Textbook of Physiotherapy in Surgical Conditions Pushpal K Mitra
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Role and Scope of Physical Rehabilitation after SurgeryChapter 1

Any surgical intervention on the human body is a traumatic event. Undergoing and then recovering from a surgical operation can be both physically and emotionally challenging for the patient. Restoring the patient's health after surgery is the job of the surgeon and the physician. But restoring the patient to gainful and enjoyable life is the task of the postoperative rehabilitation team.
This is achieved through preoperative evaluation to identify potential red flag areas that may lead to postoperative complications, followed by appropriate treatment measures to manage potential trouble before for the surgery.
As soon as the patient has stabilized after surgery, diligent post operative assessment is needed to identify short-term complications, as they develop, and long-term problems, even before they manifest.
It is the responsibility of the entire surgical team—acute care and rehab personnel, to work in tandem to get optimum outcome of the surgery.
Any efficient surgical team works like a symphony orchestra. The surgeon as the leader, like the conductor of an orchestra, guides the team consisting of a group of professionals, each having a specific jurisdiction and set of responsibilities, through the preoperative and postoperative stages of recovery.
Pre- and postoperative care combines the efforts of the nurse, the physical therapist and occupational therapist, apart from the medical and surgical inputs from respective specialists. Final rehabilitation, however may need inputs from medical social worker, clinical psychologist and vocational counselor.
Role and scope of various surgical team members in postoperative rehabilitation process.
 
ROLE OF NURSING CARE
The embodiment of care in human suffering is the nurse. Every individual patient is unique. So, too, are their needs, the extent and type of care required for them. Understanding physical and mental needs of the patient for optimal well-being is necessary for best care of the patient.
2Specially trained nurses are an important part of the surgical team. Apart from assisting the surgeon in the operation theater, they closely monitor the condition of the patient and render care as advised by the surgeon immediately after the surgery and may continue to do so throughout the hospital stay.
On discharge after the surgery, the patient may have specific issues such as catheterization, nasal tube feeding, pressure sore or wound care, all that require follow-up care by a trained nurse. Therefore transitioning from a hospital back home can be difficult without the proper rehabilitation nursing services.
 
ROLE OF PHYSICAL THERAPY
Physical therapy is a health care profession, which views human movement as central to the health and well-being of an individual.
Physiotherapists treat a patient by stimulating natural healing mechanisms of the body without the use of drugs, to restore the patient to optimum functional ability.
Physiotherapists are expected to identify and maximize movement potential through health promotion, preventive health care, treatment and rehabilitation.
Physiotherapy is a holistic approach to health care, and plays a vital part in pain relief, healing of injured musculoskeletal tissue, improving cardiorespiratory fitness and functional rehabilitation in most surgical conditions.
Physiotherapy has its applications in all most all disciplines of modern surgery— Orthopedics, Neurology, Cardiothoracic, Oncology, Obstetrics and Gynecology, General Surgery, Plastic Surgery and Cosmetic Surgery, etc.
In pre- and postoperative situations, the physiotherapist are required to assess the nature of actual or potential postoperative complication, identify the site and actual cause of a problem and relate it to the complaints and clinical background of the patient before arriving at a working diagnosis.
Once a clinical decision has been made, the situation should be explained to the patient and then the most appropriate therapeutic treatment should be started with the concurrence of the surgeon. The response to the treatment should be reviewed at every treatment session and the therapy modified as required.
Physical therapy should attempt to prevent or treat the common postoperative complications such as postoperative atelectesis, DVT, pressure sores, etc. Physical therapy can also help in minimizing long-term disability in those patients who have lost, partially or totally, cardiopulmonary fitness due to prolonged bed rest or the use of a body part that has been damaged due to the adverse effect of surgery, thereby 3depriving the patient of functional independence. Physical therapy helps patients to regain fitness, improve muscle strength and postural balance, improve mobility and restore walking skills, and to cope better with the pain and trauma associated with surgery. The benefits of physical therapy are multiple, meaningful and mostly permanent, as each patient can receive help and guidance tailored specifically for his/her individual needs.
 
ROLE OF OCCUPATIONAL THERAPY
Occupational therapy provides therapeutic benefits through structured activities that are designed to help patients to achieve the best possible level of independence in their daily life. It focuses on training of self-care skills like independent eating and dressing, mobility skills like transferring from bed to wheelchair and wheelchair handling and grooming skills like toileting and bathing.
Occupational therapy intervention also aids in easing emotional stress and promotes social and vocational adjustment necessitated due to permanent loss of function following surgery. All this helps the patient to cope better with the aftermath of a surgery, with or without residual disability and helps early return to work.
 
