“Patients exchanging habits of activity for complete rest are likely to become rapidly worse.”
This quote fuels my everyday. These words have informed nonsurgical and surgical rehabilitation and its evolution from handing out bed rest like Oprah hands out cars to getting people moving early and keeping them moving often. Here’s the crazy thing: This quote was said by Austin Flint in 1886 in specific reference to the rehabilitation of patients with heart disease. 134 years later, we are still fighting the battle against overly-restrictive precautions and rest orders across all disciplines and diagnoses.
I don’t know if you are aware of how a sternotomy goes down, but it’s pretty aggressive. There is a lot of tissue stretching, stabbing (yes, literally), cutting, burning, and wiring. And then there’s the retractors. Those babies get in that tiny space and make it so much larger! No wonder patients are sore afterward. You can go watch a video on YouTube to see what it’s all about. Patients typically have discomfort in their thoracic and cervical spines, shoulders, ribs, anterior superior chest and joint articulations… and that’s just for a standard valve replacement! If you add a CABG, we can add peripheral wounds in the arms and legs, and if we are talking organ replacement, the back of the head, low back, and hips can get pretty sore from positioning and the use of a bump to help open the rib cage.
Even though the first coronary artery bypass graft (CABG) wasn’t performed for the treatment of heart disease until 1960, infection and dehiscence of the sternotomoy were relatively common (not terribly surprising considering what goes in to it!). Of those who experienced these complications, up to 50% died. Needless to say, surgeons felt like they needed to get extra cautious. However, there was never any research performed to discern which movements of the body or extremities stressed the sternum the most, and whether or not this stress impaired healing. Thus, sternal precautions were laid down.
There is NO set standard for sternal precautions
Yup. Different surgeons, medical centers, and states all do it differently. There is also no set standard for when or how to reduce or remove sternal precautions. In the heart and lung transplant arena, our surgeons and facilities tended to decrease sternal precautions over time, allowing one or two upper extremity movements every month or so and decreasing the weight lifting restriction by 5-10 pounds every month or so. Real consistent, right? For further evidence of these inconsistencies, check out this table which shows you three different sets of “sternal precautions” from three different major medical centers.
And to complicate matters even further, many post-operative exercise prescriptions often involve a standard set of exercises, many of which violate one or several sternal precautions that are initially given! I’ve found this to be true at more than one location! One survey performed in 2011 found more than 28 different versions of sternal precautions! And, to add one more level of complication, Physical Therapists and Cardiothoracic Surgeons do sternal precautions very differently.
Top 5 sternal precautions prescribed by cardiothoracic surgeons:
- Lifting no more than 10 pounds of weight bilaterally
- Lifting no more than 10 pounds of weight unilaterally
- Bilateral sports restrictions
- No driving
- Unilateral sports restrictions
Top 5 sternal precautions reported by physical therapists in order of importance:
- Lifting no more than 10 pounds of weight bilaterally
- No hand over head activities bilaterally
- Bilateral sports restrictions
- No driving
- Active bilateral shoulder flexion no greater than 90°
And ACSM tells us this:
For 5 to 8 weeks after cardiothoracic surgery, lifting with the upper extremities should be restricted to 5 to 8 pounds (2.27-3.63 kg). Range of motion (ROM) exercises and lifting 1 to 3 pounds (0.45-1.36 kg) with the arms is permissible if there is no evidence of sternal instability, as detected by movement in the sternum, pain, cracking, or popping. Patients should be advised to limit ROM within the onset of feelings of pulling on the incision or mild pain.
There has been some limited research that showed that pushing up from a chair during sit to stand activities provided the greatest physical stress force to the sternum. However, these patients had known chronic sternal instabilities, so the cases are slightly different. Even though the stress has been measured to be physically less, unilateral loaded arm movements caused the greatest pain in these patients. Clinically, I have seen this to be the case. Unilateral upper extremity loading, such as when laying on the side or reaching for a cup of coffee, always seems like the most painful things.
Take notice, there is nothing in any of these discussion on sternal precautions that mentions splinting the sternum. For as many years as I remember, including before I was a therapist, we have used nice heart or lung shaped pillows to splint the sternum during coughing or sneezing. If the pillow wasn’t available, we taught patients to splint their sternum with their hands or a different pillow. I even took to educating patients about their first sneeze and being ready. That stuff doesn’t show up anywhere in here.
Speaking of a sneeze, there was a study published in Thoracic Cardiovascular Surgery that stated the force across the sternum with a single cough is greater than that measured lifting 40-pound weights. The authors had serious concerns about the lack of surgeon confidence in their owns repairs if the sternotomy couldn’t support 5 pounds of force.
And, we need to talk about the biggest elephant in the room…
Driving. Everyone’s first question after they get home is, “When can I drive again?” There is absolutely no standard recommendation for this one, either. Some physicians say 3-4 weeks once they’ve had their follow-up visit, whereas some say 6-8 weeks. Some patients have been told to lay in the back seat or not wear a seatbelt when they are traveling in a car! These are just generally not safe recommendations from any provider, considering there is a long history of research telling us that wearing a seatbelt and using an airbag decreases the risk of a driver’s sternum contacting the steering wheel. Are we concerned about the patient being in an accident? Sure! But you can’t control everything. The research shows us that there is no higher risk of sternal fracture after a healed sternotomy than if there was no sternotomy.
