Friday, May 29, 2020

Physical Therapy After Abdominal Surgery




I had my first abdominal surgeries were in grade school from 1995-1996 and endured severe back pain particularly during this time. By the time I was in high school, I started noticing increased back issues as I was unable to sit up from a forward bend position. My doctor referred me to physical therapy where I learned my back issues stemmed from weak abdominal muscles from my abdominal surgeries. After completion of a physical therapy program, my back issues significantly improved. That's why I thought it would be beneficial to learn about physical therapy after abdominal surgeries and so I requested this blog post from a local physical therapist.

This is a guest post by Christine Poteet, a Physical Therapist

 A guiding principle of physical therapy is “proximal stability before distal mobility.” In physical therapy school, my sports professor said this phrase more times than I care to remember, but it got the point across! Basically, it means that if your core (proximal) is not strong enough to handle what you’re doing with the rest of your body (distal), that function or performance will likely be less than optimal and may lead to a breakdown, injury, or pain at or beyond the area of weakness. I liken this to the biblical story of building your house on a rock versus sand. If you don’t build your house on a solid foundation, then, as the story goes, “the rain falls, the floods come, and the winds blow and beat against your house, and it will fall.” Similarly, if your body’s foundation (your core) isn’t strong, it won’t be able to stand up to everything that life throws at you. This may manifest as increased local pain (such as back pain) or pain in other places along with, or due to, the breakdown of muscles, joints, tendons, or ligaments. When your core isn’t doing its job, those other parts are taking on additional stress, and while our bodies are pretty resilient, those other parts can only take that increase in usage for a limited time. Depending on the part, a breakdown could result in a cascade of additional faulty movement patterns and injuries. 

The core is made up of several muscle groups including the abdominals (most famous), gluteals (booty!), pelvic girdle (lots of small hip and pelvic floor muscles), paraspinal muscles (back muscles along the spine), and a few more. These muscles form the walls of a box that surround our internal organs, with the abdominals in the front and sides, paraspinal and glute muscles in the back, diaphragm on top, and the pelvic floor and hip muscles creating the bottom of the box. These muscles stabilize the spine and pelvis, reduce compression forces at the spine, and allow for appropriate force distribution and generation so the body can move with the most optimal efficiency and strength to get the job done with as little stress, compression, shear, etc. as possible (Akuthota, 2008). In other words, these muscles give lift and decompression to the spine, reducing the stress of gravity and the incumbent weight of the body pressing on the vertebrae and intervertebral discs which can cause nerve compression, pain, and dysfunction.

Our core and postural muscles are “on” whenever we are in any position other than lying down, which is typically 16-18 hours per day. Certain core muscles have been found to fire before limb movements in order to stabilize the spine, which is further evidence of the “proximal stability before distal mobility” principal. However, these muscle reactions can be delayed in folks with certain maladies, such as low back pain. So you can see how important they are for everything we do.

Personally, I didn’t have the opportunity to see many folks following abdominal surgery in my outpatient orthopedic practice, but I did see many with low back pain and post back or hip surgeries. Most tend to have an excellent recovery whenever they are consistent with their exercise program. Since my transition to the home health setting, I’ve seen several people, mainly women, who did not have physical therapy immediately following surgery and now have other complications, injuries, or difficulties.  Many of them have required a walker as they were unable to fully stand due to a combination of back pain and core weakness. Keep in mind that my average patient is now about 70 years old. I always include a balance component with my treatments, so I have patients practice proprioceptive exercises at their kitchen counter by standing without holding on. Many of them slowly droop down toward the countertop because their core musculature is so weak that it can’t hold their torso erect for more than a few seconds. After several visits of supine core and lower extremity exercises, not only were these patients able to stand upright for the full 30-second goal, they were also able to maintain a more erect posture with static standing and walking. They also reported feeling stronger and more stable, which translated to observable functional improvements in their everyday lives. 

