My schedule of bed exercises
Exercises Following Surgery
During surgery, you are usually anaesthetised, immobilised and lie on the operating table still and motionless for a significant period of time. Usually, blood is pumped around your body through the arteries by the heart under pressure. The return of blood to the heart happens through the veins, which are not pressurised in the same way. This mechanism in the body is dependent on the muscles in the limbs and other body parts compressing to create pressure and send the blood back to the heart.
When you are anesthetised, immobile and/or paralysed, this action of the muscles pumping blood back to the heart from the limbs cannot happen on its own. Consequently, this can result in the pooling of stationary blood in the veins. In most cases, this pooling of blood takes place in the veins present in the legs, calves, and thighs. Over time, the stationary blood pooled in the veins can form a blood clot, which can get bigger in size. The clot obstructs the way of the blood flow and can damage the valve system in the vein. Besides that, the clot can also dislodge itself and travel with the blood flow towards the heart. Both of these situations can cause severe complications that can have long-lasting side-effects. This clot is what is referred to as a Deep Vein Thrombosis or a DVT.
Exercises after surgery are essential
Exercises following surgery reduce the pooling of the blood in the veins and muscles of the legs and encourage normal blood flow back to the heart. Exercises also encourage deep breathing and promote air entry into the small bronchioles of the lungs. This reduces the build up of fluid and secretions in the lungs, improved oxygen uptake by the blood and reduces the risk of post-surgical chest infections and pneumonia. Exercises also reduce the chance of fluid collection in the feet, and ankles as oedema. This may also occur in the buttocks and back of the pelvis. Lying in bed also puts great pressure on certain pressure points of the heels, sacrum, pelvis and ischial tuberosities and the elbows. Early exercises encourage, blood flow, the reduction of fluid build up and oedema and reduces pressure on the pressure points and the risk of pressure sores.
In the Recovery Room
After the surgery, while you’re in the recovery room, it is likely that the use of any TED stockings, foot or calf pumps will continue. Once you wake up and feel up to it, it is a good idea to do some Chest and Deep Breathing Exercises the first thing. Along with that, you should then move your ankles and feet by doing the first exercise i.e. the Calf Stretch Exercise. To do the Calf Stretch Exercise move each ankle up and down as far as it will go, alternately for each ankle. Do this 20 times on each side. This should only take a couple of minutes and should be repeated every 15 minutes or so.
Since this doesn’t engage your abdomen directly, these exercises should not be painful at all to do after waking up from surgery. This is an important time and no matter how awful, drowsy or the degree of pain you feel starting exercises and encouraging movement at this time is important.
Breathing and Chest Exercises
During abdominal surgery, you will be deeply anaesthetised in order to relax your abdominal muscles and make the surgery go much easier. Along with being anaesthetised, you will also have an endo-tracheal tube put down through your throat into the trachea and lungs. This tube will be used to pump air and oxygen into your lungs to help you breathe whilst you are down for the surgery and your muscles are paralysed. Since the surgery can go on for many hours, the assisted breathing will be used for the entire time. During this time, secretions may collect in the trachea, bronchi and lungs. The anaesthetist usually ensures that these secretions are removed at the end of the procedure. However, the removal of secretions may be incomplete or some additional secretions may collect in the immediate post-operative period.
In some cases, if the patient is a smoker or had a cold or chest infection prior to surgery, there might be some excessive secretions that might be difficult to remove. It’s important to pay attention to these secretions as they might cause coughing or partially block the trachea and bronchioles and prevent the lungs from working properly. Other than that, the secretions may provide bacteria with a medium to grow in and then cause a chest infection or post-operative pneumonia.
In order to minimise problems from the collection of secretions, it is important to undertake Chest and Deep Breathing exercises as soon as possible after the surgery. Also, it is important that you repeat them regularly until you are fully recovered. You can start doing these exercises in the recovery room with deep breathing. Inhaling in the air, make sure your lungs get inflated with fresh oxygen, hold it for a few seconds and then slowly let it out. This should be repeated three times, every 10 minutes for the first few hours and then perhaps hourly. During the night and the rest of the day, this should be repeated whenever you are awake.
