Giardini Marica (Istituti Clinici Scientifici Maugeri IRRCS, Department of Physical and Rehabilitation Medicine Unit, Institute of Veruno, Italy)
Libiani Gianluca (Istituti Clinici Scientifici Maugeri IRRCS, Department of Physical and Rehabilitation Medicine Unit, Institute of Veruno, Italy)
Guenzi Marco (Istituti Clinici Scientifici Maugeri IRRCS, Department of Cardiac Rehabilitation, Institute of Veruno, Italy)
Arcolin Ilaria (Istituti Clinici Scientifici Maugeri IRRCS, Department of Physical and Rehabilitation Medicine Unit, Institute of Veruno, Italy)
Godi Marco (Istituti Clinici Scientifici Maugeri IRRCS, Department of Physical and Rehabilitation Medicine Unit, Institute of Veruno, Italy)
In patients with median sternotomy, during post-operative period, the supine to sitting postural change is a movement in which the sternal wound is placed under stress, despite is essential for patient’s autonomy. The current sternal precautions are considered overly restrictive, potentially limiting patients’ recovery (1,2). Pain has emerged as a reliable indicator of movement safety (3). A device known as “IDSS” (Individual Device for Supine-to-Sitting), which utilizes a rope attached to the bed to facilitate the supine-to-sitting transition, has demonstrated lower pain and effort levels compared to traditional rotational techniques (4). Despite these benefits, sternal displacement during these movements has not been thoroughly investigated.
This study aims to analyse two techniques for performing the supine-to-sitting postural change in patients who have undergone median sternotomy. The goal is to compare these techniques in terms of pain and sternal edge motion, ultimately identifying the safest and least painful method for patient use.
This research is a prospective, observational, monocentric study approved by the relevant ethical committees. Patients who had undergone median sternotomy and met the inclusion criteria were recruited between the 20th and 25th postoperative days. The Sternal Instability Scale (SIS) was used to record clinically detectable sternal instability. Patients were required to perform movements such as coughing and supine-to-sitting postural changes using two techniques: the rotational and the ‘IDSS.’ In each movement and in a static starting position, patients were asked about their pain using the Numerical Rating Scale (NRS), and ultrasound measurements were employed to determine the distance between sternal edges in both antero-posterior and latero-lateral displacements.
The study included 17 subjects, 24% of whom were women, with an average age of 64 ±15 years. 12 patients had a score of 0 on the SIS and were declared stable. Pain levels increased during movements compared to static conditions (at least, p<0.05), with higher pain reported during the rotational technique compared to the ‘IDSS’ (p<0.05). During the required movements, some sternal micromotions less than 2 mm in the antero-posterior direction and about 1 mm in the medio-lateral direction were measured. However, sternal displacement did not present statistically significant differences between measurements (p=0.57) neither on the latero-lateral plane, nor on the antero-posterior plane (p=0.12). In the subgroup of unstable patients (n=5), displacement differed between coughing and rotational movements in the latero-lateral direction (p<0.05), with the rotational movement causing greater displacement.
Restricting the use of the upper limbs and trunk following cardiac surgery via median sternotomy is not justified for all patients. A small amount of multiplanar motion is normal and part of the healing process. Pain should guide the choice of postural transition technique, with “IDSS” being preferred due to its association with less pain (4). Further studies are needed to tailor postural transitions for patients with sternal instability. Both techniques for supine-to-sitting transitions were found to be similar in terms of the risk of sternal mobilization, but “IDSS” is recommended due to its lower associated pain. Further research is necessary to develop personalized approaches for these patients.
