Korean J Thorac Cardiovasc Surg 2018;51:293-307 □ COLLECTIVE OF CURRENT REVIEW, LECTURE □

ISSN: 2233-601X (Print) ISSN: 2093-6516 (Online) https://doi.org/10.5090/kjtcs.2018.51.5.293

Essentials of Physiotherapy after Thoracic Surgery:

What Physiotherapists Need to Know. A Narrative Review
Ahmad Mahdi Ahmad, Ph.D.
Department of Physical Therapy for Cardiovascular and Respiratory Disorders,
Faculty of Physical Therapy, Cairo University

Physiotherapy has recently become an essential part of enhanced recovery protocols after thoracic surgery.
The evidence-based practice of physiotherapy is essential for the effective management of postoperative
patients. Unfortunately, only a small body of literature has discussed the rationale of the physiotherapy inter-
ventions that are routinely implemented following thoracic surgery. Nonetheless, we can integrate the avail-
able knowledge into our practice until new evidence emerges. Therefore, in this review, the principles of
physiotherapy after thoracic surgery are presented, along with a detailed description of physiotherapy inter-
ventions, with the goals of enhancing the knowledge and practical skills of physiotherapists in postoperative
care units and helping them to re-evaluate and justify their traditional practices.

Key words: 1. Physiotherapy

2. Management
3. Postoperative
4. Thoracic surgery

Introduction hospitalization, and increased morbidity and mortality.

Physiotherapy has been routinely implemented after
Over the past century, thoracic surgery has been thoracic surgery as a fundamental component of
the primary intervention used to treat pulmonary, postoperative management. Recently, physiotherapy
pleural, chest wall, and mediastinal disorders. The has been recommended by the European Society of
main presenting problems of postoperative patients Thoracic Surgeons, the European Respiratory Society,
who have undergone thoracic surgery include im- and the American College of Chest Physicians, and it
proper patient positioning; incision and/or chest is now considered an essential element of enhanced
drain pain; ineffective cough; reduced lung volume; recovery protocols (ERPs) or “fast-track” protocols in
postoperative pulmonary complications (PPCs), which thoracic surgery that accelerate the functional recov-
can be non-infectious (e.g., atelectasis and respiratory ery of postoperative patients and minimize the
failure) or infectious (e.g., pneumonia); impaired air- length of the hospital stay [3,4]. Therefore, the role
way clearance; frozen shoulder on the thoracotomy of physiotherapy in these “fast-track” protocols after
side; postural abnormalities; and persistent chest thoracic surgery warrants further clarification.
wall tightness [1,2]. These problems, particularly Unfortunately, in practice settings, little is cur-
PPCs, can lead to delayed patient recovery, prolonged rently known about clinically evidence-based physi-

Received: May 17, 2018, Revised: August 5, 2018, Accepted: August 16, 2018, Published online: October 5, 2018
Corresponding author: Ahmad Mahdi Ahmad, Department of Physical Therapy for Cardiovascular and Respiratory Disorders, Faculty of
Physical Therapy, Cairo University, Giza, Egypt
(Tel) 20-01007056624 (Fax) 20-237617692 (E-mail) [email protected]
© The Korean Society for Thoracic and Cardiovascular Surgery. 2018. All right reserved.
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly
cited.

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Ahmad Mahdi Ahmad

Table 1. Postoperative initial patient assessment

Variable Content
Database information • Preoperative investigations: chest X-ray, computed tomography scan, pulmonary function tests, or
(from medical records) 6-minute walk test
• Surgical procedure and incision
• Concise medical history: personal history, present history, relevant past history (i.e., previous surgery),
drug history including respiratory and/or cardiac medications
Subjective information • Detailed medical history: personal history, smoking history, history of alcohol or drug abuse, chief
complaint, present history, past medical and surgical history, social history, family history
• Open-ended questions: how do you feel?
• Pain assessment: a verbal descriptor scale or a visual analogue scale is used to measure incision or
shoulder pain. The patient should be asked about the efficiency of the postoperative analgesia method
in delivering adequate pain relief.
• Cough and sputum assessment: the patient's ability to cough and expectorate should be assessed. The
colour, volume, and consistency of sputum should be observed.
Objective information • Clinical examination: inspection, palpation, percussion, and auscultation
(from clinical examination, • Method of pain control: the physiotherapist must be aware of the various routes of analgesia (i.e.,
monitoring tools, and intravenous, epidural, paravertebral, and intercostal nerve blocks). If a patient-controlled analgesia
postoperative pump is used, it should be verified that the patient can use it properly.
investigations) • Oxygen delivery system: level of fraction of inspired oxygen
• Type of chest drain
• Postoperative complications: pulmonary, cardiovascular, wound, neurological, musculoskeletal,
gastrointestinal, renal, and central nervous system complications.
• Cardiovascular and respiratory status: the clinical stability of postoperative patients should be assessed
by checking their heart rate and rhythm, blood pressure, respiratory rate, and oxygen saturation.
• Range of motion assessment: for the shoulder and trunk on the operated side
• Biochemical data, arterial blood gas analysis, chest X-ray

otherapy following thoracic surgery. Furthermore, an accurate initial assessment of postoperative pa-
there is a lack of standardized postoperative physi- tients [6]. Ongoing re-assessment is also recom-
otherapy programs after thoracic surgery. In addition, mended to judge the effectiveness of treatment, to
in research work, few well-designed studies have modify the treatment plan, and to identify new
been conducted with robust methodologies capable problems. Following the initial assessment, a problem
of identifying ideal physiotherapy treatment protocols list for postoperative patients can be developed,
based on scientific evidence [5]. Likewise, limited re- which most commonly includes pain, a poor breath-
search reviews have been done on physiotherapy in- ing pattern, reduced lung volume, ineffective cough-
terventions for postoperative patients who have un- ing, retained secretions, and reduced shoulder range
dergone thoracic surgery. Therefore, the purposes of of motion (ROM) [2]. Table 1 presents the compo-
this review were to explore the role of physi- nents of the initial postoperative patient assessment.
otherapists in “fast-track” protocols following thoracic
surgery and to present evidence-based strategies for Postoperative physiotherapy treatments
postoperative physiotherapy management. This re-
view sheds light on the role of physiotherapy within Patients who undergo lung surgery using the post-
ERPs in thoracic surgery and may enhance the clin- erolateral thoracotomy approach need more physi-
ical practice of physiotherapists in postoperative care otherapy treatment than other patients who undergo
units by helping them to re-evaluate and justify their the same extent of surgical lung resection via vid-
traditional practices. eo-assisted thoracoscopic surgery (VATS). This is be-
cause open thoracotomy is associated with more
Postoperative physiotherapy assessment PPCs than muscle-sparing VATS [7]. PPCs are consid-
ered to be the most frequent cause of postoperative
Appropriate postoperative physiotherapy treatment death after lung resection and account for about
plans can only be designed and/or initiated based on 84% of such deaths [8]. Chest physiotherapy can ef-

