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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.
What does this tell you about protocols?
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This article highlights the lack of reliability between post-op protocols that I feel is common in many of the orthopaedic post-op conditions we see in OP orthopaedics. As a new clinician, I’ve found myself using protocols often but as I’ve gotten more comfortable, they are becoming more of a guideline than step by step process as every patient progresses and presents differently. I think this article also speaks to the importance of using our clinical reasoning and knowledge on tissue healing timelines as well as exercise training principles to treat post-op patients.
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Going off of Ian’s response, the article even pointed out that most of the rehab protocols are clinical commentaries that lack high quality evidence and consensus between them. I don’t have as much experience working with post-op patients, but whenever I look up a protocol to use I often find this myself and how some of the protocols contradict one another which makes it confusing as a new grad. Especially when the timelines and precautions listed don’t match up with each other which the article mentioned for both the TSA and RTSA protocols. I agree the article points out the importance of using evidence based practice when it comes to using the protocols. Another PT at my clinic also mentioned he just uses them mostly as a guideline as well and adjusts it as needed.
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Yes
thats exactly the goal- to go off them as guidelines and understand tissue healing
I am glad you are getting that. Sadly some PTs 10 years out do not understand that.
Emily- great point about the research. Some MDs just make them without much science behind them.
We need to use research and evidence based protocols if we are going to use them. Maybe use the surgeons as a guide but make sure to compare it with one that has strong validity -
Something that has come up in mentoring sessions is the activation of the RTC muscles with various exercises, especially AAROM exercises that have more activation in EMG studies than one might think. Without going too off topic, I was wondering what everyone’s early intervention exercise prescription includes for patient’s that are post-op shoulder, especially when the procedure involved RTC repair. When should AAROM exercises be implemented to avoid over activation of the RTC and potential failure? Also, what do you think should be the guideline or threshold for RTC activation, how much is too much early on in rehab?
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Great questions Ian. To be honest I have not had any patients so far that are post-op shoulder so I can’t provide any recommendations based on my experience. I think you bring up a great point that is different between protocols for post-op patients. In the article attached it brought up that patients with the subscap repair who were held off from physical therapy treatment initially did better versus others who started physical therapy earlier on. I think this comes down to confidence with knowing tissue healing time frames, considering the patients PMH and PLOF, and assessing symptoms and response to treatments to know how to progress/regress treatment as appropriate.
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Hi everyone, sorry I’m jumping into this discussion a little late! I happen to keep getting post-op shoulder EVALs actually. In regard to your most recent question Ian, activation of the RTC muscles too early and too much is something that I am typically worried about. I’ve gotten conflicting information not only from protocols, but other clinicians in clinic. I know that some wait 6 weeks at times to begin submax isometrics if the pt is over 65 and therefore they progress a lot slower than the pt’s I’m seeing who are younger. I think Emily’s point of being confident with tissue healing time frames, PMH and PLOF is the way to go. I’ve been basing my progressions off of this and the pt’s own response to active motion – typically waiting until between 6-8 weeks to really start more active motion/strengthening with any resistance based on the patients progress thus far.
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