STERNAL PRECAUTIONS AND EXERCISE PRESCRIPTION FOLLOWINGCARDIAC SURGERY PERFORMED VIA A MEDIAN STERNOTOMY IN MALAYSIA: A SURVEY

M.A. Katijjahbe^1,2, N.A. Md Ali³, S. Ahmad¹, N. Ismail¹, A.M. Abdul Rahman¹, Z. Lok¹, M.R.M. Abdul Manaf⁴, D. El-Ansary^2,5

¹Hospital Canselor Tuanku Muhkriz, Physiotherapy, Cheras, Kuala Lumpur, Malaysia, ²Swinburne University of Technology, Hawthorn, Victoria, Physiotherapy, Melbourne, Australia, ³Cardiothoracic Surgery Unit, Heart and Lung Centre, UKM, Cardiothoracic Surgery, Cheras, Malaysia, ⁴UKM, Department of Community Health, Faculty of Medicine, Cheras, Kuala Lumpur, Malaysia, ⁵University of Melbourne, Cardiothoracis Surgery, Victoria, Australia

Background: Sternal precautions are universally prescribed by the cardiac surgeon and other health practitioners from four weeks up to three months to patients following median sternotomy. However, the evidence reveals the efficacy of sternal precautions is low.

Purpose: The aim of this study were:
General

• to investigate the current post-operative physiotherapy practice in outpatient cardiac rehabilitation programs

Specific:
to investigate

• the prescription and progression of sternal precautions, upper limb and trunk exercises.
• methods used to assess sternal complications.
• how upper limb and trunk exercises, as well as functional tasks are modified in the presence of sternal complications.

Methods: We used a constructed survey questionnaire distributed via google form which has been validated and published previously(Balachandran et al, 2014). Permission for the use or adaptation of the questionnaire or other tools used in this study has been obtained appropriately on 5^th November 2019 from the authors. The questionnaire was then validated to identify any problems with the English version among a group of volunteers of 30 physiotherapist from two tertiary care hospitals in Kuala Lumpur. The survey was given via an email obtained from the list of Physiotherapy working in Cardiac Rehabilitation. The participants were required to submit the survey form back within one months.

Results: 83 participants with 73% response rate from 13 public and 5 private hospital conducting outpatient Cardiac Rehabilitation responded. There was variation in practice onsternal precautions prescribed by most centre in the first 4–8 weeks with 80.5 % placing restrictions on upper limbs and trunk exercises. At 6 weeks postoperatively 61% and 74% of respondents still placed restrictions on unloaded and loaded unilateral upper limb elevation exercises respectively. Similarly, 56% and 74% placed restrictions on unloaded and loaded bilateral upper limb elevation exercises, respectively. Most center have not adopted alternatives approaches such as ``Keep Your Move in the Tube'', which promotes motion close to the body with short lever arms to facilitate early recovery after median sternotomy, than placing restrictions on use of the upper limbs as part of sternal precautions. Strengthening exercise for upper limbs were only prescribed at 4-8 weeks post-op. There was a lack of consensus on the type and timing of these restrictions, with medical and health professional advice has been the main parameter used to guide sternal precautions and upper limbs exercise activities and progression. 80.7% reported screening for sternal instability based on patient’s subjective symptoms of sternal pain/discomfort and if detected patient was re-referral to Doctor/Specialist for further management (70.1%) with 28.9% will intervene with modifications of excises and activities.

Conclusions: Sternal precautions and upper limb exercises prescription isnot consistent or standardised, with significant variation in what constitutes “sternal precautions” as well as for what duration they should be applied within outpatient cardiac rehabilitation in Malaysia. Further research is warranted to establish evidence-based guidelines on SP in this population.

Implications: This study provide health professionals important information concerning SP and the prescription and progression of upper limb exercise following cardiac surgery in Malaysia.

Funding acknowledgements: None

Keywords:
Sternal Precautions
Upper Limbs Exercise Prescription and Progression
Web Survey

Topics:
Cardiorespiratory

Did this work require ethics approval? Yes

Institution: UKM

Committee: UKM Ethics Committee (Number:JEP-2019-654)

Ethics number: (UKM/PPI/111/8/JEP-2020-299).