How do you heal after invasive surgery?

Just recently I had two athletes each bemoaning the fact that they were not successful in returning to training within 2 weeks of surgery. They had both had abdominal incisions and were having issues with the wound not sealing and a lot of pain in the surgical area.

So how soon can you start back to training?

I thought that it would be useful to understand the hard work that our bodies are doing in this time. The hard part of today’s ‘instant-everything’ world is that we are not giving ourselves a chance! But we can help ourselves by looking after the wound and the healing process.

The healing process is 4 stages – and last in total over a year and possibly two years!

The four stages of healing happen in an organised and sequential way – but they can progress better or worse, depending on factors associated with you (both as a patient and how you treat the wound). The second part of this blog will look at the factors for you to promote better healing.

Stage 1 seals the wound and is really quick!

The hemostasis phase closes the wound with a clot (usually in a matter of minutes/hours). Various components of the blood combine to create a mesh that forms a clot that adheres to the wound and closes it off. You need to protect that. There used to be a school of thought that you had to let the wound be open to air for the scab to harden properly, but the new hospital dressings allow it to do this without removing the dressing – so you will probably be advised by the hospital to keep the same dressing on for some time, in order to stop infection entering the area.

Stage 2 prepares the wound area for the growth of new tissue

The defensive/inflammatory phase focuses on destroying bacteria in the area and removing any debris, such that the wound area is all set for the growth of the new skin and tissue. White blood cells and microphages in the blood do this. It normally takes around 6 days and you can often see and/or feel swelling, redness of the skin, heat and pain. Obviously if the area keeps getting new infections into the area, then this period is extended. During this time it is absolutely critical to keep the scab dry – so you will need to find some good waterproof dressings or a different way of staying clean (wrapping cling-film over the area does not work!)

Stage 3 is the progressive filling and covering the wound, starting from the outside edges

The proliferative phase follows three distinct stages: 1) filling the wound, 2) contraction of the wound margins, and 3) covering the wound with new skin. You probably remember watching this as a child, as the new, pink skin forms from the shallowest and outside parts of the wound and eventually closes it up. It is a very clever process that remakes the blood vessels, tighten the open wound (often giving an uncomfortable feeling of tightness for a time) and then the skins cells work their way up from inside the body to form the boundary layer. This can all last anywhere from 4 to 24 days, and during this time dissolvable stitches on the surface should drop out. In order to protect the wound, it is still really important to keep the scan dry in order to protect it from damage, although to the latter end of the timeframe many nurses say that you can have a quick shower, but must keep away from baths and any kind of swimming pool/hot tubs etc until it is all completely sealed. Also across this time, a lot of nurses suggest gently putting Vaseline or moisturiser on the scab, in order to keep it flexible and stop it cracking and getting damaged.

Stage 4 is where the scar gains strength and flexibility

The maturation phase is where the tissues reorganise and remodel as they mature. During the proliferative phase the tissue gets laid down haphazardly, whereas the uninjured tissue is all lined up in a standard structure. Over the usual replacement of the layers of skin, this slowly gets addressed and as it does the way that the scar tissue moves stops being a big block and starts to move with the body and has strength. This phase can vary from 21 days to 2 years, and you can help it by gently massaging the wound and encouraging the tissue to realign. Also many nurses recommend rubbing in Bio Oil or a Vitamin E cream, which seems to visibly help the scar to fade in colour and settle back to flat with the skin.

So it all takes time

Back to our athletes – getting the wound to seal and be ready for the forces of movement in the area of the surgery is probably around 6 weeks, and within this time nurturing the area to maximise the healing will really help.

Things that you can do to encourage faster healing

There are many factors that mean that people heal differently. Some of these are inherent to you as the patient. Age has a direct effect on how fast we heal – as we get older, the skin is thinner and less elastic so we need to allow it more time. There are also factors associated with your body make-up in terms of how your body lays down the scar tissue, which you cannot change.

However, there are a number of things that you can look after.

