Keywords
diaphragmatic hernia - hernia rehabilitation - traumatic acquired hernia
Introduction
A diaphragmatic hernia (DH) occurs when the diaphragm, the muscle separating the abdomen
and chest cavity, develops a defect, allowing abdominal contents to protrude into
the thoracic cavity.[1] While some cases are congenital, acquired DHs typically occur as a result of blunt
or penetrating trauma, requiring careful detection and suspicion. The incidence of
DH is estimated to be around 0.8 to 5 per 10,000 births.[2] Acquired DHs are primarily caused by trauma, which leads to increased pressure in
the pleuroperitoneal region and the formation of anatomical defects in the diaphragm
at weak fusion sites.[3] This allows the upper abdominal contents to herniate into the thoracic cavity.[4] The pathophysiology of this condition involves circulatory and respiratory depression
due to impaired diaphragm function, compression of the lungs by abdominal contents
in the chest, displacement of the mediastinum, and potential compromise to cardiac
function.[5]
[6]
The research landscape surrounding rehabilitation strategies for acquired DH is relatively
sparse, with limited studies exploring nonsurgical interventions. While surgical intervention
remains the cornerstone in clinical practice for repairing acquired DHs, the current
body of research primarily emphasizes operative techniques and outcomes. However,
these surgeries can impact lung function and give rise to various complications, including
reduced lung volume, decreased functional residual capacity, impaired clearance of
mucus from the airways, and abnormalities in gas exchange.[7] Consequently, postoperative pulmonary complications can occur even after hernia
repair. Delayed mobilization has been associated with an increased risk of these complications.[8] Additionally, postthoracotomy pain syndrome and a decrease in range of motion and
strength in the upper extremities on the affected side are commonly observed postoperative
issues.[9] Limited attention has been directed toward investigating comprehensive rehabilitation
strategies to optimize postoperative recovery. This gap in the literature underscores
the need for a more nuanced understanding of nonsurgical interventions that can complement
surgical approaches and address aspects such as respiratory function, mobility, and
overall well-being.
To facilitate postoperative recovery, promote independence, and enhance the quality
of life for patients undergoing traumatic DH repair, comprehensive inpatient rehabilitation
is crucial. Therefore, this case report presents a comprehensive rehabilitation protocol
developed for a patient undergoing repair of an acquired DH. The aim of this report
is to outline a structured plan for the rehabilitation of acquired DH patients.
Case Presentation:
A 32-year-old woman, a homemaker, presented to a tertiary hospital with chief complaint
of recurrent fever accompanied by chills. The febrile episodes were intermittent in
nature and accompanied by additional symptoms such as episodes of nausea, vomiting,
and a burning sensation during urination. The patient reported experiencing these
symptoms for the past 4 months following a minor traumatic event. Despite being previously
diagnosed with renal calculi and urinary bladder cystitis, her symptoms failed to
improve with conservative medical management.
Upon admission on March 8, 2023, the patient underwent comprehensive radiographic
and hematological investigations as part of the initial assessment. However, the persistent
abdominal pain remained her primary concern. To further investigate her condition,
a contrast-enhanced computed tomography (CECT) scan of the chest with high-resolution
computed tomography (HRCT) was performed. The imaging findings unveiled a left-sided
DH, wherein the stomach, spleen, pancreas, and a segment of the colon were identified
as the herniated contents. The size of the defect in the diaphragm was measured at
7.1 cm, resulting in the compression collapse of the left lung and displacement of
the mediastinum and heart toward the right side ([Figs. 1] and [2]).
Fig. 1 High-resolution computed tomography (HRCT).
Fig. 2 Chest X-ray. *Compression collapse of the left lung.
Consequently, the patient underwent DH repair utilizing a laparoscopic approach. However,
due to the presence of adhesions hindering the complete reduction of the herniated
contents, the surgical procedure had to be converted to an open subcostal incision.
