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doi: 10.2522/ptj.20100373
Published online September 23, 2011PHYS THER.
Johnston
Lara J. Tuyl, Jennifer H. Mackney and Catherine L.
Australia: A Web-Based Survey
Median Sternotomy by Physical Therapists in
Management of Sternal Precautions Following
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Management of Sternal Precautions
Following Median Sternotomy by
Physical Therapists in Australia:
A Web-Based Survey
Lara J. Tuyl, Jennifer H. Mackney, Catherine L. Johnston
Background. Sternal precautions are utilized within many hospitals with the aim
of preventing the occurrence of sternal complications (eg, infection, wound break-
down) following midline sternotomy. The evidence base for sternal precaution
protocols, however, has been questioned due to a paucity of research, unknown
effect on patient outcomes, and possible discrepancies in pattern of use among
institutions.
Objective. The objective of this study was to investigate and document the use of
sternal precautions by physical therapists in the treatment of patients following
median sternotomy in hospitals throughout Australia, from immediately postsurgery
to discharge from the hospital.
Design. A cross-sectional, observational design was used. An anonymous, Web-
based survey was custom designed for use in the study.
Methods. The questionnaire was content validated, and the online functionality
was assessed. The senior cardiothoracic physical therapist from each hospital iden-
tified as currently performing cardiothoracic surgery (N⫽51) was invited to
participate.
Results. The response rate was 58.8% (n⫽30). Both public (n⫽18) and private
(n⫽12) hospitals in all states of Australia were represented. Management protocols
reported by participants included wound support (n⫽22), restrictions on lifting and
transfers (n⫽23), and restrictions on mobility aid use (n⫽15). Factors influencing
clinical practice most commonly included “workplace practices/protocols” (n⫽27)
and “clinical experience” (n⫽22).
Limitations. The study may be limited by response bias.
Conclusions. Significant variation exists in the sternal precautions and protocols
used in the treatment of patients following median sternotomy in Australian hospitals.
Further research is needed to investigate whether the restrictions and precautions
used are necessary and whether protocols have an impact on patient outcomes,
including rates of recovery and length of stay.
L.J. Tuyl, BPhysio, Maitland Private
Hospital, Maitland, New South
Wales, Australia.
J.H. Mackney, MClinEd, BAppSc
(Physiotherapy), School of Health
Sciences, The University of New-
castle, Callaghan, New South
Wales, Australia.
C.L. Johnston, MAppSc (Cardio-
pulmonary Physiotherapy), BAppSc
(Physiotherapy), School of Health
Sciences, The University of New-
castle, Callaghan 2308, New
South Wales, Australia. Address all
correspondence to Ms Johnston at:
cath.johnston@newcastle.edu.au.
[Tuyl LJ, Mackney JH, Johnston CL.
Management of sternal precau-
tions following median sternot-
omy by physical therapists in Aus-
tralia: a Web-based survey. Phys
Ther. 2012;92:xxx–xxx.]
© 2011 American Physical Therapy
Association
Published Ahead of Print: XXX
Accepted: July 11, 2011
Submitted: November 7, 2010
Research Report
Post a Rapid Response to
this article at:
ptjournal.apta.org
January 2012 Volume 92 Number 1 Physical Therapy f1
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Cardiac surgery, such as coro-
nary artery bypass grafting
(CABG) and valve replace-
ment, is commonly used in the man-
agement of heart disease.
1–4
More
than 17,000 CABGs are performed
annually in Australia, and more than
300,000 CABGs are performed annu-
ally in the United States.
1–3
Median,
or midline, sternotomy is the most
frequently used incision during car-
diac surgery, as it provides optimal
access to the heart and surrounding
blood vessels.
5–8
Median sternotomy
involves the division of the manu-
brium and sternum centrally and
wide separation using retractors.
5
The sternum is most commonly
closed using stainless steel wires.
8,9
For the majority of patients, the ster-
num heals well. The incidence of
postoperative sternal complications,
such as sternal dehiscence, infec-
tion, and sternal instability, is
reported as between 1% and 5%.
5,10
Deep wound infection is the most
severe of the possible sternal compli-
cations and is associated with pro-
longed hospitalization, high costs,
and high rates of morbidity and
mortality.
11–14
Protocols and policies have been
developed within institutions relat-
ing to the sternal precautions used
by physical therapists in their
treatment of patients who have
undergone median sternotomy.
15–18
Restrictions on movement and ster-
nal loading are frequently imposed
on patients, including limiting
upper-limb movements to bilateral
movements only and limiting
weight bearing through the upper
limbs.
15–19
Despite the common use
of postoperative restrictions, the
impact of upper-limb movement
and loading on the healing sternum
is not known, and current precau-
tions, therefore, are based only on
proposed theoretical rationale.
17–21
Furthermore, sternal precautions fol-
lowing median sternotomy have
been criticized in recent literature,
with suggestions that current pro-
tocols are overly restrictive and
impede patients’ recovery and post-
operative quality of life.
18,19,22,23
There is limited research investi-
gating the sternal precautions used
by physical therapists in their treat-
ment of patients who have under-
gone median sternotomy, and no
clinical guidelines in this area have
been published.
17,18,20,21
The physi-
cal therapy treatment of patients fol-
lowing cardiac and thoracic surgery
has previously been investigated in
Australia and New Zealand,
21,24,25
in
the United Kingdom,
26
and more
recently in Canada
27
and Sweden.
28
To our knowledge, no such studies
have been published in the United
States. Most of these studies, how-
ever, investigated the overall physi-
cal therapy treatment of patients
who had undergone cardiac surgery.
Although more recent studies
27,28
included questions relating to ster-
nal care, none addressed specifically
or in detail sternal protocols and
precautions, such as upper-limb
movement and loading restrictions.
