This set of chest rehabilitation guidelines has been created in response to a futile attempt by a triple bypass (CABG - Coronary Artery Bypass Graft) surgery patient ("Bill") to get help with what to do to rehabilitate the chest muscles that were damaged during entry into the chest cavity (thorax). He got no significant advice from his surgical team - mainly an admonition against using exercise machines, as would be found in athletic or health clubs. It was feared that the exercise machines might exert too much stress on the bones and muscles of the chest, and incur additional damage.

After being confronted by this problem , I ("I" is a Certified Personal Trainer, but with no involvement in the execution of these exercise guidelines. Anyone who chooses to use any of this information is free to use his/her own Personal Trainer or Physical Therapist, or proceed on their own.) looked for, and was also unable to find an existing plan to handle the problem; so we decided to collaborate to build one. It rapidly became apparent that other people confront this same issue, and might be helped by this plan (Set of guidelines, actually - in no way should this be construed as a medically approved plan.). So the focus of our efforts switched from "Bill" to "Everyman." It is important to note; however, that Bill's coronary artery problem was found and corrected before he suffered the trauma of a heart attack, or any other related problems. Therefore, cardiovascular or cardiopulmonary problems are ignored in our plan. Others who have had thoracic surgery, for whatever reason, may find this information useful, but must consult their own physician before adopting any of it.

Post thoracic surgery chest rehabilitation actually begins in a hospital, and is continued after discharge. The initial activity, herein called the Pre-Exercise Phase, is dedicated primarily to stretching, with a goal of recapturing a full range-of-motion (ROM), which may be the most important task faced by the patient. But, under no circumstances should ROM be forced, and understand that this is a long-range goal. Regaining strength follows the flexibility goal. Toward achieving these ends, three stages are defined:

1. Pre-Exercise Phase

2. Initial Post-Release Phase

3. Final Rehabilitation Phase

This section, basically stretches that can be done (very carefully and gently) as your healing process starts, really begins in the hospital; it may vary somewhat from place-to-place, but here is a sample program - the one given to Bill:

• Do a set of deep breathing - in through the nose, out through the mouth. Note that this exercise may well be the most important of this phase. It will help you to get rid of the shallow breathing habit that you may have picked up because of the chest pain associated with breathing after being "cut open."

• From a seated position, straighten each leg five times.

• Do heel raise/toe raise combination - raise up on your toes five times, then pull your toes toward your shins five times.

• Lift your knees (leg bent) five times each. [Do five repetitions of each exercise in this group.]

• Shrug your shoulders.

• Rotate your head 180 degrees (side-front-side) - do not roll your neck backward because of potential spinal damage.

• Holding one foot slightly off the floor and rotate it at the ankle. Repeat on the other side.

• In a seated position, raise your arms to chest level.

• With elbows out, hands on shoulders; rotate the arms in a circular motion.

• Now you are ready to do some walking.

This next set of exercises are for when you are released from the hospital, and may be added to, or replace, the in-hospital group. The exercises shown are not the only, or maybe even the best, but they were designed by, and successfully used by, "Bill;" who was unable to get significant help from other sources - not an uncommon problem after surgery and hospital release. Chest surgery often requires cutting of the pectoral muscles, and ribs or sternum, which results in significant loss of strength. Usually the patient is left on his own to take care of that problem, and that is what these Guidelines are all about. Some fortunate souls manage to avoid much of the damage due to a relatively new technique called "keyhole" surgery, and it is just what it sounds like. Only a small hole is made, and the actual surgery is done much like arthroscopic knee surgery with very little external damage. But, being new, it isn't commonly available.

III. - INITIAL POST-RELEASE EXERCISES

1. Lift arms (laterally) overhead and touch hands - basically provides chest expansion.

2. With your arms extended out to the sides, at chest level; move your arms until your hands touch in front of your chest; now move them back to the initial position.

