Role of Physiotherapy in various

abdominal surgeries
Dr. Vaishali, Sr. Lecturer,
N.R.I.P., Ahmedabad.
• Unless the surgery is specifically for gall bladder disease, inguinal or femoral
hernia, or nephrectomy, the incision will be a paramedian or midline with
extension as necessary to allow for adequate exposure.
• There are common abdominal surgeries like gastrectomy, cholecystectomy,
colostomy, appendicectomy, hysterectomy, hernioplasty and hernia repair,
explorative laparotomy, in which physiotherapy varies as per the incision and
procedure of surgery.
Gastrectomy:
• A gastrectomy is a medical procedure where all or part of the stomach is surgically
removed.
• A gastrectomy is often used to treat stomach cancer.
• Less commonly, it's used to treat:
• life-threatening obesity
• oesophageal cancer
• stomach ulcers (peptic ulcers)
• non-cancerous tumours
• Gastrectomy is usually an effective treatment for cancer and obesity.
Types of Gastrectomy:

• Partial gastrectomy: During a partial, or subtotal gastrectomy, a portion of the

stomach (typically the lower portion) is removed and in some cases, lymph nodes
and other organs and tissues may also be removed, e.g. Bilroth and Polya type
operation
• Total gastrectomy: During a total gastrectomy, the entire stomach is removed. In
cases of cancer, lymph nodes and other organs may be removed as well. This
procedure will require that the small intestine be connected to the remaining
portion of the esophagus.
• Sleeve gastrectomy: During a sleeve gastrectomy, the left portion of the stomach
is removed, typically during weight loss surgery.
• Esophago-gastrectomy: During an esophago-gastrectomy, the upper portion of
the stomach and a portion of the esophagus is removed.
• A gastrectomy can be performed using several surgical approaches, including:
• Open procedure: During an open gastrectomy, a large incision will be made
through the abdominal wall to access the abdominal organs; the incision will be
closed with staples or sutures.
• Laparoscopic procedure: During a laparoscopic gastrectomy, several small
incisions are made and laparoscopic surgical tools are inserted into these small
openings to access the abdominal cavity, versus the large open incision.
• As the operation is closely related to diaphragm there is likely to be irritation of
adjacent tissues which could cause increased production of mucus, particularly of
the lower lobe of left lung.
• After gastrectomy, the patient may develop left pulmonary atelectasis and the
physiotherapist needs to emphasize localized breathing(segmental breathing) to
both lower lobes but particularly to the left. The diaphragm will have been
handled in the operative procedure and the patient will be reluctant to breathe
deeply because of pain.
1. The notes must be read and the extent of the operation noted, together with the
nursing record of the patient’s condition since his return from the operating
theatre.
2. The position of drainage tubes, intravenous lines, catheter and type of dressing
should be noted. Note about the diet.
3. If analgesic drugs have been prescribed, the physiotherapist should arrange that
they are given before the physiotherapy.
• Coughing will be inhibited by pain and the presence of Ryle’s tube. So it is very
important that the physiotherapist pays special attention to the chest.

• Generally the patient may be treated pre-operatively with emphasis on deep

breathing, particularly lower costal, and taught how to cough effectively. Teach
him diaphragmatic breathing.

• Post-operatively the patient must be encouraged to do the deep breathing with

emphasis on the left lower costal area. Before attempting to cough the patient
should be helped to sit up in bed and lean slightly forward as this makes it easier
for him to huff and cough. Huffing must be taught first.
• Assistive cough manoeuvre can be used to teach coughing by means of hands or
cough belt. The patient places his hands over the incision while the physiotherapist
supports him in sitting and places one hand over the patient’s hands and the other
round his back to give pressure on the left lower costal area.

• Treatment to the chest should be intensive, particularly if there is the slightest

indication of a problem.