In the postoperative phase in the intensive care unit, the patient underwent uneventful
extubation. Following extubation, she presented with tachycardia, tachypnea, and an
abnormal breathing pattern. According to the documentation in the file, we found that
despite these challenges, the patient remained conscious, alert, and responsive. Subsequently,
the patient was closely monitored in the surgical intensive care unit ([Fig. 3]), and an inpatient rehabilitation program was initiated after obtaining patient's
informed consent starting from the second day postsurgery. Pertinent postoperative
investigations were conducted to assess the patient's progress and recovery ([Fig. 4]).
Fig. 3 Drain and incision site after operation.
Fig. 4 Drain and incision site at 1 week postoperatively.
Outcome Measures
The study utilized various outcome measures, including the inch tape method to assess
chest expansion, mobility evaluation of the diaphragm muscle, pulmonary function tests,
strength assessment of respiratory muscles, Functional Independence Measure (FIM)
scale for daily activity independence, and Abdominal Surgery Impact Scale (ASIS) for
quality-of-life evaluation.
Assessment
[Table 1] presents vital parameters and chest expansion assessments post-DH repair. Positive
progress was observed: heart rate decreased from 124 to 92 bpm, respiratory rate reduced
from 35 to 18 brpm, and oxygen saturation improved from 92 to 99%. The breathing pattern
shifted, and chest expansion increased, indicating enhanced lung function. Mild asymmetry
was noted on day 15.
Table 1
Vital parameters and chest expansion assessment
|
Vital parameters
|
|
Parameters
|
Postoperative day 2
|
Postoperative day 7
|
Postoperative day 15
|
|
Heart rate
|
124 bpm
|
106 bpm
|
92 bpm
|
|
Respiratory rate
|
35 brpm
|
27 brpm
|
18 brpm
|
|
Oxygen saturation
|
92% with O2 support via the venturi mask
|
96% with O2 support via the nasal cannula
|
99% at room air
|
|
Pattern of breathing
|
Abdominothoracic
|
Abdominothoracic
|
Thoracoabdominal
|
|
Chest expansion (inches)
|
|
Axillary level
|
0.4
|
0.8
|
1
|
|
Nipple level
|
0.6
|
1
|
1.2
|
|
2 cm above the xiphisternum
|
1.4
|
1.8
|
2
|
|
Chest asymmetry
|
Asymmetrical
|
Asymmetrical
|
Mild asymmetry
|
Abbreviations: bpm, beats per minute; brpm, breaths per minute.
[Table 2] illustrates the outcomes of the diaphragm muscle manual examination on postoperative
days 2 and 15. Initial limitations in movement and strength progressively improved
by day 15, signifying enhanced diaphragmatic function and mobility.
Table 2
The diaphragm muscle manual examination
|
Evaluation areas
|
Postoperative day 2
|
Postoperative day 15
|
|
Right
|
Left
|
Right
|
Left
|
|
Costal movements
|
2
|
5
|
1
|
3
|
|
Anterior costal margin
|
2
|
5
|
1
|
3
|
|
Diaphragmatic domes
|
3
|
5
|
1
|
3
|
|
Posterolateral areas
|
2
|
5
|
1
|
3
|
|
Xiphoid costal area
|
Not applicable
|
|
Medial pillar
|
|
Lateral pillar
|
[Table 3] details the results of pulmonary function tests and respiratory muscle strength
assessments on postoperative day 15, emphasizing rigorous precautions to ensure accuracy
and patient safety. Findings include positive outcomes such as forced expiratory volume
in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, vital capacity (VC),
maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP), indicating
improved respiratory function and muscle strength.
Table 3
Pulmonary function test and respiratory muscle strength assessment
|
Parameters
|
Postoperative day 15
|
|
Pulmonary function test
|
|
FEV1 (L)
|
2.19
|
|
FVC (L)
|
2.78
|
|
FEV1/FVC (L)
|
79
|
|
VC (%)
|
2.88
|
|
Respiratory muscle strength
|
|
Maximal inspiratory pressure (MIP)
|
48 cm H2O
|
|
Maximal expiratory pressure (MEP)
|
32 cm H2O
|
Abbreviations: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity;
VC, vital capacity.
