An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy

Post-sternotomy movement strategies in adults: a scoping review

AIMS

Post-sternotomy movement strategies for adults should be an evidence-informed approach and support a safe, independent return to daily activity. Recent new movement strategies have emerged. The aim of this scoping review was to identify and summarize the available evidence for post-sternotomy movement strategies in adults.

METHODS AND RESULTS

The electronic databases searched included MEDLINE, Embase, Sport Discus, CINAHL, Academic Search Complete, the Cochrane Library, Scopus, and PEDro. The search did not have a date limit. After 2405 duplicates were removed, 2978 records were screened, and 12 were included; an additional 2 studies were identified through reference searching for a total of 14 included studies. A data extraction table was used, and the findings are summarized in a tabular and narrative form. Three post-sternotomy movement strategies were identified in the literature: sternal precautions (SP), modified SP, and Keep Your Move in the Tube (KYMITT™). The authors suggested that the practice of SP was based on expert opinion and not founded in evidence. However, the evidence from the identified articles suggested that new movement strategies are safe and allow patients to choose an increased level of activity that promotes improved functional status and confidence.

CONCLUSION

More prospective cohort studies and multi-centred randomized control trials are needed; however, the current evidence suggests that modified SP and KYMITT™ are as safe as SP and can promote a patient-centred approach.

REGISTRATION

University of Calgary's Digital Repository PRISM http://hdl.handle.net/1880/115439.

The effect of resistance training on PCSK9 levels in patients undergoing cardiac rehabilitation after coronary artery bypass grafting: a randomized study

BACKGROUND

Resistance training is commonly recommended as part of secondary prevention for post-coronary artery bypass graft (CABG) patients in conjunction with aerobic exercise. Despite its potential benefits, there is currently a lack of studies investigating the impact of resistance training on proprotein convertase subtilisin kexin 9 (PCSK9).

AIM

To evaluate the effect of intensive resistance training on proprotein convertase subtilisin kexin 9 (PCSK9) levels among post-CABG patients undergoing cardiac rehabilitation (CR).

METHODS

In this prospective, open-label, randomized trial, 87 post-coronary artery bypass graft (CABG) patients were randomly assigned into two groups: moderate to high intensity resistance training and aerobic training (n = 44) or aerobic training alone (n = 43) for a total of 12 sessions. Changes in PCSK9 levels was determined as a primary endpoint, while secondary endpoints included changes in the six-minute walk test (6-MWT) results, aerobic capacity, WHO-5 well-being index, fasting blood glucose, and lipid profile. Both groups underwent intention-to-treat analysis.

RESULTS

Following completion of cardiac rehabilitation program, the intervention group demonstrated a significant decrease in mean PCSK9 levels when compared to the control group (β = -55 ng/ml, 95% CI -6.7 to -103.3, p = 0.026), as well as significant improvements in the 6-MWT result (β = 28.2 m, 95% CI 2.4-53.9, p = 0.033), aerobic capacity (β = 0.9 Mets, 95% CI 0.1-1.7, p = 0.021), and WHO-5 well-being index (β = 8.1, 95% CI 2.0-14.4, p = 0.011) in patients who received resistance and aerobic training. No statistically significant changes were observed in fasting blood glucose, cholesterol, LDL-C, HDL-C, and triglyceride levels.

CONCLUSION

Resistance training in CR significantly reduced PCSK-9 levels and increases patient's functional capacity and quality of life. (NCT02674659 04/02/2016).

A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

arly u ervised ncremental esistance raining (ESpIRiT) following cardiac surgery via a median sternotomy: a study protocol of a multicentre randomised controlled trial

INTRODUCTION

There is no consistency in current practice pertaining to the prescription and progression of upper limb resistance exercise following cardiac surgery via median sternotomy. The aim of this study is to investigate whether less restrictive sternal precautions with the addition of early-supervised resistance training exercise improves upper limb function and facilitates recovery following median sternotomy.

METHODS AND ANALYSIS

This is double-blind randomised controlled trial, with parallel group, concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. 240 adult participants who had median sternotomy from eight hospitals in Malaysia will be recruited. Sample size calculations were based on the unsupported upper limb test. All participants will be randomised to receive either standard or early supervised incremental resistance training. The primary outcomes are upper limb function and pain. The secondary outcomes will be functional capacity, multidomain recovery (physical and psychological), length of hospital stay, incidence of respiratory complications and quality of life. Descriptive statistics will be used to summarise data. Data will be analysed using the intention-to-treat principle. The primary hypothesis will be examined by evaluating the change from baseline to the 4-week postoperative time point in the intervention arm compared with the usual care arm. For all tests to be conducted, a p value of <0.05 (two tailed) will be considered statistically significant, and CIs will be reported. The trial is currently recruiting participants.