• The patient is likely to tire quickly and so the treatment should be given for short
duration and frequently. The patient must be taught to practise on his own.
• Prevent thrombosis of the legs by encouraging active leg movements or by
performing passive exercises, for example: ankle pump, active hip-knee flexion,
isometrics for quads and gluteal muscles, isometric erector spinae.
• Educate about stockings and leg elevation (trendelenberg’s position).
• General mobilizing and strengthening exercises by means of combined active limb
movements with respiration, isometric abdominals(IA), straight leg raising(SLR-
unilateral followed by bilateral on progression), obliques muscles strengthening.
• As the patient’s condition is improving educate the technique to sit and stand
(teach open kinematic to close kinematic exercise).
• Emphasise on core muscle (abdominals, multifidus, pelvic floor, diaphragm)
strengthening in various positions, sitting, standing, walking and during
activity. Helps to enhance core stability and prevents long term
complications.
• Educate the patient about diet and long term exercise protocol, helps to prevent
post operative complications which may develop after along time.
• Recent advances evidenced the effect of kinesio-taping over abdominal
muscles post-operatively by means of inhibiting pain over the incisional site,
helps in faster healing of incisions and improve the posture.
• Certain complicated cases in which incisions are delayed to heal,
electrotherapeutic modalities i.e. Ultra-sound, ES, LASER can be useful.
Cholecystectomy:
• This operation may be performed following the development of stones in the gall-
bladder and cystic duct(Cholelithiasis). The stones cause attacks of colic and
jaundice and may obstruct bile duct. If there is an acute attack of cholecystitis, the
surgeon may treat the condition conservatively until the inflammation has
subsided and then operate. The pain experienced by the patient may be very acute
and cause considerable distress.
• A Kocher’s incision, a right paramedian or midline incision are used.
Following the removal of the gall-bladder a T-tube is inserted and left for
approximately 48 hours or longer if necessary to allow drainage of any bile or
blood into a bag. The amount of bile is measured to ascertain whether any
leakage is occurring. The patient makes a good recovery.
• Removal of the gall-bladder does not require any special diet once the patient has
recovered from the operation.
• Complications that may occur after this operation are: pulmonary, haemorrhage or
leakage of bile.
• The problem that is most likely to concern the physiotherapist is the risk of
pulmonary complications. Preoperative assessment is essential and decide on the
treatment required.
• The patient may be taught breathing exercises and how to cough effectively.
A careful explanation must be given to the patient about the reasons for treatment
and what will be expected of him after surgery.
• The actual surgical procedure is very close to the diaphragm and the
irritation may cause the production of increased mucus secretions in the lung.
• Post-operatively deep breathing will be painful because of the position of the
incision and the presence of the drainage tube. Initially the patient will have a
Ryle’s tube which will make coughing difficult.
• Atelectasis is most likely to occur in the lower lobe of the right lung because of
the position of the gall-bladder on the right side of the upper part of the abdominal
cavity. Analgesics given to relieve pain before treatment.
• Emphasis must be placed on gaining good expansion of the right lung and getting
rid of any secretions.
• The physiotherapist should give the patient lower limb exercises and advice about
the amount of activity to try to prevent any circulatory problems.
• There is a tendency for these patients to be overweight and if so they may not have
been very active before the operation which further increases the risk of
pulmonary and circulatory complications.
Colostomy:
• There is an artificial opening in the large bowel to divert the faeces to the exterior
where they are collected in a disposable, adhesive plastic bag. Usually this
procedure is carried out because of obstruction or disease of the large intestine
caused by diverticulitis, Crohn’s disease or carcinoma. The colostomy may be
temporary or permanent. A temporary colostomy is often placed in relation to the
transverse colon whereas a permanent one is usually placed as far distally as
possible.
• There are a number of problems for a patient with a permanent colostomy. Firstly,
there is the worry about the success of the operation if it has been carried out to
