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

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.

Functional status of patients during subacute recovery from coronary artery bypass surgery.

BACKGROUND: Patients recovering from coronary artery bypass (CAB) surgery are particularly vulnerable to impaired functional status because in addition to the direct effects of heart disease on cardiac performance, many surgical factors may contribute to loss of function. OBJECTIVES: The purposes of this study were to describe functional status across multiple domains using performance-based and self-report assessments and to determine the relationship among different domains of functional status in patients recovering subacutely (<6 months) from CAB surgery. METHODS: The participants in this study (n = 25) had undergone CAB surgery in the past 6 months. This cross-sectional descriptive study measured functional status in several domains using self-report and performance-based assessments. RESULTS: The study results indicate that participants had deficits in health-related quality of life, activities of daily living performance, endurance/aerobic capacity, and cognitive/memory ability. Several correlations between the scores for outcome measures in different domains were found in this study. CONCLUSIONS: Impaired functional status occurs in patients recovering subacutely from CAB surgery. Different aspects of functional status are related, and an understanding of these relationships may help to improve the medical management of patients after CAB surgery.

Utility of the late life function and disability instrument as an outcome measure in patients participating in outpatient cardiac rehabilitation: a preliminary study.

PURPOSE: The purpose of this study was to examine the concurrent validity of the Late Life Function and Disability Instrument (LLFDI) in patients with coronary heart disease (CHD) and to evaluate the accuracy of information obtained through self-report questionnaire versus interview formats. METHODS: The study included 29 patients older than 60 years attending an outpatient cardiac rehabilitation program. Participants completed the LLFDI, three additional self-report criterion measures, and six performance-based tests; they completed the LLFDI a second time via interview. We used descriptive statistics, correlations, and t-tests to analyze the data. RESULTS: All LLFDI components were correlated (rs=0.36-0.83) with the self-report criterion measures. The Function Component of the LLFDI was moderately correlated with the 6-Minute Walk Test (r=0.62), timed up-and-go (r=-0.58), walking speed (r=-0.57), and timed sit-to-stand (r=-0.56) scores. The LLFDI demonstrated a ceiling effect (10%) only in the Disability Limitation component. All LLFDI component scores obtained via self-report questionnaire were correlated with scores obtained via interview; except in a single subcategory, there was no difference between LLFDI scores obtained through self-report questionnaire and those obtained through interview. CONCLUSIONS: RESULTS indicate that the LLFDI has appropriate validity for older patients (>60 years) with CHD and can be completed independently by patients rather than administered by clinicians.

Sternal Precautions: Is It Time for Change? Precautions versus Restrictions - A Review of Literature and Recommendations for Revision.

The processes that occur with normal sternal healing and potential complications related to median sternotomy are of particular interest to physical therapists. The premise of patients following sternal precautions (SP) or specific activity restrictions is the belief that avoiding certain movements will reduce risk of sternal complications. However, current research has identified that many patients remain functionally impaired long after cardiothoracic surgery. It is possible that some SP may contribute to such functional impairments. Currently, SP have several limitations including that they: (1) have no universally accepted definition, (2) are often based on anecdotal/expert opinion or at best supported by indirect evidence, (3) are mostly applied uniformly for all patients without regard to individual differences, and (4) may be overly restrictive and therefore impede ideal recovery. The purpose of this article is to present an overview of current research and commentary on median sternotomy procedures and activity restrictions. We propose that the optimal degree and duration of SP should be based on an individual patient's characteristics (eg, risk factors, comorbidities, previous activity level) that would enable physical activity to be targeted to particular limitations rather than restricting specific functional tasks and physical activity. Such patient-specific SP focusing on function may be more likely to facilitate recovery after median sternotomy and less likely to impede it.

Exercise self-efficacy, habitual physical activity, and fear of falling in patients with coronary heart disease.

The purpose of this study was to determine if a relationship exists between self-efficacy for physical activity and other pertinent factors in patients with coronary heart disease (CHD). A secondary purpose of this study was to determine if self-efficacy and exercise behavior are different in patients who report a fearing of falling (fallers) as compared to patients who do not report a fear of falling (non-fallers). This study included 50 patients who were admitted to the hospital for a CHD related diagnosis. Patients completed assessments of cardiac self-efficacy (Modified Barnason Efficacy Expectation Scale) and exercise behavior self-efficacy (Self Efficacy for Exercise Behavior Scale). In addition, the Physical Function subscale of the RAND 36-Item Health Survey and the Telephone Interview of Cognitive Function were used to characterize physical and cognitive function, respectively. Data analysis consisted of descriptive statistics, correlations, t-tests, and chi-square. Older patients reported higher levels of cardiac self-efficacy. Further, a positive correlation was found between cardiac self-efficacy and pre-hospitalization level of physical function. Patient income level and Self-efficacy for Exercise Behavior Resisting Relapse subscale scores were significantly correlated. A higher percent of fallers failed to meet minimum exercise guidelines as compared to non-fallers. It is important to identify the factors that are associated with exercise self-efficacy to improve health behavior adoption and adherence in patients with CHD.

Indicators of functional deficits after coronary artery bypass surgery.

The purposes of this study were to determine if ratings of difficulty or pain were more likely to detect deficits in activities of daily living (ADL) than degree of dependency and to longitudinally examine ADL in patients recovering from coronary artery bypass (CAB) surgery. This study included 40 patients who had recently undergone CAB surgery. We evaluated ADL performance using 3 subcategories of the Functional Status Index: mobility, personal care, and hand activities. Subjects completed the Functional Index before, 2 weeks after, and 2 months after CAB surgery. The percent of participants reporting difficulty or pain on the FSI was greater than the percent needing assistance except for hand activities preoperatively. Up to 65% of study participants reported deficits in ADL performance. In conclusion, assessments of ADL abilities that rely only on need for assistance may underestimate the presence of functional deficits in patients recovering from CAB surgery. Understanding functional level will assist in determining patient's need for rehabilitation services after CAB surgery.

Psychometric evaluation of the heart surgery symptom inventory in patients recovering from coronary artery bypass surgery.

PURPOSE: The purpose of this study was to evaluate the test-retest reliability, internal consistency, and concurrent validity of the Heart Surgery Symptom Inventory (HSSI) in patients following coronary artery bypass surgery. METHODS: This study included 28 patients attending outpatient rehabilitation who had undergone coronary artery bypass surgery within the past 6 months. Patients completed self-report instruments including a medical history form, HSSI, and Medical Outcomes Study Short Form-36. Patients also completed a second HSSI at a later time on the same testing day. HSSI scores were summed to create a total score and 4 subcategory scores (general, cardiac, trunk, lower extremity). Correlations were calculated for scores obtained during 2 trials of the HSSI to evaluate test-retest reliability, between individual items, subcategory, and total scores to evaluate internal consistency, and between HSSI scores and Medical Outcomes Study Short Form-36 scores to evaluate concurrent validity. RESULTS: Correlations for the 2 trials of the HSSI total and all subcategories were significant (P < .05) and ranged from 0.89 to 0.99. Subcategories to total correlations were all significant and ranged from 0.59 to 0.85. Subcategories to subcategory correlations were all significant except for lower extremity to cardiac and lower extremity to general comparisons. Individual item to total correlations ranged from 0.02 to 0.84. Individual item to subcategory correlations ranged from 0.01 to 0.85. The correlations between the HSSI total and all Medical Outcomes Study Short Form-36 scores were significant. CONCLUSIONS: Results indicate that the HSSI has appropriate reliability and validity for clinical and research applications. The HSSI can be a useful clinical and research tool to evaluate quality of life in patients after coronary artery bypass surgery.