ETHICS AND DISSEMINATION

The study was approved by a central ethical committee as well as the local Research Ethics Boards of the participating sites (UKM:JEP-2019-654; Ministry of Health: NMMR-50763; National Heart Centre: IJNREC/501/2021). Approval to start was given prior to the recruitment of participants commencing at any sites. Process evaluation findings will be published in peer-reviewed journals and presented at relevant academic conferences.

TRIAL REGISTRATION NUMBER

International Standard Randomised Controlled Trials Number (ISRCTN17842822).

Paediatrician's guide to post-operative care for biventricular CHD: a review

IMPORTANCE

Paediatricians play an integral role in the lifelong care of children with CHD, many of whom will undergo cardiac surgery. There is a paucity of literature for the paediatrician regarding the post-operative care of such patients.

OBSERVATIONS

The aim of this manuscript is to summarise essential principles and pertinent lesion-specific context for the care of patients who have undergone surgery or intervention resulting in a biventricular circulation.

CONCLUSIONS AND RELEVANCE

Familiarity with common issues following cardiac surgery or intervention, as well as key details regarding specific lesions and surgeries, will aid the paediatrician in providing optimal care for these patients.

Effectiveness and Safety of Early Initiation of Poststernotomy Cardiac Rehabilitation Exercise Training: The SCAR Randomized Clinical Trial

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.

SAfety and Feasibility of EArly Resistance Training After Median Sternotomy: The SAFE-ARMS Study

OBJECTIVE

The purpose of this study was to determine the safety and feasibility of subacute upper limb resistance exercise on sternal micromotion and pain and the reliability of sternal ultrasound assessment following cardiac surgery via median sternotomy.

METHODS

This experimental study used a pretest-posttest design to investigate the effects of upper limb resistance exercise on the sternum in patients following their first cardiac surgery via median sternotomy. Six bilateral upper limb machine-based exercises were commenced at a base resistance of 20 lb (9 kg) and progressed for each participant. Sternal micromotion was assessed using ultrasound at the mid and lower sternum at 2, 8, and 14 weeks postsurgery. Intrarater and interrater reliability was calculated using intraclass correlation coefficients (ICCs). Participant-reported pain was recorded at rest and with each exercise using a visual analogue scale.

RESULTS

Sixteen adults (n = 15 males; 71.3 [SD = 6.2] years of age) consented to participate. Twelve participants completed the study, 2 withdrew prior to the 8-week assessment, and 2 assessments were not completed at 14 weeks due to assessor unavailability. The highest median micromotion at the sternal edges was observed during the bicep curl (median = 1.33 mm; range = -0.8 to 2.0 mm) in the lateral direction and the shoulder pulldown (median = 0.65 mm; range = -0.8 to 1.6 mm) in the anterior-posterior direction. Furthermore, participants reported no increase in pain when performing any of the 6 upper limb exercises. Interrater reliability was moderate to good for both lateral-posterior (ICC = 0.73; 95% CI = 0.58 to 0.83) and anterior-posterior micromotion (ICC = 0.83; 95% CI = 0.73 to 0.89) of the sternal edges.

CONCLUSION

Bilateral upper limb resistance exercises performed on cam-based machines do not result in sternal micromotion exceeding 2.0 mm or an increase in participant-reported pain.

IMPACT

Upper limb resistance training commenced as early as 2 weeks following cardiac surgery via median sternotomy and performed within the safe limits of pain and sternal micromotion appears to be safe and may accelerate postoperative recovery rather than muscular deconditioning.

Effectiveness of low-level laser therapy compared with other conventional therapies on wound healing and pain reduction in patients with median sternotomy: a systematic review protocol

OBJECTIVE

The objective of this review is to evaluate the effect of low-level laser therapy, used alone or in combination with conventional therapies, on wound healing and pain reduction in patients with median sternotomy.

INTRODUCTION

In the previous two decades, the incidence of postsurgical complications following median sternotomy has remained reasonably unchanged. Owing to the shortcomings of conventional therapies in wound healing, alternative solutions are sought. Photobiomodulation with low-level laser therapy has become a preferred therapy for augmenting tissue repair and stimulating immediate analgesia by releasing local neurotransmitters and endorphins, or through anti-inflammatory effects.

INCLUSION CRITERIA

This review will include only randomized controlled trials that studied the effects of low-level laser therapy used as a monotherapy or in combination with other conventional therapies in promoting wound healing and reducing pain in adult patients with median sternotomy. Comparators may include other forms of photobiomodulation therapy/phototherapy, other conventional therapies, control, or placebo/sham interventions.