ROLE OF PROSTHETICS AND ORTHOTICS
Postoperatively, particularly after trauma or orthopedic reconstruction or following amputation, a patient may become functionally deranged and need external support in the form of simple splints, straps, belts or advanced orthosis. If an Amputee, he will also need a replacement for lost extremity in the form of prosthesis. The prosthetics and orthotics specialist is kept aware of the needs of the patient and has to work closely with the surgical team to assess, take measurements, fabricate the device and prepare the patient before the fitment of the orthotic/prosthetic devices. After fitment of the device, the checkout is done by the physiotherapist in presence of the prosthetics and orthotics engineer to ensure comfortable fit and therefore better compliance in using of the aids and appliances provided.
 
ROLE OF FOLLOW-UP MEDICAL CARE
After surgery, some medical issues, sometimes pre-existing, may persist with the patient. These issues include long-term complications of surgery itself or pre-existing medical conditions such as diabetes, hypertension, ischemic heart disease, which may complicate the outcome of the surgery. During hospital stay the patient will be monitored on a day to day basis by the house physician. Follow-up with a family physician usually is sufficient once the patient goes home.4
 
ROLE OF DIETETICS AND NUTRITION
After a major surgery, specifically involving the gastrointestinal (GI) tract, a patient may be unable to eat properly and thus become a victim of malnutrition. A qualified dietician is needed to guide the postoperative nutrition plan once the patient is allowed to take oral food. The diet plan will need to workout the Required Daily Intake (RDI) of various foods such as carbohydrates, proteins, fat, essential trace elements and vitamins for a well-balanced nutrition, thus ensuring rapid repair of the body after surgery.
 
ROLE OF CLINICAL PSYCHOLOGY, VOCATIONAL AND SOCIAL SERVICES
As mentioned earlier, surgery of any kind is a stressful event. This stress multiplies several times when the patient has serious issues such as multiple fractures, burn, cancer, etc. for which extensive surgery is needed. Depression and anxiety are a constant companion of such patient and since morale of the patient in such cases play a great role in the rate of recovery after the surgery, counseling by a qualified clinical psychologist plays a great role in the final outcome of the surgery. Ensuring social support and future economic well-being are within the purview of the social worker and the vocational counselor. Their task may begin well before the surgery and ends only when the patient has been gainfully integrated in the society.
 
How can Physiotherapy Help after Surgery?
The benefits of physical therapy after any kind of surgery are undisputed. Physiotherapy, a medically oriented therapeutic practice has been around since Ancient Greece. The overall goal of physiotherapy is for the patient to regain a proper degree of normalcy in all aspects of their life after any illness, including surgery.
The physiotherapist needs to interact closely with the surgeon to understand the preoperative needs of the patient, surgical approach planned for surgery, precautions needed, possible postoperative compli-cations, etc. Only then the therapist should evaluate the options available for the rehabilitation process and make an informed decision on the available assessment data.
The principal reasons why someone would need the aid of a physical therapist after surgery are as follows:
  1. to control and minimize postoperative pain
  2. to promote rapid healing of surgical wounds
  3. to reduce respiratory incompetence
  4. to combat loss of cardiac conditioning due to prolonged bed rest
  5. to strengthen and mobilize weakened and stiff muscles
  6. to prevent worsening of pre-existing disorders, such as arthritis.
5Each of the above and other similar conditions can benefit greatly from physical therapy.
Broadly postoperative physiotherapy involves the use of:
  • Corrective positioning of the body and passive/assisted/active movements of the extremities
  • Breathing exercises
  • Electrotherapy modalities for pain management, muscle reconditioning, fluid mobilization and tissue healing
  • Soft tissue massage to promote blood circulation and lymphatic drainage.
 
