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Role of Physiotherapy in Enhanced Recovery after Surgery

Role of Physiotherapy in Enhanced Recovery after Surgery

Published By Anjana , 3 years ago

Enhanced post-operative recovery (ERAS) is a combination of components of perioperative care based on a multimodal approach that includes evidence-based methods to avoid convalescence across multiple surgical procedures. Post-surgical outcomes also progressed among patients since ERAS was first implemented in healthcare about twenty years ago. With no subsequent increase in readmission rates, that average length of stay has decreased with concurrent improvements in clinical outcomes thus having a beneficial impact on healthcare resources. In order to accelerate the achievement of discharge criteria, ERAS programs are supported by evidence-based preoperative, intraoperative and postoperative procedures. ERAS emerged in appointments surgical treatment and has spread to many other surgical sub - specialties, including gastrointestinal, hepatobiliary, orthopaedic, cardiac, thoracic, head and neck, breast and gynaecological surgery.

Physiotherapy and ERAS

For both preoperative and postoperative procedures, the function of physiotherapy inside the ERAS system is important. In anticipation for a forthcoming physiological stressor, the implementation of a preoperative strength program has been shown to promote musculoskeletal adjustments (Carli et al. 2010), and is an emerging key component of ERAS. A literature review found preoperative exercise to be very well accepted and efficient in patients eligible for cardiovascular, thoracic, abdominal and major joint replacement surgery. The ERAS guidelines also prescribe postoperative exercise practices that promote muscle hypertrophy and come back to work following surgical procedure.

A fundamental principle of good physiotherapy practice and of ERAS programmes is immediate mobilisation. The rate of morbidity and duration of stay after multiple surgeries were shown to decline, with immobilisation causing a decreased muscle strength, insulin adherence and functional ability due to hospitalisation. Early mobilisation can accelerate the fulfillment of discharge criteria that has been shown to decrease the rate of pulmonary complications, venous thromboembolism and infection following operation. Only adequate palliative care can achieve early mobilization; multimodal drug regimes, which are essential to ERAS programmes, are necessary. In ERAS, this is a core idea in that each intervention, whether therapeutic and/or analgesic regimens, must take into consideration its impact on rehabilitation goals and how to adequately support early postoperative mobilisation. There are many barriers to early mobilisation specific to surgery, highlighting the importance of a strategy for just a multidisciplinary care team.

Intensive care stay

Following elective surgical procedure, a patient may be admitted to an intensive care unit (ICU) if they require postoperative support due to the complexity of the surgery or because of co-existing health conditions. Among all major surgeries that adopt ERAS principles, ICU admission is not always standard, with orthopaedic procedures typically the most well-tolerated by patients and therefore often requiring ICU admissions. ERAS guidelines highlight that, depending on the situation after operation, gynaecological, cardiac, pancreaticoduodenectomy, colorectal, hepatic and neck and head cancer patients may require transfer to an Intensive care unit. Patient and surgery-specific admission to an ICU, with many programs using preoperative risk models inside an attempt to predict a need for emergency surgery and length of stay. Postoperative ICU treatment can be structured to reduce the incidence of stay while increasing postoperative complications. A multidisciplinary team that employs a model of perioperative care components to enhance rehabilitation must comprise programs within ICUs.

Physiotherapy within intensive care units

The goal of physiotherapy therapy offered within ICUs can be narrowly divided into two: enhancing respiratory function and starting the process of recovery. In order to support their breathing, patients in an ICU can need artificial ventilation, but this may lead to pulmonary complications. Where appropriate, respiratory physiotherapy includes early mobilization, repositioning patients in bed to improve respiratory function, and using manual procedures or manipulation of ventilator settings to clear lung secretions that form inside the lungs while there is restricted movement and, subsequently, deep breathing. This helps lower the risk of pulmonary problems. Initially, rehabilitation physiotherapy focuses on preserving the range of joint motion to avoid contractures and on reducing the muscle loss that occurs when a patient is in an ICU due to immobility. Then, recovery focuses on sitting, standing and then walking as soon as possible to encourage their return to physical activity. Patients may rapidly become frail, and muscle atrophy and joint dysfunction that can occur may be minimized with the use of exercises, electrical stimulation and ambulation practice.

In order to accelerate the achievement of discharge requirements, the above functions of a physiotherapist inside an ICU are closely assimilated with the main ERAS values. The task of the physiotherapist is critical in order to ensure that a patient admitted to the ICU continues to achieve functional recovery. The effect of the perioperative ERAS program has been shown to minimize the occurrence of pulmonary complications with continuous improvement, which is evident one year after implementation in patients admitted to an ICU after elective major surgery. In contrast to non-specialist treatment for ICU patients, the use of an evidence-based physiotherapy procedure that addresses pulmonary dysfunction and encourages early mobility has been shown to be safe and reliable. In order to function safely in a critical care setting, an adequate level of clinical competence should be needed and an algorithm to direct non-specialist therapists can be built to best encourage practice physiotherapy promoted within ERAS guidelines.

