Sternal Precautions: Is It Time for Change? Precautions versus Restrictions - A Review of Literature and Recommendations for Revision.

The processes that occur with normal sternal healing and potential complications related to median sternotomy are of particular interest to physical therapists. The premise of patients following sternal precautions (SP) or specific activity restrictions is the belief that avoiding certain movements will reduce risk of sternal complications. However, current research has identified that many patients remain functionally impaired long after cardiothoracic surgery. It is possible that some SP may contribute to such functional impairments. Currently, SP have several limitations including that they: (1) have no universally accepted definition, (2) are often based on anecdotal/expert opinion or at best supported by indirect evidence, (3) are mostly applied uniformly for all patients without regard to individual differences, and (4) may be overly restrictive and therefore impede ideal recovery. The purpose of this article is to present an overview of current research and commentary on median sternotomy procedures and activity restrictions. We propose that the optimal degree and duration of SP should be based on an individual patient's characteristics (eg, risk factors, comorbidities, previous activity level) that would enable physical activity to be targeted to particular limitations rather than restricting specific functional tasks and physical activity. Such patient-specific SP focusing on function may be more likely to facilitate recovery after median sternotomy and less likely to impede it.

Variation in outcome after subarachnoid hemorrhage: a study of neurosurgical units in UK and Ireland.

BACKGROUNDS AND PURPOSE: The purpose of the study was to describe the characteristics, management, and outcomes of patients with confirmed aneurysmal subarachnoid hemorrhage and to compare outcomes across neurosurgical units (NSUs) in the UK and Ireland. METHODS: A cohort of patients admitted to NSUs with subarachnoid hemorrhage between September 14, 2001 and September 13, 2002 was studied longitudinally. Information was collected to characterize clinical condition on admission and treatment. Death or severe disability, defined by the Glasgow Outcome Score-Extended, was ascertained at 6 months. RESULTS: Data for 2397 patients with a confirmed aneurysm and no coexisting neurological pathology were collected by all 34 NSUs in the UK and Ireland. Aneurysm repair was attempted in 2198 (91.7%) patients (surgical clipping, 57.7%; endovascular coiling, 41.2%; other repair, 1.0%). Most patients (65.0%) were admitted to the NSU on the same day or the day after their hemorrhage; 32.0% of treated patients had the aneurysm repaired on the day of admission to the NSU (day 0), day 1 or day 2 and a further 39.3% by day 7. Glasgow Outcome Score-Extended at 6 months was obtained for 90.6% of patients (2172), of whom 38.5% had an unfavorable outcome. The median risk of an unfavorable outcome for all patients was 31% (5(th) and 95(th) percentiles, 12% and 83%), depending on prerepair prognostic factors. After adjustment for case-mix, the percentage of patients with an unfavorable outcome in each NSU did not differ significantly from the overall mean. CONCLUSIONS: In this study that collected representative data from the UK and Ireland, there was no evidence that the performance of any NSU differed from the average.

Overview of telehealth and its application to cardiopulmonary physical therapy.

Advances in telecommunication technology provide unique opportunities for the provision of medical services to underserved and geographically displaced patients. Health care professionals currently use voice and video systems to communicate with patients and colleagues in a variety of clinical venues. Unfortunately, such systems have limited presence in physical therapy settings. A variety of factors, including lack of familiarity with existing devices and perceived system purchase and operation costs, appear to be limiting its use. Even the terminology is confusing with such terms as telehealth, telemedicine, and telerehabilitation often used interchangeably. The purpose of this paper is to present an overview of this technology and to provide a clinical perspective regarding the use of telehealth in cardiopulmonary physical therapy practice.

Interdisciplinary approach to the rehabilitation of an 18-year-old patient with bronchopulmonary dysplasia, using telerehabilitation technology.

We describe the use of telehealth technology in the rehabilitation of a college student with bronchopulmonary dysplasia. The present telerehabilitation application was necessitated by the absence of a formal university-based pulmonary rehabilitation program at Texas State University-San Marcos. Patient referral, evaluation, and rehabilitation were accomplished via interdisciplinary efforts of 3 separate university entities. Initial referral was obtained from the student health center, with pulmonary evaluation provided by the respiratory care department. Commercially available telerehabilitation equipment was then utilized to resolve exercise supervision and physiologic data-acquisition concerns. Forty-five individualized exercise sessions were administered by physical therapists via telerehabilitation distance voice and vision technology. Results reveal no substantive changes in pulmonary function test results, but there was improvement in functional aerobic capacity. Given the reduced life expectancy associated with bronchopulmonary dysplasia, investigators were afforded a unique opportunity to study an adult patient with this condition. Further, it appears the combined application of telerehabilitation technology and interdisciplinary cooperation among university departments is efficacious in the identification, evaluation, and rehabilitation of students with selected pulmonary disorders.

Developmental changes in male Siberian hamsters (Phodopus sungorus) exposed to different gestational and postnatal photoperiods.

