physiotherapy management after abdominal surgery

Despite the evidence, application on a broad-scale is poor. ERAS guidelines have recommendations regarding preoperative preparation of patients undergoing elective UAS with preoperative counselling recommended in all guidelines [54–58]. In patients awaiting elective UAS, education and planning allows for some manner of psychological preparedness for surgery and what it entails. Postoperatively, all participants received standardised early ambulation, and no … Whilst caution is warranted in extrapolating data from Louis et al. Patient education regarding the necessity for physiotherapy interventions should be implemented post-operatively as soon as feasible to ensure patients are engaged in their own recovery and understand complication prevention strategies such as respiratory physiotherapy and early mobilisation. Gently pull the tape along the side of your scar, moving in the direction of the restriction. physiotherapist immediately after the standardised physiotherapy assessment and delivery of the booklet. Surgery is the treatment of injuries or disorders of the body by incision or manipulation, often with the use of instruments. There are many evidences that the number of PPC after abdominal surgery and open-heart surgery is reduced by preoperative PT programs. A further example includes patients following elective pancreaticoduodenectomy and states such patients should be actively mobilised from the morning of the first post-operative day, with mobilisation targets to be met each day [55]. Outcome measures were functional exercise capacity and HRQoL but these varied in both their measurement and the tool used for measurement. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 594.96 842.04] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Upper abdominal surgery (UAS) has the potential to cause post-operative pulmonary complications (PPCs). Physiotherapy advice following Laparoscopic Abdominal Surgery Introduction This leaflet gives you advice about the techniques recommended by the physiotherapy department to assist you with your recovery after your operation and reduce the risk of complications. Overall, the quality of the evidence was low and study findings were inconsistent; some studies reported improvements in functional exercise capacity and others not. You will feel better some days than others, this is normal. Don't apply it too tightly; the tape should have a … Our readership spans scientists, professors, researchers, librarians, and students, as well as business professionals. Clinical trials have not reported widely on the rates of negative effects of NIV. Level of alertness, ability to follow instructions and haemodynamic and respiratory stability will be carefully assessed before any therapeutic intervention is considered. Determining tools with satisfactory psychometric and clinimetric properties in patients undergoing both elective and emergency abdominal surgery warrants further investigation. Why: Help strengthen your deep abdominal muscles, enhance blood flow to the area and promote healing. Studies investigating physiotherapy rehabilitation practices in acute surgical care commonly report LOS and post-operative complications as proxy outcome measures, but these measures have limitations when demonstrating the functional changes associated with physiotherapy interventions [70]. The abdominal cavity contains organs such as the stomach, liver, gallbladder, spleen, pancreas, small and large intestines and kidneys. This chapter will provide an overview of the common complications that occur following abdominal surgery including emergency surgery, specifically focussing on those that may be remediated by physiotherapy interventions. Preliminary data have shown that high-flow nasal prongs (HFNP) are comparable to NIV in the treatment of hypoxemic respiratory failure yet with better patient compliance [69]. The ‘acute abdomen’ is defined as a sudden onset of severe abdominal pain developing over a short time period. This chapter reviews the evidence in these populations and propose that, until further studies are available to direct care, this evidence is extrapolated to patients following emergency abdominal surgery. A reasonable question arises; if NIV has been shown to be superior to usual care in the prevention of PPC following abdominal surgery, why is it that this therapy is not widely provided as standard care? The role of physiotherapy within ERAS and intensive care units (ICU) is important. The hospital and patient costs of blanket NIV application may outweigh the benefit of preventing PPC, especially if the PPC incidence rate is low. Whilst the measurement properties of the MGS have not yet been fully demonstrated, the tool has been shown to have excellent inter- and intrarater reliability and good clinical utility when compared to other similar diagnostic tools [25]. Posted on October 1, 2013 November 7, 2019. 