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REHABILITATION PROTOCOLS AND PHYSICAL THERAPY

by / Monday, 03 April 2017 / Published in Articles, Physical Therapy

REHABILITATION PROTOCOLS

The use of rehabilitation protocols in physical therapy continues to be best practice. We recently participated in a survey and it appears that most agree. Out of thousands of clinicians who participated, 73% of them reported that they use protocols in their treatments to enhance their care and 27% said they do not.

However, a recent trend on social media has been to criticize these guidelines and those that follow them. We have heard a few complaints over the years, like:

• We need to use our intellect, not follow a piece of paper
• Physical therapists shouldn’t follow a cookbook recipe
• Physical therapy isn’t black and white
• We need to individualize our treatment approach

road_to_recoveryWe understand and agree, to an extent at least. As a physical therapist (or other rehabilitation specialist), we’ve spent countless hours, money and energy learning how the human body functions, becoming a doctor of physical therapy and mastering our craft. We’ve spent years refining our skills based on our experiences and patient outcomes and continue to.

We absolutely should be using our brains and intuition as physical therapists, individualizing programs based on each person. Rehabilitation protocols can help us do this better if used properly. To highlight this, it helps to break down exactly what rehabilitation protocols are, and are not, in physical therapy to best understand how we should be using them in our clinical practice.

REHABILITATION PROTOCOLS ARE NOT COOKBOOKS

Rehabilitation protocols are not designed to be complete cookbook recipes. This is where a physical therapist can often become paralyzed by the protocols, thinking that they can’t do anything that isn’t specifically listed in the protocol.

recipesThe real purpose of a great rehabilitation protocol is to: 1) Clearly define the goals 2) Give necessary precautions 3) Give timelines to gradually apply load to healing tissue. Protocols are designed based on our understanding of the in depth science of the healing process and the application of evidence-based medicine.

There is a still a substantial gray area between what you definitely SHOULD be doing and what you definitely SHOULD NOT be doing.

Powerful protocol use can be thought of as an opportunity to customize the recipe and make your own sandwich. You need to put bread on both sides, but what meat, cheese, and condiments you put between the slices of bread will depend on the type of patient, your training, and your experience.

It is common during treatment for a physical therapist to perform interventions with patients that are not listed in a protocol but we know align with the goals, precautions, and timelines of tissue specific healing. A good example is working the soft tissue of the traps after rotator cuff repair or including core training in the early phases of ACL rehabilitation. Just because they are not specifically included in the protocol, doesn’t mean we shouldn’t perform them.

Rehabilitation protocols are the foundation of a strong physical therapy program, which should be adjusted based on:

• The unique goals of each person
• The stage of tissue healing
• The specific injury or surgery
• Any concomitant injuries, which are common

REHABILITATION PROTOCOLS ARE GUIDELINES FOLLOWING INJURY

A common misconception of protocols is that they are concrete rules that cannot be changed, instead of guidelines. All of the non-operative rehabilitation protocols that we have created over the years are intended to help guide consistent high-skilled results through the steps of returning a patient from an injury.

In fact, many protocols don’t even have strict timelines associated with them, but rather phases with specific criteria required to progress. For example, here’s what some of the goals of each phases would be when rehabilitating a basketball player that has had an ACL reconstruction with Bone – Patellar – Bone Autograft:

• Phase 1: Restore full passive knee extension, Diminish joint swelling and pain, Restore patellar mobility, Gradually improve knee flexion, Re-establish quadriceps control, Restore independent ambulation.
• Phase 2: Maintain full passive knee extension, Gradually increase knee flexion, Diminish swelling and pain, Muscle control and activation, Restore proprioception/neuromuscular control, Normalize patellar mobility, Normalize gait.
• Phase 3: Restore full knee range of motion (5- 0 to 125 degrees) symmetrical motion, Improve lower extremity strength, Enhance proprioception, and neuromuscular control, Improve muscular endurance.
• Phase 4: Return to sport progression, Achieve maximal strength and endurance, Normalize neuromuscular control, Progress skill training.

