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so obvious is the fact that developing accelerated protocols means we are questioning the older, assumed (and possibly outdated) protocols.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