4 0 obj To date, the current research investigating the effectiveness of respiratory physiotherapy interventions in a population following emergency UAS is inconclusive due to limited low-quality research and poor sample sizes. Physiotherapy advice after abdominal surgery 5 of 6 Rest Your body is using energy to heal itself so you will feel more tired than normal. To date, the MGS has been used following abdominal [18, 26–28] and thoracic surgery [25, 29], and whilst further studies investigating its clinimetric properties are warranted, it currently remains the best tool for physiotherapists to determine the presence of a PPC amenable to their care. The effectiveness of physiotherapy to prevent complications and improve recovery for patients undergoing elective abdominal surgery has been well documented over the past 20 years [3]. Evidence shows that adverse events occur in only a small number of patients (1–4%) [47, 49–52]. By Kate Sullivan, Julie Reeve, Ianthe Boden and Rebecca Lane, Submitted: November 17th 2015Reviewed: April 27th 2016Published: September 21st 2016, Home > Books > Actual Problems of Emergency Abdominal Surgery. This phase begins as soon as you are discharged from surgery and carries on until your tissues have healed, the swelling from surgery has dissipated and the pain associated with the surgery has mostly resolved. Further studies are needed to test the hypothesis that early and frequent ambulation reduces ileus rates. As a result, recent research has focussed on the effectiveness of providing early ambulation alone in preventing post-operative complications [46]. Physiotherapy Following Emergency Abdominal Surgery, Actual Problems of Emergency Abdominal Surgery, Dmitry Victorovich Garbuzenko, IntechOpen, DOI: 10.5772/63969. Pain relief 2. The following information should help you understand your options for pain management. No single physical therapy functional outcome measure has yet been found to be valid and reliable specifically in patients following elective or emergency UAS. Despite the true incidence being unclear, emergency surgery is seen as an independent risk factor for PPC across all surgery types [16]. The pathophysiological effects of abdominal surgery on the respiratory system are well known. Simple exercises t… Systematic reviews and meta-analyses of NIV as a treatment for respiratory failure following abdominal surgery have not yet been performed due to the lack of clinical trials on this topic. Given the absence of evidence investigating the effect of rehabilitation programmes on patients having undergone elective or emergency abdominal surgery, and the limitations in the evidence in a population following critical illness, further investigation of the value of post-discharge physical rehabilitation programmes is warranted. Atelectasis [22], alterations in mucociliary transport [23], respiratory muscle dysfunction and altered chest wall mechanics [5, 22], reduced lung volumes and decreased cough strength [22] are thought to contribute to an increased risk of PPC through the combined impact of general anaesthesia, post-operative pain and immobilisation, and handling of the viscera [22]. It may be more appropriate to stratify patients into high- and low-risk groups. Incisional hernias can develop after abdominal surgery. Gentle manual therapy to restore joint range of motion 4. Additionally, not all clinically significant PPCs are amenable to physiotherapy interventions, for example, a pneumothorax. Post-operative ileus (POI) is a normal, transient impairment of bowel motility and is considered an inevitable consequence of abdominal surgery [36–38]. Considering the consequences of respiratory complications, much focus has been placed on their prevention. Contact our London head office or media team here. As PhD students, we found it difficult to access the research we needed, so we decided to create a new Open Access publisher that levels the playing field for scientists across the world. Never lift weight that causes you to strain in both the short and long-term after hysterectomy surgery. Such devices have been purported to aid in improving lung volumes and secretion clearance although a systematic review concluded that PEP conveys no additional benefit over other respiratory techniques [60]. A clinically significant ileus, or prolonged ileus, is defined as lasting longer than three days [37, 39] and involves symptoms such as nausea and vomiting, inability to tolerate an oral diet, abdominal distension and delayed passage of flatus or stool [37, 38]. [81] to patients following emergency abdominal surgery, the feasibility of inpatient rehabilitation programmes has been determined in recent studies for patients recovering from critical illness [83, 84]. For audit, research and clinical purposes, the Melbourne Group Score should be used to diagnose PPCs that are amenable to physiotherapy intervention. It may not be necessary or cost-effective to treat all patients with prophylactic NIV. Such protocols contain recommendations regarding, amongst other interventions, the importance of early ambulation after abdominal surgery, specifying the frequency and duration required to be undertaken. Respiratory therapies include deep breathing and coughing exercises, positive expiratory pressure devices, incentive spirometry and non-invasive ventilation. Physical therapy is an important part of recovery after abdominal surgery. On the balance of available evidence, prophylactic delivery of NIV should be targeted towards all patients at high risk of developing a PPC and this includes all patients having emergency open upper abdominal surgery. Physiotherapy interventions after major surgery include early mobilisation and respiratory physiotherapy techniques. Anchor the tape along one side of your scar. The rectus fascia is intact, and the condition should therefore not be confused with a ventral hernia. Mobilisation should be commenced as soon as possible to prevent complications associated with prolonged immobility. Increase repetitions as able: Position: Lie on your bed with your head on a pillow, knees bent and feet flat on the bed. Core exercises can help you start strengthening your abdominal muscles. Following emergency UAS, some patients may be unable to ambulate due to, for example, haemodynamic instability or traumatic injury, and thus, the inclusion of DB&C should be considered to be of value after emergency UAS [46]. This will help you heal faster and prevent infection. Reference. Regardless of specific protocols, there is general consensus that to counteract the deleterious effects of immobility following any abdominal surgery patients