PRACTICE PATTERN OF PHYSIOTHERAPIST IN A PATIENT

WITH UPPER ABDOMINAL SURGERY IN GUJARAT-A CROSS

SECTIONAL STUDY

SUBMITTED BY

DHARA APARNATHI

TO,

DRS. KIRAN & PALLAVI PATEL GLOBAL

UNIVERSITY(KPGU),VADODARA.

TOWARDS PARTITAL FULLFILMENT OF

MASTER OF PHYSIOTHERAPY

IN CARDIO-RESPIRATORY AND INTENSIVE CARE

UNDER GUIDENECE OF

DR.TEJAS CHOKSHI(PT)

ASSISTANT PROFESSOR

MPT CARDIOPULMONARY SCIENCE (ICU)

KRISHNA SCHOOL OF PHYSIOTHERAPY & REHABLITATION

KRISHNA EDUCATION CAMPUS VADODARA-MUMBAI NH#8

VARNAMA, VADODARA-391243
 INDEX

SR NO. TITLE PAGE NO.

1 INTRODUCTION 1-4

2 AIM & OBJECTIVES 5

3 REVIEW OF LITERATURE 6-7

4 MATERIALS & METHODOLOGY 7-9

5 REFERENCES 10-11
INTRODUCTION:
Abdominal surgery is a wide term used in surgical procedures in abdominal

area for diagnosis and treatment of presenting medical problems .[1]Abdominal

surgery is performed to remove tumor cell, to resolve visceral tissue perforations or to

remove inflammatory bowel segments, benign growths or vascular aneurysms. It is

the most frequently using surgery. World-wide, approximately 500 to 1,000

procedures per 1,00,000 head of population are performed annually in developed

countries .[2]

Abdominal surgery can be divided according to the location and length of the

main incision.[2].Different type of technique and medical procedures may be used

according to abdominal organ involved and the type of condition being

examined.[1]Upper abdominal surgery (UAS) involves an incision above or extending

above the umbilicus and lower abdominal surgery (LAS) involves incisions below the

umbilicus. Surgery may be open (with an incision >5cm), laparoscopic or a

combination of both.[2]

Upper abdominal surgery was defined as any surgical procedure performed

through an incision above or extending above the umbilicus.[1]

The incisions used for exploring the abdominal cavity can be classified as :[3]

(A) Vertical . These may be (i) Midline (ii)Paramedian

(B) Transverse and oblique incisions :

(i) Kocher's sub costal (a) Chevron (Roof topModification)(b) Mercedes Benz

Modification

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(ii) Transverse Muscle dividing (iii) Mc Burney’s Grid iron or musclespliting (iv)

Oblique Muscle cutting(v) Pfannenstiel (vi) Maylard Transverse Muscle cutting

(C) Abdominothoracic.

There are chances of pulmonary complication after upper abdominal surgery

and proper measures should be taken to prevent pulmonary complication. Risk factors

for the development of PPCs include duration of anesthesia, current smoking status

of patient, respiratory co morbidities, obesity, increased age and multiple surgeries.

Postoperative complications are common following major abdominal surgery with

one third to half of all patients having some type of complication following their

operation.[4]

PPC's have been defined as "an identifiable disease or dysfunction that is

clinically relevant and adversely affects the clinical course. This umbrella term

includes pneumonia, atelectasis, respiratory failure, bronchospasm and acute

exacerbation of COPD[5].Early postoperative days are associated with fatigue and

limited respiratory movements. Pathophysiological changes post abdominal surgery

cause respiratory muscle dysfunction due to altered muscle integrity, length-tension

relationship, and thoracoabdominal mechanism, leading to postoperative pulmonary

[6].
complications (PPCs) Respiratory muscle function and diaphragmatic movements

are affected due to the anesthetic effect, site of the surgical incision reduced physical

activity, and positional dependence.[7]]Surgical duration, anesthesia, and nociception

impair respiratory function, exacerbate mucociliary clearance depression, and

suppress the cough reflex leading to secretion retention and reduced lung volumes,

thereby contributing to atelectasis and the development of infection.[8] General

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anesthesia and peri-operative drugs affect breathing regulation by altering neural

drive, further reducing functional residual capacity postoperatively and disrupting

ventilation-perfusion ratio by decreasing pulmonary compliance, eventually causing

hypoxemia and an increase in respiratory rate.[9] Due to reflex inhibition of the phrenic

nerve and nerve innervating abdominal muscles, surgical incisions near the diaphragm

and abdominal muscles cause postoperative pain and limit respiratory movement.

Similarly, the length of the incision has an additional effect on the development of

PPC, as the peritoneal area near the abdominal viscera is severely affected as the

length of the incision increases. As a result, open abdominal surgery has a higher rate

of PPC development than laparoscopic surgery.[1]

Complications, such as postoperative pulmonary complications (PPC),

prolonged post operative ileus and the squeal of prolonged immobility are potentially

preventable with physiotherapy interventions. Physiotherapists have routinely

provided care to patients undergoing abdominal surgery since the 1950s.

