Recovering from Nephrectomy A Conditioning and Post Recovery Case Study For Basma Musmar March 2013 CTTC, BASI 2013 Rosemere, Quebec
Abstract Nephrectomy is the surgical removal of a kidney. It may involve: o The removal of part of one kidney (Partial Nephrectomy) o The removal of all of one kidney (Simple Nephrectomy) o The removal of one entire kidney, surrounding lymph nodes, and the adrenal glad (Radical Nephrectomy) o The removal of a healthy kidney from a donor for the purpose of transplantation (Donor Nephrectomy) This procedure is performed on patients with severe kidney damage, whether it is from disease, traumatic injury or congenital conditions. Nephrectomy surgery could be a minimally invasive surgery, laparoscopic surgery, or an open surgery. In laparoscopic nephrectomy, four small incisions in the abdomen wall are administered to allow a videoscope and surgical instruments to be inserted into the abdominal cavity to assist with the removal procedure. In open nephrectomy, a 6-10 in incision is made on the side or the front of the abdomen through several layers of muscles. In some cases, a rib may need to be removed to be able to perform the procedure. 2
Table of Content Abstract 2 The Anatomy a. The Kidneys 4 b. The Abdominal Wall 5 Introduction 7 Towards the Recovery - The First 4-6 Weeks 8 - The Progression 11 Conclusion 16 Bibliography 17 3
The Anatomy a. The Kidneys The kidneys are a pair of bean- shaped organs located in the back of the abdomen, just below the rib cage, one on each side of the spine. Each kidney is about 4 or 5 inches long - - about the size of a fist. The kidneys function to filter the blood from wastes, control the body's fluid balance, and regulate the balance of electrolytes. Kidneys dispose of these wastes in the form of urine, which collects in the kidneys' pelvis, funnel- shaped structures that drain down tubes called ureters to the bladder. 4
Surface projections of the organs of the trunk showing kidneys at the level of T12 to L3. b. The Abdominal wall The abdominal wall is defined cranially by the xiphoid process of the sternum and the costal margins, and caudally by the iliac and pubic bones of the pelvis. It extends to the lumbar spine, which joins the thorax and pelvis and is a point of attachment for some abdominal wall structures. [1] The anterior abdominal wall s function is to protect the viscera (the interior organs or the guts) and assist with respiration and control of urination, defecation, coughing, vomiting and giving birth. They also work with the back muscles to flex and 5
extend the trunk at the hips, and rotate the trunk at the waist. They also assist in maintaining pressure on the curve of the low back, resisting excess lumber lordosis sway back and extension of the low back. The anterior abdominal wall consists of three layers of flat muscles (Transversus Abdominis, Internal Oblique and External Oblique), the tendons (aponeurosis) of which interlace in the midline, and a vertically oriented pair of segmented muscles (Rectus Abdominis). 6
Introduction Cathy has been diagnosed with Renal Cell Carcinoma (RCC), which is the most common type of kidney cancer in adults, and has contacted us after only a couple of weeks of having an open radical nephrectomy surgery. Cathy didn t like to say much about it but she has shared that she had stitches all the way from her sternum to the pubic bone and that she was undergoing chemotherapy. She seemed to be in high spirit and was determined to overcome her weakness towards a fast recovery. Cathy has done some Pilates in the past and was aware of some of the principles. She had no other health issues or physical constraints. Before getting started we have discussed and agreed on some logistics. Mainly, Cathy will target to come in for a one- hour session twice a week Whenever she felt weak or not up to it, specifically after chemotherapy, to just cancel the session and focus on relaxing and regaining her strength Whenever she felt any discomfort or pain during the session, to stop and clearly vocalize that and not push herself through any movement she feels not up to Cathy has also agreed to come in around 15 minutes before the session and lie down on her back with her knees bent and focus on breathing and relaxing She is to keep her medical practitioners updated with her Pilates progress and share any feedback or comments they had 7
