Occupational rehabilitation following open mesh surgical repair of an inguinal hernia. (Case Report).

Most hernias in the groin are inguinal hernias (IHs), which require an estimated 609,000 inpatient and ambulatory surgical repairs each year. (1) Forceful lifting, coughing, sneezing, or a fall can cause a groin area hernia, because the transverse fascia and other structures located near the inguinal ring are weak and can fail to resist intra-abdominal pressure. (2-4) This weakness can result in bulging or rupture of the structures that form the floor or posterior wall of the inguinal canal. Although symptoms following an IH may vary somewhat depending on the location and extent of the injury, they typically include a sudden, sharp discomfort in the groin area, with increased intra-abdominal pressure sufficient to cause a force to be applied to the compromised area.

Surgical repair of an IH consists of either an open or a closed surgical technique. (5-7) The open technique consists of opening the inguinal canal, reducing the hernia, and reinforcing the floor of the inguinal canal with a synthetic mesh. With the closed technique, the surgeon uses a laparoscope to introduce the tools and mesh through puncture holes to reduce the herniation and reinforce the posterior wall of the inguinal canal. Surgeons commonly use both procedures, and both procedures have associated benefits and complications, although the open procedure is generally accepted as the lower-cost option. (5,8-12)

The most recent occupational injury data available indicate that 29,200 hernia injuries that involved days away from work were reported in 2000. (13) Occupational groups with the highest risk of work-related hernias are laborers/handlers and mechanics/repairers (ie, employment where heavy manual labor is a large component of the job). (14) Several reports have demonstrated the effectiveness of occupational rehabilitation in work-related cases of low back pain (15,16) and upper-extremity disorders (17); however, we found no studies published in the last 30 years that examined the effectiveness of rehabilitation following a surgical repair for a work-related hernia. This lack of research is important, because the major cost of IHs that require surgical repair is the patient's postoperative inability to return to work. (18) Since 1998, the Occupational Medicine Department at the New England Baptist Hospital (NEBH) has been using an occupational rehabilitation approach with patients referred following surgery for a work-related IH. The purpose of this case report is to describe the occupational rehabilitation program of a person whose work-related IH was surgically repaired. This person was not exceptional but typifies patients most often seen in the program.

Case Description

Patient

The patient was a 35-year-old, left-handed man employed by a major airline as a baggage service attendant. The patient had sudden right groin pain while lifting a heavy suitcase onto a conveyor belt. After examination by the airline health service agent, the patient was referred to a general surgeon. During the initial visit, the general surgeon described the patient as having right groin pain aggravated by exertion. A general medical screening questionnaire at the time of his initial examination indicated a right IH 5 years previously, which was repaired using an open procedure without residual deficits. The questionnaire did not indicate any other relevant problems in the patient's medical history.

A standard maneuver used during physical examination is a digital palpation technique, in which the examiner feels the floor of the inguinal canal for an increase in pressure known as an impulse. (19) The surgeon felt an impulse in the right inguinal canal and noted increased sensitivity in this area. He diagnosed a right IH and prescribed anti-inflammatory medication (ibuprofen, 400 mg) 4 times a day. The surgeon advised the patient to rest and not to return to work, and instructed him to return in 1 week for re-evaluation. Against the recommendations of the surgeon, the patient returned to full-duty work after a few days, when the patient said he "felt better." Upon re-evaluation, the surgeon, noting the patient's early return to work, removed any work restrictions and discontinued the patient's use of anti-inflammatory medication. Two weeks later, the patient's right groin pain returned while at work. At this time, 9 weeks since the initial injury, the patient decided to undergo open mesh surgical repair of his IH.