Physical therapy seeks to reduce post-op complications, including pneumonia, deep vein thrombosis (blood clots), and to improve range of motion, strength, endurance, stability, and restore normal movement patterns. Surgery can disturb the skin, underlying tissues, and nerves, which can result in a lack of coordinated muscle activation. So ,even if the muscles are strong, the nerves aren’t able to communicate with the muscles appropriately, resulting in an inability to contract those muscles in a full and coordinated manner. This is referred to as neuromuscular dysfunction. I tell my patients that the nerve is hacked off about the surgery because it was cut on, moved, or otherwise interrupted. And though the surgery was “for a good cause,” the nerve doesn’t know that and needs time to simmer down.

Physical therapy following abdominal surgery can help restore that nerve-muscle communication, allowing for a more coordinated and efficient muscle contraction. This can manifest as stronger muscle contractions due to increased muscle fiber recruitment and more support of the spine, more efficient movements with fewer substitutions. Meaning you’re using the right muscle for the job, and depending less on random other parts to do the work, which can initiate the cascade of breakdown at or beyond that weak link. Physical therapy can also play an important role in the restoration of overall physical function including muscular strength, cardiovascular endurance, and balance and proprioception. All of these aspects of function are essential to optimal performance of daily life tasks, especially if you have any kind of strenuous demands on your life (i.e. children, sports, job activities, sex, etc.).

Thankfully, many abdominal surgeries are now performed laparoscopically, reducing the invasiveness of the procedures. Minimally invasive procedures have been shown to decrease recovery time, complication rates, and length of hospital stay. (Reeve, 2016) This translates to less disruption of muscle, nerve, connective, and other body tissues improving post-surgical rehabilitation.

EXERCISES
This is by no means meant to replace the professional opinions of your personal physician or physical therapist who can actually lay eyes on and evaluate you, and recommend an individualized program based on what you actually need. But here are some of my favorite basic core exercises to prescribe (and that I do in my own workouts):

The Abdominal Draw In (DI) is one of my favorites because it recruits the deepest of your core muscles - the Transversus Abdominis. This muscle has horizontal fibers that, when activated, function like a girdle around your abdomen giving your spine support and decompression. The DI also simultaneously recruits your pelvic floor muscles which, if you remember from previously in the article, are the bottom of the “box,” and strengthening them can help if you have any sort of urinary incontinence problems (though that’s a whole other topic that I could spend some significant time on). For this exercise, I usually instruct my patient to lay down on their back with knees bent, feet flat on the bed, and tell them, “bring your belly button down toward your spine, like you’re trying to fit into a tight pair of jeans.” Another way of thinking of it is “hollowing out” your belly. Make sure you keep breathing during the exercise - don’t hold your breath. Also, make sure to keep your head relaxed on the pillow or the floor if you aren’t using one - don’t try to lift your head up toward the ceiling. (Pro tip: you might get a cramp in your hamstrings - that’s pretty normal in my experience - just stretch it out and you should be alright.) Depending on the person’s strength, I’ll have them hold the contraction for anywhere between 3 and 10 seconds, and have them do about 10 repetitions. I love this exercise because there are so many variations and progressions that you can add in once they have the basic part down. For example:
 Posterior Pelvic Tilt: This one is much more difficult in concept but easy to execute once you understand. I’m including several links on this one so that you can see it in various ways. Just remember that it’s all about the TILT so that your back presses into the bed or the floor (I recommend doing this on the floor because a bed is very soft and the floor gives you a bit more feedback, so that when you feel your back pressing into the floor, you know you’re doing it right).  

Glute Squeeze: (Um, can I just tell you how much I love this picture? Hilarious!) It’s like you’re trying to pinch a penny between your cheeks. 

 Adductor Squeeze with a ball or pillow between the knees

 Dead Bug: This one is more difficult than it looks and is a progression in itself. I always have a patient start by adding just the arms to the DI and do several reps. Then, when they become proficient with that, I’ll have them switch to just the legs. Then, when they get that down, I’ll have them add arms and legs together - opposite arm moving toward opposite leg. If I see that they can’t keep the back in contact with the floor at any time, the exercise is stopped because the core muscles either aren’t functioning properly or are fatigued. 

 Hip External Rotation:  I generally have the person lay with legs bent, feet flat. While keeping one knee stable, the other knee drops out to the side, like this picture. Then I progress to bands when they are show good stability and strength with this exercise. The photo shows moving both knees at the same time but I always have them move just one at a time until they show they can control it. 

