine-to-Sitting Postural Change in Patients with Sternotomy. J Clin Med 2023; 12:4665. [PMID: 37510778 PMCID: PMC10380334 DOI: 10.3390/jcm12144665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Patients with sternotomy are advised to follow sternal precautions to avoid the risk of sternal complications. However, there are no standard recommendations, in particular to perform the supine-to-sitting postural change, where sternal asymmetrical force may be applied. The aim of this study was to compare the rotational movement and the use of a tied rope (individual device for supine-to-sitting, "IDSS") to perform the supine-to-sitting postural change. A total of 92 patients (26% female) admitted to a rehabilitative post-surgery ward with sternotomy were assessed for sternal instability. Levels of pain and perceived effort during the two modalities of postural change and at rest were assessed. Patients reported higher values of pain and perceived effort (both p < 0.0005) during rotational movement with respect to the use of the IDSS. Moreover, patients with sternal instability (14%) and female patients with macromastia (25%) reported higher pain than those stable or without macromastia (both p < 0.05). No other risk factors were associated with pain. Thus, the IDSS seems to reduce the levels of pain and perceived effort during the supine-to-sitting postural change. Future studies with quantitative assessments are required to suggest the adoption of this technique, mostly in patients with high levels of pain or with sternal instability.
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Affiliation(s)
- Marica Giardini
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Physical Medicine and Rehabilitation of Veruno Institute, 28013 Gattico-Veruno, Italy
| | - Marco Guenzi
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Cardiac Rehabilitation of Veruno Institute, 28103 Gattico-Veruno, Italy
| | - Ilaria Arcolin
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Physical Medicine and Rehabilitation of Veruno Institute, 28013 Gattico-Veruno, Italy
| | - Marco Godi
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Physical Medicine and Rehabilitation of Veruno Institute, 28013 Gattico-Veruno, Italy
| | - Massimo Pistono
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Cardiac Rehabilitation of Veruno Institute, 28103 Gattico-Veruno, Italy
| | - Marco Caligari
- Istituti Clinici Scientifici Maugeri IRCCS, Integrated Laboratory of Assistive Solutions and Translational Research (LISART), Scientific Institute of Pavia, 27100 Pavia, Italy
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3
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Ennis S, Lobley G, Worrall S, Evans B, Kimani PK, Khan A, Powell R, Banerjee P, Barker T, McGregor G. Effectiveness and Safety of Early Initiation of Poststernotomy Cardiac Rehabilitation Exercise Training: The SCAR Randomized Clinical Trial. JAMA Cardiol 2022; 7:817-824. [PMID: 35731506 DOI: 10.1001/jamacardio.2022.1651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Guidelines recommend that cardiac rehabilitation (CR) exercise training should not start until 6 weeks after sternotomy, although this is not evidence based. Limited data suggest that starting earlier is not detrimental, but clinical trials are needed. Objective To compare the effectiveness and safety of CR exercise training started either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy. Design, Setting, and Participants This was an assessor-blind, noninferiority, parallel-group, randomized clinical trial that conducted participant recruitment from June 12, 2017, to March 17, 2020. Participants were consecutive cardiac surgery sternotomy patients recruited from 2 outpatient National Health Service rehabilitation centers: University Hospital, Coventry, UK, and Hospital of St Cross, Rugby, UK. Interventions Participants were randomly assigned to 8 weeks of twice-weekly supervised CR exercise training starting either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy. Exercise training adhered to existing guidelines, including functional strength and cardiovascular components. Main Outcomes and Measures Outcomes were assessed at baseline (inpatient after surgery), after CR (10 or 14 weeks after sternotomy), and 12 months after randomization. The primary outcome was the change in 6-minute walk test distance from baseline to after CR. Secondary outcomes included safety, functional fitness, and quality of life. Results A total of 158 participants (mean [SD] age, 63 [11.5] years, 133 male patients [84.2%]) were randomly assigned to study groups; 118 patients (usual-care CR, 61 [51.7%]; early CR, 57 [48.3%]) were included in the primary analysis. Early CR was not inferior to usual-care CR (noninferiority margin, 35 m); the mean change in 6-minute walk distance from baseline to after CR was 28 m greater in the early CR group (95% CI, -11 to 66; P = .16). Mean differences for secondary outcomes were not statistically significant, indicating noninferiority of early CR. There were 46 vs 58 adverse events and 14 vs 18 serious adverse events in usual-care CR and early CR, respectively. There was no difference between the groups in the likelihood of participants having an adverse or serious adverse event. Conclusions and Relevance Starting exercise training from 2 weeks after sternotomy was as effective as starting 6 weeks after sternotomy for improving 6-minute walk distance. With appropriate precautions, clinicians and CR professionals can consider starting exercise training as early as 2 weeks after sternotomy. Trial Registration ClinicalTrials.gov Identifier: NCT03223558.
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Affiliation(s)
- Stuart Ennis
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Grace Lobley
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Sandra Worrall
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Becky Evans
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Peter K Kimani
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Amir Khan
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Richard Powell
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom.,Centre for Sport, Exercise and Life Sciences, Research Institute for Health & Wellbeing, Coventry University, Coventry, United Kingdom
| | - Prithwish Banerjee
- Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Department of Cardiology, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Tom Barker
- Department of Cardiothoracic Surgery, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Gordon McGregor
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom.,Centre for Sport, Exercise and Life Sciences, Research Institute for Health & Wellbeing, Coventry University, Coventry, United Kingdom
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4
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Gray EA, Skinner MA, Hale LA, Bunton RW. Preparation and support for physical activity following hospital discharge after coronary artery bypass graft surgery: A survey of current practice in New Zealand. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2022; 27:e1940. [PMID: 35120260 DOI: 10.1002/pri.1940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/31/2021] [Accepted: 12/30/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND PURPOSE Engagement in physical activity following coronary artery bypass graft (CABG) surgery has many benefits and also many potential barriers, especially during the first few months. It is important to explore current clinical practice before investigating ways to optimally prepare and support people to progressively increase their physical activity post-hospital discharge and to navigate the challenges. The aim of the study was to explore current practice in New Zealand hospital services for preparing and supporting people who have had CABG surgery to engage in physical activity following hospital discharge. METHODS Locality authorisation to participate in the study was sought from all 11 hospitals providing cardiac surgery services in New Zealand. The most senior health professional responsible for preparing people to engage in physical activity following CABG surgery was invited to participate by completing a purpose designed questionnaire on behalf of their hospital service. Respondents were also requested to provide any patient information handouts regarding progressive physical activity engagement following CABG surgery. RESULTS Responses were received from all nine hospitals that granted locality authorisation. All nine hospitals prepared people to engage in aerobic exercise prior to discharge, predominantly through the provision of a walking schedule. In contrast, no hospitals provided information about engagement in resistance exercise. There was wide variability in both the advice provided regarding sternal precautions and time to return to activities of daily living. Additionally, the facilitation of some elements of self-management for physical activity, in particular problem solving and providing follow up support outside of the cardiac rehabilitation setting was provided infrequently. DISCUSSION The findings demonstrated variability in service delivery in a number of areas and highlighted potential areas for improvement in light of what is known from the literature. Provision of follow up support for those unable to access outpatient cardiac rehabilitation is a key need.