While exhaling the last deep breath during your exercises, make sure to cough out any secretions that might have collected in your throat. However, this may produce some pain in an abdominal wound. Therefore, you should cough as the best you can without causing yourself too much pain. If any degree of coughing is too painful to undertake, a deep growl or rasp of air through the trachea may help expel any secretions. If you’re in so much pain that even undertaking a deep breath or a cough seems difficult, then you should bring this to the attention of the nurse or doctors right away.
On Returning to the Ward
Once you have been transferred to your ward and have settled in your bed, start doing the Calf Stretch Exercises. You can do that by doing 20 repetitions for each ankle every half hour. After my surgery, I dozed half awake and half asleep on the first night but I remembered to move my ankles alternately and continuously up and down. As for the Chest and Deep Breathing exercises and coughing or rasping, you should do them every 15 minutes or so when you’re awake.
Next, you should try to have a few small sips of water if you are physically able to. Although you may be on a drip, it is likely that you will be a little dehydrated during the surgery. It is always a good idea (if allowed in the post-operative instructions) to take regular sips of water. It refreshes the mouth and encourages the stomach and kidneys to recover. An alternative is sucking ice cubes.
For however long your surgery goes on for, you’ll be lying very still on your back on the operating table. And although these tables and recovery trolleys are padded, they are way too firm and stiff to be comfortable. So as a result, you might feel a bit of soreness in your back, the back of your pelvis, the sacral area and your heels. Once you have returned to the ward, the nurses should check these areas to make sure you’re not in too much pain.
Changing the position from your back might help relieve some of the pressure you were feeling for several hours while in surgery and prevent any possible pressure sores from developing. In elderly patients, padded heel cups may be used or a special mattress for that purpose. For younger and able-bodied patients, slightly rolling to one side and changing to the other side an hour or so later will help.
Fortunately, I was provided with a bolster which I found to be very useful in this respect. It was just a towel rolled into a pad and secured with tape by a very helpful nurse. I was able to put this under one side of the pelvis and then the other. It had the effect of just relieving the pressure from one side of my pelvis and sacrum for a few hours, tilting me just a little to the other side. I used the bolster on alternating for two hours each side. I found this useful for the first 24 hours and then at night for the first 5 days or so. I did take it home with me so the NHS temporarily lost the use of one of its towels.
The First Morning
When you wake the first morning – that is, if you got any sleep at all – remember to repeat the Calf stretch exercises by moving each ankle up and down as far as it will go. Do this 20 times on each side. This should only take a couple of minutes and should be repeated every 15 minutes or so. Along with that, also do the Chest and Deep Breathing Exercises and attempt to cough every 15 minutes with the ankle exercises. This may seem fairly active, and yes, the point of the exercises is to get you going and set you off on the path to recovery. It may seem intensive but again, it is beneficial and should be easily achievable. Trust me, you’ll end up feeling better and they’ll get progressively a little easier each time they are undertaken.
You should also now try the second exercise. This may stress your stomach muscles, which may be sore. But it is best to start it now, slowly and carefully, whilst you can and before the nurses and physiotherapists come round to get you going. They will probably not take no for an answer. So it’s better that you start doing this on your own rather than being forced into doing them.
The second exercise that should be started on the first morning is the “Foot Slide with a Knee Bend”. You start whilst lying in bed on your back, under the sheets if necessary. Slowly bend your knee up, sliding the foot along the sheet so that the heel is near the buttock. Then slowly reverse the movement until the leg is flat straight on the bed again. Then repeat the exercise for the other leg. Work towards being able to achieve 20 repetitions with each leg during the first day.