Examination and Evaluation

On the sixth postoperative day (POD), the surgeon referred the patient for physical therapist examination and intervention. Initially, the patient reported having difficulty walking longer than 15 minutes and lifting a 4.5-kg (10-lb) laundry basket from the floor to his waist. He also said he had "tingling" in the anterior groin area and a "pulling" sensation in the same region when lifting objects. A job requirements assessment obtained from the patient indicated that, in his work, he needed to be able to lift a maximum of 40.5 kg (90 lb) and frequently lifted 22.5 kg (50 lb). The patient reported that he was often required to carry the 22.5-kg load a distance of 15 m (50 ft). The patient also said that he often had to walk up inclined surfaces at his workplace. The patient's work schedule was a normal 5-day, 40-hour workweek with occasional overtime of up to 5 hours per week. The patient was out of work, and light duty was not available in his work environment.

Although no reliability measurements were performed prior to reporting this case report, the same therapist took all measurements in the same manner in an attempt to reduce measurement error. During the physical examination, the patient's right hip flexion was rated 3+/5 and his trunk flexion was rated 3+/5, using manual muscle testing as described by Hislop and Montgomery. (20) All other measurements of the hip joints and trunk muscles were 5/5. All other motions at the hip and trunk, including a supine straight leg raise, ((21)(pp38-45) were within normal limits. The patient demonstrated a positive Thomas test ((22)p482) bilaterally, with 8 degrees of hip flexion on the left and 15 degrees on the right. (23) (Fig. 1A). Postural assessment indicated that the patient had an anterior pelvic tilt bilaterally with a mild lumbar lordosis. ((21)pp71-116)

[FIGURE 1 OMITTED]

The patient was able to perform a full squat 3 times. His lifting tolerance was limited to one floor-to-waist lift of a box weighing 4.5 kg. While raising the 20.3- x 38.1-cm (8- x 15-in) box, the patient reported a sensation that he characterized as "pulling in my groin." Following a treadmill assessment using a modified Bruce Protocol of 0.75 m/s (1.7 mph) at a O-degree incline, (24) the patient reported right anterior groin pain with hip extension during the late stance phase of gait, and the test was stopped at 1 minute 30 seconds. The modified Bruce protocol was used to assess the patient's ability to walk up a ramp because it is a standardized test incorporating varying speeds and inclines on a treadmill.

Evaluation of the initial examination data indicated that the patient had impaired muscle force, impaired ambulation, and a decreased ability to return to work due to the limited lifting tolerance. The condition of the patient was typical of that of other patients seen in the past following their IH surgery who returned to full-time, full-capacity work following an occupational rehabilitation approach. For this reason, we expected the patient would recover fully, and a physical therapy program was begun with an expectation that the patient would require up to 12 additional visits before he was ready to return to his job.

Intervention

The protocol that NEBH uses with patients following open surgery for IH is shown in Figure 2. Although the protocol is the recommended pathway, the intervention for each patient may be individually adjusted, based on the patient's condition and response to the intervention. Patients normally have physical therapy for 60 to 90 minutes, 2 to 3 times per week, for up to 6 weeks before re-examination. If a patient reports adverse symptoms during the intervention, it is discontinued and the patient is referred to a physician. The adverse symptoms include a sudden onset of pain or swelling, particularly if it is in the area of the surgery, and any radiating pain into the ipsilateral testicle, which may indicate nerve entrapment. Progression through the IH protocol typically follows the pathway as indicated; however, adjustments are made for patients who progress at faster or slower rates.

[FIGURE 2 OMITTED]

Following the initial examination, the patient was instructed in a home exercise program (HEP). The HEP consisted of a hip flexor stretch in the half-kneeling position, maintaining a neutral spine as the patient shifted his weight forward (Fig. 1B). Passive stretching has been demonstrated to improve the hip extension range of motion necessary for limb motion during terminal stance phase of gait without changes in gait economy. (25) The patient was shown where he should feel the stretch, was instructed to hold each stretch for 1 minute, and was asked to perform 3 repetitions of the stretch twice a day, based on the stretching duration recommendations of Moller et al. (26) The patient demonstrated the HEP in the clinic with good body mechanics prior to commencement at home. The HEP was reviewed for correctness throughout the course of the treatment.

