Discharge Education Classroom Guide for the Keep … Proceedings/2016_Vol_29/No_1/29...Discharge...

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Discharge Education Classroom Guide for the Keep Your Move in the Tube Graphic

Introduction

The conservative sternal precautions often used in traditional post‐sternotomy discharge

education can leave patients and family members feeling anxious about the activities that

patients can perform when they return home. Our alternative educational approach, depicted

in the Keep Your Move in the Tube graphic, focuses on kinesiological movements rather than

load and time restrictions.1 We have used the graphic for the past two years in an inpatient

post‐sternotomy discharge education class, and the following text covers the educational

points, patient questions, and family anecdotes that have been discussed. This compilation is

provided to help other clinicians and patient educators use the Keep Your Move in the Tube

graphic to promote active living following sternotomy. (Note: The graphic and its accompanying

sternotomy illustration are included at the end of this guide.)

Legend: Teacher comments are in boldface type

[ACTIONS/EXPLANATIONS ARE IN CAPITALS AND ENCLOSED IN BRACKETS]

Patient/family member questions and comments are italicized

Example Class

Hi, everyone. How are you feeling? Probably like you got hit by a Mack truck, right? Well,

thanks for being in this class with me. My name is Jenny and I am from Cardiac Rehab. I am

here today to tell you about what you CAN do in the way of activity and exercise.

[TEACHER HANDS PATIENTS A COPY OF KEEP YOUR MOVE IN THE TUBE]

Before we start, I want to ask you: Has anyone given you any advice such as “don’t lift more

than 5 pounds” or “don’t lift more than a gallon of milk”?

Yes, my doctor told me not to lift more than a Dallas phone book. I don’t even have a phone

book, so what should I do?

1 Adams J, Lotshaw A, Exum E, Campbell M, Spranger CB, Beveridge J, Baker S, McCray S, Bilbrey T,

Shock T, Lawrence A, Hamman BL, Schussler JM. An alternative approach to prescribing sternal precautions after median sternotomy, “Keep Your Move in the Tube.” Proc (Bayl Univ Med Cent) 2016;29(1):97–100.


You will also hear this kind of advice from all kinds of people during your healing journey. I

am here today to share some new research findings with you about what you can safely do

after your surgery.

We actually did a research study to measure how much force it takes to move everyday

objects. For example, it takes 14 pounds of force to open that door over there. When you

leave the hospital, using your arm to hold the elevator door open takes about 12 pounds.

Opening your car or truck door is at least 14 pounds. So you see, if you actually lift no more

than 5 pounds, you won’t be able to do much of anything because not many things weigh 5

pounds or less. You will be discharged from the hospital, but you won’t be able to leave

because opening the door to your hospital room takes more than 5 pounds.

That is ridiculous. I think I will leave anyway!

I agree. I want you to be able to leave, but in a safe way, so that is why we are talking today

about how to perform activities safely.

We did research studies on the amount of force a cough has on the sternum, or breastbone.

Have you coughed yet while you have been in the hospital?

Yes. Oh my gosh, it was awful!

Well, that cough put about 60 pounds of force on your sternum. If a cough was 60 pounds, we

wondered what a sneeze would be, so we did another research study to find out. Do any of

you want to guess how much force a sneeze might put on the sternum?

I bet a sneeze is more than a cough, because if I didn’t have this pillow to hold, a sneeze might

really be painful.

Well, we found out that a sneeze puts about 90 pounds of force on your sternum. Now even

though that is true, it doesn’t mean that I would ever ask you to hold a 45‐pound dumbbell in

each hand and do dumbbell flyes.

[TEACHER DEMONSTRATES DUMBBELL FLYE]

Oh gosh, I could never do that. It would pull on my chest.

So, instead we are going to talk about what you CAN do safely. Is this ok with you?

Yes, please, because my family and I are very worried about my chest breaking open.

Ok. I would like you to look at this picture of the bones and muscles in the chest.

[TEACHER HOLDS UP ILLUSTRATION OF THE STERNUM AND CHEST MUSCLES]


During your surgery, was your sternum bone cut open?

Yes.

Well, they cut this sternum bone, pulled your ribcage apart, and worked on your heart. Then,

they put wires through the two sides of the bone to sew it back together. That is why you feel

like you have been hit by a truck.

Yes, it is pretty rough to go through!

The main thing I want you to notice about this picture is that the chest muscles are attached

on either side to your upper arm bones. Do you see what I mean?

Yes, I never knew that until now.

[TEACHER DEMONSTRATES BOTH ARMS MOVING TO DUMBELL FLYE POSITION]

What do you think would happen if I did this motion?

