April- Post Op

[Kyle Feldman]

Please go back and read the intro post from January before you read and respond to this post.

APRIL DISCUSSION:

A 68 year old female comes into your clinic 3 weeks s/p L RTSA. Her MD provided a very generic protocol so, you decided to do what a great clinician would do, and do a literature review on post op protocols.

You come across the attached article.

Questions for thought

What does this tell you about protocols?

Have any of you worked at different clinics and seen totally different protocols for the same procedure?

Why do you believe protocols vary so much between MD’s and locations?

What do you believe factors into progressing patients during a rehabilitation after surgery?

A Systematic Review of Proposed Rehabilitation Guidelines Following Anatomic and Reverse Shoulder Arthroplasty
DOI: 10.2519/jospt.2019.8616
(if you don’t have access, let me know)

[Sarah Frunzi]

Hey Kyle! That article demonstrates the inconsistency between protocols as well as the subjective liberty with designing them that can take place based off of surgeon experience, opinion, and surgical method done. While this may not be a bad thing, as we utilize similar methods with our own practice, this does mean that there isn’t a very specific guideline to follow for post-op procedures. I am limited in my experience with multiple clinics, I have noticed different protocols for same/similar procedures. The biggest factors for progressing patients during rehab for me personally are based off of patient’s symptom irritability/severity, prior level of function, and compliance with PT recommendations and HEP.

[Laura Thornton]

Thanks for sharing Sarah. We do see a lot of inconsistency between protocols for a number of factors and individuality plays a significant role in development of a plan of care.

But on the flip side, the consistencies between protocols may be more important. Protocols do provide clinicians with a guideline on what to protect and how to protect. They may not be as important for what to do, but what not to do.

Can you or David find an example of this in the study Kyle listed?

[David Brown]

Sarah and Laura both bring up great points about how it is arguably more important that we know what to avoid in the protocols rather than following the suggestions of what to do. I agree with Sarah that ultimately the patient’s pain and irritability will ultimately dictate everything that we do. I think protocols definitely have a place as a framework or a guide with surgeries, especially when it comes to procedures that we’re not familiar with. I think as long as we have a good understanding of the surgical procedure, the anatomy involved, and the current state of the patient, we should be able to navigate the rehab without relying on the protocol. If we truly know what was involved with the surgery, then we will automatically have a good idea as to what to avoid when rehabbing the patient. This coupled with our understanding of tissue healing timelines will help us guide our patients back to their PLOF. I think a very interesting part of the article was how, although the exact exercises and timelines for incorporating these interventions varied between physicians, the phases and progressions for the protocols were more or less the same. I think thanking the timeline into account, coupled with the response to the patient with increased loads, should help navigate these types of surgeries.

[Kyle Feldman]

Great points everyone. For some reason I did not subscribe to my own post so I did not see this.

I am treating a pitcher who had tommy john surgery and I am combining 3 protocols together to make his.

It allows you to be creative and tailor to the patient but still have a foundational research backed program. This helps if anything goes wrong, you can at least have support why you did what you did.

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