Is manual percussion contraindicated in a patient with a pacemaker (permanent artificial cardiac pacemaker)?

From the Guidelines

Manual percussion is not contraindicated for someone with a pacemaker, but caution should be exercised to avoid direct percussion over the pacemaker site. When performing manual percussion on a patient with a pacemaker, it is essential to avoid direct percussion over the pacemaker site itself, which is typically located in the upper chest below the clavicle. Percussion can be safely performed on other areas of the chest, back, and abdomen as needed for assessment purposes. The concern with percussion directly over the pacemaker is the theoretical risk of device displacement or damage to the leads, though this risk is minimal with standard manual percussion techniques 1. Healthcare providers should use gentle to moderate force when percussing near the device and observe the patient for any unusual symptoms such as dizziness, palpitations, or changes in heart rate during the procedure. If percussion is needed for respiratory assessment or other diagnostic purposes, it can typically be performed safely while maintaining a reasonable distance from the implanted device. Some studies suggest that patients with pacemakers should be informed in detail about possible complications and written consent to the examination should be obtained, especially if the patient is pacemaker-dependent 1. However, the most recent and highest quality study on the topic of manual percussion in patients with pacemakers is not directly available, but studies on cardiac pacing and resynchronization therapy provide guidance on the precautions to be taken when performing procedures that may interfere with pacemaker function 1. In general, patients with newer pacemaker models generally have devices that are well-protected against external mechanical forces, further reducing any potential risk. It is also important to note that the use of manual percussion in cardiac arrest is not recommended, according to the 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1. Overall, manual percussion can be safely performed on patients with pacemakers, as long as caution is exercised and the pacemaker site is avoided.

From the Research

Manual Percussion and Pacemakers

• There is limited research directly addressing the contraindications of manual percussion for individuals with pacemakers.
• A study from 2009 2 reviewed the interaction between physiotherapy modalities and cardiac rhythm devices, including pacemakers, and found that while there are potential interactions, there are no specific guidelines for the use of physiotherapy modalities in patients with pacemakers.
• The study suggested that some physiotherapy modalities, such as transcutaneous electrical nerve stimulation (TENS), diathermy, and interferential electrical current therapy, may be best avoided in patients with cardiac rhythm devices, but did not specifically address manual percussion.
• Another study from 1994 3 discussed the use of manual percussion as a form of chest physiotherapy, but did not mention pacemakers or cardiac rhythm devices.
• A study from 2007 4 discussed percussion pacing as a treatment for haemodynamically unstable bradycardias, but this is a different context than the use of manual percussion as a form of physiotherapy.
• Overall, there is limited evidence to suggest that manual percussion is contraindicated for individuals with pacemakers, but it is recommended that physiotherapists exercise caution and consider the individual patient's condition and medical history when using manual percussion or other physiotherapy modalities.

Physiotherapy Modalities and Pacemakers

• The study from 2009 2 found that international societies and device manufacturers offered few specific or consistent recommendations for the use of physiotherapy modalities in patients with pacemakers.
• The study suggested that active collaboration between physiotherapists and cardiac rhythm device clinic physicians may allow for the safe application of most physiotherapy modalities.
• However, the study also noted that further research is required to fully understand the interactions between physiotherapy modalities and cardiac rhythm devices.

Chest Physiotherapy and Respiratory Mechanics

• A study from 2011 5 found that chest physiotherapy, including manual percussion, can improve respiratory mechanics and increase dynamic lung compliance in mechanically ventilated patients with acute lung injury.
• The study found that the palm-cup percussion technique was the most effective in increasing dynamic lung compliance without any accompanying detrimental effects on peripheral oxygen saturation.
• However, this study did not specifically address the use of manual percussion in patients with pacemakers.

Airway Clearance Techniques

• A study from 2007 6 reviewed the use of positive expiratory pressure and oscillatory positive expiratory pressure therapies as airway clearance techniques.
• The study found that these therapies can be effective in airway clearance, but did not specifically address the use of manual percussion or its contraindications in patients with pacemakers.