Physiotherapy Management in Vascular Surgery

Introduction to Vascular Surgery and Physiotherapy Management

• Presented by Nicole Leptonen, Senior Physiotherapist at The Princess Alexandra Hospital.
• Part three of three lectures on vascular surgery.

Recap of Previous Lectures

• First Lecture:
    - Discussed peripheral vascular disease (PVD): prevalence, causes, risk factors (emphasis on smoking and diabetes).
    - Explored chronic PVD including symptoms:
      - Claudication
      - Resting pain
      - Ulceration
    - Conservative management of PVD focused on:
      - Control of risk factors
      - Exercise programs, e.g., vascular rehabilitation.

• Second Lecture:
    - Different types of vascular surgeries:
      - Endovascular procedures
      - Inflow and outflow operations
      - Endarterectomy
      - Abdominal aortic aneurysm (AAA) repairs.
    - Importance of managing risk factors to minimize surgical interventions.

Today's Focus - Physiotherapy Management of Vascular Surgery Patients

• Discussion will include:
    - Physiotherapy considerations pre and post vascular surgery.
    - Acute limb ischaemia contrasted with chronic cases.

Preoperative Considerations

• Best practice involves conducting a preoperative review:
    - Developing Rapport: Establish trust to encourage post-operative mobilization and therapy engagement.
    - Collecting Information:
      - Social Information: Understand home environment (e.g., stairs).
      - Mobility Assessment: Prior level of mobility (mobility aids, falls history, exercise tolerance).
      - Comorbidities Assessment: Identify conditions that might affect recovery (lung or heart conditions).
      - Patient Motivation: Gauge willingness to participate in therapy.
    - Patient Education: Topics include:
      - Importance of mobility
      - Risk of venous thromboembolism (VTE) and prevention strategies.
      - Risk of chest infections and mitigation techniques:
        - Use of incentive spirometers
        - Deep breathing exercises.
        - Supported cough techniques for patients with abdominal wounds.
    - Preoperative assessment enhances patient receptiveness to information before pain post-op.

Postoperative Considerations

• Circulation Assessment:
    - Check for calf swelling, redness, tenderness, capillary return.
    - Watch for DVT signs; physiotherapists often the first to identify symptoms.
• Chest Review: Assess respiratory function:
    - Observe, palpate, auscultate for respiratory compromise.
• Functional Review: Commence mobility assessment appropriately.
• Techniques and Treatments to Implement:
    - Circulation and bed exercises.
    - Chest therapy for identified issues.
    - Gradual mobility starting with rollator or forearm support frame, progressing as tolerated.

Specific Surgical Considerations

• Greater surgeries (e.g., open AAA repairs) involve:
    - Multiple attachments complicating mobility.
    - Pain management crucial, especially with abdominal wounds.
• Individualized exercise programs tailored for home, including:
    - Graduated walking programs.
    - Continued education on lifestyle changes for risk factor reduction.

Unique Considerations for Non-Weight Bearing and Amputated Limb Patients

• Non-weight bearing or amputated patients should avoid hopping on the unaffected leg to prevent injury and overuse.
• Focus on:
    - Wheelchair transfer training rather than crutches or rollators.
    - Monitoring foot care meticulously to preempt infections or wounds.

Understanding Acute Limb Ischaemia (ALI)

• Presentation Indicators: The six P's of acute limb ischaemia:
    - Pain
    - Pallor
    - Pulselessness
    - Paresthesia
    - Paralysis
    - Poikilothermia (cool limb).
• Cause of ALI:
    - Complications can arise from failed bypass due to infection, blood clots, heart conditions, or compartment syndrome.
• Assessment of Limb Viability:
    - Options: revascularization (bypass graft, thrombectomy, thrombolysis) vs. amputation decisions based on limb viability status.
• Considerations in Decisions: Patient frailty, comorbidities, and impact on quality of life.

Amputation Considerations

• Types of Amputations and Considerations:
    - Amputation levels from toes to pelvis based on healing potential.
    - Rehabilitation potential varies (transfemoral vs. transtibial amputation).
• Assessment Tool Utilization:
    - Blart assessment tool: Evaluates rehabilitation potential for prosthetic limbs.
• Foot and Toe Amputations:
    - Healing impacted by blood flow restoration from bypass operations.

Post-Operative Management of Amputees

• Transtibial Amputation:
    - Rigid, removable dressings and modification for increased healing.
    - Emphasis on preventing falls and ensuring safety in mobility.
• Transfemoral and other Amputations: Potential challenges in functional recovery and prosthetic usage.

Patient Case Study - Mr. X

• Patient Profile:
    - A 69-year-old man with PVD and necrosis.
    - Past medical history: coronary artery disease, hypertension, diabetes, COPD.
    - Living situation: single-storey house requiring assessment for accessibility post-op.
• Preoperative Goals:
    - Assess mobility, patient chest parameters, and educate on mobility and foot care.
• Postoperative Adjustments:
    - Following complications leading to a transtibial amputation, focus on revised education, transfers, and circulation exercises.

Discharge Planning and Considerations

• Discharge evaluations must include:
    - Mobility capabilities with potential wheelchair usage.
    - Home environment assessments for accessibility (i.e., ramps for stair navigation).
    - Education on stump care, wound monitoring, etc.
    - Equipment trials for wheelchairs, ensuring comfort and usability at home.

Conclusion

• Importance of physiotherapy in post-vascular surgery recovery has been emphasized throughout.
• Role extends from preoperative assessments to rehabilitation post-surgery.
• Acknowledgment of challenges faced by patients in recovery and the satisfaction derived from aiding their rehabilitation journey.
• Invitation for further questions and connections post-lecture.