remove a malignant tumour. Secondly, the patient will probably be concerned
about his ability to manage a colostomy, if he is elderly. Thirdly, the patient will be
concerned about whether he can lead a normal life and once out of hospital may
tend to shun social activities. The patient must be helped to overcome these
problems by all the members of the team. Specially trained nurses dealing with
colostomies are known as stoma nurses or therapists.
• As this operation involved the lower part of the abdominal cavity and pelvis there
is an increased risk of a DVT developing postoperatively. Must teach the patient
lower limb exercises preoperatively and they should be continued for a couple of
weeks postoperatively. It may be considered that the patient is active enough when
he is up and walking but this activity may be minimal and it is wise to encourage
the patient to do a series of leg exercises before getting out of bed and at regular
intervals when sitting in a chair.
• Breathing exercises pre and post-operatively should be taught if the patient is at
risk because of a chest condition or he smokes or he is elderly and relatively
inactive.
• Before the patient leaves hospital he should be taught how to lift correctly and
avoid excessive strain on the abdominal muscles. The physiotherapist must help
the patient to appreciate that he will be able to undertake normal activities both
physically and socially after he has recovered.
Ileostomy:
• This is similar to a colostomy except that the opening is in the right side of the
lower abdominal cavity. Usually it follows a more extensive resection of the colon
than a colostomy.
• Physiotherapy remains the same as colostomy.
Nephrectomy:
• The kidney may be removed because of a malignant tumour or infection, provided
the remaining kidney is normal. The kidney lies close proximity to the diaphragm
and so pulmonary complications following surgery are a risk.
• The emphasis should be on posterior basal and lower costal breathing,
concentrating on the side of the nephrectomy.
Prostatectomy:
• This is usually carried out for benign growths of the prostate which commonly
occur in elderly men. It is less commonly performed for carcinoma because early
diagnosis is difficult and the growth may have spread too far. However, surgery
may be required to relieve urinary obstruction.
• Pulmonary complications may occur because these patients are elderly and
may be relatively inactive. Also a number are likely to suffer from chronic
chest disease and so are at risk. In view of this, these patients should be
carefully assessed and treated if necessary. They are generally up within a day or
two after surgery but it is important to see they are sufficiently active otherwise
there is the risk of developing pulmonary complications.
Hernia:
• A hernia is a protrusion of a viscus or part of a viscus through an abnormal
opening in the wall of the containing cavity.
• Various types of hernia: Hiatal hernia, Inguinal hernia, Femoral hernia,
Strangulated hernia, Umbilical hernia and Incisional hernia.
• Hiatal hernia: In this condition there is a weakness in the oesophageal opening of
the diaphragm and part of the stomach may pass upward into the thoracic cavity.
Treatment may be conservative but if this fails, surgery may be required. The
surgeon may use a thoracic or abdominal route, although the latter is preferable as
it may be necessary to investigate for other causes of dyspepsia. There are various
surgical procedures that can be used but the main aim is to repair the hiatus.
• As the operation is closely related to diaphragm there is likely to be irritation
of adjacent tissues which could cause increased production of mucus,
particularly of the lower lobe of left lung.
• The patient may develop left pulmonary atelectasis and the physiotherapist
needs to emphasize localized breathing(segmental breathing) to both lower lobes
but particularly to the left. The diaphragm will have been handled in the operative
procedure and the patient will be reluctant to breathe deeply because of pain.
1. The notes must be read and the extent of the operation noted, together with the
nursing record of the patient’s condition since his return from the operating
theatre.
2. The position of drainage tubes, intravenous lines, catheter and type of dressing
should be noted. Note about the diet.
3. If analgesic drugs have been prescribed, the physiotherapist should arrange that
they are given before the physiotherapy.
• Coughing will be inhibited by pain and the presence of Ryle’s tube. So it is very
important that the physiotherapist pays special attention to the chest.