Below are the specific criterion found on the protocol that need to be met before an ACL -PTG
Reconstructed patient should progress to phase 2 of rehabilitation.layered_protocols

• Quad Control (ability to perform good quad set and SLR
• Full passive knee extension
• PROM 0-90 degrees
• Good patellar mobility
• Minimal effusion
• Independent ambulation with one or two crutches

Looking at the above phases and criterion for progression, you can use these guidelines to determine what is and what is not appropriate for each phase. This is where a physical therapist’s professional preferences come into play. I like pepper jack cheese on my ham sandwich, you like swiss cheese. We won’t judge. They are both appropriate.

Postoperative is different animal and will be covered below, and we’ll discuss that more below, but for nonoperative this is how you should use a protocol. Non-operative injuries there are times that you may want to limit an exercise or activity for a period of time. More often non-operative protocols are used to divide the rehab sequence into manageable chunks.

REHABILITATION PROTOCOLS ARE NEEDED FOLLOWING SURGERY

We feel strongly and believe in the need for rehabilitation protocols after surgery. Rehabilitation protocols are crucial components of post-operative physical therapy. Certain standards of care following a surgery must be set and communicated from surgeon and physical therapist to assure patients progress appropriately after surgery, and that the surgeons goals are met.
Many of these protocols may be surgeon specific, meaning that certain doctors will want to go faster or slower based on their experience and the extent of the specific surgery. As physical arm_surgerytherapists, we must respect these guidelines from the operating surgeon. They know their surgery and the inside of the patient and what has specifically occurred during the surgery of this patient. WPT physical therapists are aware that the “Rehabilitation Program Must Match the Surgery”. There are so many variations to the type of surgery and the patient’s response to it. A team approach between the physical therapist and the surgical team is the ideal approach to heal the patient.

After surgery, protocols are used to assure we : 1) Protect the tissue 2) Facilitate healing
3) Gradually apply correct load to the injured tissues.

Simply “winging it” and not following a protocol will give the least likely chance that the patient will return as quickly and safely as possible. For example, you don’t want too much or too little shoulder range of motion at 6 weeks following an anterior labral repair, both can be detrimental. A well designed and carried out postoperative rehabilitation protocol will put the patient in the best position to gain optimum outcome and return to prior level of function.

It is also difficult to prioritize the precautions and restrictions of complicated patients. For example, our rehabilitation protocols have 13 variations of rotator cuff repair protocols and 16 variations of ACL reconstruction protocols. We change the guidelines based on several factors and concomitant injuries. This is a necessity!

IS IT TIME TO STOP USING REHABILITATION PROTOCOLS?

We vehemently think protocols should not be abandoned. In fact, we are proponents of rehab protocols when used correctly and from the right source. Yes, it is easy in this era to go straight to Dr. “Google” and find any protocol that is online. These types of protocols are commonly from random sources that are not evidenced-based or verified. Clinicians that know how to understand and use the best evidence-based rehab protocols are invaluable in the rehab process. This is one of the keys to ensure that the patient returns optimally to full function.

A protocol simply gives you guidelines as to what you can and cannot do. What you “can” do is not restricted to what is within the protocol. It helps to think of them as guidelines to assure that we are not going too slow or too fast with the patient. Realistically, a protocol does not list every treatment and exercise that should be included. This is where the skill and expertise of the therapist comes into play. We must determine what other interventions can safely be performed to help the patient, while assessing if that chosen intervention fits safely within the protocol restrictions.

IN SUMMARY

Physical therapists should not follow a rehabilitation protocol without thought. That is not “skilled” physical therapy. However, we must appreciate the timelines associated with the protocols and healing tissues. The expert clinician realizes this and combines the guidelines of a solid evidence-based rehabilitation protocol with their vast experience and treatment preferences.pic4

When these protocols are used to clearly define the goals, give necessary precautions, and help in timelines to gradually apply load to healing tissue, they are consistently effective in the quick and safe recovery of your patients.

With regard to post-operative patients, a certain standard of care following surgery must be set and communicated from surgeon and physical therapist to assure patients progress appropriately as the rehabilitation matches the surgery performed.

We have developed and adopted over 175 non-operative, pre-operative, post-operative protocols for shoulder, elbow, hip, knee, foot, ankle, and interval return to sport programs. We update these on a consistent basis when the research guides us to. These protocols are based on decades of research, scientific evidence, experience, and mentorship with world renown physical therapists and surgeons. There are several variations of protocols to account for the various procedures and concomitant surgeries.

