PT developed post operative protocols?

Other Discussions Pain Science & Rehab Discussion
1

What thoughts do PTs have about poster op protocols developed by surgeons? I know that is important to have surgeon input since they know more about their procedure and its strengths and weaknesses. However when a surgeon does have a protocol they often seem outdated and poorly adhered to by therapists and surgeons themselves. Does any have any thoughts about PT developed protocols? (It think Mike Reinold has some but they are full of manual therapy, modalities, questionable exercises) Does anyone want to discuss/develop some as guidelines here since we are more similar in our thinking in a way that also doesn’t align very well with standard practice?

Some I would be interested in are:
rotator cuff repairs
TKA
THA
ACL
Achilles tendon repair
TSA/RTSA

Or would anyone be open to theoretical discussion of rehabilitation principles at least?

2

I’m open to discuss this topic. The idea of protocols is one not discussed enough.

3

That is how I feel. It seems physicians sometimes send some smorgasbord of exercises that many times don’t make sense with regards to muscle activity. They are usually outdated. And most PTs do not follow them. I think some general restrictions/precautions like with total hips from the surgeon is what would serve rehab professionals the best. Then let the rehab profession decide on a protocol as long as it is in agreement with the precautions. Then have the rehab professionals develop a protocol that has pt.'s moving along the same expected direction and pace until for some reason the pt. proves they are different (special snowflake). I think this would help us with research and outcome projections.

4

Like you, I have seen numerous protocols. From what I’ve seen, surgeon specific protocols are very generic and follow simple tissue load tolerance progression (i.e. PROM s/p RTC repair 4-6 weeks, progressing to AAROM and AROM at 6-8 weeks) based on the surgical procedure. Those are great. Simple and based on tissue healing timeframes.

When I get protocols that physical therapists helped create, things get overly complicated with countless, non-evidence, opinion informed options: manual therapies, glides, overly specific silly exercises, “proprioceptive” “rhythmic stabilization” etc.

For any condition, there is no “protocol” for rehabilitation. That’s the “art” part. I say keep it simple. Tissue protection based on procedure, patient history/comorbids/lifestyle factors. After a period of relative protection, gradual loading to tolerance.

Happy to hear your thoughts.

5

Matt,

Totally agree and that is why I’m here. I think a simplified but slightly more specific protocol could be helpful for some of us that would like to minimize/eliminate the complicated, non-evidence informed options. Starting with a rotator cuff repair for discussion/example.

My simple rotator cuff “protocol” (maybe too simple)

Weeks 0-2: sling use complete protection, reduce pain and allow inflammatory stage to run its course

Weeks 2-6:
multidirection pendulums every 1-2 hours or as much as tolerated
multidirection PROM to tolerance (produce, no worse in MDT language)

Weeks 6-8:
continue pendulums and PROM
pulleys 1-2 times per day for about 5 minutes to tolerance (produce, no worse)
supine AAROM flexion to tolerance x 10-20, 4-6 times per day up to every 1-2 hours
shoulder isometrics x 5-10s x 10, 2-4 times per day

Weeks 8+:
AAROM to AROM to resisted AROM in all planes
general shoulder, upper back, upper arm strengthening to tolerance (perhaps daily, perhaps more in line with general strength training 2-4x/week)
add velocity as indicated per patient goals and tolerance

What do you all think? That is generally what I think gives you the most bang for your buck. It includes no joint mobilization, no soft tissue work, and no specific motor control exercises. Are there things that should be added, removed, or timelines changed?

I definitely agree there is some “art” to our profession but I think a starting point is good to have.

6

There are some factors to keep in mind with regards to a procedure like a rotator cuff repair. The procedure itself can be effective but structural failures are not uncommon. This can be further complicated when paired this with patient co-morbidities and related factors (age, smoking, diabetic, etc). Interestingly, structural failure does not seem to lead to poorer functional outcomes. Failure typically occurs within 3-6 months so protection is important. Recent literature suggests early mobilization may increase the risk of failure (though not be much) without additive benefit. It doesn’t seem early mobilization improves outcomes and it doesn’t seem longer immobilization worsens outcomes.

A recent consensus (cited below) suggested strict immobilization for 2 weeks, followed by protective PROM and gradual increase to AROM at 6 weeks and progressive loading at 12 weeks. The authors acknowledge their opinion and reference surgeons and scientists standing by a 6 week strict immobilization period.

There are a number a references that look at EMG (which has its limitations) activity for pendulums, ADL’s and specific exercises on the rotator cuff. I think a clinician rehabbing post-operative shoulders should have a basic understanding of movements and activities that load the rotator cuff. They can then make informed decisions on application of loading in the clinic. Pair this with progressive overload and specificity and I think a rehab professional has done what they can to help with a positive outcome.

Thigpen, Charles A., et al. “The American Society of Shoulder and Elbow Therapists’ consensus statement on rehabilitation following arthroscopic rotator cuff repair.” Journal of shoulder and elbow surgery 25.4 (2016): 521-535.

Reinold, Michael M., et al. “Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes, part 2: injury prevention and treatment.” Sports Health 2.2 (2010): 101-115.

