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.

An alternative approach to prescribing sternal precautions after median sternotomy, "Keep Your Move in the Tube".

Traditional sternal precautions, given to sternotomy patients as part of their discharge education, are intended to help prevent sternal wound complications. They vary widely but generally include arbitrary load and time restrictions (lifting no more than a specified weight for up to 12 weeks) and may prohibit common shoulder joint and shoulder girdle movements. Having observed the negative effects of restrictive sternal precautions for many years, our research team performed a series of studies that measured the forces exerted during various common activities and their relationship to the sternum. The results, though informative, led us to realize that the goal of identifying "the" appropriate load restriction to prescribe for sternotomy patients was futile. The alternative approach that we introduce applies standard kinesiological principles and teaches patients how to perform load-bearing movements in a way that avoids excessive stress to the sternum.

Quality of life and physical performance in land- and water-based pulmonary rehabilitation.

PURPOSE: Traditional land-based pulmonary rehabilitation (PR) has been shown to provide improvement in physical performance and quality of life in patients with chronic obstructive pulmonary disease (COPD). The training effects of a water environment in pulmonary patients have only been briefly investigated. The purpose of this retrospective study was to compare quality of life and physical performance in land- and water-based PR. METHODS: The study included participants of a land- or water-based PR program. Twenty land- and water-based participants with stable COPD disease were retrospectively matched within 20 mL of their forced expiratory ventilation in 1 second. A multivariate analysis of variance was performed on each group's 6-minute walk test distance; 6-repetition maximum strength tests for the knee, hip, and shoulder; and mental and physical health summary scores of the Medical Outcomes Short-form 36. RESULTS: Each group significantly improved in all outcome measurements, but there was no difference found in the improvements between the land- or water-based groups. CONCLUSION: Clinicians can consider water-based PR exercise program as another treatment option, if available, for patients with COPD and expect similar benefits to traditional land-based PR programs including improved walk distances, strength, and perception of well-being.