In this case report, the ASIS evaluated the patient's quality of life post-DH repair,
while the FIM reflected a significant improvement from 47 to 78% in functional independence
after rehabilitation.
Physical Therapy Rehabilitation
Physical Therapy Rehabilitation
In week 1 of the rehabilitation protocol post-DH repair, a holistic approach was employed
([Table 4]). Patient education about surgery and potential complications preceded rehabilitation,
with baseline vital parameter recording on all postoperative days. Dyspnea evaluation
through the modified Borg's scale before and after sessions played a crucial role
in addressing respiratory challenges. Careful patient positioning, continuous vital
sign monitoring, and meticulous incision site care demonstrated the commitment to
patient well-being.
Table 4
Postoperative rehabilitation protocol (week 1)
|
Goals
|
Protocol
|
Dosage/frequency (sets and repetitions)
|
|
Week 1 (postoperative days 2–7)
|
|
Patient education
|
Patient and family education about the surgery and its complication
|
|
Patient position
|
Patient positioning: head end elevated at 30 degrees
|
With monitoring vitals
|
|
To improve breathing pattern
|
Diaphragmatic breathing exercise
|
2 sets of 8–10 repetitions
|
|
To improve chest expansion
|
Self-assisted segmental chest expansion
|
2 sets of 8–10 repetitions
|
|
Incentive spirometry
|
2 sets of 8–10 repetitions
|
|
To mobilize secretions
|
Active cycle of breathing technique
|
10–12 min
|
|
To improve mobility of thorax
|
Assisted thoracic mobility exercises paced with diaphragmatic breathing
|
2 sets of 8–10 repetitions
|
|
To reduce circulatory complications
|
Heel taps and heel raises
|
2 sets of 8–10 repetitions
|
|
Active ROM exercises for bilateral Upper limb in the available pain free range
|
2 sets of 8–10 repetitions
|
|
Ankle pumps and in bed heel slides
|
2 sets of 8–10 repetitions
|
|
To maintain correct posture
|
Postural correction exercise: neck stretches, shoulder bracing exercises
|
3 min
|
|
To improve functional capacity
|
Bedside sitting
|
15–30 min
|
|
Bedside supported sit to stand
|
2 sets of 8–10 repetitions
|
|
Bedside ambulation with support
|
3-4 min
|
Abbreviations: ROM, range of motion.
Emphasis on cleanliness and infection prevention was evident, with physical therapists
wearing sterile gloves and using surgical gowns. Exercises were executed with smooth
transitions, minimizing strain and ensuring optimal healing. Early rehabilitation
goals, spanning from days 2 to 4, targeted breathing pattern improvement, chest expansion,
secretion mobilization, thoracic mobility, circulatory complication reduction, and
posture maintenance.
In the subsequent days, from days 5 to 7, the focus shifted to mobility enhancement
and functional capacity improvement. Tailored rehabilitation interventions were administered
based on ongoing assessments, ensuring patient-specific care throughout recovery.
Week 2 extended the week 1 regimens and introduced new techniques such as scapular
stability exercises and chest neuromuscular facilitation ([Table 5]). From days 11 to 14, a strengthening program commenced, progressing from isometric
to isotonic exercises targeting various muscle groups. Increased sitting and ambulation
activities aimed at enhancing functional capacity and promoting independence.