It seems like it would pull on the sternum bone and it might hurt pretty badly.

Now that you understand what happened to you and what the issue is, my goal today is to

teach you how to do activities safely when you get home. Is this ok with you? Are you ready?

Yes, I have my pen and I am ready to take notes.

Before you start teaching, does anyone here mind if I ask a personal question?

No, of course not. You can ask anything you want to.

Thank you. Well, I am 30 years old and my husband is 32. He just had valve surgery and is back

in his room. He didn’t even feel like coming to this class because he is feeling sad and frustrated

because he was told he cannot pick up our newborn baby and also can’t have sex with me for 3

months. I hope all of you are ok with me asking about this.

[GROUP SEEMS TO FEEL SORRY FOR HER AND SAYS OF COURSE, KEEP ASKING YOUR QUESTION]

Are you telling me that he can pick up our baby?

Yes, I have great news. I am going to tell you how he can safely pick up your baby.

I hope I am not offending anyone by asking about the sex, but he is really down and out about

this.

[THE GROUP IS ATTENTIVE AND EMPATHETIC. THEY SAY THEY ARE NOT OFFENDED AND

ENCOURAGE HER TO CONTINUE]


Ok, thanks. So are you telling me that we can have sex?

Yes, I am telling you that you and your husband can have sex. He will be fine. You may have

to modify positions so he will be comfortable, but you can figure that out together.

Really? He will be glad to hear that!

[TEACHER FOCUSES ON THE PERSON ASKING THE QUESTION]

When it comes to having sex, the person I am most worried about is you. Your husband will

know what his body feels like and whether or not he is comfortable. You, though, might be

worried about him and try to take responsibility for him. Hopefully, you can try not to have

anxiety and enjoy having sex with him. This might be difficult for you, but I think you can do it

if you truly believe that he will be ok.

Thank you all so much for letting me ask these questions. It hasn’t been an easy road for us, and

I can’t wait to tell him this information. All we had to go on until today was “don’t lift more than

5 pounds.” That advice was scary to both of us. I mean, it was like telling him he was an invalid.

Before this happened, he was thinking he had his whole life ahead of him. We both have been

struggling and feeling down, so I can’t thank you enough for answering my questions.

I love teaching this class. Thank you for asking those great questions! You know, at our

hospital, we don’t want to fix you with the surgery and then turn around and tell you not to

“live” because you can’t lift more than 5 pounds. We believe patients have the surgery

because they want to get out there and enjoy the world. What would be the reason for going

through this difficult surgery unless you can go out there and live your life?

For many years, we simply told patients not to lift more than 5 pounds. Over time, however,

we realized that patients were frightened by that advice; they become couch potatoes—

depressed, fearful, and miserable. We are trying to change things with this class so people

like you can go and live your life and enjoy your activities. Are there any other questions so

far?

Ok. Please turn to the handout that is called Keep Your Move in the Tube.

[TEACHER STANDS UP FOR DEMONSTRATION AND PRETENDS TO BE HOLDING A VERY LARGE

PAPER TOWEL TUBE]

Ok, if I had a very large paper towel tube and I could slide it over your body, what would it do

to those upper arm bones?

Oh, I get it. The upper arm bones would be down by the side of the body.


Right! So, look at the drawing of the guy in the wheelchair. The red tubes signify “out of the

tube,” and the green tubes signify “in the tube.”

Is the red wheelchair guy in the tube or out of the tube?

Out.

Correct. In the old days, we used to give an educational handout to patients like you that

said, “If you are in a wheelchair, don’t roll it.” I found that to be ridiculous. All those years I

kept thinking, why would a person sit in a wheelchair if he or she couldn’t roll it to go

somewhere?

Did you really have a handout that said that?

Yes, although I am embarrassed to admit it. So now we have changed things. If you sit in a

wheelchair and pretend that you are surrounded by an imaginary tube, you will modify your

rolling strategy.

[TEACHER PRETENDS TO BE IN A WHEELCHAIR AND HOLDS ARMS BACK, OUT OF THE TUBE]

Look at me. Am I in the tube or out of the tube?

Out.

[TEACHER THEN DEMONSTRATES SHORT‐MOVEMENT ROLLING WITH ARMS INSIDE THE TUBE]

Do you see what I mean? If you need to roll somewhere in a wheelchair, just modify your

rolling strategy and keep your move in the tube.

Now, let’s take a look at the guy with his arms over his head.

[TEACHER REACHES OVERHEAD, OUT OF THE TUBE]

Am I in the tube or out of the tube?

Out

Did you know that if you sit down for 3 days and don’t do anything, you can lose muscle mass

the size of an orange each day?