  • What you eat is really important – You need to ensure that you are getting some good protein at each meal, and foods that are high in zinc, copper, vitamins A, B and C can also help the healing,
  • Good hydration really helps too, as this has a direct effect on the blood stream.
  • A good overnight sleep is key. The body’s repair mechanisms work hardest during the deep sleep cycle – so do make sure that you are getting your head down and getting a good quality 8 hour overnight sleep (or more if your body needs it)
  • Reducing inflammation – many people swear by arnica. Obviously the cream cannot be applied to open wounds, but I found major reduction in the bruising around where the cannula was inserted by using the cream on the adjacent skin areas. And you can buy oral arnica from homeopathic providers such as https://www.helios.co.uk/ and it generally does not have any interactions with other medication that you may be taking (although check with your own Doctor and/or surgeon)
  • Managing your weight – skin heals better when it has the blood supply into the tissue, which muscles give but fat does not. This helps the supply of all of the agents for the different phases of healing, as well as oxygenating the wound area.
  • Keeping the wound area dry and clean – this is so important for the right conditions for wound healing. This can be hard to do, but is a really significant factor. Try to get the right balance between waterproof dressings to stop external moisture and getting it open to the air if it is in an area of your body that stays damp and then covering it again.
  • Medication can slow healing down – some medications slow healing by impairing the inflammatory response, leading to a reduction in the collagen production which is key, especially in the 3rd and 4th stages. Treatments such as chemotherapy affect the new cells, so have a strong impact on healing, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that you may commonly take as over-the counter drugs can also slow down the process. Obviously you are likely to need medication after major surgery, but it will help if you can keep it to the minimum that you need and bear in mind that you may need to allow longer for your body to heal. 

So best of luck with your healing – do nurture your amazing body to do its thing! And after a major surgery taking a good month or 6 weeks off training that involves the juddering of impact, or the strain of strength training could be well worth it. It is also worth saying that there are other factors from surgery – for instance, anecdotally many Doctors say that it takes around 6 months for the body to completely recover from a general anaesthetic.

How do I know that I am going to a good physiotherapist?

This was a question that I Googled over and over again, and had some pretty scary experiences. In the absence of finding any answers online, here is my view:

A physiotherapist is there to help make you better, so their first rule has to be DO NO HARM!

So – if at any stage- you feel  a sense of a lack of trust, or you feel that they are not listening to you, or if the way that they are manipulating you is not respecting your body, then I would immediately ask them to stop, sit up, step down from the table and say why you think that the appointment needs to stop there. And if they do not make you feel comfortable by talking through the treatment plan that they have for you and how it will make you better, then simpl pay, leave and never go back! I wish that I had thought through in advance of a couple of appointments how I would respond if I was unhappy with the way that I was being treated and what I would do – as in the moment you can feel frozen and under pressure to just take whatever you are being given.

When I first got referred to a physiotherapist by the consultant after reviewing my scans, I asked people who had been before what made a good one. It’s frustrating – whilst we can each get a very detailed understanding of what it might be like to eat out at a given restaurant or stay at a certain hotel based on ratings and reviews sites or specialist guides, there is no such thing for physiotherapists (or any of the medical profession)! Many have a couple of google reviews – usually all 5 stars and not more than two. My hunch is that these are done by friends, as in order to get a good google listing you need a couple of reviews. I never found a useful or insightful one on physiotherapists.

What is the difference between a physiotherapist, an osteopath and a chiropractor?

Google search shows that this is a very common question, but there are not many simple answers.   My answer is that it is all a spectrum in the ‘manual therapy’ part – ie the hands-on part (as against giving you exercises and watching you). Some physios will only give you exercises, and this would be a potential marker of a poor physio for me – a huge proportion of injuries will not get better without some manual therapy assistance and will certainly need some hands-on testing to understand areas of tightness. But within the manual therapy spectrum, physios seem to focus more on the muscular (and also sometimes fascia) connections, with osteopaths and chiropractors both focusing more on the nervous system, spinal involvement/alignment and into ligaments/tendons connections. My own experience is that the osteopathy end of the spectrum is more gentle and helpful in pain relief and relaxing issues associated with excessive tightness. Whilst the chiropractic end of the spectrum is more active and associated with actively addressing issues to get to ongoing alignment, including retraining muscles, ligaments and tendons.

The interesting part is that orthopaedic surgeons and GPs will all tend to send you to a physiotherapist and never one of the others. My understanding for the reason behind this is that physios have more years of academic training than the others, and are therefore held in higher esteem by the more traditional part of the medical establishment. But you may find that your body responds much better to the touch and skills of a different practitioner.

What are the signs that I have found a good physiotherapist?