• Generally the patient may be treated pre-operatively with emphasis on deep

breathing, particularly lower costal, and taught how to cough effectively. Teach
him diaphragmatic breathing.

• Post-operatively the patient must be encouraged to do the deep breathing with

emphasis on the left lower costal area. Before attempting to cough the patient
should be helped to sit up in bed and lean slightly forward as this makes it easier
for him to huff and cough. Huffing must be taught first.
• Assistive cough manoeuvre can be used to teach coughing by means of hands or
cough belt. The patient places his hands over the incision while the physiotherapist
supports him in sitting and places one hand over the patient’s hands and the other
round his back to give pressure on the left lower costal area.

• Treatment to the chest should be intensive, particularly if there is the slightest

indication of a problem.

• The patient is likely to tire quickly and so the treatment should be given for short
duration and frequently. The patient must be taught to practise on his own.
• Prevent thrombosis of the legs by encouraging active leg movements or by
performing passive exercises, for example: ankle pump, active hip-knee flexion,
isometrics for quads and gluteal muscles, isometric hamstrings, isometric erector
spinae.
• Educate about stockings and leg elevation(trendelenberg’s position).
• General mobilizing and strengthening exercises by means of combined active limb
movements with respiration, isometric abdominals(IA), straight leg raising(SLR-
unilateral followed by bilateral on progression), obliques muscles strengthening.
• As the patient’s condition is improving educate the technique to sit and stand
(teach open kinematic to close kinematic exercise).
• Emphasis on core muscle (abdominals, multifidus, pelvic floor, diaphragm)
strengthening in various positions, sitting, standing, walking and during
activity. Helps to enhance core stability and prevents long term complications.
• Educate the patient about diet and long term exercise protocol, helps to prevent
post operative complications which may develop after along time.
• Recent advances evidenced the effect of kinesio-taping over abdominal muscles
post-operatively by means of inhibiting pain over the incisional site, helps in faster
healing of incisions and improve the posture.
• Certain complicated cases in which incisions are delayed to heal,
electrotherapeutic modalities i.e. Ultra-sound, ES, LASER can be useful.
• Inguinal hernia: this may be indirect or direct and is a protrusion of a sac of
peritoneum containing omentum and possibly intestine through the inguinal canal.
• The indirect hernia is usually congenital and passes through the length of the canal
whereas the direct hernia is medial and projects through a weakness in the
posterior wall of the canal.
• The direct hernia occurs in middle-aged to elderly men and often associated with
stress on the abdominal wall caused by a chronic cough or strain on lifting. In
infants with a congenital abnormality a herniotomy with removal of the sac may
be adequate. In the adult more extensive surgery is preferable.
• There are risk of pulmonary and circulatory problems.
• The operation performed is a herniorrhaphy which reduces the herniation and
repairs the weakness of the posterior wall.

• Femoral hernia: these are more common in women and are a protrusion of the
peritoneal sac through the femoral ring. The increase of intra-abdominal pressure
that occurs in pregnancy may be a precipitating cause. Surgery is usually the
treatment of choice because of the risk of strangulation.
• Incisional hernia: these may occur through previous operation scars, usually
because of infection at the site of operation or poor healing which weakens the
incisional area. Surgery may be necessary if the hernia cannot be controlled with a
pad and abdominal belt as there may be a risk of strangulation.
• Strangulated hernia: this may require emergency surgery with resection of the
gangrenous section of the bowel.
• Umbilical hernias: these are more common in children although they can occur in
older, obese patients with weak abdominal muscles and possible weakness of
tissues in the umbilical region.
Role of Physiotherapy in Hernia:

• For patients undergoing surgery for an inguinal hernia, pulmonary complications