The interventions for the patient's 5 visits following the initial evaluation are listed in the Table. The patient performed treadmill exercise to improve his walking tolerance. The treadmill incline angle was progressively increased to 15% because the patient had indicated that ambulation up inclines was required for his job. Manual stretching by the therapist was performed in the clinic at each visit using a modified Thomas test position (27) with manual pressure applied in a downward direction just superior to the patella to reinforce the HEP. Strengthening exercises to improve the patient's trunk flexion were chosen based on the surface electromyography (sEMG) findings of trunk and lower abdominal muscle performance during the sit-up activity. (28-31) In a comparison of several variants of abdominal exercises, Konrad et al (28) and Godfrey et al (29) demonstrated that hook-lying abdominal crunches (HLACs), otherwise known as flexed knee sit-ups, were the most effective exercise positions for generating peak activation and greatest duration of activity in the abdominal muscles. In addition, rotating the trunk during HLACs has been demonstrated by sEMG to be an effective exercise for strengthening the rectus abdominis and oblique muscles while minimizing the degree of lumbar flexion. (30) In an attempt to improve strengthening exercise targeted at the lower abdominal area, the patient also did HLACs with the lower extremities abducted and with the lower extremities supported on a 65-cm-diameter ball. Vera-Garcia et al (31) demonstrated that performing abdominal muscle activities with the lower extremities supported on a movable surface resulted in a higher demand on motor control and muscle activation than more stable positions. The use of a seated abdominal exercise machine allowed the patient to add variable resistance, within tolerance, to the exercise effort (Fig. 1C). Each of the HLAC exercises was performed making sure that the patient's scapulae cleared the mat during the "crunching" component.

To address the functional component of the patient's job, he performed simulated tasks requiring repetitive lifting and maximum lifting. These activities required him to lift boxes with both upper extremities as the repetitions and the weight of the boxes increased. As the patient's tolerance for lifting improved, lifting was progressed to include carrying the object for progressively longer distances to simulate the act of lifting and carrying suitcases. All exercises and stretching were increased within the patient's tolerance. Beginning with the patient's second visit (POD 11), he reported less "tingling" in his anterior groin region and less discomfort in his abdominal area. At the time of discharge, the patient was without symptoms of discomfort in the area of injury and surgical repair.

Outcomes

During the patient's sixth and final visit (POD 22), he was re-examined. At the conclusion of 7 total visits (initial examination and evaluation, 5 physical therapy sessions, and one final visit to assess the patient's status following intervention), the patient had achieved all goals and outcomes, thus leading to an early discharge. The patient had 30 degrees of hip extension and a negative Thomas test (22) bilaterally. Abdominal and hip flexion muscle force was rated as 5/5, using a manual muscle test. (2(1)pp146-176) The patient tolerated treadmill ambulation at 1.32 m/s (3.0 mph) at a 15-degree incline for 15 minutes without observable gait abnormalities. He was able to simulate performance of his normal work activities using proper body mechanics without discomfort. For job simulation tasks, the patient's single maximum lifting capacity was 41.9 kg (93 lb) using a Baltimore Therapeutic Equipment Co (BTE) work simulator * (Fig. 1D). His repetitive lifting capacity was 36 kg (80 lb), which he could tolerate for 10 repetitions carrying the weight each time for 30 m (100 ft) without adverse symptoms. The patient was discharged at this time because he was pain-free, no longer exhibited any impairments or functional limitations, and was cleared by his surgeon to begin full-capacity work. At a 1-year follow-up, the patient had remained at work full-time since his discharge from physical therapy.

The fees for this patient with a work-related IH illustrate the total cost of management to return him to full-time, full-duty employment. The total cost of the physician visits and surgery was $3,174.96. The cost for physical therapy--examination and evaluation, 5 intervention visits, and one discharge visit--was $600.43. Beginning with the day of his surgery, the patient missed 19 workdays, during which he received workers' compensation at 60% of his salary. While the patient was off work, the employer paid a replacement baggage handler a full-time salary plus benefits. Although the cost for the physician and physical therapy services are relatively fixed, the costs for paying the injured and replacement workers are unfixed costs determined by the number of days missed from work.

