Medical Journal of Dr. D.Y. Patil Vidyapeeth

: 2022  |  Volume : 15  |  Issue : 6  |  Page : 830--839

The impact of a less restrictive post-sternotomy activity protocol compared with standard sternal precautions in patients following cardiac surgery: A systematic review

Sridhar Shirodkar1, Amit Sharma2,  
1 PhD Scholar, School of Physiotherapy, RK University, Rajkot, Gujarat; Associate Professor, Terna Physiotherapy College, Nerul, Navi Mumbai, Maharashtra, India
2 Professor, School of Physiotherapy, RK University, Rajkot, Gujarat, India

Correspondence Address:
Sridhar Shirodkar
Terna Physiotherapy College, Terna Medical College Campus, III Floor, Nerul (W), Navi Mumbai - 400706, Maharashtra


Despite limited evidence, to support movement and weight limitations following median sternotomy, sternal restrictions are routinely prescribed. This systematic review aims to determine what the literature defines as sternal restrictions, how sternal restrictions are applied and progressed; what are the less restraining sternal restrictions, revised sternal restrictions, and uniformity in the prescription of sternal restrictions. (N=2027) studies were identified. Databases screened were CINAHL (1957), PubMed (47), EMBASE (06), ICTRP (04), and COCHRANE (13). After including scholarly articles, screening records, removing duplicates, and including potentially relevant articles, Five (n = 5) studies were included in the qualitative synthesis. Studies included papers written in English. A precautionary approach, rather than a restraining attitude would expedite better healing and practicable recovery post-median sternotomy. This comprehensive analysis clearly supports the fact that patients need progressive rehabilitation after surgery to enhance thoracic motion, pulmonary function, symptoms, and functional status.

How to cite this article:
Shirodkar S, Sharma A. The impact of a less restrictive post-sternotomy activity protocol compared with standard sternal precautions in patients following cardiac surgery: A systematic review.Med J DY Patil Vidyapeeth 2022;15:830-839

How to cite this URL:
Shirodkar S, Sharma A. The impact of a less restrictive post-sternotomy activity protocol compared with standard sternal precautions in patients following cardiac surgery: A systematic review. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2023 Jan 30 ];15:830-839
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Full Text


In most coronary operative procedures, comprising CABG procedures, valvular reconstruction, and/or restoration, the preferred surgical approach is median sternotomy.[1] This approach has been preferred extensively by cardiothoracic surgeons for decades, as it delivers better access to the heart, gives excellent exposure, heals faster, and is relatively pain-free.[2] A surgical incision extending from the jugular notch to the base of the xiphisternum is taken in median sternotomy. The major advantage of this strategy is that it allows the surgical team to have complete control over the surgical field, both optically and physically. It has entirely transformed the field of cardiovascular-thoracic surgeries.[3],[4]

Sternal restrictions (SRs) are commonly advised to patients following median sternotomy surgeries. However, clinically, SR mostly shows a wide array of utilitarian limitations. Following sternotomy, patients are advised to follow certain SRs.[5] SRs primarily include restrictions like no pushing-pulling, no movement of arms above head, and no reaching hand behind the back. In addition, there are many activity-related restrictions during mobility and transfers.[6] The sole purpose is the prevention of complications like wound dehiscence, infections, or mal-union.[6],[7]

The reported incidence rates of sternal complications are the bare minimum from 0.6% to 12%. However, it is linked with high mortality figures of over 50%, which cannot be neglected. The rationale behind imposing strict SRs is to promote bone healing by osteo- synthesis.[5] A broad search in PubMed Medline and CINAHL suggested paucity of published systematic reviews supporting clinical importance of SRs. Moreover the articles promoting strict precautions were on cadaver studies. This was purely based on expert opinion, bygone rules and practices, healing of bone (radius).[5],[8]

This systematic review provides a summary of current suggestions/protocols regarding (1) Patients' difficulties and associated hazards, (2) The effect of shoulder girdle movements on the sternum and 3) Suggestions for early movement and activity after median sternotomy, (3) practical association of SRs, and 4) suggestions for early movement and activity after median sternotomy.[9],[10] This paper promotes early resumption of activity following median sternotomy through a clinical exemplar.