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fectively reduce the overall rate of pulmonary com- cations in moderate post-thoracotomy pain (i.e., after
plications after lung resection [9]. Physiotherapy a muscle-sparing thoracotomy incision) and very ef-
treatment must be started postoperatively between 4 fective as the sole pain-control treatment in patients
and 12 hours after recovery from general anaesthesia. with mild post-thoracotomy pain (i.e., after a VATS
The estimated session time is 30 minutes, with 2–3 incision) [13].
daily sessions [3]. Hence, TENS therapy can reduce the need for addi-
tional analgesic doses, thus minimizing the total dose
1) Physiotherapy pain management of analgesic medications and thereby reducing their
Thoracic procedures are considered to involve side effects. TENS relieves postoperative incision pain
some of the most painful surgical incisions and are and ipsilateral referred shoulder pain. It can also be
associated with severe postoperative pain. This is used for persistent incision pain after removal of an
one of the reasons why various alternative modalities epidural or paravertebral block [2].
have been developed to replace the standard post- TENS has multiple mechanisms of action, the first
erolateral thoracotomy, such as muscle-sparing tech- of which is closing the gates of pain perception in
niques and VATS [10]. Pain impairs the patient's the brain. The second mechanism is that TENS stim-
ability to take deep breaths or to cough effectively, ulates the release of endogenous opioids. For effec-
which could lead to reduced lung volume and spu- tive postoperative analgesia with TENS, the intensity
tum retention, making re-intubation more likely. Pain of the electric current should be strong, but comfort-
also induces sympathetic stimulation; which leads to able for the patient. The duration of TENS applica-
increases in the respiratory rate, heart rate, and tion can be for 20–30 minutes at 3-hour time inter-
blood pressure, which can affect the hemodynamic vals on the day following surgery. The frequency of
stability of surgical patients. Moreover, pain can re- the electric current can be either high-frequency or
strict shoulder and scapula ROM, leading to frozen low-frequency, although it is also possible to alter-
shoulder. Finally, pain increases patients’ anxiety, and nate high and low frequencies of 2–100 Hz [14].
causes sleep disturbance and daytime tiredness, Stimulation with alternating high and low frequencies
which may lead to poor cooperation during physi- was found to be the most effective method because
otherapy sessions [11]. For these reasons, pain as- the alternation of high and low frequencies causes
sessment has recently become a standard component the release of different neurotransmitters, which have
of each physiotherapy session, so that early proactive a synergistic effect with exogenously administered
steps can be taken to optimize patients’ requirements opioids. Furthermore, alternating high- and low-fre-
for analgesia prior to physiotherapy treatment. quency TENS has the advantage of delaying the de-
Physiotherapists should work closely with the medi- velopment of opioid tolerance by approximately 5
cal team to ensure the adequacy of analgesia for days compared to either low- or high-frequency
each patient [12]. The aim of physiotherapy pain re- TENS alone [15].
lief interventions is not to substitute for analgesic (2) Cryotherapy (cold therapy): After major sur-
medications, but to reduce the total dose of analgesic gery, the application of simple ice packs over the in-
medications received by postoperative patients, cision dressing during the first 24 hours following
thereby reducing their unavoidable side effects. surgery and afterwards is known to produce remark-
(1) Transcutaneous electrical nerve stimulation: able relief of incisional pain and less need for nar-
Transcutaneous electrical nerve stimulation (TENS) is cotic painkillers [16]. The cold reduces pain by re-
a complementary postoperative analgesic modality ducing the sensitivity of the nerve endings to pain
that is safe and effective in alleviating postoperative and by inducing vasoconstriction, which reduces in-
pain and improving patient recovery, resulting in bet- flammation and swelling. Ice packs can also be used
ter outcomes after thoracic surgery. The current evi- before or during coughing and deep breathing ex-
dence shows that TENS treatment is ineffective when ercises to reduce the aggravation of incision pain by
used alone in patients with severe post-thoracotomy these postoperative physiotherapy interventions [17].
pain (i.e., after a posterolateral thoracotomy incision), (3) Wound support: It is very important to sup-
but useful as an adjunct to other analgesic medi- port the patient’s incision and intercostal drain sites

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Ahmad Mahdi Ahmad

with firm but gentle pressure, taking care not to of or the first day after surgery. If they cannot sit in
press directly on the incision or drain site. This re- a chair, they should be encouraged either to sit up-
duces pain and allows the patient to breathe in right in bed or to adopt a high side-lying position
deeply and/or to cough with little discomfort. with the operated lung on top, but they should not
Different methods for wound support can be used be allowed to be in a supine or in a slumped posi-
during coughing, huffing, sneezing, and/or deep tion in bed, as these positions reduce lung volume
breathing exercises. One method can be done with [19].
the physiotherapist standing on the contralateral (b) Lateral (side-lying) positioning: High side-lying
side, with one hand placed on the anterior chest wall with the operated lung on the top may be encour-
to stabilize the incision from the front, and the other aged in some circumstances. The reason for keeping
hand placed on the posterior chest wall to stabilize the non-operated lung at the bottom is to ensure ad-
the incision from behind, while at the same time the equate ventilation-perfusion matching, as gravity di-
physiotherapist’s forearms stabilize the entire chest rects perfusion to the non-operated lung, which is at
and create a “bear-hug” hold. Another method for the bottom, thereby improving oxygenation [19].
wound support can be done by the patient, by plac- Another reason is to allow for adequate expansion of
ing the hand of the un-operated side across the front the operated lung, which is placed on the top.
of the thorax as far as possible, resting firmly over However, after pneumonectomy, if the side-lying po-
the incision and drain sites, while the other hand re- sition is adopted for draining the remaining lung, the
inforces the hugging hold by clasping the opposite el- patient should be positioned carefully on the oper-
bow and pulling it against the thoracic wall. ated side, because if patient lies on the non-operated
Alternatively, the patient may be taught to hold a pil- side, the bronchial stump may be bathed with fluid if
low firmly against the incision while coughing, or to the anastomosis is not well sutured [18,20].
wear an external thoracic support [18]. (2) Gravity-assisted positions to assist the clear-
ance of bronchial secretions: The modified (horizon-
2) Positioning tal) postural drainage position is recommended first,
After thoracic surgery, the easiest method to in- instead of the classical (head down) position, in post-
crease functional residual capacity and to prevent operative patients, as the latter can lead to decreased
lung atelectasis is early appropriate positioning [19]. arterial oxygenation [22], and could induce more car-
Positioning patients after thoracic surgery utilizes diovascular stress [23]; furthermore, it may increase
gravity to provide 2 major benefits: the first is to en- the risk of aspiration in postoperative patients with
hance ventilation, perfusion, and gas exchange; and uncontrolled or unprotected airways.
the second is to help clear excess bronchial secretions.
(1) Gravity-assisted positions to improve ventilation 3) Early mobilization and ambulation
and gas exchange: The term postoperative mobilization refers to a
(a) Early upright sitting: The optimal postoperative change in the patient’s position from the supine or
position is the upright sitting position in or out of slumped position in bed to upright sitting in or out
bed, which should be emphasized as soon as the pa- of bed (e.g., in a bedside chair), standing, or walking.
tient is woken following surgery to facilitate lung According to the European Society of Intensive Care
ventilation. After being woken, the patient may sit in Medicine statement on physiotherapy for adult pa-
a chair out of bed with the endotracheal tube still in tients with a critical illness [24], the physiotherapist
place [20]. Positioning is considered an important should be responsible for starting early mobilization
part of postoperative management. The benefits of and exercise prescription, and should make the ap-
upright positioning include an increase in dia- propriate recommendations for progression of these
phragmatic excursion, improved ventilation and in- interventions together with other team members.
creased lung volume and capacity, improvements in Mobilization and walking in patients after car-
oxygenation with a reduced need for supplemental diothoracic surgery should be based on scientific
oxygen, and enhanced forced expiratory flow [21]. principles. The aim of mobilization is to stress the
Many patients can sit out of bed in a chair the day cardiopulmonary system of the postoperative patient