Physiotherapy interventions aim to prevent or remediate PPCs and post-operative

complications associated with the sequelae of immobility such as venothrombotic

events and to facilitate recovery from surgery and a return to normal activities of daily

living and function. Physiotherapy interventions after major surgery include early

mobilisation and respiratory physiotherapy techniques. Respiratory therapies include

deep breathing and coughing exercises, positive expiratory pressure devices, incentive

spirometry and non-invasive ventilation.[4]

The primary goal of physiotherapy is to facilitate recovery from surgery by preventing

or treating postoperative complications and providing physical rehabilitation to aid in

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returning to premorbid physical function. While physiotherapy primarily focuses on

physical rehabilitation, it may impact several other domains. Rehabilitation begins

preoperatively and continues throughout the acute and subacute postoperative periods

and may extend beyond hospital discharge into community-based or ambulatory care

to assist with a return to normal activities of daily living and function[10].Chest

physiotherapy includes deep breathing techniques, splinted active coughing, incentive

spirometry(IS),inspiratory muscle training, and education regarding early

mobilization. Practical training improves respiratory function preoperatively and

benefits in improving lung expansion postoperatively than no intervention.[11]

NEED OF STUDY :-
Current post operative UAS physiotherapy management within GUJARAT

has not been clearly documented. So, this study is aimed to document and report the

assessment and management of practice pattern of physiotherapists in UAS.

4
AIM:
To determine practice patterns of physiotherapist in the patient with upper

abdominal surgery in Gujarat State.

OBJECTIVES:

 To determine physiotherapy assessment techniques in upper abdominal

surgery patients.

 To determine physiotherapy management techniques in upper abdominal

surgery patients.

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REVIEW OF LITRETURE

1. A Study “Physiotherapy Practice for Management of Patients Undergoing

Upper Abdominal Surgery in United Arab Emirates – A National Survey”
conducted by Fatima Zaid et.at .in UAE. This study conducted that
Research work on physiotherapy postoperatively has shown demonstrated
prominence of mobilization but is not yet reflected in current practice among
physiotherapists caring for post-UAS cohorts in the UAE. The vast difference
in the choice of screening tools preferred by physiotherapists in diagnosing
high-risk patients postoperatively reflects a lack of corroborating evidence
available to physiotherapists.

2. A Study “The physiotherapy management of patients undergoing abdominal

surgery” conducted by Julie C Reeve et.at.in Australia.This study conducted
that The research regarding physiotherapy in the perioperative period for
patients undergoing abdominal surgery is limited and equivocal.
Physiotherapy services rely not only on the balance of evidence but on the
balance of resources to provide these services. It is feasible that the potential
high cost of PPCs following abdominal surgery justifies the provision of low
cost interventions such as physiotherapy. Until this has been confirmed with
good quality research and cost analysis studies, physiotherapists should
provide a service based on the best available evidence.

3. A Study “physiotherapy following abdominal surgery Actual Problems

Emergency Abdominal Surgery”conducted by Kate Sulivan et . at. In Australia.
This study concluted that Complications following emergency abdominal
surgery include PPCs and the sequelae of prolonged immobility.
Physiotherapy aims to remediate these problems, but to date, the
effectiveness of these interventions in patients following emergency
abdominal surgery has been poorly investigated.
4. A Study “physiotherapeutic management of patients following upper
abdominal surgery: a pragmatic approach to interpret equivocal evidence”
conducted by Hanekom SD et.at.in south Africa .This study concluded that
Due to the poor quality of the primary research, and the danger of beta
errors in this body of work, uncertainty about the value of routine
physiotherapy in the prevention of pulmonary complications following
abdominal surgery, remain. Through a process of consensus, the
international Delphi panel interpreted the equivocal evidence and, combined
with the collective expert opinion, formulated an algorithm. This algorithm
now provides clinicians with a hierarchical framework within which optimal
clinical management decisions can be made at the bedside.

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 5. A Study “Physiotherapy in upper abdominal surgery - what is current practice
in Australia?” conducted by Patman S et.at. in Australia.This study concluded
that This study found that most Australian physiotherapists are mobilising
their patients away from the bedside early in the post-operative period
following UAS, with many continuing to also incorporate routine respiratory
interventions. The interventions currently implemented by physiotherapists
for patients post-UAS are reflective of the guidelines from Hanekom
et.al.However, more recent evidence emphasises the use of early
mobilisation as a standalone treatment , which was not yet reflected in
current practice. The variability of screening tools used amongst clinicians to
identify high-risk patients post-operatively was reflective of the scarce
amount of validated evidence available to physiotherapists.

MATERIALS AND METHODOLOGY:

SOURCE OF DATA:

1.Multidisciplinary or specialty hospital of Gujarat where surgeries are conducted and

refer for patient.

2] NABH accrideted and MCI registered hospitals will be preferred.

STUDY DESIGN : Cross sectional study.

