Blog

Surgical Rehabilitation

The role of rehabilitation in patients admitted under the Department of General Surgery

Who comprise the Surgical PMR team? 

1. PMR Doctor 

2. Physiotherapist

3. Occupational Therapist 

4. Prosthetist and Orthotist

5. Psychologist 

Goal of PMR

• Enhance and restore functional ability of those with physical impairments or disabilities
• Maximize patients’ independence in activities of daily living and improve quality of life

Burns

• The emphasis is on EARLY assessment by the rehabilitation team.
• Passive therapies including splinting and positioning should be initiated to minimize the risk of burn scar contracture
• Improve respiration and reduce the risk of ventilator-associated pneumonias

• Complications like Heterotropic Ossification  (most common over posterior elbow)- can also be prevented by continuing movement at the joint. Physiotherapists play a big role in contracture and HO prevention as the main method of prevention is early passive movement followed by active movement. (M.B. Klein, S. Logsetty, B. Costa, et al.: Extended time to wound closure is associated with increased risk of heterotopic ossification of the elbow. J Burn Care Res)

• Contracture after burn injury is common, with the shoulder, elbow, and knee being the most common joints . Appropriate positioning for burn patients needs to be practiced from the initial acute stage. Positioning the axilla at more than 90deg abduction has had some concerns of brachial plexopathy, infrequently described in literature. ( J.C. Schneider, R. Holavanahalli, P. Heim, et al.: Contractures in burn injury: defining the problem. J Burn Care Res. 27 (4):508-514 2006, Whitehead C, Serghiou M. A 12-year comparison of common therapeutic interventions in the burn unit 30(2):281-287, 2009. )

• Applying splints to prevent or even treat a developed contracture also needs mentioning. They can be safely applied over acute burn wounds or even fresh skin grafts. e.g Aeroplane splint can be used for axillary burns, hand splints can be used to place the hand in a functional position, elbow splints can also be used to prevent elbow flexion contractures. P & O play a role here in providing good customized splints. (R. Richard, R.S. Ward: Splinting strategies and controversies. J Burn Care Rehabil. 26 (5):392-396 2005)

• Depression and anxiety disorders are reported to be the most prevalent mental issues(25% to 65%) in burn survivors during the first year after injury. Our role does not end with a lack of contractures and deformities, but with re-integration back into the community and society, a part which a Psychologist and Social Worker play.

  Some live with scars, physically and emtoionally. This psychosocial adjustment also needs to be addressed before we send them back to the community.

Wounds and Ulcers

• Pressure ulcers are more prone in certain pressure points and in those with long term comorbidities/ sensory changes like Spinal Cord Injury patients. Frequent change in position (every 2 hours) is necessary to prevent the formation of new ulcers and to heal old ulcers faster. It is important to mention a note about "donut cushions". These cushions should be avoided especially for Ischial and low sacral ulcers as they are more likely to produce more ulcers than prevent them.(R. Crewe: Problems of rubber ring nursing cushions and a clinical survey of alternative cushions for ill patients. Care Sci Pract. 5:9-11 198).  A better option would b contoured foam cushions which provide even pressure relief. 

• Prolotherapy is a process where solutions are injected for repair or restoration of soft tissue.  Dextrose, Sodium Morrhuate, Phenol, Patelet Rich Plasma and Adult Stem Cells are considered to be proliferants and their use for repair or functional restoration of soft tissue is considered Prolotherapy. Regeneration is brought by an increase in the balance of growth factors in the wounded area. (Waldman, S. (2011). Pain management. Philadelphia, PA: Saunders). 

Most of the studies done so far have focused on the use of PRP because of its high concentration of fibrin and growth factors which help promote healing. Many of these studies reported faster rate of healing of the ulcer. However, a Cochrane review (Martinez Zapata M, Marti Carvajal AJ et al, 25th May 2015, Autologous platelet rich plasma for Chronic wounds), reported that there MAY be an increased rate of healing in diabetic ulcers but there is a need for more robust, well controlled, randomized clinical trials to definitively demonstrate its efficacy.

