For some surgical procedures, in addition to having the
typical rehabilitation protocol, there are “accelerated rehabilitation
protocols.” While there are benefits to
these protocols, there are some possible pitfalls to them as well.
The Good
First, let’s discuss the obvious one – with
clinicians/physicians recognizing that some patients can be progressed quicker
than the usual protocols suggest, this leads to a faster recovery and quicker return
to their desired sport/activity.
The not so obvious is the fact that developing accelerated
protocols means we are questioning the older, assumed (and possibly outdated)
protocols. Nothing bothers me more in
the medical community (or really any field) when a question is asked about why
something is done a certain way and the person answers with, “Because that’s
just how it’s always been done” or “Because everyone else does it that way.” I bet that many of our typical, current
protocols were thought of as accelerated (and potentially even dangerous) years
ago. Some of the modifications to older
rehab protocols came about when doctors would find that non-compliant patients
were doing fine and progressing quicker than typical patients.
The Bad
The thing that bothers me most about accelerated protocols
is how we choose to use them. Typically
they seem to be used by basing it on a patient’s prior fitness level and this can
put you down a dangerous road. Instead,
implementing them should be based on the quality of the surgical procedure. Using an accelerated protocol should be based
upon the weakest link of the surgery performed – usually this is some type of
fixation. If that weakest link isn’t really
that “weak,” then it is appropriate to use those protocols.
If a super-freak athlete has a poor quality, tenuous
achilles tendon repair, we shouldn’t be trying to go at an accelerated pace. He’ll probably be able to move around better
than your average patient, but you don’t want to over-stress that weak repair
(admittedly, throttling back on these patients can be challenging). And if a middle-aged weekend golfer has a
partial rotator cuff repair that required fewer sutures than usual and had good
tendon quality, an accelerated protocol may be appropriate.
Another issue is thinking that because the patient has been
deemed appropriate for an accelerated rehab you can go full-throttle on them all
the time. Protocols are there to be a guide, not requirements; “listen” to your
patients’ body’s response and progress patients accordingly - use joint
soreness rules, effusion, end-feels, etc. as reasons for progressing – not just
what a piece of paper says.
The Ugly
Would be a combination of all “the bad” with a below-average,
yet cocky therapist (if you read this blog regularly, you probably aren’t one
of them, but we all know they’re out there).
Somebody like that using an accelerated protocol on the wrong patient
and going full-steam ahead while putting caution to the wind is a recipe for
disaster.
What are your thoughts on accelerated rehab protocols?
Contributed by Dr. Dennis Treubig, PT, DPT, SCS, CSCS
Keeping it Eclectic...
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