Early mobilization in an ICU of critically ill patients is a secure and productive intervention that can lead to substantial changes in functional performance. Accordingly, an ICU admission does not mean that a patient is excluded from the ERAS path. It can actually be argued that it is the patients admitted to the ICU who require ERAS the most. Activities including sitting, standing, ambulation and passive movements done by the physiotherapist may be used in mobilizing a patient. For patients receiving a passive or active exercise training session for 20 minutes a day, functional exercise ability, self-perceived functional status and muscle force were reported to be greater at hospital discharge. Early mobilisation has also been associated with a decrease in the length of mechanical ventilation when a multidisciplinary team with a known leader will change the culture and practice of the ICU.

Barber and colleagues (2015) established a lack of resources and coordination as obstacles to early mobilization within ICUs; emphasizing the importance of educating and including the ICU team within the conventional ERAS team of anaesthetists, surgeons, and ward-based nurses and allied health professionals. ERAS patients, for instance, are always managed on a particular ERAS pathway document; this needs to fit together with documentation of ICU pathways.

Rehabilitation post discharge

Patients can experience physical, psychological and cognitive problems after a serious illness or a prolonged stay in an ICU, which can adversely affect their health-related quality of life. Intensive care unit-acquired weakness (ICUAW) is a clinical condition that happens when a patient is intubated and manually ventilated due to muscle atrophy and loss of muscle mass. With the duration of stay, recovery time increases, and a successful rehabilitation program is important to ensuring that a patient can return to their preoperative physical and mental health as closely as possible.

Long after discharge, there may be functional deficiencies and chronic weaknesses, so there is a need to improve the understanding and participation of physiotherapists in the outpatient setting. Physiotherapists are an integral component of the healing pathway and should ensure that, once they are released from an ICU, patients follow ERAS values, which have been shown to promote recovery. A patient's recovery needs should be individualized, and evaluations are essential in deciding which services are needed for physiotherapy and counselling. As a result, there is a need for a sufficient number of well-informed physiotherapists who are specialized in treating critical care patients in an outpatient environment.

There is insufficient evidence of the efficacy of physiotherapy treatments following admission to an ICU, and post-discharge rehabilitation protocols for ERAS are still changing. Recent research has indicated that the recovery of high intensity will lead to greater changes in functional results relative to lower intensity programs. To improve the hypertrophy of a patient, enhancing their strength, balance and muscular endurance, the use of progressive resistance training has been highlighted. Jones et al found an effective self-help therapy manual to help physical healing and alleviate depression; but many patients also remembered delusional ICU memories, prompting the need for more psychiatric treatment. It has been shown that a physiotherapy, outpatient rehabilitation program, including training sessions and circuit-based training, has increased exercise capacity and major psychological benefits following discharge from an ICU.

With this in mind, a Cochrane study of exercise therapy for post-discharge recovery from an ICU was unable to assess the overall outcome of the recovery impact of exercise training. Six studies were examined: three of the papers published findings in favor of training programs for post-discharge exercise and the remaining studies found no impact. Running, strengthening exercises, education, arm and leg cycling exercises and manuals for self-help recovery were included in the interventions. The authors emphasize the relevance of physical therapy for recovery after a critical disease, despite inconclusive findings.

Conclusion

The task of ERAS physiotherapy and post-intensive care rehabilitation is significant and will become increasingly important as the advancement of ERAS services leads to a change in outcome indicators from the current surrogate period of stay to functional and activity-based recovery markers. Restricted research is available based on the impact of the ERAS program on outcomes for patients discharged after elective major surgery from an ICU. A multimodal approach that incorporates evidence-based interventions can benefit the most from this cohort. Physiotherapists in critical care take on positions that closely assimilate with key ERAS values and can play a crucial role in ensuring that patients stay on board while in an ICU with their ERAS pathway. It is hypothesized to enhance recovery by providing a more intensive, structured rehabilitation program for patients after discharge from an ICU, provided by a specialist physiotherapist and assisted by a multidisciplinary team.

Future research and investigation

Future research should concentrate on the development of a comprehensive ERAS-based recovery program that can be provided by specialist physiotherapists within an ICU and in an outpatient setting. To evaluate the long-term impact of early mobilisation and exercise-based approaches, prospective studies are required. Compared with baseline function values, the ability to rebound after discharge from an ICU can be more reliably assessed, enabling physicians to consider patients with pre-existing co-morbidities that are less likely to respond to recovery treatments. It is therefore important to investigate a secure and efficient method for assessing preoperative functional capacity. The emphasis of physiotherapy research in the future should be on how to achieve and substantially assess functional rehabilitation, presenting proof of its inclusion in tomorrow's ERAS programmes.

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