Globally, inconsistent definitions and prescriptions have fuelled research into the effect of shoulder girdle movement on sternal complications and other results over past years. According to surveys and reviews present practice regarding there is no standard definition for SRs. This was concerning acute care cardiac rehabilitation. Besides, guidelines for prescribing and progressing upper body exercises are inconsistent (unpublished data).[5],[10],[11],[12],[13]


This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Eligibility criteria and search method

Research questions addressed for this systematic review were:

Can reducing SRs for cardiac surgery patients via median sternotomy improve physical function, pain, kinesiophobia, and health-related quality of life?

Data sources

The key concept for strategic survey included: Thoracic-surgery; Heart-surgery; Sternal approach; Sternal precautions; sternal instability; movement constraints. Literature review from 1st January 2003 to 31 January 2022 was done in the CINAHL, ICTRP, PubMed, COCHRANE, and PEDRO electronic databases.

For every idea, the Boolean “OR” operator was combined with keywords and Medical Subject Heading Indexing (MeSH) terms, and concept search results were joined with the “AND” operator.

The references of all relevant publications were explored for any additional references or unidentified trials. However, due to limited resources, publications remained in English only.

Primary screening

Study titles and abstracts were reviewed by two independent assessors. Selection of randomized interventional studies inclusive of cardiac surgical procedure such as coronary artery bypass grafting (CABG), valve replacement, sternal incision, cardiac rehabilitation, early mobilisation, sternal precautions. We also excluded letters, abstracts, and editorials.

Secondary screening

Later, full-text articles were reviewed by the same assessors: They comprise (1) Inclusion criteria of patients above 18 years of age. (2) Interpretation and analysis regarding sternal complications; and (3) Describing the analytical strategies classifying risk factors. Patients who underwent alternative surgical approaches other than sternotomy done were not included. In situations where disparity among the first and second reviewers was seen, a consultation from a third reviewer was taken.

Data extraction and synthesis

The primary assessor extracted and recorded data on the study methodology, participant population, sternal problem(s), and risk factors. We considered sternal complications related to the heart surgery population in situations where more than one study is reported as an independent predictor.

Based on the primary literature search, 2027 studies were identified. Only four clinical trials from the PubMed database were screened. CINAHL open-access database articles 263 were included during the screening process. Other databases screened were, EMBASE (06), COCHRANE (13), ICTRP (04). After applying the primary and secondary screening criteria, a total of 290 articles were screened. Among these (n = 194) duplicate articles were eliminated. A total of (n = 83) of the original (n = 95) titles were subsequently discarded due to issues such as lack of clarity about the intervention, pilot design, patient demographics with inadequate data, and unsuitable outcome measures. Further, the article count narrowed down to (n = 12), from which seven (n = 7) were excluded citing issues like, unclear randomization method and inconsistencies in study designs. Potentially pertinent full-text available articles five (n = 5) full-text studies were included in the final review. These five studies were found to be potentially relevant for qualitative synthesis [Figure 1].{Figure 1}


A PICO question was designed to guide the research conducted

P Population: Post Cardiac surgery via Mediastinal Sternotomy. I Intervention: Cardiac rehabilitation SRs; Conventional vs Modified SRs.

C Comparison: Conventional vs Modified SRs O Outcome measures: Functional disability questionnaire, SPPB, Pain intensity (NRS); Tampa scale of kinesiophobia. Does taking sternal measures help patients avoid sternal problems and have a better recovery among patients who undergo sternotomy?

Study characteristics

Inconsistencies in the definition, and prescription of SRs, have supported research on knowledge attitude and practise during clinical practice. The impact of shoulder girdle exercises on sternal problems. Description about various outcome measures used contemplating global affection in the past few years.

Among the five studies included, two were RCT's, cross-sectional, single-blinded pilot trials, and quasi-experimental design one each. The location of the studies was the United States of America, Canada, and Australia. Many surveys are done in this area, predominantly in Australia and New Zealand. [Table 1].{Table 1}

Age distribution

Three of the five studies included subjects above 62 years of age. However, two studies have included samples right from the age of 18. The sample size of trials ranged from as less as n = 38 to n = 364. The duration of studies varied from four months to a year.

