by Carolyn Thomas ♥ @HeartSisters
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’re 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’ responses 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 longterm 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)
Watch this video on “Keep Your Move in the Tube” via KSAT 12-ABC news
Finally, the Parker/Adam 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. 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). 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 30% off the list price).
See also:
–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)
-Learning to love your open heart surgery scar
–How long does it take to heal from open heart surgery?
–Why your heart needs work – not rest! – after a heart attack
–Heading home tips following open heart surgery
–Bed rest and other kinds of cardiac overtreatment
–The “new normal” – and why patients hate it
Heart Sisters 
This has really cemented in what we are currently going through with my husband’s open heart surgery! He had a quadruple bypass Sept. 22, did amazingly well. The last month he has been having pain to the right of his sternum that is achy, sometimes sharp and radiating with movement and use.
We have talked tirelessly to his PCP, cardiologist, surgeon, and rehab nurses. Each one tells us to contact the other and no one knows what is causing the pain. It’s been a month…. And the best they’ve done is put him on gabapentin….
I don’t know what else to do anymore.
LikeLiked by 1 person
Hello Melissa – when post-op recovery is going “amazingly well”, it can be a puzzling surprise when a change like pain starts up a month later. Sometimes, this is seen when patients start feeling so much better that they start overdoing it. If this is the issue, pain when moving can be a clue to slow down and go back to the careful post-op ‘sternal precautions’ that bypass patients are told about in the early weeks of healing (protecting the chest while lifting up and down from bed, or coughing/sneezing, etc.)
I’m not a physician so cannot comment specifically on your husband’s case, but I can say generally that recuperation from open heart surgery does seem to vary widely from person to person. I wrote more on this here – where I quoted Cleveland Clinic experts who say:
“You’ll do most of your healing – about 80 per cent – in the first 6-8 weeks after surgery. Complete recovery can take about one full year. . .”
Another cardiac surgeon I quoted there said this: “I used to say three months to recover, but now I say 3-6 months.”
I was surprised when I learned about this wide range of recovery estimates depending on one’s cardiac surgeon and a number of other factors (patient’s age, fitness, severity of the cardiac condition, how carefully the patient was following post-op ‘sternal precautions’, etc.) You and your husband might find that article of interest if you haven’t read it yet.
A symptom journal might also be a good idea if you’re feeling concerned: a simple record of date, time of day, description and location of the symptom, how long they last, what patient was doing/feeling/just before the onset of symptoms. Sometimes, a pattern can begin to emerge that could be useful to share with the doctor.
If your husband’s symptoms get worse, don’t hesitate to have yet another conversation with your cardiologist to rule out (rare) complications.
Please remember to take care of yourself while you’re taking on this new and often worrying role of caregiver.
♥
LikeLike
NOTE FROM CAROLYN: This comment has been removed because it was attempting to sell you a miracle cure which, if it were even remotely credible, would have already been patented by the drug industry and prescribed by doctors… For more info on how to get your comment deleted, please read my disclaimer page.
LikeLike
I would consider it very usual if someone had heart surgery and was NOT depressed for a while, probably 3 to 6 weeks at a minimum.
Depression is the body’s natural response to being wounded; it is a way of saving energy while resources are devoted to healing.
Much of the literature on depression after heart incidents does not do a good job at defining the level of depression, of which there are many. This is one resource can help to sort this out….
https://patient.info/doctor/patient-health-questionnaire-phq-9
I’ve spent a lot of time in depression after heart interventions: most of it was well spent.
And thanks as usual for bringing these issues to people’s attention. I know it must be Sunday when I see a link to your new post.
LikeLiked by 1 person
You are right, Dr. Steve – it IS Sunday today! Thanks so much for your comment. I still quote your observation of depression as “the body’s natural response to being wounded” and “a way of saving energy while resources are devoted to healing.”
Yours is an important voice on this largely ignored companion to heart disease, and deserves to be widely heard. I’m going to add a link under the “See Also” section above to one of the articles in which I’ve quoted you and your message.
I just wish that, given the known stats on the prevalence of this situational depression among heart patients, every patient would learn BEFORE being discharged from the hospital that this diagnosis is very common, usually temporary and treatable, and to be expected. As you once said: “There are damned good reasons to feel anxious and depressed!”
Being informed of this likelihood ahead of time while still in the hospital will not make depression feel any better (feeling that bad is awful while it lasts!) but the advantage would be that we wouldn’t keep wailing “What is WRONG with me?!?!” as I kept asking myself over and over, day after day… I prefer your take on this: this is just my body giving me this opportunity to lay low, rest, and focus only on healing…
Take care, stay safe… 🙂
LikeLike
I am going to have an aortic root aneurysm repaired soon – not scheduled yet, but I did have a heart cath last week as part of getting ready/cleared for the surgery. I have been paying attention to what movements I can feel in my chest area and was surprised at how much I can feel just a little stretching.
I have already moved my pills to a lower shelf, so I won’t have to reach for them. I love the “Move in the Tube” concept and will try to remember to ask my cardiologist/surgeon about it.
LikeLiked by 1 person
Best of luck to you with your upcoming surgery, whenever it is scheduled to happen.
Very good move to already start looking around the house to make small adjustments to limit the need to do too much post-op reaching and stretching.