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 Essentials of Physiotherapy after Thoracic Surgery

at a level sufficient to increase minute ventilation onds was also found to be correlated with poor pe-
and cardiac output while still being within safe phys- ripheral perfusion [27].
iological limits. Mobilization, conventionally, should (d) All patient's connections should be checked be-
be started on the first postoperative day by having fore mobilization and/or ambulation, and care should
the patient sit on the edge of bed or in a chair out be taken not to pull any of the patient’s lines, drains,
of bed, and then taking short steps to walk around or tubes during mobilization to avoid dislodgement.
the bed [1,20]. However, it has been shown that ear- Nasogastric tube dislodgement may increase the risk
lier mobilization, with sitting in bed at 3.5 hours af- of aspiration [1]. In case of accidental dislodgement
ter surgery, maintaining a sitting position for 30 mi- of an intercostal drain, the patient is asked to imme-
nutes, and then ambulation in the fourth hour fol- diately breathe out, and firm pressure with a sterile
lowing surgery led to better recovery of pulmonary dressing is applied to the insertion site at the end of
function than conventional mobilization (walking on expiration. While maintaining pressure, the patient is
the first postoperative day) in patients who under- asked to breathe normally till medical help arrives
went lobectomy [25]. [20].
(1) Safety guidelines for early mobilization and/or (e) Adequate analgesia must be given before mobi-
ambulation: lization for patients after thoracotomy, as pain from
(a) An appropriate assessment of the clinical sta- the incision and/or from chest drain can be quite se-
bility of postoperative patients is extremely im- vere, limiting patients’ ability to cooperate during
portant before mobilization. Mobilization should only physiotherapy mobilization sessions [1].
be initiated for patients with clinically stable car- (f) Before upright mobilization, in addition to the
diopulmonary and cardiovascular conditions. A pa- previously mentioned guidelines, the patient’s ability
tient’s clinical status is considered unstable if the vi- to follow commands should be assessed, sitting bal-
tal signs exceed any of the following thresholds: ance should be checked, and the sensory and motor
heart rate less than 40/min or greater than 140/min, functions of the lower limbs should be tested, espe-
respiratory rate less than 8/min or greater than cially in patients who have received spinal block
36/min, oxygen saturation less than 85%, and blood [20]. Once a postoperative patient is able to sit un-
pressure less than 80 or more than 200 mm Hg sys- supported on the edge of the bed for 5 minutes and
tolic or greater than 110 mm Hg diastolic [26], mean can perform a full bilateral knee extension along
blood pressure ˂65 mm Hg, and extremes of temper- with clinically acceptable vital signs, the patient can
ature that are also highly suggestive of clinical progress to standing and ambulation [28].
instability. In addition to core temperature, skin and (g) Upon standing, it is important to check for or-
extremity temperatures have been correlated with thostatic hypotension, which can manifest by a drop
patient outcomes. It has been shown that patients in systolic blood pressure of ＞20 mm Hg and a
with cool extremities have a lower cardiac output drop in diastolic blood pressure of ＞10 mm Hg,
than patients with warm extremities [27]. and/or in the form of symptomatic dizziness or
(b) After becoming eligible for mobilization, clin- light-headedness. It can even cause the patient to feel
ically stable patients should receive continuous and faint. It has been recommended that 2 people should
close monitoring by the physiotherapist during and provide assistance when a patient stands or walks
immediately after mobilization. This ongoing monitor- for the first time because of the risk of postural hy-
ing is essential because even clinically stable patients potension [20]. If the hospital does not have enough
may have some potential to become unstable during manpower, a physiotherapist can make it easier for
and/or after mobilization [1]. the patient to stand by using a tilt table.
(c) An appropriate assessment of organ perfusion (h) For patients’ safety, patients should start am-
is also important prior to ambulation. Urine output bulation with a high level of assistance, as mentioned
and capillary refill time (CRT) are frequently used as earlier either by 2 or 3 personnel or by using assis-
clinical surrogates of organ perfusion. Postoperative tive devices such as a wheeled walker, dynamic or-
oliguria suggests inadequate renal perfusion and re- thotics, or a mechanical lift. Then, as the patient pro-
duced cardiac output. A postoperative CRT ＞4.5 sec- gresses with ambulation and shows good outcomes,