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Affiliation(s)
- Emily Anne Gray
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Margot Alison Skinner
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Leigh Anne Hale
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
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Fiani B, Chacon D, Covarrubias C, Sarno E, Kondilis A. Sternotomy Approach to the Anterior Cervicothoracic Spine. Cureus 2021; 13:e19421. [PMID: 34926015 PMCID: PMC8654047 DOI: 10.7759/cureus.19421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
The anterior cervicothoracic spine is a challenging region to approach given the various vascular, osseous, nervous, and articular structures, which prevent adequate exposure. This region is susceptible to lesions ranging from tumors, degenerative disease, infectious processes, and traumatic fractures. Our objective was to critically evaluate the sternotomy approach in spine surgery to give the technical implications of its usage. The safety and efficacy of the transsternal approach are discussed as well as the advantages, disadvantages, indications, and contraindications. The transsternal approach is the most direct access to pathologies in the upper anterior cervicothoracic spine and enables the spine surgeon to gain direct exposure to the cervicothoracic junction for ideal visualization. Anatomical considerations must be kept in mind while performing a sternotomy to prevent complications such as denervation or bleeding. This technique is useful for the armamentarium of spinal surgeons.
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Affiliation(s)
- Brian Fiani
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Daniel Chacon
- Medicine, Ross University School of Medicine, Bridgetown, BRB
| | | | - Erika Sarno
- Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, USA
| | - Athanasios Kondilis
- Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, USA
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6
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Brown KD, van Zyl JS, da Graca B, Adams J, Meyer DM. Keep Your Move in the Tube® Method and Self-Confidence After Coronary Artery Bypass Graft Surgery. J Cardiopulm Rehabil Prev 2021; 41:438-440. [PMID: 34727564 DOI: 10.1097/hcr.0000000000000648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Katelyn D Brown
- Baylor Scott & White Sports Therapy & Research Center at The STAR, Frisco, Texas. Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas. Department of Cardiac Rehabilitation, Baylor Scott & White Heart and Vascular Hospital, Dallas, Texas
| | - Johanna S van Zyl
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas
| | - Briget da Graca
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas
| | - Jenny Adams
- Department of Cardiac Rehabilitation, Baylor Scott & White Heart and Vascular Hospital, Dallas, Texas
| | - Dan M Meyer
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas
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7
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Gray E, Dasanayake S, Sangelaji B, Hale L, Skinner M. Factors influencing physical activity engagement following coronary artery bypass graft surgery: A mixed methods systematic review. Heart Lung 2021; 50:589-598. [PMID: 34087676 DOI: 10.1016/j.hrtlng.2021.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Engagement in physical activity during the initial months following coronary artery bypass graft (CABG) surgery is important in order to improve health, quality of life and functional outcomes. There are, however, many potential barriers to physical activity engagement during the recovery period. No review studies have focused on barriers and facilitators to engagement in physical activity during the early stages of recovery following CABG surgery. OBJECTIVE To explore the factors that influence engagement in physical activity during the first three months following CABG surgery. METHODS Four electronic databases were searched. Extracted data from selected studies were synthesised using the Joanna Briggs Institute convergent integrated approach. RESULTS Nineteen studies met the inclusion criteria. Four main themes that influenced engagement were identified: sociodemographic variables; physical symptoms; psychosocial factors; and environmental factors. More barriers were identified than facilitating factors. Psychosocial factors were the most commonly reported barriers in the literature. CONCLUSIONS The findings of this review provide insights into factors that inhibit and facilitate engagement in physical activity following CABG surgery. Further research specifically exploring factors that influence engagement, especially facilitators, is required.
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Affiliation(s)
- Emily Gray
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Suranga Dasanayake
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Bahram Sangelaji
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Leigh Hale
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Margot Skinner
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
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8
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Brown KD, Shirkey HW, Shock T, Thornton K, Rafael-Yarihuaman AE, Bindra A. Impact of symptom-guided, progressive cardiac rehabilitation after left ventricular assist device implantation. Proc (Bayl Univ Med Cent) 2021; 34:631-633. [PMID: 34456497 DOI: 10.1080/08998280.2021.1918816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
A 29-year-old woman with a left ventricular assist device (LVAD) completed a progressive, symptom-limited cardiac rehabilitation program consisting of boxing, weight-lifting, and aerobic exercise, where she improved her exercise capacity by 2.7 metabolic equivalents (P < 0.001) and demonstrated significant myocardial recovery, allowing for successful LVAD explant 9 months after implantation.
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Affiliation(s)
- Katelyn D Brown
- Department of Cardiac Rehabilitation, Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas
| | - Heath W Shirkey
- Department of Cardiac Rehabilitation, Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas
| | - Tiffany Shock
- Department of Cardiac Rehabilitation, Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas
| | - Katherine Thornton
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas
| | | | - Amarinder Bindra
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas
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9
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de Waard D, Fagan A, Minnaar C, Horne D. Prise en charge des patients après un pontage aortocoronarien: guide pour les professionnels en soins primaires. CMAJ 2021; 193:E1107-E1113. [PMID: 34281973 PMCID: PMC8315203 DOI: 10.1503/cmaj.191108-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Dominique de Waard
- Faculté de médecine (de Waard, Fagan, Horne), Université Dalhousie; Division de la chirurgie cardiaque (de Waard, Fagan, Horne), Hôpital Queen Elizabeth II, Halifax, N.-É.; Hôpital Bethesda (Minnaar), Steinbach, Man
| | - Andrew Fagan
- Faculté de médecine (de Waard, Fagan, Horne), Université Dalhousie; Division de la chirurgie cardiaque (de Waard, Fagan, Horne), Hôpital Queen Elizabeth II, Halifax, N.-É.; Hôpital Bethesda (Minnaar), Steinbach, Man
| | - Christo Minnaar
- Faculté de médecine (de Waard, Fagan, Horne), Université Dalhousie; Division de la chirurgie cardiaque (de Waard, Fagan, Horne), Hôpital Queen Elizabeth II, Halifax, N.-É.; Hôpital Bethesda (Minnaar), Steinbach, Man
| | - David Horne
- Faculté de médecine (de Waard, Fagan, Horne), Université Dalhousie; Division de la chirurgie cardiaque (de Waard, Fagan, Horne), Hôpital Queen Elizabeth II, Halifax, N.-É.; Hôpital Bethesda (Minnaar), Steinbach, Man.