may be a risk when there is a chronic chest condition, in which case pre and post-
operative breathing exercises are important. The surgeon may request
physiotherapy to improve the condition of the chest before he will operate.
• A DVT is a possible complication after herniorraphy and so exercises for the legs
should be given before and after surgery. These patients are likely to have weak
abdominal muscles which should be strengthened after surgery. A progressive
scheme of exercises starting with static contractions in the middle to inner range
and following with free active exercises should be implemented.
• Care should be taken not to go beyond the ability of the individual patient and
exercises in the outer range of the abdominal muscles should be avoided.
• Patients should be instructed in correct lifting techniques especially when the
history indicates that lifting might have been a precipitating cause in producing a
rupture.
• Patients undergoing surgery for a femoral hernia should have similar
physiotherapy. The risk of pulmonary complications is smaller but there may be a
greater risk of developing a DVT. Correct lifting techniques should be taught so
that the intra-abdominal pressure is not abnormally high during lifting.
Appendicectomy(appendectomy)
• It is a surgical operation in which the vermiform appendix (a portion of the
intestine) is removed. Appendectomy is normally performed as an urgent or
emergency procedure to treat acute appendicitis.
• The incision is made over McBurney's point (one-third of the way from ASIS to
the umbilicus, right side), which represents the most common position of the base
of the appendix. Other incisions used are Lanz incision, Rutherford morrision,
Paramedian incision.
• As this operation involved the lower part of the abdominal cavity and pelvis there
is an increased risk of a DVT developing postoperatively. Must teach the patient
lower limb exercises preoperatively and they should be continued for a couple of
weeks postoperatively. It may be considered that the patient is active enough when
he is up and walking but this activity may be minimal and it is wise to encourage
the patient to do a series of leg exercises before getting out of bed and at regular
intervals when sitting in a chair.
• Breathing exercises pre and post-operatively should be taught if the patient is at
risk because of a chest condition or he smokes or he is elderly and relatively
inactive.
• Before the patient leaves hospital he should be taught how to lift correctly and
avoid excessive strain on the abdominal muscles. The physiotherapist must help
the patient to appreciate that he will be able to undertake normal activities both
physically and socially after he has recovered.
Hysterectomy:
• Total hysterectomy refers to the removal of the uterus and one or both tubes and
ovaries may be included depending on the condition.
• Wertheim’s hysterectomy is an extended operation removing uterus, tubes and
ovaries and includes lymphadenectomy.
• Hysterectomy is used in the treatment of organic pelvic diseases for the following
conditions:
1. Dysfunctional uterine bleeding after failure of hormone treatment.
2. Endometrial carcinoma and carcinoma of the cervix.
3. Severe uterine or ovarian endometrioma type cysts.
4. Myomatal-bening tumours that develop in the myometrium of the uterus.
• The hysterectomy is performed through either an abdominal or a vaginal incision.
The abdominal incision most commonly used is the lower midline incision.
• Repair operations: the range covers corrective surgery relating to prolapse.
Prolapse is a form of hernia and occurs through failure of some of the supporting
tissues of the muscular vagina and transverse cervical ligaments of the uterus.
Depending on the degree of strain there is often enough tone in the supporting
tissues to prevent prolapse until the climacteric (menopause). Then muscular
atrophy occurs and prolapse may become evident. For this reason operative repair
procedures are more common after the age of 45 years.
• Vaginal prolapse: when the anterior wall of the vagina is damaged it may cause
herniation of the bladder and damage to the posterior wall may affect the rectum.
• Utero-vaginal prolapse: descent of the uterus is accompanied by the upper vagina
and is also associated with rectocele and cystocele.
• Operations used:
1. Anterior and posterior colporrhaphy- repair of vaginal tissue and fascia
2. Manchester repair which combines colporrhaphy with amputation of the cervix
and shortening of the transverse cervical ligaments.
• Pre-operative care and advice: the physiotherapist teaches the patient the value
of postoperative physiotherapy and the main exercises are taught.
• Post-operative care and advice: the aims of the physiotherapist will be to,
1. Assist in the prevention of circulatory and respiratory complications.
2. Strengthen pelvic floor, abdominal and back muscles.
3. Teach postural correction.
4. Advise on back care.
5. Advise on progression of activities to full function.
• Method of treatment:
1. Deep breathing and frequent foot and leg movements practised slowly in full-
range assist general circulation, aiding venous return in the first 48 hours.
2. The patient is taught to remove secretions by coughing, supporting the
abdominal or perineal incision, with forearms supporting the abdominal wall
over a pillow to prevent the pain of the abdominal movement, supporting the
perineum, one hand placed on a sanitary pad with gentle pressure upwards
prevents pain after vaginal surgery. Long, slow breaths emphasizing the breath
out and repeated ‘huffs’ will help project mucus into the mouth with minimum
discomfort.
3. Exercises: Pelvic tilting is performed slowly and smoothly. This helps to relieve
