Type of Article:  Original Research

Volume 7; Issue 4 (August 2019)

Page No.: 3163-3172

DOI: https://dx.doi.org/10.16965/ijpr.2019.151


Ansel LaPier 1, Kimberly Cleary *2.

1 Research Student, Physical Therapy Department, Eastern Washington University, Spokane, Washington USA.

*2 Professor, Physical Therapy Department, Eastern Washington University, Spokane, Washington USA.

Corresponding Author: Dr. Kimberly Cleary, PT, PhD, Professor, Physical Therapy Department, Eastern Washington University, Spokane, Washington USA. (509) 828-1373 E-Mail: kcleary@ewu.edu


Background: Patients often need to use their arms to assist with functional activities, but after open heart surgery pushing with the arms is limited to minimize force across the healing sternum.

Objectives: The main purposes of this study were to determine: 1) how accurately patients can estimate arm weight bearing with 10 lb or less of force and 2) if feedback training is effective for improving ability to estimate arm force and reduce pectoralis major muscle contraction during functional activities.

Materials and Methods: An instrumented walker was used to measure arm force during functional mobility tasks including walker ambulation and sit-stand transfers. Pectoralis major muscle electromyography (EMG) activity was measured simultaneously in study participants (n = 21). After baseline testing, study participants underwent a brief session of visual and auditory concurrent feedback training. Data analyses included t-tests, ANOVA, and Pearson correlations (P<0.05).

Results: Results showed that self-selected arm force was greater than 10 lb for all tasks (11.7-19.0 lb) but after feedback training, it was significantly lower (8.3-9.8 lb). During most trials (67%), study participants used more than 12 lb of arm force. Pectoralis major muscle EMG values were less than 10% of maximal voluntary contractions and were reduced (2.7-3.3%) after feedback training.

Conclusions: Results indicate that patients may not be able to accurately estimate upper extremity force used during weight bearing activities, and that visual and auditory feedback improves accuracy. Activation of the pectoralis major muscle during arm weight bearing is minimal, suggesting minor force occurs across the sternum. An instrumented walker and feedback training appear to be very clinically useful for patients recovering from open heart surgery.

KEY WORDS: Sternal precautions, median sternotomy, feedback training, functional mobility, walker ambulation, open heart surgery.


