PRM interventions in surgical and systemic diseases. Preoperative preparation and early postoperative rehabilitation. Prevention of complications associated with immobilization and surgery. PRM interventions in endocrine, gastrointestinal, renal, and gynecological disorders. Interdisciplinary approach and individualization of the rehabilitation program

01Surgery, bed rest and the body

Rehabilitation in surgery rests on one fact: the body keeps only what it uses. An operation adds stress (tissue damage, pain, anaesthesia, inflammation, fasting) to the cost of lying still. The fitter a patient goes in, and the sooner they move afterwards, the less they lose and the faster they recover.

The professor's school calls this loss hypodynamy or hypokinesia (too little movement) and treats it with a planned movement regimen that widens step by step: strict bed rest, then exercises in bed, then sitting and short walks on the ward, then a free regimen. It is the same idea as modern early mobilisation, now done much faster.

lost by fit young men in three weeks of bed rest

about a quarterof aerobic capacitylost by fit young men in three weeks of bed rest

lost by healthy older adults in ten days of bed rest

about 1 kgof leg musclelost by healthy older adults in ten days of bed rest

when walking usually starts in enhanced recovery

day 1after surgerywhen walking usually starts in enhanced recovery

02Preoperative preparation

The weeks before a planned operation are a chance. A patient who goes in fitter has more to lose before falling below the line where they can no longer manage alone. This is prehabilitation: a short, intense programme before surgery, most useful for older, frail or unfit patients facing major abdominal, thoracic, cardiac or joint surgery.

Assessment before surgery uses simple tests: the 6-minute walk test, the sit-to-stand test, grip strength, a frailty scale, and in high-risk cases cardiopulmonary exercise testing.

03Early postoperative rehabilitation

After surgery the job is to get the patient upright and moving as soon as it is safe, and to keep the lungs open. This is part of enhanced recovery after surgery (ERAS), care bundles that combine good pain relief, early eating, few drains and tubes, and early mobilisation. In trials, mostly of bowel surgery, they shorten the hospital stay and lower complications, mainly the medical ones such as chest infection, without changing mortality.

1. 1

   In bed, from the first hours

   Deep breathing every hour, supported cough, ankle pumps and leg exercises for the calf pump, turning, head of the bed up 30 to 45 degrees.
2. 2

   Day 0 to 1

   Sit on the edge of the bed, then in a chair; stand and walk a few metres with help. Check blood pressure and dizziness on getting up.
3. 3

   The following days

   Walk further several times a day, stairs before discharge if needed, back to self-care.
4. 4

   After discharge

   Graded walking at home, return to lifting and work as the wound allows, an outpatient programme if function stays low.

Specific care follows the operation:

• Abdominal surgery. Support the wound when coughing and getting up (log-roll to the side). No heavy lifting for some weeks; gentle abdominal exercises later help prevent an incisional hernia. With a stoma, avoid heavy straining early, and build up the abdominal muscles gradually.
• Thoracic surgery. Breathing and coughing, shoulder exercises on the side of the incision to prevent a stiff shoulder, early walking.
• Cardiac surgery. After a median sternotomy, traditional sternal precautions limit lifting, pushing and pulling with the arms for about 4 to 8 weeks while the breastbone knits (rules vary between centres); a trial of less restrictive, pain-guided arm use found the same outcomes, and many centres now use it. Then cardiac rehabilitation (see cardiopulmonary rehabilitation).
• Joint replacement and fractures. See hip and knee arthroplasty and fractures and trauma.
• Intensive care. Positioning to help breathing and protect the skin, passive and then active exercises, sitting on the edge of the bed and standing as soon as the patient is stable, to limit ICU-acquired weakness.

04Prevention of complications of immobilisation and surgery

Each complication has a reason, and the reason tells you how to prevent it.

Breathing exercises are the backbone of chest prevention (more in the pulmonary section of cardiopulmonary rehabilitation):

05Endocrine and metabolic disorders

Diabetes mellitus

In diabetes, exercise is a medicine. Working muscle takes up glucose by a route that does not need insulin, and regular training makes muscle more sensitive to insulin for a day or two after each session. Over months it lowers HbA1c by roughly half a percentage point, helps weight, blood pressure and lipids, and lowers cardiovascular risk.

The prescription follows the general guideline for adults: at least 150 minutes a week of moderate aerobic activity spread over at least three days, with no more than two days in a row without exercise; resistance exercise 2 to 3 times a week; and less time sitting, with breaks every 30 minutes. Balance and flexibility help older patients and those with neuropathy.

The safety rules follow from what diabetes damages:

See also diabetic complications and the treatment of diabetes.

Obesity and metabolic syndrome

In obesity, exercise alone loses less weight than people hope, because a session burns little compared with a day's eating. Its real value is in health: fitness, blood pressure, glucose, liver fat, mood, and keeping weight off after it is lost. Rehabilitation chooses low-impact activity that spares the knees and back (walking, cycling, water exercise), builds up to 150 to 300 minutes a week or more, adds resistance training to hold muscle during weight loss, and treats the joint pain that keeps people inactive. After bariatric surgery, exercise helps keep muscle while weight falls.

Other endocrine disorders

• Thyroid disease. In hypothyroidism, fatigue and slow muscles improve once treated; exercise is built up gradually. In uncontrolled hyperthyroidism, the heart is already racing, so vigorous exercise waits until the patient is controlled.
• Osteoporosis. Loading exercise, resistance and balance training and fall prevention; see osteoporosis.
• Long-term corticosteroids (Cushing's syndrome): proximal muscle weakness and bone loss, so strength and loading exercise and fracture prevention.