In order to facilitate further research,
advance patient care, and provide
a basis for the development of
evidence-based clinical guidelines,
current practice needs to be docu-
mented and evaluated. The aim of
this study was to investigate and doc-
ument current sternal care practices
being utilized by physical therapists
in their treatment of patients follow-
ing median sternotomy.
Method
This study used a cross-sectional,
observational survey design.
Survey Instrument
There was no existing survey instru-
ment that met the objectives of
this study. A Web-based survey,
therefore, was custom designed by
the authors using professional
knowledge and clinical experience
in the field of cardiothoracic physical
therapy. The survey items were
reviewed by a panel of 10 experts
who had presented at the 2005
and 2007 Australian Physiotherapy
Association National Cardiothoracic
Group Conferences in the area of
cardiothoracic surgery. Feedback on
question content and validity and on
overall survey readability and utility
was provided by the experts, and the
survey was modified accordingly.
The Web-based functionality of the
survey then was tested using a sam-
ple of convenience of 10 cardiotho-
racic clinicians from 5 hospitals
(public and private). The Web-based
platform was found to function well.
However, as a result of the test, small
adjustments were made to the man-
ner in which the outcome data were
provided to the researchers. The
responses of the participants to the
survey questions were not analyzed
at this stage.
The final version of the Web-based
survey questionnaire consisted of
40 questions in 7 sections. The first
4 sections related to domains of
practice (wound support, lifting,
transfer, and mobility aid restric-
tions). In Australia, wound support
for a sternotomy is widely acknowl-
edged and accepted as anterior hand
pressure centrally over the wound
using a pillow. The remaining sec-
tions included respondent demo-
graphics, factors influencing prac-
tice, and a final open-ended section
where respondents could provide
any additional information. Ques-
tions were mainly in closed categor-
ical form, with some open-ended
questions for written responses. The
survey questionnaire is presented in
the Appendix.
Target Population
Senior cardiothoracic physical thera-
pists from all hospitals in Australia
where cardiac surgery was per-
formed using median sternotomy
were invited to participate. “Senior
physical therapist” is a commonly
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used and accepted clinical role in
Australian hospitals (public and pri-
vate). The “senior cardiothoracic
physical therapist” would be under-
stood by all to be the person who has
the most senior role and oversight of
the group of physical therapists man-
aging the care of patients undergo-
ing cardiothoracic surgery in the par-
ticular hospital.
A list of appropriate hospitals was
produced by investigating the Aus-
tralian Institute of Health and Wel-
fare and the Australasian Society of
Cardiac and Thoracic Surgeons Web
sites. Individual hospital Web sites
then were examined. If cardiotho-
racic surgery (including median ster-
notomy) was not clearly identified as
being performed at the site, the sur-
gical departments of these hospitals
were contacted by telephone for
simple clarification. In all, 51 hospi-
tals were included, and the senior
cardiothoracic physical therapist
from each identified hospital was
invited to participate. There were no
exclusion criteria.
Data Collection
Information packs were sent to each
identified hospital in June 2010.
These packs included an information
statement, consent form, site iden-
tification card, and self-addressed
reply-paid envelope. Respondents
were requested to sign and return
the consent form, which included
the provision of a contact e-mail
address. Those who completed the
consent process as requested were
sent login details and instructions
to complete the Web-based survey.
Site identification cards and com-
pleted consent forms were returned
to separate investigators. The site
identification cards, therefore, could
not be matched to the returned con-
sent forms, maintaining the respon-
dents’ anonymity. Use of site iden-
tification cards facilitated tracking
of responses and, through the use
of reminders, allowed the maximi-
zation of response rate. Invited par-
ticipants who had not returned
their consent form within 3 weeks
were sent a reminder in the form of
a second information pack. Those
who had been provided with login
details as a result of returning their
signed consent form, but had not
completed the survey, were sent 2
reminder e-mails (2 weeks apart).
Data Analysis
Data were downloaded from the sur-
vey Web site into a database and ana-
lyzed using JMP (version 8.0) and
SAS (version 9.2) statistical software
programs (SAS Institute Inc, Cary,
North Carolina). Descriptive analysis
included frequency and contingency
tables for categorical variables and
calculation of median and range for
continuous variables. The chi-square
test was applied to contingency
tables for comparisons between the
categorical variables of type of ster-
nal precaution (ie, wound support,
lifting restrictions, transfer restric-
tions, and mobility aid restrictions)
and responses from public and pri-
vate hospitals. The Fisher exact test
was used (using SAS software when
necessary) when tables contained
low expected cell counts or when
the chi-square test Pvalue was
below .3. The continuous variables
“years of experience in physical
therapy” and “years of experience in
cardiothoracic physical therapy”
were grouped into categories to
facilitate interpretation. Open writ-
ten responses were analyzed via sim-
ple thematic analysis.
Results
From the 51 hospitals sent invita-
tions to participate, 32 consent
forms (62.7%) were returned. The
respondents were allocated login
details and enrolled in the Web-
based survey. Of those who returned
their consent form and were
enrolled in the Web-based survey, 30
went on to complete the Web-based
survey (58.8%). Analysis for each
question was performed in relation
to the number of possible respon-
dents. For example, there were 24
possible respondents for the sec-
tions investigating wound support,
lifting restrictions, transfer restric-
tions, and mobility aid restrictions.
The flow of respondents through the
study is shown in the Figure.
Responses were obtained from all
states in Australia currently perform-
ing cardiothoracic surgery, as well as
the Australian Capital Territory. Both
public hospitals (n⫽18) and private
hospitals (n⫽12) were represented.
There was a statistically significant
difference between the response
rates of public and private hospitals
(P⬍.004). The response rate of pri-
vate hospitals was 44.4% (12/27)
compared with the public hospital
response rate of 83.3% (20/24).
