Feedback Training Improves Compliance with Sternal Precaution Guidelines during Functional Mobility: Implications for Optimizing Recovery in Older Patients after Median Sternotomy

Patients often need to use their arms to assist with functional activities, but after open heart surgery, pushing with the arms is limited to <10 lb (4.5 kg) to help minimize force across the healing sternum. The main purposes of this study were to determine if older patients (>60 years old) (1) accurately estimated upper extremity (UE) weight bearing force of 10 lb or less and (2) if feedback training improved their ability to limit UE force and pectoralis major muscle contraction during functional activities. An instrumented walker was used to measure UE weight bearing force, and electromyography was used to measure pectoralis major muscle activity simultaneously during 4 functional mobility tasks. After baseline testing, healthy older subjects ( n = 30 ) completed a brief session of visual and auditory concurrent feedback training. Results showed that the self-selected UE force was >10 lb for all tasks (20.0-39.7 lb [9.1-18.0 kg]), but after feedback training, it was significantly reduced (10.6-21.3 lb [4.8-9.7 kg]). During most trials (92%), study participants used >12 lb (5.5 kg) of arm weight bearing force. Pectoralis major muscle peak electromyography activity was <23% of maximal voluntary isometric contraction and was reduced (9.8-14.9%) after feedback training. Older patients may not be able to accurately estimate UE arm force used during weight bearing activities, and visual and auditory feedback improves accuracy and also modulation of pectoralis major muscle activation. Results suggest that an instrumented walker and feedback training could be clinically useful for older patients recovering from open heart surgery.

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The Influence of Age and Feedback Training on Ability to Modulate Upper Extremity Weight Bearing Force and Pectoralis Major Muscle Recruitment While Following Sternal Precautions

Physical Therapy and Rehabilitation ◽

10.7243/2055-2386-8-1 ◽

2021 ◽

Vol 8 (1) ◽

pp. 1

Author(s):

Ansel LaPier ◽

Kimberly Cleary

Keyword(s):

Upper Extremity ◽

Weight Bearing ◽

Pectoralis Major Muscle ◽

Pectoralis Major ◽

Muscle Recruitment ◽

Feedback Training ◽

Bearing Force

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Development of a Feedback Training Protocol and Clinical Force Measuring Walker for Older Patients with Restricted Upper Extremity Weight Bearing

10.20944/preprints202110.0238.v1 ◽

2021 ◽

Author(s):

Ansel LaPier

Keyword(s):

Upper Extremity ◽

Older Patients ◽

Patient Adherence ◽

Callus Formation ◽

Weight Bearing ◽

Training Session ◽

Subsequent Development ◽

Functional Mobility ◽

Feedback Training ◽

Training Protocol

Patients recovering from bone disruption due to trauma or surgery need to limit movement to minimize shear force, thereby protecting callus formation and osteogenesis. Patients often use their arms to assist with functional activities, but pushing is frequently limited to <10 lb (4.5 kg). With only verbal instructions, patients’ ability to accurately limit weight-bearing (WB) force is poor. A therapeutic intervention to improve patient adherence with upper extremity (UE) WB guidelines during functional mobility using an instrumented walker could be beneficial. Therefore, the purpose of this article is to describe a feedback training protocol to improve the ability to modulate weight-bearing force in older adults and then provide an overview of the efficacy of this protocol and subsequent development of a Clinical Force Measuring Walker. An instrumented walker was used to measure UE WB during functional mobility in older healthy subjects (n = 30) before, during, and after (immediately and 2 hours) a visual and auditory concurrent feedback training session. During feedback training, force was significantly reduced with all 3 sessions as compared to baseline. When using the front wheeled walker, UE WB force during the second and third feedback training trials went down compared to the first trial. During the third feedback training trial, force was greater than the two previous trials while transferring sit-to-stand and stand-to-sit. After completion of practice with feedback, UE WB force was significantly reduced and remained so 2 hours later. These findings suggest that feedback training is effective for helping patients to modulate UE WB. Use of an instrumented walker and feedback training would be beneficial in clinical practice, especially with older patients. A more intensive feedback training with additional trials and or simultaneous visual and auditory cues during whole-practice may be needed to get UE WB below a 10 lb threshold.

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FEEDBACK TRAINING IMPROVES ACCURACY OF ESTIMATING UPPER EXTREMITY WEIGHT BEARING DURING FUNCTIONAL TASKS: IMPLICATIONS AFTER OPEN HEART SURGERY

International Journal of Physiotherapy and Research ◽

10.16965/ijpr.2019.151 ◽

2019 ◽

Vol 7 (4) ◽

pp. 3163-3172

Author(s):

Ansel LaPier ◽

◽

Kimberly Cleary ◽

Keyword(s):

Upper Extremity ◽

Heart Surgery ◽

Weight Bearing ◽

Open Heart Surgery ◽

Open Heart ◽

Feedback Training

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Use of a force measuring walker to optimize recovery after median sternotomy

European Journal of Cardiovascular Nursing ◽

10.1093/eurjcn/zvab060.132 ◽

2021 ◽

Vol 20 (Supplement_1) ◽

Author(s):

A Lapier ◽

K Cleary

Keyword(s):

Heart Surgery ◽

Open Heart Surgery ◽

Median Sternotomy ◽

Functional Mobility ◽

Emg Activity ◽

Vertical Force ◽

Open Heart ◽

Design Elements ◽

Feedback Training ◽

Older Subjects

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Patients often need to use their arms to assist with functional activities, but after open-heart surgery, pushing with the arms is often limited to <10 lb (4.5 kg), to minimize force across the healing sternum. Restricting arm use often limits patient functional independence which can contribute to longer hospital stays and greater need for care after hospitalization. Therefore, appropriate arm use is important for return to function. Currently, no method exists to measure patient upper extremity weight bearing (UEWB) forces objectively in clinical settings. The ultimate goal was to develop a walker that provides UEWB force feedback to patients recovering from median sternotomy. This research project included three interrelated parts that sequentially built on each other. PART 1 First, I conducted a secondary data analysis comparing UEWB force and Pectoralis Major Muscle EMG during functional mobility in younger vs. older subjects (n = 65). Results showed that the mean arm force was >10 lb before feedback training during all functional mobility tasks for both groups. There were significant differences in UEWB force and EMG between groups (young vs. old) and trials (pre- vs. post-feedback training). There was significantly greater improvement (change) in the UEWB force in the older than younger subjects. We also found a significantly greater reduction in EMG activity in the older subjects than younger subjects for all tasks except during stand-to-sit. Results suggested that patients, particularly older ones, may not accurately estimate UEWB force <10 lb, and feedback training is effective for improving accuracy. This established proof-of-concept, the need for a Clinical Force Measuring (CFM) walker, and the efficacy of its use with feedback training. PART 2 Next, I completed a qualitative study to obtain critiques of a CFM walker prototype from rehabilitation professionals through structured interviews that were recorded and transcribed. I coded key statements and phrases that allowed "themes" to emerge (Table 1), which guided device revisions. PART 3 Lastly, I fabricated and tested a second CFM Walker prototype (Figure 1) based on key design elements including: 1) integrated vertical force measuring capability, 2) ergonomic handles, 3) simple visual and auditory feedback with upper limit alarms, 4) streamline, stable, and manoeuvrable frame, 5) lightweight construction, 6) minimal drag, 7) adjustable height, 8) ability to disinfect, and 9) affordable cost. CONCLUSIONS The CFM Walker could help patients recover safer and faster from open heart surgery, especially elderly adults.

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