Pre and Post Physiotherapy for Pediatric undergoing Cardiac Surgery

Cardiac Surgery is successfully performed on numerous Pediatric patients suffering from many different congenital heart defects. The frequency of heart surgery in children with congenital heart disease is very high, and the occurrence of pulmonary complications in post-operative heart surgery is equally common. Children also have postoperative pulmonary risks similar to adults. Since the complications like atelectasis and pneumonia are highlighted among them, it is important to make use of effective means to prevent, reduce or treat such complications. These complications are minimized by drugs, and by Physiotherapy. Positive results have been found after providing physiotherapy services in preoperative and postoperative pediatric cardiac surgery patients. This blog summarizes the efficacy of Pediatric Physiotherapy treatment through different techniques emphasizing the importance of early mobilization and ambulation and also promotes the application of physiotherapy pre and post-operative pediatric cardiac surgery.

 

PHYSIOTHERAPY

Physiotherapy in the pre-and postoperative period in pediatric cardiac surgery is used to reduce the risk of pulmonary complications like atelectasis, retention of secretions, and pneumonia. Physiotherapy interventions contribute to the appropriate ventilation and successful extubation.

 

Pre-operative Physiotherapy:

Physiotherapy techniques used are clearance, re-expansion, abdominal support, and guidance on the importance and objectives of physiotherapy intervention for parents.

 

Post-operative Physiotherapy:

Postoperative physiotherapy includes vibration in the chest wall, percussion, compression, manual hyperinflation, re-expansion maneuver, positioning, postural drainage, cough stimulation, aspiration, breathing exercises, mobilization, and acceleration of expiratory flow.

• After heart surgery, the child must be repositioned (approximately every two hours) throughout the day to ensure that the lungs stay well-expanded and free of mucous. This will also help the child to recover the movement. Whether the child is still on the breathing machine or is breathing by himself, the physiotherapist will check whether the lungs are clear of secretions. The physiotherapist will use techniques to help increase the air going to the lungs and to clear the secretions from the lungs. These techniques may include positioning, deep breathing exercise, chest percussion, and coughing.
• The child should start moving soon after the operation and the physiotherapist will help the child with sitting out of bed if the child is old enough, start walking in the first couple of days after surgery.
• Good positions post-operation includes turning the child onto the side, onto the back, holding him in the arms, and placing them into an infant seat. This will help the child recover sooner so that he can go home.
• Aspiration with the techniques of respiratory physiotherapy such as manual vibration, positioning, percussion, compression, manual hyperinflation, and postural drainage are found to be beneficial. Physiotherapy tends to produce improvement in pulmonary compliance, expiratory tidal volume, and pulmonary resistance.
• The treatment for atelectasis consists of physiotherapy, deep breathing, incentive spirometry, etc. However, sometimes, atelectasis is difficult to reverse and it is necessary to associate it with another method, respiratory physiotherapy, and inhalation of hypertonic saline solution with NaCl at 6% is recommended.
• Chest radiographs and four physiotherapy sessions lasting 20 minutes were performed daily, using maneuvers of bronchial hygiene, pulmonary re-expansion, postural drainage, and tracheal aspiration shows significant results. Immediately before and after physiotherapy inhalation of hypertonic saline solution with NaCl at 6% can be given.
• Breathing exercises are recommended in cases of atelectasis due to thoracic or upper abdominal surgery, because they improve respiratory efficiency, increase the diameter of the airways, which helps to dislodge secretions, prevent alveolar collapse, and facilitate the expansion of the lung and peripheral airways clearance.
• Significant increase in oxygen saturation and reduction in cardiac and respiratory rate after intervention with the increased expiratory flow in children with pneumonia has been proven and the physiotherapeutic technique for bronchial hygiene is found to be effective in improving lung function.
• When the presence of pulmonary complications is associated with other complications regarding the time of hospital stays, such as sepsis, pneumothorax, pleural effusion, and others, if the patient is treated by physiotherapy before and after surgery it shows a lower risk of developing such complications.

Post Surgery:

• Avoid activities that disturb the wound.
• Avoid lying on the tummy.
• Take care of the chest muscles and bones during any movement.
• Avoid lifting the toddlers under the arms. Lift the baby under the head/neck and bottom.
  
  

Physiotherapy is included in the multidisciplinary team that contributes significantly to the better prognosis of Pediatric patients undergoing heart surgery, as it prevents and treats pulmonary complications using various techniques. The effectiveness of physiotherapy in reducing the risk and/or treating pulmonary complications caused by surgical procedures in children with congenital heart disease has been proven.

 

Physiotherapy in Leprosy | A guide to Help People with Injury and Disability

In the past leprosy has been shrouded in mystery and characterized by deformity. While today much more is known about this disease, allowing most of the patients to be treated without much difficulty. Physiotherapy in leprosy has grown out of a need to minimize, prevent, and correct deformities caused by the disease. This blog outlines the role of physiotherapy in the management of leprosy patients with permanent paralysis.

