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Mehani SHM, Helmy ZM, Ali HM, Mohamed Mahmoud MI. Effect of Adding Integrated Core and Graduated Upper Limb Exercises to Inpatient Cardiac Rehabilitation on Sternal Instability After Coronary Artery Bypass Grafting: A Randomized Controlled Trial. Arch Phys Med Rehabil 2024:S0003-9993(24)01193-6. [PMID: 39218245 DOI: 10.1016/j.apmr.2024.08.012] [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: 12/26/2023] [Revised: 08/20/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To evaluate the effect of adding integrated core and graduated resistance upper limb exercises to an inpatient cardiac rehabilitation program in patients with acute sternal instability after coronary artery bypass grafting (CABG). DESIGN This was a single-center, randomized, controlled, parallel-group intervention study. SETTING This study was conducted at the National Heart Institute. PARTICIPANTS Forty patients with post-CABG with sternal instability aged 50-60 years completed this study and were randomized into 2 groups: an intervention group (n=20) and an active control group (n=20). INTERVENTION The intervention group (A) received a routine inpatient rehabilitation program from the first postoperative day plus integrated core and graduated resistance upper limb exercises, which started from the seventh postoperative day for approximately 4 weeks, whereas the control group (B) received only the routine inpatient rehabilitation program. MAIN OUTCOME MEASURES Sternal separation measured by ultrasonography, visual analog scale for measuring pain, and activities of daily living (ADL) index were main outcome measures. RESULTS Patients in the intervention group (A) showed a significant reduction in sternal separation from the supine and long sitting positions, whereas those in the control group (B) showed a significant increase in sternal separation (P=.0001). Both groups showed a reduction in pain, and an increase in the ADL score was observed in group A. There was a significant interaction between the time and group effects (P=.0001). CONCLUSION Adding integrated core and graduated upper limb exercises to inpatient cardiac rehabilitation for patients with sternal instability after coronary artery bypass grafting significantly improved sternal healing, pain, and ADL.
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Affiliation(s)
- Sherin Hassan Mohammed Mehani
- Physical Therapy Department for Cardiovascular / Respiratory Disorders and Geriatrics, Faculty of Physical Therapy, Beni-Suef University
| | - Zeinab Mohammed Helmy
- Physical Therapy Department for Cardiovascular / Respiratory Disorders and Geriatrics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
| | - Heba Mohammed Ali
- Physical Therapy Department for Cardiovascular / Respiratory Disorders and Geriatrics, Faculty of Physical Therapy, Beni-Suef University
| | - Mahmoud Ibrahim Mohamed Mahmoud
- Physical Therapy Department for Cardiovascular / Respiratory Disorders and Geriatrics, Faculty of Physical Therapy, Beni-Suef University.
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Royse AG, El-Ansary D, Hoang W, Lui E, McCusker M, Tivendale L, Yang Y, Canty DJ, Royse CF. A randomized trial comparing the effects of sternal band and plate fixation of the sternum with that of figure-of-8 wires on sternal edge motion and quality of recovery after cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:863-870. [DOI: 10.1093/icvts/ivaa040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/17/2020] [Accepted: 02/03/2020] [Indexed: 12/15/2022] Open
Abstract
Abstract
OBJECTIVES
We sought to compare the effects of conventional wire cerclage with that of the band and plate fixation of the sternum.
METHODS
A parallel randomized open-label trial with 1:1 allocation ratio compared healing after adult cardiac surgery using ‘figure-of-8’ stainless steel wire cerclage or a band and plate system (plates). The primary end point was maximal sternal edge displacement during active coughing of ≥2 mm in ≥2 of 4 sites measured with ultrasound by 2 assessors blinded to the other at 6 weeks postoperatively. Secondary end points at 12 weeks included ultrasound assessment, computed tomography (CT) scan and multidimensional assessment of quality of recovery using the Postoperative Quality of Recovery Scale.
RESULTS
Of 50 patients, 26 received plates and 24 wires. Two patients died and 1 withdrew consent leaving 25 plates and 22 wires for primary end point analysis. Operations included 37 coronary, 5 valve and 8 combined coronary and valve procedures. At 6 weeks, less sternal movement was observed in patients with plates than those with wires, 4% (1/25) vs 32% (7/22), P = 0.018. Agreement between observers was high, kappa = 0.850. At 12 weeks, less ultrasound motion was seen in patients with plates, 0% (0/23) than those with wires, 25% (5/20), P = 0.014. Recovery from pain was higher for patients with plates 92% (22/24) than those with wires 67% (14/21), P = 0.004. CT bone edge separation was less for plates 38% (9/24) than wires 71% (15/21), P = 0.036. CT mild bone synthesis or greater was similar between patients with plates 21% (5/24) and wires 14% (3/21), P = 0.71.