Information regarding participant
and site characteristics is displayed
in Table 1.
Wound Support
Use of sternal wound support was
reported by most respondents
(n⫽22, 91.7%). Of these respon-
dents, almost all reported that
wound support commenced imme-
diately postsurgery (n⫽21, 95%).
Cessation of wound support was
variable, and responses included:
“ⱕ7 days post-op” (n⫽8, 36.4%),
“8–14 days post-op” (n⫽5, 22.7%),
“⬎14 days post-op” (n⫽6, 27.3%),
and “once the sternum is healed”
(n⫽3, 13.6%). There was no signifi-
cant difference (P⫽1.0) in the num-
ber of respondents using wound sup-
port between public hospitals (14
out of 15) and private hospitals
(7 out of 8).
Lifting Restrictions
Lifting restrictions were used by
95.8% of the respondents (n⫽23).
Respondents were asked to define
their use of lifting restrictions by
commenting on both weight and
height restrictions. This information
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is shown in Table 2. All respondents
reported that lifting restrictions com-
menced immediately postsurgery.
The reported time of cessation of
both height and weight restrictions
was variable. The reported use of
lifting restrictions was very similar
for public hospitals (16 out of 16)
and private hospitals (7 out of 8)
(P⫽.3).
Transfer Restrictions
Transfer restrictions, which included
bed mobility restrictions, were
reported to be used by 95.8% of the
respondents (n⫽23). Information
relating to the use of transfer restric-
tions is displayed in Table 3. Almost
all respondents reported that trans-
fer restrictions commenced imme-
diately postsurgery (n⫽22, 95.6%).
The cessation of transfer restrictions
was reported by the majority of
respondents to occur 3 to 6 weeks
postoperatively (n⫽15, 65.2%).
However, other responses included
“once the sternum is assessed to be
stable” (n⫽4, 17.4%) and “when
medical clearance is given by the
general practitioner or surgeon”
(n⫽3, 13.0%). The proportions for
public and private hospitals using
transfer restrictions were the same
as for lifting restrictions (P⫽.3).
Mobility Aid Restrictions
Mobility aid restrictions were used
by 62.5% of the respondents (n⫽15).
Further details of mobility aid restric-
tions used are displayed in Table 3.
In responses where “Other” was
selected, respondents usually indi-
cated that mobility aids were
allowed if patients had a problem
with balance or were unable to
mobilize independently and that
patients were to minimize weight
bearing through their arms as much
as possible. Most respondents indi-
cated that restrictions on the use of
mobility aids commenced immedi-
ately postsurgery (n⫽12, 80.0%).
The reported time of cessation of
mobility aid restrictions again was
Table 1.
Demographics of the National Survey of Senior Cardiothoracic Physical Therapists in
Hospitals Performing Cardiothoracic Surgery in Australia
Respondent and Site Demographics N %
Physical therapy experience
⬍4 years 5 16.7
4–9 years 9 30.0
⬎9–15 years 4 13.3
⬎15 years 12 40.0
Cardiothoracic physical therapy experience
⬍4 years 7 23.3
4–9 years 8 26.7
⬎9–15 years 8 26.7
⬎15 years 7 23.3
Qualifications
Bachelor’s degree 30 100.0
Honors 4 13.3
Master’s degree 4 13.3
PhD 0 0.0
Type of facility
Public 18 60.0
Private 12 40.0
Participants
enrolled to
participate in
online survey
n=32 (63%)
Completion of
online survey
n=30 (59%)
All identified
sites
N=51
Non-
completion of
online survey
n=2 (4%)
Figure.
Flow diagram of respondents to survey investigating current physical therapy manage-
ment of sternal precautions following median sternotomy.
Management of Sternal Precautions Following Median Sternotomy
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variable. Respondents from private
hospitals were less likely to place
restrictions on the use of mobility
aids, and this difference was statisti-
cally significant at discharge, with 12
out of 16 public hospitals reporting
use of this restriction compared with
only 3 out of 8 private hospitals
(P⬍.027). All respondents from pri-
vate hospitals indicated that no
restrictions are placed at discharge
“as long as that aid can be indepen-
dently and safely used.”
Rationale for and
Purpose of Restrictions
Respondents’ opinions about the
purpose of and rationale for each
domain of practice were sought.
Responses relating to wound sup-
port, lifting restrictions, transfer
restrictions, and mobility aid restric-
tions are shown in Table 4.
Discussion
This is the first study worldwide to
investigate and publish current prac-
tices specifically relating to the use
of sternal precautions in the physical
therapy treatment of patients who
have undergone median sternotomy.
The response rate of 59% is consis-
tent with commonly reported sur-
vey response rates and superior to
average reported response rates of
Web-based surveys.
29–36
Because the
inclusion criteria included all hospi-
tals in Australia, the response rate
represents a substantial proportion
of the population of interest. Both
public and private hospitals from all
Australian states currently perform-
ing cardiothoracic surgery were rep-
resented in our survey. The results,
therefore, are likely to be generaliz-
able to the wider Australian popula-
tion of physical therapists involved
in treatment of patients following
median sternotomy.
The findings of this study reveal that
there is considerable variation in the
sternal precautions used by physical
therapists throughout Australian hos-
pitals in the treatment of patients
who have undergone median ster-
notomy. Sternal wound support was
used in most settings and lifting,
transfer, and mobility aid restrictions
were commonly enforced. The types
of restrictions and the timing of their
cessation were variable. The preven-
tion of sternal instability and pain
management were the most com-
monly cited reasons for the use of
the restrictions.
Lifting Restrictions
Lifting limitations included both
weight and height restrictions.