3. Leg stretches - For the inner and outer thighs, stand with feet outside of shoulder width, then lean, from the hips, to one side with your trunk still vertical. Pause, then slowly shift to the other side. For the calves, step forward with one leg, while keeping the foot of the back leg flat on the floor. Bend the knee of the forward leg. Repeat for both legs. For the hamstrings, again step forward with one foot and keep the knee straight and with your toes up off of the floor. Bend the knee of your back foot, and bend forward from your hips. Keep the bent knee over your ankle, your neck in line with your spine, and a flat back. An alternative hamstring stretch is to put one heel on a "step," while keeping the knee of that leg straight. Whatever you use, the point in to put your foot on something that will keep it above floor level - not too high (a few inches are enough). Then lean forward from the hips, while keeping your back "flat;" i.e., don't hump it, and your knee extended.

4. Starting with arms extended overhead, bend to the right, then to the left - good side stretch.

5. Holding arms at shoulder height, press hands together for one or two seconds and release - this is an isometric exercise to contract the pectoral muscles - the elbows should be bent, and be very cautious about this exercise.

6. Lock fingers and pull for a few seconds, repeating 10 times.

7. Add some aerobic activity to the previous stretches/exercises. It may be walking, exercise bike, treadmill, etc.

IV. - FINAL REHABILITATION EXERCISES

IV (A). - AEROBIC TRAINING

This exercise mode isn't specifically for chest rehabilitation, but more for conditioning/reconditioning the entire body (especially the cardiovascular aspect) after the time (typically several weeks, I'd guess) just after chest surgery, regardless of the reason.

During this time of relative inactivity, the body will be deconditioned - a special problem for those who weren't in very good condition to start with. Walking is probably almost a universally accepted prescription during the initial recovery phase.

IV (B). - FLEXIBILITY TRAINING

It is important to work on maintaining or improving one's range-of-motion (ROM). There are a number of stretches designed to specifically work on the flexibility of the chest muscles (mainly the pectorals). Here are three:

1. Place your hands behind your head with your elbows pointed out to the sides. Move your elbows backward, and feel the pectorals stretch. You can use an assistant for this exercise - to gently pull back on your elbows.

2. In a corner or doorway (I prefer the doorway), extend your arms with one hand on each wall (or each side of a doorway), just above shoulder level; now lean forward from your ankles (let your elbows bend), and, again, you will feel a significant stretch of the pectoral muscles - the entire rib cage, actually.

3. This is just a slight variation of the previous stretch, and you can choose one or the other. Again, in a corner or doorway, position yourself so that your forearms are resting against the walls in a corner, or on the door frame; then lean forward as in the previous stretch.

IV (C). - STRENGTH TRAINING

Note that this exercise phase will typically not start until 30 days post-op, when the surgeon will release the patient. Also note that the length of time may vary from doctor-to-doctor, or patient-to-patient.

This category of exercises includes both calisthenics (body weight only), and resistance training (dumbbells (DBs), bands, etc.). My feeling is that this exercise phase should not be entered until full healing has taken place. The exercises that follow are more-or-less standard chest exercises, but obviously should be done very much in control (i.e., slow), and without trying to force out reps or ROM. Clearly, you may not progress beyond the first exercise (Wall Push-ups) for a long time; and never do you need to do them all in one session. The point is to give a selection, from which you may choose.

Please note that the figures depicting the following exercises do not always match the verbal descriptions - go by the descriptions.

Wall Push-up

Stand facing a wall, with your feet 18 inches, or more away - the farther back, the higher the intensity, obviously. Now place your hands on the wall just outside of shoulder width. Your elbows should be pointed out to the sides - arms should be parallel to the floor (see Figure 1a).

Figure 1a

Now lean toward the wall, from your ankles, by bending your elbows. How far you lean depends on you alone - how far you can go, depending on current healing and strength/flexibility. Lean forward, pause, then straighten your elbows to return to the initial position. That's one. Note that the simple push-up can be used effectively during and after recovery. As you get stronger, transition to doing floor push-ups (see Figure A-1b) - first on your hands and knees (so-called women's push-ups), and then hands and toes.

Figure 1b

Bench Press

On your back on a bench (see Figure 2), the floor, a pillow, lounge chair, recliner - whatever - and holding DBs (forearms are extended vertically and just outside of shoulder width), lower the weights (your elbows are pointed out to the sides) to about chest level (if you can - initially, your ROM might be only an inch or two). Pause, then push the weights up again. That's one, continue for as many reps as you like.