STUDY DURATION: Study will be conducted over a period of 10 to 12

months after obtaining ethical approval.

STUDY POPULATION: physiotherapist involved in the treatment of post

operative upper abdominal surgery patients .

INCLUSION CRITERIA:

1.hospitals having a surgical ICU/Ward set up,where physiotherapy is

administered qualified physiotherapists.

2.Physiotherapist with minimum of 6 month of experience in treating

abdominal surgery patients.

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EXCLUSION CRITERIA:

1.Physiotherapist who does not have Gujarat State Council For

Physiotherapy registration.

PROPOSED SAMPLE SIZE: As this study is descriptive and no

hypothesis.So, calculation of sample size is not done. A purposeful sample of

convenience will be used . All hospitals performing upper abdominal surgery in

GUJARAT will be targeted and contacted with an invitation to participate in survey.

The study will invite 100-150 physiotherapists from hospitals , where UAS is

performed across the GUJARAT to participate in the survey.

SAMPLING TYPE: Convenient sampling.

MATERIAL TO BE USED:

1. Phone

2. Laptop

3. Google form

METHOD: Institutional ethical approval will be obtain. Hospitals will

be approach by referring NABH website,MCI website,direct contact.

Physiotherapist will be include in this study based on inclusion criteria.

Informed e-consent will be taken from all the physiotherapist who agreed

to participate. Once they give consult therapist will be has to answer all

the questions. Practice among the physiotherapy after upper abdominal

surgery in GUJARAT will be assessed using "matrix scale ".There will be

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54 questions divided into 7 sections. Questions related to participant

information, patient demographics, outcome measures, Patient -

physiotherapy factors for commencing treatment, prescription and dosage

of intervention, Mobility Prescription following UAS, Frequency,

Intensity and Duration of Mobility Prescription, Discharge

planning.There will be 20 minute to answer the questions.

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REFERENCES:

1. Aldhuhoori FZ, Walton LM, Bairapareddy KC, Amaravadi SK, Alaparthi GK.

Physiotherapy Practice for Management of Patients Undergoing Upper

Abdominal Surgery in United Arab Emirates - A National Survey. J Multidiscip

Healthc. 2021 Sep 14;14:2513-2526. doi: 10.2147/JMDH.S328528. PMID:

34548794; PMCID: PMC8449636.

2. Reeve JC, Boden I. The physiotherapy management of patients undergoing

abdominal surgery. N Zealand J Physiotherapy. 2016;44(1):254.

doi:10.15619/NZJP/44.1.05.

3. Patnaik, V.V.G,Singla, Rajan K,Bansal V.K.Surgical Incisions—Their Anatomical

Basis Part IV-Abdomen.J Anat. Soc. India 50(2) 170-178 (2001)

4. Sullivan K, Reeve J, Boden I, Lane R. Physiotherapy following emergency

abdominal surgery. Actual Problems Emergency Abdominal Surgery.

2016;1:109.

5. Hanekom SD, Brooks D, Denehy L, et al. Reaching consensus on the

physiotherapeutic management of patients following upper abdominal

surgery: a pragmatic approach to interpret equivocal evidence. BMC Med

Inform Decis Mak. 2012;12(1):1–9. doi:10.1186/1472-6947-12-5

6. Casali CC, Pereira AP, Martinez JA, de Souza HC, Gastaldi AC. Effects of

inspiratory muscle training on muscular and pulmonary function after

bariatric surgery in obese patients. Obes Surg. 2011;21(9):1389–1394.

doi:10.1007/s11695-010-0349-y

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7. Dronkers J, Veldman A, Hoberg E, Van Der Waal C, Van Meeteren N.

Prevention of pulmonary complications after upper abdominal surgery by

preoperative intensive inspiratory muscle training: a randomized controlled

pilot study. Clin Rehabil. 2008;22(2):134–142.

doi:10.1177/0269215507081574

8. Patman S, Bartley A, Ferraz A, Bunting C. Physiotherapy in upper abdominal

surgery–what is current practice in Australia? Arch Physiotherapy.

2017;7(1):1. doi:10.1186/s40945-017-0039-3

9. Canet J, Gallart L, Gomar C, et al.; ARISCAT group. Prediction of postoperative

pulmonary complications in a population-based surgical cohort. J Am Soc

Anesthesiologists. 2010;113(6):1338–1350.

10. Reeve J, Anderson L, Raslan Y, Grieve C, Ford J, Wilson L. The physiotherapy

management of patients undergoing abdominal surgery: a survey of current

practice.N Zealand J Physiotherapy. 2019;47(2):88.

doi:10.15619/NZJP/47.2.02

11. Kumar AS, Alaparthi GK, Augustine AJ, Pazhyaottayil ZC, Ramakrishna A,

Krishnakumar SK. Comparison of flow and volume incentive spirometry on

pulmonary function and exercise tolerance in open abdominal surgery: a

randomized clinical trial. J Clin Diagnostic Res. 2016;10(1):KC01.

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