Here is my top 10 list:

  1. They really listen to you describe the symptoms and pain sites, and ask good questions.
  2. They do a full body screening set of tests of range of movement, movement patterns and pain in all parts of your body, even if these are not the site of the injury or problem. And then as your treatment progresses, they keep going back to these tests and monitoring progress.
  3. They listen to your feedback on pain levels, and if you say that you cannot take any more, they stop. Especially if it is your first time having acupuncture or dry-needling. These should create a strong relaxation of the muscle, but some people do have a reaction to it – so if the needles continue to hurt they should take all of the needles out.
  4. They explain their thinking on the problem and their treatment plan – and answer questions if you have them. And in the case of the physio that I respected the most, I went to see him 3 times before he was ready to share his view of this, because he was building a more detailed picture and evaluating it before rushing in. One of the most useful questions I found at this point was to ask what a standard case of a XXX injury would look like a this many weeks after, and then to compare how I fitted against that.
  5. They are prepared to talk with the surgeon to build a connected treatment plan, based on all of the scans and expert judgement. This makes such a difference, as they are able to have a different conversation from the one that you can have with the surgeon. Plus, if you end up having multiple surgical interventions, it gives you as the patient the confidence that going to further surgery is the right plan, and the surgeon really does have the full picture.
  6. They welcome feedback from you (and ideally help you to structure it in a way that gives them the information that they need in a simple way) about how the pain levels and progress on the exercises has been since the last appointment
  7. They give a really clear protocol of what they want from you. Genuine misunderstandings are so rife: ‘take it easy’ can mean anything from no hard running, through to nothing more than a gentle walk! Likewise sitting might be really bad. Having a detailed protocol agreed of how you will approach general life, as well as the exercises, is really important.
  8. They layer their exercises from the simplest and least weight-bearing form of the exercise, building the complexity when your body can handle it. The most frustrating times for me have been with 2 different physios after different surgeries, when they said “oops, I chose a set of exercises that were just too advanced for you. We’ll have to try something else”. These in each case put me in a situation of being unable to move at all for days in one case and weeks/months in the other
  9. They demo exercises and then watch and correct your form on the exercises so that you can be confident of doing a perfect rep when you get home, and spot when to stop when you lose perfect form – rather than when you are crying with pain.
  10. They are prepared to say when you do not need to see them too! There are points when you continuing with the strengthening exercises and giving it time will be enough – and a good physio will say this, rather than continue to take your money!

The no pain, no gain view of physiotherapy is really unhelpful

Everyone who I spoke to before seeing a physio had the view that physiotherapy has to be painful for it to work – that the manual manipulation has to hurt to release problems and that exercises have to hurt to work. I totally refute this. I think that there is really good evidence that when a body is swimming in the chemical markers associated with pain and everything is contracting and tightening from the electrical stimulus of pain then the problems are increasing, not decreasing. This is not to say that like in sports massage sometimes pressure can help a muscle release and there may be times where a physio will warn you that there could be a little discomfort – but this should only be very short-term.

I regret having gone to see those physiotherapists whose exercises and interventions increased my pain.

As an athlete, I would steer away from hospital physiotherapists

Initially, we thought that going to the hospital physiotherapists would be the best plan straight after surgery, because we thought that they would be deep experts because they saw lots of cases of this specific surgery (given that they are at the hospital) and because we assumed that just out of surgery all patients would be in pretty much the same situation. This was a bad call. The physios that I saw seemed to always be surprised at the level of muscle strength that I had (even though after a year of problems, I had lost 15 kg of muscle mass on the body composition scales). As a consequence they regularly chose exercises that were way too difficult and caused problems. And to compound the issue, they then seemed to bounce into another set of parallel exercises with slightly different approaches that also caused more pain and problems.

So do you have to go to know?

I think that there is a certain amount that you can do before meeting a physio – you can ask specific questions to previous clients who recommend them, you can phone and ask the clinic how the physio approaches things, and you can ask to talk through your case on the phone or via email before meeting them – in order to understand whether you and they think that they can help to make you better.

But at the end of the day, some of it will unfold as the diagnosis and treatment unfolds. Keep asking yourself (and them!) the questions. If you are not improving, then you need to understand whether your time and money would be better spent somewhere else.

And finally…

As an athlete you may have built a mentality of pushing through pain to finish a race (or even a training set). Physio exercises are not like that. If they are hurting (not the good and comfy ache of activation, but jagged and unpleasant pain), then stop and do not do them again before talking with the physio. You may be rating yourself as the failure (as I was), but actually pushing over multiple days to try to complete just one set when it is the wrong exercise can cause a lot of damage. Listen to your body first, and the physiotherapist second.

Best of luck with finding a partner who can help you rehabilitate your body and get you back to the movement and activities that you love. You deserve that. There are many people out there, and many apply just the same approach to everyone who comes through the door. If that one happens to help you to improve – brilliant. But if you have to keep going, knocking on lots of different doors to find the person with the approach that fixes you – it is not a failure and it does not mean that your condition cannot be fixed.  Listening to your body, testing and monitoring progress on the key measures and finding the right person or people will move you forward, one step at a time. Keep at finding the right person, just as you would keep at finding the right coach or the right training approach. You have the resilience to do this – even when you are at your lowest ebb.

Your basic bodycare toolkit