Elsevier

Heart, Lung and Circulation

Volume 28, Issue 10, October 2019, Pages 1549-1559
Heart, Lung and Circulation

Review
Resistance Training Following Median Sternotomy: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.hlc.2019.05.097Get rights and content

Objective

Despite no evidence to support weight limitations following median sternotomy, sternal precautions continue to be routinely prescribed. Moreover, international cardiac rehabilitation guidelines lack sufficient detail for the implementation of resistance training. This systematic review and meta-analysis aimed to determine what the literature defines as resistance training; how resistance training is applied, progressed and evaluated; and, whether resistance training improves physical and functional recovery postoperatively in the cardiac surgical population.

Data Sources

Five (5) electronic databases were searched from inception to 28 September 2018 for studies published in English that investigated the effects of a resistance training intervention on physical and functional recovery following median sternotomy.

Results

Eighteen (18) trials (n = 3,462) met eligibility criteria and were included in the analysis. Seven (7) randomised controlled trials shared common outcome measures, allowing meta-analysis. The performance of resistance training appears to be safe and feasible, and resulted in similar improvements in both cardiopulmonary capacity and anthropometry, when compared to aerobic training alone. However, the definition and application of resistance training is frequently a lower intensity and volume than recommended by the American College of Sports Medicine. Furthermore, sternal precautions are not reflective of the kinematics and weights used when performing many activities of daily living. For this reason, resistance training needs to be task-specific, reflecting functional tasks to promote recovery.

Conclusion

Resistance training, in isolation or when combined with aerobic training, may lead to greater improvements in physical and functional recovery following cardiac surgery via median sternotomy; however, further research is required to inform clinical guidelines.

Introduction

Median sternotomy is the gold standard in providing optimal access during cardiac surgical procedures, including coronary artery bypass graft and cardiac valve repair/replacement surgery; despite recent developments in minimally invasive surgical techniques. [1], [2], [3], [4], [5] Over 1.5 million procedures are performed annually, worldwide [6]. Despite evidence to support moderate intensity exercise [7], and a more active approach to postoperative recovery and cardiac rehabilitation [8], [9], sternal precautions are typically prioritised over exercise involving the upper limbs and trunk for 8 to 12 weeks following surgery [10], [11], [12], with the rationale that they prevent sternal complications. [13], [14], [15], [16], [17], [18], [19], [20], [21] In addition to the restriction of use of the upper limbs and trunk, sternal precautions generally prohibit the lifting of weights >1 kg until the sternum unites. [10], [11], [12]. However, there is no evidence to suggest that restricting upper limb and trunk movements improves bone healing and prevents sternal complications [8], [13], [22]. Furthermore, sternal precautions are inconsistently applied and are contrary to the promotion of physical activity by health professionals to facilitate recovery. Emerging evidence to support the safety and efficacy of moderate intensity exercise, and upper limb and thoracic progressive exercise, has prompted a move away from a restrictive approach following surgery to one that encourages movement and physical activity [7], [8], [9], [23].

Resistance training refers to exercise techniques that improve musculoskeletal function, including the use of free weights, body weight, machine weights and resistance bands [11], [12], [24]. Whilst a number of organising bodies recommend the inclusion of resistance training, worldwide cardiac rehabilitation focusses primarily on aerobic training with resistance exercise guidelines varying significantly [25]. The lack of consensus between sternal precautions, cardiac rehabilitation guidelines and emerging evidence is problematic for clinicians who are required to deliver evidence-based exercise interventions [14], [15].

Resistance training not only augments improvements in cardiovascular fitness and muscle strength [24], [26], [27], [28], [29]; recent evidence suggests that it may play a role in the reduction of inflammation, cognitive dysfunction and sarcopaenia [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], which can persist for several months after surgery; and improve quality of life [26], psychological wellbeing [40], morbidity [41] and ability to perform household activities [28]. Postoperative recovery can be compromised by physical inactivity, [11] which is inadvertently encouraged when adhering to activity restrictions implied by sternal precautions. However, despite the aforementioned benefits of resistance training, to our knowledge, no systematic reviews have been conducted to investigate the safety, feasibility, application and effectiveness of resistance training in the cardiac population undergoing procedures via median sternotomy, at any time point postoperatively.

Therefore, the specific research questions for this systematic review were:

  • 1

    What is ‘resistance’ training after median sternotomy?

  • 2

    How is resistance training applied, progressed and evaluated at any stage of cardiac rehabilitation following median sternotomy?

  • 3

    Does resistance training improve physical and functional recovery following median sternotomy in comparison to standard care or aerobic training?

Section snippets

Method

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and is registered on the International prospective register of systematic reviews (PROSPERO No. CRD42018098623).

Study Selection

The database and reference list searches identified 1,468 unique references for possible inclusion. Review of titles and abstracts identified 70 for full-text reviews, of which, 18 publications met the criteria for inclusion (Figure 1) [26], [27], [28], [29], [40], [41], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55].

Study Characteristics

The 18 studies included in the qualitative analysis of the review included 3,462 patients with coronary artery disease, inclusive of patients treated

Resistance Training Following Median Sternotomy

This systematic review found that the definition and application of resistance training was inconsistent with the ACSM guidelines. Resistance training was applied in varying forms, including the use of free weights, weight machines, resistance bands, body weight and calisthenics exercises. The ACSM states that the types of resistance training used can include free weights (i.e. barbells, dumbbells, and ankle weights), body weight (i.e. push-ups, squats), machine weights and resistance bands.

Conclusion

There is evidence to support the safety and efficacy of progressive unweighted upper limb and trunk movements; and moderate intensity exercise in patients following cardiac surgeries via median sternotomy. However, a precautionary approach to cardiac rehabilitation has perpetuated the poor translation of resistance exercise in cardiac rehabilitation settings and has resulted in the preferential use of aerobic training to facilitate postoperative recovery. This study highlighted that there is no

PROSPERO No

CRD42018098623

This manuscript has been presented at the Australian Cardiovascular Health and Rehabilitation Annual Scientific Meeting in 29 July-1 August, 2018 in Brisbane, Qld, Australia and the Australia New Zealand Society of Cardiac and Thoracic Surgeons Annual Scientific Meeting 8-11 November, 2018 in Noosa, Qld, Australia.

Competing Interests

Nil to declare.

Acknowledgements

Nil.

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