Discussion

This case report describes occupational rehabilitation for a patient with a work-related IH and subsequent surgery who returned to full-duty employment following intervention. Occupational rehabilitation, as described by the American Physical Therapy Association, (32) involves examination and intervention for any person with work-related impairment, functional limitations, disabilities, or other health-related conditions that prevent performance of an occupation and is clearly within the scope of practice of physical therapists. AS Hart et al (33) explained, occupational rehabilitation should be based on identification of a worker's functional capacity "to determine what the individual can do at work on a safe and dependable basis." This case report illustrates the need to examine patients following IH repairs for impairments in muscle force, flexibility, normal functional abilities, and work-related activities such as lifting.

Health care commissioners often look to all costs related to the injury in determining which treatment programs to endorse. (34) Cost-effectiveness includes not only the surgical procedure but also factors such as quality of life and the health economics associated with work replacement and reimbursements following a worksite injury. (35) Although the individual contribution of surgery or rehabilitation to the patient's overall recovery cannot be identified, several points can be made supporting the cost-effectiveness of combining them together. First, our patient's IH was repaired using the open mesh surgical procedure, previously mentioned as a less costly technique for repairing an IH. (5,8-12) Second, we believe that the choice for postoperative occupational rehabilitation can reduce the amount of time that is required to return a worker to premorbid work activity. Twenty-two days after surgery, the patient in this case report had returned to full-time, full-duty work capacity following physical therapy that focused on an occupational rehabilitation approach. As a source of comparison, Salcedo-Wasicek and Thirlby (36) have shown that patients with work-related hernias, repaired using an open procedure, averaged 33.5 [+ or -] 4.6 (mean [+ or -] SE) days off work. Although this case report supports the use of the open mesh surgical procedure followed by occupational rehabilitation, research is needed to determine whether this is a cost-effective option for all patients with work-related IHs.

A partial explanation for the lack of literature related to rehabilitation of patients with IHs may be the difficulty in correctly diagnosing a groin injury. (2-4) Considering the many structures in the groin area and variety of alternative injuries that can occur in the groin area, postoperative interventions are often vague and the course of rehabilitation can be difficult to determine. (37) We believe that the goal of the rehabilitation protocol, regardless of the etiology, should be for the patient to safely and completely return to work-related activities.

The protocol that we presented is the result of a 4-year history of physical therapy for patients who have undergone surgery to repair work-related hernias using an open mesh surgical repair method. We presented this case not as a unique case but as an example of deficits typically seen in patients following IH surgery and of the intervention and the recovery that follows. Research is needed, however, to determine the effectiveness of our occupational rehabilitation approach.

Table.
Treatment Program (a)

                                      Strengthening
                          Stretching
            Ambulation    (Number x   Sets x
Visit  POD  Training (b)  Time) (c)   Repetitions  Exercise

