Tuesday, July 21, 2009

Post-op: Getting back into shape

One of the things women in the later stages of postop recovery often ask on our message list is when and how they can resume or begin an exercise program to really get back into shape. That's a very good question because we definitely lose conditioning when we're inactive during early recovery and yet we need to return to physical activity in a manner that does not damage our healing.

Sadly, many surgeons, unless they have a personal interest in fitness, are not the best individuals to advise us. They will tell us to gradually increase our activity and avoid putting too much stress on our abdominals, but beyond that, unless they practice a sport themselves, they may not know what does or does not particularly require midbody strength.

Physical Therapy

In the physical therapy department of the hospital, however, are folks who are trained in exactly this: safely ramping up physical activity. Not every woman will need their help, but women with particularly extensive surgeries, multiple repairs, those who were in especially bad shape pre-op, or those who suffered surgical complications may well benefit from their expertise in getting started back on the track to better healthy activity.

Your surgeon may not offer, but if you ask he is likely to be perfectly willing to write a prescription for at least a short period of physical therapy to get you started. With a prescription, most insurance programs will cover these costs (but, obviously, check your own program's limitations beforehand).

So if you feel you are particularly challenged in terms of getting started and knowing how to move forward in regaining strength and endurance, this may well be the sort of expert help to seek out.

Early recovery activity

We may not think of it as exercise, but many of the things we do early on are in fact just that.

Our first exercise begins the day of surgery itself when we sit and then stand up for the first time. We should take the time to center ourselves, get steady on our feet, and then stand tall. Yes, it will feel as though our guts are going to fall out on the floor, but no, they really won't. We may need to support our bellies with a folded towel or pillow for security until we learn to trust our sutures, and that's fine. But it's important to stand up fully straight so those muscles don't shorten and our scars contract.

Each time we get up, those early days, we should take a few moments before walking to stand tall and start to make a conscious effect to support our abdominal contents with our belly muscles. Go ahead: suck them in. I don't mean try to flatten the swelling or pull so hard you have to hold your breath, but we can gently begin to tension them and remind them do their normal work. This is good, and it's not going to tear anything.

Walking is our first and most important exercise, and we begin that the very day we have surgery. Every day we should walk a little bit more. Every day, we should walk a little longer, a little further, a little more often.

As we do it, that walking should be gentle on our bellies--we don't need to gallop along with our bellies flopping about; that only causes damage. And for every walk we take, we need enough rest afterward so that we don't feel the effects of it. Many small walks are the way to build up to longer walks.

When we can't easily get our walking done in a gentle and protected fashion indoors, we're ready to go outside or to extend our walks using a treadmill. Working on a flat treadmill is best at the beginning, just because elevating it puts greater stress on the abdominals from the stepping-up motion.

Note, please, that I'm not giving you firm guidelines on walking so many blocks by such and such a week of recovery. In fact, we'll all vary on what the right amount of exercise is for our own bodies. Some of us were in great physical shape pre-op and have those muscles ready to go; some of us could barely stagger from bed to bathroom even before surgery and may not have walked a block for years. Some of us have simple surgeries and our bodies heal well and quickly; some of us had complicated surgeries, multiple repairs, and may have suffered poor health for years. Because of these many personal factors, we'll each progress at a different rate.

What matters is not the numbers but that we each progress in some fashion that challenges us but does not tire us beyond our ability to rest back to a good energy level. This metric will guide us throughout our recovery: we should do however much we can bounce back from with our next rest period. If we don't feel fatigue at the end of our exercise, we're ready to increase. If after a nap or a night's sleep we're still tired, we've done too much and should hold there (or maybe back off a tad) until we are more fully rested.

Other early exercise

In the first postop two or three weeks, we're discouraged from doing stretching exercises that put tension on our operative area. At the same time, in this period it's critical that we not walk around hunched over grasping our bellies and suffer poor posture and shortening of our scars. The gentle exercise of lying flat on the back on a firm surface and fully stretching out in a relaxed way, not actually pulling the tissues, is a very good one for this period.

While it's possible to lie on furniture on your back, this is rarely firm enough to let us really flatten our backs out well. For those who can manage it, the floor provides a better surface for this exercise.

And yes, it's difficult getting up and down from the floor. The best tip I've seen for this is to use the top of stairs: climb up (carefully at first!) until you are a few steps from the top and then sit on the top. From there, you should be able to slide and lie back onto the floor, using your arms to ease down onto your side. To get up again, reverse the process, sliding towards the stairs, feet first, until you can "walk" your feet down the stairs and stand up, using the rail to help with balance and steadiness. In the first week or at least the first few times you do this, be sure to have someone standing by to help steady you if you feel wobbly.

Getting that belly flat

Post-op swelling happens to all of us. There's a good reason why: just as swelling occurs with a twisted ankle to provide immobility and protection, so fluid collects in our bellies to help immobilize the contents and protect from injury while healing. And indeed, just as our twisted ankle may swell with use for months later, long after it looks to us to be healed, so belly swelling will continue to celebrate excessive activity.

What's important to remember about this is that this is fluid doing this, not muscular weakness. We cannot exercise this away. Only time and healing will reduce this.