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Ahmad Mahdi Ahmad

the physiotherapist may reduce the level of ceive appropriate analgesia prior to ambulation be-
assistance. In addition, using a gait belt while trans- cause chest drains can cause severe pain, limiting the
ferring or walking a postoperative patient provides patient’s ability to ambulate and to cooperate with
increased safety and security for both the patient the physiotherapist. Furthermore, the physiotherapist
and the physiotherapist. Furthermore, for patients should make sure that the drainage system is work-
with stable vitals while sitting, but profound weak- ing properly; symptoms of tachypnea, dyspnea, in-
ness of the lower extremities, the use of standing creased use of the accessory muscles, orthopnoea, a
lifts can be helpful during transfer to avoid injury to restless or increased heart rate, or cyanosis may in-
the staff [28]. dicate malfunctioning of the drain system. Moreover,
(i) A graduated walking program should be adopt- if no swing is seen in the underwater seal tube, this
ed for mobilizing postoperative patients [20]. The may indicate kinking of the chest tube, a loop in the
physiotherapist must start low and go slow; that is, chest tube filled with fluid, or clotting in the tubing;
to start with sessions that are short (i.e., 3–5 mi- alternatively, the patient may be lying on the tube.
nutes), more frequent (i.e., 2–3 times/day), and rela- Care should also be taken that the patient keeps the
tively non-intense (inducing a level of patient effort drainage system upright and below the level of the
of ＜13 on the rating of perceived exertion [RPE] patient’s chest by least 0.5 m during all mobilization
scale or at 60% of maximum heart rate [HRmax]) activities. Mobilization activities for patients who are
[28]. This is because postoperative patients at this connected to wall suction include bed-side marching
stage have limited cardiopulmonary reserve due to on the spot or doing steps up on a fixed single step
their medical or surgical conditions. later on, patients [1,20]. Additionally, the physiotherapist should be
can progress to more intense, less frequent, and lon- aware of emergency procedures, such as chest tube
ger walks. clamping, if unexpected tube disconnection occurs.
(j) Stair climbing is initiated once the patient can (m) When walking a patient who is receiving sup-
walk for a considerable distance on a flat surface plemental oxygen, the physiotherapist should monitor
with optimum cardiovascular and cardiopulmonary oxygen saturation the entire time, and the amount of
stability. Stair climbing generally can occur on the oxygen given to the patient must be enough to keep
fourth or fifth day after thoracic surgery, but it can oxygen saturation ≥90% during ambulation. If oxy-
be initiated as early as the third postoperative day in gen saturation drops below the prescribed minimum
low-risk cases [20]. level, the physiotherapist should increase the amount
(k) During all mobilization activities, careful atten- of delivered oxygen to keep the saturation in the
tion should be paid to subjective symptoms of ex- prescribed range, and may also choose to reduce the
ercise intolerance, such as shortness of breath, chest intensity and/or the duration of patient's activities
pain, dizziness, cold sweating, leg fatigue, and pain, [28].
and these symptoms should be monitored carefully (n) When walking a patient with an epidural still
during mobilization. In such cases, activities must be in place, the physiotherapist must pay great attention
stopped immediately until hemodynamic stability re- to avoid pulling on the epidural catheter during
turns and then these stressful activities should be activities. The physiotherapist must be aware of com-
modified in subsequent mobilization sessions. The mon side effects of epidural analgesia. Thus, an as-
RPE can be used to assess patients’ perceived feeling sessment of the muscle strength of the lower ex-
of exertion, and patients are initially encouraged to tremities and orthostatic hypotension is needed be-
mobilize with an effort not exceeding a breath- fore upright ambulation. Some postoperative care fa-
lessness of 13 on the RPE scale, which corresponds cilities restrict mobilization when an epidural cathe-
to about 60% of HRmax [12,28]. The use of breathing ter is in situ. Thus, physiotherapists should be aware
control during mobilization activities may improve of unit-specific policies [1].
exercise tolerance (i.e., walking at a pace that leaves (o) Ambulation is not allowed in: postoperative pa-
the patient slightly short of breath). tients with unstable vital signs; patients who are not
(l) When walking a patient with an underwater able to follow commands; patients with untreated
seal drainage tube still in place, the patient must re- deep venous thrombosis or pulmonary embolism; pa-

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 Essentials of Physiotherapy after Thoracic Surgery

tients on high ventilatory support (i.e., a high frac- al drainage position. Deep breathing exercises induce
tion of inspired oxygen of ˃80%, positive end ex- large and sustained increases in trans-pulmonary
piratory pressure (PEEP) or continuous positive air- pressure, which in turn increase lung volume, im-
way pressure [CPAP] of more than 10 cm H2O); pa- prove ventilation and oxygenation, prevent basal ate-
tients with orthopaedic injuries or neurological limi- lectasis, re-inflate collapsed lung regions, and reverse
tations to ambulation [28]; patients with hypo- minimal postoperative atelectasis [29,30]. Because
tension, uncontrolled arrhythmia (e.g., atrial fi- periodic deep breathing is very important for lung
brillation), uncontrolled decompensated heart failure, inflation, a recommended protocol for deep breathing
or recent myocardial infarction, as these conditions exercises that can be prescribed to postoperative pa-
can lead to severe compromise of cardiac output tients is 5 deep breaths with a 3-second end-in-
during ambulation activities; and patients with acute spiratory hold per every waking hour [31].
renal failure. In such cases, the patient can start with Techniques for supporting the incision wound and
deep breathing and airway clearance techniques in drain sites oneself during all deep breathing ex-
bed. ercises can be taught to patients to allow them to
(p) All Patients unable to be mobilized and/or am- take in large breaths with little pain.
bulated can start breathing exercises, circulatory ex- (a) Thoracic expansion exercises (lateral costal
ercises, and/or airway clearance techniques in bed. breathing exercises): Thoracic expansion exercises
(q) After mobilization and/or ambulation has been (TEEs) are deep breathing exercises that emphasize
ended; the physiotherapist should re-assess the pa- inspiration. Inspiration is active and may be accom-
tient’s vital signs for any abnormal responses. panied by a 3-second hold at the end of deep
inspiration. TEEs include apical, upper lateral, middle,
4) Lung expansion manoeuvres lower lateral, and posterior basal expansion exercises,
After thoracic surgery, lung volume and functional and can be unilateral or bilateral [32]. Unilateral
residual capacity are reduced due to anaesthesia, TEEs are preferable in postoperative patients after
chest wall pain, and/or recumbency. This can lead to thoracotomy. These exercises are most efficiently
lung atelectasis, which is considered to be one of the performed in the high side-lying position, with the
most significant non-infectious PPCs. Clinically, this operated side on the top and the arm on the in-
condition manifests through progressive hypoxaemia, volved side brought to abduction at the level of the
increased breathing frequency, dyspnoea, increased head [28]. First, the physiotherapist should support
heart rate, decreased breath sounds, fine late in- the incision site by applying gentle but firm pressure
spiratory crackles (crepitations), a dull note on per- with his or her hand. Placement of the physi-
cussion, and areas of opacification on a chest X-ray. otherapist’s hand over the operated region can also
Some physiotherapy interventions and adjunct thera- induce tactile stimulation, which facilitates lung ex-
pies aim to improve lung expansion and to increase pansion [19]. Then, the patient is asked to breathe in
lung volume and capacity following thoracic surgery. slowly, as deep as possible, to push the physi-
These include deep breathing exercises, incentive spi- otherapist’s hand up, to hold his or her breath for 2–
rometry, and inspiratory muscle training (IMT). 3 seconds, and finally to exhale gently from the
These techniques aim to reduce the likelihood of mouth. Roughly 3 expansion exercises are
lung atelectasis, improve hypoxaemia, and/or reduce appropriate. It is also important to support the chest
the need for re-intubation. No individual lung ex- drain site during TEEs to reduce pain, allowing the
pansion manoeuvre is significantly superior to anoth- patient to breathe in deeply with little discomfort.
er, and a combined approach may be more effective Alternatively, bilateral basal TEEs can be employed
than a single intervention [29]. postoperatively for surgical patients in the erect sit-
(1) Deep breathing exercises: Because lung volume ting position [1].
is affected by body position, deep breathing exercises The slow inspiratory flow rate that occurs in TEEs
are most often performed in the erect sitting posi- improves ventilation to the dependent lung regions
tion, but they can be also practiced while the patient that are most strongly affected following surgery
is in high side-lying position or in a modified postur- [33]. Moreover, the 3-second end inspiratory hold