There was some uniformity in the
weight restrictions used, and the
common use of a weight restric-
tion of 2 to 5 kg (4.4–11 lb) through-
out Australia is consistent with
suggestions that strict movement
and weight limitations often are
placed on patients following median
sternotomy.
15,19,22,23
Table 2.
Lifting Restrictions Used in the Physical Therapy Treatment of Patients Who Have
Undergone Median Sternotomy
Variable n %
Lifting restrictions used
A weight restriction on unilateral lifting 18 78.2
A weight restriction on bilateral lifting 22 95.6
Restricting the height an object can be lifted to 5 21.7
Other 7 30.4
Weight restrictions specified initially
1 kg 2 8.7
2–5 kg 18 78.5
6–10 kg 1 4.3
Lifting of any weight prohibited 1 4.3
Any weight within pain limitation 1 4.3
Weight restrictions specified at discharge
1 kg 0 0.0
2–5 kg 19 82.6
6–10 kg 1 4.3
Lifting of any weight prohibited 0 0.0
Any weight within pain limitation 3 13.0
Height restrictions specified initially
Lifting height to onset of pain 3 13.0
Lifting height to ⱕ90° of shoulder flexion 3 13.0
No overhead lifting 6 26.1
No height restriction applied 13 56.5
Other 3 13.0
Height restrictions specified at discharge
Lifting height to onset of pain 5 21.7
Lifting height to ⱕ90° of shoulder flexion 2 8.7
No overhead lifting 4 17.4
Not applicable, no height restriction applied 13 56.5
Other 5 21.7
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It has been argued that the weight
restrictions placed on patients fol-
lowing sternotomy are too strin-
gent.
18,19,22,23
Adams et al
19
calcu-
lated the forces required to perform
a number of activities of daily living
(ADL); however, they provided a lim-
ited description of the methods used
to measure force, and their study
participants were healthy. Despite
these limitations, they found that
many of the activities investigated
(eg, opening and closing doors)
required 5.7 kg (12.5 lb) or more of
force.
19
Patients would commonly
be performing such ADL tasks at
discharge without restriction. These
findings highlight the potentially
illogical nature of some documented
restrictions, which recommend lift-
ing less than 2.27 kg (5 lb) following
sternotomy.
19
Compared with these
guidelines, the instructions given to
patients at discharge in Australian
hospitals are slightly less restrictive.
Upper-limb movement and exercise
during the recovery process fol-
lowing median sternotomy provide
benefits.
17–20
Upper-limb movement
and exercise are thought to enhance
circulation to the muscles of the
chest wall, shoulder girdle, and
sternum.
17,19
Remaining active also
is important to prevent general
physiological decline, such as the
development of adhesions and
muscle atrophy.
17,19
It is possible
that instructions given to patients at
discharge limiting upper-limb activ-
ity could be detrimental to their
recovery by restricting their func-
tional ability and preventing or
delaying the resumption of normal
activities.
15,18,19
Restrictive limita-
tions may compromise the ability
of patients, especially those of
older age and those with previously
impaired mobility, to perform sim-
ple, independent functional tasks,
such as getting out of bed and stand-
ing from a chair.
Table 3.
Transfer Restrictions, Mobility Aid Restrictions, and Other Restrictions Used in the
Physical Therapy Treatment of Patients Who Have Undergone Median Sternotomy
Variable n %
Transfer restrictions specified initially
No upper-limb unilateral pulling permitted 16 69.6
No upper-limb unilateral pushing permitted 17 73.9
No upper-limb bilateral pulling permitted 5 21.7
No upper-limb bilateral pushing permitted 8 34.7
Pain limited bilateral arm movements 9 39.1
Pain limited unilateral arm movements 6 26.1
Other 4 17.4
Transfer restrictions specified at discharge
No upper-limb unilateral pulling permitted 13 56.5
No upper-limb unilateral pushing permitted 14 60.9
No upper-limb bilateral pulling permitted 5 21.7
No upper-limb bilateral pushing permitted 7 30.4
Pain limited bilateral arm movements 10 43.5
Pain limited unilateral arm movements 8 34.8
None 0 0.0
Mobility aid restrictions specified initially
No use of unilateral walking sticks permitted 6 40.0
No use of 4-wheel walkers permitted 1 6.7
No use of pick-up frames permitted 5 33.3
No use of forearm support frames permitted 3 20.0
All patients mobilizing with a forearm support frame
a
post-sternotomy
0 0.0
Other
b
8 53.3
Mobility aid restrictions specified at discharge
No use of unilateral walking sticks permitted 4 26.7
No use of 4-wheel walkers permitted 2 13.3
No use of pick-up frames permitted 4 26.7
No use of forearm support frames permitted 4 26.7
None as long as the aid can be independently and
safely used
8 53.3
Other
Driving restrictions
c
4 44.4
No sleeping on side 1 11.1
Increased strictness and length of precautions in
patients identified as at risk
1 11.1
a
A forearm support frame is widely acknowledged in Australia as a wheeled walking frame with
forearm rest pads, which provide support to the upper body during mobilization.
b
Responses usually indicated that use of mobility aids was restricted unless patients were unable or it
was unsafe to mobilize independently.
c
Driving restrictions usually lasted for 6 weeks.
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Transfer Restrictions
With respect to transfer and bed
mobility restrictions, unilateral push-
ing and unilateral pulling were
the movements most commonly
restricted during hospitalization and
at discharge. Restrictions on bilat-
eral pushing and pulling were used
less commonly. There may be some
theoretical support for these restric-
tions in the published literature.
17,21
The use of bilateral upper-limb
movements, producing symmetri-
cal load on the sternum, may be
more beneficial for sternal healing
compared with the asymmetrical
loads produced by unilateral upper-
limb movements.
