occupational therapy sternal precautions

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.

ot sternal precautions breathing

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. 

sternal-precautions-exercise

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

Activities of Daily Living after Heart Surgery Handout (UW Medicine)

How to Protect Your Chest After Heart Surgery Handout (UHN)

Sternal Precautions After Open Heart Surgery (Verywell Health)

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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.

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12 comments

  • Philippine General Hospital (Philippines) October 17, 2017   Reply →

    Thank you, everything was very useful

  • Erika Arndt January 14, 2020   Reply →

    Our patients are told to only ride in the BACK SEAT of a car because airbags and sternal incisions don’t mix!

    • Sarah Stromsdorfer, OTR/L January 15, 2020   Reply →

      So true!

  • Katrina Guenter February 17, 2020   Reply →

    Thanks for the informative post. I haven’t found many reliable resources regarding sternal precautions and toileting hygiene (I.e. the internal rotation required to wipe). Do you have any recommendations for that, especially for a person of larger stature? Lower extremity dressing is another area not much addressed in the literature, yet many post-CABG clients I’ve encountered experience discomfort with reaching down for socks/pants. Do you have any recommendations for that, aside from long-handled reachers?

    • Sarah Stromsdorfer, OTR/L February 19, 2020   Reply →

      There is actually some new, interesting research that is emerging called “Move in the Tube” (here is the research article) in which the patient can perform more upper extremity movement (in the “tube,” as shown in the article) than traditional sternal precautions with less restriction on weight precautions and more on the range of motion. Since this is newer research, you’d want to get the okay from the surgeon before following, which may still take some time for them to get on board. Either way, if the movements required to wipe are causing pain/discomfort and/or are breaking precautions, I would suggest a low-cost bidet toilet attachment (that can be found on Amazon). For lower body dressing, my go-to would still be the reacher if reaching down during dressing remains uncomfortable.

  • Beth September 7, 2020   Reply →

    Hi Sarah! Thanks so much for this information! πŸ™‚
    Just a couple quick questions, you may be able to answer/offer your input:
    1.) Is the purpose of an Eva/cardiac walker so that patients can bear weight through their forearms/elbows more post cardiac sx rather than putting too much stress on their shoulders/chest?
    2.) What If a patient doesn’t have enough leg strength for a sit to stand and puts too much weight through their arms? Would it be better to use a machine to assist with this until they are able to build up that leg strength or are there different tips to help with this? Thanks so much πŸ™‚

    • Sarah Stromsdorfer, OTR/L September 8, 2020   Reply →

      Hi Beth! You could definitely use a cardiac walker post-op if you have one available. When you have patients with significant weakness through their legs with sternal precautions, I would suggest practicing sit to stands from an elevated surface initially during treatments when possible while you provide them extra assist with their gait belt. As far as devices go, you might have better luck with a walker vs a SaraSteady since that does involve more pulling up with their arms in front compared to a walker. I hope this helps and I would love to hear anyone else’s suggestions πŸ™‚

  • Edith Morris October 3, 2020   Reply →

    I am having open heart surgery next week. Because of spinal injury I have to use crutches. Would appreciate any info on best way to deal with recovery under these conditions.

    • Sarah Stromsdorfer, OTR/L October 7, 2020   Reply →

      Hi Edith, if they don’t already, I recommend your doctor order you Occupational Therapy and Physical Therapy to educate you on using your crutches after surgery. Just to make sure you have therapy ordered, I would ask your surgeon before your surgery as well. They will likely have therapy on board but this is just a good extra step πŸ™‚

  • David McCombs May 3, 2021   Reply →

    Glad you updated this with the KMIT protocol. I read the study saying that sternal precautions haven’t really been backed as evidence. They’re really just a precautionary measure, but as therapists we flip out when people are following them perfectly.

