Teens with pectus excavatum (a condition that causes the sternum, or breastbone, to sink in) may have surgery to push the breastbone forward to improve lung and heart function. The Nuss bar procedure is a type of pectus excavatum repair surgery.
In order to prepare for and recover from a Nuss bar procedure, you and your teen will work with a team that includes many health-care professionals, including a physiotherapist.
Physiotherapy treatment before the procedure
The PT will meet with you before surgery to review the strategies mentioned below. Learning these strategies before surgery can better prepare you and your teen for their recovery after surgery.
Post-operative recommendations
After the procedure, you can expect that your teen will have some pain. Pain may make it harder for your teen to take deep breaths and resume day-to-day movements. Your teen will need to exercise to keep their lungs clear and well-expanded. This will help decrease post-operative respiratory problems.
After surgery, your teen will need to participate in exercises to help keep their lungs well expanded and free of mucus. These exercises include:
- deep breathing
- splinted coughing
- moving (e.g., sitting up, walking)
The health-care team will also support you in helping your teen to start moving. First, your teen will sit at the edge of the bed. Later, they will progress to taking short walks.
| Activity | How long and how often | Instructions |
|---|---|---|
|
Incentive spirometer to promote deep breathing. |
10 breaths every hour (while awake) for up to 1 week post discharge  |
Your teen will need to sit up tall and hold the incentive spirometer in an upright position. They will place the mouthpiece in their mouth, then close their lips tightly around the mouthpiece. Next, they should:
|
| Splinted cough | Every hour (while awake) after spirometer |
Cross arms across the chest while hugging a pillow. Take a deep breath and cough 2 or 3 times to clear any mucus while hugging a pillow to support the chest. |
| Moving around | Gradual increase. Once discharged home, try to gradually increase activity levels by ~10% per day with the end goal of spending ~80% of the day moving around. |
At first, your teen will need help to sit up in bed. Next, help your teen to get up and sit in a chair. Finally, encourage your teen to start walking around the room and ward with assistance (if needed). While admitted, aim for 3 walks/day. Once discharged, your teen should be mobilizing as per their per-operative baseline. |
Activity guidelines
After your teen’s surgery, it is safe and encouraged to resume activities of daily living (using and raising their arms to brush teeth, get dressed, comb hair, etc.) and gentle cardiovascular activity (walking, biking) guided by their tolerance level.
One week after surgery
For the first week after surgery, your teen should:
- Use the incentive spirometer every hour for deep breathing.
- Avoid pulling themselves up into a sitting position.
Until first follow-up appointment
Your teen should avoid the following activities until their first follow-up appointment:
- rolling
- lifting their arms high
- bending, twisting, straining, heavy lifting
- push-ups, sit-ups or pulling themselves up on furniture
- carrying a backpack at school
- contact sports
Postural exercises after surgery
Below you will find some exercises that can help improve your teen’s posture and range of motion after having a Nuss bar procedure.
In general, your teen should try to use their arms as normally as possible, within comfortable limits, for activities such as eating, dressing and toothbrushing. This will help their recovery. In the first few days after surgery, your teen can start to perform each exercise daily. As they become more comfortable with the exercises, they can work up to doing them two to three times per day.
The activities below can be performed for the first four to six weeks after surgery or until your teen’s movements have improved and their posture is back to normal. Be sure to keep the following in mind as your teen performs the activities:
- Your teen should do the activities within their pain comfort limits. The exercises should not cause pain or worsening discomfort.
- The exercises should be done in a slow and controlled manner.
- If your teen experiences significant pain that does not improve over time, please speak to their health-care provider.
Posture check (sitting up straight)
Your teen should check their posture frequently during the day to make sure they are sitting or standing straight and not leaning forward or to the side. They should try to:
- Sit with their feet flat on the floor.
- Sit or stand up straight, with their shoulders pulled back and down.
- Their shoulders should be stacked above their hips, sitting up as straight as they can.