METHODS

Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), CINAHL (EBSCO), AMED (EBSCO), Physiotherapy Evidence Database (PEDro), and Scopus will be searched from database inception to the present date. Two reviewers will independently screen, extract data, and examine methodological quality of the eligible studies using the JBI critical appraisal checklist for randomized controlled trials. A meta-analysis will be done if adequate data with homogeneous population, interventions, and outcomes are available. The overall level of evidence will be synthesized using the Grading of Recommendations, Assessment, Development and Evaluation criteria.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020203011.

Perceptions and experiences of engaging in physical activity following coronary artery bypass graft surgery

BACKGROUND

Engagement in physical activity (PA) during the recovery period following coronary artery bypass graft (CABG) surgery improves physical and health-related quality-of-life outcomes.

OBJECTIVE

To explore people's perceptions and experiences of engaging in PA during the first three months following CABG surgery.

METHODS

A mixed methods study design was utilized. Quantitative data were collected via accelerometer activity capture and standardized questionnaires. Qualitative data were collected via semi-structured interviews at weeks 1, 3, 6 and 12 post-hospital discharge. Interviews were analyzed using inductive thematic analysis.

RESULTS

Two overarching themes described the overall experience of engaging in PA: 1) "Navigating a difficult and unfamiliar road to recovery" and 2) "Still cautious but becoming more confident and able." These themes described the impact over time that various physical (i.e., fatigue, pain, medical complications, and physical deconditioning), psychological (i.e., fear, confidence, uncertainty, and motivation), and environmental (support) factors had on PA engagement, as well as the relationships between these factors.

CONCLUSION

The findings provided insight into the physical, psychological, and environmental factors that impacted participants' PA engagement following CABG surgery. This knowledge may benefit health professionals to optimize preparation and support for adults to engage in PA post-hospital discharge following CABG surgery.

Effects of 12-Week Supervised Early Resistance Training (SEcReT) Versus Aerobic-Based Rehabilitation on Cognitive Recovery Following Cardiac Surgery via Median Sternotomy: A Pilot Randomised Controlled Trial

AIMS

To investigate the effects of a 12-week early moderate-intensity resistance training program compared to aerobic-based rehabilitation on postoperative cognitive recovery following cardiac surgery via median sternotomy.

METHODS

This was a multicentre, prospective, pragmatic, non-blinded, pilot randomised controlled trial (1:1 randomisation) of two parallel groups that compared a 12-week early moderate-intensity resistance training group to a control group, receiving aerobic-based rehabilitation. English-speaking adults (≥18 years) undergoing elective cardiac surgery via median sternotomy were randomised using sealed envelopes, with allocation revealed before surgery. The primary outcome was cognitive function, assessed using the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog), at baseline, 14 weeks and 6 months postoperatively.

RESULTS

The ADAS-cog score at 14 weeks was significantly better for the resistance training group (n=14, 7.2±1.4; 95% CI 4.3, 10.2, vs n=17, 9.2±1.3; 95% CI 6.6, 11.9, p=0.010). At 14 weeks postoperatively, 53% of the aerobic-based rehabilitation group (n=9/17) experienced cognitive decline by two points or more from baseline ADAS-cog score, compared to 0% of the resistance training group (n=0/14; p=0.001).

CONCLUSION

Early resistance training appears to be safe and may improve cognitive recovery compared to standard, aerobic-based rehabilitation following cardiac surgery via median sternotomy, however as this was a pilot study, the sample size was small and further research is needed to determine a causal relationship.

Location and Patterns of Persistent Pain Following Cardiac Surgery

OBJECTIVES

To investigate the specific clinical features of pain following cardiac surgery and evaluate the information derived from different pain measurement tools used to quantify and describe pain in this population.

METHODS

A prospective observational study was undertaken at two tertiary care hospitals in Australia. Seventy-two (72) adults (mean age, 63±11 years) were included following cardiac surgery via a median sternotomy. Participants completed the Patient Identified Cardiac Pain using numeric and visual prompts (PICP), the McGill Pain Questionnaire-Short Form version 2 (MPQ-2) and the Medical Outcome Study 36-item version 2 (SF-36v2) Bodily Pain domain (BP), which were administered prior to hospital discharge, 4 weeks and 3 months postoperatively.

RESULTS

Participants experienced a high incidence of mild (n=45, 63%) to moderate (n=22, 31%) pain prior to discharge, which reduced at 4 weeks postoperatively: mild (n=28, 41%) and moderate (n=5, 7%) pain; at 3 months participants reported mild (n=14, 20%) and moderate (n=2, 3%) pain. The most frequent location of pain was the anterior chest wall, consistent with the location of the surgical incision and graft harvest. Most participants equated "pressure/weight" to "aching" or a "heaviness" in the chest region (based on descriptor of pain in the PICP) and the pain topography was persistent at 4 weeks and 3 months postoperatively. Each pain measurement tool provided different information on pain location, severity and description, with significant change (p<0.005) over time.