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10
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de Waard D, Fagan A, Minnaar C, Horne D. Management of patients after coronary artery bypass grafting surgery: a guide for primary care practitioners. CMAJ 2021; 193:E689-E694. [PMID: 33972222 PMCID: PMC8157999 DOI: 10.1503/cmaj.191108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Dominique de Waard
- Faculty of Medicine (de Waard, Fagan, Horne), Dalhousie University; Division of Cardiac Surgery (de Waard, Fagan, Horne), QEII Hospital, Halifax, NS; Bethesda Hospital (Minnaar), Steinbach, Man
| | - Andrew Fagan
- Faculty of Medicine (de Waard, Fagan, Horne), Dalhousie University; Division of Cardiac Surgery (de Waard, Fagan, Horne), QEII Hospital, Halifax, NS; Bethesda Hospital (Minnaar), Steinbach, Man
| | - Christo Minnaar
- Faculty of Medicine (de Waard, Fagan, Horne), Dalhousie University; Division of Cardiac Surgery (de Waard, Fagan, Horne), QEII Hospital, Halifax, NS; Bethesda Hospital (Minnaar), Steinbach, Man
| | - David Horne
- Faculty of Medicine (de Waard, Fagan, Horne), Dalhousie University; Division of Cardiac Surgery (de Waard, Fagan, Horne), QEII Hospital, Halifax, NS; Bethesda Hospital (Minnaar), Steinbach, Man.
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11
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Gach R, Triano S, Ogola GO, da Graca B, Shannon J, El-Ansary D, Bilbrey T, Cortelli M, Adams J. "Keep Your Move in the Tube" safely increases discharge home following cardiac surgery. PM R 2021; 13:1321-1330. [PMID: 33527697 DOI: 10.1002/pmrj.12562] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 01/07/2021] [Accepted: 01/19/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Restrictive sternal precautions intended to prevent cardiac surgery patients from damaging healing sternotomies lack supporting evidence and may decrease independence and increase postacute care utilization. Data regarding the impact of alternative approaches on safety and outcomes are needed to guide evidence-based best practices. OBJECTIVE To examine whether an approach allowing greater freedom during activities of daily living than permitted under commonly used restrictive sternal precautions can safely decrease postacute care utilization. DESIGN Before-and-after study, using propensity score adjustment to account for differences in patient clinical and demographic characteristics, surgery type, and surgeon. SETTING 600-bed acute care hospital. INTERVENTION Beginning March 2016, the acute care hospital replaced traditional weight- and time-based precautions given to patients who underwent median sternotomy with the "Keep Your Move in the Tube" (KMIT) approach for mindfully performing movements involved in the activities of daily living, guided by pain. MAIN OUTCOME MEASURES The study compared sternal wound complications, discharge disposition, 30-day readmission, and functional status between consecutive cardiac surgery patients with "independent" or "modified independent" preoperative functional status who underwent median sternotomy in the 1.5 years before (n = 627, standard precautions group) and after (n = 477, KMIT group) KMIT implementation. RESULTS The odds of discharge to home, versus to inpatient rehabilitation or skilled nursing facility, were ~3 times higher for KMIT than standard precautions patients (risk-adjusted odds ratio [rOR], 95% confidence interval [CI] = 2.90, 1.95-4.32, and 3.03, 1.57-5.86, respectively). KMIT patients also had significantly higher odds of demonstrating "independent" or "modified independent" functional status on final inpatient physical therapy treatment for bed mobility (rOR, 95% CI = 7.51, 5.48-10.30) and transfers (rOR, 95% CI = 3.40, 2.62-4.42). No significant difference was observed in sternal wound complications (in-hospital or causing readmission) (rOR, 95% CI = 1.27, 0.52-3.09) or all-cause 30-day readmissions (rOR, 95% CI = 0.55, 0.23-1.33). CONCLUSIONS KMIT increases discharge-to-home for cardiac surgery patients without increasing risk for adverse events and reducing utilization of expensive institutional postacute care.
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Affiliation(s)
- Richard Gach
- The Acute Therapy Department, Memorial Regional Hospital, Hollywood, Florida
| | - Susan Triano
- The Acute Therapy Department, Memorial Regional Hospital, Hollywood, Florida
| | - Gerald O Ogola
- Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, Texas
| | - Briget da Graca
- Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, Texas.,Robbins Institute for Health Policy & Leadership Baylor University, Waco, Texas
| | - John Shannon
- The Acute Therapy Department, Memorial Regional Hospital, Hollywood, Florida
| | - Doa El-Ansary
- Department of Surgery, Melbourne Medical School, The University of Melbourne, Melbourne, Australia.,School of Health and Biomedical Sciences, Swinburne University of Technology, Melbourne, Australia
| | - Tim Bilbrey
- Cardiac Rehabilitation Department, Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Michael Cortelli
- Department of Cardiac Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Jenny Adams
- Cardiac Rehabilitation Department, Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas
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12
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Abstract
Enhanced recovery after surgery (ERAS) protocols recognize early postoperative mobilization as a driver of faster postoperative recovery, return to normal activities, and improved long-term patient outcomes. For patients undergoing open cardiac surgery, an opportunity for facilitating earlier mobilization and a return to normal activity lies in the use of improved techniques to stabilize the sternal osteotomy. By following the key orthopedic principles of approximation, compression, and rigid fixation, a more nuanced approach to sternal precaution protocols is possible, which may enable earlier patient mobilization, physical rehabilitation, and recovery.