For me, Caroline my nurse burst in the room with energy and enthusiasm to get me out of bed at 7 am on the first morning. Her first words were that I first had to do my leg exercises. She was surprised when I confidently told her that I had already done them. The problem was that Caroline then proceeded to convince me to get up and sit on the side of the table with my feet on the floor. Whilst she left me like this for a few minutes to get my balance while sitting, I repeated the Ankle Exercises and Calf Stretches again. I was motivated to complete these exercises as I wanted to minimise the risk of getting a dreaded DVT or Deep Vein Thrombosis.
Caroline then got me out of bed and sat me in a high chair near the bed. This felt uncomfortable on my sore bottom, so I placed a pillow on the chair under my thighs. This took the weight off my bottom whilst holding it well back, making me much more comfortable and stable on the chair. Once I settled into the chair, I continued my Ankle Exercises and Calf Stretches.
In addition to these, I could now easily add in a third exercise, which I could undertake while sitting comfortably in my chair and without any pain or discomfort. First I did my Floor Slide Exercises by simply sliding my foot (within the TED stocking) forwards on the floor as far as I could and then pulling it back under the seat as far as it would go. I repeated this on each side until I had achieved 20 repetitions. As with the Ankle Exercise and Calf Stretch and the Chest and Deep Breathing exercises, I repeated this every 15 minutes religiously the first day. Consequently, I am happy to report that it kept me busy, active, positive and progressing towards recovery.
Progressively Increase the Exercises Each Day
Each time you undertake the exercises, they should become slightly easier. It’s understandable that you might start out pretty slow and wonky, but eventually, you’ll get there with persistence. So try to achieve more repetitions each time until you reach the magic number of 20 for each side. When you have achieved 20 repetitions, try to undertake the exercise faster or with more vigour and intensity. As you progress in your recovery, try to even more physical activity by adding in additional exercises each day. The exercises may be initially uncomfortable or even bordering on painful. Once stopped though, there should be no residual pain. But if you are in pain, then perhaps you have done a little too much and you need to slow down a bit.
The Second Day
When I was awake and lying in bed that second morning, I repeated my three exercises including the Chest and Deep Breathing Exercises, Ankle and Calf Stretching Exercises and the Knee Bend with Foot Slide. On the second morning, I was able to slowly, carefully and methodically do these and was pleased to achieve 20 repetitions of each exercise.
I did not think at the time of the next two exercises, but would have started them on that second day if I had. The first of the two is the Head Raise Exercise. This is a pretty simple exercise that involves lifting the head off the pillow and nodding forwards, such that the chin touches the front of the chest. This may sound simple but to a small degree, will use the abdominal muscles which may be uncomfortable. Again, try to achieve 20 repetitions.
Along with that, you should also be able to do the fifth exercise gently on the second morning. This exercise if the Crossed Arm Stretch Exercise. Start out by stretching out your arms and shoulders; this step activates not only these muscles but also the oblique abdominal musculature. Next – with one arm raised at 90 degrees, bend the elbow over your chest. If starting with the right arm, move the arm over the chest to the left, lifting the right shoulder and scapula off the sheet. This will necessitate some rotation of the trunk and abdomen. This may feel sore and so should be started gently, progressing slightly over several days such that the arm may be vigorously moved from the right to the left with the elbow resting on the sheets until the arm is fully over the front of the chest, the right shoulder is off the bed and the hand is touching the sheets over to the left side. As usual, this should be repeated 20 times on one arm and then 20 times on the other. This may take 3-5 days to achieve completely and perhaps 1-2 weeks before it can be undertaken with some speed, vigour and enthusiasm. The key is consistency and persistence!
These exercises can be undertaken when lying in bed in the morning but should be repeated when you return to bed after sitting out in the afternoon and again in the evening.
Days Four to Seven
The initial five exercises should become progressively easier over the first four days. By the fourth morning, you should be able to undertake 20 repetitions of each exercise with each arm and leg. This may be a little uncomfortable and stressful but it will get you active and get your muscles engaged. By the fourth day, you should feel that you are making a significant amount of progress as the exercises become easier and less painful. You should be feeling more mobile and able to do the exercises with some speed and vigour.