 

Leprosy Disease

Leprosy disease is a granulomatous disease caused by mycobacterium Leprae, an acid and alcohol fast bacillus. It is one of the most serious, disabling diseases that attack the skin and the nerves. Leprosy also known as Hansens Disease, can cause peripheral neuritis. The disease is spread by droplets from the sneeze of leprosy patients. Though it is not known whether the organism enters by inhalation or through the skin. Some people who have high resistance do not get infected by leprosy disease even though they get in contact with an infectious person. Even the patients who have been taking adequate treatment for 3-6 months are no longer infected if they have been taking adequate treatment for 3-6 months and need to continue drug treatment for a long time.

It is a chronic infection, the disease attacks mainly nerves and skin. It is treated by drugs and can be controlled by taking precautions that can reduce physical damage or disability from occurring.  It may also cause great emotional distress to the patient and may seriously affect the social life of the patient.

The mycobacterium Leprae bacteria that causes leprosy multiplies very slowly, thus symptoms usually do not begin at least until 1 year after people have been infected. Usually, symptoms may appear 5 to 7 years after infection. Once symptoms begin, they progress slowly.

The most severe symptoms include a reduced sense of touch and an inability to feel pain and temperature. Patients with peripheral nerve damage may unknowingly burn, cut, or otherwise harm themselves and also cause muscle weakness, resulting in deformities such as fingers may be weakened, causing them to curve inward. Muscles may become too weak and thus make it difficult to flex the foot. Repeated damage may lead to loss of fingers and toes. Other areas of the body like the nose (stuffy nose and nosebleeds), eyes (glaucoma or blindness), kidneys (kidney failure), feet (Sores), and sexual function (impotence and infertility) may also be affected by Leprosy Disease.

 

Physiotherapy Treatment

The good news is that leprosy is curable. As it is difficult to eradicate leprosy bacteria thus antibiotics must be continued for a long time. Depending on the severity of the infection sometimes the treatment is recommended for lifelong. The major aim of physiotherapy is to prevent or reduce complications, deformities, and disabilities in the body through physiotherapy.

 

Thermotherapy

Heat therapy or thermotherapy helps to increase the range of motion by soaking the affected part in warm water and then performing passive movement of the part affected.

 

Cleaning the skin

Cleaning the skin by soaking the part in soap water, rubbing off thick skin, oiling, self-massage, and protecting the part from infection.

 

Elevation

Elevation helps to decrease swelling and inflammation, followed by active and passive exercises.

 

Special Training

Special training can be offered to leprosy patients. For example, they can be taught compensation techniques for using anesthetic hands for example cooking activities, the patient can be taught how to cook while protecting the affected limbs. Special training can also be provided for different groups of patients such as farmers, carpenters, mechanics, tailors, and so on.

 

Tendon transfer surgery

Motor impairments may result in paralysis and compromise hand functions such as grasp, pinch, and prehension. The lost movements can be restored with tendon transfer surgeries. Due to contractures, absorption of digits, and various other reasons all paralyzed hands may not benefit from tendon transfer procedures. In such circumstances, the use of adaptive devices can facilitate the functional ability of the hand.

 

Muscle Re-education after tendon transfer

After tendon transfer, the physiotherapist helps to restore new skills in movements provided by tendon transfer. Leprosy may affect an individual's activities of daily living (ADL) as well as work- and leisure-related activities. The goal of the physiotherapist is to enable and enhance performance in ADL and work and leisure-related activities.

 

Exercises

Muscle weakness of lesser duration can recover with appropriate exercises. For areas that are paralyzed for a longer duration, exercises might only help in maintaining muscle bulk and tone. Exercises prescribed for paralyzed muscles are passive exercises, for weak muscles, active and active assisted exercises are prescribed, and for strong active resisted exercises are recommended.

 

Strengthening Exercises

Strengthening exercises help to improve strength, especially in tendon transfer.

 

Assistive technology/devices

Assistive devices like mittens are provided to protect anesthetic hands from heat-related injuries during cooking. Often, the tools used by the patient are padded with soft materials to protect hands from pressure injuries, such as screwdrivers, sickles, spades, and hammers. Padding protects hands from pressure injuries and also enables better grip while using tools. Loss of digits on hands is a common complication in leprosy-affected people with long-term impairments. Due to this their functional abilities to perform their daily activities are compromised. Grip aids are a kind of adaptive device that enhances the ability of the hands to hold objects such as pens, spoons, shaving razors, etc.

 

Splinting

Splints are supportive devices that are used to immobilize the affected part of the body. Splints are of two types splints and dynamic splints. Static splints immobilize a joint to prevent movement in the area. Dynamic splints allow movements that help in maintaining function while other areas are immobilized.