17,21
El-Ansary et
al
17
investigated the relationship
between upper-limb movements
and pain in patients with chronic
sternal instability and found that
unilateral upper-limb movements
(loaded or unloaded) were signifi-
cantly associated with sternal pain
compared with bilateral upper-
limb movements. These authors sug-
gested that unilateral upper-limb
movements may produce mechani-
cal “shearing” forces on the oppos-
ing ends of the sternum in all planes
of movement, which could cause
irritation of bony and neural struc-
tures.
17
Studies using human cadav-
ers
37
and synthetic sternum models
38
also have investigated the effects
of forces through the sternum.
McGregor et al
37
found that bilateral
forces applied from a lateral direc-
tion caused greater cadaver sternal
distraction than forces applied in an
anterior-posterior or rostral-caudal
direction. No measurements were
made of unilateral distraction forces
on sternal separation; therefore, no
inferences can be drawn from the
data to describe the effect of uni-
lateral upper-extremity movements
on sternal separation. There also
have been no studies conducted
with patients in the acute post-
operative recovery phase. Until fur-
ther research into the effects of
unilateral and bilateral upper-limb
movements on the healing ster-
num is undertaken, the basis for
implementing restrictions on unilat-
eral upper-limb movement remains
theoretical.
17,18,20
The initial restrictions reported by
many respondents differed from the
restrictions specified at discharge.
During the first 4 to 6 weeks of the
bone healing process, the callus
formed is still very weak,
39
which
brings into question the rationale for
the initial prescription of modifica-
tions and for the modification of
restriction specifications at dis-
charge. Patients are commonly dis-
charged approximately only 5 to 7
days following their surgery,
16
and it
is likely that no significant healing
would have taken place by this stage.
As with lifting restrictions, the
impact of transfer restrictions on
patients’ ability to perform ADL
tasks is uncertain and needs to be
considered. The ability to perform
ADL tasks is rarely used as an out-
come measure following cardiac sur-
gery.
15,40
LaPier et al
15
investigated
the impact of CABG on the ability
to perform ADL tasks. However, as
sternal precautions prohibited some
of the ADL tasks on the Functional
Status Index (FSI), the tasks that
were overtly limited by the sternal
precautions were omitted. Their
results showed a significant loss of
function in the remaining indices
immediately postsurgery. Problems
commonly experienced by partici-
pants included difficulty opening
containers, putting on clothing, and
rising from a chair.
15
The authors
suggested that sternal precautions,
fear of activity, and exacerbation of
symptoms may be related to this
postoperative loss of physical func-
tion.
15
For example, patients endeav-
oring to adhere to sternal precau-
tions relating to transfer restrictions
may have reported the problem of
difficulty in rising from a chair, as for
some patients this activity may place
significant force through the upper
limbs. Potentially, difficulties with
ADL tasks experienced by patients
who have undergone CABG may be
further affected by their adherence
to sternal precautions.
Table 4.
Rationale Used by Senior Cardiothoracic Physical Therapists for Use of Wound Support and Restrictions in Patients Who Have
Undergone Median Sternotomy
a
Rationale for Use
Wound
Support
(nⴝ22)
Lifting
Restrictions
(nⴝ23)
Transfer
Restrictions
(nⴝ23)
Mobility Aid
Restrictions
(nⴝ15)
n%
a
n%
a
n%
a
n%
a
Prevention of incision dehiscence 9 40.9 20 87.0 10 43.5 7 46.7
Prevention of sternal instability 14 63.6 23 100.0 22 95.7 15 100.0
Prevention of sternal breakdown and infection 7 31.8 10 43.5 9 39.1 8 53.3
Pain management 20 90.9 16 69.6 16 69.6 7 46.7
I am not sure 0000
a
Percentage of the number of possible respondents for each question.
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Mobility Aid Restrictions
There was significant variation in
both the restrictions on types of
mobility aids used and when these
restrictions ceased. Although a large
proportion of respondents reported
restricting the type of mobility aid
permitted, many indicated that
restrictions on mobility aids were
not applied if the patient was unsafe
or unable to walk independently. It
is possible that patients requiring
mobility aids postoperatively are
more likely to have multiple comor-
bidities such as obesity or diabetes
mellitus. As these comorbidities are
documented as being risk factors for
sternal complications,
7,10,41
it may be
argued that it is these patients with
whom these restrictions should be
enforced rather than other patients.
Private hospitals were less likely
than public hospitals to specify
mobility aid restrictions at discharge,
and this difference was statistically
significant (P⬍.027). The reason
for this difference is unclear. One
possible explanation may be that
patients in public hospitals are, on
average, from lower socioeconomic
groups and have more complex
conditions.
42
They may be more
likely, therefore, to require a mobil-
ity aid. Furthermore, these patients
may be managed within the public
system, as these sites often have the
increased capacity required to pro-
vide adequate care to patients at
higher operative risk.
Of the respondents who reported
implementing mobility aid restric-
tions at discharge, restrictions on the
use of unilateral and bilateral mobil-
ity aids were equally reported. These
restrictions are inconsistent with
the reported restrictions on trans-
fers (unilateral upper-limb move-
ments being the most commonly
restricted in this instance). Mobility
aids involving the use of bilateral
forces through the upper limbs
(ie, pick-up frames and forearm sup-
port frames) were reported to be
restricted as frequently as mobility
aids involving unilateral forces (ie,
unilateral walking sticks).
These restrictions also raise the issue
of the postoperative mobility and
functional capacity of patients who
had premorbidly required a walking
aid. If the instruction is to not allow
any weight bearing through the
upper limbs, utilizing a mobility aid
is difficult. When the use of mobil-
ity aid restrictions is considered in
combination with lifting and trans-
fer restrictions, it is evident that
there is immense potential to have a
detrimental impact on patient recov-
ery, including functional capacity
and ability to perform necessary
ADL tasks. Time required to attain
independent mobility also could be
affected, potentially leading to an
increased length of stay and greater
resource utilization.
