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Effectiveness of Respiratory and Abdominal Strength Exercises in Postoperative Patients with Abdominal Surgeries: A Narrative Review
Correspondence Address :
Dr. Anjan R Desai,
Associate Professor, Department of Neuro Physiotherapy, SPB Physiotherapy College, Surat, Gujarat, India.
E-mail: anjandesai@gmail.com
Abdominal surgeries are performed to diagnose and/or to treat different medical conditions by opening the abdominal cavity through large incision in the abdominal wall. Weakness of abdominal muscles, pulmonary complications and incisional pain are more common after abdominal surgeries. There has been significant research on managing such complications by using variety of physiotherapy interventions. This review intended to narrate the available literature on the effects of respiratory exercise and abdominal muscle strength training on pain and abdominal muscle strength after major abdominal surgeries. A systematic search of online databases was conducted and based on the reference lists of selected articles, further studies were identified. Twelve articles that met the inclusion criteria were analysed. Many of the previous studies concluded that respiratory exercise and abdominal muscle strength training after open abdominal surgeries improve abdominal muscle strength and decrease pain. Respiratory functions were also reported to be improved. But recent evidence regarding such effectiveness is insufficient and these aspects need to be explored in future.
Abdominal muscles, Laparotomy, Pain, Physical therapy
With an estimated 234 million surgeries being performed yearly, it can be said that surgery has become an integral part of global healthcare. As per the report of The World Bank in 2002, it was reported that approximately 11% of entire global disease burden, i.e., 164 million disability-adjusted life years, are attributed to surgically treatable conditions (1). Abdominal surgery refers to any surgical operation on abdominal organs performed for treatment of a variety of reasons, including infection, obstruction, tumours or inflammatory bowel disease (2). Postoperative Pulmonary Complications (PPCs) are common in patients undergoing abdominal surgery and are responsible for the increased morbidity and mortality as well as length of hospital stay and health related cost of care (3),(4).
Atelectasis, pneumonia, acute respiratory failure, trachea-bronchitis, wheezing, and prolonged mechanical ventilation are the most commonly observed PPCs (5). It is known that the decrease in lung volumes and capacities, abnormal respiratory pattern, abnormal gas exchange, and pulmonary defense in patients undergoing open abdominal surgeries start with anaesthetic induction and perpetuate in the postoperative period, contributing to the occurrence of these PPCs (6),(7). The incidence of PPCs in these subjects is related to the existence of preoperative risk factors such as advanced age, smoking, malnutrition, obesity, lung diseases, and clinical diseases. Surgical and anaesthetic factors such as the time of surgery, type of surgery, and the effects of anaesthetic drugs on the respiratory system also contribute to the development of PPCs (8).
Physiotherapy treatment for patients after open abdominal surgery consists of a variety of interventions intended to improve cardiopulmonary and/or physical function and reduces the incidence of PPCs. These interventions may include lung expansion exercises, secretion clearance techniques, limb exercises, progressive mobilisation programs, and other techniques. It has been reported that postsurgical physiotherapy interventions after open abdominal surgeries reduce the incidence of PPC (8). More recently, the focus on strategies to reduce and improve postoperative health-related quality of life has shifted to include pre rehabilitation. It may be described as the process of improving the functional capacity of the individual prior to a planned intervention, commonly surgery, to enable the individual to withstand the anticipated cardiovascular, respiratory, neuromuscular or musculoskeletal stressors (9).
Various systematic reviews and meta-analyses have been conducted focusing on the effects of respiratory therapy (2), incentive spirometry (10), preoperative inspiratory muscle training (11), preoperative exercise therapy (12), positive expiratory pressure breathing (13) and chest physiotherapy (14) on PPCs. While these studies have provided a valuable contribution to the literature, they have limited scope with respect to effectiveness of respiratory exercise and abdominal strength training program on pain and abdominal muscle strength. In order to justify the use of abdominal muscle strengthening exercises along with the regular respiratory exercise in postoperative patients with open abdominal surgeries, one need to be confident that the efficacy of these interventions is worthwhile with minimal chances of harm. Therefore, this review assesses the available literature to determine whether use of this intervention is justified.