These protocols are a vital tool to help guide your patients rehabilitation treatment approach. If you are interested in learning more about our protocols, how we implement them in our treatment approach, or reviewing any of the following, please email tyler@wrightpt.com.

 

WRIGHT PHYSICAL THERAPY PROTOCOL TABLE OF CONTENTS

Ankle – Achilles PRP Injection Protocol – (2017).pdf
Ankle – Achilles Tendinitis Protocol – (2017).pdf
Ankle – Achilles Tendon Repair – Accelerated – (2017).pdf
Ankle – Lateral Ankle Sprain Protocol – (2017).pdf
Ankle – Plantar Fasciitis Protocol – (2017).pdf
Ankle – Postoperative Rehabilitation following Achilles Tendon Repair – (2017).pdf
Elbow – Distal Biceps Tendon Repair Protocol – (2017).pdf
Elbow – Ebow Injuries Non Operative – (2017).pdf
Elbow – Elbow Arthroscopy with Microfracture of OCD Lesion Protocol – (2017).pdf
Elbow – Epicondylitis Protocol – (2017).pdf
Elbow – General Arthroscopic Protocol – (2017).pdf
Elbow – Lateral Epicondylitis PRP Injection Protocol – (2017).pdf
Elbow – LCL Reconstruction Protocol – (2017).pdf
Elbow – Loose Body Removal Protocol – (2017).pdf
Elbow – Non-Operative Ulnar Collateral Sprain in Throwers – Accelerated – (2017).pdf
Elbow – Non-Operative Ulnar Collateral Sprain in Throwers – Regular – (2017).pdf
Elbow – Olecranon ORIF Protocol – (2017).pdf
Elbow – Radial Tunnel Release Protocol – (2017).pdf
Elbow – UCL Docking Protocol – (2017).pdf
Elbow – UCL Preop Protocol – (2017).pdf
Elbow – UCL PRP Injection Protocol – (2017).pdf
Elbow – UCL Reconstruction with Autogenour Gracilis Graft – Accelerated – (2017).pdf
Elbow – UCL Reconstruction with Autogenous Gracilis Graft – Regular – (2017).pdf
Elbow – UCL Reconstruction with Autogenous Palmaris Longus Graft – Accelerated – (2017).pdf
Elbow – UCL Reconstruction with Autogenous Palmaris Longus Graft – Regular – (2017).pdf
Elbow – UCL Repair with Augmentation Protocol – (2017).pdf
Elbow – Ulnar Nerve Subcutaneous Transposition Protocol – (2017).pdf
Elbow – Valgus Extension Overload with Posterior Decompression Protocol – (2017).pdf
Elbow – Valgus Extension Overload with Posterior Decompression with Microfracture Protocol – (2017).pdf
Elbow – Wrist Flexor Pronator Release with Debridement – (2017).pdf
Elbow – Wrist Flexor Pronator Release with Debridement and Extensor Release Protocol – (2017).pdf
Golfers Ten Program – (2017).pdf
Hip – Femoroplasty and Labrum Repair Protocol – (2017).pdf
Hip – Hamstring Repair Proximal Protocol – (2017).pdf
Hip – Hamstring Strains Protocol – (2017).pdf
Hip – Iliopsoas Release Protocol – (2017).pdf
Hip – Labral Repair Protocol – (2017).pdf
Hip – Microfracture Arthroscopy Protocol – (2017).pdf
Interval Sport – Football Throwing Program – (2017).pdf
Interval Sport – Golf Rehabilitation Program – (2017).pdf
Interval Sport – Hitting Program – (2017).pdf
Interval Sport – Internal Javelin Throwing Program – (2017).pdf
Interval Sport – Interval Throwing Program Windmill Softball Pitchers Phase II – (2017).pdf
Interval Sport – Little League Injury Prevention Program – (2017).pdf
Interval Sport – Running Program – (2017).pdf
Interval Sport – Softball Throwing Program Phase I – (2017).pdf
Interval Sport – Tennis Program – Advanced – (2017).pdf
Interval Sport – Tennis Program – Standard – (2017).pdf