Rationale for and
Purpose of Restrictions
Sternal precautions are used in an
effort to prevent the occurrence of
sternal complications such as sternal
dehiscence, infection, and sternal
instability following median sternot-
omy.
7,10,40,41
In this study, the most
commonly reported rationale for the
use of restrictions was the preven-
tion of sternal instability and for the
use of wound support was pain man-
agement, followed by prevention of
sternal instability. Sternal instability
involves nonphysiologic or abnormal
motion of the sternum after either
bone fracture or disruption of sternal
wires and is characterized by click-
ing, pain, and discomfort during ADL
tasks.
17,20,43
Despite the purposes of sternal pre-
cautions reported by respondents,
the causes of sternal complications
such as instability or dehiscence
are likely to be unique to the indi-
vidual. Preoperative risk factors
that may contribute to the risk of
developing sternal complications
include diabetes mellitus, obesity,
smoking, chronic obstructive pul-
monary disease, osteoporosis, larger
female breast size, and previous
sternotomy.
5,7,10,41
Perioperative risk
factors reported include prolonged
bypass time, bilateral internal mam-
mary artery grafting, transfusions,
and prolonged hospital stay.
5,41,44,45
Thus, it may be argued that sternal
precautions may be better used by
patients who have, or develop, risk
factors for sternal complications
rather than by all patients regardless
of risk.
The impact of movement and load-
ing on the healing sternum is not
known. Therefore, restrictions such
as those described are not currently
based on any empirical evidence.
Other factors, such as a stable and
enduring approximation,
8,46
may be
more important in promoting ster-
nal union. The significant strain
placed on the sternum by frequent
coughing also has been acknowl-
edged.
8,18,22,45,46
Brocki et al
18
sug-
gest that unsupported, frequent
coughing is the single main cause of
mechanical stress through the ster-
num. This conclusion supports the
argument that strict postoperative
lifting and movement restrictions
may be unnecessary.
18,19,22
Indeed
coughing may be a far more signifi-
cant factor in the development of
sternal complications than whether
precautions are used in the treat-
ment of patients who have under-
gone median sternotomy.
18
This sur-
vey did not investigate respondents’
opinions regarding the effect of
coughing on sternal healing.
Web-Based Survey Design
The advantages and disadvantages
of Web-based surveys compared
with paper-based surveys were
considered. Advantages include cost
efficiency, immediate access to
the results, faster data analysis,
decreased likelihood of incomplete
Management of Sternal Precautions Following Median Sternotomy
8fPhysical Therapy Volume 92 Number 1 January 2012
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responses, and minimization of tran-
scription and data entry errors.
47–49
Disadvantages include increased
effort, expertise, and costs of sur-
vey development; computer or
Internet access problems; and lack of
computer literacy of the respon-
dent.
48–50
For the convenience of
both investigators and respondents,
it was decided that a Web-based
survey instrument was more appro-
priate for our investigation. One
positive aspect was that the Web-
based survey prevented respondents
from completing sections that were
not appropriate based on earlier
responses. This aspect contributed
to the accuracy of the responses and
reduced the potential for error.
Limitations
One limitation of this study is a
potential response bias. There was
a statistically significant difference
between the response rates of public
and private hospitals (P⬍.004). One
possible explanation for this finding
is that private facilities or surgeons
may contract with their preferred
physical therapy providers and the
therapists are not based on site. The
information packs were sent to hos-
pital addresses, and in the case of
some private hospitals, the packs
may not have reached the appropri-
ate person.
Only one physical therapist from
each site was invited to participate
in this study. It is possible that
other physical therapists at the same
site might have given different
responses. However, as most ques-
tions related to factual information
and the survey was to be completed
by the senior cardiothoracic physical
therapist, it is likely that responses
among individuals at the same site
would generally be consistent. Dif-
ferent responses may have been
given to the questions relating to
personal opinion (eg, relating to
rationale for restrictions); therefore,
all questions relating to personal
opinion can be taken to represent
only the individual responding to the
survey and not the site in general.
Conclusions
To our knowledge, this is the first
study to conduct and publish results
of a national survey specifically
investigating the current sternal
precautions used in the treatment
of patients who have recently under-
gone median sternotomy. Interna-
tionally, published literature has
investigated the physical therapy
treatment of patients who have
undergone cardiac surgery.
24,26–28
No studies, however, have investi-
gated in detail the management of
the sternum. Tucker and col-
leagues
24
and Reeve and Ewan
26
con-
ducted comprehensive investiga-
tions of the general physical therapy
treatment of patients undergoing
cardiac surgery in Australia and the
United Kingdom, respectively. How-
ever, sternal precautions were not
investigated. We also are not aware
of any published studies investigat-
ing the current practices of physical
therapists in the United States. To
our knowledge, only 2 published
studies have included questions
relating to sternal management.
27,28
Overend and colleagues,
27
in their
Canadian study, found that sternal
precautions and restrictions varied.
Interestingly, their results differed
from ours in that bilateral upper-limb
exercises were restricted more com-
monly than unilateral exercises.
Westerdahl and Moller,
28
in their
national survey of Sweden, found
that although sternal precautions
were commonly enforced, they also
were variable.
Our results show that significant
variation exists in the sternal pre-
cautions used by physical thera-
pists in public and private hospi-
tals throughout Australia. Similar
studies in the United States and the
United Kingdom would provide
comparative information regarding
international nuances of sternal
management following median ster-
notomy. In addition, further research
into this area is necessary to investi-
gate the effect of movement and
loading on the healing sternum,
whether the restrictions and pre-
cautions used are necessary, and
whether protocols affect patient out-
comes, including functional capac-
ity. Results of future research may
contribute to the development of
evidence-based guidelines for the
treatment of patients who have
undergone median sternotomy.
