Academic journal article Physical Therapy

Management of Sternal Precautions Following Median Sternotomy by Physical Therapists in Australia: A Web-Based Survey

Academic journal article Physical Therapy

Management of Sternal Precautions Following Median Sternotomy by Physical Therapists in Australia: A Web-Based Survey

Article excerpt

Cardiac surgery, such as coronary artery bypass grafting (CABG) and valve replacement, is commonly used in the management of heart disease. (1-4) More than 17,000 CABGs are performed annually in Australia, and more than 300,000 CABGs are performed annually in the United States. (1-3) Median, or midline, sternotomy is the most frequently used incision during cardiac surgery, as it provides optimal access to the heart and surrounding blood vessels. (5-8) Median sternotomy involves the division of the manubrium 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 sternum heals well. The incidence of postoperative sternal complications, such as sternal dehiscence, infection, and sternal instability, is reported as between 1% and 5%.s,m Deep wound infection is the most severe of the possible sternal complications and is associated with prolonged hospitalization, high costs, and high rates of morbidity and mortality. (11-14)

Protocols and policies have been developed within institutions relating to the sternal precautions used by physical therapists in their treatment of patients who have undergone median sternotomy. (15-18) Restrictions on movement and sternal 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 precautions, therefore, are based only on proposed theoretical rationale. (17-21) Furthermore, sternal precautions following median sternotomy have been criticized in recent literature, with suggestions that current protocols are overly restrictive and impede patients' recovery and postoperative quality of life. (18,19,22,23)

There is limited research investigating the sternal precautions used by physical therapists in their treatment of patients who have undergone median sternotomy, and no clinical guidelines in this area have been published. (17,18.20,21) The physical therapy treatment of patients following 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, however, investigated the overall physical therapy treatment of patients who had undergone cardiac surgery. Although more recent studies (27,28) included questions relating to sternal 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 documented and evaluated. The aim of this study was to investigate and document current sternal care practices being utilized by physical therapists in their treatment of patients following median sternotomy.

Method

This study used a cross-sectional, observational survey design.

Survey Instrument

There was no existing survey instrument 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 sample of convenience of 10 cardiothoracic clinicians from 5 hospitals (public and private). …

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