Almost 200 years ago, newspapers reported on the outcome of a surgical amputation performed in London by Robert Liston (apparently known as the “fastest knife in the West End” – because speed was important in pre-anaesthesia 1829). Here’s how this was described:
“The operation was successful, but the patient died.”
We don’t know much about the unfortunate patient who went under the knife that day (thus making that ironic description famous in medical circles). But fast forward through the centuries to a duo of modern researchers who wondered why some patients who are undergoing successful cardiac surgery end up having poor outcomes, too. .
I also wondered about this after last week’s Heart Sisters blog post (“How Long Does it Take to Heal From Open Heart Surgery?“). For example, when cardiac surgeons were asked what they were advising their open heart surgery patients in response to that one question, why were their answers all over the map – ranging from six weeks to one year or more?
The research duo of Dr. Robert D. Parker and Dr. Jenny Adams knew that poor post-surgery outcomes were not necessarily the result of either the patient’s illness or the quality of medical care provided. Previous studies had already identified psychosocial issues linked with poor outcomes. Researchers suggest, for example, that patients who experienced new onset depression or anxiety associated with their open heart surgery had higher hospital re-admission rates(1), and a higher mortality risk.(2)
But why do heart patients who have had a successful surgical procedure end up feeling depressed or anxious?
That’s a trick question, of course, and no surprise to regular Heart Sisters readers who already know how common situational depression/anxiety is among freshly-diagnosed heart patients – those requiring surgery or not. See also: “When Are Cardiologists Going to Start Talking About Depression?
Parker and Adams also suggest that, for some heart patients, there may be a link between these poor outcomes and “medical professionals who may unintentionally contribute to patients’ anxiety and depression by giving post-surgical activity instructions that are inadequate, overly restrictive, or even flippant.”
Post-surgical activity restrictions are called sternal precautions – a list of shoulder movements, lifting or reaching activities that open heart surgery patients should avoid doing in the early weeks to help the breastbone (sternum) heal, and to help prevent infections and other complications. As Dr. Adams explains:
“Sternal precautions are intended to help protect patients, but instead they may inadvertently impede recovery. A restriction such as ‘Don’t lift more than 5 pounds’ can reinforce fear of activity, leading to the substantial muscle atrophy that occurs during short-term disuse. Resistance exercise training is necessary for regaining muscle mass lost during a period of disuse; therefore, ‘Don’t lift more than 5 pounds’ is the opposite of what patients need to hear.”
In the Parker-Adams study, heart patients who had successfully undergone open heart surgery were asked:
“What advice were you given post-surgery about resuming the activities of normal daily living?”
Here are just a few examples of unhelpful advice on activity restrictions:
- “I was told, ‘Don’t lift anything heavier than a fork.’”
“When I’ve tried to pin my doctors down on some specifics, they have told me just to use common sense.”
“When I asked questions about my condition, they say ‘you survived the ‘main event’ so just be happy and live your life.’ “
“At the time of my hospital discharge, I was given a short 5-minute talk about what I shouldn’t do, and the time was quickly over although I had many more questions to ask.”
“My original surgeon told me, at my 1-month follow-up, that I should be able to do everything I did before such as horseback riding and lifting bales of hay. But at my 3-month checkup, I saw a different doctor and he said NO to riding and lifting hay bales. So one says one thing and another says different. I sold my horses.”
“I was told, ‘We don’t really know what to do with you in cardiac rehab. We’ve never had anyone here who survived what you survived.’”
“I was told by my doctors that I would never be able to cycle again. Cycling was a huge part of my life. I was seriously depressed over that.”
Parker and Adams concluded:
“Most of the comments categorized as ‘unhelpful’ are only restrictive, meaning that they lack positive emphasis on returning to pre-surgical life. In addition, we contend that they are dangerous in that they can reduce functional ability, leading to depression and sub-optimal outcomes.”
Examples of helpful post-op advice include:
“I was in good physical shape, and the surgeon said I could keep doing the physical activity I had done after the recuperation period.”
“At a subsequent meeting with a health-exercise specialist, my lifting restrictions were updated.
“The rehab specialist said not to lift to the point where I grunt and turn red in the face. More recently, my cardiologist has also updated the advice.”
The most striking finding, according to Parker and Adams, is that over 80 per cent of the patients’ comments were about having their questions dismissed unanswered, receiving vague advice, or not receiving advice that they would characterize as useful for resuming their pre-surgical lives.
The questions that further drove the Parker-Adams research, were:
“Do the activity restrictions that heart patients are given after major surgery affect their recovery? Can the activity restrictions increase the risk of morbidity despite a successful surgical procedure?”