LITERATURE SEARCH
Full texts of the articles were included for narrative review if their purpose(s) included the use of respiratory exercise and/or abdominal muscle strengthening for preventing abdominal pain and/or improving abdominal strength. Articles were excluded from the review if they fell into one of the following categories: 1) commentaries, cost analyses, surveys, patient monographs, letters, and guidelines; 2) the use of respiratory exercises for other purposes, such as for inspiratory muscle training and bronchodilator administration, or as a monitoring tool; and 3) use of respiratory exercises in non surgical populations.
Search Strategy
The search strategy included primary and secondary searches:
Primary search: Computerised databases (MEDLINE, CINAHL, PubMed, and Google Scholar) were searched from year 1990 to 2020. Key terms for the search included “respiratory therapy,” “breathing exercises,” “chest physical therapy,” “respiratory exercise”, “abdominal muscle strength”, “open abdominal surgery”, “open laparotomy”, “abdominal pain” and “pulmonary complications.”
Secondary search: Involved scanning all reference lists from the studies identified in the primary search. Both searches were limited to human studies that are performed in English.
One author screened all titles and abstracts of papers to identify relevant studies for inclusion. Both the authors reviewed relevant full texts which were found to be eligible in primary screening. Secondary search was done in the reference lists of the full texts and grey literature for other articles of relevance.
Selection process: The primary computer database search yielded 31 articles. The secondary search provided seven additional articles for a total of 38. Full texts of the articles were accepted (n=16) for narrative review if their purpose(s) included the use of respiratory exercise and/or abdominal muscle strengthening for preventing abdominal pain and/or improving abdominal strength. It was found that out of these 16 studies, three studies were repeated in two different databases and one full text was found to be in Korean language, so was excluded (Table/Fig 1).
Variability of study designs, population covered, interventions applied, etc., was analysed and tabulated. Risk of bias assessment for randomised studies using the visualisation tool for risk of bias assessment in a systematic review (robvis), risk-of-bias tool for randomised trials (RoB2) and the risk of bias in non randomised studies of interventions (ROBINS-1) for observational studies was done (15).
Search Results
(Table/Fig 2) shows the summary of analysis of articles included in this narrative review (2),(8),(10),(11),(12),(13),(14),(16),(17),(18),(19),(20). The risk of bias for systematic reviews, non randomised studies and randomised trials are given in (Table/Fig 3),[Table/Fig-4,(Table/Fig 5) (2),(8),(10),(11),(12),(13),(14),(16),(17),(18),(19),(20).
Efforts were focused on finding and discussing studies related to effects of respiratory exercise and abdominal strength training on pain and abdominal muscle strength for postoperative patients with 16abdominal surgeries. The following questions were formulated, and answers were sought during this process:
• Does respiratory exercise affect pain for postoperative patients with abdominal surgeries?
• Does abdominal strength training affect pain for postoperative patients with abdominal surgeries?
• Does respiratory exercise affect abdominal muscle strength for postoperative patients with abdominal surgeries?
• Does abdominal strength training affect abdominal muscle strength for postoperative patients with abdominal surgeries?
Respiratory exercises and pain: Pain is one of the most common postoperative complications limiting patients’ functional ability and increased duration of hospitalisation. Respiratory exercises are reported to improve oxygen saturations of postoperative patients without increasing pain (17). Exercises aimed at increase respiratory capacity following standard guidelines reduce incisional and postoperative pain (2),(11). A negative association between postoperative respiratory training and pain intensity and duration was reported in one of the previous studies (18). Decline in respiratory muscle performance after surgery is associated with pain, drains and pneumoperitoneum. The current evidence suggests that physiotherapist-directed postoperative exercise decreases pain over usual care for patients following open surgeries, and physiotherapists may be able to help these patients if referrals are made in this direction (18).