In clinical practice, SRs attempt to decrease or prevent sternal problems. SR is often prescribed soon after heart surgery in clinical practice. The exact source of SR is unknown. However, primary concerns regarding sternal infection may have intensified topic awareness. When you add the possibility that certain upper extremity activities could jeopardize sternum healing, the 'precaution' (or, more accurately, 'restriction') stage is set.

On the first postoperative day, patients were instructed to perform active shoulder exercises. A pain-free movement and a limited sternal exercise should be performed.

The phase of rehabilitation

During the first and second phases of cardiac rehabilitation, SRs and/or variations in SRs are implemented.[11],[12] A less restricted approach allows unrestricted, weightless arm movements, as long as there is no worsening of pain in chest. Throughout their stay in the hospital, patients, and families received pictures and illustrations showing exercises. During preoperative and discharge instructions both verbal and written directions were provided. Posters in their hospital rooms, depicting SRs or (lesser restriction) LR program.[13] On discharge, patients were advised to follow all the instructions given. Follow-up with the surgeon was coordinated with physiotherapy departments in the hospitals.

Sternal restrictions

Post-surgery, external restrictions are supposed to help protect the patient, but they can inadvertently do the opposite. Following surgery, upper limb use is restricted for one month to four months. In the control group, physiotherapy included advice on restricting upper-limb use for four to six weeks following surgery. Hence, authors have used kinesiological principles to develop a new approach. One of the studies under review used the term 'SMART' where the restrictions were limited to pain. Another study has modified the term “KYMITT' an abbreviation for Keep your move in the tube approach. The term “KYIMTT” is based on ergonomics that shorten the outstretched arm's length (lever arm reduction), enabling patients to perform previously contraindicated movements. The remaining studies used terminologies like lesser restrictions modified restrictions.

Outcome measures

Return to function over time, wound healing, pain intensity, pain medication use. Sternal Instability Scale; Pain episodes; Length of hospital stay; “SPPB Secondary outcomes included upper limb function, Kinesiophobia, and HRQOL. 6 MWT, functional fitness, quality of life, and cost-effectiveness.[14] Health anxiety questionnaire (HAQ); Wound healing; Analgesic and antibiotic use are few outcome measures.

Primary outcome measures

Primary outcome measures were chosen on the basis on its higher interrater as well as intrarater reliability scores. They were sternal instability and Pain on NRS.

Sternal instability

This outcome measure was taken in two of the studies reviewed. It indicated improper healing, cause of pain, impaired function, infection, and dehiscence. It helped evaluate both patient perceptions of instability and surgeon measurements of instability.[5],[15] 0 means normal), 1 indicated minimal separation. 2 showed partial separation and 3 indicated complete separation. The SIS is aligned with the established methods used by the surgeons to assess sternal instability. The SIS has excellent interrater reliability (ICC = 0.97) and intrarater reliability (ICC = 0.98). This review confirms that there were no between-group differences for measures of sternal stability among trials.[15]


Pain as an outcome measure was evaluated as the patient's perception of pain. When the results from trials were combined, both groups showed a trend toward less pain over time. Although some postoperative discomfort is to be expected, substantial pain, as determined by a pain rating on a Likert scale and qualitative reactions, was considered a negative consequence of the assigned sternal protocol. Pain was measured by pain rating on a Likert scale and qualitative responses, was seen as an adverse outcome of the assigned sternal protocol. This NRS rating has been proved to be a rapid, sensitive, reliable, and valid method.[16],[17] In one of the trials the data on analgesics (as a measure of pain/discomfort) were acquired through a health record audit. The pooling of results showed no significant difference between conventional sternal precautions and modified precautions in the improvement of pain perception.

Secondary outcome measures

Short physical performance battery (SPPB)

The SPPB is made up of three different tests: Gait speed, standing balance, and a chair rise task. Scores range from 0 (poor function) to 12 (great function) (excellent function). Because it evaluates an individual's total functional performance in relation to everyday functional tasks, the SPPB was chosen to be the key result.[18],[19]

The SPPB scores of the groups were moderate to severe at the post-operative baseline. Patients in both groups improved in this measure over time after surgery. Both groups demonstrated moderate to severe SPPB impairments at post-operative baseline. Two out of five studies showed, participants improved on SPPB values over time. In most rehabilitation programs, the main goal over four to twelve weeks is to improve their functional performance.