  • Chris January 1, 2022   Reply →

    I worked in Cardiac Rehab for years and agree the sternal precautions sometimes get taken to the extreme. One spouse was feeding her husband! When I pointed out he could even do some jobs around the house, like fold laundry, he looked at me like, “Thanks, I had a pretty good thing going here.” πŸ˜‰ I also found that when a patient needed assistance getting out of a chair, if I put my hand under their elbow vs pulling their arm, it provided a little resistance for them to push against and I could kind of lift up as well, therefore assisting them gently while maintaining sternal alignment

    I really like the KMIT protocol idea. I always told patients to use both arms together. This way, they don’t put any stress on their sternum and keep it aligned and no torque on sternum. So, instead of not raising arms at all, raise both arms together or instead of reaching R or L for something, using both arms keeps sternum aligned but allows some independence. It is kind of like keeping upper body like a tube as described with this method, I just didn’t have a name for it. The goal is to not torque the sternum but patient can still can move and use arms. I used to tell the pts that it was important to stretch neck forward and side to side, relax shoulders as they tend to tighten them as a protective measure, shrugging them up tight. I caught myself doing this after a mastectomy. I had to consciously tell myself to relax them. So neck stretches and shoulder shrugs up and down while still maintaining a straight sternum is important. This should help prevent muscle tightness, but a little myofascial massage to shoulder blades is helpful. A tennis ball in a tube sock is nice so patient can put it where he wants like shoulder blades and lean back in chair against it. Sometimes just a rolled up towel to lie back on to give some direct pressure to a tight spot helps. At about 6 weeks patients often c/o pain at suture area. I used to think it was nerves pain but after a mastectomy, as I mentioned, I learned alot about myofascial release as the discomfort was caused by scar tissue that was shrinking and pulling every which way. To release this tight grip on the fascia, this is after 6 weeks, place a flat palm over the scar, or to the side of it, press gently then displace a little and to the side and hold for a minute of so. The light, gentle pressure helps release the fascia allowing it to let go. Too much pressure causes it to grip tighter. It took me having a mastectomy to figure that out and I think of how many patients I kind of dismissed cuz I didn’t realize, “We need to pay more attention to our scars.” I had a patient who, on a Friday, was so worried about this chest tightness he was having 6 weeks post op, although pain wasn’t same as he had before surgery. I taught him this technique, cautioning that just gentle pressure was all that was needed. He came in with a big smile on Monday as it really helped.

    All in all, patients do very well. We had a patient that just had to use her arms and she did fine. The surgeon told us to lighten up and told us we need to remember they are wired pretty tightly. Of course any pravtice getting out of a chair, bed, etc. before surgery is always helpful but matters not at all for emergency surgery. I think it is important to remind patients that it takes a year to realistically expect to be back to normal. We focus on 6 weeks and patients are often disappointed when not totally there at 6 weeks. We need to tell them that that is when they can START using their arms more, or sooner using the KMIT method, but it still takes time for bone remodeling. I had a patient who was 3+ months post op doing very well. His grandkids showed up and without thinking, scooped one of them up in his arms. That sudden, swift movement is what broke his early bone remodeling loose and now, after months of careful sternal precautions, he had a “hinge” instead of an intact sternum. It was very sad and disappointing for him and us as well. Don’t forget to remind them of the importance of calcium, Vit D and Vit K2-7 as well to aid in bone growth. I have recently learned that K2-7 helps direct calcium to the bone and teeth vs the soft tissue like arteries and kidneys and does not affect the clotting mechanisms of the blood. Of course, as always, do your own research but my experience is that docs are not aware of alot of this stuff, particularly myofascial release, yet it is a very important tool for any post op rehabilitation. That is why they send their patients to us and what I told patients often when they complained that their doctor didn’t tell them these things.

    • Sarah Stromsdorfer, OTR/L January 5, 2022   Reply →

      Chris, thank you so much for your very helpful insight! This is so informative and it really complements the article, especially with your personal and patient experiences! Thanks again πŸ™‚

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