ROLE OF CORRECTIVE POSITIONING AND EXERCISES
Pain, weakness and stiffness arising from prolonged bed rest after surgical operations can greatly decrease the quality of life in an individual. Physical therapists prescribe and demonstrate to the primary caregiver procedures such as proper positioning on bed using rolls and pillows, two hourly turning of the patient from one side to the other and give passive/assistive/active exercises that will prevent contractures and help the patient regain normal use of the body, improve function, reduce pain, and restore mobility.
Individually tailored exercises are prescribed for increasing flexibility, strength, and rebalancing of muscle action, increasing coordination, improving breathing efficiency and restoring function. Progressive resistance exercise programs (PRE) are indicated for postoperative patients in the final stages of recovery. Main benefit of movement therapy concerns secondary joint pain arising from pre-existing disorders such as arthritis.
The therapist will assist the patient in performing exercises and procedures aimed at regaining optimum range of motion that the joint once enjoyed. Usually, joints become stiff due to lack of use because of the pain that patients do not wish to endure. Therefore, the patient should perform activities to loosen up joints that will restore movement and overall ease discomfort.
Abdominal surgeries, which may include removal of diseased gut, ovarian cysts, hernia repairs, hysterectomy, and numerous other techniques, may downgrade abdominal muscle power and efficiency of intra abdominal pressure, so essential for spinal stability, respiratory and circulatory functions. After abdominal surgery, patients tend to decrease their activities to avoid pain, thus allowing muscles of abdomen to weaken further. Weak abdominal muscles lead to poor posture, compromises venous return from lower extremities and reduces diaphragmatic excursion. Simple isometric exercises of the abdominal muscles in most cases can be given once the sutures have healed, if not otherwise forbidden by the surgeon.
6A physical therapist will provide a thorough evaluation and help manage the debilitating effects of abdominal surgery. Physical treatment may include some of the following:
  • Exercises to perform while in bed during recovery to maintain good blood flow and prevent stiffness.
  • Movement techniques to lessen the stretch on the incision.
  • Deep breathing and coughing techniques.
  • Exercises and self-help techniques to help reduce postsurgical pain from abdominal gas.
  • Relaxation training.
  • Instructions in home exercises to help promote strengthening of the back, abdominal and pelvic muscles.
  • Instructions in wound and skin care, including scar care after healing.
  • Instructions in proper lifting and movement techniques to make daily activities safe and easier.
 
ROLE OF CHEST PHYSIOTHERAPY
Breathing exercises can be used to optimize gas exchange, promote lung expansion, minimize postoperative atelectasis, decrease dyspnea, and promote secretion removal. The postoperative and even preoperative regime of physiotherapy will focus on two major types of breathing exercises with different benefits:
  1. Those used to promote lung expansion and minimize atelectasis in individuals with no pre-existing lung disease. These techniques include deep breathing, deep breathing with breath stacking, deep breathing with inspiratory hold, and incentive spirometry.
  2. Those used to reduce dyspnea (shortness of breath—SOB), to promote lung expansion and to minimize atelectasis in individuals with moderate to severe chronic respiratory disease such as chronic obstructive pulmonary disease (COPD). These include all of the above techniques in addition to teaching breathing control, minimizing work of breathing, improving exercise tolerance and pursed lip-breathing techniques to cope with severe SOB.
 
ROLE OF ELECTROTHERAPY
Electrotherapy devices work in different ways, depending on what type of problem they are treating. Certain devices excel at treating pain, while others specialize in muscle rehabilitation and fluid movement.
 
Electrotherapy in Pain Management
Electrotherapy devices that help control both chronic and acute pain fall into one of three categories: Interferential, Microcurrent, or Transcutaneous Electrical Nerve Stimulation (TENS). Each type of device works in a 7slightly different way, but they all provide an effective, non-narcotic alternative or supplement to drug therapy.
 
Interferential Therapy
Interferential therapy devices use two separate electrical frequencies that work together to stimulate large impulse nerve fibers—ones that “close the spinal gate of pain”. Their frequencies interfere with the transmission of pain messages at the spinal cord level, and help block their transmission to your brain. Obviously, the fewer pain messages that make it through, the less it hurts. Interferential therapy uses two independent frequencies that deeply penetrate muscles and stimulate parasympathetic nerve fibers for increased blood flow. Like hundreds of tiny rivers, these vessels and capillaries quickly flush out old waste and usher in new blood.
 
Microcurrent Therapy
Microcurrent therapy is thought to mimic the body's own electrical system. It uses subtle current to build upon naturally occurring impulses to decrease pain. Microcurrent devices take what the patients already have and make it stronger, amplifying the ability to heal oneself, otherwise known as bio-feedback.
 
Transcutaneous Electrical Nerve Stimulation (TENS)
Transcutaneous electrical nerve stimulation (TENS) devices use a two-pronged approach to pain relief. First, they target sensory nerves, stimulating them to block pain signals and prevent their transmission to the brain. Second, TENS also promotes production of endorphins, the body's natural pain reducing substances. Because of its effectiveness, TENS therapy is routinely used to treat back and cervical muscular and disk syndromes, RSD, arthritis, shoulder syndromes, neuropathies and other painful conditions. It is also a very effective replacement for narcotic analgesics, often a habit forming drug used to control postoperative pain. However, to be effective in postoperative pain TENS may be needed to be applied continuously at the operation site, through surface electrodes fixed on either sides of the suture line and that the patient may not take any narcotic analgesic at all before or after surgery.
 
