Advertisement

Skin deformation during shoulder movements and upper extremity activities

  • Weiqing Ge
    Correspondence
    Corresponding author.
    Affiliations
    Department of Physical Therapy, Youngstown State University, One University Plaza, Youngstown, OH 44555, USA
    Search for articles by this author
  • Author Footnotes
    1 Currently with Anchor Health and Rehabilitation, Aiken, SC 29803, USA.
    Alison Sfara
    Footnotes
    1 Currently with Anchor Health and Rehabilitation, Aiken, SC 29803, USA.
    Affiliations
    Department of Physical Therapy, Youngstown State University, One University Plaza, Youngstown, OH 44555, USA
    Search for articles by this author
  • Author Footnotes
    2 Currently a traveling physical therapist.
    Brittany Hians
    Footnotes
    2 Currently a traveling physical therapist.
    Affiliations
    Department of Physical Therapy, Youngstown State University, One University Plaza, Youngstown, OH 44555, USA
    Search for articles by this author
  • Author Footnotes
    1 Currently with Anchor Health and Rehabilitation, Aiken, SC 29803, USA.
    2 Currently a traveling physical therapist.

      Highlights

      • The necessity of sternal precautions has been questioned.
      • The skin deformation was negative for flexion, abduction, lifting, and pushing.
      • The only movement requiring attention is bilateral shoulder extension.
      • No significant difference for flexion and the amounts of weights for lifting.
      • Preoperative physical therapy should include stabilizing scapular muscles.

      Abstract

      Background

      The necessity of sternal precautions for patients following cardiac surgery with median sternotomy has been questioned by clinicians, researchers, and even patients. The primary purpose was to determine if sternal skin deformation during shoulder movements and upper extremity activities is compressive or distractive and if there are any significant differences between the skin deformation at different positions during shoulder movements and upper extremity activities. The secondary purpose was to determine if sternal skin deformation is correlated with scapular stabilizer muscle strength.

      Methods

      The research design was a cross-sectional non-experimental descriptive study. A 3D electromagnetic tracking system was used to measure sternal skin deformation quantified by strain.

      Findings

      The sternal skin strain was −10.8 (SD 6.2) % and −9.8 (SD 6.1) % at 90 and 180° flexion (P = 0.45), −2.7 (SD 3.4) % and −10.4 (SD 7.9) % at 90 and 180° abduction (P < 0.01), −3.6 (SD 4.1) %, −4.9 (SD 6.4) %, and −6.8 (SD 5.2) % when lifting 0, 5, and 10 lb weights (P = 0.07), 0.7 (SD 2.5) % for extension, and −1.1 (SD 5.0) % for pushing up from a chair. There is a trend of strain magnitude decrease with the increase of rhomboid strength without significant association (R = 0.14).