Long, Joy L., et al. “Activation of the shoulder musculature during pendulum exercises and light activities.” journal of orthopaedic & sports physical therapy 40.4 (2010): 230-237.

Murphy, Cynthia A., et al. “Electromyographic analysis of the rotator cuff in postoperative shoulder patients during passive rehabilitation exercises.” Journal of shoulder and elbow surgery 22.1 (2013): 102-107.

Uhl, Timothy L., Tiffany A. Muir, and Laura Lawson. “Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises.” PM&R 2.2 (2010): 132-141.

7

I have been looking to design a protocol to present to some local surgeons we work closely with and this is very helpful information!

8

Floydd,

I do have a question on your protocol. It’s one I pose to a lot of PT’s and students.

Why do we ask patients to do “strengthening” (using that term lightly). exercises daily? Range of motion I can understand, but there comes a time where many patients are prescribed “strengthening” exercises daily, multiple times per day (i.e. 2 x 10; 3-5x/day).

My question is why not have the patient perform ADL’s to tolerance (brushing hair, teeth, reaching to cabinet, etc; higher frequency low resistance movements), but performed a structure resistance program no differently than standard principles?

9

Truly appreciate the discussion and the references. This is all a work in progress for me and I appreciate the input from more experienced therapists that at least have some similar beliefs.

As for the strengthening question. I have not decided which is best. I ask the same question all the time with therapists and with myself with just about every exercise I prescribe. I experiment with both.

When I use daily or multiple time per day strengthening I make that decision with the rationale that the stress is so low from each session that an increase in frequency may be beneficial until the stress becomes greater. I also wonder if you start with low stress and high frequency if you may be able to maintain high frequency even if stress gradually increases. A bricklayer who does no other “strength and conditioning” is often stronger than an office worker who does no other “strength and conditioning” and he “works out” everyday at his job. I will also utilize more frequent “strengthening” to simply encourage increased activity or decrease pain perception. I think of “Squat Everyday” when I prescribe high frequency strengthening. PRs are not set every day.

When I prescribe a more traditional strength and conditioning program I justify it with the rationale of higher stress needing longer recovery time or that the patient is sufficiently active on their own with other activities. I stress a higher percentage of sessions setting PRs.

Unless completely contraindicated due to stage of healing or examination findings ADLs are always to tolerance. But many patients cannot perform ADLs so increasing duration or “intensity” is not possible so “assistance” exercises are needed to drive progress in ADLs.

10

That’s the difficulty with “protocols.” There is no cookbook recipe and patients all differ in age, background, medical history, etc etc. The best you can do is monitor/track progress (subjective report, objective measures, self-report measures) to drive practice. I can say as years go by, I have patients doing less and promote a very basic gradual return to activity. Most folks I see could care less about “training” thus my “less in more” approach. In many cases basic return to ADL’s is what they are looking for. For those wanting more, an initiation of basic strength training gets them on track.

11

I’m all about less is more and individualizing rehab when necessary but there has to be a starting point, for at least a few reasons.

  1. Less experienced clinicians need something to start with.
  2. We need some standardization to improve research and its application to clinical practice.
  3. So we can give patients a more accurate prognosis early in rehab/pre-surgical counseling.
12

My thoughts on your list.

1.The starting point is immobilization to protect the repair/sutures/tissues. It appears based on the evidence you can mobilize earlier (1-2 weeks), but the benefit does not exceed longer immobilization periods (6 weeks). When initiating movement, performing activities placing low stresses on the repair (PROM, pendulums, table slides). After a period of protection (4-6 weeks), progressing from low load isometrics, AAROM to AROM to isotonic progressive overload

  1. What specific question are you looking to answer when you say we need some standardization to improve research? To me, this is enough standardization. I’m content if a surgeon places specific duration on the phases. They did the procedure and understand the tissue quality well enough to make that determination.

  2. As far as prognosis goes, I’d say there is plenty of evidence out there to counsel patients.

13

  1. So basically error on the side of caution for 6 weeks. Then slowly increase load as tolerated.

  2. I was more talking about within PT. I am surrounded by manual therapy, stabilization, scapulohumeral rhythm exercises every day. Do I need these? It seems you are saying the research says no. Is that correct?

  3. Alright I’ll keep trying to learn.

14

Hi Floydd,

I’d say number 1 about covers it. Some gradual, best tolerated range of motion may be indicated as well, but that could be up for debate to the philosophical types. Most post-op rehab programs consist of some form of range of motion: PROM/AAROM/AROM leading to progressive strengthening.

Number 2 would be harder to answer. It would require a specific RCT that answer the question. I don’t know if we can answer that question as it relates to post-op rehab in current state. My bias is no and I take that from the literature suggesting a scapular based exercise program is no better than a RTC program for shoulder pain or function. Of course this research is for generalized shoulder pain (tendonopathy/etc). The use of exercise or manual therapy does not alter or change scapulohumeral rhythm. Scapulohumeral rhythm has little to no relevance to shoulder symptoms. It’s more likely a response to pain than anything else. The effects of manual therapy (to the neck, shoulder or scapula) are unimpressive to me and at best, provide little to no additional value when added to or compared to active interventions.

Interested in other’s thoughts…