Interval Sport – Throwing Program Catchers Phase II – (2017).pdf
Interval Sport – Throwing Program for Baseball Players – (2017).pdf
Interval Sport – Throwing Shoulder Following Injection 10 days – (2017).pdf
Interval Sport – Throwing Shoulder Following Injection 14 days – (2017).pdf
Interval Sport – Throwing Shoulder Following Injection 21 days – (2017).pdf
Knee – ACL – Following Acute ACL, MCL, LCL, PL Protocol – (2017).pdf
Knee – ACL – Following Acute ACL, PCL, LCL, PL with Lateral Hamstring Repair – (2017).pdf
Knee – ACL – Nonoperative Rehab Following ACL Injury (3-3- 4-4 Protocol) – (2017).pdf
Knee – ACL – PCL Combined Reconstruciton Protocol – (2017).pdf
Knee – ACL – PTG Following Contralateral ACL Reconstruction for Early Return to Competition – Accelerated – (2017).pdf
Knee – ACL – PTG Following Contralateral ACL Reconstruction with LCL Primary Repair Protocol – (2017).pdf
Knee – ACL – PTG Reconstruction – Accelerated – (2017).pdf
Knee – ACL – PTG Reconstruction Protocol – (2017).pdf
Knee – ACL – PTG Reconstruction with Acute LCL Repair – (2017).pdf
Knee – ACL – PTG Reconstruction with LCL – PL Corner Reconstruction with Medial Capsule Involvement – Accelerated – (2017).pdf
Knee – ACL – PTG Reconstruction with MCL Repair – Accelerated – (2017).pdf
Knee – ACL – PTG Reconstruction with Microfracture and Meniscus Repair – Accelerated – (2017).pdf
Knee – ACL – PTG Reconstruction with PCL Reconstruction with MCL Repair – Accelerated (2017).pdf
Knee – ACL – PTG Reconstruction with PCL Repair and LCL and PL Corner Repair – Accelerated – (2017).pdf
Knee – ACL – PTG with Meniscus Repair Protocol – (2017).pdf
Knee – ACL – Semitendinosus Reconstruction (HAMSTRING) Protocol – (2017).pdf
Knee – ACL Pre Operative Protocol – (2017).pdf
Knee – ACL Reconstruction with Allograft – Accelerated – (2017).pdf
Knee – Articular Cartilage – Arthroscopic Chrondroplasty Protocol – (2017).pdf
Knee – Articular Cartilage – Osteochondral Autograft Transplant Protocol – (2017).pdf
Knee – Articular Cartilage – Osteochondral Autograft Transplantation Trochlea Protocol – (2017).pdf
Knee – Autologus Chondrocyte Implantation (ACI) Protocol – (2017).pdf
Knee – Hamstring Strain Protocol – (2017).pdf
Knee – High Tibial Osteotomy Protocol – (2017).pdf
Knee – Hyaluronic Acid Injection Protocol – (2017).pdf
Knee – Knee Arthroscopy Protocol – (2017).pdf
Knee – Lateral Release Protocol – (2017).pdf
Knee – MCL Non Operative Protocol – (2017).pdf
Knee – Meniscus – Arthroscopic Debridement with Partial Menisectomy Protocol – (2017).pdf
Knee – Meniscus Repair (Complex Tears) Protocol – (2017).pdf
Knee – Meniscus Repair (Peripheral Tears) Protocol – (2017).pdf
Knee – Meniscus Transplant Protocol – (2017).pdf
Knee – Osteoarthritis – Non Operative Protocol – (2017).pdf
Knee – Osteoarthritis – TKA Preop Protocol – (2017).pdf
Knee – Osteoarthritis – Total Knee Arthroplasty – Active Patient – (2017).pdf
Knee – Osteoarthritis – Uni Compartmental Knee Arthroplasty Protocol – (2017).pdf
Knee – Osteorarthritis – Total Knee Arthroplasty Protocol – (2017).pdf
Knee – Patellofemoral – Arthroscopic Anteromedial Plica Resection Protocol – (2017).pdf
Knee – Patellofemoral – Distal and Proximal Realignment Protocol – (2017).pdf
Knee – Patellofemoral – Distal Realignment Protocol – (2017).pdf