pain by preventing protective muscle spasm in abdominal and back muscles.
Abdominal muscle contractions can help to relieve flatulence and the discomfort of
this. Pelvic floor exercise(known as KEGEL exercises) which is common
following hysterectomy and some repair operations that catheterization is used to
drain the bladder and rest repaired tissues. The catheter is usually removed within 48
hours. Some surgeons prefer pelvic floor exercises to be delayed until after the
catheter is removed.
4. posture: once drainage tubes are out the patient is encouraged to ease herself out
of bed comfortably with knees together and to stand and walk tall. It is very
tempting to stoop to guard against pain of the abdominal wound but if the advice is
followed pain is lessened because standing tall corrects the spinal curves, and
muscle balance, removing the protective tension that adds to pain.
5. Advice on level of activity until returning to normal function from hospital
discharge:
a. Rest and activity should be balanced; lying on the bed for an extra rest daily for
3-4 weeks.
b. Reduce standing. Sit on a stool or chair for light household tasks.
c. Avoid pushing or pulling objects forcefully.
d. Graduated exercises will help to strength abdomen and back muscles:
• crook lying knee rolling,
• crook lying sit up,
• crook lying hip hitching,
• 2-3 weeks prone lying buttocks tightening, alternate leg raising.
e. Avoid lifting and carrying for 6 weeks. When lifting, hold objects close in to the
body, feet apart. Use leg muscles by bending knees- never stoop.
f. Return to work will vary between 6 and 12 weeks.
• It is important, however, that for at least a year she pays attention to warm up and
stretching before sport or heavy household tasks such as furniture removing.
• Kinesio-taping is evident:
The research proved that KT(kinesio-taping) method is highly effective in treating
patients after abdominal surgery.
Resulted in improvement in intestinal peristalsis, pain relief, reduction of
measured abdominal circumference.
Partial relief of subjective pain sensation during the day following KT application
and reduced need for using analgesic agents.
An opportunity for patients to undergo the whole kinesiotherapy procedure, which
was previously limited due to pain and discomfort sensation.
• There are four basic therapeutic aims:
Mechanical correction
Restoration of normal fluid perfusion
Support for muscular activity
Analgesic system activation
Advancement of postoperative wound healing
• KT is applied over the abdominal muscles locations, NOT over the incision
site or dressings.
Caesarian section:
• Caesarean section, also known as C-section, or caesarean delivery, is the use
of surgery to deliver babies.
• A caesarean section is often necessary when a vaginal delivery would put the
baby or mother at risk. This may include obstructed labor, twin pregnancy, high
blood pressure in the mother, breech birth, or problems with
the placenta or umbilical cord.
• A caesarean delivery may be performed based upon the shape of the
mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-
section may be possible. The WHO recommends that caesarean section be
performed only when medically necessary.
• A C-section typically takes 45 minutes to an hour. It may be done with a spinal
block, where the woman is awake or under GA, Urinary catheter is used to drain
the bladder, and the skin of the abdomen is then cleaned with an antiseptic. An
incision(Pfannentiel’s or lower midline) of about 15 cm (6 inches) is then typically
made through the mother's lower abdomen. The uterus is then opened and the
baby delivered. The incisions are then stitched closed. A woman can typically
begin breastfeeding as soon as she is awake and out of the operating room. Often,
several days are required in the hospital to recover sufficiently to return home.
• C-sections result in a small overall increase in poor outcomes in low-risk
pregnancies. They also typically take longer to heal from, about six weeks, than
vaginal birth. The increased risk include breathing problems in the baby
and amniotic fluid embolism and postpartum bleeding in the mother.
• Role of physiotherapy remains the same as hysterectomy.
Explorative laparotomy:
• An explorative laparotomy is a surgical operation where the abdomen is opened
and the abdominal organs examined for injury or disease. It is the standard of care
in various blunt and penetrating trauma situations in which there may be multiple
life-threatening injuries and in many diagnostic situations in which the operation is
undertaken in search of a unifying cause for multiple signs and symptoms of
disease.
• These applications are distinct from laparotomy performed for specific treatment,
in which the surgeon plans and executes a therapeutic procedure.
• Indications and procedure: The trauma ex-lap is the most comprehensive ex-lap,
usually undertaken after evidence of internal bleeding.
• A midline incision is carried down to the linea alba and the fascia is incised. The
peritoneum is entered and any immediate, life-threatening bleeding is identified
and controlled. The lateral, superior and anterior surfaces of the liver are packed
with sponges and the superior, lateral spaces around the spleen are similarly
packed. The gastrocolic ligament is incised and the lesser sac is explored,
including the posterior stomach and the anterior pancreas. The surface of the
spleen is examined for evidence of laceration and fracture. The liver is similarly
examined.
• If the duodenum is at risk, a Kocher’s maneuver may be performed to examine the
posterior duodenum and the head of the pancreas.
• The ex-lap can lead immediately to a number of other procedures, including