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Ahmad Mahdi Ahmad

helps recruiting collateral ventilatory pathways and upon returning to the starting position (i.e., coordi-
allows time for asynchronous ventilation to take nating exhalation with arm extension, arm adduction,
place, thereby promoting a greater increase in lung trunk flexion, or trunk-side bending towards the op-
expansion [34]. Additional increases in lung volume erated side). Support of the incision and drain sites
can also be achieved by the “sniffing manoeuvre” at should be provided during these activities.
the end of deep inspiration, which stimulates further (d) Sustained maximal inspiration (3-second hold
diaphragmatic descent. This simple manoeuvre can at total lung capacity): This technique refers to hold-
be done as follows: after reaching maximum inspira- ing one’s breath for 3 seconds after reaching deep
tion, the patient is asked to take in a quick and a inspiration. This is of great importance in facilitating
short breath using strong inspiratory effort [34]. more equal filling of the lung regions, as it allows for
Furthermore, physiotherapists may apply a quick variation in time constants among different lung re-
stretch of the intercostal muscles before the begin- gions [1].
ning of inspiration, this technique is thought to en- (2) Incentive spirometry: Incentive spirometry is a
courage maximal inspiration [35]. Quick stretch can visual feedback system used to encourage and moti-
be done as follows; with hands on both sides of the vate postoperative patients to perform deep breath-
chest, and just before the patient starts to breathe in, ing and to engage in sustained maximal inspiration
the physiotherapist quickly pushes in and down on (i.e., a 3-second end inspiratory hold) to open up
both sides of the patient’s chest wall. The physi- atelectatic alveoli. There are 2 types: flow-incentive
otherapist may also choose to give a slight resistance spirometry and volume-incentive spirometry. In
throughout the beginning of inspiration, followed by flow-incentive spirometry, the magnitude of air flow
sudden release of this resistance. This creates an ac- achieved during inhalation is indicated by the num-
tion known as "rib springing", which immediately ber of balls and the level to which they rise. In vol-
opens up the thoracic cage and allows for larger ume-incentive spirometry, the volume of the air dis-
amount of air to be sucked and inhaled into the placed during inhalation is indicated on a scale lo-
airways. cated on the device. The patient is asked to breathe
(b) Deep diaphragmatic breathing: Diaphragmatic in slowly and deeply for as long as possible through
movement is inhibited by pain following thoracic the mouth piece of the device to maximally distrib-
surgery. Therefore, deep diaphragmatic breathing ute ventilation, and then holds the deep breath for a
should be emphasized postoperatively. Deep dia- period of 5 seconds, which is then followed by a
phragmatic breathing should be practiced while the normal expiration [36]. Although incentive spi-
patient is sitting upright, with his or her back sup- rometry is used routinely after thoracic surgery,
ported and the pelvis in the posterior tilting position. there is no evidence that it is superior to deep
The posterior pelvic tilt position optimizes the breathing exercises or even augments physiotherapy
length-tension relationship of the diaphragm, which sessions; however, it is a useful tool to assess the
facilitates efficient diaphragmatic breathing [28]. The ability of the postoperative patient to effectively take
patient is asked to relax the upper chest and should- a deep breath after thoracic surgery, as poor per-
er and to breathe in from the nose as deeply as pos- formance may indicate pulmonary deterioration [37].
sible, trying to make his or her abdomen swell like a Guidelines no longer recommend the routine use of
balloon by expanding the lower chest and abdominal postoperative incentive spirometry [29].
regions, and then to exhale gently. If the patient still (3) Inspiratory muscle training: IMT is a major
cannot relax the accessory muscles of respiration, a component of preoperative pulmonary rehabilitation
contract-relax technique can be used prior to dia- programs. However, its postoperative role and its
phragmatic breathing [28]. possible superiority to other components of a stand-
(c) Deep breathing exercises coupled with arm or ard physiotherapy program, including deep breathing
trunk movement: The patient may be taught to coor- exercises and early ambulation, for increasing lung
dinate deep breathing with arm flexion, arm abduc- volume or preventing atelectasis still need further
tion, trunk extension, or trunk side flexion away research. A recent study by Brocki et al. [38] has
from the operated side, while coordinating exhalation shown that the addition of IMT to standard post-