  1. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics – 2018 update: a report from the American Heart Association. Circulation. 2018;137:e67-e492.
  2. Alhalawani AM, Towler MR. A review of sternal closure techniques. J Biomater Appl. 2013;28(4):483-497.
  3. Dieberg G, Smart NA, King N. Minimally invasive cardiac surgery: a systematic review and meta-analysis. Int J Cardiol. 2016;15(223):554-560.
  4. Zubair MH, Smith JM. Updates in minimally invasive cardiac surgery for general surgeons. Surg Clin North Am. 2017;97(4):889-898.
  5. Losanoff JE, Collier AD, Wagner-Mann CC, et al. Biomechanical comparison of median sternotomy closures. Soc Thorac Surg. 77:203-209, 2002.
  6. Balachandran S, Lee A, Denehy L, et al. Risk factors for sternal complications after cardiac operations: a systematic review. Ann Thorac Surg. 2016;102(6):2109-2117.
  7. Casha AR, Manche A, Gatt R, et al. Mechanism of median sternotomy dehiscence. Interact Cardiovasc Thorac Surg. 2014;19(4):617-621.
  8. Brocki 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(2):77-84.
  9. Balachandran S, Lee A, Royse A, et al. Upper limb exercise prescription following cardiac surgery via median sternotomy: a web survey. J Cardiopulm Rehabil Prev. 2014;34(6):390-395.
  10. Tuyl 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(1):83-97.
  11. Graham A, Brown CH. Frailty, aging, and cardiovascular surgery. Anesth Analg. 2011;124(4):1053-1060.
  12. Min L, Mazzurco L, Gure TR, et al. Longitudinal functional recovery after geriatric cardiac surgery. J Surg Res. 2015;194(1):25-33.
  13. Edgerton JR, Herbert MA, Mahoney C, et al. Long-term fate of patients discharged to extended care facilities after cardiovascular surgery. Ann Thorac Surg. 2013;96(3):871-877.
  14. Stocicea N, You T, Eiterman A, et al. Perspectives of post-acute transition of care for cardiac surgery patients. Front Cardiovasc Med. 2017;27(4):70.
  15. Cleary K, Kinney LaPier TL. Perceptions of exercise and quality of life in older patients in the United States during the first year following coronary artery bypass surgery. Physiother Theor Pract. 2015;31(5):337-346.
  16. Guimaraes MN, Filho C. Functional status change in older adults undergoing coronary artery bypass surgery. Sao Paulo Med J. 2011;129(2):99-106.
  17. Adams J, Cline MJ, Hubbard M, et al. A new paradigm for post-cardiac event resistance exercise guidelines. Am J Cardiol. 2006;97(2):281-286.
  18. Swanson LB, Kinney LaPier T. Upper extremity forces generated during activities of daily living. J Acute CarePhys Ther. 2014;5(2):70-76.
  19. Riebe D, Ehrman JK, Liguori G, Magal M, American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. Philadelphia, PA: Wolters Kluwer, 2018.
  20. Boettcher CE, Ginn KA, Cathers I. Standard maximum isometric voluntary contraction test for normalizing shoulder muscle EMG. J Orthop Res. 2008;26:1591-1597.
  21. Anton D, Mizner RL, Hess JA. The effect of lift teams on kinematics and muscle activity of the upper extremity and trunk in brick layers. J Orthop Sport Phys Ther. 43(4):232-241.
  22. Gruevski KM, Hodder JN, Keir PJ. Upper extremity muscle activity during in-pase and anti-phase continuous pushing tasks. Human Factors. 2017;59(7):1066-1077.
  23. Zasadzda E, Borowicz AM, Roszak M, Pawlaczyk M. Assessment of the risk of falling with the use of timed up and go test in the elderly with lower extremity osteoarthritis. Clin Interven Aging. 2015; 10:1289-1298.
  24. Kojima G, Masud T, Kendrick D, et al. Does the timed up and go test predict future falls among British community-dwelling older people? Prospective cohort study nested within a randomised controlled trial. BMC Geriatrics. 2015;15:38.
  25. Po-Chen Y, Cherng L. Using walker during walker: a pilot study for health elder. Work. 2012;41:2081-2085.
  26. Ishikura T. Biomechanical analysis of weight bearing force and muscle activation levels in the lower extremeties during gait with a walker. Acta Med Okayama. 2001;55(2):73-82.
  27. Fast A, Wang FS, Adrezin RS, et al. The instrumented walker: usage patterns and forces. Arch Phys Med Rehabil. 1995;76:484-491.
  28. Raaben M, Holtslag HR, Leenen LPH, Augustine R, Blokuis TJ. Real-time visual biofeedback during weight bearing improves therapy compliance in patients following lower extremity fractures. Gait Posture. 2018;59:206-210.
  29. Ruiz FK, Fu MC, Bohl DD, et al. Patient compliance with postoperative lower extremity touch down weight bearing orders at a level I trauma center. Orthop. 2014;37(6):e552-556.
  30. Hustedt JW, Blizzard DJ, Baumgaertner MR, Leslie MP, Grauer JN. Is it possible to train patients to limit weight bearing on a lower extremity? Orthop. 2012;35(1):e31-37.
  31. Hustedt JW, Blizzard DJ, Baumgaertner MR, Leslie MP, Grauer JN. Effect of age on partial weight-bearing training. Orthop. 2012;35(7):e1061-1067.
  32. McQuade KJ, Finley M, Oliveira AS. Upper extremity joint stresses during walker-assisted ambulation in post-surgical patients. Rev Bras Fisioter. 2011;15(4):332-337.
  33. Anglin C, Wyss UP. Arm motion and load analysis of sit-to-stand, stand-to-sit, and walking and lifting. Clin Biomech. 2000;15:441-448.
  34. Schultz AB, Alexander NB, Ashton-Miller JA. Biomechanical analysis of rising from a chair. J Biomech. 1992;25(12):1383-1391.
  35. Chamorro-Moriana G, Moreno AJ, Sevillano JL. Technology-based feedback and its efficacy in improving gait parameters in patients with abnormal gait: a systematic review. Sensors. 2018;18:142.
  36. Sawers A, Hahn ME, Kelly VE, Czerniecki JM, Kartin D. Beyond componentry: how principles of motor learning can enhance locomotor rehabilitation of individuals with lower limb loss – a review. J Rehabil Res Dev. 2012;49(10):1431-1442.
  37. Uhl TL, Carver TJ, Mattacola CG, Mair SD, Nitz AJ. Shoulder musculature activation during upper extremity weight-bearing exercise. J Orthop Sports Phys Ther. 2003;33(3):109-117.
  38. Marcolin G, Petrone N, Moro T, Battaglia G, Bianco A, Paoli A. Selective activation of shoulder, trunk, and arm muscles: a comparative analysis of different push-up variants. J Athletic Train. 2015;50(11):1126-1132.
  39. Khodadadi M, Baniasad MA, Arazpour M, Farahmand F, Zohoor H. Designing instrumented walker to measure upper-extremity’s efforts: a case study. Assist Tech. 2018;26:1-9.
  40. David G, Magarey ME, Jones MA, et al. EMG and strength correlates of selected shoulder muscles during rotations of the glenohumeral joint. Clin Biomech. 2000;15:95-102.
  41. Leung C-Y, Yeh P-C. Vertical force and wrist deviation angle when using a walker to stand up and sit down. Perceptual Motor Skills. 2011;113(1):229-241.
  42. Hustedt JW, Blizzard DJ, Baumgaertner MR, Leslie MP, Grauer JN. Lower-extremity weight-bearing compliance is maintained over time after biofeedback training. Orthop.2012;35(11):e1644-1648.
  43. Pataky Z, Rodriguez D, Golay A, Assal M, Assal J, Hauert C. Biofeedback training for partial weight bearing in patients after total hip arthroplasty. Arch Phys Med Rehabil. 2009;90:1435-1438.