Table 5
Postoperative progressive rehabilitation protocol (week 2)
|
Goals
|
Progression protocol
|
Dosage/frequency (sets and repetitions)
|
|
Week 2 (postoperative days 8–14)
|
|
To improve ROM
|
Active ROM exercises for bilateral upper limb in the available pain-free range
|
2 sets of 8–10 repetitions
|
|
Scapular stability exercises
|
|
To improve breathing pattern
|
Chest NFR: abdominal co-contraction
|
5–6 repetitions
|
|
To improve chest expansion
|
Segmental chest expansion: apical, lateral, and posterior
|
2 sets of 8–10 repetitions
|
|
Incentive spirometry with holds
|
2 sets 8–10 repetitions with 2- to 5-s holds
|
|
To improve mobility of thorax
|
Thoracic mobility exercises paced with diaphragmatic breathing
|
2 sets of 8–10 repetitions
|
|
To maintain correct posture
|
Stretching of the pectoralis major and sternocleidomastoid muscles
|
2 sets 8–10 repetitions with 10- to 12-s holds
|
|
To increase muscle strength
|
Static abdominals: activation of transverses abdominis muscle
|
2 sets of 8–10 repetitions, 5- to 7-s holds
|
|
Strengthening of muscles of the lower limb (isometric to isotonic in progression)
Hip: flexors, extensors, adductors, and adductors
Knee: flexors and extensors
|
2 sets of 8–10 repetitions
|
|
To improve functional capacity
|
Bedside sitting
|
30–50 min
|
|
Spot marching
|
2 sets of 8–10 repetitions
|
|
Bedside ambulation independently
|
1–2 laps of 20–30 m
|
Abbreviations: NFR, neurophysiological facilitation of respiration; ROM, range of
Motion.
The rehabilitation plan's adaptability, based on ongoing assessments and the patient's
response, ensured a comprehensive recovery following DH repair, highlighting the commitment
to individualized care and patient well-being.
Discussion
In this specific case report focusing on physical therapy rehabilitation for acquired
DH, our primary goal was to address diaphragm mobility and recruitment, emphasizing
pulmonary function and incorporating endurance and strength training for extremity
muscles.
Our rehabilitation program aligned with recommendations from the European Society
of Intensive Care Medicine, emphasizing the pivotal role of physical therapists in
early mobilization and exercise prescription for critically ill patients.[10] Commencing with relaxation techniques and therapeutic positioning, our approach
aimed to optimize diaphragmatic function and enhance respiratory muscle coordination.
Specific diaphragmatic breathing exercises were employed to retrain altered postoperative
breathing patterns, resulting in reduced respiratory rate and improved breathing depth.
The observed reduction in heart rate can likely be attributed to rhythmic and slow
breathing techniques, known to impact cardiovascular parameters, particularly in hypertensive
individuals. Engaging in deep and slow breathing practices enhances baroreflex sensitivity,
contributing to efficient blood pressure control.[11] These techniques also reduce chemoreflex activation, regulating respiratory and
cardiovascular functions.
Upon stabilizing vital signs, we progressed to mobilization activities, stressing
the cardiopulmonary system to enhance overall cardiovascular fitness and respiratory
function safely. In the second week, we introduced chest neuromuscular proprioceptive
facilitation techniques, focusing on diaphragm recruitment and core muscle activation.
Integrating proprioceptive neuromuscular facilitation (PNF) techniques through resistance
training aimed to increase respiratory muscle strength and stimulate reflex respiratory
movement responses.[12]
Our comprehensive multisystem approach, encompassing various interventions, likely
played a crucial role in enhancing muscle strength and endurance. By engaging in exercises
targeting diverse muscle groups, our strategy synergistically contributed to improved
muscle recruitment patterns, ultimately leading to increased strength and endurance.
Throughout the program, we prioritized incision site care and infection prevention
measures to ensure patient safety. While our structured treatment protocol provides
a framework, individualized care and ongoing assessment remain crucial for tailoring
the program to meet each patient's specific needs and ensuring successful outcomes.
This case underscores the significance of a targeted and comprehensive rehabilitation
approach in managing DH postsurgery.
Conclusion
The case report highlights the significance of a comprehensive rehabilitation program
in the management of acquired DH. Physical therapy interventions play a crucial role
in optimizing respiratory function, enhancing mobility, reducing complications, and
promoting functional recovery.
