Below is a discussion on an APTA section listserv on the topic of sternotomy precautions s/p CABG. How much consensus do you find in these responses?

Sternal Precautions are commonly used s/p Open Heart. I have done what I consider to be an extensive literature review AND have talked to some of APTAs "leaders" in Cardiopulm. I have looked in the PT texts that I have including ones mentioned in previous posts, and they don't site WHERE these precautions came from. My original question is: where did these precautions come from? Where they just set by some MD and now we all follow them? What is the evidence?
EVERYONE (MDs., PAs, PTs, OTs) tell me "they just make sense". Our surgeons told me "just follow them."
Hmmm. I have worked with 90yr old demented post open heart who CANNOT follow these precautions, they do fine. I have worked with obese 50yr olds who can't get up without using there hands, but otherwise would be fine, but who go to rehab because of that one issue, using hands to stand. Lots of money spent for one issue! We use walkers in our hospital for our unsteady patients because they "must walk", but aren't they pushing with their arms at least 8-10# worth?
The medical literature states that the wiring used to hold the chest closed post open heart is STRONGER than the original bone! The medical literature states that dehiscance from infection occurs from inside to outside and diabetics are at the highest risk. The medical literature states that INFECTIONS weaken bone, no literature states using arms to push or using arms on a walker does. I also know some surgeons at some hospitals don't follow sternal precautions. If someone can give me the SOURCE of WHO started sternal precautions and their reason (evidence, other than "its logical", it ain't to me!) I would really appreciate it. This has been a tiny pet project of mine for 3 years now. I think for 50% of patients that get referred to me post open heart these sternal precautions limit them GREATLY and are often interpreted differently by different disciplines. For some it means going in to a nursing home for a while.


I have been thinking about the same thing. Where is the evidence? I find that when my home care patients continue to follow precautions (and they do since someone in acute care instilled an irrational fear that their chest is going to split open and heart fall out) they end up with a forward head, protracted internally rotated shoulders,kyphosis,and decreased diaphragmatic and chest expansion. All of which contribute to functional limitations and disability. I have the hardest time breaking them of these "precautions" and convincing them that they are not going to break. I like to get them gently stretching, doing retraction,and external rotation, cervical ROM, postural correction, and deep breathing as soon as I get them usually about 10 - 15 days post op. I suppose some precautions immediately post op are only logical, but how strict? which ones?, and from my perspective how long should they be maintained? I also have looked but have not been able to find any good evidence. Let's go make some!

I think many of these precautions originate with the surgeons, and they are not standard. I have worked with cardiac surgeons who have said their wiring of the sternum is extremely strong and advocated against sternal precautions for their patients. Though we did not collect hard data, my
experience is that we did not have any higher incidence of complications in this group compared to the group that did follow sternal precautions. The difficulties that I have had came with those patients who required strong UE use for functional mobility. For example, those patients who use crutches or a standard walker for limited weight bearing in a LE. In those situations, a conversation with the surgeon regarding the risks and benefits of allowing walker could usually provide a solution that was best for the patient.

I do agree that most often we need to seek the evidence, but there are some things in medicine that are done because they work--such as a pap smear (one of our physicians uses it as an example in a lecture he gives.)-and because not doing them has such poor consequences.
Working in acute care, and being privileged to have a DeBakey Heart Institute in our facility, we do follow sternal precautions. I must say you have made me curious enough to try to search out an answer, but I have seen the results of patients who do not follow the precautions (very rare, but it can happen). Yes the wires are strong, but they do break--I have seen it--or they separate from the bone. This usually happens during supine to sit or sit to stand transfers. We monitor UE weight bearing during gait with the walker, and rarely use the walker past the first couple days--once the chest tubes come out. Using a front-wheeled walker helps to decrease the stress in my opinion, and we tell the patient to use it for balance and not support. With cognitively impaired patients, we sometimes use hand-hold support and not the walker.
Our precautions are no lifting >5#, no arm motion past 90 degrees flex or abd, no bending/twisting/pushing or pulling during transfers or ADLs. Patients are taught a modified log roll transfer that uses minimal UE force and are not allowed to use their UEs when going sit to stand.

This is a question that has been troubling me since about June this year when I returned to work in the cardiothoracic field in Australia and found that the staff in the hospital were obsessed with sternal protection. I carried out a literature search, feeling I must have missed something - no result.
My cardiothoracic experience started as a student in a leading London (UK) hospital in 1979 (no sternal precautions). On qualifying in 1981, I went to a teaching hospital in the south of England (no sternal precautions), followed by a private hospital in the same area (no sternal precautions.) In 1991 I started the cardiac surgery programme at a hospital in NSW (no sternal precautions) where I worked for 6 years before returning to the UK. There I worked in a leading cardiac transplant hospital just outside London (no sternal precautions) before returning to NSW to the private hospital as mentioned above, to find them obsessed with patients clinging onto their sternums at all costs (quite possibly at the cost of independent mobilisation). Where does this come from???? From my experience over 2 countries, several different hospitals and 26 years, sternal wounds dehisce as a result of infection. Mechanical dehisccence must be extremely rare and certainly does not justify the kyphotic stance engendered by continually clutching a folded towel to ones chest in fear that ones sternum will fall apart!!! Has anyone studied the infection rates associated with this practice?? - could well be a contributary factor in the very thing it seeks to prevent!