Towards the recovery The First 4-6 weeks As previously mentioned, Cathy has undergone an open surgery just two weeks prior to starting her Pilates program and is continuing to take chemotherapy periodically. The first 2-3 weeks were critical. Cathy s wounds were not yet completely healed and extreme caution needed to be considered in selecting the right exercises within the given constraints. Cathy has received the following relevant directives (among others) from her doctors for the initial healing phase: Breath deeply Avoid bending from the waist; bend knees to pick up things from the floor Walk daily not only to help build strength but also to prevent blood clots from the legs Stairs should not be a problem Avoid heavy lifting Avoid strenuous activity Light exercise is good to keep healthy and lively and to help with stress The goal for the first few sessions had 2 folds: Maintain stabilization of the trunk throughout the workout avoiding any flexion, extension, lateral flexion/rotation of the spine at the start, introducing these only gradually as Cathy regains some of her strength and while her wound heals Secure a calm and relaxing environment during the session and provide encouragements and emotional support where needed BASI BLOCK WARM UP First 5 sessions (2-3 weeks) Focusing on intercostal breathing Leg Lifts with a small Range Of Motion (ROM) Pelvic curl was introduced but without lifting of bottom as a start; the focus was on the movement of curling Second 5 sessions (2-3 weeks) Breathing. Pelvic curl with small lifts of the bottom Leg Lifts and Leg Changes Also, Cathy was ok with doing small knee sways with legs bent and feet on mat maintain trunk stabilization 8
of the pelvis with the breathing pattern. FOOT WORK Using light- medium spring setting, Cathy was able to do the leg series: Parallel Heals, Parallel Toes, V position Toes, In addition of the foot work series introduced the first 2-3 weeks, we introduced Single Leg Heel, Single Leg Toes Open V Heals (not too wide), Open V Toes, Calf raises, Prances and Prehensile ABDOMINAL WORK - Keeping head down and resting on a pillow and legs in tabletop, Cathy was introduced to the Hundred Prep and Hundred without lifting of the head and chest. Maintaining the same position of resting head and chest and legs in tabletop, Cathy was then able to do the Hundred (allowing her to stop once she felt too tired to continue) Using the Short Box, Tilt was introduced with the ROM that Cathy felt comfortable with HIP WORK Using very small range of movement and light- medium springs, Cathy was able to do Openings and Circles (Down, Up) Using light- medium springs, Cathy was able to do Frog, Circles (Down, Up), Openings. Extended Frog and Extended Frog Reverse SPINAL ARTICULATION - - STRETCHES Sitting on the short box on the Reformer and using the Pole, Cathy was able to do Shoulder Stretch Using the Short Box, Cathy did Shoulder Stretch and Overhead Shoulder Standing Lunge was introduced with light springs 9
FULL BODY INTEGRATION 1 ARM WORK FULL BODY INTEGRATION 2 LEG WORK LATERAL FLEXION/ROTATION Cathy was able to do Flat Back (Knee Stretch series) on very light springs Arms Supine Series were introduced using light- medium springs, Extension, Adduction, Up Circles, Down Circles and Triceps - Using a soft ball between the knees, and while lying supine, Cathy was able to do Adductor Squeeze maintaining a neutral pelvis throughout and focusing on breathing - Scooter with flat back and light springs with 3-4 repetitions each side was introduced focusing on stabilization of the trunk and shoulders and disassociation of the hips Arms Sitting Series were introduced. Cathy was able to do Chest Expansion, Biceps, Rhomboids, Hug- A- Tree and Salute - Using the soft ball between knees and while lying supine, Cathy did the Adductor Squeeze, Knees (in tabletop), and also with straight legs on a diagonal line, Cathy was able to do Ankles Lying on her side, we introduced Side Lifts with legs slightly forward of center line and focusing on the stabilization of the trunk and abdominal obliques control BACK EXTENSION - Cathy was still unable to lay prone due to her wounds. Very basic back extension was achieved by having her lay supine on a foam roller and opening her arms to side in T 10
