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Therapist rehab

Post-operative Assessment:​

Reassess the following:

  • Posture
  • Pain
  • Activity tolerance
  • Skin/tissue integrity (assess for infection, scars, hematoma, seroma, etc.)
  • Function (i.e. quick dash, LLIS, PSFS)
    • Level of functional activity
  • Limb Volume/Edema
    • Especially upper arm/trunk circumference under axillary fold. Note: post surgical swelling is normal. Axillary fold may measure smaller s/p top surgery due to tissue removal, however, will likely continue to reduce as swelling subsides. Upper arm may be larger due to swelling
  • Strength (not appropriate until 6 weeks post op):
    • Arm curl test
    • Dynamometer
    • Shoulder manual muscle test
  • Range of motion (not appropriate until 2+ weeks post op):
    • Shoulder: flexion, scaption, horizontal abduction, external/internal rotation, hands behind back/hands over back
    • Scapular mobility
    • Trunk: flexion, extension, lateral flexion, rotation

Post-operative Sample Documentation of Assessment and Plan​

  • Patient presents to therapy to compare baseline preoperative measurements/outcome measures to their current level of function. This patient will benefit from 1:1 skilled intervention to assess for and treat post operative sequelae. They currently present with limitations/deficits such as [pain, functional reach, scar adhesions, seroma, edema, muscular weakness/imbalance, limited active range of motion, muscular/joint tightness, etc.] which are limiting participation in [XYZ function]. This patient will benefit from [therapeutic exercise, manual therapy, neuromuscular re-education, and an individualized home exercise plan] in order to return to previous level of function and decrease symptom report.

Post-operative Goals​

  • Patient will return to baseline shoulder active range of motion as measured at pre-operative evaluation by at least 5 weeks post-op to improve bilateral upper extremity functional activities.
  • Patient will improve QuickDASH scores by MCID (decrease of 11 points) from % to % to indicate improved functional tolerance of ADLs and reduced upper extremity pain by 6 weeks post-op.
  • Patient will restore full upright posture as compared to pre-operative findings (by at least 4 weeks post-op) as measured by (decrease in pain, AROM trunk extension, etc).
  • Patient will improve Patient Specific Functional Scale scores by MCID (decrease of 2 points) from #/10 to #/10 (average score of 3 activities) to indicate improved functional tolerance with activities such as [XYZ].
  • Patient will demonstrate appropriate wound dressing changes (per post-surgical protocol) to reduce infection risk within 1-2 weeks after chest masculinization surgery.
  • Patient’s post-surgical swelling in the involved quadrant will decrease and/or stabilize within 8 weeks as evidenced by circumferential measurements, clinical observation and patient report as compared to measurements at first post-op visit.
  • Patient will return to previous level of strength as measured by [arm curl test, dynamometer, etc] within 10 weeks of surgical date.

*The real goal here: Patient will live their best life...as my partner says, "chesticle free!" ;)

Interventions​

  • Diaphragmatic breathing and 360º breathing
  • Appropriate exercises/Strengthening
    • Encourage functional exercise within surgical protocol (laundry, dishes, etc.)
    • Educate in importance of cardio and resistance training (for improved bone density, improved muscle pump action to reduce swelling as appropriate, decrease risk of secondary health issues such as cancer, cardiovascular problems, etc.)
    • Reduced movement can lead to tissue adhesions, stiffness, decreased lymphangiomotoricity
    • Too much movement can lead to seroma, lymphatic overhead resulting in swelling
    • Neuromuscular retraining
  • Flexibility/ROM
    • Limit shoulder active range of motion for 1-2 weeks <90º to reduce risk of seroma; As tolerated within surgical protocol after 2 weeks
  • Endurance training
    • Walking is good for pain control and calming nervous system if precautions observed; generally, first 4 weeks HR <100BPM
    • Encourage approx 180 min weekly of exercise once return to PLOF
  • Swelling management
    • Manual lymphatic drainage: The lymphatic system filters metabolic waste products, inflammatory agents, dead cell particles, proteins, long chain fatty acids, bacteria/virus, cancer cells, foreign particles, large un-digestable macromolecules, etc. from the interstitial space (basically the body’s sewage system). Initial lymphatic collectors are able to receive interstitial fluid (which becomes lymphatic fluid when it enters the lymph system) when the skin is stretched. Lymphatic collectors have some smooth muscle but relies heavily on muscle pump action; therefore, when muscles are immobile/inactive, swelling often occurs. Once the lymph fluid reaches the lymph node (if intact), it is filtered, travels through a branch, to a duct and then enters the circulatory system at the subclavian vein (meaning it has a long way to go in a gravity dependent position!).
    • Elevation/positioning
    • Educate in compression benefits: decreased risk of seroma/edema; front closure compression bra/vest or pull up from hips to don in first few weeks
    • Expect post op swelling until approximately 6 weeks
    • Assess UEs and trunk for swelling with palpation (pitting?) and circumferential measurements
    • Elastic tape as appropriate for lymphatic stimulation
    • Low level laser for edema, scar management, tissue healing
    • Compression garments and/or cherry pit pak or foam pads to address scar tissue, swelling, seroma, etc.
  • Infection risk reduction
    • Assess for warmth, redness, pain, swelling in local area
    • Seroma management
      • Compression (elastic garments, compression pads)
      • Avoid stretching of soft tissue within border of seroma if tissue is watery; initiate stretching and MLD/MFR once fluid becomes firm and tissue stiffens
      • Elastic tape (assess skin)
  • Pain management recommendations
    • Posture and positioning
      • Silicone / otoform for scars
  • Manual therapy for swelling, scar massage, etc.
    • Tissue “rolling”
    • Address scar adhesions around incision and drains
    • IASTM/Myofascial decompression cupping (scar management, tissue imbalance, swelling)
    • Joint Mobilizations
  • Post-op Hematomas
    • Treat with moist heat and compression once stabilized

ICD codes​

  • Z90.13 Acquired absence of bilateral breasts and nipples
  • R60.0 Localized edema
  • M25.619 Stiffness of shoulder
  • M62.81 Muscle weakness
  • L90.5 Scar conditions and fibrosis
  • R07.89 Pain in chest
  • M79.601 Pain in right arm
  • M79.602 Pain in left arm
  • R29.3 Abnormal posture
  • Other conditions that may affect recovery (i.e. anxiety, diabetes, musculoskeletal changes, etc.)