|Year : 2015 | Volume
| Issue : 1 | Page : 34-39
Occurrence of shoulder disorders among postcoronary artery bypass surgery patients in India
Shifa Manhal1, Mohamed Sherif Sirajudeen1, Padmakumar Somasekharan Pillai1, Harish R Nair2, Jayashankar Marla3
1 Physiotherapy College, Yenepoya University, Mangalore, Karnataka, India
2 Department of Cardiac Surgery, Yenepoya Specialty Hospital, Mangalore, Karnataka, India
3 Department of Cardiac Surgery, A.J. Hospital and Research Centre, Mangalore, Karnataka, India
|Date of Web Publication||13-Apr-2015|
Dr. Mohamed Sherif Sirajudeen
Yenepoya Physiotherapy College, Yenepoya University, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The range of motion and function of the shoulder girdle and upper back are believed to be impaired following coronary artery bypass graft surgery (CABG) through median sternotomy. Until date, there is no study published in India, which determines the occurrence of shoulder disorders in CABG patients. Objective: To determine the occurrence of shoulder disorders among post-CABG patients and to explore the associated factors. Materials and Methods: In this cross-sectional survey, 45 postoperative CABG patients were recruited. Details regarding demographic data, operative data, pre-and post-operative physiotherapy management and the occurrence of shoulder disorders were collected by face-to-face interview method using a questionnaire specifically designed for this study. Results: The occurrence of shoulder disorders among post-CABG patients was 36%. Predominance of shoulder disorders was found at the time point 3-4 months after CABG. No significant association was found between age, gender and performance of upper limb exercises and the occurrence of shoulder disorders. Conclusion: Given the high occurrence of shoulder disorder, it is crucial that rehabilitation professionals take essential steps to assess and treat these complications in the immediate postoperative period and continue the same following discharge from the hospital. The paper concludes by calling for further research to explore and develop a more directed prophylactic exercise regimen for the musculoskeletal complications following CABG.
Keywords: Cardiac rehabilitation, coronary artery bypass graft surgery, coronary artery disease, shoulder disorders
|How to cite this article:|
Manhal S, Sirajudeen MS, Pillai PS, Nair HR, Marla J. Occurrence of shoulder disorders among postcoronary artery bypass surgery patients in India. Arch Med Health Sci 2015;3:34-9
|How to cite this URL:|
Manhal S, Sirajudeen MS, Pillai PS, Nair HR, Marla J. Occurrence of shoulder disorders among postcoronary artery bypass surgery patients in India. Arch Med Health Sci [serial online] 2015 [cited 2019 Jun 25];3:34-9. Available from: http://www.amhsjournal.org/text.asp?2015/3/1/34/154941
| Introduction|| |
The World Health Organization has reported coronary artery disease (CAD) the major cause of death in the developing countries. It accounts for about 13.7% of the total number of deaths (5.27 million deaths).  The current burden of CAD in India stands >32 million patients.  The leading cause behind this is the rapid and unplanned urbanization taking place among traditional societies, which has led to lifestyle characterized by reduction in physical activity, smoking, and unhealthy nutrition. This unhealthy lifestyle is associated with risk factors for chronic diseases such as hypertension, diabetes mellitus, dyslipidemia, and obesity, which is in turn major risk factors of CAD.  India has seen a big leap in the fields of interventional cardiology and cardiac surgery in recent times. Coronary artery bypass graft surgery (CABG) was first performed in India in 1975 about 13 years after its advent in 1962. Presently, the annual number of CABG surgeries carried out in India stands at 60,000. Due to the absence of a central registry, the exact numbers are not apparent. 