[TEACHER HOLDS UP FIST TO SHOW SIZE OF ORANGE FOR EMPHASIS]

What, really? That is a lot of muscle!

Yes, and muscles give us energy. This is what I believe happens: After patients have surgery,

family members who love them and naturally worry about them start to do everything for


them. Then, the patients sit on the couch and their muscles start to decrease in size. We call

that muscle atrophy. Patients who just sit all the time get skinny and then don’t have any

energy. This is not the best way to try and get better.

And I thought I could go home and sit on the couch and get waited on for a change!

Well, you could do that, but you really should get up and move around so you won’t lose that

muscle mass. Anyway, let’s go back to the guy reaching overhead.

Let’s say you ask your wife to get a glass from the kitchen cabinet and bring you some water.

Your wife should say, “Please go get it yourself, but remember to keep your move in the

tube.”

[TEACHER REACHES OVERHEAD OUT OF THE TUBE]

Is this in the tube or out of the tube?

Out.

Here is how to keep your move in the tube while getting a glass out of the kitchen cabinet. It

helps to think of yourself as a T. rex dinosaur for a while.

[TEACHER DOES T. REX DINOSAUR MOTION AND WALKS OVER TO IMAGINARY CABINET AND

REACHES UP IN THE TUBE]

I get what you are saying. So, how long do I have to be in the tube?

I will not limit the amount of weight you can lift or tell you how long you must stay in the

tube. Your body is different from everyone else’s, and you will know when it is time to get

out of the tube.

Let’s keep looking at these examples on the Keep Your Move in the Tube handout. Do you

remember how much force I said it takes to open the door over there?

14 pounds.

Right. You were listening—great job. So when you get discharged from here, are you going to

stand in your room since opening the door takes more than 5 pounds, or are you going to

keep your move in the tube and open the door?

I am opening the door. I’m ready to leave this this hospital and go home!

[TEACHER DEMONSTRATES OPENING DOOR USING HIPS, KEEPING MOVE IN THE TUBE]

That makes complete sense. I can do this tube stuff!


Now, if you take a look at the guy lifting the box, obviously you can lift things as long as you

lift them in the tube.

My grandchild weighs 35 pounds. Are you telling me I can lift my grandchild?

Yes, I am telling you that would be ok. My only concern is that small children sometimes

wiggle around a lot, and they could hit you in the incision site. But the weight of the child is

not a problem. Remember that I told you a sneeze put 90 pounds of force on the sternum?

Well, we believe that people will self‐pace after this surgery, and I don’t think anyone would

try and lift a 90‐pound sack of fertilizer, for example, even in the tube. Your pain level will

keep you from doing anything extreme.

Oh gosh, I just realized my mother reached out of the tube the other day to get a tissue. Do you

think her wires popped open?

That is a great question. I am not trying to make you walk around with your arms in the tube

all the time in fear. Actually, my arm weighs 6 pounds, and I have a co‐worker whose arm

weighs 10 pounds. It is completely safe to reach out of the tube right now.

When you are lifting things, it is wise to lift in the tube. But we have to use logic and think

about a tissue weighing almost nothing. I think your mom is just fine. Since our arms don’t

weigh that much, you can move out of the tube immediately following the surgery to perform

activities like toilet hygiene, washing your hair, and even scratching your back.

Let’s look at the last picture on the Keep Your Move in the Tube handout. Do any of you have

a big, comfortable chair at home?

I do, and I can’t wait to sit there and watch football!

Well, sometimes people put their arms back to push up when they try to stand up.

[TEACHER DEMONSTRATES ARMS BACKING OUT OF TUBE WHEN GETTING OUT OF A CHAIR]

Are my arms in the tube or out of the tube?

Out.

Right. So it is fine to sit in the big chair, but when you try to get up, move your hands up by

your hips so you can push up out of the chair and stay in the tube.

Are there any more questions about the Keep Your Move in the Tube handout?

No, it is really easy to understand.


Your job is to practice moving around in your hospital room and keeping your move in the

tube. At some point, a clinician will come by your room and observe your movement. If you

demonstrate that you can move around, then they will likely discharge you home instead of

to an inpatient rehabilitation center.

You mean I might have to go to another hospital?

If you can show the clinician that you can get up and move around, you will more than likely

be discharged to your home.

Then, when you get home, look around to see if there are any activities that you need to

modify so you can be active while you keep your move in the tube.

Are there any more questions?

No, but I want to thank you for this. I have been so worried about my husband. You see, we have

a workshop behind our house. He cuts wood with a hand saw and hammers nails there, and I

know he is going to go back there as soon as he gets out of here. I can’t stop him, but I am so

worried he is going to hurt himself.

