{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T16:39:35Z","timestamp":1789576775568,"version":"build-2803163510"},"reference-count":74,"publisher":"Oxford University Press (OUP)","issue":"12","license":[{"start":{"date-parts":[[2019,9,2]],"date-time":"2019-09-02T00:00:00Z","timestamp":1567382400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2019,12,16]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Cardiac surgery via median sternotomy is performed in over 1 million patients per year worldwide. Despite evidence, sternal precautions in the form of restricted arm and trunk activity are routinely prescribed to patients following surgery to prevent sternal complications. Sternal precautions may exacerbate loss of independence and prevent patients from returning home directly after hospital discharge. In addition, immobility and deconditioning associated with restricting physical activity potentially contribute to the negative sequelae of median sternotomy on patient symptoms, physical and psychosocial function, and quality of life. Interpreting the clinical impact of sternal precautions is challenging due to inconsistent definitions and applications globally. Following median sternotomy, typical guidelines involve limiting arm movement during loaded lifting, pushing, and pulling for 6 to 8\u00a0weeks. This perspective paper proposes that there is robust evidence to support early implementation of upper body activity and exercise in patients recovering from median sternotomy while minimizing risk of complications. A clinical paradigm shift is encouraged, one that encourages a greater amount of controlled upper body activity, albeit modified in some situations, and less restrictive sternal precautions. Early screening for sternal complication risk factors and instability followed by individualized progressive functional activity and upper body therapeutic exercise is likely to promote optimal and timely patient recovery. Substantial research documenting current clinical practice of sternal precautions, early physical therapy, and cardiac rehabilitation provides support and the context for understanding why a less restrictive and more active plan of care is warranted and recommended for patients following a median sternotomy.<\/jats:p>","DOI":"10.1093\/ptj\/pzz126","type":"journal-article","created":{"date-parts":[[2019,8,27]],"date-time":"2019-08-27T11:34:35Z","timestamp":1566905675000},"page":"1587-1601","source":"Crossref","is-referenced-by-count":50,"title":["An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy"],"prefix":"10.1093","volume":"99","author":[{"given":"Doa","family":"El-Ansary","sequence":"first","affiliation":[{"name":"Department of Health Professions, Faculty of Art, Health and Design , Swinburne University of Technology, Melbourne, Victoria, Australia; Department of Surgery, School of Medicine, University of Melbourne, Melbourne, Australia; and Clinical Research Institute, Sydney, Australia. Address all correspondence to Associate Professor El-Ansary at: delansary@swin.edu.au"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tanya Kinney","family":"LaPier","sequence":"additional","affiliation":[{"name":"Department of Physical Therapy , Eastern Washington University, Spokane, Washington. Dr LaPier is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jenny","family":"Adams","sequence":"additional","affiliation":[{"name":"Baylor Institute for Rehabilitation , Baylor University Medical Center, Dallas, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Gach","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Services , Memorial Regional Hospital, Hollywood, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan","family":"Triano","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Services , Memorial Regional Hospital, Hollywood, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Md Ali","family":"Katijjahbe","sequence":"additional","affiliation":[{"name":"Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology Department of Physiotherapy , Hospital Canselor Tuanku Muhriz, UKM Medical Centre, Cheras, Kuala Lumpur, Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew D","family":"Hirschhorn","sequence":"additional","affiliation":[{"name":"MQ Health Physiotherapy and Department of Health Professions , Faculty of Medicine and Health, Macquarie University, Sydney, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sean F","family":"Mungovan","sequence":"additional","affiliation":[{"name":"Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology, Clinical Research Institute and Westmead Private Physiotherapy Services , Westmead Private Hospital, Sydney, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Lotshaw","sequence":"additional","affiliation":[{"name":"Baylor Institute for Rehabilitation, Baylor University Medical Center . Dr Lotshaw is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lawrence P","family":"Cahalin","sequence":"additional","affiliation":[{"name":"Department of Physical Therapy, Miller School of Medicine , University of Miami, Coral Gables, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2019,9,2]]},"reference":[{"key":"2023011903540335700_ref1","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1177\/0885328213495426","article-title":"A review of sternal closure techniques","volume":"28","author":"Alhalawani","year":"2013","journal-title":"J Biomater Appl."