I really like that “Keep Your Move in the Tube” concept, too – so simple. Watch that video
if you haven’t already: the demonstration of going from lying down to sitting up is a good illustration of keeping upper arms close to the body as if they’re inside a tight imaginary tube (that pushing up movement getting out of bed is always a bit tricky to master in the very early days). It’s not that you can’t do it – but you’ll just be learning HOW to do it in a way that won’t pull on your sternum while it’s healing – hence the “tube” move. Better than warning patients “not to lift” would be to teach how to lift SAFELY…
Take care, stay safe… ♥
LikeLiked by 1 person
Thanks for your encouragement. I agree that teaching how to lift safely would be a much better strategy. My surgeon has recommended sleeping in a recliner to begin with so I don’t roll over on my side. That will eliminate the need to get up from bed. My surgery hasn’t been scheduled yet. I hope to hear about it this week. Waiting is hard.
LikeLiked by 1 person
Several of my blog readers have said the same thing: they preferred sleeping on a recliner in the early days/weeks post-op. Some have even rented one for a month.
The more you can think ahead to making your recuperation life easier (and safer), the better! It’s called “pre-hab”, as this surgeon at the University of Michigan illustrates: “If you’re going to do a 5K race, you would train. Surgery is a lot more taxing and stressful, but we don’t train our patients in the way that any of us would train for an athletic endeavor.”
Here’s more on that… including “4 Ways to ‘Train’ for Surgery”
LikeLiked by 1 person
That’s a good article. I am lucky, as I was in the process of training for a half marathon when I found out about needing this surgery. I was up to running 11 miles, so I think I have the exercise portion down. I had also cleaned up my eating in the process. I’m not running at the moment, because of the heart cath and other reasons, but am trying to walk around 10K steps a day. I don’t smoke. I do have friends and family that can help while I recuperate. So, sounds like I’m doing everything right. LOL
LikeLiked by 1 person
You are every cardiac surgeon’s dream patient!
I too was a half-marathoner for 19 years before my heart attack (which at first ticked me right off – how could I be having a heart attack??!) – until my cardiologist told me that this level of distance running likely meant that I had managed to postpone my cardiac event by a decade – plus runners tend to have healthy collateral arteries that also help us to survive those cardiac events!
Keep up that great work!
LikeLiked by 1 person
Good for you! Do you still run?
LikeLiked by 1 person
Not anymore – wonky knee! Still walk every day though… FYI, here’s my essay in Runner’s World on being a former runner.
LikeLiked by 1 person
My first open heart surgery… I was told not to lift anything heavier than 5 lbs and not to drive until my 6 week check up.
What they did not emphasize was to not stretch or reach and I remember the shooting pains of trying to reach my Kleenex that was more than an arms length away. The info was given in the hospital and I’m not sure how much I retained. I started cardiac rehab at 6 weeks but had so much fatigue just getting there became undoable.
I realized later that it was the beta blockers and the failure of the surgery itself that probably contributed to the severe fatigue.
My second open heart re-do was done at Mayo Clinic in Rochester. I was given a detailed recovery book that I referred to often …. as my “ pump head” memory was a bit faulty. I believe I was allowed to drive and rehab at 4 weeks.
I had trouble with sternal non-union, most likely contributed to by my diabetes. But I was reassured by my Mayo surgeon that as long as it was not causing me pain and there were no signs of infection, that there was no need for any intervention.
So I just trust my 6 sternal wires and 6 years later so far so good. Anemia contributed to severe fatigue post op the second time.
Even though the obstruction of my HOCM is now removed, HCM is chronic and often progressive. There are many days I feel like I have never quite recovered, regardless of what my echocardiogram says…..
Having one of those days,
Thanks for listening Carolyn. 🙏
LikeLiked by 2 people
Hi Jill – I’m sorry you’re having “one of those days” today…
Thanks for pointing out that so many other factors can make fatigue worsen (anemia, beta blockers, surgical complications, often just the nature of the diagnosis itself, etc).
I love the concept of your detailed recovery book. This should be standard practice at every hospital for every heart patient, shouldn’t it? Mine was called “Recovery Road” and I too referred to it often, sometimes several times a day in the beginning! It covered EVERYTHING, even the stuff I’d already been told by the nurses in CCU, but clearly had already forgotten by the time I got home. Also very useful for my family who then got to read up on what I should or shouldn’t be doing/eating/feeling etc.
I really like this “Keep Your Move in the Tube” concept for reminding open heart surgery patients to keep their upper arms close to their bodies as if they’re inside a tight imaginary tube. Brilliant visual reminder to help with that reaching & stretching!
I hope tomorrow will be a better day for you…
Take care, stay safe… ♥
LikeLike
I really can’t remember my postoperative instructions because I heard them through a haze of narcotic pain relievers and psychological shock.
What I do remember is being told cheerfully that I could resume sex at six weeks, no problem. As if that were my priority at all.
LikeLiked by 1 person
Hi Dr. Anne – you’re right about that haze and psychological shock. How can we comprehend anything at a time like that? It’s funny that the only part you do recall was that you could have sex at six weeks!
When I first met my cardiologist in the Emergency Department, I could see his lips moving and I could hear sounds coming out of his mouth, but I suspect he was speaking Swahili because I simply couldn’t understand anything he was saying.
It’s why we need to to be told several times and also given – as the Parker-Adams study suggested: “written information about the surgery and its after effects.”
Take care, stay safe…♥
LikeLiked by 1 person
Dr Anne….
Thank you for bringing up “sex”. I am divorced and not at all interested in another relationship. But nobody bothered to know me well enough to understand that And continued to give that as some sort of carrot to get to six weeks UGH!!
LikeLike