[HUSBAND SHEEPISHLY SMILES AND NODS, INDICATING THAT HE PLANS TO GO BACK TO HIS

WORKSHOP AS SOON AS POSSIBLE]

It seems that you are really worried and he is ready to go. I hope that you will work together

to find ways for him to be active while still promising to keep his move in the tube. Does

anyone else have a question?

I do. Is it ok if I walk my dog?

What kind of dog do you have?

A Labrador retriever.

This is a tricky question, and I am glad you asked it. If you think about holding a dog’s leash, it

may seem easy to keep your arm in the tube. However, if you have a dog that may suddenly

chase a rabbit or squirrel and pull your arm out of the tube, you might want to let someone

else hold the leash when you go on the walk. It is important to think ahead about what might

unexpectedly pull your arm out of the tube during an activity. Another example would be

riding a bicycle. You could easily stay in the tube while holding the handlebars, but if you

were to fall off of your bike, you might instinctively hold your arms outside the tube to break

your fall. So you need to think logically about what may or may not happen and make good

decisions.


I love to golf. Is it ok for me to play? My wife says I shouldn’t.

Well, I have always wondered why we tell people not to golf. I even asked a surgeon why,

because if you think about it, the whole golfing motion is in the tube.

[TEACHER DEMONSTRATES GOLF MOTION]

But to be fair to the spouses and family members here, I believe they are going to want to

pamper you and take care of you. At the same time, you have a responsibility to not worry

them, so it is a give‐and‐take situation that requires working together to establish trust.

Maybe you could agree to go putt first and promise to keep your move in the tube. Then,

after you putt a few days, you could tell your wife that are going to take a few easy swings,

but still keep your move in the tube. She will be happy to hear the updates and will be less

likely to worry. Personally, I can’t think of a better place to recover from surgery than out on

a beautiful golf course with your friends.

The best way for each family to work out these situations is to identify activities around the

house that are out of the tube and find ways to modify them and keep them in the tube.

Before I go, can you think of any activities like that around your house that you have

questions about?

Oh, yes. I know for certain that my husband is going to want to mow the grass as soon as we

pull into the driveway.

What kind of mower do you have?

A gas‐powered push mower.

Ok, this is a great example of how you could work together to resolve this issue. Instead of

telling him “you can’t mow,” say “let’s figure this out together.” First of all, the patient will

know when he or she feels like mowing. So, when that time comes, let’s think about this.

[TEACHER DEMONSTRATES MOWING MOTION]

To me, mowing is mostly in the tube, unless you are pulling the mower back in some tall

grass.

[TEACHER PULLS ARMS BACK IN DUMBBELL ROW MOTION TO SHOW THAT IT IS OUT OF THE

TUBE]

Do you see what I mean?

Yes—you are saying he could mow if he promises to stay in the tube.


You are correct, but there is one more thing about mowing we haven’t discussed.

Oh, right (wife has lightbulb moment). I didn’t think of it until just now, but pulling the cord to

start the mower is way out of the tube.

Exactly. So does that mean he can’t mow since he can’t start the mower?

No, I will start the mower for him!

[HUSBAND SMILES, WIFE LOOKS LESS ANXIOUS]

That was a great job of problem solving. Teaching this class has been the best part of my day.

I hope all of you recover quickly, and I really hope your experience here has been a great one.

We want you to be ok.

Thank you so much. You have been so helpful. We had so many worries and questions.

Thank you, and take care.

Summary of Primary Points

Point LogicPatients are encouraged to pursue active living following sternotomy.

Immobility for more than 3 consecutive days can result in muscular atrophy equaling the size of an orange per day.

Immediately after surgery, patients can reach “out of the tube” with their arms when performing non–load‐bearing activities (e.g., toilet hygiene, washing their hair, and scratching their back).

A typical arm weighs between 6 and 10 pounds. The cough and sneeze research studies reflected means of 60 and 90 pounds, respectively, and patients often endure both coughs and sneezes following the surgery.

There is no time requirement for staying “in the tube.” Patients should let pain be their guide when they attempt load‐bearing activities “out of the tube.”

Standard time limits should not be given because of the many variables that influence individual rates of sternal healing (e.g., age, osteoporosis, diabetes, obesity, and tobacco use).

Any load‐bearing activity can be performed as long as the patient can modify it to be performed “in the tube.”

Load limits are irrelevant when lifting “in the tube” because, according to kinesiology principles, such movements will not affect the sternum.


Keep Your Move in the Tube handout:


Sternotomy illustration for explaining the Keep Your Move in the Tube concept:

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