When many patients undergo abdominal wall reconstruction, usually they do not work with a physical therapist throughout their recovery period. According to Howard Levinson, MD, an associate professor in the Departments of Surgery, Pathology and Dermatology at Duke University Medical Center, in Durham, N.C., this probably should change. At the 2021 annual meeting of the American Hernia Society, Dr. Levinson delivered a lecture on how physical therapy should be an integral part of an abdominal wall reconstruction practice.
“When a patient undergoes hand surgery or leg surgery for musculoskeletal disease, they almost always work with a physical therapist or occupational therapist postoperatively, so it only makes sense for a patient undergoing hernia surgery—which is also a musculoskeletal disease—to also work with a physical therapist postoperatively,” Dr. Levinson said.
At Duke University Medical Center, all patients undergoing abdominal wall reconstruction are offered a physical therapy rehabilitation program postoperatively. At the beginning of the rehabilitation program, patients have an assessment of abdominal wall strength. This involves creating an abdominal wall strength score by scoring trunk-raising and double leg-lowering tests (Figures A and B). Using the strength score and the World Health Organization International Classification of Functioning, Disability and Health for Ventral Hernia, patients are stratified into a low-intensity, medium-intensity or high-intensity rehabilitation program. The frequency, time, type and intensity of exercise increases from low to high. Exercises include single-leg hip bridges, modified planks, modified side planks, clam shells and toe raises.
“If you have a patient [who] comes in who is a runner or very active, they should be able to tolerate a more aggressive rehab program. Based on the simple physical performance tests, we are likely going to find that they have a stronger score,” said Michael Schmidt, PT, DPT, MHA, the clinical coordinator of rehabilitation services in the Department of Surgery at Duke University Medical Center. “If you have a patient that comes in [who] is very deconditioned or medically unstable, they are likely going to have a weaker core based on the tests, and we would do a more lower-intensity rehab program to improve their conditioning.”
Patients are sent home with instructions on how to do their rehabilitation program. “The benefit of the program that we have developed is that it is mostly independent. We are doing the initial assessment and then really allowing patients to implement the exercises on their own. Many of the patients are traveling to Duke for just one visit. As long as patients are adhering to the exercises, we are seeing good benefit,” said Rebecca Fillipo, PT, DPT, a physical therapist at Duke University Medical Center. She said there have been no recurrences to date in patients who have participated in the rehabilitation program since 2019.
Ms. Fillipo said when they first started their rehabilitation program for hernia, they only had one protocol for every patient, but they found they weren’t dosing people appropriately. “People weren’t being challenged enough, or it was too challenging and people couldn’t get through the program. Each protocol level now increases in difficulty and is based on what the patient is trying to get back to,” she said. “Patients get moving the very first week after their surgery. The first four to six weeks all look pretty similar, just different repetitions or amount of resistance. But then between week 6 to week 12, we get to more activity-specific or sports-specific exercises. Different from a lot of the other programs, we took away lifting restrictions, with the idea of using a pain-guided approach and letting that dictate how they progress. We say they shouldn’t go past a 2-point jump in their pain when lifting.”
Mr. Schmidt said the program incorporates cognitive-behavioral therapy approaches to help with coping after major surgery and trying to help patients reduce their fear of moving after a surgery. “From an outcomes standpoint, we utilize the PROMISE 29 v2.0 measures of patient-reported outcome measures used in the hernia population,” he said.
Mr. Schmidt said clinicians can get more information on their rehabilitation guidelines by contacting him at Michael.Schmidt@duke.edu.
According to Richard Pierce, MD, PhD, an assistant professor at Vanderbilt University Medical Center, in the Division of General Surgery, and the director of the Vanderbilt Center for Hernia Care and Abdominal Core Health, in Nashville, Tenn., the Duke rehabilitation program is only one option for rehabilitation programs after hernia. The Abdominal Core Health Quality Collaborative has published three abdominal core surgery rehabilitation protocol guides on its website (bit.ly/3r3KcA8). There is a patient guide, a guide to be used with a physical therapist, and an in-hospital guide for patients and physical therapists. “The guides are very straightforward. You can print them out and hand them to patients,” Dr. Pierce said.
ARYAN'S BLOG 