should be mobilised early and often [54–58]. However, the PFIT and Acute Care Index of Function were developed for measuring mobility in patients with critical illness and the mILOA has been shown to be reliable, valid and responsive in assessing the mobility status of acute hospital inpatients [73] and their use could be extrapolated to the emergency surgery population. During this session, participants were educated about the possibility of PPCs after surgery and given an individualised risk assessment.7 The effect of anaesthesia and abdominal surgery on mucociliary clearance and lung volumes was explained. Rates of PPC vary greatly depending on the diagnostic criteria used to define them, and such inconsistencies make identifying clinically significant PPCs, comparison of PPC rates and interpretation of research findings problematic. However, despite data showing a higher incidence of complications and poorer physical recovery for patients undergoing emergency abdominal surgery [4, 5], the benefits of physiotherapy for this patient group are yet to be reported in detail. Utilising standardised and repeatable outcome measures early in the post-operative period will provide a means by which changes in condition may be measured. The overall quality of the evidence precluded meta-analysis. The review found no effect on HRQoL. Publishing on IntechOpen allows authors to earn citations and find new collaborators, meaning more people see your work not only from your own field of study, but from other related fields too. The benefits of PEP and IS are currently unknown in emergency surgery populations; however, considering that emergency abdominal surgery patients are at high risk of PPC and that these devices are generally low cost, on the balance of risk versus benefit, such devices should be considered as a prophylactic respiratory physiotherapy treatment in patients considered high risk for the development of a PPC. Abdominal rectus diastasis is a condition where the abdominal muscles are separated by an abnormal distance due to widening of the linea alba, which causes the abdominal content to bulge. Recovery has been previously described as a return to normality and wholeness through an energy requiring process and involves multiple domains, namely physical, physiological, psychological, social and economic [1, 2]. Emergency UAS dictates that premorbid status is often unknown and the impact of the surgery and subsequent rehabilitation on physical function may be unclear. Post-operative complications are common following major upper abdominal surgery (UAS) with up to 50% of all patients having some type of complication following their surgery [8, 9]. Education focused on PPCs and their prevention through early ambulation and self directed breathing exercises to be initiated immediately on regaining consciousness after surgery. Risk factors for the development of PPCs include duration of anaesthesia, emergency upper abdominal surgery, current smoker status, respiratory comorbidities, obesity, increased age and multiple surgeries. Background and purpose: Physiotherapy is considered an essential component of the management of patients after thoracotomy, yet the type of interventions utilized, and evidence for their efficacy, has not been established. Physiotherapists caring for patients following emergency surgery can only base their interventions on evidence extrapolated from elective abdominal surgery and literature for critically ill patients. To date, there have been limited data regarding physiotherapy interventions following emergency abdominal surgery. The majority of trials compared NIV to usual care of oxygen therapy alone and/or respiratory physiotherapy (DB&C ± incentive spirometry/PEP) in the post-operative period. There is evidence to suggest prophylactic NIV is effective in preventing PPCs following abdominal surgery. Simple, low-cost prophylactic measures such as self-directed DB&C exercises, IS or PEP devices may be all that is required to prevent a PPC from occurring after low-risk abdominal surgery. Additionally, the paucity of cost-benefit and risk analysis evidence for NIV versus standard care may also be a factor. By identifying the factors that predispose to the development of PPCs and the populations most at risk, prophylactic therapeutic interventions can be more appropriately targeted. It has a large number of possible causes and so a structured approach is required. These trials demonstrate NIV may reduce PPC risk by half, with a further significant sub-group effect specifically for the prevention of pneumonia [64, 65]. The Melbourne Group Score PPC diagnostic criteria. Until detailed cost-benefit analysis and adverse event rates are reported in more detail, this remains unknown. It is conceivable that following abdominal surgery post-operative exercise rehabilitation programmes (both in the inpatient and outpatient environment) might hasten recovery, alter discharge destination and improve long-term outcomes. The development of even minor post-operative complications has been demonstrated to be a major determinant of hospital readmission, long-term adverse outcomes and death [77, 78]. Whilst there is little evidence demonstrating effective physiotherapy techniques specifically for the emergency UAS population, there is good quality evidence to demonstrate that physiotherapy focusing on early rehabilitation in the immediate post-operative period is both safe and effective following elective UAS, and for patients with a critical illness (including following emergency surgery) in intensive care. Following major intestinal surgery in elderly patients, mortality, LOS, complication rate, discharge destination and discharge home with/without help were found to be significantly better in patients undergoing electively