Guest Post: Accelerated Rehabilitation Protocols – The Good, The Bad, and the Ugly | Modern Manual Therapy Blog

Guest Post: Accelerated Rehabilitation Protocols – The Good, The Bad, and the Ugly


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so obvious is the fact that developing accelerated protocols means we are questioning the older, assumed (and possibly outdated) protocols.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...

2 comments:

  1. I personally am not a big fan of "protocols" at all. I agree with you that, at the most, they are intended to be guides, not requirements. However, I feel that in many cases surgeons send over their protocol because that's how they want things done, and the majority of PT's are afraid to do something other than what the surgeon has requested. In reality, protocols are just a cookbook for rehabilitation (something that many PT's now realize is a bad thing), and may not work for all patients the same way. I am of the opinion that we need to abandon the cookbook medicine and get rid of protocols. Using evidence based guidelines we can determine the best possible interventions for a given condition, and then apply them based on the status of the patients tissues. Additionally, there is no reason a surgeon should ever prescribe the PT protocol. This would be equivalent to a physical therapist selecting the appropriate surgical approach. Surgeons are not trained, or licensed to do physical therapy, and when they send a protocol it simply signals a lack of respect for the physical therapist they are working with. I have abandoned protocols altogether, and rather simply follow evidence based guidelines. A protocol (even when evidence based) is just a recipe in a cookbook, and they can often be inflexible when used by less educated or assertive PT's who just want to please the surgeons they work with.

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  2. Let me first say that the reason I wanted to write a little something about protocols is because there are plenty of clinicians out there who, like you mentioned, act like a robot when they get them and I wanted to get clinicians to start questioning them (unfortunately those clinicians probably don't read blogs like this).

    Now, I completely agree with what you said and, just like you, have a hard time having a surgeon tell me how to do PT (I don't think they would take too kindly to us telling them how to perform surgery). I usually find protocols from surgeons to be somewhat comical as they recommend outdated, basic PT treatment ideas. If I get a protocol from a patient/surgeon, I glance over it quickly just to get an idea of the surgeon's mentality (and usually get a good chuckle) and then evaluate the patient and come up with my plan. Like you said, PTs are well aware of tissue healing and how to treat post-op patients. Another reason I quickly glance over a protocol is so that I can educate/coach my patient on what to tell the surgeon they are/aren't doing when they go for a check-up (sad, but true). Also, it is rather scary how many surgeons have no idea what their own protocols say - typically because they just copied them out of a book.

    I don't think that we can just flat out abandon protocols though, instead my recommendation is that we should make up "Milestones" for each surgical procedure. I would much rather a surgeon say in 6 weeks I would like this patient to achieve ABC and by 12 weeks, XYZ, and then we, as PTs, can get them there by using our individual toolset. For example: Milestones after ACL reconstruction: discharge crutches 3 days after surgery, discharge brace no later than 4 weeks, ambulate with normal gait (without brace) by 4 weeks, have symmetrical knee extension (assuming uninvolved has no issues) and 90% of knee flexion by 4 weeks and so on.

    Like every other profession out there, the bad ones ruin it for all the good ones and there will always need to be some form of guidance from the surgeon's perspective as they don't always know what type of PT the patient is seeing.

    Thanks for reading and taking the time to comment.

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