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13
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Park L, Coltman C, Agren H, Colwell S, King-Shier KM. "In the tube" following sternotomy: A quasi-experimental study. Eur J Cardiovasc Nurs 2020; 20:160–166. [PMID: 33611341 DOI: 10.1177/1474515120951981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/20/2020] [Accepted: 07/30/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Traditionally, physical movement has been limited for cardiac surgery patients, up to 12-weeks post-operatively. Patients are asked to use "standard sternal precautions," restricting their arm movement, and thereby limiting stress on the healing sternum. AIM To compare return to function, pain/discomfort, wound healing, use of pain medication and antibiotics, and post-operative length of hospital stay in cardiac surgery patients having median sternotomy who used standard sternal precautions or Keep Your Move in the Tube movement protocols post-operatively. METHODS A quasi-experimental design was used (100 standard sternal precautions and 100 Keep Your Move in the Tube patients). Patients were followed in person or by telephone over a period of 12-weeks postoperatively. Outcomes were measured at day 7, as well as weeks 4, 8, and 12 weeks. RESULTS The majority of participants (77% in each group) were male and had coronary artery bypass graft surgery (66% standard sternal precautions and 72% Keep Your Move in the Tube). Univariate analysis revealed the standard sternal precautions group had lesser ability to return to functional activities than the Keep Your Move in the Tube group (p<0.0001) over time. This difference was minimized however, by week 12. Multivariate analysis revealed that increasing age, body mass index, and female sex were associated with greater functional impairment over time, but no difference between standard sternal precautions and Keep Your Move in the Tube groups. CONCLUSIONS Keep Your Move in the Tube, a novel patient-oriented movement protocol, has potential for cardiac surgery patients to be more confident and comfortable in their recovery.
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Affiliation(s)
- L Park
- Libin Cardiovascular Institute of Alberta, University of Calgary, Canada
| | - C Coltman
- Libin Cardiovascular Institute of Alberta, University of Calgary, Canada
| | - H Agren
- Libin Cardiovascular Institute of Alberta, University of Calgary, Canada
| | - S Colwell
- Libin Cardiovascular Institute of Alberta, University of Calgary, Canada
| | - K M King-Shier
- Libin Cardiovascular Institute of Alberta, University of Calgary, Canada.,Faculty of Nursing, University of Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Canada
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14
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Holloway C, Pathare N, Huta J, Grady D, Landry A, Christie C, Pierce P, Bopp C. The Impact of a Less Restrictive Poststernotomy Activity Protocol Compared With Standard Sternal Precautions in Patients Following Cardiac Surgery. Phys Ther 2020; 100:1074-1083. [PMID: 32302408 DOI: 10.1093/ptj/pzaa067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 09/17/2019] [Accepted: 12/08/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Guidelines following median sternotomy typically include strict sternal precautions (SP). Recently, alternative approaches propose less functional restrictions while avoiding excessive stress to the sternum. The study aimed to determine the effect of a less restrictive (LR) approach versus a standard SP protocol after median sternotomy. METHODS The study was a cross-sectional design (n = 364; SP: n = 172, 66.3 [SD = 11.2] years; LR: n = 196, 65.2 [SD = 11.2] years). This study ran in 2 consecutive phases and compared 2 groups after median sternotomy at a community-based hospital. The LR group received instructions on the Keep Your Move in the Tube approach. At 2 to 3 weeks after discharge, sternal instability was assessed using the Sternal Instability Scale, and patients completed a self-reported survey (perceived pain rating/frequency, sternal instability, and functional mobility). The 2 groups were compared using the Mann-Whitney U test and chi-square test (P < .05). RESULTS There were no significant differences between the 2 groups for all the outcomes, Sternal Instability Scale, pain rating, pain frequency, perceived sternal instability, difficulty with functional mobility, length of stay, and discharge disposition. CONCLUSIONS In our study, the implementation of the LR approach, Keep Your Move in the Tube, had no adverse effect on outcomes 2 to 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. IMPACT STATEMENT These data are useful in clinical decision-making regarding alternative approaches for mobility following sternotomy.
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Affiliation(s)
- Caitlyn Holloway
- CCRN-CMC, PCCN, TNCC, St. Peter's Hospital/St. Peter's Health Partners-Clinical Support and Research, Albany, New York
| | - Neeti Pathare
- The Sage Colleges, Department of Physical Therapy, 65 1st Street, Troy, NY 12180 (USA)
| | - Jean Huta
- Peter's Hospital/St. Peter's Health Partners-Physical Therapy
| | - Dana Grady
- St. Peter's Hospital/St. Peter's Health Partners-Occupational Therapy
| | - Andrea Landry
- CCRN, St. Peter's Hospital/St. Peter's Health Partners-Cardiovascular Surgery
| | - Claire Christie
- Sunnyview Hospital and Rehab/St. Peter's Health Partners-Rehabilitative Services, Schenectady, New York
| | - Patricia Pierce
- St. Peter's Hospital/St. Peter's Health Partners-Occupational Therapy
| | - Charity Bopp
- ACSM-CEP, St. Peter's Hospital/St. Peter's Health Partners-Cardiovascular Surgery
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Wang C, Goel R, Noun M, Ghanta RK, Najafi B. Wearable Sensor-Based Digital Biomarker to Estimate Chest Expansion During Sit-to-Stand Transitions-A Practical Tool to Improve Sternal Precautions in Patients Undergoing Median Sternotomy. IEEE Trans Neural Syst Rehabil Eng 2020; 28:165-173. [PMID: 31714229 PMCID: PMC7027954 DOI: 10.1109/tnsre.2019.2952076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sternal precautions are a universal part of the discharge education for post-sternotomy patients to reduce the risk of sternal complications. However, they are always designed based on physical therapists' or surgeons' subjective judgment without any objective evidence. Thus, they could be overly restrictive to hinder the patients' recovery, physically and psychologically. To fill this gap, this paper proposes a digital biomarker to estimate chest expansion during sit-to-stand transitions based on wearable inertial sensing and data fusion technologies. First, we carried out bench tests to evaluate the reliability of the digital biomarker to represent relative sensor rotation. We also verified effectiveness of this digital biomarker to detect subtle skin extension in proactive chest expansion trials by 11 healthy volunteers. Then, we measured the digital biomarker during sit-to-stand transitions with different strategies and some daily routine activities (walking, sitting, and standing) performed by the healthy volunteers and 22 post-sternotomy patients. The comparison between these measurements evaluated the effectiveness of several known guidelines of sternal precautions for sit-to-stand transitions. The results showed that first, pushing up from a chair by taking support from armrests induced larger chest expansion ( p = 0.009 ) compared with sit-to-stand transition while keeping the arms relaxed; second, crossing the arms or hugging a pillow can help reduce chest expansion ( ) compared with keeping the arms relaxed during sit-to-stand transitions; third, pushing up while taking support from a frontal support (e.g., table or walker) induced the same level of chest expansion ( ) as that during sit-to-stand transition while keeping the arms relaxed.