Because it examines total functional performance of ordinary physical tasks, the SPPB was chosen as the primary outcome. The interventions were based on the idea that the SPPB scores would affect overall functional performance.[18] Other studies looked at functional capacity using the six-minute walk test, health assessment questionnaire (HAQ), length of hospital stay, upper limb function (functional disability questionnaire), five-times sit-to-stand test (FTSTS), and isometric leg muscle strength.


The 11 item Tampa Scale of Kinesiophobia measured pain-related fear beliefs about movement and re-injury. Participants were asked to rate each of the 11 items on a 4-point, Likert-type scale. A reduction of at least 4 points on the measure maximizes the likelihood of correctly identifying an important reduction in fear of movement.[20]

Perhaps postoperative kinesiophobia was exacerbated by education on a restrictive programme characterized by the avoidance of certain upper limb motions. Attendance at exercise-based cardiac rehabilitation may be influenced by fear of pain, according to one study. In three out of five studies, it was hypothesized that kinesiophobia was a contributing factor that influenced physical recovery. When all the results were put together, there was no clear difference between traditional sternal precautions and modified precautions in how well kinesiophobia got better. However, the authors have commented that an association between kinesiophobia and physical rehabilitation will require more research in the future.[21]

Hand grip strength

The hand grip was used as an outcome measure to assess functional ability. A hand-held dynamometer was used to measure it in kg. There were no differences in physical function or hand grip strength observed in the study.[22] The majority of individuals subjectively perceived considerable difficulties at first, but reduced difficulty over time.


This systematic review analysis suggests that there were no differences between groups when it came to measuring sternal stability. Pooling data, revealed both groups in different trials showed a trend toward less pain over time. Results however demonstrated no difference between standard and modified sternal precautions in pain perception. At the baseline after surgery, the SPPB scores of the groups ranged from moderate to severe. It was seen that this measure got better over time after surgery. Traditional sternal precautions and modified precautions did not differ in how well outcome of kinesiophobia improved.


The stimulus for this study was the planned amalgamation of cardiac surgery services globally and the lack of uniformity in practicing guidelines for physiotherapy treatment in this population. Following a broad and consolidated literature search of the arm and shoulder girdle motion and tasks after median sternotomy, we propose an intangible approach to encourage optimal and faster recovery for patients following median sternotomy. This can be achieved by changing the current clinical culture after median sternotomy. A protocol encouraging free (pain limiting) exercises of arms and shoulder girdle during the rehabilitation of patients after median sternotomy.

Previously authors have commented that there has not been a systematic review of the best physical therapy care for cardiac surgery patients, necessitating surveys. Absence of any such ''best'' evidence from the literature, researchers are forced to use lower grades of evidence.[6],[23] Hence this systematic review will be a boon for setting up a more effective and judicious approach related to SRs during cardiac rehabilitation.

The incidence of external complications is rare, and there are numerous risk factors: Sternal infection, instability, dehiscence, and mal union.[12],[13],[14],[24] None of the trials included in the review had shown sternal complications due to lesser/modified SRs. The trials have demonstrated that sternal healing took almost the same time in patients with modified or lesser restrictions compared to more restrictive SRs. This directly had an impact on the length of hospital stay.

Instability in the sternum results from clicking and excessive motion, which creates pain and discomfort, making it difficult to perform daily activities.[16],[17] The review concurs with earlier evidence from trials and surveys, that in the immediate postoperative phase, the protocol did not lead to any complications. Especially important is the finding for cardiovascular and thoracic surgeons, nursing personnel, as well as physiotherapy clinicians. This review will encourage early kinesis and freedom of movement to their patients. This approach will curtail, the reluctance or resistance among health care professionals for early exercise and recovery.[25]

In implementing a new postoperative rehabilitation protocol, the painful sternum is an indicative measure. The established consequences of median sternotomy on the development of pain are of prime importance for post median sternotomy patients. All the clinical trials reviewed have emphasized no significant change in pain ratings during the functional task as well as exercises.[19] This will be a boon to patients as well as clinicians physiotherapists who seek early mobility and all the benefits therein.

In further pursuits of improved quality of life, clinical observations in four out of five reviewed articles found improved values in lesser restrictive groups. This could be attributed to lesser complications, better stability, lesser pain, improved movement and activities, and independence in self-care activities.