Ms Mackney and Ms Johnston provided
concept/idea/research design, project
management, and facilities/equipment. All
authors provided writing and data collection
and analysis. The authors thank all of those
who took part in this survey.
Ethics approval for this study was sought and
obtained from the Human Research Ethics
Committee of The University of Newcastle.
An abstract of selected outcomes from this
study was presented at the 16th Interna-
tional Congress of the World Confederation
for Physical Therapy; June 20–23, 2011;
Amsterdam, the Netherlands.
DOI: 10.2522/ptj.20100373
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Appendix
Web-Based Survey Questionnaire
a
Sternotomy Management Survey
(Note: this is a hard copy version; the final version is Web-based)
Question 1. In your clinical setting, are the post-op care and instructions given to patients post-sternotomy
influenced by the healing sternum? (tick one)
▫Yes ▫No
(*Respondents who answer “No” to Question 1 are directed to Section F, Question 30)
Section A
Question 2. In your clinical setting, does the management of patients post-sternotomy include the use of wound
support? (tick one)
▫Yes ▫No
(*Respondents who answer “No” to Question 2 are directed to Section B, Question 6)
Question 3. In your clinical setting, when does the use of wound support commence? (tick one)
▫Immediately post-op ▫1–3 days post-op ▫⬎3 days post-op
▫Other, please specify: _____________________________________________________________________________
Question 4. In your opinion, what is the purpose of wound support? (tick all that apply)
▫Prevention of incision dehiscence ▫Prevention of sternal instability
▫Prevention of sternal breakdown/infection ▫Pain management
▫I am not sure
▫Other, please specify: _____________________________________________________________________________
Question 5. In your clinical setting, when does the use of wound support cease? (tick one)
▫ⱕ7 days post-op ▫8–14 days post-op
▫⬎14 days post-op ▫Once the sternum is healed
▫Once the sternum is assessed to be stable
Section B
Question 6. In your clinical setting, does the management of patients post-sternotomy include the use of lifting
restrictions? (tick one)
▫Yes ▫No
(*Respondents who answer “No” to Question 6 are directed to Section C, Question 16)
Question 7. In your clinical setting, what is considered a lifting restriction? (tick all that apply)
▫A weight restriction on unilateral lifting
▫A weight restriction on combined bilateral lifting
▫Restricting the height an object can be lifted to
▫Other, please specify: ____________________________________________________________________________
Question 8. In your clinical setting, when does the use of lifting restrictions commence? (tick one)
▫Immediately post-op ▫1–3 days post-op ▫⬎3 days post-op
▫Other, please specify: _____________________________________________________________________________
Question 9. In your opinion, what is the purpose of lifting restrictions? (tick all that apply)
▫Prevention of incision dehiscence ▫Prevention of sternal instability
▫Prevention of sternal breakdown/infection ▫Pain management
▫I am not sure
(Continued)
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Appendix
Continued
Question 10. In your clinical setting, what is the initial weight restriction given to patients post-sternotomy? (tick one)
▫1kg ▫2–5 kg ▫6 –10 kg
▫No weight restriction specified ▫Any weight within pain limitation
Question 11. In your clinical setting, what weight restrictions do you specify on discharge? (tick one)
▫1kg ▫2–5 kg ▫6 –10 kg
▫No weight restriction specified ▫Any weight within pain limitation
Question 12. In your clinical setting, when does the use of weight restrictions cease? (tick one)
▫⬍1 week post-op ▫1–3 weeks post-op
▫3–6 weeks post-op ▫Once the sternum is healed
▫Once the sternum is assessed to be stable
▫When medical clearance is given by the general practitioner or surgeon
Question 13. In your clinical setting, what is the initial height restriction applied to lifting objects? (tick all that
apply)
▫Lifting height limited to onset of pain
▫Lifting height limited to ⱕ90 degrees of shoulder flexion
▫No overhead lifting
▫No height restriction applied
▫Other, please specify: ____________________________________________________________________________
Question 14. In your management of patients post-sternotomy, what height restrictions do you specify on
discharge? (tick all that apply)
▫Lifting height limited to onset of pain
▫Lifting height limited to ⱕ90 degrees of shoulder flexion
▫No overhead lifting
▫Not applicable, no height restriction applied
▫Other, please specify: _____________________________________________________________________________
Question 15. In your clinical setting, when does the use of height restrictions cease? (tick one)
▫⬍1 week post-op ▫1–3 weeks post-op
▫3–6 weeks post-op ▫Once the sternum is healed
▫Once the sternum is assessed to be stable
▫When medical clearance is given by the general practitioner or surgeon
▫Not applicable, no height restriction applied
Section C
Question 16. In your clinical setting, does the management of patients post-sternotomy include transfer restric-
tions? (tick one)
▫Yes ▫No
(*Respondents who answer “No” to Question 16 are directed to Section D, Question 22)
Question 17. In your clinical setting, what bed mobility and transfer restrictions do you apply? (tick all that apply)
▫No upper-limb unilateral pulling permitted
▫No upper-limb unilateral pushing permitted
▫No upper-limb bilateral pulling permitted
▫No upper-limb bilateral pushing permitted
▫Pain limited bilateral arm movements
▫Pain limited unilateral arm movements
▫Other, please specify: ____________________________________________________________________________
(Continued)
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Appendix
Continued
Question 18. In your clinical setting, when does the use of bed mobility and transfer restrictions commence? (tick one)
▫Immediately post-op ▫1–3 days post-op ▫⬎3 days post-op
▫Other, please specify: _____________________________________________________________________________
Question 19. In your opinion, what is the purpose of bed mobility and transfer restrictions? (tick all that apply)
▫Prevention of incision dehiscence ▫Prevention of sternal instability
▫Prevention of sternal breakdown/infection ▫Pain management
▫I am not sure
Question 20. In your clinical setting, what bed mobility and transfer restrictions do you specify on discharge?
