Sternal Precautions in Occupational Therapy: Learn the Basics
Adhering to sternal precautions following cardiac surgery can be quite a challenge, just ask any of your patients post-op and they’ll let you know how hard it is!
If you think about, how often do you automatically use your arms during daily activities like getting up from a low surface, dressing, or carrying something?
It can also be tough as an occupational therapist or OT student to remember what all of the sternal precautions are if you don’t see cardiac patients post-sternotomy on a regular basis.
So what are the general sternal precautions your patients will want to follow?
Important Disclaimer: These precautions are based on my personal research and experience. Your patient’s surgeon may have additional or differing precautions. Be sure to always check with their surgeon when you’re treating a patient post-cardiac surgery if you’re concerned or don’t have full clarification. This covers the traditional sternal precautions, with information about “Keeping your move in the tube” at end the of the article.
1. No lifting, pushing, or pulling anything over 5-10 pounds
As mentioned above, this is always depending on the doctor’s orders, but is the general rule.
Some surgeons will say 5 pounds, others will allow 10 pounds. If the doctor’s order states their limit is 10 pounds, you can use the analogy of not lifting anything heavier than a gallon of milk, which is about 8 pounds.
This restriction is a big challenge after your patients go home, as many IADLs like laundry, grocery shopping, and child care activities are limited.
Including safe ways to modify these activities can help increase your patient’s confidence with this post-discharge from therapy.
2. Following safe functional mobility strategies
Functional mobility in this case includes any type of transfer, whether it’s in the bed, bathroom, or chair. Be very mindful of teaching your patient not to use too much force with arms during bed mobility tasks.
With sit to stands, you can educate the patient on several methods to use their legs and transition to stand. This might take a lot of practice at first since it isn’t a natural movement for people.
In the shower, gently remind your patient not to pull up from grab bars until they are cleared to do so.
Many surgeons will provide your patient with a heart pillow. You can cue your patients hold onto the pillow when performing any transfers to assist and remind them to avoid using their arms.
3. No reaching back behind or up above shoulder height during self care tasks
This is hard to remember not to do as well, especially during self care tasks like toileting, grooming, and bathing. Upper body dressing is also a new challenge since your patient won’t be able to lift both arms up like they’re used to doing.
Reteaching safe self-care methods will be a big part of your treatment plan if you’re in the acute care or rehab setting.
Posting large print visual handouts in their room along with keeping their heart pillow within reach will help to cue them to use appropriate mechanics to keep their surgical site safe.
4. Being aware of any discomfort
If your patient feels any discomfort with an activity, they should stop the activity and assess what could be causing the pain or discomfort. Also, immediately stop any activity that causes any clicking or cracking in the chest.
5. Remembering to breathe
Completing functional mobility and exercise following these surgeries is hard work, but remind your patient to keep breathing through the activity. Educating on deep breathing techniques can also help if maintaining steady breaths is a struggle.
6. Bracing during coughing, laughing or sneezing
Coughing, laughing or sneezing can cause increased pressure on the surgical site. Cueing your patient to hold their heart pillow when laughing, coughing or sneezing is a great way to “brace” themselves for increased comfort.
7. No driving until cleared by physician.
This is usually a six to eight week time frame to ensure your patient doesn’t get into any accidents which would of course not be good for their incision. Again, they can verify with their surgeon during their follow-up appointment since you usually won’t see them after a couple of weeks post-op.
Is exercise appropriate for patients with sternal precautions?
Yes. But if you’re concerned about your patient, check with the medical team if you aren’t sure. I still like to check in with my therapist partners if I’m in doubt at all. When appropriate, physical exercise is great to rebuild overall strength, endurance, and cardiovascular health.
If your patient needs cardiovascular conditioning, the UBE (arm bike) may be okay if it has NO resistance. I monitor my patients’ vitals throughout as well as monitor their MET Level with them to make sure they aren’t overexerting themselves.
If I feel the patient needs strengthening with arm weights, I do very light weight (think 1 or 2 pounds max), and I don’t like to do movements past shoulder-height (90 degrees). I also only do one arm at a time to ensure I avoid putting any pressure on the sternum. I like to err on the side of caution with this.
If your patient doesn’t need arm strengthening specifically, a great functional exercise is walking around the unit (if physically able) or going outside for several minutes at a time.
Always incorporate rest breaks and check-ins to further build up activity tolerance. Sit to stands without using hands are a favorite of mine to build up leg strength to be able to stand with greater ease.
Be sure to check out our list of occupation-based activity tolerance interventions here for other ideas to increase your patient’s endurance. Just remember to incorporate sternal precautions during these as needed!
Updated Sternal Precautions
Since we first published this article, new research has come out regarding updated, much less restrictive sternal precautions. The newest modified sternal precaution is known as “Keeping your move ‘in the tube’ (KMIT).” This allows the person to perform unloaded arm movements within a pain-free range of motion, with loaded arm movement allowed as long as the arms stay close to the body (Physiopedia).
Here is a helpful video that shows what KMIT looks like in more detail. Research is showing that this is a promising protocol, showing increased patient discharges to home from acute care vs. rehab by 3 times in one study, while also providing less and shorter restrictions for post-op cardiac patients.
Since this is still such a new protocol, however, many cardiac surgeons have yet to adopt it. Because of this, you will need to ensure your patients’ surgeon has approved the KMIT protocol before you teach it to your patients.
Additional Resources For Your Patients
I hope this post helps clear up any questions you might have had about working with sternal precautions in your occupational therapy practice! Utilizing these tips and strategies, working with post-cardiac surgery patients will become a breeze.
Would you add anything to this article? Please let us know in the comments below!
This post was originally published on Oct. 9, 2016 and updated on Aug. 4, 2019 and Mar. 28, 2021.