Figure 2

Flye (lying)

In a lying position (as above), start with your arms extended vertically above your chest, with a DB in each hand, and using a "neutral" grip - that is: palms facing each other. Now lower the DBs directly out to the sides from shoulder level, with elbows slightly bent. The DBs move in an arcing motion, and shouldn't go below chest level (bench level after complete rehabilitation). Pause, then return to the up position. You are now positioned for the second rep. (See Figure 3.)

Figure 3

Pullovers (either straight or bent arm)

This exercise involves both back and chest muscles, and gives a good stretch to the pectoral muscles and the rib cage (and the intercostal muscles). Start from a supine position on a bench (see Figure 4), with your head at one end of the bench, and your arms extended above your chest (you may be holding either one or two DBs, or a barbell if you happen to have one). Keeping your elbows straight (not locked, but slightly flexed - or "soft"), move the weight back and down as far as you can without bending your elbows (this is another arcing movement). Pause, then return to the initial position.

Figure 4

An alternative is to lay perpendicular to the bench, with your shoulders supported. The action is the same as above, except that you use bent elbows and can get a wider ROM, hence a fuller chest stretch. But note that there are some who consider this version of the pullover to have too much potential for injury - too much stretch - in order for them to recommend it.

Shoulder Press

I prefer to have this exercise (see Figure 5) done in a seated position, preferably with a backrest. With elbows pointed out, forearms vertical, hands grasping DBs with palms facing forward (as if you were holding a bar), and with hands at shoulder height, or slightly higher; press the DBs straight up past your ears to near full extension (elbows should stay soft, not locked. Pause, then lower to the initial position. That's one. Face forward throughout this exercise (keep-your-neck- in-line-with-your-spine, for this, and all exercises). This shoulder exercise also involves the pectoral muscles of the chest.

Figure 5

Dips (forward leaning)

For this triceps exercise (see Figure 6), to maximally involve the pectoral muscles: with your back to a chair or bench, grip the edge of the whatever, and sit down (with a slight forward lean) until your upper arms are roughly parallel to the floor. Your only supported body parts at this time are your hands and feet. When first beginning this exercise, keep your knees bent about 90 degrees. As you get stronger, you can move your feet out farther to increase exercise intensity. Oh, I almost forgot, you are still "sitting" with your butt by the floor, and your muscles screaming. Just straighten your arms to raise your body - maintain your forward lean, and you can help with your legs until you progress to where your legs are fully extended.

Figure 6

Initially, doing any of the recommended strengthening exercises should involve NO use of weights. I recommend building up to 15 repetitions, and a nearly normal ROM before starting to use weights to increase intensity. After transitioning to weights (DBs or tubes/bands) be sure to keep all movements slow and controlled, and work through as full a ROM as you can - if it is still less than normal, continue trying to increase it; but be patient - don't try to force it.

A related issue is that it is recommended that opposing muscle groups be exercised, and; therefore, the back (specifically the muscles of the upper and middle back - trapezius, rhomboids, rear deltoids, and latisimus dorsi should be trained as well as the chest. I think that back training should be incorporated into your plan once you are well into the weight training phase. It is important to maintain relative equality between chest and back muscles.

BACK EXERCISES

1) Shoulder Shrug

Standing, and holding DBs with arms hanging along your sides (see Figure 7); move your shoulders straight up toward your ears, pause, then lower them slightly below normal. This movement is like the universal "I don't know," with a shrug. Both the up and down movements should be well controlled (i.e., slow). This exercise targets the trapezius and rhomboid muscles of the upper back; as well as the levator scapulae, which connects between the base of the skull and the shoulder blades.

Figure 7

2) Upright Row

In a standing position, with hands hanging in front of your thighs, and holding DBs (see Figure 8); pull the DBs up under your chin, with you elbows as high as you can get them. The pull should be very close to your body, and your elbows should move up and back to really concentrate on the back. The wider your hands are, the more the rear deltoid muscles are involved (part of the shoulder "cap"), in addition to rhomboids and trapezius muscles.