CONCLUSION

Mild-to-moderate pain was frequent after sternotomy, improved over time and was mostly located over the incision and mammary (internal thoracic) artery harvest site. Persistent pain at 3 months remained a significant problem in the community within this surgical population.

Feedback Training Improves Compliance with Sternal Precaution Guidelines during Functional Mobility: Implications for Optimizing Recovery in Older Patients after Median Sternotomy

Patients often need to use their arms to assist with functional activities, but after open heart surgery, pushing with the arms is limited to <10 lb (4.5 kg) to help minimize force across the healing sternum. The main purposes of this study were to determine if older patients (>60 years old) (1) accurately estimated upper extremity (UE) weight bearing force of 10 lb or less and (2) if feedback training improved their ability to limit UE force and pectoralis major muscle contraction during functional activities. An instrumented walker was used to measure UE weight bearing force, and electromyography was used to measure pectoralis major muscle activity simultaneously during 4 functional mobility tasks. After baseline testing, healthy older subjects (n = 30) completed a brief session of visual and auditory concurrent feedback training. Results showed that the self-selected UE force was >10 lb for all tasks (20.0-39.7 lb [9.1-18.0 kg]), but after feedback training, it was significantly reduced (10.6-21.3 lb [4.8-9.7 kg]). During most trials (92%), study participants used >12 lb (5.5 kg) of arm weight bearing force. Pectoralis major muscle peak electromyography activity was <23% of maximal voluntary isometric contraction and was reduced (9.8-14.9%) after feedback training. Older patients may not be able to accurately estimate UE arm force used during weight bearing activities, and visual and auditory feedback improves accuracy and also modulation of pectoralis major muscle activation. Results suggest that an instrumented walker and feedback training could be clinically useful for older patients recovering from open heart surgery.

Sternal Precautions and Prone Positioning of Infants Following Median Sternotomy: A Nationwide Survey

PURPOSE

To describe current practice of pediatric sternal precautions (PSPs) and prone positioning restrictions (PPRs) in infants after median sternotomy.

METHODS

A Web-based survey with 21 questions was developed on the basis of a review of current literature and expert consultation. Snowball sampling resulted in 68 participants well represented by profession throughout the United States.

RESULTS

Approximately 80% of participants reported having institutional protocols for PSPs. Most common reported PSPs were no lifting at the axillae and no pulling of arms to achieve sitting. PSPs also included PPRs. The opinions of participants supported no PPRs or modified PPRs compared with strict PPRs.

CONCLUSIONS

Types of PPRs varied across participants, with the majority of participants in favor of modified PPRs while PSPs were less varied. Research is needed to examine the effects of PSPs and PPRs in infants post-median sternotomy.

Orthopedic Principles to Facilitate Enhanced Recovery After Cardiac Surgery

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.

Effects of Supervised Early Resistance Training versus standard care on cognitive recovery following cardiac surgery via median sternotomy (the SEcReT study): protocol for a randomised controlled pilot study

Introduction

Mild cognitive impairment is considered a precursor to dementia and significantly impacts upon quality of life. The prevalence of mild cognitive impairment is higher in the post-surgical cardiac population than in the general population, with older age and comorbidities further increasing the risk of cognitive decline. Exercise improves neurogenesis, synaptic plasticity and inflammatory and neurotrophic factor pathways, which may help to augment the effects of cognitive decline. However, the effects of resistance training on cognitive, functional and overall patient-reported recovery have not been investigated in the surgical cardiac population. This study aims to determine the effect of early moderate-intensity resistance training, compared to standard care, on cognitive recovery following cardiac surgery via a median sternotomy. The safety, feasibility and effect on functional recovery will also be examined.

Methods

This study will be a prospective, pragmatic, pilot randomised controlled trial comparing a standard care group (low-intensity aerobic exercise) and a moderate-intensity resistance training group. Participants aged 18 years and older with coronary artery and/or valve disease requiring surgical intervention will be recruited pre-operatively and randomised 1:1 to either the resistance training or standard care group post-operatively. The primary outcome, cognitive function, will be assessed using the Alzheimer’s Disease Assessment Scale and cognitive subscale. Secondary measures include safety, feasibility, muscular strength, physical function, multiple-domain quality of recovery, dynamic balance and patient satisfaction. Assessments will be conducted at baseline (pre-operatively) and post-operatively at 2 weeks, 8 weeks, 14 weeks and 6 months.

Discussion

The results of this pilot study will be used to determine the feasibility of a future large-scale randomised controlled trial that promotes the integration of early resistance training into existing aerobic-based cardiac rehabilitation programs in Australia.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001430325p. Registered on 9 October 2017. Universal Trial Number (UTN): U1111-1203-2131.