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El-Ansary D, LaPier TK, Adams J, Gach R, Triano S, Katijjahbe MA, Hirschhorn AD, Mungovan SF, Lotshaw A, Cahalin LP. An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy. Phys Ther 2019; 99:1587-1601. [PMID: 31504913 DOI: 10.1093/ptj/pzz126] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 03/07/2019] [Accepted: 04/30/2019] [Indexed: 02/07/2023]
Abstract
Cardiac surgery via median sternotomy is performed in over 1 million patients per year worldwide. Despite evidence, sternal precautions in the form of restricted arm and trunk activity are routinely prescribed to patients following surgery to prevent sternal complications. Sternal precautions may exacerbate loss of independence and prevent patients from returning home directly after hospital discharge. In addition, immobility and deconditioning associated with restricting physical activity potentially contribute to the negative sequelae of median sternotomy on patient symptoms, physical and psychosocial function, and quality of life. Interpreting the clinical impact of sternal precautions is challenging due to inconsistent definitions and applications globally. Following median sternotomy, typical guidelines involve limiting arm movement during loaded lifting, pushing, and pulling for 6 to 8 weeks. This perspective paper proposes that there is robust evidence to support early implementation of upper body activity and exercise in patients recovering from median sternotomy while minimizing risk of complications. A clinical paradigm shift is encouraged, one that encourages a greater amount of controlled upper body activity, albeit modified in some situations, and less restrictive sternal precautions. Early screening for sternal complication risk factors and instability followed by individualized progressive functional activity and upper body therapeutic exercise is likely to promote optimal and timely patient recovery. Substantial research documenting current clinical practice of sternal precautions, early physical therapy, and cardiac rehabilitation provides support and the context for understanding why a less restrictive and more active plan of care is warranted and recommended for patients following a median sternotomy.
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Affiliation(s)
- Doa El-Ansary
- Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology, Melbourne, Victoria, Australia; Department of Surgery, School of Medicine, University of Melbourne, Melbourne, Australia; and Clinical Research Institute, Sydney, Australia. Address all correspondence to Associate Professor El-Ansary at:
| | - Tanya Kinney LaPier
- Department of Physical Therapy, Eastern Washington University, Spokane, Washington. Dr LaPier is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy
| | - Jenny Adams
- Baylor Institute for Rehabilitation, Baylor University Medical Center, Dallas, Texas
| | - Richard Gach
- Department of Rehabilitation Services, Memorial Regional Hospital, Hollywood, Florida
| | - Susan Triano
- Department of Rehabilitation Services, Memorial Regional Hospital, Hollywood, Florida
| | - Md Ali Katijjahbe
- Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology Department of Physiotherapy, Hospital Canselor Tuanku Muhriz, UKM Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Andrew D Hirschhorn
- MQ Health Physiotherapy and Department of Health Professions, Faculty of Medicine and Health, Macquarie University, Sydney, Australia
| | - Sean F Mungovan
- Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology, Clinical Research Institute and Westmead Private Physiotherapy Services, Westmead Private Hospital, Sydney, Australia
| | - Ana Lotshaw
- Baylor Institute for Rehabilitation, Baylor University Medical Center. Dr Lotshaw is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy
| | - Lawrence P Cahalin
- Department of Physical Therapy, Miller School of Medicine, University of Miami, Coral Gables, Florida
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Resistance Training Following Median Sternotomy: A Systematic Review and Meta-Analysis. Heart Lung Circ 2019; 28:1549-1559. [DOI: 10.1016/j.hlc.2019.05.097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/10/2019] [Accepted: 05/03/2019] [Indexed: 12/17/2022]
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Ratajska M, Chochowska M, Kulik A, Bugajski P. Myofascial release in patients during the early postoperative period after revascularisation of coronary arteries. Disabil Rehabil 2019; 42:3327-3338. [PMID: 31050562 DOI: 10.1080/09638288.2019.1593518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: The evaluation of the impact of soft tissue manual therapy with a myofascial release on pulmonary function, postoperative pain, fatigue, breathing difficulties and physical fitness, in patients during the early postoperative period after coronary artery bypass grafting and off-pump coronary artery bypass grafting surgery.Materials and methods: The study included 80 subjects (59 males) with an average age of 64.13 years old. They were randomised into two groups: group I (n = 40) received a conventional form of rehabilitation and group II (n = 40) additionally, from day 3 to day 6 post-surgery, was provided the Carol Manheim form of myofascial release. Subjects were evaluated three times: before the surgery, on day 4 and 6 post-surgery. Using the visual analogue scale, the following symptoms were measured: pain intensity, breathing difficulties and level of physical endurance. Fatigue after performing physical exercises was measured using the Borg scale. Spirometry was used to measure the one-second forced expiratory volume and forced vital capacity.Results: Positive changes were observed in both groups with regard to all analysed variables. However, group II compared to group I showed a significantly greater improvement (p < 0.05; the Mann-Whitney U test) in relation to: pain intensity on day 4 (mean 5.46 vs 6.58) and on day 6 (mean 3.05 vs 5.35) after the surgery; lower breathing difficulties on day 6 post-surgery (mean 4.08 vs 5.63); limiting physical fitness on day 6 post-surgery (mean 6.35 vs 5.13). Between the condition prior to the surgery and day 6 post-surgery in group II compared to group I, there was a significantly smaller (p < 0.05; Student's t-test) decrease in one-second forced expiratory volume (mean -0.65 vs -0.9 L/s) and the volume of forced vital capacity (mean -0.63 vs -1.33 L). Between day 4 and 6 post-surgery in group II compared to group I, there was a significantly higher (p < 0.05; Student's t-test) increase in the one-second forced expiratory volume (mean 0.21 vs 0.11 L/s) and forced vital capacity (mean 0.32 vs 0.12 L).Conclusions: Implementing myofascial release techniques in the conventional form of cardiosurgical rehabilitation might enhance the improvement in pulmonary function, lessen breathing difficulties, pain intensity and fatigue, it might augment the increase in physical endurance among patients during the early postoperative period after coronary artery bypass grafting and off-pump coronary artery bypass grafting surgery.Implications for rehabilitationThe implementation of myofascial release techniques in conventional cardiac rehabilitation may improve the pulmonary function in patients during the early postoperative period, after revascularisation of coronary arteries.The adoption of myofascial release techniques in conventional cardiac rehabilitation may decrease breathing difficulties, pain intensity, fatigue and increase the physical fitness in patients during the early postoperative period, after the revascularisation of the coronary arteries.The implementation of myofascial release techniques in conventional cardiac rehabilitation may enhance patients' improvement during the early postoperative period, after the revascularisation of the coronary arteries.