1      8    1.19 m/s      3x1min      3x8          HLACs
              (2.7 mph),              3x8          HLACs with LE
              0[degrees]                             abduction in
              incline                                ~30[degrees]
                                      3x8          Seated abdominal
                                                     weight machine
                                                     with 15.8 kg
                                                     (35 lb)
2      11   1.32 m/s      3x1min      3x5          HLACs
              (3.0 mph),              3x15         HLACs with LE
              0[degrees]                             abduction in
              incline                                ~30[degrees]
                                      3x8          Seated abdominal
                                                     weight machine
                                                     with 20.3 kg
                                                     (45 lb)
                                      3x8          HLACs with Les
                                                     on a 65-cm-
                                                     diameter
                                                     (25.6-in) ball
3      14   1.32 m/s      3x1min      3x8          In hook-lying,
              (3.0 mph),                             alternate
              5[degrees]                             elbow to
              incline                                opposite
                                                     knee
                                      3x15         HLACs
                                      3x20         HLACs with LE
                                                     abduction in
                                                     ~30[degrees]
                                      3x12         Seated abdominal
                                                     weight machine
                                                     with 20.3 kg
                                                     (45 lb)
4      15   1.32 m/s      3x1min      3x8          In hook-lying,
              (3.0 mph),                             alternate
              10[degrees]                            elbow to
              incline                                opposite
                                                     knee
                                      3x15         HLACs
                                      3x20         HLACs with LE
                                                     abduction in
                                                     ~30[degrees]
                                      3x12         Seated abdominal
                                                     weight machine
                                                     with 20.3 kg
                                                     (45 lb)
5      17   1.32 m/s      3x1min      3x12         In hook-lying,
              (3.0 mph),                             alternate
              12[degrees]                            elbow to
              incline                                opposite
                                                     knee
                                      3x15         HLACs
                                      3x20         HLACs with LE
                                                     abduction in
                                                     ~30[degrees]
                                      3x12         Seated abdominal
                                                     weight machine
                                                     with 20.3 kg
                                                     (45 lb)

            Job Simulation

Visit  POD  RLT              MLC

1      8    9-kg (20-lb)     Unable to completely lift
              box, 1 x 10     11.3-kg (25-1b) box
                              due to pain

2      11   15.8-kg (35-1b)  18 kg (40 lb)
              box, 2 x 10
                             Carried 9 kg (20 lb) for
                              6 m (20 ft) in right
                              UE, then left UE--to
                              simulate carrying a
                              suitcase--without symptoms

3      14   20.3-kg (45-1b)  24.8 kg (55 lb)
              box, 1x8

4      15   22.5-kg (50-lb)  24.8 kg (55 lb)
              box, 1 x 10
                             Carried 22.5 kg (50 lb)
                              for 30 m (100 ft)
                              without symptoms

5      17   31.5-kg (70-lb)  40.5 kg (90 lb)
              box, 1 x 10
                             Carried 31.5 kg (70 lb)
                              for 30 m (100 ft)
                              without symptoms

(a) POD=postoperative day, RLT=repetitive lifting tolerance,
MLC=maximum lifting capacity, HLACs=hook-lying abdominal
crunches, LE=lower extremity, UE=upper extremity.

(b) Ambulation training lasted 15 min.

(c) Stretching consisted of manual stretching of both
lower extremities in a modified Thomas test position.

* Baltimore Therapeutic Equipment Co, 7455-L New Ridge Rd, Hanover, MD 21076.

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KE Pesaneili, PT, MS, is Physical Therapist, Occupational Medicine Department, New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120 (USA) ([e-mail]). Address all correspondence to Ms Pesanelli.

JA Cigna, PT, PhD, is Assistant Clinical Professor, Department of Physical Therapy, Bouve College of Health Sciences, Northeastern University, Boston, Mass, and Physical Therapist, New England Baptist Hospital.

SG Basu, MD, FACS, is General Surgeon, Department of Surgery, New England Baptist Hospital.

AR Morin, PT, MS, is Staff Physical Therapist, North Shore Medical Center, Salem, Mass.

All authors provided writing and consultation (including review of manuscript before submission). Ms Pesanelli, Dr Cigna, and Dr Basu provided concept/project design. Ms Pesanelli and Dr Cigna provided data collection. Dr Cigna provided data analysis and project management. Dr Basu provided subjects. Ms Pesanelli and Dr Basu provided facilities/equipment. Ms Pesanelli provided institutional liaisons. Mr Morin provided clerical support.

The Institutional Review Board of the New England Baptist Hospital and the Institutional Compliance Division at Northeastern University approved this case report. The subject read and signed an informed consent statement allowing the authors to present the findings of his case.

This article was submitted September 21, 2001, and was accepted July 4, 2002.