The Progression Throughout the past 4-6 weeks, Cathy has continued to regain her strength although there were some days were she felt more tired than others, most probably due to the medications and the chemotherapy that she was still undergoing. However, Cathy maintained a positive attitude throughout and a focus on getting better and stronger. I have come to know that Cathy was also seeing a Chiropractic Network Spinal Analysis (NSA) practitioner. NSA focuses on developing a breath pattern where a wave of unforced and un- manipulated breath passes through the spine from the coccyx to the occiput (tailbone to the base of the cranium) promoting a powerful mind- body connection. It is beyond the scope of this research paper to go more into NSA, but it is worth noting that Cathy and I have found such holistic care to be complimentary to her Pilates program in helping her finding the balance she needed for healing. Refer to the references list for more on NSA. For the next phase of Cathy s Pilates program, and as most of the constraints introduced for the initial healing phase has subsided, it was appropriate to gradually progress the program to work on strengthening the abdominals and back muscles while continuing with general conditioning and strengthening, targeting increase of Range of Motion, intensity and overload (where appropriate) while continuing to focus on using the correct mechanics and muscle recruitment skills throughout. 11
BASI BLOCK 11-20 SESSIONS 21+ ONWARD WARM UP Cathy was able to do Pelvic Curl lifting the bottom off the mat but with a small ROM initially and gradually increasing to the shoulder bridge position. Spine Twist Supine was introduced assisted with the big ball under the feet and with small ROM at first. Leg Lifts/Changes FOOT WORK ABDOMINAL WORK As a variation, we used the Wunda Chair for the Foot Work series with medium springs settings, Parallel Heels, Parallel Toes, V Position Toes, Open V Heels, Open V Toes, Calf Raises, Single Leg Heel, Single Leg Toes On the Wunda Chair, Standing Pike Reverse was introduced as the first spine flexion exercise for Cathy allowing her to start with a small ROM and increase it gradually. On the Reformer, Cathy was then able to do Hundred Prep, and Hundred (with legs in tabletop). Whenever Cathy was feeling more tired than usual, the Hundred was performed with her head resting on the carriage. On the Cadillac in other sessions, Mini Roll- Ups, Mini Roll- Ups Oblique, Roll- Up Top Loaded Cathy is now able to do Pelvic Curl, Spine Twist Supine (straightening legs on the side before going back to center. On the Cadillac, Mini Roll- Ups, Mini- Roll Ups Oblique, and Roll- Up Top Loaded were used as a warm up On the Cadillac, Cathy was able to do Parallel Heels, Parallel Toes, V Position Toes, Open V Heels, Open V Toes, Calf Raises, Single Leg Heel, Single Leg Toes The following is a combination of exercises that Cathy was now able to do in her sessions: On the Cadillac: (In addition to the Warm Up Series), Breathing with Push Through Bar, Bottom Lift with Roll Up Bar. On the Wunda Chair, Standing Pike Reverse, Pike Sitting, and soon she will be able to do Standing Pike and Cat Stretch Kneeling as she feels stronger to do more deep flexion. On the Reformer, Cathy has started doing some of the Short Box Series such as Round Back, Flat Back, 12
HIP WORK SPINAL ARTICULATION STRETCHES FULL BODY INTEGRATION 1 As Cathy has gained more control, Hip Work was introduced on the Cadillac with focus on more control and balance of the movements with awareness of any imbalances. This included the Basic Leg Springs series such as the Frog, Circles (Down, Up), Walking, and Bicycles Bottom Lift was introduced with a small ROM initially and gradually increasing to the shoulder bridge position. In addition to Standing Lunge, Cathy was able to do Side Splits with good control, focusing on maintaining a neutral pelvis and spine throughout In addition to the Scooter which Cathy is now able to do with more control, Up Stretch 1 and Elephant were introduced focusing on trunk and shoulder stabilization and abdominals and back extensors control. Also in other sessions, Cathy was able to execute the Knee Stretch Series, namely Tilt and Twist. She was also capable of doing the Rowing series at this point More work was introduced focusing on control and balance of the movements. This included the Single Leg Supine series such as Frog, Circles (Down, Up), Hip Extension, and Bicycle Bottom Lift with Extension was introduced on the Reformer and also Monkey. Short Spine and Long Spine were NOT yet introduced at this point but will be as Cathy gains more abdominal strength and control Stomach Massage Round Back (with a comfortable flexion ROM), Stomach Massage Flat Back, and Stomach Massage Reaching were introduced on the Reformer. On the Cadillac, Side Reach and Kneeling Cat Stretch, both from the Push Through Series, 13