Shoulder rolls
This exercise encourages good posture and improves shoulder movement while maintaining neck posture. Your teen should:
- Sit in a good posture (see posture check instructions above).
- Slowly and gently roll their shoulders in circles forward and back.
- Focus on relaxing the shoulders down within pain-free limits (meaning this exercise should not cause pain).
- Repeat five to 10 times.
Chin tucks
This exercise encourages good posture and prevents forward chin posture, which can cause neck discomfort. Your teen should:
- Sit in a good posture.
- Sit up tall, drawing their shoulder blades towards the centre of the spine.
- While holding this posture, focus on bringing their chin back so their neck is long.
- Hold for five to 10 seconds to feel the stretch.
- Repeat five to 10 times.
Sleeping and transfer recommendations
Your teen should not lie on their stomach or side unless told otherwise by the health-care team. Instead, they should lie on their back when sleeping.
When your teen is first discharged home, it may be difficult for them to get up from lying flat on their back. To make it easier, elevate their upper body using a positioning wedge (or multiple pillows) when they are sleeping.
Since your teen should not be rolling or lying on their side until told otherwise by their health-care team, they may find it more challenging to get in and out of bed. See this video for a demonstration and step-by-step instructions on how to best get back into bed: Pre-operative physiotherapy education session: Nuss bar procedure.
Starting Position: Sitting at edge of bed
Step 1: Bring your legs up onto the bed.
Step 2: Place your hands by your side and slowly bend one elbow at a time.
Step 3: Slowly walk your hands backwards as you lower yourself into a lying position.
These steps can be repeated in reverse when getting out of bed.
Managing pain after surgery: The 3P approach
Your teen will have some pain after the Nuss bar procedure. Your teen’s health-care team will help your teen manage their pain using a combination of pharmacological (medicines), physical and psychological approaches (a ‘3P’ approach).
Pharmacological strategies
Pain medications can help manage your teen’s post-operative pain. If your teen prefers one form of medication to another, have them play a key role in deciding which option is best for them.
Always talk to a health-care provider before you use pain medications, especially if you are not sure which medication to use or which form of medication might work best for your teen. The health-care provider can advise you if a pain medicine is safe and effective for your teen’s type of pain.
Physical strategies
Activity pacing
Activity pacing can help with managing pain and improving function after surgery. Pacing involves learning how to balance activity and rest so that your teen can gradually build up to doing important everyday activities such as returning to school or visiting their friends.
Try using the traffic light analogies below to help your teen follow their routines after surgery without making their pain worse.
- Red light: Stop and rest.
- Key phrase: “I need to take a break. I can use my coping strategies for relaxation and recovery so that I am ready to go again after my rest.”
- Yellow light: Be alert.
- Key question: “Am I overdoing it, or can I use my coping strategies to keep going a bit longer?”
- Green light: Be active but save some energy.
- Key phrase: “I am being active, and I am fine.”
Graded movement
Graded movement can be used to gradually build your teen’s endurance after surgery. Try gradually increasing the amount of walking or sitting upright that they do by 10 per cent per day.
Psychological strategies
Distraction
Distraction can be a particularly helpful psychological strategy when a teen is experiencing post-operative pain. Active distraction, such as doing an interesting activity, talking or playing a video game, is better than passive distraction such as watching TV.
Guided imagery
To use guided imagery, ask your teen to imagine that they are in a calm, peaceful environment or to remember a pleasant experience from their past. Encourage your teen to describe what they see, as well as any smells, sounds or other sensations.
Deep breathing
Deep breathing helps your teen slow down their breathing, become more relaxed and manage pain. Encourage your teen to take a few slow deep breaths into their belly, breathing in through their nose and out through their mouth.
They can place their hands over their belly to check that it is rising with every in-breath and falling with every out-breath.
Resources for parents and caregivers
For more information about pain management after surgery, please see the following pages:
Acute pain: How to treat and manage in teens
Chronic pain: How to treat and manage in teens
Resources for teens
Guided Meditations Learning Hub: This page contains a library of guided audio meditations your teen can use to help them relax and cope with pain.