 

Offloading measures for Plantar Ulcers

Bohler Iron can be used in the walking cast to transmit weight and pressure to the calf area, preventing weight bearing on the foot, and extending from the neck of the fibula to the tip of the toes. This technique helps ulcers to heal more quickly and is indicated in the presence of a heel ulcer in a foot, whether or not the foot is deformed. A window can be kept in the cast over the ulcer area to enable dressings.

 

Molded Double Rocker Shoe (MDRS) / Boot

This cast is shaped like a boot and can be used to heal plantar ulcers on the forefoot. An MDRS is not used in the presence of foot drop, stiff claw toes, or heel ulcers. The cast is applied below the malleoli and covers the entire foot, just like a boot.

 

Preventing Further Deterioration of Impairments

Some of the impairments in leprosy are irreversible because of late diagnosis, and the severity of causative factors leading to late treatment. Such impairments will not be completely reversed. The goal of the physiotherapy team in cases is to prevent any new impairment or the worsening of a primary impairment.

 

The main aim of the treatment is to increase, maintain, and improve functional skills. Proper treatment results in satisfaction and independence while carrying out routine activities and participating in social activities.

 

Strength Training for Elderly | A Guide to Build Muscle and Power

Incorporating Strength Training into our routine is a great way to build up our physical strength. Strength Training or resistance training is an important part of any fitness regime. It is the ability to perform a given set of exercises, with ease and comfort. These exercises are a combination of repetition and load.  As an individual gets stronger, the repetition and load for an exercise can be increased. While recommending strength training your physiotherapist has to take care of the proper dosage. In older adults, it is difficult to properly dose strength training as there is a loss in muscle strength and power, which can lead to decreased function and increased fall risk. This article will discuss why proper dosage is important and how to properly dose strength training exercises in older adults.

In older adults, it is difficult to properly dose strength training to avoid any injury. Older adults exert considerably more effort to perform daily tasks. For example, to rise from a chair, a young individual works at 42% relative effort while an older adult works at 80% relative effort. We can increase that capacity through strength training and other forms of exercise so that older adults can function easily and comfortably.

Many older adults have pathologies like osteoporosis, arthritis, decreased tissue elasticity, and decreased recovery capacity. But still, older adults can safely perform and benefit from strength training.  Even though there is a risk of causing adverse cardiac events in older adults. The physiotherapist designs programs specifically for complex patients so that these patients can exercise at a relatively high intensity, simultaneously monitoring their vital signs and symptoms.

To improve strength, we need to give training in the intensity range of 60-85% 1RM, with higher intensities resulting in greater strength gains. An intensity of 60% represents the minimum to get stronger, while the 70-85% range is optimal for strength adaptations.

1RM stands for one repetition maximum. It is the maximum amount of weight an individual can lift for a single repetition. In the same way, 2RM is the maximum amount of weight an individual can lift for two repetitions, 3RM is the maximum weight an individual can lift for three repetitions, and so on.

To test % 1RM, this can become time-consuming when performing various exercises, e.g., assessing % 1RM for a leg press, bench press, lunge, lat pull down, etc. Simultaneously, strength also fluctuates based on a variety of factors.  Also, with rapid gain in the first weeks of training clients will get stronger over time, so the usually % 1RM will not always match the individual's abilities for a given session. Therefore, a target rep range can be used instead and RPE to achieve that intensity.

RPE stands for Rate of Perceived Exertion, which is the measure of exercise intensity, a scale designed for cardiovascular exercise. It gives an estimate of the actual heart rate during activity. To use it, multiply the RPE by 10 to get an estimated heart rate. For example, if RPE is 12, then 12 x 10 = 120 beats per minute.

The use of the OMNI Resistance Exercise Scale has been validated for use in older adults. This scale is explained and shown to older adults. During strength training aim should be to work in the range of 6-15 repetitions, loads that can be performed for 6 reps are approximately 85% 1RM, and loads that can be lifted for 15 reps are approximately 60% 1RM. Starting an individual with higher rep sets of 15 and over several weeks work down to lower rep sets of 6, if appropriate and tolerated.

Use RPE to make sure an individual is working in that 60-85% 1RM range. To assess RPE, ask the patient to rate their exertion level at the set’s end.

An individual should not be pushed till absolute muscle failure. The patient should work up to an RPE of 6-8 ("somewhat hard" to "hard") within that 6-15 rep range, to ensure that enough load is applied to make the patient stronger.

Some patients may start with greater than 15 reps and intensities of less than 6 RPE and that is ok if tolerated. Later. they should be progressed into the 6-15 rep range with RPEs of 6-8 to reach the 60-85% 1RM intensity that is optimal for strengthening.

If an individual performs a given repetition and load combination for several weeks and the RPE increases or stays the same, this could mean that the client is not getting stronger by that exercise. In this case, it might be time to change the strength training program.

To assess the progress an individual over time should be able to perform more reps with heavier loads, and with a similar level of RPE.

High-intensity exercises are often considered important for young athletes, while older adults are given gentle exercises. But at the same time, we need to sufficiently recommend strength training exercises to our older adults so that they can function and live better.