Increasingly, since you will now be getting up in the morning and getting dressed, the exercises should still be undertaken in the morning before getting up and repeated when you rest in the afternoon and evening. The more you can reasonably do and progress, the faster and better your recovery and mobility will be.
From day four, you should be able to progress even further and undertake some exercises that will engage the abdominal muscles to strengthen them. This will help control the trunk, balance, help with walking, and sitting; but more importantly at this stage, it will help you move around in bed and roll over. These exercises should be started gently, slowly and the number of repetitions slowly built up to the magic number of 20.
The sixth exercise, the Knee Bend and Tuck Exercise, is a progression of the knee bend with a foot slide. You can do this exercise while lying in bed flat on your back, either under the sheets or on top. For the Knee Bend and Tuck Exercise, the knee is bent up until the heel is right up against the buttock. Then you bend the knee bend continue lifting it up off the bed and towards your chest. The movement is limited by the thigh pressing against the stomach. So it should be slowly reversed until the leg is straight again and rests flat on the bed. The exercise can be repeated by alternating your legs until eventually building up to 20 repetitions on each side. However, this may take several days. I think in my case, this was not achieved until the 6th or 7th day.
The seventh exercise in line is the Cross Knee Twist Exercise. To do this exercise, you need to bend up the knee so that the thigh is at 90 degrees to the bed, pointing upwards. Then move the leg out to the side and then slowly move over to the other side, before returning to the middle. Since this exercise is a bit tougher, you should build it up starting with 5 repetitions on each leg to 20 repetitions over the next few days. This exercise demands the stability of the pelvis and trunk muscles but also a contribution from the abdominal muscles to stabilise the pelvis. Collectively, the exercise builds strength in the lower abdominal musculature.
The eighth exercise i.e. the Cross Ankle Stretch Exercise is slightly more demanding than the Cross Knee Twist Exercise. Start by lying on your bed and raising one ankle off the sheet, keeping the leg straight. Then, move the right foot over the front of the left leg, as far as it can go and then allow it to touch the sheet before being moved back to the right and out to the side as far as it will go before again touching the sheet and then returned to the middle. This demands significant activity from the abdominal muscles to stabilise the pelvis and in order to allow the leg to swing from side to side. So, this exercise should be built up over a few days until 20 repetitions can be repeated with either leg.
Day Seven and the Second Week
As the pain and discomfort in the abdominal muscles settle over the next few days, all the exercises can be undertaken with more stretching, speed and vigour. You can also add other exercises into your routine to further activate and strengthen your abdominal wall muscles. These should be progressively added after the seventh day as discomfort and the recovery allows it.
The Cross Arm Stretch Exercise: Now the arm can be fully stretched over the front of the chest, raise the shoulder and twist the trunk and abdomen. Again, this can be repeated 20 times with each arm.
The Head Raise Exercise can be progressed further by stretching the chin further down the chest and then lifting the head, neck and shoulders off the bed.
The Cross Knee Twist Exercise can be advanced in a way that when you twist the right knee over to the left side, the knee is brought down towards the sheet and lifts the right side of the pelvis and twists the trunk and abdomen. Again, each exercise can be repeated 20 times for each leg.
Once all these exercises can be repeated three times a day without very much discomfort or trouble, it is time to get down to the gym for more intensive exercises. Going to the gym along with doing the abovementioned exercises, you should be able to return to your full fitness gradually. First, however, I will explain the progression needed in walking and gait.
Now progress to the next follow on exercises which are described in the next advice sheet “Walking is Not That Simple: Exercises to Improve Your Walking After Surgery”.
Progressing: Walking To Jogging and the Bits In Between
- The Technique of Walking
- Getting into and Out of a Chair and the Toilet
- Having a Wash or a Shower
- Improving Your Walking
- Returning to Jogging
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