},{"key":"2023011903540335700_ref2","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1016\/j.jhin.2018.05.026","article-title":"Prevention of deep sternal wound infection in cardiac surgery: a literature review","volume":"100","author":"Vos","year":"2018","journal-title":"J Hosp Infect."},{"key":"2023011903540335700_ref3","doi-asserted-by":"crossref","first-page":"889","DOI":"10.1016\/j.suc.2017.03.002","article-title":"Smith JM. Updates in minimally invasive cardiac surgery for general surgeons","volume":"97","author":"Zubair","year":"2017","journal-title":"Surg Clin North Am."},{"key":"2023011903540335700_ref4","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1097\/01823246-201122010-00002","article-title":"Sternal precautions: Is it time for change? Precautions versus restrictions \u2013 a review of literature and recommendations for revision","volume":"22","author":"Cahalin","year":"2011","journal-title":"Cardiopulm Phys Ther J."},{"key":"2023011903540335700_ref5","doi-asserted-by":"crossref","first-page":"134","DOI":"10.5811\/westjem.2013.11.19344","article-title":"Delayed presentation of deep sternal wound infection","volume":"15","author":"Joseph","year":"2014","journal-title":"West J Emerg Med."},{"key":"2023011903540335700_ref6","doi-asserted-by":"crossref","first-page":"831","DOI":"10.1016\/S1010-7940(02)00124-0","article-title":"Disruption and infection of median sternotomy: a comprehensive review","volume":"21","author":"Losanoff","year":"2002","journal-title":"Eur J Cardiothorac Surg."},{"key":"2023011903540335700_ref7","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1097\/01592394-201102030-00007","article-title":"Risk factors associated with sternal complications in patients following open heart surgery and implications for activity precautions","author":"Chatellier","year":"2011","journal-title":"J Acute Care Phys Ther."},{"key":"2023011903540335700_ref8","doi-asserted-by":"crossref","first-page":"2109","DOI":"10.1016\/j.athoracsur.2016.05.047","article-title":"Risk factors for sternal complications after cardiac operations: a systematic review","volume":"102","author":"Balachandran","year":"2016","journal-title":"Ann Thorac Surg."},{"key":"2023011903540335700_ref9","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1016\/S0004-9514(14)60310-X","article-title":"Musculoskeletal and neurological complications following coronary artery bypass graft surgery: a comparison between saphenous vein and internal mammary artery grafting","volume":"46","author":"El-Ansary","year":"2000","journal-title":"Aust J Physiother."},{"key":"2023011903540335700_ref10","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1097\/HCR.0000000000000053","article-title":"Upper limb exercise prescription following cardiac surgery via median sternotomy: a web survey","volume":"34","author":"Balachandran","year":"2014","journal-title":"J Cardiopulm Rehabil Prev."},{"key":"2023011903540335700_ref11","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.jphys.2018.02.013","article-title":"Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' trial): a randomised trial","volume":"64","author":"Katijjahbe","year":"2018","journal-title":"J Physiother."},{"key":"2023011903540335700_ref12","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1016\/S0003-4975(97)01003-5","article-title":"Mediastinitis after cardiovascular operations: a case-control study of risk factors","volume":"65","author":"Bitkover","year":"1998","journal-title":"Ann Thorac Surg."},{"key":"2023011903540335700_ref13","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1002\/jcu.20669","article-title":"Role of sonography in the emergency room to diagnose sternal fractures","volume":"38","author":"You","year":"2010","journal-title":"J Clin Ultrasound."},{"key":"2023011903540335700_ref14","doi-asserted-by":"crossref","first-page":"1513","DOI":"10.1016\/j.athoracsur.2006.10.058","article-title":"Measurement of non-physiological movement in sternal instability by ultrasound","volume":"83","author":"El-Ansary","year":"2007","journal-title":"Ann Thorac Surg."},{"key":"2023011903540335700_ref15","doi-asserted-by":"crossref","first-page":"62","DOI":"10.12968\/ijtr.2017.24.2.62","article-title":"Is ultrasound a reliable and precise measure of sternal micromotion in acute patients after cardiac surgery?","volume":"24","author":"Balachandran","year":"2017","journal-title":"Int J Ther Rehabil."