So what do we actually know?
What we know from the most recent research is that sternal precautions don’t matter. There, I said it. I spent years teaching other therapists about sternal precautions, all the while thinking, “why do we do this to ourselves and our patients?”
What actually matters is allowing patients’ pain or discomfort at their sternum to guide their movements. A randomized multi-center single blinded study showed that there was absolutely no difference in physical, kinesphobic, pain, or quality of life outcomes and no increased rate of complications when patients were simply asked to just let their post-operative discomfort guide their movement.
“There is no universally accepted definition causing application of SP [sternal precautions] to be largely arbitrary.”Cahalin, et al. 2011
As far as driving goes, after sternotomy, only minimal forces on the sternum were found with the activities of driving. We actually have found that the safest place in the car for the patient to be is in a seat with an airbag and wearing a seat belt. Whether that is a front passenger or a driver is unclear. Not only does the ability to drive have a huge impact on quality of life, but the lack of driving ability restricts patients from participating in cardiac rehabilitation programs because they can’t get there!
Now, of course, there are wonderful home care therapists to help with this, but they are not always available in all areas and many can’t provide standardized sub-maximal and maximal exercise tests because those require a treadmill or exercise bike and EKG monitoring. So, patients end up having to sit at home, not rehabbing for up to 8 weeks. That’s 8 weeks that they are not only losing muscle mass, aerobic capacity, and functional ability, but 8 weeks that they are NOT working toward improving any of those things like they could in Cardiac Rehab! That’s 16 total weeks of lost time in the recovery from one procedure, simply because the patient couldn’t drive.
Of course, not all patients are appropriate to drive after having an open-heart related procedure, but evidence shows us that if they are tolerating their medications well and aren’t having persistent arrhythmias, they should be cleared to drive as soon as they are able. I will say, though, that having seen many patients at home for a PT evaluation after open-heart surgical procedures of all kinds, I’m typically pretty glad we got to do a home-based session. Many of them need education on positioning for sleep, infection control, and activity guidelines. You all know by now that I’m a pusher so I always work these people pretty hard. But, you know what? They all got better and there were never any negative outcomes associated with exercise or activity participation. Darn… Should have done a retrospective study on that one…
So what’s the answer? Some authors have suggested a graded approach to precautions instead of the standard blanket precautions laid down on everyone for the same procedures. Some authors have suggested letting discomfort be their guide and allowing any activities and movements that are not placing the patient at a significantly increased risk of nonunion. Some authors have suggested only giving some kind of patient-specific sternal precautions those patients who are already at higher risk of nonunion due to other comorbidities (such as diabetes or osteoporosis).
Overall, most of the rehab-focused research on sternal precautions has found that they are overly-cautious, restrictive instead of cautionary, and impede physical rehabilitation, which we know is so desperately needed by many after these procedures.
What are the sternal precautions at your facility? Do different doctors give you different precautions? Tell me more in the comments!
Balady, G.J., Ades, P.A., Bittner, V.A., Franklin, B.A., Gordon, N.F., Thomas, R.J., Tomaselli, G.F., Yancy, C.W., American Heart Association Science Advisory and Coordinating Committee. (2011). Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation. 124(25):2951-60.
Cahalin, L. P., Lapier, T. K., & Shaw, D. K. (2011). Sternal Precautions: Is It Time for Change? Precautions versus Restrictions – A Review of Literature and Recommendations for Revision. Cardiopulmonary physical therapy journal, 22(1), 5–15.
Crabtree TD, Codd JE, Fraser VJ, Bailey MS, Olsen MA, Damiano RJ. Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center. Sem Thorac Cardiovasc Surg. 2004;16:53–61.
El-Ansary D, Waddington G, Adams R. Relationship between pain and upper limb movement in patients with chronic sternal instability following cardiac surgery. Physiother Theory Prac. 2007;23(5):273–280.
Gach, R., Triano, S., El-Ansary, D., Parker, R., & Adams, J. (2019). Altering driving restrictions after median sternotomy. Proceedings (Baylor University. Medical Center), 32(2), 301–302. https://doi.org/10.1080/08998280.2018.1551298
Katijjahbe, M. A., Granger, C. L., Denehy, L., Royse, A., Royse, C., Bates, R., Logie, S., Nur Ayub, M. A., 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(2), 97–106. https://doi.org/10.1016/j.jphys.2018.02.013
Knobloch, K., Wagner, S., Haasper, C., Probst, C., Krettek, C., Otte, D., Richter, M. (2006). Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims. Ann Thorac Surg. 82(2):444-50.
McGregor, W.E., Trumble, D.R., Magovern, J. A. (1999). Mechanical analysis of midline sternotomy wound closure. J Thorac Cardiovasc Surg. 117(6):1144-50.
Parker, R., Adams, J.L., Ogalo, G., et al. (2008) Current activity guidelines for CABG patients are too restrictive: a comparison of the forces exerted on the median sternotomy during a cough vs. lifting activities combined with valsalva maneuver. Thorac Cardiovasc Surg. 56(4):190–194.
Pratt, J.H. (1920) Rest and exercise in the treatment of heart disease. South Med J. 13:481–485.
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