#sternal

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Recovery after median sternotomy is often slowed down by too restrictive precautions.

Sternal precautions should be patient specific and focus on patient characteristics and function to improve recovery instead of slowing it down, authors Cahalin LP et al. write in an extensive literature research published in Cardiopulmonary Physical Therapy Journal. (*1.)

The authors review available research related to median sternotomy procedures and the physical activity patients are allowed to do.

No universally accepted definition of sternal precautions exists for patients who have had a sternotomy.

The guide for precautions is usually anecdotal or expert opinion at best supported by indirect evidence. In most cases patients receive the same instructions over a fixed time-frame without regard to individual differences, risk factors for complications or clinical status of the recovery process.

Physical activities, functional tasks and recommended exercise are too restrictive in the immediate postoperative period, the authors write. Such restrictions can hinder an optimal sternal healing. As other muscles are not being exercised, the consequence can be atrophy of the chest wall muscles and weakening of the connective tissue structures.

The authors believe that numerous postoperative symptoms such as constant pain, impaired lung function and chest wall movement can be caused by overly restricting activities. They write that many other clinicians and researchers increasingly share the same view and are questioning whether sternal precautions are too restrictive.

Upper body exercise has a beneficial effect on circulation of blood in the arms and chest wall which promotes healing.

The authors have the opinion that an optimal degree and duration of activity should be based on the patients’ characteristics such as risk factors, comorbidities and previous activity levels etc. They also believe activities should have a progression in stages.

Cahalin et al. present a proposal for a step-by-step procedure with well-defined instructions for patient activity after sternotomy.

The algorithm presents a less restrictive and more individual, dynamic application of sternal precautions.

Patients are divided into risk categories for sternal complications based on known risk factors, clinical evaluation of the wound characteristics and other patient factors. The type and degree of activity precautions is determined according to the risk category for the individual patient. The algorithm allows for progression of activity based on each patient’s recovery characteristics in stead of a sudden lifting of all precautions at a certain time-point.

This publication is a strong support for QualiBreath: QualiBreath is an elastic sternum and thorax support. It can be adjusted to be as firmly supportive on the patient’s chest as desired. Whatever risk category a patient is placed into, QualiBreath can be adapted to fit the patients specific characteristics and needs.

The precisely defined elasticity of the QualiBreath material will support the patient’s thoracic muscles during activities in stead of restricting them.

QualiBreath, referred to as an adjustable fastening brace, is quoted in the publication:  “El-Ansary et al recently investigated the effects of supportive devices in patients with chronic sternal instability and found that use of an adjustable fastening brace [QualiBreath] improved pain and lessened sternal separation”.

The authors conclude: “A precautionary approach rather than restrictive approach is likely to better facilitate optimal sternal healing and functional recovery after a median sternotomy”. Their extensive literature research strongly confirmed that progressive rehabilitation is needed to improve thoracic motion, pulmonary function, symptoms and functional status after sternotomy.

It’s time for change. Sternal precautions must focus on function and patient characteristics to facilitate recovery rather than impede it.

What is your opinion on this ? Leave a comment below.

QualiBreath decreases the sternal gap in patients with an unstable sternum, and improves their discomfort, pain, feeling of support, ease of breathing and their ability to function!

This is the conclusion in a study from Australia by Doa El-Ansary et al., where they compared the QualiBreath sternum support, called “Adjustable Fastening Brace” in the article, to an elastic compression binder, and sports tape - used to control sternal instability.

Control of Separation in Sternal Instability by Supportive Devices: A Comparison of an Adjustable Fastening Brace, Compression Garment, and Sports Tape  Doa El-Ansary, PhD, Gordon Waddington, PhD, Roger Adams, PhD.  Arch Phys Med Rehabil 2008;89:1775-81.

You can find the full article here: http://www.archives-pmr.org/article/S0003-9993(08)00399-7/fulltext

The authors wrote: “The wearing of a brace (QualiBreath) may counter the lateral forces that result from rises in intra-thoracic pressures on coughing and the torsional forces that result from mobilization, upper-limb movements, and mobility transfers.”

The authors also had this to say about external chest support devices: “….supportive devices have been reportedly designed to reduce sternal pain, prevent wound breakdown and sternal instability.” …and ….. “The rationale for the use of these devices is that they provide circumferential support and resistance to increases in intra-thoracic pressure that may result in distractive forces on the sternum during activities of daily living. They may also act to complement the parasternal muscles (intercostals, sternalis, transverse thoracis) and muscles of the anterior abdominal wall, which are thought to play a role in the stabilization of the thoracic cage.”

El-Ansary et al. evaluated the effects of upper limb exercises on sternal separation in patients with sternal instability while wearing either QualiBreath, sports tape, an elastic compression binder or no support at all. The sternal separation was measured using ultrasound.

Routine active range of shoulder motion exercises, typically used by physiotherapists for patients after cardiac surgery, were used as well as unilateral arm elevation with and without a weight, and bilateral arm elevation with and without a weight. Two functional tasks were evaluated too: pushing up from a chair and flexion at the elbow against an elasticised rubber band with a low to moderate resistance performed unilaterally and bilaterally.

Furthermore patients were asked to rate comfort, pain, feeling of support, ease of upper-limb movement, and ease of breathing in the resting period after the exercises with each mode of intervention.

QualiBreath (Adjustable Fastening Brace) showed the best results in all measurements.

Here is what the authors said: “Results from the implementation of a set of  supportive devices for patients with chronic sternal instability consistently favored the use of an adjustable fastening brace (QualiBreath), which reduced the amount of sternal separation by one fifth. Measures tended to improve with  the amount of support offered by the device (QualiBreath)."

The patients ratings on the ability to perform arm activities, discomfort, pain, feeling of support, and ease of breathing also consistently gave the best results to QualiBreath. Furthermore almost all patients said they would have elected to use a brace immediately after surgery.

The authors suggested to perform a new study with QualiBreath used directly after surgery, and said: “The positive findings here regarding the effects of supportive devices on reported pain and ease of performance of everyday functional tasks in patients with sternal instability suggest that future studies should examine the use of supportive devices in the period immediately after cardiac surgery for their effect on both pain and sternal integrity.”

Logic says: If QualiBreath is shown to decrease the sternal gap in patients with  an unstable sternum, and improve their discomfort, pain, feeling of support, ease of breathing and their ability to function, then the probability for QualiBreath to do the same for patients immediately after cardiac surgery is very high.