splenectomy, repairs of the vena cava, repairs of the aorta, pericardial window,
repairs of iliac arteries or veins, distal pancreatectomy, bowel repair, gastric
diversion and the trauma whipple.
• Depending on the stability of a patient following an exploratory laparotomy, the
abdomen may either be sutured closed primarily or may be temporarily closed
with a vacuum dressing, saline bag or towel clips to facilitate further non-surgical
resuscitation prior to definitive closure.
• The first documented ex-lap was performed by Frank Zurfley in 1842, on a patient
with suspected peritoneal haemorrhage after being run over by a Conestoga
wagon.
• The aims of the physiotherapist will be to,
1. Assist in the prevention of circulatory and respiratory complications.
2. Strengthen pelvic floor, abdominal and back muscles.
3. Teach postural correction.
4. Advise on back care.
5. Advise on progression of activities to full function.
• Method of treatment:
1. Deep breathing and frequent foot and leg movements practised slowly in full-
range assist general circulation, aiding venous return in the first 48 hours.
2. The patient is taught to remove secretions by coughing, supporting the
abdominal or perineal incision, with forearms supporting the abdominal wall
over a pillow to prevent the pain of the abdominal movement, supporting the
perineum, one hand placed on a sanitary pad with gentle pressure upwards
prevents pain after vaginal surgery. Long, slow breaths emphasizing the breath
out and repeated ‘huffs’ will help project mucus into the mouth with minimum
discomfort.
3. Exercises: Pelvic tilting is performed slowly and smoothly. This helps to relieve
pain by preventing protective muscle spasm in abdominal and back muscles.
Abdominal muscle contractions can help to relieve flatulence and the discomfort of
this. Pelvic floor exercise, which is common following hysterectomy and some
repair operations that catheterization is used to drain the bladder and rest repaired
tissues. The catheter is usually removed within 48 hours. Some surgeons prefer
pelvic floor exercises to be delayed until after the catheter is removed.
4. posture: once drainage tubes are out the patient is encouraged to ease herself out
of bed comfortably with knees together and to stand and walk tall. It is very
tempting to stoop to guard against pain of the abdominal wound but if the advice is
followed pain is lessened because standing tall corrects the spinal curves, and
muscle balance, removing the protective tension that adds to pain.
5. Advice on level of activity until returning to normal function from hospital
discharge:
a. Rest and activity should be balanced; lying on the bed for an extra rest daily for
3-4 weeks.
b. Reduce standing. Sit on a stool or chair for light household tasks.
c. Avoid pushing or pulling objects forcefully.
d. Graduated exercises will help to strength abdomen and back muscles:
• crook lying knee rolling,
• crook lying sit up,
• crook lying hip hitching,
• 2-3 weeks prone lying buttocks tightening, alternate leg raising.
e. Avoid lifting and carrying for 6 weeks. When lifting, hold objects close in to the body,
feet apart. Use leg muscles by bending knees- never stoop.
f. Return to work will vary between 6 and 12 weeks. Advise to resume personal activities
too. It is important, however, that for at least a year she pays attention to warm up and
stretching before sport or heavy household tasks such as furniture removing.
• A laparotomy is a major operation and once home it may take a few months to return to
normal level of activity.
Case reports:
• Cholecystitis Case Report
• Keywords
Cholecystitis, Murphy’s Sign, Musculoskeletal Origin, Systemic Origin,
Physical Therapist, Referral
• Author/s
Laura Matrisciano and Spencer Fuehne
• Abstract
A patient is complaining of a musculoskeletal problem (RUE), but has
signs and symptoms that could indicate the pain is systemic in origin.
This is an example of how physical therapists can effectively handle
situations that are not within our scope of practice.
• Systemic problems can present with symptoms that are similar to musculoskeletal
problems. Sometimes patients have trouble correlating their systemic signs and
symptoms to their musculoskeletal signs and symptoms. For example, sometimes
a patient may not realize that their stomach pain may be related to their
recent onset of shoulder pain. As physical therapists, we are responsible for
recognizing if a patient’s pain is coming from a musculoskeletal structure or a
visceral source. If it doesn’t follow a musculoskeletal pattern, we need to be able
to refer the patient to the proper medical professional. Asking appropriate
questions and recognizing clusters of symptoms are an important skill for physical
therapists to develop in order to ensure each patient receives the medical attention
he or she requires.
• Case Presentation
45-year-old Native American woman reports to your clinic with complaints of an achy pain in her
right shoulder. She reports that she also feels the pain along her right scapula and in between
her scapulas. Her current pain level is 4/10. The patient can’t remember a specific incident that
started causing her shoulder pain, but has been experiencing the pain off and on for the past 3
months. At worst her pain is an 8/10. When asked, she notes that she does tend to experience
discomfort in her abdomen with eating. She has had a few episodes of fever, nausea, and
vomiting over the past 3 months, but credits that to the “bug that has been going around.” Pt.
reports that she has been feeling full lately, but denies jaundice. She also fails to report on whether
or not there have been changes in her stool.