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Affiliation(s)
- Maria Ratajska
- Department of Cardiovascular Surgery, Strus Hospital Poznan, Poznan, Poland
| | - Małgorzata Chochowska
- Department of Rehabilitation, Poznan University School of Physical Education, Gorzow Wielkopolski, Poland
| | - Anita Kulik
- Department of Rehabilitation, Poznan University School of Physical Education, Gorzow Wielkopolski, Poland
| | - Paweł Bugajski
- Department of Cardiovascular Surgery, Strus Hospital Poznan, Poznan, Poland.,Poznan University of Medical Sciences, Poznan, Poland
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Ge W, Hians B, Sfara A. Noncontact Measurement of the Deformation of Sternal Skin During Shoulder Movements and Upper Extremity Activities Restricted by Sternal Precautions. Phys Ther 2018; 98:911-917. [PMID: 30107567 DOI: 10.1093/ptj/pzy089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 07/31/2018] [Indexed: 11/14/2022]
Abstract
BACKGROUND Existing variation has been identified in the rehabilitation programs for patients following cardiac surgery. Sternal precautions are believed to be overly restrictive and detrimental to patient recovery both physically and psychologically. OBJECTIVE The objective of this study was to determine the deformation of sternal skin during shoulder movements and upper extremity activities using a noncontact approach. DESIGN This was a cross-sectional, nonexperimental observational study. METHODS Two black dots were marked on participants' skin overlying sternoclavicular joints using an erasable marker. The coordinates of the dots were recorded using a digital camera and obtained using ImageJ, a public domain image processing program. Skin deformation between the 2 dots was quantified as biomechanical strain. RESULTS The sternal skin strain was - 15.3% (SD = 5.6) and - 12.0% (SD = 7.0) at 90 and 180 degrees of flexion; 0.0% (SD=0.0) and-12.8% (SD=5.8) at 90 and 180 degrees of abduction; and - 6.4% (SD=2.8), - 8.9% (SD=3.8), and - 9.8% (SD=4.6) when lifting the 0-, 5-, and 10-lb weights, respectively. The sternal skin strain was 7.9% (SD=3.9) for extension to the end range and-2.5% (SD=5.8) for pushing up from a chair. There is a trend of strain magnitude decrease with the increase of rhomboid strength, but no statistically significant association was found between them (R=0.12). LIMITATIONS Limitations included convenience sampling, small sample size, and using skin deformation as a proxy for mechanical loading of the bony structures. CONCLUSIONS The data do not support the restriction on most of the shoulder movements and upper extremity activities following cardiac surgery. The approach has the advantage of measuring skin deformation in the entire sternal region.
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Affiliation(s)
- Weiqing Ge
- Department of Physical Therapy, Youngstown State University, One University Plaza, Youngstown, OH 44555 (USA)
| | - Brittany Hians
- Department of Physical Therapy, Youngstown State University; and Premier Therapy, Beaver Falls, Pennsylvania
| | - Alison Sfara
- Department of Physical Therapy, Youngstown State University; and Anchor Health and Rehabilitation, Aiken, South Carolina
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Balachandran S, Denehy L, Lee A, Royse C, Royse A, El-Ansary D. Motion at the Sternal Edges During Upper Limb and Trunk Tasks In-Vivo as Measured by Real-Time Ultrasound Following Cardiac Surgery: A Three-Month Prospective, Observational Study. Heart Lung Circ 2018; 28:1283-1291. [PMID: 30194001 DOI: 10.1016/j.hlc.2018.05.195] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 05/02/2018] [Accepted: 05/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite a paucity of evidence, patients following cardiac surgery via median sternotomy are routinely prescribed sternal precautions that restrict upper limb and trunk movements, with the rationale of reducing postoperative sternal complications such as sternal wound dehiscence, instability, infection and/or pain. The primary aim of this study was to measure motion at the sternal edges during dynamic upper limb and trunk tasks to better inform future sternal precautions and optimise postoperative recovery. Motion at the sternal edges was measured using ultrasound, which has been demonstrated to be a clinically valid and reliable measure in patients following cardiac surgery. METHODS Seventy-five (75) patients following cardiac surgery via median sternotomy with conventional stainless steel wire closure were recruited. Motion at the sternal edges in the lateral (coronal plane) and anterior-posterior (sagittal plane) directions was measured at the level of the fourth intercostal space (mid-sternum) using ultrasound. Ultrasound measures were taken at rest and during five dynamic upper limb and trunk tasks (deep inspiration, cough, unilateral and bilateral upper limb elevation and sit to stand), over the first 3 postoperative months (3 to 7 days, 6 weeks and 3 months postoperatively). Sternal pain, functional status and sternal healing were also observed over the same postoperative period. RESULTS The magnitude of overlap of the sternal edges in the lateral direction, and separation of the sternal edges in the anterior-posterior direction, both significantly decreased by 0.01cm, over the first 3 postoperative months (p<0.01). Coughing, however, produced a significant increase in separation of the sternal edges in the lateral direction (0.01-0.02cm) and pain (12-63%), compared to rest and all other tasks, at each postoperative time point (p<0.01). Additionally, there was a significant decrease in sternal pain (81%) and increase in postoperative function (79%) over the same postoperative period (p<0.01). At 3 months postoperatively, five (7%) participants demonstrated radiological sternal union and one (1%) participant was diagnosed with clinical sternal instability. CONCLUSIONS A small magnitude of multi-planar motion at the sternal edges, at the mid-sternum, was demonstrated during dynamic upper limb and trunk tasks in a cohort of cardiac surgery patients post-sternotomy, over the first 3 postoperative months. Future research investigating motion at different levels of the sternum, with varying methods of sternal closure, and over a longer postoperative period is warranted to better inform sternal precautions and optimise postoperative recovery.