How long? Constant swelling will diminish after the first few months but we'll swell with activity for six months or more, depending upon just how much surgery we've had. For example, returning to work often marks a notable resumption of belly swelling that takes a week or more to regain the level it had towards the end of our recuperation period. We need to remember this and dress with this expansion room in mind so we don't end up throttled halfway through our day. By six to eight months post-op, though, this becomes much less common and we gradually see it disappear.

At the same time, women who have had abdominal incisions are aware of lost muscle tone. "When can I start doing situps?" they ask on message lists. In fact, that's not something to do for a few months. But that doesn't mean that your belly isn't working at all.

From the day of surgery, we're resuming belly toning. We use those muscles to sit up and to stand up straight. That walking I've been talking about? Totally uses belly muscles. Walking up stairs or on an inclined treatmill? Once we're cleared to put stress on those belly muscles by our surgeons (ask at your two-week checkup), those things that look like they're using our legs actually also involve our abdominals and are the next step in toning back up.

We will also, as we resume our normal household activities, be regaining belly tone. Some of the things we're forbidden early on, like loading a dishwasher or doing the laundry, involve bending and twisting and are forbidden then exactly because they do work our bellies. Once we're cleared to do them, then, they are providing an early workout for those muscles. We tend to think of chores as neutral things that don't count as exercise, but as we recover, they most certainly are just that and should be treated as such.

Other exercises

The point where we transition from just chores and normal tasks, like walking up the stairs, to a more structured workout program happens when our bodies are ready for further challenge. We are ready to to build not only muscle tone, but regain cardiovascular and muscle endurance. Walking, even at a more brisk pace, doesn't demand enough effort any more.

At the same time, we still need to limit the jouncing and shear motions to our abdominal contents. For this reason, running and bicycling are not considered good early reconditioning activities. Running is the queen of belly bouncing and pedaling a bike, whether indoors or out, requires a great deal of abdominal muscular effort. They are best left for a few months further along in our recovery, when we are less likely to disrupt internal healing. What we need now is to use our legs and arms and cardiovascular system, not jounce our midsection.

For that reason, swimming is an excellent exercise once our incisions are closed: it supports us from that jouncing and yet allows us to work the rest of the body very hard.
My doctor gave me permission to swim after my two-weeks check, and said only to take it easy on my midbody. I was in the habit of swimming laps for an hour three times a week before surgery, and when I first got back in the pool at about 2 1/2 weeks (when I was able to walk an easy mile without strain), I swam very gently for about 10 minutes and found that my knees were so wobbly that it took me another 5 minutes to climb out of the pool. I found that kicking was much more difficult than I expected (again, it uses the abdominals) so the kickboard was out, but that a gentle crawl or backstroke worked fine for me. I gradually increased my swims by no more than 5 minutes a week, just to keep from pushing faster than my body could keep up with and still heal, and found that by holding to that time limit, I could swim a little harder each time. Long before I was able to achieve aerobic level activity any other way, I could swim to get my heartrate up and work all of my limbs without undue stress on my healing belly. This sort of approach is good for postop recovery just because it does permit hard work without overstressing healing areas.
On our message list we often get questions about using weights or doing yoga. Since both of those rely upon strong, activated mid-body muscles for support, even when working other areas, we need to be very very careful how we move forward.

When working with weights, we need to start very slowly with very light weight and focusing strongly on feeling how we're using our abdominals. This is where working with a physical therapist or very experienced trainer who understands rehab is more likely to be effective at both moving us forward and avoiding injury than just taking the word of some jock at the gym.

For those looking to resume yoga practice, standing in tadasana or moving to sit in balasana would be very good for early focus on gently starting the abdominals to work; moving to table and cat/cow in a gentle way might be a good advance after a few weeks postop.The more demanding warrior or twisting poses should probably be deferred for some time and full sun salutations are going to be much too stressful for some months. Someone experienced in their practice is probably centered in their body enough to work to a gentle extent, but I would not recommend early recovery period as a time to begin yoga, just because it can be too easy, without a very experienced and attentive instructor, to try to be more gymnastic than is compatible with safe and sensible recovery.

Nonetheless, yoga is a good way to gradually work up the demands on our abdominals (in the hands of a good instructor who knows that we're working on rehab) and can be especially useful because it balances flexibility and twisting with pure abdominal muscle contraction—something that just doing situps fails to provide. Further, yoga, with its focus on doing and holding one pose very very well can put us more in tune with our bodies than the more competitive atmosphere at the gym with its "push it further" philosophy, while still providing a workout that can leave us utterly limp at the end of an hour.

No firm rules other than good sense

So the main idea in this time is to first regain and control good posture gently supported by our abdominals and stretching our spine out tall, then to extend our stamina by walking further and further. It's better—by which I mean ultimately more effective—to walk a mile with our belly muscles supporting good posture than to force ourselves to begin doing a situp. We should at all times only do what does not provide strain and only do as much of it as we can rest from in our next rest period. How and what we extend our conditioning with depends upon what appeals to us and what resources we have available to practice it, but this is a time to take advantage of expert guidance if we're unclear on how to work out without stressing our abdominal healing.

While it may take many months to fully put our healing behind us, recovery of physical conditioning begins as soon as we leave the OR. Even for women who have no desire for athletics, working on good posture and body control while healing well will pay off in better comfort and stamina in all of their daily activities.