The development of neurological and musculoskeletal problems following CABG surgery through median sternotomy incision can be attributed to the procedures followed during a bypass graft surgery. , Study performed in Adelaide by Stiller et al. demonstrated 30% of post-CABG patients developed shoulder complication that interfered with their level of comfort and function.  Furthermore, Roy et al. were successful in establishing an association between internal mammary artery (IMA) harvest and musculoskeletal complaints and/or neurological dysfunction. In his study, 39% of patients with IMA graft (IMAG) had musculoskeletal complaints and/or neurological dysfunction, compared with 17% of patients with saphenous vein graft (SVG).  A study performed by El-Ansary et al. states the predominant areas in the body that go for musculoskeletal dysfunction post-CABG are anterior chest wall, cervical spine, thoracic spine, lumbar spine, and shoulder.  Seven prospective studies have documented upper limb neurological complications post-CABG with incidence ranging from 1.9% to 18.3%, respectively. ,,,,,,
The range of motion (ROM) and function of the shoulder girdle and upper back are believed to be impaired following CABG through median sternotomy, due to the effect of sternal retraction on the joints and soft tissues of the thorax. Consequently, this makes the patient vulnerable to develop musculoskeletal and neurological complications.  When the shoulder girdle and upper back do not receive ROM exercises, it leads to development of adhesions, which in turn leads to shortening and weakening of muscles.  A delay in performing upper extremity ROM exercises may result in more discomfort for the CABG surgery patient during the recovery period, and the time required to achieve full recovery may be longer.  Looking at the broader spectrum these musculoskeletal problems may also affect the quality of life of the cardiac patients making him/her feel less capable.
Despite the high percentage of musculoskeletal dysfunction in post-CABG patients the number of studies performed in this field are very limited.  With the growing number of CAD patients in India, there is a proportional growth in the number of patients going for CABG. There is literature on the number of centers in India performing CABG, but there is a dearth in literature about the postoperative physiotherapy management provided to these patients as well as the number of centers providing cardiac rehabilitation to postoperative CABG patients.
To the best of our knowledge, there is no study published in India, which determines the prevalence of shoulder dysfunction in CABG patients. With the increasing number of CABG subjects and also lack of literature about postoperative physiotherapy management to these patients, there is sufficient reason to believe there is a growing population of postoperative CABG patients with shoulder dysfunction.
Therefore, this study was conducted with the primary objective to determine the prevalence of shoulder dysfunction among postoperative CABG patients and to evaluate the relationship between selected factors and the prevalence of shoulder dysfunction.
| Materials and Methods|| |
A cross-sectional, descriptive study was carried out to evaluate the prevalence of shoulder dysfunction among postoperative CABG patients and also to determine any association between selected factors and the prevalence of shoulder dysfunction. The study design was a questionnaire survey. Forty-five postoperative CABG patients were recruited from two hospitals-based in Mangalore, Karnataka namely Yenepoya Specialty Hospital and A.J. Hospital and Research Center. The study was carried out in the cardiology out patient's department (OPD) of the respective hospital. The objectives and methods of the study were clearly explained to the participants after which the participant was asked to sign an informed consent. Study protocol was reviewed and approved by the Yenepoya University Ethics Committee Board and A.J. Ethics Committee.
Subjects were included in the study if they had undergone CABG via median sternotomy with a minimum postoperative period of 45 days and maximum 6 months, fluent in speaking and understanding English.
This research required drafting of a questionnaire for use with post-CABG patients. Questionnaires and information from various sources were reviewed and the draft questionnaire items were created. ,,,, The draft questionnaire composed of 26 items (19 closed ended and 7 open ended) related to demographic data, surgery details, physiotherapy management, and prevalence of shoulder dysfunction. A focus group was held to evaluate the content validity of the draft questionnaire. The objective of the focus group was to reach the consensus on overall comprehensiveness of the questionnaire.
A total of 45 subjects satisfying the selection criteria were recruited for the study. After obtaining an informed consent, data were collected by face-to-face interview method using the questionnaire and was tabulated in Microsoft Excel Sheet.
Descriptive statistics was produced for demographic data, operative data, pre-and post-operative physiotherapy management and the prevalence of shoulder dysfunction. The prevalence of shoulder dysfunction was calculated by taking the number of subjects with shoulder problems and dividing it by the total number of subjects interviewed.
