For Healthcare Professionals: Postsurgical Rehabilitation

In 2010, Memorial Sloan-Kettering expanded its Outpatient Rehabilitation Center, enabling physiatrists and therapists to focus on new ways to assess and rehabilitate patient motor skills, neurological impairments, and cardiopulmonary strength.

When an inpatient is referred by a Memorial Sloan-Kettering physician, one of our rehabilitation therapists evaluates the case and creates and implements a treatment plan. Our physical therapists establish goals for patients and monitor their progress.

Treatment is individualized for each patient and may include:

• Therapeutic exercise
• Occupational and cognitive therapy 
• Hands-on (manual) therapy
• Application of modalities
• Postural reeducation
• Neuromuscular reeducation
• Prosthetic and/or orthotic training
• Bed mobility and transfer training
• Gait training, with or without an assistive device
• Breathing exercises
• Pulmonary drainage/pulmonary toileting

Additionally, patients and their caregivers are educated to maximize progress during the hospital stay and after discharge.

We provide a variety of services for patients with head and neck malignancies, as well as other types of cancer, through our Speech, Hearing, and Rehabilitation Program.

The Postoperative Early Intervention Program at Memorial Sloan-Kettering is designed for high-risk patients who have had open surgical procedures for gynecologic, genitourinary, thoracic, and gastrointestinal malignancies. 

The program includes:

• Pulmonary rehabilitation – Restorative and preventive intervention to decrease respiratory symptoms and increase exercise tolerance. This alleviates respiratory impairments such as dyspnea at rest or exertion, hypoxemia, decreased exercise tolerance, pneumonia or atelectasis, and weak respiratory muscles. 
• Ambulation and exercise training – When allowable, a six-minute walking test is performed by a physical therapist to assess the patient’s endurance and functional level. Ambulation training is used to increase endurance and function, and includes upper and lower extremity training, flexibility and range of motion (ROM) exercises, respiratory muscle training, and a home exercise program. Patients can use the least restrictive device (such as a platform walker) to facilitate ambulation initially, but are weaned from the device as soon as possible to resume their normal walking pattern.
• Functional training – Occupational therapy is initiated on an as-needed basis when assistance is required for activities of daily living (such as self-feeding, personal hygiene, and getting dressed) and to prepare for hospital discharge.
• Education – Our patient and family education programs emphasize the importance of deep breathing, coughing, and walking, and include written instructions for an exercise program. Therapists also teach patients proper guarding techniques to decrease pain.

Physical therapy for patients who have undergone open surgical procedures typically involves aggressive pulmonary hygiene therapy beginning 24 hours after surgery. This includes postural drainage, retraining of the diaphragm, and instruction on coughing techniques. Medically stable patients are encouraged to begin ambulation and to perform deep-breathing exercises in bed and in a chair. Therapists initiate patient education, and 48 hours postsurgery ROM exercises and muscle strengthening are begun. Seventy-two hours postsurgery, patients are encouraged to start independent transfer training, postural training is provided, and occupational therapists work with patients to initiate self-care activities.

The extent of surgery and the required length of stay vary for each patient; pulmonary therapy, transfer training, therapeutic exercise, and ambulation are continued until the patient is discharged. Emphasis is placed on increasing independence, endurance, and participation in activities of daily living. 

Our therapists aim to treat patients as early and as aggressively as possible to prevent postoperative complications, reduce the length of the hospital stay, and improve overall quality of life. Each therapy session is performed at the patient’s bedside and lasts up to 30 minutes.

For patients who need additional assistance to move out of bed for therapy, specialized equipment (such as the Moveo^™) may be utilized. The Moveo provides the therapist with a safe way to enhance strength and function in this patient population. Once patients can safely manage 70 percent of their own body weight, they progress to standing and walking. 

Specialized chest physical therapy is indicated for patients at risk for pneumonia and atelectasis following open surgical procedures such as interventional bronchoscopy, tracheal resections, or other thoracic procedures. As a result of depressed respiration following surgery, chest physiotherapy is prescribed to help return the patient's lungs to normal and prevent congestion. 

Our respiratory rehabilitation department has established a comprehensive program focused on pulmonary hygiene and early mobilization to improve function and reduce complications in high-risk patients. The program includes:

• Percussion and vibration is initiated on the first postoperative day in a side-lying position. The Trendlenberg position is indicated for patients with positive findings on chest x-rays.
• Deep breathing exercises are initiated on the first postoperative day to optimize lung expansion.
• Patients are encouraged to be out of bed and walking as much as possible; therapists set a daily goal for the number of laps around the hospital floor.
• Patients receive education on the pain and discomfort they will experience while coughing and deep breathing as well as on the importance of continuing their exercises during recovery.  

Exercises include:

• Coastal expansion
• Diaphragmatic breathing
• Sniffing
• Pursed lip breathing
• Deep breathing with tissue
• Incentive spirometer
• Acapella, flutter valve – with copious secretions
• General expansion, including reaching overhead
• Postural exercises – shoulder rolls, scapular retraction, pectoralis stretch, and scapulothoracic PROM
• Upper extremity resistance program to increase strength

Respiratory therapists set the frequency of exercises based on an initial evaluation. They generally follow patients for the first three days postoperatively, providing skilled intervention and program modifications as needed until the patient is well enough to be discharged.

Videos

Day to Day Coping with Lymphedema

Jeannette Zucker, a physical therapist and lymphedema specialist at Memorial Sloan-Kettering Cancer Center, discusses how cancer treatment can lead to lymphedema and ways to reduce the risk and better manage lymphedema following cancer treatment.

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Lymphedema may result from the treatment of melanoma or breast, gynecologic, or prostate cancers, when lymph nodes are surgically removed for analysis or radiation therapy is delivered.

At Memorial Sloan-Kettering, specially trained occupational and physical therapists help patients manage the symptoms of lymphedema, including reducing or stabilizing swelling, caring for the skin in the affected area, regaining mobility after surgery, and making choices about participation in daily activities and energy conservation to prevent worsening of swelling. 

Each patient receives comprehensive education about the impact of treatment on the lymphatic system, and how to care for the limb and skin where the lymph nodes were removed or where radiation treatment was targeted. 

Depending on the location and extent of the lymphedema, therapy is conducted at one of our satellite facilities or at Memorial Sloan-Kettering’s main campus in Manhattan. 

A patient’s first visit with an occupational therapist includes an assessment of cognitive function and safety awareness. Based on the patient’s activities, the therapist and patient decide together on the treatment goals, a treatment plan, and the frequency of visits. Treatment plans generally focus on:

• The use of devices to help get dressed, make a meal, or fasten buttons more easily
• Fine motor skills to cut food with a knife and fork
• Hand and arm strength, so objects are less likely to be dropped
• Planning daily activities to conserve energy
• Memory
• Concentration
• Movement with less or no pain
• Use of splints and braces to allow a joint to heal
• Ways of moving that prevent strains and injury
• Awareness of unsafe areas in the home or workplace
• Arrangement of home and work areas to make daily tasks easier