ARM WORK FULL BODY INTEGRATION 2 LEG WORK LATERAL FLEXION/ROTATION Round Back, and Flat Back On the Cadillac, Arms Standing Series were appropriate with a focus on stabilization of the trunk while working to strengthening shoulder, and elbow extensors and flexors and increasing ROM of the shoulder joint. Cathy was able to do Chest Expansion, Hug- A- Tree, Circles (Up, Down), Punches and Biceps. For variation, some Wunda Chair Arm Work was introduced in some sessions such as Shrugs, Triceps Press Sit and Side Kneeling Arm - A variation of the following Leg Work exercises was introduced to Cathy: Side Leg Lift, Forward and Lift, and Froward with Drops. Also Cathy was able to do the Gluteals Kneeling Series such as Hip Extension Bent Knee, Hip Extension Straight Leg and Adductor Lift. Sitting on the side of the Reformer, a simple Spine Twist was introduced at first allowing small ROM and focusing on Abdominal oblique control. As Cathy was ok were introduced. As Cathy has worked hard on achieving good level of trunk stabilization, the Arms Kneeling Series on the Reformer were appropriate at this time such as Chest Expansion, Up Circles, Down Circles, Triceps and Biceps. The Rowing Series was also introduced as Cathy was comfortable now with more flexion and has better trunk control. These included: Rowing Back 1, Rowing Back 2, Rowing Front 1 and Rowing Front 2 Long Back Stretch can be introduced at a later stage once Cathy develops more strength and control On the Wunda Chair: Cathy was introduced to Leg Press Standing focusing on balance while working on the hip and knee extensors control. She was also able to do Hamstring Curl, Hip Opener as well as Frog Front. Squats was also introduced on the Cadillac Mermaid is executed with more proficiency and control. On the Wunda Chair Side Stretch was also introduced as another variation maintaining focus on 14
BACK EXTENSION with this, Mermaid was introduced. The focus was more on spinal mobility at this point rather on mastering of the movement. Lying prone on a soft mat basic Back Extension was introduced avoiding lifting high but rather cuing to focus on long neck, long back and long legs spinal mobility and abdominals oblique control Lying prone on the Cadillac, Prone 1 using the Push Through Bar was introduced focusing on articulating the spine as the trunk lifts and lowers, cuing to lift only within a comfortable ROM 15
Conclusion Open abdominal surgery, is considered one of the most invasive types of surgeries as it usually requires a large incision through many layers of muscles causing more pain and longer periods of recovery than the laparascopic approach. It is amazing that a Pilates program can be started as early as two weeks after surgery in some cases as was the case in this paper. Despite many constraints on hand, Pilates programs can be designed to help restore mobility, strength, and overall balance. It is imperative before designing a post recovery Pilates program to thoroughly understand the client s health condition, physical and psychological limitations. It is also crucial to understand the client s state of mind and physical abilities before starting each session, and to encourage him/her to vocally express any discomfort or pain. It is through a well- balanced and truly integrated mind- body program that the healing process can begin and ultimately lead to well being. Through such a program, a Pilates instructor s role is to help clients find and appreciate this mind- body connection through awareness, breath, balance, control, concentration, center, efficiency, flow, precision and harmony. 16
Bibliography [1] Flament JB. Functional anatomy of the abdominal wall. Chirurg 2006 [2] http://www.med.umich.edu/1libr/urology/postcare/nephrectomy.htm [3] http://www.kidney.org/atoz/content/nephrectomy.cfm [4] http://www.surgeryencyclopedia.com/la- Pa/Nephrectomy.html [5] Benjamin Cummings, Kapit, Waynn, The Anatomy Coloring Book, Elson, Lawrence M., 3 rd ed 2002 [6] http://www.netdoctor.co.uk/surgical- procedures/nephrectomy- kidney- removal.htm#ixzz2m9g10vn8 [7] 3D Anatomy Tutorial, http://www.youtube.com/watch?v=mxoajxo8mx0 [8] http://www.nlm.nih.gov/medlineplus/ency/article/003001.htm 17