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operative physiotherapy improved hypoxaemic status patient preference is the most important consid-
in high-risk patients after lung cancer surgery, but eration when prescribing a chest clearance technique
had no additional benefit for preserving respiratory to a postoperative patient, because patient preference
muscle strength. improves adherence. For example, patients who pre-
fer being independent might prefer airway clearance
5) Airway clearance techniques techniques that can be self-administered [19].
The inability to cough and clear airway secretions (1) Supported cough: Prior to coughing, the patient
leads to an increased risk for infection and the de- sits upright and takes several deep breaths. For ef-
velopment of postoperative pneumonia [29]. fective coughing, the patient tilts the shin up, sup-
Airway clearance techniques refer to manual or ports the wound with a pillow, takes a deep breath
mechanical procedures that are used to assist the combined with trunk extension, and momentarily
mobilization of secretions from the airway after holds his or her breath. Then, while maintaining
thoracic surgery [28]. These include supported cough- wound support, the patient carries out a series of
ing, huffing, the forced expiration technique (FET), sharp expirations while leaning forward to increase
the active cycle of breathing technique (ACBT), modi- intra-abdominal pressure [28]. Coughing can trigger
fied postural drainage positioning with or without vi- incision or drain site pain, so the physiotherapist
bration, and the positive expiratory pressure (PEP) may ask whether a patient wants to use PCA before
therapy. An airway clearance technique should be the treatment session or may request an additional
started as soon as the patient wakes on the day of bolus dose of analgesia before treatment. One major
surgery and/or on the first postoperative day. It disadvantage of coughing is that the higher intra-
should be repeated every 30 minutes [20]. Following thoracic pressure generated triggers incision pain,
thoracic surgery, lung secretions become persistent which may be not tolerated by patients. Furthermore,
as a result of anaesthesia, infection, or dehydration the increased intrathoracic pressure can lead to pre-
[2]. Because of this, the following sequence should be mature airway collapse and air trapping in post-
followed: (a) opening up the airway with nebulized operative patients with unstable airways (e.g., those
bronchodilators; (b) thinning out secretions with with co-existing chronic obstructive pulmonary dis-
heated humidification, mucolytic agents, and ensuring ease or bronchospasm), which in turn leads to re-
adequate systemic hydration of the patient himself duced forced expiratory flow and failure to clear se-
(by increasing oral or intravenous fluid intake); (c) cretions [1].
and clearing out secretions by choosing the most (2) Huffing: Compared to coughing, the forced ex-
suitable airway clearance technique [39]. Airway piration occurs in huffing without closure of the
clearance techniques may aggravate incision pain, so glottis. Physiotherapists can employ huffing in post-
the physiotherapist must coordinate the treatment operative settings as an alternative to coughing for
sessions with the peak effect timing of analgesic patients who find coughing too painful [28]. Huffing
medications and may ask about an additional bolus instead of coughing is better tolerated by post-
dose of analgesia before the physiotherapy session if operative patients, as it requires less effort due to
the pain is severe. For patients using patient-con- the lower intrathoracic pressure generated [20].
trolled analgesia (PCA), the physiotherapist should (3) The forced expiration technique: The FET is a
ask patient whether he or she prefers to use the PCA combination of 1–2 forced expirations (huffs) and a
system before the session. If the PCA system is in period of breathing control [40]. It has been reported
the “lock-out” mode, the physiotherapist should post- that the FET may be the most effective component of
pone the session till the lock-out signal is cleared. chest clearance physiotherapy [19]. When compared
Wound support while performing an airway clear- to coughing, the FET can loosen and propel distal
ance technique is also required, and the use of ice lung secretions towards larger airways and the tra-
packs over the incision dressing before deep breath- chea, where they can then be expelled by coughing.
ing and coughing may be helpful. It is best suited for postoperative patients for whom
There is a lack of evidence supporting the use of explosive expirations during coughing are very pain-
any airway clearance technique over another. Therefore, ful [39]. The FET has 2 components as follows.

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(a) Huffing: To loosen and mobilize distally situ- control again (20–30 seconds or 6 breaths). Finally,
ated secretions, the patient is asked to take a me- the patient practices the FET. According to whether
dium-sized breath; and then with mouth and glottis secretions are distal or proximal, a medium-sized
open, to breathe out forcefully and slowly (i.e., as if breath with a long huff or large-sized breath with a
trying to steam up a mirror). The huff should be shorter huff should be practiced, respectively. The
long enough to be effective in mobilizing the distally whole cycle should be repeated 2–3 times every wak-
situated secretions. However, it should not be too ing hour. The ACBT can be practiced in a sitting po-
long, as too long a huff may lead to unnecessary par- sition, or occasionally in a gravity-assisted positions.
oxysmal coughing, with a subsequent rise in intra- The ACBT is flexible and can be adapted for each pa-
thoracic pressure. Likewise, it should not be too tient individually. For example, one set of TEEs may
short, as too short a huff is ineffective. However, be followed by the FET, but if the secretions loosen
when secretions have reached the upper airway, a slowly, it may be more appropriate to use 2 sets of
shorter huff or cough with high lung volume may be TEEs interspersed with a period of breathing control,
sufficient to clear them. To carry out a huff or cough followed by 2 sets of the FET [32,34].
with high lung volume; the patient is asked to take a (5) The positive expiratory pressure technique:
deep breath, and then to exhale forcibly, squeezing Unlike CPAP, patients who use PEP therapy only re-
air out from the chest [19]. ceive positive pressure at the end of the expiration.
(b) Breathing control: An essential part of the FET PEP is most commonly applied with physiotherapy
is the pause for breathing control after 1 or 2 huffs sessions once or twice daily to aid chest clearance
to prevent any further compression and narrowing of [19]. There are 3 types of PEP devices; (a) a flow re-
the airway. Breathing control is tidal breathing at the sistor, through which patients exhale against a
patient’s own rate and depth, while the patient fixed-size orifice chosen according to age and ex-
adopts relaxed diaphragmatic (abdominal) breathing piratory flow; (b) a threshold resistor, where patients
[32,41]. For breathing control, the patient is in- exhale against an adjustable spring-loaded valve or
structed to rest one hand on the abdomen and to reverse Venturi device; and (c) vibratory PEP
keep his or her shoulders and upper chest relaxed. (acapella and flutter), where patients exhale against a
Then, the patient is asked to let the air flow in from threshold resistor with an expiratory valve oscillating
the nose (if possible), to feel the abdomen rise as he at 10–30 Hz. If the aim is to clear retained secre-
or she does so, and to feel it fall while he or she tions, as in postoperative patients, then a vibratory
breathes out. The length of the breathing control pe- PEP device is the most appropriate choice [39]. PEP
riod varies from patient to patient. In patients with can be performed against high or low pressure. For
bronchospasm or unstable/collapsible airways, a lon- proper PEP application, (a) the patient sits upright or
ger pause for breathing control is needed, while in leans slightly forward with his or her elbows sup-
other patients with no bronchospasm, the pause may ported on a table and holds the mouthpiece or the
be shorter. mask firmly against his or her face; (b) the patient is
(4) Active cycle of breathing technique: The ACBT asked to slowly take in a larger than normal breath
refers to a cycle of breathing control, TEEs, and FET. with a short breath hold (3–5 seconds) and to exhale
It can be used in postoperative patients to clear ex- through the PEP device with active but not forced
cess bronchial secretions with or without assistance. expiration against an expiratory resistor, giving a re-
The patient should start with breathing control for sistance that ranges from 6 to 25 cm H2O; (c) the
20–30 seconds. The patient then practices TEE 3–4 patient breathes for 10–20 breaths/cycle with a total
times. In addition to increasing lung volume, TEEs of 4–8 cycles/session or for a maximum of 20 mi-
play an important role in clearing excess bronchial nutes; and (d) after each cycle, the FET or supported
secretions. The mechanism is that TEEs with a 3-sec- coughing may be practiced by the patient to clear
ond inspiratory hold allow the air to flow via collat- the already mobilized secretions. For postoperative
eral channels and to come in behind the sputum patients, short periods of PEP every waking hour
stuck in small airways and mobilize it towards the have been recommended as a prophylactic treatment
larger airways. The patient then re-starts breathing [19,32,39].