Arm activities and exercise during cardiac rehabilitation after median sternotomy provide benefits. These exercises are thought to improve circulation to the muscles of the chest wall, sternum, and shoulder girdle.[6],[23],[26],[27] It is very important to remain active to prevent a decline in general physiological conditions such as adhesions and muscle atrophy.[26],[28] The restriction of upper-limb activity in patients at discharge may cause problems for their recovery by limiting their functional ability and preventing or delaying the return to regular activities.[6],[23] Certain restrictions may make it difficult for patients, especially those who are older or have previously been immobilized, to perform simple, independent functions, such as standing up from a chair or getting out of bed.[29],[30]

Lastly, “Whenever SRs are feasible and relatable to daily activities, then patients are more likely to act accordingly. Fear of trauma to bodies, will limit the possibilities of a patient to explore and there by hinder early recovery.” In one of the literature review patient describes this approach as a “do-system” rather than as a “don't do-system.” Indeed, it is a “patient-centred approach that emphasizes possibilities as opposed to restrictions.”[27],[31]


It is important to acknowledge some limitations. Due to inadequate resources and personnel abilities to translate, the literature survey and review process was limited to English-language publications. This might have missed on opportunities with multilingual report. We also excluded publications due to the non-availability of the complete text and sufficient details required for consummate interpretation. As a result, additional studies may have been condensed from the review, affecting the results. The quality of the studies also included limited results of this review.

Review weaknesses included exclusion of studies in case of limited access to database. There was also limited bias assessment due to incomplete reporting for all types of studies; therefore, the effects of exercise may have been underestimated in this study. This was a systematic review, a meta-analysis would have added more meaning to this review. International exercise prescription guidelines and exercise testing guidelines, along with inconsistent outcome measures, pose a potential challenge to future research interpretation. These were some of the factors that limit the strength.


The SRs implemented following median sternotomy are quite restrictive. Instead, they could have been precautionary in nature. Evidence is strongly suggestive that a proactive and preventive approach will be far more beneficial than a conservative, restraining approach. It will be favorable for superlative healing as well as rehabilitation post-surgery.

In addition, advanced rehabilitation following CABG is imperative to improve shoulder girdle ranges, lung capacity, functional status, and chest-related symptoms after surgery involving the sternum.

Extensive systematic reviews and meta-analyses will help the development of patient-specific SRs. This will help better focus on patient function and patient characteristics.