Figure 8

3) 1-Arm Row

This exercise strongly works the latisimus dorsi - the major middle back muscle. Stand next to a bench facing parallel to its long axis. Now put your inside knee on the bench, and the inside hand , as well (for support). Your back should be flat - stick your butt back , and maintain the slight inward arch in the lower back. With your outside hand (arm fully extended) holding a DB, pull it up and move your elbow as high as you can, but without rolling your back. The overall movement can be characterized as "sawing a log." As you lower the weight, you also slide it slightly forward, and as you pull it up, you slide it slightly backward. This motion lets you move through a full ROM. And the higher your elbow moves above the level of your back, the more effective the exercise. (See Figure 9.)

Figure 9

There are several "cautions" that should be observed for exercise in general.

1. CRACKING or POPPING sounds - if you hear them, stop immediately; you might have just reinjured your sternum.

2. PAIN - If you feel any, quit immediately.

3. Work toward full ROM.

4. Don't neglect your BACK exercises.

5. BREATHE

6. Use only SLOW AND CONTROLLED movements

7. Consult a DOCTOR about your exercise plan.

8. Keep your NECK IN-LINE-WITH-YOUR-SPINE.

9. Maintain a FLAT BACK. That is, the position it should be in when you are standing. When you are bent forward from the hips, there should be no hump in your back. Stick your butt out (back) as if you were going to sit down; and maintain the small inner curve in the lower back (lumbar spine). Note: if you don't have one (small inner curve, that is) you don't have to maintain it, but stick your butt out anyway.

V. - LIFESTYLE CHANGES

V (A). - Reduce Risk Factors - Excessive body fat, smoking, and excessive use of alcohol are huge factors that work toward putting us in an early grave, or at least degrading whatever time that we have been allotted. Even things like family history of early heart attacks can, at the least, be mitigated.

V (B). - Exercise - The first goal is to repair your body, but don't stop there. Think about what led you to surgery in the first place, and keep firmly in mind that you don't want to return to that state. Exercise can be a key to a healthy life. Exercise is as close as we have to the "magic pill." It will keep you stronger for daily living; it reportedly can improve your immune system; it is a powerful component of weight control; it slows the aging process; it can improve your appearance; it helps reduce stress; and more. Make exercise an important part of the rest of your life. It might well have helped you avoid the condition that required surgery in the first place, and will help your recovery from, or avoidance of, the next one. And, I hesitate to mention this, but exercise doesn't have to be aerobics classes and visits to a gym. It can be gardening, dancing, playing with the kids - just get more active; but formal exercise is obviously more effective.

V (C). - Nutrition - Now that you are starting on a healthier path - giving up bad health habits, and starting to exercise; it is important that your new lifestyle includes healthy eating. This doesn't mean a complete and radical change, but a transition away from the unhealthy and to the healthy - in steps. And you don't have to totally give up anything (e.g., if you eat pizza once a week, change to once a month.

Some nutrition issues are:

• How often?

• What, and in what proportions?

• Fat?

• Water?

1. Your energy level will drop, and your brain may take a "nap" during the day.

2. Eating a big meal just before your activity level fall off, seems to promote fat storage; as your metabolism slows down to maintenance mode.

3. The "lump" in your stomach isn't likely to promote a good night's sleep.

Fiber, not technically a nutrient, is normally included in the carbohydrate section.

A mix of roughly 60% carbohydrates, 20% protein, and 20% fat was once recommended as healthy. But this has become a complicated issue with no correct answer. Pritikin (remember him?) pushed for 75%, or more, carbohydrates; and only 5% fat. Others now advocate a 40%-30%-30% diet. There is currently a lot of controversy about this issue, but, until the smoke clears, I recommend 65-20-15 as a starting point.

What about Fat?  Fat is at the center of a current nutrition controversy (one of them). "Cut the fat" has been hammered into the U.S. public for quite some time now. Why? Because we are getting fatter and fatter as a population. And fat is over twice as calorie-dense as the other substrates, there is little calorie-cost to storing it, and it is less metabolically active than other forms of tissue; not to mention its artery-clogging feature. So, fat is an easy target as the culprit - and that is partly true; but, in our exuberance to "cut the fat, " there has been a shift to low-/non-fat substitutes, but those products have largely been beefed-up, calorie-wise, by sugar and other sweeteners. Since it is calories, and not their source, that cause excessive fat gain, we just keep on getting fatter and fatter.