},{"key":"2023011903540335700_ref16","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1080\/095939800307584","article-title":"Sternal instability following coronary artery bypass grafting","volume":"16","author":"El Ansary","year":"2000","journal-title":"Physiother Theory Pract."},{"key":"2023011903540335700_ref17","doi-asserted-by":"crossref","first-page":"1","DOI":"10.15344\/2455-7498\/2018\/140","article-title":"Physical assessment of sternal stability following a median sternotomy for cardiac surgery: validity and reliability of the Sternal Instability Scale (SIS)","volume":"4","author":"El-Ansary","year":"2018","journal-title":"Int J Phys Ther Rehab."},{"key":"2023011903540335700_ref18","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1055\/s-2000-9945","article-title":"Sternal instability after midline sternotomy","volume":"48","author":"Robicsek","year":"2000","journal-title":"Thorac Cardiovasc Surg."},{"key":"2023011903540335700_ref19","doi-asserted-by":"crossref","first-page":"1775","DOI":"10.1016\/j.apmr.2008.01.025","article-title":"Control of separation in sternal instability by supportive devices: a comparison of an adjusted fastening brace, compression garment, and sporting tape","volume":"89","author":"El-Ansary","year":"2008","journal-title":"Arch Phys Med Rehabil."},{"key":"2023011903540335700_ref20","doi-asserted-by":"crossref","first-page":"617","DOI":"10.1093\/icvts\/ivu184","article-title":"Mechanism of median sternotomy dehiscence","volume":"19","author":"Casha","year":"2014","journal-title":"Interact Cardiovasc Thorac Surg."},{"key":"2023011903540335700_ref21","doi-asserted-by":"crossref","first-page":"1144","DOI":"10.1016\/S0022-5223(99)70251-5","article-title":"Mechanical analysis of midline sternotomy wound closure","volume":"117","author":"McGregor","year":"1999","journal-title":"Thorac Cardiovasc Surg."},{"key":"2023011903540335700_ref22","first-page":"1027","article-title":"Denehy L et\u00a0al. Do directed cough maneuvers improve cough effectiveness in the early period after open heart surgery? Effect of thoracic support and maximal inspiration on cough peak expiratory flow, cough expiratory volume, and thoracic pain","volume":"53","author":"Fiore","year":"2008","journal-title":"Respir Care."},{"key":"2023011903540335700_ref23","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1016\/j.ejcnurse.2009.11.009","article-title":"Precautions related to midline sternotomy in cardiac surgery: a review of mechanical stress factors leading to sternal complications","volume":"9","author":"Brocki","year":"2010","journal-title":"Eur J Cardiovasc Nurs."},{"key":"2023011903540335700_ref24","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1136\/hrt.2007.117606","article-title":"Women's Recovery from Sternotomy-Extension (WREST-E) study: examining long-term pain and discomfort following sternotomy and their predictors","volume":"94","author":"King","year":"2008","journal-title":"Heart."},{"key":"2023011903540335700_ref25","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1093\/icvts\/ivt240","article-title":"Prevention of sternal wound complications after sternotomy: results of a large prospective randomized multicentre trial","volume":"17","author":"Gorlitzer","year":"2013","journal-title":"Interact Cardiovasc Thorac Surg."},{"key":"2023011903540335700_ref26","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1016\/S0004-9514(07)70006-5","article-title":"Trunk stabilisation exercises reduce sternal separation in chronic sternal instability after cardiac surgery: a randomised cross-over trial","volume":"53","author":"El Ansary","year":"2007","journal-title":"Aust J Physiother."},{"key":"2023011903540335700_ref27","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1016\/j.nut.2011.02.007","article-title":"Postoperative loss of skeletal muscle mass, complications and quality of life in patients undergoing cardiac surgery","volume":"28","author":"van Venrooij","year":"2012","journal-title":"Nutrition."},{"key":"2023011903540335700_ref28","first-page":"10","article-title":"Prevalence and severity of symptoms in patients recovering from coronary artery bypass graft","volume":"16","author":"Kinney LaPier","year":"2007","journal-title":"Acute Care Perspectives."},{"key":"2023011903540335700_ref29","doi-asserted-by":"crossref","first-page":"211","DOI":"10.2147\/POR.S131060","article-title":"Prevalence of neuro-musculoskeletal pain and dysfunction in open-heart surgical patients preoperatively and at 6 and 12 weeks postoperatively: a prospective longitudinal observation study","volume":"8","author":"Bellet","year":"2017","journal-title":"Pragmat Obs Res."},{"key":"2023011903540335700_ref30","doi-asserted-by":"crossref","first-page":"1387","DOI":"10.1111\/j.1365-2044.2009.06169_1.x","article-title":"A survey of post-sternotomy chronic pain following cardiac surgery","volume":"64","author":"Carle","year":"2009","journal-title":"Anaesthesia."