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(6) Modified postural drainage positions: Modified pyema, large pleural effusion, or unstable pneumo-
positions are much more likely to be used post- thorax; and/or (d) cachexia or osteoporosis, partic-
operatively in patients where classical (head-down) ularly in elderly postoperative patients. Chest vi-
positions are not well tolerated or may cause aspira- bration during exhalation over the affected lung re-
tion, vomiting, breathlessness, cardiovascular com- gions below the incision is better tolerated than per-
promise, and/or pulmonary hypoxaemia. The recom- cussion in postoperative patients, and is considered
mended modifications include approximating the po- to be a useful alternative [28,42]. Manual vibration is
sition as closely as possible to the original classical implemented in conjunction with modified postural
position using the horizontal lateral decubitus and drainage positions to aid in secretion clearance. To
supine positions [39] or the leaning forward position perform manual vibration properly, the palmar as-
from sitting. For example, a modified position to pect of the physiotherapist’s hands should be in full
drain the lateral segment of the right lower lobe contact with the patient’s chest wall, or one hand
would be the side-lying position with the bed flat, may overlap the other hand. Then, after the end of
rather than the head-down position. However, in deep inspiration and throughout exhalation, the phys-
postoperative patients after lobectomy or pleur- iotherapist gently exerts an oscillating pressure on
ectomy, if the modified position proves to be in- the patient’s chest wall till the end of the exhalation.
effective in mobilizing distally situated secretions, the Mechanical vibrator devices can also be used, but
head-down position may be used with caution (e.g., manual vibration is preferable, as the physiotherapist
less time spent in the position), as the head-down can assess the depth and the pattern of breathing
position is not absolutely contraindicated in such cir- during vibration and coordinate the oscillating pres-
cumstances [1]. Modified postural drainage positions sure of vibration with the patient’s breathing pattern
can be used exclusively or in combination with any [28].
other airway clearance techniques. In order to drain
all the affected lung regions, different positions are 6) Postural correction
used in each treatment session, and each position Post-thoracotomy patients tend to side-flex their
should be maintained for 5–10 minutes or as trunk towards the thoracotomy side; that is, to drop
tolerated. The patient’s face should always be in the the shoulder and raise the hip on the operated side,
frontal view, so that any signs or expressions of po- because this is less painful. The patient is dis-
sition intolerance are monitored. Postural drainage couraged from adopting this protective posture, and
positioning is immediately discontinued as soon as is encouraged to keep moving the shoulder on the
the patient complains of breathlessness, cyanosis, operated side [18]. Patients should also be educated
haemoptysis, dizziness, nausea, vomiting, anxiety, ta- to keep both shoulders at the same level and the
chycardia, bronchospasm, hypertension, and/or any trunk straight while sitting, standing, or walking.
musculoskeletal pain or discomfort [28].
(7) Manual chest physiotherapy techniques: Shaking 7) Shoulder ROM exercises and gentle scapula
the chest wall following thoracic surgery is not an mobilization exercises
appropriate choice due to the presence of a chest After thoracotomy, approximately 80% of patients
wall incision, but a compressive support may be a have shoulder pain on the side of the incision [43],
better choice to promote the clearance of secretions which may cause them to immobilize the arm on the
[19]. Furthermore, manual chest percussion with pos- thoracotomy side, potentially leading to frozen
tural drainage positions is rarely used after thoracic shoulder. For this reason, auto-assisted or active
surgery [1]. This may be due to the presence of: (a) ROM exercises for the shoulder (e.g., arm elevation)
chest wall problems, such as a chest wall incision within pain limits can be started as early as possible,
and/or pain, healing tissues, subcutaneous emphyse- starting on the first postoperative day [19,20], with
ma, the presence of monitoring leads, or recent pace- attention to the chest tube site. In addition, the scap-
maker placement; (b) haemodynamic instability and/or ula on the operated side can be mobilized gently
cardiac arrhythmia; (c) PPCs, such as bronchopleural through its full range of protraction, retraction, ele-
fistula, pulmonary oedema, pulmonary embolism, em- vation, and depression, while the patient is in the

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Ahmad Mahdi Ahmad

side-lying position. These exercises need to be per- uated walking program can be initiated following
formed 3–4 times daily [10,18]. However, shoulder hospital discharge, as follows. Immediately after dis-
abduction and external rotation are initially avoided charge, the postoperative patient should start walk-
to prevent increased stress on the incision. ing at a moderate level of effort for about 3 times a
day for 5 minutes each time for a total of 15 mi-
8) Leg, trunk, and thoracic mobilization exercises nutes/day. Then, the patient should gradually in-
Non-resistance leg exercises (i.e., quadriceps and crease the total walking time each week by 5 mi-
ankle exercises) can be started on the first post- nutes, so that he or she becomes able to walk for a
operative day to minimize circulatory stasis and to total of 30 minutes either intermittently or con-
prevent circulatory problems such as deep vein tinuously by the first month postoperatively. The pa-
thrombosis and pulmonary embolism [20,44]. The tient can be educated to self-monitor effort intensity
patient can also start non-resistance arm exercises during walking. This can be achieved by observing
and thoracic mobilization exercises on the first post- his or her ability to talk during walking without feel-
operative day with the aims of increasing thoracic ing short of breath. That is, if the patient is able to
cage mobility, easing deep breathing with subsequent keep talking while walking without interruption in
increased lung volume, and preventing chronic re- speech or feeling difficulty in breathing, this means
strictions in chest wall expansion [20]. Thoracic mo- that he or she is walking at a moderate intensity.
bilization exercises include thoracic extension ex- However, if during walking, the patient feels unable
ercises, chest wall rotation exercises, and thoracic to keep talking continuously (i.e., his or her speech is
lateral flexion exercises [19]. For thoracic extension interrupted), and/or feels shortness of breath while
exercises, the patient is seated on a chair with back talking, this means that his or her walking intensity
support and is asked to put his or her hands behind has risen above the moderate level. At that point, the
the neck, to move the head backwards, and to slowly patient can slow down and pace walking with
extend the thoracic spine, using the edge of the back breathing to return to the targeted moderate in-
support as a fulcrum for the movement. For chest tensity level of exercise.
wall rotation exercises, the patient is asked to cross
his or her arms across the chest and to slowly turn 10) Postoperative exercise training
the body, as if trying to look behind one way, and After discharge from the hospital, patients may still
then the other. For thoracic lateral flexion exercises, suffer from incision pain, breathlessness, and easy fa-
the patient is asked to put his or her hands behind tigability, resulting in limitations in their activities of
the neck or across the chest, and to slowly bend the daily living and poor quality of life [5]. This can per-
trunk from side to side. Thoracic mobilization ex- sist despite the instructions of a home program;
ercises should be performed 5 times daily with ad- which may be because not all patients follow post-
equate pain relief and/or wound support. operative home programs properly, depending on pa-
tient compliance and family or caregiver supervision,
9) Discharge and home program awareness, and support. This emphasizes the need
Patients can be discharged from physiotherapy for supervised exercise training programs on a tread-
treatment at varying points according to their mill or cycle ergometer in the postoperative phase. A
recovery. A low-risk patient without postoperative small number of studies with controversial results
complications may need only 3–4 days of physio- have investigated the impact of exercise training af-
therapy. However, high-risk patients and those suffer- ter thoracic surgery. One study showed that su-
ing from pulmonary complications may need more pervised aerobic training was safe and feasible for
days of physiotherapy. Once discharged, patients postoperative patients, and that aerobic exercise
should be provided with a detailed home program to training was associated with significant improve-
stick with. They are advised to continue regular ments in quality of life and cardiopulmonary end
breathing exercises, to gradually increase their mobi- points [45]. However, a more recent study inves-
lity and daily activities, and to practice an airway tigated the effect of a 12-week multidisciplinary re-
clearance technique whenever necessary [2]. A grad- habilitation program that began 1 month post-