Bridges are a great exercise for basically all the large muscle groups from core to lower legs. For this exercise, lay on your back in the same position as the DI. Squeeze your belly and glutes and raise that booty up off the ground. Try to make a straight line between your shoulders and your knees. Progressions included in the notes at the end. Start with 5-10 reps and progress to a few sets of 10-15 with breaks in between.
Bridges
Progressions:
-       Single leg: (Keep your knees together) 
-       Glute bridge
-       Bridge walkout: Essentially you want to maintain a bridge while walking your feet slowly away from your bottom and then walk them back toward your bottom. 


So many of us have no idea (and neither did I until I became a Physical Therapist) just how much weak glutes affect our everyday lives, especially as we age! Your glutes are not only part of your core, they help stabilize your back and pelvis, especially during strenuous activities such as lifting, squatting, running, or even walking. They’re important in general propulsion during walking and running, and keep hips stabilized during single leg stance (which we do with every step we take as we are at least momentarily standing on one leg). They help the knee track appropriately and when strong, reduce the risk of knee and back injury associated with lifting, running, etc. That’s why maintaining those strong booty muscles is so important. My basic, go-to exercise is the Clam (or clamshell - the internet seems to like this term better for some reason). Lying on your side, bring your knees and feet together and bend at the hip and the knee such that your knees are slightly in front of the rest of your body. Torso should be on the floor and you can rest your head on your hand, a pillow, or your outstretched arm. Raise the top knee up and out (like a clamshell opening). Keep your feet together and don’t allow your top hip to rotate backwards - it’ll have a tendency to do this so you have to fight against it. Put a hand on your top hip so you can feel if it’s moving posteriorly. Again, start with 5-10 reps and progress to sets of 10 with breaks in between. 

 Clams
This is a great little video explaining the importance of the glutes, especially for women, and demonstration of the clam exercise. (Even though he was doing a mild backwards rotation of the top hip) Video
Progressions:
-       With resistance band
-       With ball between feet. And a resistance band if you want. I couldn’t find a picture of this but you can just use a medicine ball or a kid’s toy ball (~8-10 inches in diameter) between your ankles.


Another fantastic glute exercise is hip abduction. Abduction just means any motion that moves a body part away from your midline in the frontal plane. Lying on your side again, legs out straight this time, and hips stacked one on the other with a hand on the top hip to keep yourself from dropping that top hip backwards, raise the top leg out to the side. Make sure to keep your knee and toes point straight toward the wall in front of you, not toward the ceiling. This is how you know you’re activating the correct muscle, otherwise you will get another muscle trying to take over (called substitution). Same starting reps as the previous ones, progressing to 2-3 sets of 10-15 and then adding a weight or band.
HipAbduction:  Her toes are turned downward in this photo, which is fine, but will be more difficult. You don’t have to do this, just make sure your toes are pointed straight forward.
This video shows this and a couple other exercises.  Video
Progression:
-       With band
-       With ankle weight


Christine Poteet is a Home Health Physical Therapist working in the Oklahoma City Metro area. She graduated from the University of Oklahoma with a Doctor of Physical Therapy and has been a practicing physical therapist for 5 years. She has worked in home health for 2 years but began her career practicing and studying orthopedics in the outpatient setting where she became an Orthopedic Certified Specialist. She truly enjoys helping people reach and restore their physical and health potential. She also has 2 giant fur children who pretty much run (circles around) her life. When she is not physical theraping or dog wrangling, she enjoys road cycling, hiking, and various other outdoor activities with friends and family.




 References

 

  1. Akuthota V,  Ferreiro A, Moore T, Fredericson M (2008). Core Stability Exercise Principles. Spine Conditions: Section Articles. Current Sports Medicine Reports (7) 1, 39-44. doi: 10.1097/01.CSMR.0000308663.13278.69

  1. Reeve J, Boden I (2016). The Physiotherapy Management of Patients undergoing Abdominal Surgery. New Zealand Journal of Physiotherapy 44(1): 33-49. doi: 10.15619/NZJP/44.1.05

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