},{"key":"2023011903540335700_ref31","doi-asserted-by":"crossref","first-page":"1433","DOI":"10.1002\/ejp.866","article-title":"Persistent postoperative pain after cardiac surgery: incidence, characterization, associated factors and its impact in quality of life","volume":"20","author":"Guimaraes-Pereira","year":"2016","journal-title":"Eur J Pain."},{"key":"2023011903540335700_ref32","first-page":"390","article-title":"Efficacy of gabapentin versus diclofenac in the treatment of chest pain and paresthesia in patients with sternotomy","volume":"9","author":"Biyik","year":"2009","journal-title":"Anadolu Kardiyol Derg."},{"key":"2023011903540335700_ref33","first-page":"552","article-title":"Factors associated with the development of chronic post-sternotomy pain: a case-control study","volume":"30","author":"Da Costa","year":"2015","journal-title":"Braz J Cardiovasc Surg."},{"key":"2023011903540335700_ref34","first-page":"E213","article-title":"Prevalence of and risk factors for persistent postoperative nonanginal pain after cardiac surgery: a 2-year prospective multicentre study","volume":"186","author":"Choiniere","year":"2014","journal-title":"CAMJ."},{"key":"2023011903540335700_ref35","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1016\/j.hrtlng.2006.09.002","article-title":"Functional status of patients during subacute recovery from coronary artery bypass surgery","volume":"36","author":"Kinney LaPier","year":"2007","journal-title":"Heart Lung."},{"key":"2023011903540335700_ref36","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1097\/01823246-201412000-00003","article-title":"Functional deficits at the time of hospital discharge in patients following coronary artery bypass surgery \u2014 a pilot study","volume":"25","author":"Kinney LaPier","year":"2014","journal-title":"Cardiopulm Phys Ther J."},{"key":"2023011903540335700_ref37","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1097\/00008483-200603000-00010","article-title":"Psychometric evaluation of the heart surgery symptom inventory in patients recovering from coronary artery bypass surgery","volume":"26","author":"Kinney LaPier","year":"2006","journal-title":"J Cardiopulm Rehabil."},{"key":"2023011903540335700_ref38","doi-asserted-by":"crossref","first-page":"337","DOI":"10.3109\/09593985.2015.1004770","article-title":"Kinney LaPier T. Perceptions of exercise and quality of life in older patients in the United States during the first year following coronary artery bypass surgery","volume":"31","author":"Cleary","year":"2015","journal-title":"Physiother Theory Pract."},{"key":"2023011903540335700_ref39","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1097\/01823246-200718020-00003","article-title":"Functional status in patients during the first two months following hospital discharge for coronary artery bypass surgery","volume":"18","author":"Wintz","year":"2007","journal-title":"Cardiopulm Phys Ther J."},{"key":"2023011903540335700_ref40","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1080\/02703180802206215","article-title":"Analysis of activities of daily living performance in patients recovering from coronary artery bypass surgery","volume":"27","author":"Kinney LaPier","year":"2008","journal-title":"Phys Occup Ther Geriatr."},{"key":"2023011903540335700_ref41","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1097\/01.HCR.0000270688.63516.db","article-title":"Indicators of functional deficits after coronary artery bypass surgery","volume":"27","author":"LaPier","year":"2007","journal-title":"J Cardiopulm Rehabil Prevent."},{"key":"2023011903540335700_ref42","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1111\/ggi.12547","article-title":"Course of functional status in elderly patients after coronary artery bypass surgery: 6-month follow-up","volume":"16","author":"Niemeyer-Guimaraes","year":"2016","journal-title":"Geriatr Gerontol Int."},{"key":"2023011903540335700_ref43","doi-asserted-by":"crossref","first-page":"2333","DOI":"10.1161\/CIRCULATIONAHA.112.000729","article-title":"Coronary artery bypass graft surgery in the elderly: a review of postoperative quality of life","volume":"128","author":"Shan","year":"2013","journal-title":"Circulation."},{"key":"2023011903540335700_ref44","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1016\/j.jss.2014.10.043","article-title":"Longitudinal functional recovery after geriatric cardiac surgery","volume":"194","author":"Min","year":"2015","journal-title":"J Surg Res."},{"key":"2023011903540335700_ref45","doi-asserted-by":"crossref","first-page":"53","DOI":"10.3138\/ptc.2010-30","article-title":"Utility of the late life function and disability instrument as an outcome measure in patients participating in outpatient cardiac rehabilitation: a preliminary study","volume":"64","author":"Kinney Lapier","year":"2012","journal-title":"Physiother Can."