We would like to thank Dr. Medha Deo, Principal, Terna Physiotherapy College, Navi Mumbai for her constant support and guidance. We also wish to extend gratitude towards Dr. Priyanshu Rathod, Director, School of Physiotherapy RK University Rajkot. Very great full to our team for successful reviewing procedure. Last but not the least, thanking librarian for making various databases readily available.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Julian OC, Lopez-Belio M, Dye WS, Javid H, Grove WJ. The median sternal incision in intracardiac surgery with extracorporeal circulation; a general evaluation of its use in heart surgery. Surgery 1957;42:753-61.
2Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Heart disease and stroke statistics--2014 update: A report from the American Heart Association. Circulation 2014;129:e28-92.
3Alhalawani AMF, Towler MR. A review of sternal closure techniques. J Biomater Appl 2013;28:483-97.
4Vos RJ, Van Putte BP, Kloppenburg GTL. Prevention of deep sternal wound infection in cardiac surgery: A literature review. J Hosp Infect 2018;100:411-20.
5Cahalin LP, Lapier TK. 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.
6El-Ansary D, Waddington G, Adams R. Relationship between pain and upper limb movement in patients with chronic sternal instability following cardiac surgery. Physiother Theory Pract 2007;23:273-80.
7Irion GL, Gamble J, Harmon C, Jones E, Vaccarella A. Effects of upper extremity movements on sternal skin stress. J Acute Care Phys Ther 2013;4:34-40.
8Balachandran 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;34:390-5.
9Tuyl LJ, Mackney JH, Johnston CL. Management of sternal precautions following median sternotomy by physical therapists in Australia: A web-based survey. Phys Ther 2012;92:83-97.
10Overend TJ, Anderson CM, Jackson J, Deborah Lucy S, Prendergast M, Sinclair S. Physical therapy management for adult patients undergoing cardiac surgery: A Canadian practice survey. Physiother Can 2010;62:215-21.
11Westerdahl E, Moller M. Physiotherapy-supervised mobilization and exercise following cardiac surgery: A national questionnaire survey in Sweden. J Cardiothorac Surg 2010;5:67.
12Lomi C, Westerdahl E. Physical therapy treatment after cardiac surgery: A national survey of practice in Greece. J Clin Exp Cardiol 2013;S7.004, 1-5.
13Cahalin LP, Saponaro CM, Zuckerman JL, et al. Cardiothoracic surgeons perspective on sternal precautions: Implications for rehabilitation professionals. Chest 2009;136(Supplement):98S.
14Guralnik JM, Simonsick EM, Ferucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing admission. J Gerontol 1994;49:M85-94.
15Sturgess TR, Denehy L, Tully EA, McManus M, Katijjahbe MA, El-Ansary D. The Functional Difficulties Questionnaire: A new tool for assessing the physical function of the thoracic region in a cardiac surgery population. Cardiopulm Phys Ther J 2018;29:110-23.
16El-Ansary D, Waddington G, Deheny L, McManus M, Fuller L, Katijjahbe MA, et al. Physical assessment of sternal stability following a median sternotomy for cardiac surgery: Validity and reliability of the Sternal instability scale (SIS). Int J Phys Ther Rehab 2018;4:140.
17Huskisson EC. Measurement of pain. Lancet 1974;2:1126-31.
18Chapman CR, Casey KL, Dubner R, Foley KM, Gracely RH, Reading AE. Pain measurement: An overview. Pain 1985;22:1-31.
19Katijjahbe MA, Denehy L, Granger CL, Royse A, Royse C, Bates R, et al. The sternal management accelerated recovery trial (S.M.A.R.T) – Standard restrictive versus an intervention of modified sternal precautions following cardiac surgery via median sternotomy: Study protocol for a randomised controlled trial. Trials 2017;18:290.
20Guralnik JM, Simonsick EM, Ferucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing admission. J Gerontol 1994;49:M85-94.
21Dworkin RH, Turk DC, Revicki DA, Harding G, Coyne KS, Peirce-Sandner S, et al. Development and initial validation of an expanded and revised version of the short-form McGill pain questionnaire (SF-MPQ-2). Pain 2009;144:35-42.
22Bäck M, Cider Å, Herlitz J, Lundberg M, Jansson B. Kinesiophobia mediates the influences on attendance at exercise-based cardiac rehabilitation in patients with coronary artery disease. PhysiotherTheory Pract 2016;32:571-80.
23Bohannon RW. Dynamometer measurements of hand-grip strength predict multiple outcomes. Percept Mot Skills 2001;93:323-8. El-Ansary D, Adams R, Toms L, Elkins M. Sternal instability following coronary artery bypass grafting. Physiother Theory Pract 2000;16:27-33.
24Holloway C, Pathare N, Huta J, Grady D, Landry A. The impact of a less restrictive poststernotomy activity protocol compared with standard sternal precautions in patients following cardiac surgery. Phys Ther 2020;100:1074-83.
25Johnston MV, Scherer M, Whyte J. Applying evidence standards to rehabilitation research. Am J Phys Med Rehabil 2006;85:292-309.
26Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: What it is and what it isn't. Brit Med J 1996;312:71-2.
27Brocki BC, Thorup CB, Andreasen JJ. Precautions related to midline sternotomy in cardiac surgery: A review of mechanical stress factors leading to sternal complications. Eur J Cardiovasc Nurs 2010;9:77-84.
28Adams J, Cline M, Hubbard M, McCullough T, Hartman J. A new paradigm for post-cardiac event resistance exercise guidelines. Am J Cardiol 2006;97:281-6.
29El-Ansary D, Waddington G, Adams R. Control of sternal instability by supportive devices: A comparison of adjustable fastening brace, compression garment, and sports tape. Arch Phys Med Rehabil 2008;89:1775-81.
30LaPier TK, Wintz G, Holmes W, Cartmell E, Hartl S, Kostoff N, et al. Analysis of activities of daily living performance in patients recovering from coronary artery bypass surgery. Phys Occup Ther Geriatr 2008;27:16-35.
31LaPier TK, Schenk R. Thoracic musculoskeletal considerations following open-heart surgery. Cardiopulm Phys Ther J 2002;13:16-20.