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 Essentials of Physiotherapy after Thoracic Surgery

Table 2. Summary of postoperative physiotherapy treatments

No. Summary
1 Physiotherapy pain management: transcutaneous electrical nerve stimulation; cold therapy; and wound support
2 Positioning: early upright positioning; and modified postural drainage positions
3 Early mobilization and ambulation: as soon as the first postoperative day for clinically stable patients; implemented on a
scientific basis and with strict guidelines
4 Lung expansion manoeuvres: deep breathing exercises(deep diaphragmatic breathing, thoracic expansion exercises, deep
breathing coupled with arm and trunk movement, sustained maximal inspiration); incentive spirometry (flow-incentive
spirometry, and volume-incentive spirometry); inspiratory muscle training
5 Airway clearance techniques: supported coughing; huffing; forced expiration technique; active cycle of breathing
technique; positive expiratory pressure technique; modified postural drainage positions; and manual chest physiotherapy
techniques
6 Postural correction
7 Shoulder range of motion exercises and gentle scapula mobilization exercises
8 Leg, trunk, and thoracic mobilization exercises
9 Home program
10 Postoperative exercise training

operatively on quality of life and exercise tolerance physiotherapy management, as the physiotherapy
in thoracotomy patients. It showed that walking tol- treatment plan should be designed individually for
erance improved in those patients, but at the cost of each patient according to his or her own problems
more pain and more physical limitations. Moreover, and needs. Thus, efficient postoperative physi-
no effect of the rehabilitation program on quality of otherapy can be applied reducing the risk for PPCs,
life was seen. It was concluded that rehabilitation accelerating the functional recovery of postoperative
should be postponed for 3 to 4 months after hospital patients, and shortening the length of the hospital
discharge [46]. stay. Early upright positioning and mobilization im-
prove functional recovery and reduce the hospital
Conclusion stay. Safety guidelines should be followed when mo-
bilizing and/or walking a postoperative patient fol-
This study aimed to clarify evidence-based physi- lowing thoracic surgery. TENS and ice packs are very
otherapy strategies for physiotherapists in thoracic effective in relieving postoperative incision pain,
postoperative care units in order to improve their which can reduce the additional need for analgesia.
practice. High-level evidence for deciding upon opti- Wound support should be provided during deep
mal postoperative physiotherapy interventions, un- breathing exercises, coughing, FET, and arm or trunk
fortunately, does not exist. Furthermore, the evi- ROM exercises. Deep breathing exercises have been
dence-based rationale of some routinely used physi- traditionally used for postoperative patients as pro-
otherapy interventions following thoracic surgery is phylactic treatment against PPCs. Certain airway
lacking. However, until more research is done and clearance techniques, but not all, are more likely to
further information is available, physiotherapists can be used for postoperative patients. The patient’s
continue to base their practice upon the available preference for a specific physiotherapy intervention
scientific literature about the fundamentals of post- should be taken into consideration. Postural correc-
operative physiotherapy after thoracic surgery. tion and education about postural awareness are im-
Physiotherapists should use this evidence-based portant following thoracic surgery. Shoulder, scapula,
knowledge to evaluate their routine postoperative trunk, and leg mobility exercises are main compo-
practice following thoracic surgery. Postoperative nents of postoperative physiotherapy. A PEP device
management of patients after thoracic surgery begins and heated humidification are useful adjuncts to
with a thorough initial patient assessment, so that an postoperative airway clearance physiotherapy. Upon
accurate clinical problem list can be created. This discharge, patients must receive advice and a de-
represents the first step of successful postoperative tailed prescription of home program activities.

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Ahmad Mahdi Ahmad

Postoperative exercise training results are not con- 10. Li WW, Lee TW, Yim AP. Shoulder function after thoracic
clusive and need further investigation. Given the surgery. Thorac Surg Clin 2004;14:331-43.
11. Gerner P. Postthoracotomy pain management problems.
small number of high-quality studies investigating pa-
Anesthesiol Clin 2008;26:355-67.
tients who have had thoracic surgery, further re-
12. Baddeley RA. Physiotherapy for enhanced recovery in
search in this field and more studies, particularly thoracic surgery. J Thorac Dis 2016;8(Suppl 1):S107-10.
randomized controlled trials, are strongly recom- 13. Freynet A, Falcoz PE. Is transcutaneous electrical nerve
mended to clear up the best postoperative physi- stimulation effective in relieving postoperative pain after
otherapy practices after thoracic surgery. A summary thoracotomy? Interact Cardiovasc Thorac Surg 2010;10:
of postoperative physiotherapy treatments is shown 283-8.
in Table 2. 14. Kerai S, Saxena KN, Taneja B, Sehrawat L. Role of trans-
cutaneous electrical nerve stimulation in post-operative
analgesia. Indian J Anaesth 2014;58:388-93.
Conflict of interest 15. Desantana JM, Santana-Filho VJ, Sluka KA. Modulation be-
tween high- and low-frequency transcutaneous electric
No potential conflict of interest relevant to this ar- nerve stimulation delays the development of analgesic
ticle was reported. tolerance in arthritic rats. Arch Phys Med Rehabil
2008;89:754-60.
16. Watkins AA, Johnson TV, Shrewsberry AB, et al. Ice packs
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