In Siberian hamsters, juvenile somatic and reproductive development is influenced by the photoperiods experienced both during gestation and after birth. On the day of parturition, parents and young were transferred from either 16L (16 hr of light and 8 hr of darkness/day) or 10L to one of the three photoperiods (14L, 12L, and 10L), and on postnatal day 27 male juveniles were either pinealectomized or sham-operated. At various intervals from postnatal days 27-330, the following parameters were determined: body weight, testis size, pelage type, serum concentrations of follicle-stimulating hormone (FSH) and prolactin (PRL). A postnatal photoperiod <14L was required to initiate delayed pubertal development followed by an eventual 'spontaneous' achievement of body weight, testis size, pelage, and serum FSH and PRL levels characteristic of adult, long-day males. The data suggest that serum FSH 'surges' in the pineal-intact hamsters are associated with spontaneous testicular development regardless of gestation photoperiod. The results also indicate that gestational photoperiod affects the timing of the molt to winter-type pelage and its eventual spontaneous development in pineal-intact hamsters that are exposed to short photoperiod following birth. Finally, our observations suggest that the interval timer that operates during prolonged short-day exposure to ultimately trigger a transition to the summer-type physiology may begin to function before birth in the offspring of females exposed to short photoperiod during gestation.

Impaired oxygen on-kinetics in persons with human immunodeficiency virus are not due to highly active antiretroviral therapy.

OBJECTIVE: To determine the effects of human immunodeficiency virus (HIV) and highly active antiretroviral therapy (HAART) on oxygen on-kinetics in HIV-positive persons. DESIGN: Quasi-experimental cross-sectional. SETTING: Infectious disease clinic and exercise laboratory. PARTICIPANTS: Referred participants (N=39) included 13 HIV-positive participants taking HAART, 13 HIV-positive participants not taking HAART, and 13 noninfected controls. INTERVENTIONS: Participants performed 1 submaximal exercise treadmill test below the ventilatory threshold, 1 above the ventilatory threshold, and 1 maximal treadmill exercise test to exhaustion. MAIN OUTCOME MEASURES: Change in oxygen consumption (Delta.VO2) and oxidative response index (Delta.VO2/mean response time). RESULTS: Delta.VO2 was significantly lower in both HIV-positive participants taking (946.5+/-68.1mL) and not taking (871.6+/-119.6mL) HAART than in controls (1265.3+/-99.8mL) during submaximal exercise above the ventilatory threshold. The oxidative response index was also significantly lower (P<.05) in HIV-positive participants both taking (15.0+/-1.3mL/s) and not taking (15.1+/-1.7mL/s) HAART than in controls (20.8+/-2.1mL/s) during exercise above the ventilatory threshold. CONCLUSION: Oxygen on-kinetics during submaximal exercise above the ventilatory threshold was impaired in HIV-positive participants compared with a control group, and it appeared that the attenuated oxygen on-kinetic response was primarily caused by HIV infection rather than HAART.

A comparison of Qt and a-vO2 in individuals with HIV taking and not taking HAART.

PURPOSE: The aim of this study was to determine whether highly active antiretroviral therapy (HAART), rather than the direct effect of HIV infection, limits peripheral muscle oxygen extraction-utilization (a-vO(2)) in individuals infected with the human immunodeficiency virus (HIV). METHODS: Fifteen subjects (6 female and 9 male) with HIV taking HAART, 15 subjects infected with HIV not taking HAART, and 15 healthy gender and activity level matched non-HIV infected controls (N = 45) performed an maximal treadmill exercise test to exhaustion. Noninvasive cardiac output Qt was measured at each stage and at peak exercise using the indirect Fick method based on the exponential rise carbon dioxide rebreathing method. Intergroup comparisons were adjusted for interactions of peak oxygen consumption ([V02), body surface area, and [V02]t using ANCOVA. RESULTS: Peak a-vO(2) was significantly lower (P < 0.05) in subjects with HIV taking HAART (10.0 +/- 0.5 vol%) compared with subjects with HIV not taking HAART (11.7 +/- 0.5 vol%) and noninfected controls (12.7 +/- 0.5 vol%). In subjects with HIV taking HAART, peak heart rate (HR) (170.5 +/- 3.9 bpm) was lower than (P < 0.05) and stroke volume (Vs) (123.0 +/- 3.9 mL x beat-1) at peak exercise was higher (P < 0.05) than subjects with HIV not taking HAART (179.9 +/- 3.5 bpm) (106.6 +/- 3.9 mL x beat-1) and noninfected controls (185.4 +/- 3.8 bpm) (100.6 +/- 4.0 mL.beat-1) upon ANCOVA. There were no significant differences in peak [VO2]t between groups. CONCLUSION: Peak a-vO(2) was diminished in subjects infected with HIV taking HAART compared with HIV-infected subjects not taking HAART and noninfected controls matched for age, gender, and physical activity level. Findings of the current study implicated HAART as a primary contributor to decreased muscle oxygen extraction-utilization in individuals infected with HIV.