And, at the same time, many people are forgetting that there is something called "essential" fat (omega-3 and omega-6 ). We need it to survive. But this is unsaturated fat, found in cold water fish and some vegetables (most vegetable oils are a good source - but go easy on the oil), and nuts and seeds. We still need to cut calories and saturated fat.

A related, and controversial, issue is cholesterol - nothing more than a type of fat derived from animal sources. A safe bottom line seems to be to limit fats, particularly saturated fat; but "limit" does not mean "eliminate."

At the very least, eat a lot of fruits and vegetables, and drink lots of water - all fluids count, but water is best. NOTE: The information provided about water intake may be contravened by your physician. At least in cases of cardiac surgery, a drug called Lasix is normally prescribed - it reduces the swelling caused by the surgical trauma, and additional water intake can counteract the Lasix - not a desirable occurrence. Talk to your doctor about this.

You want me to drink lots of what?  Yes, water. This has to be the most important nutrient for us humans. Think about it. People have gone on hunger strikes for over a month, and survived; but go beyond about three days without water and you're dead. Our bodies are about 60% water, and muscles are even more at 65 - 75% water. The body has a number of important uses for this nutrient - one is its involvement in all metabolic activities; like burning fuel, including fat. Being even a little dehydrated can adversely affect your body's ability to function properly - including during (especially during) exercise. Dehydration, among other things, decreases your oxygen supply, and concomitantly, your ability to generate energy. Additionally, water helps transport waste products through and out of the body, carries oxygen (water is the major component of blood), helps regulate body temperature, lubricates joints, and more.

So drink plenty of water daily - we lose it constantly through urine, sweat, and stools. We should drink six to ten cups of water a day, or about two liters. But it doesn't all have to be water - juices, milk, tea - all liquid intake, some of which can even be in food (like fruit and vegetables) counts. Remember that caffeinated and alcoholic beverages are diuretics, so, if you use them, do so in moderation, or add to your water intake as compensation. Remember the urine test: yellow means drink.

As long as the subject of fruit and vegetables has come up, let's mention free-radicals and antioxidants. Cell-damaging free-radicals are produced in the body by pollutants (including our ever-favorite cigarette smoke); and even exercise (metabolism actually), mainly outdoors, and only for a short time. Thus the need for antioxidant nutrients to neutralize them. The main antioxidants are vitamins E and C, and beta carotene - although it has kind of lost its luster. Studies have cast a shadow over beta carotene (at least in supplement form). Since it isn't known for sure if beta carotene, or something else in foods containing beta carotene, eating those foods is recommended. Back to fruits and vegetables - they are the best sources of antioxidants, as well as many other vitamins and minerals (and other good stuff), so include them in your meals daily - spinach, broccoli (green leafy vegetables in general), carrots, cantaloupe, citrus, sweet potatoes, vegetable oils, etc. There are some "experts" who recommend antioxidant supplements, but the preponderance of opinion seems to support eating a varied diet instead; i.e., anti-oxidant supplements are unnecessary.

V (D). - Psychological Considerations - Psychological factors that are important in recovery from chest surgery are really of two types. First we have to deal with the depression and possible other emotional events that are tied directly to the medical problems and, more importantly, to the medications often given after surgery. It is important to remember that most of our emotions following major surgery are only temporary and can be related to our medical problems. Talk about what you are experiencing with someone you trust. If you do not have a family support group, call someone in the doctor's office or one of the recovery support groups like "Mended Hearts". In some cases an anti-depressant or anti-anxiety medication may be needed; but in most cases, simply talking it out, getting support and understanding, and realizing that "this too shall pass," will give adequate relief.

The second set of psychological issues are more difficult. These are the psychological bad habits that contributed to the heart problems to start with. First, it is critical to learn some form of meditation or relaxation exercise to lower our blood pressure and reduce the stressors that got us into trouble in the first place. You can see a professional or simply read one of the very good self help books (e.g., The Relaxation Response). Remember though that it takes daily practice to change our response to stress. It does no good just to listen to a relaxation tape or read a book. You must practice every day until you are able to call upon the relaxation response whenever you need it.

Finally, we must learn to look at our world differently. The best advice I (Bill) ever heard was in the form of the Serenity Prayer: