I think studying and developing protocols is a difficult thing to do because of variability in patient characteristics and presentation as well as surgeon preference and variations in surgeries.

Protocols are good guidelines to help make decisions, but because of many different patient factors and specifics of each surgery it is so important to use clinical reasoning to help guide progression. Also the fact that, for example in this article, it is hard to find a consensus on protocols and there is variability based on surgeon/location just further stresses the importance of using our knowledge of healing timeframe, anatomy, biomechanics, and exercise progression to guide rehab.

I find articles like the one I attached (shoutout to Eric) super helpful in helping me understand procedures and guiding rehab.

I am currently practicing at SMH. Here, patients often present with similar surgeries. However, it isn’t uncommon to receive varying post-op protocols. This is likely due to the various medical institutions that offer these procedures, and nuances of the doctor. For example, it is often the case where a patient from UVA is referred with concomitant biceps tenodesis post rotator cuff repair. Additionally, the extent of the patient’s pathology, as well as comorbidities, may warrant a surgery that is more or less invasive.

I believe the patient’s comorbidities play a large factor when progressing them through a post-op protocol. In a tissue healing sense, factors such as diabetes and smoking will work to impede recovery. Further, the mental state of the individual can also curtail progress, where patients who are anxious or depressed may be less adherent in performing their HEP. Taking these factors into consideration can allow the therapist to accelerate or slow down the protocol based on the needs of the patient.

As Anna said, protocols are good guidelines to help make decisions. However, they should not undermine the therapist’s clinical reasoning.

When I was in an outpatient clinic in Houston, I was able to see several post-op RC repairs and I feel like there were some similarities with the protocols, but each surgeon typically had their own, with small differences in ROM limitations or when to start resisted movements, but the basic timeline was similar to what the UVA docs suggest.

I agree with Steven and Anna, we really have to tailor the protocol to the needs of our patient and where they are at post operatively. I feel like I still struggle with how much to accelerate some patients on a protocol to make sure that I’m not stressing the tissues too much, too early in the healing process. I find that I go back and reread the op notes more than anything to figure out why someone may be doing very well or lagging behind. For you guys that don’t use Epic, do y’all have access to op notes/op reports at all with your documentation system?

When I was working in Northern Virginia I saw a HUGE variation in post-op protocols. The one that sticks in my head is when I was treating 2 different RC repairs of the same technique. One surgeon wanted isometrics initiated at 4-6 weeks, the other restricted any resisted movements until 15 weeks. In this case I did contact the surgeon because I didn’t agree with waiting so long and felt the patient could progress. He told me he thought the complications of re-tear outweighed the benefits of earlier strengthening. I obliged to his request as I tend to defer (especially since I was only a few months out of school at this point).If I am provided a specific protocol following a surgical procedure I tend to adhere close to it as a guide. It is an extension of the surgeon’s clinical decisions. While we have a duty to advocate for better treatments including post-operative rehab, I feel it needs to come with careful and prompt interprofessional communication.

Anecdote aside, when I was at the VPTA student conclave a few years back I sat in on a presentation that talked about being bigger than the post-op protocol. The speaker talked a lot about referring back to tissue healing times and using these to guide our rehab. Having a good understanding of what tissues are disrupted and vulnerable following a procedure helps to provide initial limits and then allows us to use our understanding of biology, biomechanics, and exercise progression to guide people forward.

Great discussion

Here are a couple additional articles in this shoulder post op protocol tract that should be in your library.

Thanks Kyle for facilitating this discussion.

Whoops – a bit late to the game here.

My other issue with protocols (that hasn’t already been discussed) is that we need better medical team communication. If a surgeon gives me a protocol, I think it depends a lot of the specific surgeon as to whether or not they are okay with me discussing tweeks to it. I think the old school surgeons tend to think we are just glorified personal trainers and should just follow their directions, while more forward thinking surgeons recognize our clinical reasoning and are open to discussion. I tend to be like Taylor and shy away from confrontation with the docs if they start to tell me I’m wrong, though I should probably be more like Eric and hit them with a bunch of research… I think I worry that if something goes wrong with their recovery/surgery, if I’m the one that went away from the protocol, it’s way more likely to be me that’s blamed for the outcomes than the surgeon.

Helen to your point of getting blamed for bumps in recovery-
Respecting your referring surgeon by adhering to their protocol is important, but I also feel as therapists it is our job to extend our knowledge as movement experts to reason how to appropriately progress within the limits of the protocol. And then be ready to defend our decisions should we be questioned.

For example, RTC isometrics can be done in various ways (different angles, speed of movement, etc.) that can be viewed as “progressions” of the exercise that we can choose to prescribe if we feel like it is appropriate for that patient but are still within the protocol that is given.

For example, RTC isometrics can be done in various ways (different angles, speed of movement, etc.) that can be viewed as “progressions” of the exercise that we can choose to prescribe if we feel like it is appropriate for that patient but are still within the protocol that is given.

Love this Anna! I do this a ton with RC isometrics in particular. Walkouts, rhythmic stabilization type exercises, ROM in other planes while maintaining isometric ER, etc. Very easy to forget the small progressions or variations that can make a big difference.

Great points Anna and Taylor. Love the creative thinking!