POST SURGERY

• POST SURGICAL PAIN MANAGEMENT - Post surgical pain can be quite distressing, sometimes under treated and if not well controlled can lead to chronic post surgical pain

  Medications and modalities are two ways in which PMR can help in this regard.

1. Medications: Simple and Opioid analgesics, Antidepressants, Anticonvulsants, Skeletal Muscle Relaxants are some useful medications

2. Modalities:

• Electrical Stimulation

Use of electricity as a “counter-irritant to pain is esepcially helpful for acute postoperative pain. Contraindicated in people with pacemakers and those with impaired sensation to pain. (S.D. Waldman: Transcutaneous electrical nerve stimulation. Pain review. ed 1 2009Saunders Philadelphia 619-622)

• Hydrotherapy

This is another modality which helps with pain and stiffness reduction, used post surgery especially after joint replacement surgeries.

The water is usually maintained at  28-30 degree celcius. Immersion of the affected body part or entire body allows the high specific gravity of water to partially eliminate the effect of gravity. The buoyant force of water reduces the effective weight of the patient by 40% (E.M. Bartels, H. Lund, K.B. Hagen, et al.: Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. (4)2007 CD005523)

• MOVEMENT AFTER SURGERY

1. Physiotherapists do a good job with exercising and preventing stiff limbs. They play an essential role in early mobility.

   The role of Occupational Therapists might not be widely understood. To get a better idea, an example of their role post hand surgery is to work on achieving small hand functions again, work on intricate details which are needed for daily functions and to use adaptive equipment if necessary. In a broader view, they work closely with a patient to help them improve their balance post surgery, they help them with their Activities of Daily Living and make the necessary modifications if needed in their environment. This is very important in patients living with a permanent disability. In this way, they complete the rehabilitation process by addressing the full need of a patient in their home or work environment. 

2. Virtual Reality : One very new and interesting tool of trained Occupational Therapists, to enhance motor skills post surgery is Virtual reality . It uses computer gaming consoles for training daily functions, motor skills, balance etc.  Although many studies have been focused on Stroke, more high quality studies need to be done for more conclusive evidence. (Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.: CD008349. DOI: 10.1002/14651858.CD008349.pub4). 

   VR is also useful for pain, in this case Phantom Limb Pain post amputation. 

   Researchers have become more confident that VR is not only capable of distracting a patient from their acute pain, but of blocking their brain's pain receptors in much the same way a prescription opioid would. The researchers found that pain decreased an average of 60% during the session and 33% after the session, and the relief lasted from 2 to 48 hours after completion of the game. In the same way, it has been used for chronic pain and burn injuries. (Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Pain Manag. 2011 Mar;1(2):147-157. doi: 10.2217/pmt.10.15. PMID: 21779307; PMCID: PMC3138477). 

REHABILITATION POST AMPUTATION

1. After an amputation of a limb, most patients lose confidence in themselves. Though it is important for them to grieve the missing limb, it is also important for them to regain confidence else moving forward with rehabilitation becomes almost impossible. Psychologists play a vital role to reintroduce hope and acceptance at this time. 

2. During the acute post operative stage, the patient deals with a lot of pain at the residual limb. This is known as phantom limb pain. Medications, modalities and exercises reduce their pain. Limb protection and shaping is also crucial for future fitting of the prosthesis. 

3. Prostheses are artificial limbs which in the best manner possible, replace a missing part of the body or make that part of the body work better. After getting the right prosthesis with the right fit, the patient begins to train with it. This includes learning all the basic prosthetic skills before progressing to more specific activities. They are then re-integrated back into the community so they can further their independence and skills.  

To conclude, proper rehabilitation can play a major role in helping surgical patients find their balance in life again.