How to Progress Post Op Patients Part 2 | Modern Manual Therapy Blog

How to Progress Post Op Patients Part 2


Part 1 of this post can be found here.
Ther-Ex

For the sake of this article, I’ll consider ther-ex as strengthening, dynamic stability, neuromuscular, etc. exercises.
I progress/regress my patients’ ther-ex programs based on my interpretation of the “Soreness Rules” (developed by the University of Delaware PT program for throwing programs) for general ther-ex.  The ‘Soreness Rules” use the presence of and duration of joint soreness after the prior session to dictate progression.  Click here for the official UDPT “Soreness Rules” (used with throwing programs).

Notice, I specifically said joint soreness and not muscle soreness.  If your patient says they were sore after a session, further question them to figure out if it was joint or muscle soreness.  Muscle soreness (DOMS) imposes no limitations and feel free to progress as tolerated.

If a patient complains of joint soreness after a session, the next important question to ask them is how long did that soreness last.  Depending on how long it lasted dictates how I progress them.

Even though I don’t think there is any evidenced-based research about it (sorry EBP police), I have found the “Soreness Rules” to be a very useful way to objectively and safely adjust patients’ the-ex programs.

Here are the “Soreness Rules” as I interpret them for my patients (who don’t come on consecutive days):

No soreness after last session
Eligible to progress
Sore after session but gone by the next morning
Eligible to progress
Sore for ~24 hours after last session
Stay with the same program
Sore for >1 day after last session
Regress program


For Knee Surgery
Another guideline, in addition to the soreness rules, I use when dealing with patients who have had a knee surgery (excluding TKA) is their knee effusion.  Measuring effusion is a simple, easy way to give you more information that will help you safely progress your patients programs.

The way I measure knee effusion is with the Stroke Test - to see how to perform this test check out Stroke Test - How to Objectively Measure Knee Effusion (video included).  I will measure knee effusion before and after the session to see if there was any change

Once you measure and grade their effusion, here are the guidelines:
  • 0, trace, or 1+ → no limitation
  • 2+ or 3+ → ther-ex not progressed
  • If effusion increases more than 2 grades → decrease ther-ex to the level prior to the change in effusion
  • If effusion now present when it was previously absent → decrease ther-ex to the level prior to the change in effusion

Other Factors I Consider
I don’t think these will come as any surprise to people, but often they are overlooked by clinicians, especially those who work in really busy clinics, and they can play an important role in a session.  I’m sure there are other factors that I think about but those are the ones that came to my head.
  • Mood - if someone is just having a bad day, you probably don’t want to add more challenging or increase intensity of ther-ex; you understand what I mean here
  • General health - are they a little under the weather, did they have a bad night’s sleep, etc. - these all get factored in to my thoughts
  • Stress - is the person always stressed out, then you’ll probably have to progress things slower because their body just won’t be able to adapt as well
  • Vacation/special event coming up - you don’t want to add in some new ther-ex if their daughter is getting married the next day, or they’re leaving for a much-needed vacation soon, etc.
  • Prior training experience - this can be a good thing (expect and understand DOMS, technique, etc) or a bad thing (have no clue what to expect afterwards, set/rep schemes, etc)

Summary
So that’s the thought process and criteria that goes through my head when deciding how to progress/regress patients’ programs.  It’s not an exact science or set in stone, but it at least gives me some set of guidelines instead of doing things randomly at will.

Let me know what other guidelines you use!



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