The association between selected factors and the prevalence of shoulder dysfunctions was analyzed using Chi-square test. 5% level of probability was used to evaluate statistical significance.
| Results|| |
During the course of 5 months (October 2012 to February 2013), a total of 76 patients underwent CABG at both hospitals. Of the 76 postoperative CABG patients, 5 patients were not reachable and 26 patients were excluded due to language barrier. Hence, a total of 45 patients were recruited for this study. Patients were contacted, if they met the inclusion criteria an appointment was fixed and the patient was interviewed at the cardiology OPD of the respective hospital. Demographic and operative data of 45 subjects are presented in [Table 1].
Larger number of participants (49%) belonged to the 50-59 years age group followed closely by 38% of participants in the 60-69 years age group. Most of the participants were men (84%) and 16% were women. Major risk factors were found to be diabetes mellitus (60%), sedentary lifestyle (60%) and hypertension (51%). Combined use of left IMA and SVG graft was found to be used more commonly in comparison to other grafts. Multivessel disease was another noteworthy finding among the participants. Pre-and post-operative physiotherapy management of patients presented in [Table 2].
About 82% of the participants reported they did not receive preoperative physiotherapy management. However, all patients reported they received postoperative physiotherapy. Variation was noted with regard to performance of upper limb exercises. About 60% of the participants reported they were instructed to perform upper limb exercises, the rest were not instructed. All participants reported receiving home advice. Commonly given home advice were walking, breathing exercise, upper limb movements, and lower limb movements. Breathing (100%) and aerobic exercise (100%) were the most common home advice given to the participants. 27% reported they did not follow the home advice. None of the participants attended cardiac rehabilitation program (CRP) postdischarge. Data regarding prevalence of shoulder dysfunction presented in [Table 3].
In this study, 16 out of 45 subjects reported shoulder dysfunctions following CABG. Hence, the prevalence of shoulder dysfunctions was found to be 36%. Pain, aching, and tingling were the commonly used terms to describe the symptoms. Most participants complained of shoulder dysfunction on the left side (56%), 25% of participants suffered with right side shoulder dysfunction and 19% complained of bilateral shoulder dysfunction. About 69% of participants suffered symptoms that lasted <24 h. Severity of symptoms ranged from mild to severe. Most participants (56%) reported severity of symptoms as moderate. About 88% of participants reported frequency of symptoms to be more than once in a week. Fifty percent of the participants reported that the shoulder dysfunction did not interfere with their activities of daily living. Nearly 31% of participants reported they consulted a physician for the shoulder dysfunction.
[Table 4] presents association between selected factors and shoulder dysfunction. The subjects with shoulder dysfunction were similar to subjects without shoulder dysfunction with regard to age (P = 0.12). The difference in proportion of shoulder dysfunctions among male and female subjects was not significant (P = 0.90). The subjects with shoulder dysfunction were similar to subjects without shoulder dysfunction with regard to performance of upper limb exercises (P = 0.31).
[Figure 1] represents the distribution of associated factors among subjects with and without shoulder disorders. Associated factors include diabetes mellitus, obesity, hypertension, sedentary lifestyle, and smoking. The most common associated factor among participants was found to be diabetes mellitus followed by sedentary lifestyle and hypertension.
|Figure 1: The distribution of risk factors among subjects with and without shoulder disorder|
Click here to view
About 19% of participants complained of shoulder dysfunction >45 days-2 months after surgery and another 31.25% of participants suffered symptoms 2-3 months after surgery. Most (44%) number of participants complained of symptoms 3-4 months after the surgery and 6% of participants reported shoulder dysfunction symptoms 4-5 months postsurgery.
| Discussion|| |
This study aimed to evaluate the prevalence of shoulder dysfunctions among postoperative CABG patients. The results of the study demonstrated 16 out of 45 subjects reported shoulder dysfunction following CABG. Hence, prevalence of shoulder dysfunction in this study was 36%. This result is similar to the rate reported in prior studies by Stiller et al., El-Ansary et al. and Roy et al. ,,
Use of sternal retractor, patient position during surgery, cannulation of the internal jugular vein and the relative devascularization of the sternum once its main blood supply has been harvested are the probable factors responsible for the development of musculoskeletal and neurological complications following CABG surgery through median sternotomy.