surgery compared with the same procedures performed as an emergency. Early feeding (oral intake of fluids or food within 24 h of surgery, irrespective of bowel sounds) after major abdominal gynecological surgery is safe and associated with reduced length of hospital stay but increased nausea. Physiotherapists have been involved in the routine provision of care to patients undergoing abdominal surgery under the assumption that complications can be prevented by assisted early ambulation and respiratory physiotherapy techniques such as deep breathing and coughing (DB&C) exercises [44–46]. After any abdominal surgery, once you have been cleared by the surgeon to participate in regular activities, thoughts might turn to firm up abdominal muscles. Further studies should focus on the cost effectiveness, patient satisfaction, and other physiological changes. Early mobilisation in the critically ill should be undertaken under highly controlled circumstances and such decisions are made according to individual patient status and haemodynamic stability. Physiotherapy advice after abdominal surgery. The initial assessment should attempt to determine if the patient has an acute surgical problem that requires immediate and prompt surgical intervention, or urgent medical therapy. Rectus diastasis can be congenital but is most commonly acquired during pregnancies and/or larger weight gain causing laxity of linea alba (1). If you experience abdominal adhesions, you can use physical therapy exercises to relieve symptoms and soften scar tissue. 2 0 obj Beyond hospital discharge, to date only a small number of studies exist which investigate the effect of post-discharge rehabilitation programmes and none of these are solely in patients undergoing abdominal surgery [85–89]. Non-invasive ventilation (NIV) in the form of either continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) reverses the known reduction in functional residual capacity (FRC) following abdominal surgery. Cobra Pose. Evidence for post-discharge rehabilitation is lacking. Enhanced recovery after surgery (ERAS) is an evidence-based, multimodal approach to optimising patient outcomes following surgery. endobj It is administered after 3 minutes of preoxygenation in the operation theatre. The preoperative PT results in a reduction of radiographic changes, a modification of objectivity chest, an improved gas exchange as well as improved QoL and a decrease in hospital stay [ 63 – 66 ]. These weakness syndromes impact patients both during their acute recovery and following discharge, with some patients experiencing ongoing weakness and functional difficulties up to two years after their ICU discharge [34]. Surgical and perioperative care should strive to improve both the quantity (life expectancy) and quality of life [76]. Systematic reviews support the use of NIV to prevent respiratory complications following abdominal surgery despite methodological limitations of the clinical trials included. During this period of time your Physiotherapist will be focused on the following; 1. Built by scientists, for scientists. Incentive spirometries (ISs) are respiratory devices, which aim to increase inspiratory volumes. Emergency surgery leaves little or no time to prepare patients psychologically for the surgery or for the process of recovery after surgery. <> Indeed, it has been argued that after emergency surgery, future studies should reconsider their focus and consider utilising long-term functional outcomes alongside more traditional outcomes such as in-hospital or 30-day mortality and morbidity [81]. Here are 3 exercises to do twice daily for approximately 3 months. Metoclopramide (10 mg) is given to increase the tone of the lower esophageal sphincter as well as to reduce the stomach contents. Exercise promotes overall better health, and getting back into the swing of exercise after surgery is one way to lower the risk of future health problems. © 2016 The Author(s). Consensus guidelines for physiotherapy assessment and treatment have been recently published and, where higher quality evidence is absent, should be used as the primary resource for recommendations for physiotherapy practice [46]. On expiration, positive airway pressure is maintained with the use of a positive end expiratory pressure (PEEP) valve. <>>> For example, for patients undergoing elective rectal or pelvic surgery the guidelines recommend they are nursed in an environment encouraging independence and mobilisation with two hours out of bed on the day of surgery and six hours out of bed each day thereafter [54]. Discontinue after appendectomy. Complications following emergency UAS are two to three times more common compared with similar elective procedures [4] with patients more susceptible to cardiopulmonary complications and sepsis [10]. Complications include post-operative pulmonary complications (PPCs), prolonged post-operative ileus, wound infection, haemorrhage and venothrombotic events [4]. Whilst preoperative education, inspiratory muscle training, and exercise training have been shown to significantly impact on PPCs in patients undergoing elective abdominal surgery [40–43], the nature of emergency surgery invariably renders this approach impossible in this patient group. Posted in Patient Information Leaflets, Physiotherapy and tagged abdomen, stomach. General anaesthetic is medication used in surgery with the purpose being loss of consciousness. Reducing swelling 3. Assistance with early walking 5. *Address all correspondence to: ianthe.boden@ths.tas.gov.au, Actual Problems of Emergency Abdominal Surgery. Pre- op physiotherapy education is given to one experimental group and after surgery post operative treatment is given to both the experimental groups. 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