(tick all that apply)
▫None
▫No upper-limb unilateral pulling permitted
▫No upper-limb unilateral pushing permitted
▫No upper-limb bilateral pulling permitted
▫No upper-limb bilateral pushing permitted
▫Pain limited bilateral arm movements
▫Pain limited unilateral arm movements
Question 21. In your clinical setting, when does the use of bed mobility and transfer restrictions cease? (tick one)
▫⬍1 week post-op ▫1–3 weeks post-op
▫3–6 weeks post-op ▫Once the sternum is healed
▫Once the sternum is assessed to be stable
▫When medical clearance is given by the general practitioner or surgeon
Section D
Question 22. In your clinical setting, does the management of patients post-sternotomy include restrictions on the
type of mobility aid used? (tick one)
▫Yes ▫No
(*Respondents who answer “No” to Question 22 are directed to Section E, Question 28)
Question 23. In your clinical setting, when do restrictions on the use of mobility aids commence? (tick one)
▫Immediately post-op ▫1–3 days post-op ▫⬎3 days post-op
▫Other, please specify: _____________________________________________________________________________
Question 24. In your clinical setting, what mobility aid restrictions do you apply? (tick all that apply)
▫No use of unilateral walking sticks permitted
▫No use of 4-wheel walkers permitted
▫No use of pick-up frames permitted
▫No use of forearm support frames permitted
▫All patients commence mobilizing with a forearm support frame post-sternotomy
▫Other, please specify: _____________________________________________________________________________
Question 25. In your opinion, what is the purpose of restricting the use of specific mobility aids during sternotomy
management? (tick all that apply)
▫Prevention of incision dehiscence
▫Stabilizing the upper limbs to allow the accessory muscles to assist in breathing
▫Prevention of sternal instability
▫Prevention of sternal breakdown/infection
▫Pain management
▫I am not sure
(Continued)
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Appendix
Continued
Question 26. In your clinical setting, what mobility aid restrictions do you specify on discharge? (tick all that apply)
▫No use of unilateral walking sticks permitted
▫No use of 4-wheel walkers permitted
▫No use of pick-up frames permitted
▫No use of forearm support frames permitted
▫None, as long as that aid can be independently and safely used
Question 27. In your clinical setting, when do the restrictions placed on mobility aid use cease? (tick one)
▫⬍1 week post-op ▫1–3 weeks post-op
▫3–6 weeks post-op ▫Once the sternum is healed
▫Once the sternum is assessed to be stable
▫When medical clearance is given by the general practitioner or surgeon
▫When cleared by the physical therapist
Section E
Question 28. In your clinical setting, does the management of patients post-sternotomy include any other
restriction/management that concerns the sternum/wound area? (tick one)
▫Yes ▫No
(*Respondents who answer “No” to Question 28 are directed to Section F, Question 30)
Question 29. Please specify this precaution:
In your opinion, what is the purpose of this precaution? ________________________________________________
In your clinical setting, when does the use of this precaution commence? ___________________________________
In your clinical setting, when does the use of this precaution cease? ______________________________________
In your clinical setting, what instructions about this precaution do you specify on discharge? _________________
Section F
Question 30. What has directed your current clinical practice relating to post-sternotomy management? (tick all
that apply)
▫University studies ▫Workplace practices/protocols
▫Clinical experience ▫Journal articles
▫Formal professional development or in-service training
▫Other
Question 31. Have you read any current literature regarding the use of sternal precautions in post-sternotomy
management? (tick one)
▫Yes ▫No
Question 32. In your professional opinion, what do sternal precautions achieve? (tick all that apply)
▫Prevention of incision dehiscence ▫Prevention of sternal instability
▫Prevention of sternal breakdown/infection ▫Pain management
▫Nothing ▫Other, please specify: _______________________________
Section G
Question 33. How long have you been working in the field of physical therapy? ______years/months
Question 34. How long have you been working in cardiopulmonary physical therapy/thoracic surgery?
______years/months
Question 35. What are your tertiary education qualifications? (tick all that apply)
▫Bachelor’s degree ▫Honors
▫Master’s degree ▫PhD
(Continued)
Management of Sternal Precautions Following Median Sternotomy
14 fPhysical Therapy Volume 92 Number 1 January 2012
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Appendix
Continued
Question 36. What year did you graduate? _______
Question 37. What state or territory are you currently working in?
▫ACT ▫NSW
▫NT ▫QLD
▫SA ▫TAS
▫VIC ▫WA
Question 38. How many patients are you treating per week?
▫0–4 ▫5–9
▫10–14 ▫⬎15
Question 39. What type of facility do you currently work in?
▫Public ▫Private
Question 40. What geographical area do you work in?
▫Metropolitan ▫Rural ▫Regional
a
Post-op⫽postoperatively, ACT⫽Australian Capital Territory, NT⫽Northern Territory, SA⫽South Australia, VIC⫽Victoria, NSW⫽New South Wales,
QLD⫽Queensland, TAS⫽Tasmania, WA⫽Western Australia.
Management of Sternal Precautions Following Median Sternotomy
January 2012 Volume 92 Number 1 Physical Therapy f15
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doi: 10.2522/ptj.20100373
Published online September 23, 2011PHYS THER.
Johnston
Lara J. Tuyl, Jennifer H. Mackney and Catherine L.
Australia: A Web-Based Survey
Median Sternotomy by Physical Therapists in
Management of Sternal Precautions Following
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