During a CABG surgery through median sternotomy irrespective of the graft used a retractor is placed on the sternum and opened to the desired extent to allow sufficient exposure of the heart and the surrounding vasculature. However, during an IMAG procedure a specially designed retractor (e.g., Rultract, Favalaro) is used to retract and evert the upper ribs asymmetrically at an angle varying between 20° and 70° from the horizontal plane until IMA is harvested. As we all know retraction and eversion of the upper ribs is a nonphysiological movement; hence, this fact alone may account for the higher incidence of anterior chest wall injury among post-CABG patients. 
This study investigated the association between age and gender with the prevalence of shoulder dysfunctions. The finding of the study indicates that the prevalence of shoulder dysfunctions is not associated with age or gender. Hence, our findings are in agreement with the findings of Stiller et al.'s study. 
The results of our study demonstrated that performance of upper limb exercises dose not reduce the risk of development of shoulder dysfunctions among CABG patients. This finding is in agreement with the finding of Stiller et al. in their study it was reported that upper limb exercise commencing in the postoperative period have no significant effect on the incidence of musculoskeletal problems 8-10 weeks postoperatively.  However, El-Ansary suggested that performance of gentle bilateral exercises of the upper limb and trunk may be necessary in the initial postoperative period (up to 6 weeks) to facilitate a return of preoperative ROM and reduce discomfort of the anterior chest. 
Study performed by Krishnaswami et al. demonstrated the peculiarities of CAD among the Indian population are young age at presentation, double and triple vessel disease, diffuse involvement, distal disease and significant left ventricular dysfunction at presentation. The higher number of participants in the 50-59 years age group and also the greater number of participants suffering with double and triple vessel disease found in this study is in agreement with the findings of Krishnaswami et al. 
Postoperative physiotherapy management was found to be practiced dutifully. However, with regard to preoperative physiotherapy management, 82% of the participants reported they did not receive any preoperative physiotherapy management. preoperative physiotherapy management for nonemergency cardiac patients was found to be provided routinely in surveys conducted in Australia, New Zealand and Sweden , During preoperative, physiotherapy management patients is educated regarding early mobilization, poststernotomy restrictions, risk of postoperative pulmonary complications, and techniques regarding getting in and out of bed/chair. These preoperative sessions help the patient cope better, while performing the exercises postoperatively and furthermore helps the patient recover faster.
We found that none of the patients attended CRP. This may be attributed to the lack of education regarding cardiac rehabilitation provided to the patient and also most importantly lack of cardiac rehabilitation center in the hospital. A number of studies among Indian population have published results in favor of cardiac rehabilitation.  In spite of such favorable results cardiac rehabilitation for post-CABG patients is still a distant cry in the Mangalore area. We recommend patients need to be made aware about these postoperative complications and the importance of performing exercises. The main limitation of this study is that the sample size is small and only shoulder joint was evaluated. Further study is needed to clarify the nature of musculoskeletal problems to establish if a more effective means of prevention or management can be developed.
| Conclusion|| |
Approximately, 36% of patients after CABG developed shoulder dysfunction. No significant association was found between age, gender, and performance of upper limb exercises with prevalence of shoulder dysfunctions. Given the high prevalence of shoulder dysfunction steps need to be taken to assess and treat these problems in the immediate postoperative period and continue the same following discharge from the hospital. Screening and evaluation of these postoperative problems may also be carried out, while the patient is attending CRP. A multidisciplinary approach must be maintained to ensure coordinated management of these problems.
| Acknowledgment|| |
We thank Dr.G.Arun Maiya and Dr.Kathy Stiller for useful comments; and Dr.P.P.Mudappa who helped in the recruitment of patients. Preliminary version of the study was presented at the 118th Congress of the German Society for Physical Medicine and Rehabilitation, 2013.
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[Table 1], [Table 2], [Table 3], [Table 4]