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Affiliation(s)
- Sulakshana Balachandran
- Physiotherapy Department, The University of Melbourne, Melbourne, Vic, Australia; Physiotherapy Department, Greenslopes Private Hospital, Brisbane, Qld, Australia.
| | - Linda Denehy
- Physiotherapy Department, The University of Melbourne, Melbourne, Vic, Australia
| | - Annemarie Lee
- Physiotherapy Department, Monash University, Melbourne, Vic, Australia
| | - Colin Royse
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Alistair Royse
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Doa El-Ansary
- Physiotherapy Department, The University of Melbourne, Melbourne, Vic, Australia; Department of Surgery, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Health Professions, Swinburne University, Melbourne, Vic, Australia; Clinical Research Institute, Westmead Private Hospital, Sydney, NSW, Australia.
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21
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Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' Trial): a randomised trial. J Physiother 2018; 64:97-106. [PMID: 29602750 DOI: 10.1016/j.jphys.2018.02.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/12/2018] [Accepted: 02/20/2018] [Indexed: 12/23/2022] Open
Abstract
QUESTION In people who have undergone cardiac surgery via median sternotomy, does modifying usual sternal precautions to make them less restrictive improve physical function, pain, kinesiophobia and health-related quality of life? DESIGN Two-centre, randomised, controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS Seventy-two adults who had undergone cardiac surgery via a median sternotomy were included. INTERVENTION Participants were randomly allocated to one of two groups at 4 (SD 1) days after surgery. The control group received the usual advice to restrict their upper limb use for 4 to 6 weeks (ie, restrictive sternal precautions). The experimental group received advice to use pain and discomfort as the safe limits for their upper limb use during daily activities (ie, less restrictive precautions) for the same period. Both groups received postoperative individualised education in hospital and via weekly telephone calls for 6 weeks. OUTCOME MEASURES The primary outcome was physical function assessed by the Short Physical Performance Battery. Secondary outcomes included upper limb function, pain, kinesophobia, and health-related quality of life. Outcomes were measured before hospital discharge and at 4 and 12 weeks postoperatively. Adherence to sternal precautions was recorded. RESULTS There were no statistically significant differences in physical function between the groups at 4 weeks (MD 1.0, 95% CI -0.2 to 2.3) and 12 weeks (MD 0.4, 95% CI -0.9 to 1.6) postoperatively. There were no statistically significant between-group differences in secondary outcomes. CONCLUSION Modified (ie, less restrictive) sternal precautions for people following cardiac surgery had similar effects on physical recovery, pain and health-related quality of life as usual restrictive sternal precautions. Similar outcomes can be anticipated regardless of whether people following cardiac surgery are managed with traditional or modified sternal precautions. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ANZCTRN12615000968572. [Katijjahbe MA, Granger CL, Denehy L, Royse A, Royse C, Bates R, Logie S, Nur Ayub MA, Clarke S, El-Ansary D (2018) Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' Trial): a randomised trial. Journal of Physiotherapy 64: 97-106].
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Ennis S, Lobley G, Worrall S, Powell R, Kimani PK, Khan AJ, Banerjee P, Barker T, McGregor G. Early initiation of post-sternotomy cardiac rehabilitation exercise training (SCAR): study protocol for a randomised controlled trial and economic evaluation. BMJ Open 2018; 8:e019748. [PMID: 29574443 PMCID: PMC5875596 DOI: 10.1136/bmjopen-2017-019748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Current guidelines recommend abstinence from supervised cardiac rehabilitation (CR) exercise training for 6 weeks post-sternotomy. This practice is not based on empirical evidence, thus imposing potentially unnecessary activity restrictions. Delayed participation in CR exercise training promotes muscle atrophy, reduces cardiovascular fitness and prolongs recovery. Limited data suggest no detrimental effect of beginning CR exercise training as early as 2 weeks post-surgery, but randomised controlled trials are yet to confirm this. The purpose of this trial is to compare CR exercise training commenced early (2 weeks post-surgery) with current usual care (6 weeks post-surgery) with a view to informing future CR guidelines for patients recovering from sternotomy. METHODS AND ANALYSIS In this assessor-blind randomised controlled trial, 140 cardiac surgery patients, recovering from sternotomy, will be assigned to 8 weeks of twice-weekly supervised CR exercise training commencing at either 2 weeks (early CR) or 6 weeks (usual care CR) post-surgery. Usual care exercise training will adhere to current UK recommendations. Participants in the early CR group will undertake a highly individualised 2-3 week programme of functional mobility, strength and cardiovascular exercise before progressing to a usual care CR programme. Outcomes will be assessed at baseline (inpatient), pre-CR (2 or 6 weeks post-surgery), post-CR (10 or 14 weeks post-surgery) and 12 months. The primary outcome will be change in 6 min walk distance. Secondary outcomes will include measures of functional fitness, quality of life and cost-effectiveness. ETHICS AND DISSEMINATION Recruitment commenced on July 2017 and will complete by December 2019. Results will be disseminated via national governing bodies, scientific meetings and peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03223558; Pre-results.
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Affiliation(s)
- Stuart Ennis
- Department of Cardiac Rehabilitation, Centre for Exercise and Health, University Hospital, Coventry, UK
- Cardiff Centre for Exercise and Health, Cardiff Metropolitan University, Cardiff, UK
| | - Grace Lobley
- Department of Cardiac Rehabilitation, Centre for Exercise and Health, University Hospital, Coventry, UK
| | - Sandra Worrall
- Department of Cardiac Rehabilitation, Centre for Exercise and Health, University Hospital, Coventry, UK
| | - Richard Powell
- Department of Cardiac Rehabilitation, Centre for Exercise and Health, University Hospital, Coventry, UK
| | - Peter K Kimani
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amir Jahan Khan
- Health and Life Sciences Research Centre, Coventry University, Coventry, UK
| | - Prithwish Banerjee
- Health and Life Sciences Research Centre, Coventry University, Coventry, UK
- Department of Cardiology, University Hospitals, Coventry, UK
| | - Thomas Barker
- Department of Cardiothoracic Surgery, University Hospital, Coventry, UK
| | - Gordon McGregor
- Department of Cardiac Rehabilitation, Centre for Exercise and Health, University Hospital, Coventry, UK
- Health and Life Sciences Research Centre, Coventry University, Coventry, UK
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Denehy L, Granger CL, El-Ansary D, Parry SM. Advances in cardiorespiratory physiotherapy and their clinical impact. Expert Rev Respir Med 2018; 12:203-215. [PMID: 29376440 DOI: 10.1080/17476348.2018.1433034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cardiorespiratory physiotherapy is an evidence-based practice that has evolved alongside changes in medical and surgical management, analgesia, the ageing society and increasing comorbidities of our patient populations. Continued research provides the profession with the ability to adapt to meet the changing patient and community needs. Areas covered: This review focuses on surgical, respiratory and critical care settings discussing the most significant changes over the past decade with an increased focus on rehabilitation across the care continuum and a shift away from providing predominately airway clearance in established disease populations but also providing this in emerging groups. Further important changes are identification and emphases on patient self-management including changing their behaviour to more positively embrace wellness, particularly increasing physical activity levels. This paper outlines these changes and offers speculation on factors that may impact the profession in the future. Expert commentary: The increasing focus on new technologies, physical activity levels, changes to the health systems in different countries and an increasingly comorbid and ageing society will shape the next steps in the evolution of cardiorespiratory physiotherapy. Continued research is vital to keep pace with these changes so that physiotherapists can provide the most effective treatments to improve patient outcomes.
