One of the things that younger clinicians as well as current affiliating PTs seem to struggle with is post op rehab.
I think one of the reasons is that many of the students seemed to worried they were somehow going to negate the effects of the repair. While there are many protocols out there for various surgeries we would see post operatively, there are things you can do outside of the protocol that will still help speed recovery.
1) Use joint mobilizations to improve threat free movement of adjacent joints
- is that ACL or rotator cuff repair still in phase 1?
- not to worry, remember, there are other joints adjacent to the one that was operated on
- due to immobilization and possible inefficient movement patterns prior to surgery, the joints proximal and distal to the one that was operated on often need some novel input
- the skin around the immobilized area will often start to adhere from the prolonged immobilization
- why wait for it to scar down before you try to "break it up?"
- use light IASTM, STM, or cupping to keep the skin and general tissue mobility at a healthy state
- teach the patient and/or caregiver to do light tissue work not necessarily right around the incision but the areas in proximity to the cut
3) Pre-operative Pain Science Education
- one of the predictors for long term success for TKAs was the amount of fear avoidance they had prior to the surgery
- in other words - not necessarily strength, prior function, mobility, etc
- if you're fortunate enough to see the patient for at least one visit prior to the surgery, make sure to tell them what to expect
- discomfort or pain is a natural response
- meds will help, but may just take off the edge rather than eliminate the pain
- as soon as you're allowed to move, clinicians will get you moving
- the body and nervous system are ever changing and how you feel and move may differ from day to day, but if you graph it out, there should be overall improvement in pain and mobility as time passes
4) Don't forget to screen the uninvolved side
- make sure you check the mobility/stability of the uninvolved/uninjured side, especially in the case of ACL injuries
- not necessarily while someone is immobilized, but when they start to progress to more functional activities and exercises, don't assume the LE that was not operated on is perfect
- for an example of this - check out Gray Cook's IFOMPT Keynote from 2012, there is a motion analysis video of the SL stability of the uninvolved LE
5) Don't waste the patient's allowed visits
- this comes from my experience as a clinical peer reviewer - phase 1 is often not skilled care - for the shoulder especially
- some of the surgeons had ridiculous protocols for post op R/C repairs
- 5x/week for 1 month, then 3x/week for 3 weeks, then 2 times/weekly for 4 weeks, you get the idea
- meanwhile, no matter what someone thinks is medically necessary, the patient is only going to get a combination of what their benefit allows (20 visits give or take) and what the reviewer thinks is medically necessary prior to over utilization
- post op R/C research has shown that with or without PT in phase one, there were no significant differences in ROM or atrophy - most likely due to the micro movements a patient does in a sling vs a hard cast
- save the visits for the skilled PT, maybe 2 in the beginning to make sure they know what to expect and for baselines (also to appease the surgeon),
- the remainder of the visits should be allotted to actual skilled care, much of phase I can be completed at home without regular visit
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
Keeping it Eclectic...