},{"key":"2023011903540335700_ref46","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2014-006904","article-title":"Does quality of life improve in octogenarians following cardiac surgery? A systematic review","volume":"5","author":"Abah","year":"2015","journal-title":"BMJ Open."},{"key":"2023011903540335700_ref47","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1186\/s13019-016-0491-2","article-title":"Pulmonary function and health-related quality of life 1-year follow up after cardiac surgery","volume":"11","author":"Westerdahl","year":"2016","journal-title":"J Cardiothorac Surg."},{"key":"2023011903540335700_ref48","doi-asserted-by":"crossref","first-page":"83","DOI":"10.2522\/ptj.20100373","article-title":"Management of sternal precautions following median sternotomy by physical therapists in Australia: a web-based survey","volume":"92","author":"Tuyl","year":"2012","journal-title":"Phys Ther."},{"key":"2023011903540335700_ref49","doi-asserted-by":"crossref","first-page":"215","DOI":"10.3138\/physio.62.3.215","article-title":"Physical therapy management for adult patients undergoing cardiac surgery: a Canadian practice survey","volume":"62","author":"Overend","year":"2010","journal-title":"Physiother Can."},{"key":"2023011903540335700_ref50","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1186\/1749-8090-5-67","article-title":"Physiotherapy-supervised mobilization and exercise following cardiac surgery: a national questionnaire survey in Sweden","volume":"5","author":"Westerdahl","year":"2010","journal-title":"J Cardiothorac Surg."},{"key":"2023011903540335700_ref51","first-page":"S7","article-title":"Physical therapy treatment after cardiac surgery: a national survey of practice in Greece","author":"Lomi","year":"2013","journal-title":"J Clin Exp Cardiol."},{"key":"2023011903540335700_ref52","doi-asserted-by":"crossref","DOI":"10.1378\/chest.136.4_MeetingAbstracts.98S","article-title":"Cardiothoracic surgeons perspective on sternal precautions: implications for rehabilitation professionals","author":"Cahalin","year":"2009","journal-title":"Chest."},{"key":"2023011903540335700_ref53","first-page":"97","article-title":"An alternative approach to prescribing sternal precautions after median sternotomy, keep your Move in the Tube","volume":"29","author":"Adams","year":"2016","journal-title":"Proc (Bayl Univ Med Cent)."},{"key":"2023011903540335700_ref54","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.clinbiomech.2017.05.007","article-title":"Skin deformation during shoulder movements and upper extremity activities","volume":"47","author":"Ge","year":"2017","journal-title":"Clin Biomech."},{"key":"2023011903540335700_ref55","article-title":"Pectoralis muscle activity during upper extremity exercise: implications for sternal precautions. Paper presented at: APTA Combined Sections Meeting","author":"Kinney LaPier","year":"29, 2019"},{"key":"2023011903540335700_ref56","article-title":"Pectoralis muscle activity during ambulation using an assistive device: implications for sternal precautions. Paper presented at: APTA Combined Sections Meeting","author":"Kinney LaPier","year":"24, 2019"},{"key":"2023011903540335700_ref57","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1097\/01.JAT.0000453141.39418.fb","article-title":"Upper extremity forces generated during activities of daily living","volume":"5","author":"Swanson","year":"2014","journal-title":"J Acute Care Phys Ther."},{"key":"2023011903540335700_ref58","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1016\/j.amjcard.2005.08.035","article-title":"A new paradigm for post-cardiac event resistance exercise guidelines","volume":"97","author":"Adams","year":"2006","journal-title":"Am J of Cardiol."},{"key":"2023011903540335700_ref59","doi-asserted-by":"crossref","first-page":"1045","DOI":"10.1016\/j.amjcard.2013.11.064","article-title":"Comparison of force exerted on the sternum during a sneeze versus during low-, moderate-, and high-intensity bench press resistance exercise with and without the Valsalva maneuver in healthy volunteers","volume":"113","author":"Adams","year":"2014","journal-title":"Am J Cardiol."},{"key":"2023011903540335700_ref60","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1055\/s-2008-1038470","article-title":"Current activity guidelines for CABG patients are too restrictive: comparison of the forces exerted on the median median sternotomy during a cough vs. lifting activities combined with Valsalva maneuver","volume":"56","author":"Parker","year":"2008","journal-title":"Thorac Cardiovasc Surg."},{"key":"2023011903540335700_ref61","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1080\/09593980701209402","article-title":"Relationship between pain and upper limb movement in patients with chronic sternal instability following cardiac surgery","volume":"23","author":"El-Ansary","year":"2007","journal-title":"Physiother Theory Pract."