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Affiliation(s)
- Linda Denehy
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
| | - Catherine L Granger
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
| | - Doa El-Ansary
- b Department of Cardiothoracic Surgery , Royal Melbourne Hospital, Royal Parade , Parkville , Australia
| | - Selina M Parry
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
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Ge W, Sfara A, Hians B. Skin deformation during shoulder movements and upper extremity activities. Clin Biomech (Bristol, Avon) 2017; 47:1-6. [PMID: 28528237 DOI: 10.1016/j.clinbiomech.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 04/13/2017] [Accepted: 05/11/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The necessity of sternal precautions for patients following cardiac surgery with median sternotomy has been questioned by clinicians, researchers, and even patients. The primary purpose was to determine if sternal skin deformation during shoulder movements and upper extremity activities is compressive or distractive and if there are any significant differences between the skin deformation at different positions during shoulder movements and upper extremity activities. The secondary purpose was to determine if sternal skin deformation is correlated with scapular stabilizer muscle strength. METHODS The research design was a cross-sectional non-experimental descriptive study. A 3D electromagnetic tracking system was used to measure sternal skin deformation quantified by strain. FINDINGS The sternal skin strain was -10.8 (SD 6.2) % and -9.8 (SD 6.1) % at 90 and 180° flexion (P=0.45), -2.7 (SD 3.4) % and -10.4 (SD 7.9) % at 90 and 180° abduction (P<0.01), -3.6 (SD 4.1) %, -4.9 (SD 6.4) %, and -6.8 (SD 5.2) % when lifting 0, 5, and 10lb weights (P=0.07), 0.7 (SD 2.5) % for extension, and -1.1 (SD 5.0) % for pushing up from a chair. There is a trend of strain magnitude decrease with the increase of rhomboid strength without significant association (R=0.14). INTERPRETATION Our data does not support the restriction for most of the shoulder movements and upper extremity activities following cardiac surgery. The only exception is bilateral shoulder extension. We propose a strategy for preoperative physical therapy to stabilize scapular muscles to decrease mechanical loading translated from shoulder to sternum.
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Affiliation(s)
- Weiqing Ge
- Department of Physical Therapy, Youngstown State University, One University Plaza, Youngstown, OH 44555, USA.
| | - Alison Sfara
- Department of Physical Therapy, Youngstown State University, One University Plaza, Youngstown, OH 44555, USA
| | - Brittany Hians
- Department of Physical Therapy, Youngstown State University, One University Plaza, Youngstown, OH 44555, USA
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Katijjahbe MA, Denehy L, Granger CL, Royse A, Royse C, Bates R, Logie S, Clarke S, El-Ansary D. The Sternal Management Accelerated Recovery Trial (S.M.A.R.T) - standard restrictive versus an intervention of modified sternal precautions following cardiac surgery via median sternotomy: study protocol for a randomised controlled trial. Trials 2017. [PMID: 28645301 PMCID: PMC5481951 DOI: 10.1186/s13063-017-1974-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background The routine implementation of sternal precautions to prevent sternal complications that restrict the use of the upper limbs is currently worldwide practice following a median sternotomy. However, evidence is limited and drawn primarily from cadaver studies and orthopaedic research. Sternal precautions may delay recovery, prolong hospital discharge and be overly restrictive. Recent research has shown that upper limb exercise reduces post-operative sternal pain and results in minimal micromotion between the sternal edges as measured by ultrasound. The aims of this study are to evaluate the effects of modified sternal precautions on physical function, pain, recovery and health-related quality of life after cardiac surgery. Methods/design This study is a phase II, double-blind, randomised controlled trial with concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. Patients (n = 72) will be recruited following cardiac surgery via a median sternotomy. Sample size calculations were based on the minimal important difference (two points) for the primary outcome: Short Physical Performance Battery. Thirty-six participants are required per group to counter dropout (20%). All participants will be randomised to receive either standard or modified sternal precautions. The intervention group will receive guidelines encouraging the safe use of the upper limbs. Secondary outcomes are upper limb function, pain, kinesiophobia and health-related quality of life. Descriptive statistics will be used to summarise data. The primary hypothesis will be examined by repeated-measures analysis of variance to evaluate the changes from baseline to 4 weeks post-operatively in the intervention arm compared with the usual-care arm. In all tests to be conducted, a p value <0.05 (two-tailed) will be considered statistically significant, and confidence intervals will be reported. Discussion The Sternal Management Accelerated Recovery Trial (S.M.A.R.T.) is a two-centre randomised controlled trial powered and designed to investigate whether the effects of modifying sternal precautions to include the safe use of the upper limbs and trunk impact patients’ physical function and recovery following cardiac surgery via median sternotomy. Trial registration Australian and New Zealand Clinical Trials Registry identifier: ACTRN12615000968572. Registered on 16 September 2015 (prospectively registered). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1974-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Md Ali Katijjahbe
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3053, Australia. .,Department of Physiotherapy, Hospital Cancelor Tuaku Mukhriz, Pusat Perubatan University Kebangsaan Malaysia, Kuala Lumpur, 56000, Malaysia.
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3053, Australia
| | - Catherine L Granger
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3053, Australia.,Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Alistair Royse
- Department of Surgery, University of Melbourne, Parkville, VIC, 3010, Australia.,Department of Surgery, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Colin Royse
- Department of Surgery, University of Melbourne, Parkville, VIC, 3010, Australia.,Department of Surgery, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Rebecca Bates
- Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Sarah Logie
- Physiotherapy Department, Melbourne Private Hospital, Parkville, VIC, 3052, Australia
| | - Sandy Clarke
- Statistical Consulting Centre, School of Mathematics and Statistics, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Doa El-Ansary
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3053, Australia
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