      Interpretation

      Our data does not support the restriction for most of the shoulder movements and upper extremity activities following cardiac surgery. The only exception is bilateral shoulder extension. We propose a strategy for preoperative physical therapy to stabilize scapular muscles to decrease mechanical loading translated from shoulder to sternum.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Clinical Biomechanics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Adams J.
        • et al.
        An alternative approach to prescribing sternal precautions after median sternotomy, ‘keep your move in the tube’.
        Proc. (Baylor Univ. Med. Cent.). 2016; 29: 97-100
        • Balachandran S.
        • Lee A.
        • Royse A.
        • Denehy L.
        • El-Ansary D.
        Upper limb exercise prescription following cardiac surgery via median sternotomy: a web survey.
        J. Cardiopulm. Rehabil. Prev. 2014; 34: 390-395
        • Brocki B.C.
        • Thorup C.B.
        • Andreasen J.J.
        Precautions related to midline sternotomy in cardiac surgery: a review of mechanical stress factors leading to sternal complications.
        Eur. J. Cardiovasc. Nurs. J. Work. Group Cardiovasc. Nurs. Eur. Soc. Cardiol. 2010; 9: 77-84
        • Cahalin L.P.
        • Lapier T.K.
        • Shaw D.K.
        Sternal precautions: is it time for change? Precautions versus restrictions - a review of literature and recommendations for revision.
        Cardiopulm. Phys. Ther. J. 2011; 22: 5-15
        • Fung Y.C.
        Biomechanics: Mechanical Properties of Living Tissues.
        Springer-Verlag, 1993
        • Ge W.
        • Sfara A.
        • Hians B.
        Sternal skin strain during shoulder movements and upper extremity activities.
        Physiotherapy. 2015; 101: e449-e450
        • Hislop H.J.
        • Avers D.
        • Brown M.
        • Daniels L.
        Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination and Performance Testing.
        Elsevier, 2014
        • Irion G.
        • Benefield P.
        • Bolton R.
        • Collins G.
        • Davidson K.
        Effects of shoulder range of motion on sternal skin stress.
        Acute Care Perspect. 2005; 14: 13-14
        • Irion G.
        • Boyer S.
        • McGinnis T.
        • Thomason M.
        • Trippe A.
        Effect of upper extremity movement and anthropometrics on sternal skin stress… Combined sections meeting: CSM2007: history repeats itself, Boston, February 14–18.
        Acute Care Perspect. 2006; 15: 22
        • Irion G.
        • Boyer S.
        • McGinnis T.
        • Thomason M.
        • Trippe A.
        Effect of upper extremity movement on sternal skin stress.
        Acute Care Perspect. 2006; 15: 1
        • Irion G.
        • Boyte B.
        • Ingram J.
        • Kirchem C.
        • Weathers J.
        Sternal skin stress produced by functional upper extremity movements.
        Acute Care Perspect. 2007; 16: 1
        • Irion G.
        • Cauthen H.
        • Gallo C.
        • Jackson J.
        • Kremer A.
        Application of kinesiotape to reduce sternal skin stress during functional movements… APTA 2011 Combined Sections Meeting New Orleans, LA.
        J. Acute Care Phys. Ther. 2010; 1: 73
        • Irion G.L.
        • Gamble J.
        • Harmon C.
        • Jones E.
        • Vaccarella A.
        Effects of upper extremity movements on sternal skin stress.
        J. Acute Care Phys. Ther. Acute Care Sect. - APTA Inc. 2013; 4: 34-40
        • Johnson N.B.
        • et al.
        CDC National Health Report: leading causes of morbidity and mortality and associated behavioral risk and protective factors--United States, 2005–2013.
        MMWR. 2014; : 3-27
        • Kim M.-S.
        • Lim K.-Y.
        • Lee D.-H.
        • Kovacevic D.
        • Cho N.-Y.
        How does scapula motion change after reverse total shoulder arthroplasty? - a preliminary report.
        BMC Musculoskelet. Disord. 2012; 13
        • Overend T.J.
        • et al.
        Physical therapy management for adult patients undergoing cardiac surgery: a canadian practice survey.
        Physiother. Can. 2010; 62: 215-221
        • Parker R.D.
        • Adams J.
        Activity restrictions and recovery after open chest surgery: understanding the patient's perspective.
        Proc. (Baylor Univ. Med. Cent.). 2008; 21: 421-425
        • Parker R.
        • et al.
        Current activity guidelines for CABG patients are too restrictive: comparison of the forces exerted on the median sternotomy during a cough vs. lifting activities combined with valsalva maneuver.
        Thorac. Cardiovasc. Surg. 2008; 56: 190-194
        • Reser D.
        • Caliskan E.
        • Tolboom H.
        • Guidotti A.
        • Maisano F.
        Median Sternotomy.
        Multimed. Man. Cardiothorac. Surg. MMCTS Eur. Assoc. Cardio-Thorac. Surg. 2015. 2015
        • Santarpino G.
        • Pfeiffer S.
        • Concistré G.
        • Fischlein T.
        Sternal wound dehiscence from intense coughing in a cardiac surgery patient: could it be prevented?.
        Il G. Chir. 2013; 34: 111-112
        • Shakouri S.K.
        • et al.
        Effect of respiratory rehabilitation before open cardiac surgery on respiratory function: a randomized clinical trial.
        J. Cardiovasc. Thorac. Res. 2015; 7: 13-17
        • Sidney S.
        • et al.
        Recent trends in cardiovascular mortality in the United States and public health goals.
        JAMA Cardiol. 2016; https://doi.org/10.1001/jamacardio.2016.1326
        • Tewarie L.S.
        • et al.
        Prevention of sternal dehiscence with the sternum external fixation (stern-e-fix) corset — a randomized trial in 750 patients.
        J. Cardiothorac. Surg. 2012; 7: 85
        • Tuttle K.
        • Mincer A.
        • Thompson A.
        Medial sternotomies: a systematic review and evidence-based guidelines for postoperative sternal precautions.
        J. Acute Care Phys. Ther. 2010; 1: 36-37
        • Tuyl L.J.
        • Mackney J.H.
        • Johnston C.L.
        Management of sternal precautions following median sternotomy by physical therapists in Australia: a web-based survey.
        Phys. Ther. 2012; 92: 83-97
        • World Health Organization
        The top 10 causes of death. WHO.
        (Available at:) (Accessed: 12th August 2016)
        • Xu J.
        • Murphy S.L.
        • Kochanek K.D.
        • Bastian B.A.
        Deaths: Final Data for 2013.
        Natl. Vital Stat. Rep. Cent. Dis. Control Prev. Natl. Cent. Health Stat. Natl. Vital Stat. Syst. 64. 2016: 1-119