Surgical Protocols: Guidelines Or Suggestions?
As research into surgical procedures, techniques and equipment improves it is only natural to question and challenge post operative protocols as we know them. There is evidence as far back as the early 90s favoring accelerated ACL protocols including more aggressive range of motion and weight-bearing progressions which lead to more rapid increases in function, and return to strength more quickly in patients who underwent the procedure. There is growing evidence of similar outcomes for Achilles Reconstruction, Rotator Cuff Repair and Joint Replacement surgeries as well. But how do we decide who would benefit the most from these accelerated protocols? Furthermore, with so many different preferences and protocols (much of which are MD specific), how can we keep track and make sure we are both progressing our patients safely while at the same time respecting the wishes of the physician?
Each week it seems we can read a prescription such as "L Knee Surgery" or "R RTC Repair" and think - is there anything else I should know? Too often we assume that everything was routine with these procedures, particularly as we continue to see them more and more frequently. I recall in one instance a simple meniscal surgery actually turned out to be a repair with microfracture to a large chondral lesion on the medial condyle. All of which would never have been known from reading the prescription of "L Knee Meniscus Sx" (It did not even say medial or lateral!). The subjective and objective measures of the patient just did not add up which prompted a phone call over the MD for clarification revealing the additional procedures. So who would receive the blame if that patient did not recover or return to their prior level of function? Was it our fault for not asking the right questions or taking the time for a simple phone call to an MD, or is the MD who wrote the prescription liable for not providing the information in the first place? It is a scary thing to consider and perhaps the answer is neither and unfortunately that patient is simply placed in the category of "failed" rehab. Just another story of a person who was never quite the same after surgery. When there is communication break down in the healthcare field it makes it that much harder to give proper care to patients. What if we asked a few simple questions with EVERY post op patient, such as: The SPECIFIC mechanism that caused the injury? The TYPE of technique that was used? The QUALITY of the tissue being repaired? The FIXATION of the screws/anchors/sutures? Lastly, what are the GOALS of the patient? How does the patient FEEL about the surgery?
In a recent discussion with an MD he seemed surprised I asked the question what his preferred technique for rotator cuff repairs was. It lead to a discussion of accelerated versus delayed healing, treatment progressions and ended with an exchange of business cards. Not everyone will fit into an accelerated protocol, not everyone will fit into a classical protocol, and still not everyone will fit into a delayed protocol. Each patient is different, each surgery is different, but by utilizing protocols we can remain accountable and keep an eye out for red flags. Treatment does not change - only expectation. Most accelerated protocols show improvements in pain and range of motion earlier in the rehab process, but not much significant difference in long term outcomes. Utilization of protocols will allow us to know when to be more aggressive or when we have time to pump the brakes or space out treatment. We have all dealt with insurance limitations before - how can we get ANYONE better in 6-8 visits following a major surgery? Some of the answer may lie in breaking from the traditional "2-3x per week for 6-8 week" mind set. If we compare objective measures for our patients and see they are demonstrating measures consistent with a "Week 4" rehab protocol why continue to see them for 2-3x per week up until that point and use visits that could have been saved? The same principle can be used for initiating strength training - if a patient demonstrates adequate control of manual muscle testing then progressing more quickly to functional strengthening seems to make clinical sense. Clinical judgement in my opinion is more important then any protocol that can be researched. Understanding that healing tissues require controlled force and input to re-organize properly, and that adjacent joints will directly be impacted is critical in addressing during the recovery process. After the operation is complete orthopedists will always move the joint around in each plane and check for integrity - they have to right? So why is it when the patient opens their eyes the "protocols" dominate our thought process? If I do not sense apprehension with movement, tissue tension, or pain is it wrong to assess a joint past the suggested ranges for that time period? I would say no, but at the same time I can caution a patient on the healing process and things that they should MODIFY not ELIMINATE. So in that regard I feel that protocols are not designed to be these hard and fast rigid "rules" - just think if you would let your patient initiate a running or throwing program simply because they hit a certain day, if they still had an extensor lag or lacked 30 degrees of full external rotation.
Some helpful tips to consider when dealing with post operative patients:
-Do not be afraid to call the MD if you have questions
-Do not be embarrassed if you are unfamiliar with the technique. Consider the safest options you can review or evaluate with a patient at the first visit and go home and do some research!
-When in doubt about a protocol (such as multiple structures being repaired) follow the MOST conservative. Then you know you will not be stressing the other tissues to much
-Set realistic expectations at day 1 with your patients. Unless you are very lucky you are likely not rehabbing Adrian Peterson. Our patients have jobs, lives and 1 million other things going on besides their rehab. Getting everyone back to sport in under 6 months just may not be realistic given the situation.
-Do not be afraid to progress! Trust your instincts
-Have the patient EARN the right to progress. Usually the first question I got with EVERY ACL is "When can I run again?". My answer is always "Let's get your knee straight first."
-Range of motion is TIME limited - Strength is NOT. Strength protocols can start at any time, but once we lose range of motion it is much harder to get back. (Think Gray Cook's "Mobility before Stability")
-Have a team approach. With insurance limitations, poor compliance rates, etc have a trainer or someone you can trust that will continue your discharge process with your patients if you cannot.
How do you deal with surgical protocols? Have you had different MDs think very differently? How do you utilize protocols into patient education and establishing expectations going forward?
Thanks for reading, until next time, happy rehabbing!