Electrotherapy in Muscle Rehabilitation
 
Neuromuscular Stimulation
It is a fact that exercise is good for you. Whether you are biking, walking or playing tennis, your movements are a carefully choreographed series of muscular contractions. Each contraction begins as an electrical impulse generated by your body. Only through repeated motion do your muscles stay strong and healthy.
8When injury sets in, muscles become stationary. Fluid builds up between the cells and they begin to lose their strength. Electrotherapy has the ability to counter these effects through neuromuscular stimulation (NMS) and high or low voltage pulsed direct current therapy.
An injured muscle usually experiences little-if any-movement. NMS therapy remedies this by using low-voltages to stimulate motor nerves to cause involuntary muscular contractions. Neuromuscular therapy induces muscle contractions which pump fluid through both the venous and lymphatic systems. This helps to resolve the swelling or fluid build-up in the area. NMS devices have the ability to increase or decrease the strength of each muscular contraction.
Like exercise, NMS helps to strengthen the injured area and has been found to effectively treat a variety of musculoskeletal and vascular conditions. Common candidates for NMS therapy are patients recovering from orthopedic surgery, muscle strains or tears, or athletes who have undergone cartilage or tendon repair.
 
High or Low Voltage Pulsed Direct Current Therapy
Injured tissues are often surrounded by an excess of fluid, which prevents nutrient- and oxygen-rich blood from reaching them. Pulsed direct current devices remove excess fluid and increase blood flow to the injured site to encourage return to normal function. Fluid (swelling) is primarily composed of negatively-charged proteins. Placing a positive electrode over the injured site within the first 24–48 hours helps prevent the build-up of excess fluid. A negative electrode placed over the injured site after the first day or two causes the fluid to disperse from the site of the inflammation. This treatment reduces swelling, allowing new blood to move in and speeding up the recovery process. High voltage pulsed direct current therapy utilizes two oppositely charged electrodes to move the plasma proteins, which comprise excess fluid and leak into spaces between cells. Initially, the stimulus prevents fluid build-up. Later, using a different protocol, it repels fluid that has built-up.
 
Electrotherapy in Fluid Movement
Excessive fluid build-up, known as edema, is detrimental to any healing process. Not only does it cause swelling around the injured area, but it also prevents removal of waste products and hinders circulation. Electrotherapy uses Interferential, NMS, and high or low voltage pulsed direct current devices or faradism under pressure to move excess fluid from injured areas back to the circulation.
 
Interferential Therapy
Interferential therapy uses two independent frequencies that deeply penetrate muscles and stimulate parasympathetic nerve fibers for increased blood flow. Like hundreds of tiny rivers, these vessels and capillaries quickly flush out old waste and usher in new blood.9
 
High or low voltage Pulsed Direct Current Therapy
High voltage pulsed direct current therapy utilizes two oppositely charged electrodes to move the plasma porteins, which comprise excess fluid and leak into spaces between cells. Initially, the stimulus prevents fluid build-up. Later, using a different protocol, it repels fluid that has built-up.
 
Neuromuscullar Stimulation
Neuromuscullar therapy induces muscle contractions which pump fluid through both the venous and lymphatic systems. This helps to resolve the swelling or fluid build-up in the area. NMS devices have the ability to increase or decrease the strenth of each muscullar contraction.
 
ROLE OF MANUAL THERAPY, MASSAGE STRAPPING AND ACUPUNCTURE
  1. Manual therapy and massage also called Hands on Treatment which includes passive mobilizing of joints, manipulation of joints, mobilization with movement, soft tissue techniques and manual traction with or without aids. A massage given by a physical therapist can help in any number of ways. For overall health, the benefits of the professional massage can reduce stress by unknotting muscles and causing the body to relax. Massages will even improve blood circulation, lymphatic drainage, range of motion and increase flexibility (Fig. 1.1).
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    Fig. 1.1: Massage
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    Fig. 1.2: Taping of the knee joint
  2. Strapping techniques are a component of manual therapy which is very useful to rest painful tissues, if required. Sports taping techniques and manual therapy taping techniques, e.g. mulligan taping are commonly used following soft tissue release and repair surgeries (Fig. 1.2).
  3. Soft tissue compression techniques such as Crepe bandage, Jones compression bandage, Jobst compression garments and intermittent pressure therapy help in preventing edema, minimizing scar formation and hypertrophy of scar along with controlling edema.
 
 
Acupuncture in Postoperative Care
Modern acupuncture with research back-up is practiced widely in physiotherapy as an effective modality for pain management. Acupuncture in postoperative cases is mainly sought for pain relief. Auriculotherapy or ear acupuncture is gaining wide acceptance in physiotherapy techniques used in surgical and traumatic conditions. Cold laser or low frequency TENS is often used to stimulate the acupuncture points as it is a sterile and safe procedure.