The studies which investigated effects of inspiratory muscle training in both the pre and postoperative phases were not included. Some of these studies reported improvements in maximal inspiratory pressure which were sustained for upto three months but, the clinical significance of these long-term effects in this population were unclear (11).
Abdominal strength training and pain: Pain associated with incision or in the peri-incisional region is thought to be affecting the course of recovery. The incision of an open laparotomy creates significant loss of strength in the abdominal muscles and the postoperative pain is reported by many to be impeding the patients’ involvement in active physiotherapy interventions (8),(12),(18). Abdominal muscle strength training is an integral part of postoperative rehabilitation and is reported to be associated with patient perceived pain relief by few studies (20),(21). The evidence of the probable mechanism for the role of abdominal strength training on pain relief is still unclear. The effects offered by abdominal muscle strength training were not reported to be extending beyond the first few days postoperatively and, thus, the study evaluated immediate postoperative training only (14).
Respiratory exercises and abdominal muscle strength: Respiratory exercises including various types of intervention strategies using supervised exercises seem to be safe and feasible and improve functional capacity in patients undergoing major elective abdominal surgeries (22). Improvements in respiratory functions are supposed to be associated with increase in strength of primary respiratory muscles as well as secondary muscles including the abdominals which provide fulcrum for diaphragmatic excursion during respiration (14),(16),(17),(18).
Though the effects of respiratory exercises have not been found to be directly associated with the strength of abdominal muscle, the improvements in abdominal muscle strength are significant following various intervention protocols adapted for these studies (9),(11),(13),(14). Only few studies including one review study has reported the probable association between the respiratory exercise and abdominal muscle strength (23),(24).
Postoperative recovery after abdominal surgery largely depends upon the patients’ ability to cope with impaired respiratory and abdominal muscle functions. Various studies have demonstrated the relationship between postoperative outcomes and measures of physical fitness including cardiorespiratory and muscle strength functions (25). It has been reported in a previous study that conventional physiotherapy along with additional resources such as incentive spirometry, early ambulation and expiratory positive airway pressure can help in reducing atelectasis as a postoperative complication and also reduces hospital stay in abdominal surgery patients (19).
Present review supports findings of previous studies and additionally emphasises the role of postoperative physiotherapy including conventional as well as advanced resources for prevention of complications and emphasises its importance in improving respiratory and physical functioning.
Abdominal strength training and abdominal muscle strength: Abdominal wall paresis is considered one of the most common postoperative complications which is causing limitation in participation and performance of Activities of Daily Living (ADLs) for patients (12). Incentive spirometry along with abdominal strengthening and inspiratory muscle training has been shown to have improvements in the abdominal muscle strength (16),(26),(27),(28),(29).
Preoperative and postoperative abdominal muscle training are reported to induce less reduction in inspiratory muscle strength after laparotomy which decrease rate of Postoperative Pulmonary Complications (PPC) (28).
Limitation(s)
As the number of studies including the topics under discussion is very less and specific interventions as well as outcome measures used are highly variable among all studies, it is difficult to comment on the strength of evidence reviewed in this study. Lack of available evidence is the main reason for considering future research on the effects of respiratory exercises and abdominal muscle strength training for preventions of postoperative complications, such as pain and abdominal weakness, in patients of open abdominal surgeries.
The available literature suggests insufficient evidence of association or effects of the respiratory training and abdominal strengthening on pain in strength for postoperative patients with abdominal surgeries. It is evidently striking that there is no study available from India. This suggests that the effectiveness of respiratory exercise and abdominal strength training programme on pain and abdominal muscle strength in postoperative patients with abdominal surgeries is undervalued and underexplored and there is need to explore these aspects in the context of Indian population.
DOI: 10.7860/JCDR/2022/52574.16290
Date of Submission: Sep 25, 2021
Date of Peer Review: Nov 19, 2021
Date of Acceptance: Feb 12, 2022
Date of Publishing: Apr 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 27, 2021
• Manual Googling: Feb 11, 2022
• iThenticate Software: Feb 15, 2022 (22%)
ETYMOLOGY: Author Origin
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
- EBSCOhost
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com