},{"key":"2023011903540335700_ref62","doi-asserted-by":"crossref","DOI":"10.1016\/j.hlc.2018.05.195","article-title":"Motion at the sternal edges during upper limb and trunk tasks in-vivo as measured by real-time ultrasound following cardiac surgery: a three-month prospective, observational study","author":"Balachandran","year":"2019;28:1283\u20131291","journal-title":"Heart Lung Circ."},{"key":"2023011903540335700_ref63","doi-asserted-by":"crossref","first-page":"110","DOI":"10.12968\/ijtr.2014.21.3.110","article-title":"A pilot thoracic exercise programme reduces early (0\u20136 weeks) sternal pain following open heart surgery","volume":"21","author":"Sturgess","year":"2014","journal-title":"Int J Ther Rehabil."},{"key":"2023011903540335700_ref64","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1016\/S1836-9553(10)70007-2","article-title":"A postoperative shoulder exercise program improves function and decreases pain following open thoracotomy: a randomised trial","volume":"56","author":"Reeve","year":"2010","journal-title":"J Physiother."},{"key":"2023011903540335700_ref65","doi-asserted-by":"crossref","first-page":"927","DOI":"10.1161\/CIR.0000000000000182","article-title":"Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association","volume":"131","author":"Kulik","year":"2015","journal-title":"Circulation."},{"key":"2023011903540335700_ref66","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jacc.2015.10.044","article-title":"Cochrane systematic review and meta-analysis","volume":"67","author":"Anderson","year":"2016","journal-title":"J Am Coll Cardiol"},{"key":"2023011903540335700_ref67","doi-asserted-by":"crossref","first-page":"995","DOI":"10.1093\/icvts\/ivs403","article-title":"Does the mode of exercise influence recovery of functional capacity in the early postoperative period after coronary artery bypass graft surgery? A randomized controlled trial","volume":"15","author":"Hirschhorn","year":"2012","journal-title":"Interact Cardiovasc Thorac Surg."},{"key":"2023011903540335700_ref68","doi-asserted-by":"crossref","first-page":"548","DOI":"10.1016\/j.amjcard.2014.11.040","article-title":"Safety of early enrollment into outpatient cardiac rehabilitation after open heart surgery","volume":"115","author":"Pack","year":"2015","journal-title":"Am J Cardiol."},{"key":"2023011903540335700_ref69","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1161\/CIRCULATIONAHA.112.121996","article-title":"An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single-blind, controlled trial","volume":"127","author":"Pack","year":"2013","journal-title":"Circulation."},{"key":"2023011903540335700_ref70","first-page":"71","article-title":"Physical activity after cardiac surgery: the first first five days","volume":"19","author":"Mungovan","journal-title":"Heart Lung Circ"},{"key":"2023011903540335700_ref71","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1016\/j.hlc.2007.09.004","article-title":"Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery-a randomised controlled trial","volume":"17","author":"Hirschhorn","year":"2008","journal-title":"Heart Lung Circ."},{"key":"2023011903540335700_ref72","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.physio.2016.08.003","article-title":"Effects of early mobilisation in patients after cardiac surgery: a systematic review","volume":"103","author":"Santos","year":"2017","journal-title":"Physiotherapy."},{"key":"2023011903540335700_ref73","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1111\/j.1469-7580.2008.00965.x","article-title":"Moment arms of the muscles crossing the anatomical shoulder","volume":"213","author":"Ackland","year":"2008","journal-title":"J Anat."},{"key":"2023011903540335700_ref74","volume-title":"Leading Change","author":"Kotter","year":"1996"}],"container-title":["Physical Therapy"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/ptj\/advance-article-pdf\/doi\/10.1093\/ptj\/pzz126\/29452897\/pzz126.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ptj\/article-pdf\/99\/12\/1587\/48761319\/ptj_99_12_1587.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ptj\/article-pdf\/99\/12\/1587\/48761319\/ptj_99_12_1587.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,7,22]],"date-time":"2024-07-22T16:18:49Z","timestamp":1721665129000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ptj\/article\/99\/12\/1587\/5558221"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,9,2]]},"references-count":74,"journal-issue":{"issue":"12","published-print":{"date-parts":[[2019,12,16]]}},"URL":"https:\/\/doi.org\/10.1093\/ptj\/pzz126","relation":{},"ISSN":["0031-9023","1538-6724"],"issn-type":[{"value":"0031-9023","type":"print"},{"value":"1538-6724","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2019,12]]},"published":{"date-parts":[[2019,9,2]]}}}