They wrote about cardiac surgery patients at one major Texas hospital who, like most if not all such patients, had been duly warned of the dangers of excessive lifting, reaching or pulling. Patients were told, for example, “not to lift anything heavier than a half-gallon of milk (about 4 pounds)” to help keep the newly split sternum stable until it had time to heal.
But Parker and Adams then compared that restriction to the effort required simply to open the big door to the cardiac rehabilitation facility in the same hospital (at that time, a door that had to be manually opened). This door required 14 pounds of force to open, yet as Parker and Adams observed, “no cardiac surgery patients have died or been injured from opening this door.”
The trouble is that these precautions may not even be consistent, depending entirely on where you happen to live.
But even in the same region, two different hospitals could issue conflicting sternal precautions.
A previous study published in the Cardiopulmonary Physical Therapy Journal, for example, noted these confusing discrepancies between hospitals. The Cleveland Clinic, for example, ordered its open heart surgery patients, “Don’t lift more than 20 pounds” for six weeks post-op to give the sternum time to heal. But just a two-hour drive away down Highway 71, the Ohio State Medical Center in Columbus ordered its patients, “Don’t lift more than 10 pounds.“ And meanwhile, the American College of Sports Medicine’s sternal precaution for safe post-op lifting: “Don’t lift more than 5-8 pounds.”(5)
So, which precaution is correct?
Another concern was that some patients didn’t interpret these precautions as being just short-term, and didn’t know that the de-conditioning harm that happens to weakened muscles when those muscles stop lifting, reaching or moving for several weeks can seriously affect recuperation.
The Parker and Adams study was called Activity Restrictions and Recovery after Open Chest Surgery: Understanding the Patient’s Perspective. The word “patient” in that title is significant – because co-author Dr. Robert D. Parker had undergone emergency open heart surgery himself five years earlier for an aortic dissection. The other author, Dr. Jenny Adams, is a well-known vascular physiologist and senior research associate at Baylor Hamilton Heart and Vascular Hospital in Dallas, Texas who has been studying post-operative precautions for many years. Her innovative “Keep Your Move in the Tube“ initiative, for example, offers a kinesiology-based safe alternative to overly restrictive sternal precautions by simply reminding patients to keep their upper arms close to their body as if they were inside an imaginary tube: “Patients can modify load-bearing movements and thus avoid excessive stress to the sternum.”(6)
More on “Keep Your Move in the Tube” via KSAT 12-ABC news
Finally, their conclusions:
“We propose that after open chest surgery, patients need:
- written information about their surgery and its after effects
- consistent advice and a way to ask questions that does not involve a physician visit
- personalized activity guidelines developed by an exercise specialist to help them resume their pre-surgical lives
“A small change in care delivery may lead to a big improvement in results.”
Pignay-Demaria V, et al. “Depression and anxiety and outcomes of coronary artery bypass surgery.” Ann Thorac Surg. 2003;75(1):314–321.
Ben-Zur H, et al. “Coping strategies, life style changes, and pessimism after open-heart surgery.” Health Soc Work. 2000;25(3):201–209
3. Parker RD, Adams J. “Activity restrictions and recovery after open chest surgery: understanding the patient’s perspective.” Proc (Bayl Univ Med Cent). 2008;21(4):421-425. doi:10.1080/08998280.2008.11928442
Grevious MA, et al. “Chest reconstruction, sternal dehiscence.” Medscape website. http://emedicine.medscape.com/article/1278627-overview
Cahalin LP, et al. “Sternal Precautions: Is It Time for Change? Precautions versus Restrictions – A Review of Literature and Recommendations for Revision.” Cardiopulm Phys Ther J. 2011;22(1):5-15.
Adams J, et al. “An alternative approach to prescribing sternal precautions after median sternotomy, “Keep Your Move in the Tube”. Proc (Bayl Univ Med Cent). 2016;29(1):97-100.
Q: What were you told after open heart surgery about sternal precautions?
NOTE from CAROLYN: I wrote much more about what you can learn if you ask patients about their lived experience in my book “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press, 2017). You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the code HTWN to save 20% off the list price).
–Heading home tips following open heart surgery (includes cardiac surgeon Dr. Jai Raman’s fantastic Extreme How-To: Step-By-Step Heart Surgery that he wrote for (yes!) Popular Mechanics)
-Managing the Open Heart Surgery Scar (a terrific resource from Elizabeth Dole’s Rehabilitate Your Heart site)