Her PMHx include Type 2 Diabetes (diagnosed 5 years ago), she takes a statin to manage her
cholesterol levels, and she reports her mother had her gall bladder removed.
• Objective:
• Ht: 5’4”
• Wt: 175 pounds
• HR: 85bpm
• BP: 146/92
• Temperature: 99.7 F
• Positive Murphy’s Sign
• Quick DASH score(Disabilities of the Arm, Shoulder and Hand): 50
• FABQ(Fear Avoidance Belief Questionnaire): 10
• Shoulder ROM measurements are all normal, movement fails to replicate
symptoms
• Shoulder strength 5/5 all planes
• Clinical Impression
The physical therapist notices that the patient’s symptoms don’t seem to
point toward a musculoskeletal origin. After finding the associated risk factors
coupled with a positive Murphy’s Sign, the physical therapist is lead to believe
the patient’s pain is originating from a visceral source.

Intervention
Send clinical findings to patient’s PCP and educate patient on pain management
and importance of seeking care from primary provider promptly.

Outcomes
Patient was suspected of having cholecystitis. Physical therapist will schedule
visits for physical therapy pending physician’s assessment of systemic symptoms.
• Discussion
Cholecystitis has symptoms that can mimic musculoskeletal problems, but
requires referral to other health professionals before further treatment by physical
therapy. Failure to improve with physical therapy may indicate a possible
underlying systemic issue. It is important that physical therapists ask prying
questions to reveal underlying systemic symptoms that can help determine
whether or not a referral is necessary.

• Resources

• The American College of Gastroenterology-www.acg.gi.org

National Digestive Disease International Clearinghouse-digestive.niddk.nih.gov
Thank you