CONCLUSIONS
Patients receiving the band and plate system had significantly less sternal edge motion than those receiving wires, 6 and 12 weeks after cardiac surgery and experienced less pain.
Clinical trial registration
clinicaltrials.gov NCT03282578.
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Affiliation(s)
- Alistair G Royse
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Health Professions, Faculty of Art, Design and Health, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Doa El-Ansary
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Health Professions, Faculty of Art, Design and Health, Swinburne University of Technology, Melbourne, VIC, Australia
| | - William Hoang
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Elaine Lui
- Department of Radiology, The University of Melbourne, Parkville, VIC, Australia
| | - Mark McCusker
- Department of Radiology, The University of Melbourne, Parkville, VIC, Australia
| | - Lynda Tivendale
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Yang Yang
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Intensive Care, Western Hospital, Melbourne, VIC, Australia
| | - David J Canty
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Anaesthesia and Pain Management, Monash Medical Centre, Melbourne, VIC, Australia
| | - Colin F Royse
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Health Professions, Faculty of Art, Design and Health, Swinburne University of Technology, Melbourne, VIC, Australia
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Outcomes Research Consortium, The Cleveland Clinic, Cleveland, OH, USA
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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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Joutsen A, Hautalahti J, Jaatinen E, Goebeler S, Paldanius A, Viik J, Laurikka J, Hyttinen J. A device for measuring sternal bone connectivity using vibration analysis techniques. Proc Inst Mech Eng H 2019; 234:81-90. [DOI: 10.1177/0954411919884802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Stability of bone splitting sternotomy is essential for normal healing after open cardiac surgery. Mechanical vibration transmittance may offer a means for early detection of separation of bone (diastasis) in the sternotomy and prevent further complications. This article describes the technical implementation and validation of vibration analysis–based prototype device built for measuring sternal bone connectivity after sternotomy. Methods: An in-house built measurement system, sternal vibration device, consisting of actuator, sensor, and main controller and signal acquisition unit was designed and manufactured. The system was validated, and three different test settings were studied in mockups (polylactide rods in ballistic gel) and in two human sternums: intact, stable wire fixation, and unstable wire fixation with a gap mimicking bone diastasis. The transmittance of vibration stimulus across the median sternotomy was measured. Results: The validation showed that the force produced by the actuator was stable, and the sensor could be calibrated to precisely measure the acceleration values. The vibration transmittance response to material cut and sternotomy was evident and detectable in the 20 Hz to 2 kHz band. The transmittance decreased when the connectivity between the sternal halves became unstable. The trend was visible in all the settings. Conclusion: Technical solutions and description of validation process were given. The device was calibrated, and the vibration transmittance analysis differentiated intact and cut polylactide rod. In the sternum, intact bone, wire fixation with exact apposition, and with a gap were identified separately. Although further studies are needed to assess the accuracy of the method to detect different levels of diastases, the method appears to be feasible.
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Affiliation(s)
- Atte Joutsen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Cardiothoracic Surgery, Tampere Heart Hospital, Tampere, Finland
| | - Juha Hautalahti
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Cardiothoracic Surgery, Tampere Heart Hospital, Tampere, Finland
| | | | - Sirkka Goebeler
- Forensic Medicine, National Institute for Health and Welfare, Tampere, Finland
| | - Antti Paldanius
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jari Viik
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jari Laurikka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Cardiothoracic Surgery, Tampere Heart Hospital, Tampere, Finland
| | - Jari Hyttinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Casha AR, Chircop K, Gauci M, Grima JN. Novel roles of vibration transmittance in fracture testing. J Cardiothorac Surg 2019; 14:53. [PMID: 30867001 PMCID: PMC6417125 DOI: 10.1186/s13019-019-0884-0] [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: 02/01/2019] [Accepted: 03/04/2019] [Indexed: 11/10/2022] Open
Abstract
This letter re-assesses a publication in the Journal of Cardiothoracic Surgery entitled 'Vibration transmittance measures sternotomy stability - a preliminary study in human cadavers.' The roles of ultrasound in testing for sternotomy stability and that of stress vibration transmittance in cases of fracture of the posterior table of the sternum or in hairline undisplaced fractures are examined in view of their differing sound wave frequency ranges.
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Affiliation(s)
- Aaron R Casha
- Department of Cardiothoracic Surgery, Mater Dei Hospital, Msida, Malta. .,Faculty of Medicine, University of Malta, Msida, Malta.
| | - Kieran Chircop
- Department of Medical Imaging, Mater Dei Hospital, Msida, Malta
| | - Marilyn Gauci
- Faculty of Medicine, University of Malta, Msida, Malta
| | - Joseph N Grima
- Metamaterials Unit, Faculty of Science, University of Malta, Msida, Malta
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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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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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