06Gastrointestinal disorders

Rehabilitation in digestive disease is mostly the surgical rehabilitation above, plus exercise for chronic disease.

• After abdominal surgery. Early walking also wakes the gut and shortens ileus. Breathing exercises matter most after upper abdominal incisions, which hurt with every breath.
• Inflammatory bowel disease. In remission, regular moderate exercise is safe and helps fatigue, bone density, mood and muscle (see ulcerative colitis and Crohn's disease).
• Liver cirrhosis. Muscle wasting (sarcopenia) is common and predicts death and poor outcomes after transplant. Supervised moderate exercise with enough protein helps; heavy straining is avoided with large varices (see liver cirrhosis).
• Functional bowel problems and constipation. Activity, abdominal massage along the colon, and for some, biofeedback training of the pelvic floor for straining with a closed outlet.
• Balneotherapy. The professor's school uses drinking cures with mineral waters (for example bicarbonate waters for dyspepsia and gallbladder complaints) and peloid (mud) applications for chronic, non-active disease.

07Renal disorders

In chronic kidney disease, patients become very inactive, and low fitness and muscle wasting predict hospital admission and death. Exercise is safe and improves fitness, strength, blood pressure and quality of life; the current international kidney guideline advises moderate-intensity activity for a total of at least 150 minutes a week, or as much as the heart and the person's tolerance allow.

• On dialysis. Cycling in bed during haemodialysis (intradialytic exercise) uses dead time, in the first half of the session when blood pressure is most stable. Protect the fistula arm from heavy loads and pressure.
• After kidney transplantation. Early walking, then gradual aerobic and resistance training; immunosuppressants and steroids make strength and bone work important.
• Cautions. Fluid overload, uncontrolled hypertension, high potassium, severe anaemia, and bone disease from mineral imbalance; heating agents and currents are used with care where sensation or circulation is poor.
• Kidney stones. The professor's book describes drinking cures with low-mineral waters to raise urine flow and keep urine dilute; the sound part of this is the advice to drink enough to make more than about 2 litres of urine a day (see nephrolithiasis).

08Gynaecological disorders

The pelvis holds organs that can be helped by training the muscles around them, and harmed by heating them in the wrong situation.

Pelvic floor muscle training

The pelvic floor is a hammock of muscle that holds the bladder, uterus and rectum and squeezes the urethra shut when pressure in the abdomen rises (a cough, a jump). Childbirth, ageing, menopause, obesity and chronic cough weaken it. Like any muscle it can be trained.

• Stress urinary incontinence. Supervised pelvic floor muscle training is first-line: at least 3 months, with at least 8 contractions three times a day, taught by a trained therapist who checks that the woman squeezes the right muscles (many push down instead). It cures or improves many women. Electrical stimulation is for women who cannot yet contract the muscles at all; neither it nor biofeedback is a routine extra. See pelvic floor and incontinence.
• Urge incontinence and overactive bladder. Bladder training: passing urine on a schedule and stretching the intervals.
• Pelvic organ prolapse. Pelvic floor training for mild prolapse; weight loss, treating constipation and cough.
• Pregnancy and after birth. Pelvic floor training in a first pregnancy lowers the risk of incontinence late in pregnancy and after birth; regular moderate activity (about 150 minutes a week) is advised in uncomplicated pregnancy. After birth, gentle pelvic floor and abdominal work, then a gradual return to exercise; after a caesarean section, the same rules as other abdominal surgery.

Pain and other gynaecological problems

• Dysmenorrhoea and chronic pelvic pain. Heat, TENS and exercise all help pain; chronic pelvic pain also needs pelvic floor relaxation (not strengthening, when the muscles are overactive) and psychological support. See endometriosis.
• Menopause. Exercise for bone, heart, weight and mood (see the climacterium).
• After gynaecological cancer surgery. Leg lymphoedema after lymph node removal is treated with complete decongestive therapy; see oncological rehabilitation.
• Chronic pelvic inflammation and adhesions. The professor's school uses peloid (mud) tampons and applications, mineral water irrigations and shortwave diathermy for chronic, non-active inflammation; the evidence is weak and this is rarely used in western Europe today.

09Interdisciplinary approach and individualisation

Rehabilitation in medical and surgical disease is a team: the surgeon or physician who treats the disease, the PRM physician who leads the rehabilitation plan, physiotherapists (kinesitherapists), occupational therapists, nurses, a dietitian, a psychologist, a social worker and, for continence, a pelvic health physiotherapist or specialist nurse.

1. 1

   Assess

   The disease and its stage, the operation, the other illnesses, the person's function before and now, their goals and home.
2. 2

   Set goals

   Specific and measurable, agreed with the patient: walk to the shops, climb the stairs at home, go back to work.
3. 3

   Choose and dose

   The type, intensity, frequency and duration of exercise, and the physical agents, fitted to the disease, the risks and the person's tolerance.
4. 4

   Monitor

   Symptoms, vital signs, glucose, wound, and the outcome measures chosen at the start.
5. 5

   Adjust and hand over

   Change the plan as the patient improves or worsens, and hand over to home and community programmes.

The same operation does not mean the same programme: a frail 80-year-old and a fit 40-year-old after the same hip fracture share the aims but not the dose. The rules that make a programme safe come from the disease (hypoglycaemia, the fistula arm, the wound); the rules that make it work come from the person (their goals and what they will keep doing).