Stomaching the Need for Physical Therapy after Abdominal Surgery
When someone requires abdominal surgery, there is an underlying dysfunction which needs to be corrected. The surgery to address the issue at hand is wide and varied depending on the situation. It may involve repairing a hernia or part of the digestive tract. It may involve removing an organ or removing an infant that cannot be delivered traditionally. While the primary problem may be corrected with surgery, dysfunction can continue after the fact. The new issues that can arise post-operatively after abdominal incisions can nonetheless be immediate, debilitating, and if left unchecked – chronic in nature.
The need for abdominal surgeries are as varied as the people whom need them. Caesarean sections (C-Sections), hysterectomies, organ resection, organ replacement, hernia repairs, and intestinal repairs just scratch the tip of the ice burg as to the potential need for an abdominal incision. As eclectic as these procedures are, they do share some common ground – they all can lead to dysfunction after the fact. This dysfunction may be in the form of pain, muscle length/flexibility restrictions, strength deficits and/or functional impairments.
Pain after abdominal surgeries has been shown to be under-reported according to various studies. 1,2,3,4 Part of this under statement may be due to patients expecting pain after abdominal surgery thereby underreporting its severity during post-operative reports/follow ups. Another possibility is that pre-medicating symptoms before pain onset results in lower pain reports. Despite these variables, some studies report pain as high as 54% in certain populations following abdominal surgery. 6 What’s more, this pain has been shown to vary in intensity from moderate to severe depending on the patient. 7 Not only can this pain present in the immediate, acute periods following the surgery, but chronically 6-12 months post-operatively.4
Post-surgical pain can originate from many sources. It can be produced somatically from the organs involved with surgery. It can be produced from the soft tissues in and around the incision site including the skin, fascia, muscles, tendons and ligaments. The nerves can also be compressed at a superficial, cutaneous level leading to neuralgia. This compromise on the nerve tissue may come by way of swelling, scar tissue entrapment, muscle length insufficiency or hyperactivity of the nerve itself. Physical Therapy can help alleviate many of the soft tissue limitations contributing to pain. Stretching, soft tissue mobilization, myofascial release, and various modalities can target these symptomatic soft tissues. Neurological desensitization techniques to reduce nerve hyperactivity can also be utilized. The results of such Physical Therapy interventions could potentially improve patients’ pain quality post-operatively and by doing so, improve a patient’s function with activities that would otherwise be limited by pain. Reducing pain could also improve the other facets that come along with pain including social functioning, physical activity, occupational proficiency, mental health, and other daily functions.6 Physical Therapy thus carries the potential to enhance a patient’s overall well-being post-operatively by improving the ability to return to activities such as recreation, work, social engagements and activities that promote physical and mental health.
From a muscular standpoint, adaptive changes can occur after abdominal surgery depending on the type of surgery and structures involved. In the case of inguinal hernia repairs, certain muscle groups are prone to dysfunction based on the anatomy of this region. The hip flexors, proximal quadriceps and lower abdominal muscle groups can shorten, weaken or become sore because of the soft tissue and nerve issues noted above. This can have the consequence of impairing such basic daily functions as walking, transferring from sitting to standing and positioning yourself throughout the day. An appropriate rehabilitation program to address the soft tissue or neurological structures involved would allow patients to improve these basic daily functions. From there, more involved and laborious activities such as exercise can be addressed and restored. Failure to improve upon these various components may lead to future problems with the recurrence of hernias. 4,5 If the stabilizing musculature is left weak and the surrounding structures remain tight after a hernia repair, there is a greater chance of reinjuring the repaired site and/or causing the development of yet another hernia. 4
High levels of pain and dysfunction have been shown in females undergoing caesarean (C-Sections) and hysterectomies. Although the incisions for these two procedures are different, the dysfunction that follows is not. Based on the anatomy of this region, the various layers of abdominal muscles and hip flexors can be affected. Muscle tightness, weakness or the complete inability to contract these muscles may occur. This can result in impaired movement patterns such as getting in/out of bed, chairs and vehicles. Changes in gait can lead to altered walking patterns that over time lead to compensation related over-use injures such as tendinitis, bursitis and arthralgia. Gait training and exercises to address the strength and flexibility impairments can help to break this downward cycle and improve mobility.
Strength deficits of the abdominal muscles after C-Sections and hysterectomies can lead to a host of hip and spine related conditions. If these muscles are tight, weak or lose the ability to contract, pain related to instability may ensue. 1 This instability can contribute to disk bulges, vertebrae positional faults, and positional faults of the hips including innominate up-slips/down-slips and rotations. All of these conditions can impair function, mobility and contribute to hip and back pain. Physical Therapy can be the first line of defense against the pain, flexibility, and weakness of these respective impairments. This can be accomplished by means of therapeutic exercise, modalities, and muscular re-education techniques. Manual approaches to address soft tissue adhesions and positional faults of the hips/spinal segments can also be utilized.
Physical Therapy has the scope of care needed to improve pain, function and mobility following abdominal surgeries. The result of this care has the potential to drastically improve the quality of life after such surgeries. While abdominal surgeries are a very common and necessary thing, the ensuing pain and dysfunction that follows doesn’t have be part of that necessity.
- Nikolajsen, L., Sorensen, H.C., Jensen, T.S., Kehlet, H. (2003). Chronic pain following caesarean section. Acta Anaesthesiologica. 220 (3), 1145-1157.
- Gupta, A., Perniola, A., et. al. (2004). Postoperative pain after abdominal hysterectomy: a double-blind comparison between placebo and local anesthetic infused intraperitoneally. Anesthesia & Analgesia. 99(4), 1173-1179.
- Courtney, C.A., Duffy, K., et. al. (2002). Chronic pain and quality of life following open inguinal hernia repair. British Journal of Surgery. 88(8), 1122-1126.
- Bay-Nielsen, M., Perkins, F., et. al. (2001). Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Annals of Surgery. 233(1), 1-7.
- Pappas-Gogos, G., Mavridou, P., et. al. (2010). Different pain scores in single transumbilical incision laproscopic cholecystectomy versus classic laproscopic cholecystectomy: a randomized controlled trial. Surgical Endoscopy. 24 (8), 1842-1848.
- Poobalan, A., Amudha S., et. al. (2003). A review of chronic pain after inguinal herniorrhaphy. Clinical Journal of Pain. 19 (1), 48-54.
- (2007). Classifying postherniorrhaphy pain syndromes following elective inguinal hernia repair. World Journal of Surgery. 31(9), 1760-1765.
- Poobalan, A.S., Bruce, J., et. al. (2001). Chronic pain and quality of life following open inguinal hernia repair. British Journal of Surgery. 88(8), 1122-1126.
- German, T. (2017). Seminar for manual therapy for low back pain: hands-on treatment for lumbar, sacroiliac, and pelvic dysfunctios. Vyne Education.