Knee – Patellofemoral – Microfracture Procedure (Femoral Condyle Medium-Large Lesions) Regular – (2017).pdf
Knee – Patellofemoral – Microfracture Procedure (Femoral Condyle Small Lesions) – Accelerated – (2017).pdf
Knee – Patellofemoral – Microfracture Procedure (Trochlear Small to Medium Lesions) Protocol – (2017).pdf
Knee – Patellofemoral – MPFL Reconstruction – (2017).pdf
Knee – Patellofemoral – MPFL Reconstruction with Lateral Release Protocol – (2017).pdf
Knee – Patellofemoral – Patella ORIF Protocol – (2017).pdf
Knee – Patellofemoral – Patellar Protection Protocol – (2017).pdf
Knee – Patellofemoral – Patellar Tendinitis – Tendonosis Recurrent Unremitting Protocol – (2017).pdf
Knee – Patellofemoral – Patellar Tendon Repair Following Revision Unilateral – (2017).pdf
Knee – Patellofemoral – Patellar Tendon Repair for Incomplete Tear Unilateral – (2017).pdf
Knee – Patellofemoral – Patellar Tendon Repair Unilateral – (2017).pdf
Knee – Patellofemoral – Quadriceps Tendonitis – Tendinosis Recurrent Unremitting Protocol – (2017).pdf
Knee – PCL – PTG Reconstruction Single Tunnel Protocol – (2017).pdf
Knee – PCL – PTG Reconstruction with PL Corner Reconstruction – Accelerated – (2017).pdf
Knee – PCL – Reconstruction with Two Tunnel Graft Protocol – (2017).pdf
Knee – PCL Non Operative Protocol – (2017).pdf
Knee – Quad Tendon Repair Unilateral Protocol – (2017).pdf
Other – Platelet Rich Plasma Rehabilitation Protocol – (2017).pdf
Shoulder – Advanced Throwers Ten Program – (2017).pdf
Shoulder – Anterior Capsular Shift – Accelerated – (2017).pdf
Shoulder – Anterior Capsular Shift – Regular – (2017).pdf
Shoulder – Bicep Tendon Repair (Proximal) – (2017).pdf
Shoulder – Fundamental Shoulder Exercises – (2017).pdf
Shoulder – Instability – Anterior and Posterior Capsular Shift Protocol (Slow Rehab for Congenital Laxity Patients) – (2017).pdf
Shoulder – Instability – Arthroscopic Anterior Shoulder Plication in the Atraumatic Patient – (2017).pdf
Shoulder – Instability – Arthroscopic Anterior Shoulder Plication in the Overhead Athlete – (2017).pdf
Shoulder – Instability – Bankart Anterior and Posterior Repair Protocol – (2017).pdf
Shoulder – Instability – Bankart Anterior Arthroscopic Revision – (2017).pdf
Shoulder – Instability – Bankart Anterior Open Repair – (2017).pdf
Shoulder – Instability – Bankart Anterior Repair Protocol – (2017).pdf
Shoulder – Instability – Capsular Anterior Arthroscopic Repair with Subscapularis Repair Protocol – (2017).pdf
Shoulder – Instability – Labral 360 Degree Arthroscopic Repair – (2017).pdf
Shoulder – Instability – Labrum Posterior Arthroscopic Repair – (2017).pdf
Shoulder – Instability – Labrum Posterior Repair Protocol – (2017).pdf
Shoulder – Instability – Laterjet Anterior Arthroscopic Protocol – (2017).pdf
Shoulder – Instability – Laterjet Procedure Arthroscopy with Posterior Capsule Plication Protocol – (2017).pdf
Shoulder – Nonoperative – Adhesive Capsulitis Protocol – (2017).pdf
Shoulder – Nonoperative – Atraumatic Shoulder Instability Protocol – (2017).pdf
Shoulder – Nonoperative – Dynamic Stability for Overhead Athlete – (2017).pdf
Shoulder – Nonoperative – Internal Impingement with Overhead Athlete – (2017).pdf
Shoulder – Nonoperative – Multi-Directional Instability – (2017).pdf
Shoulder – Nonoperative – Overhead Athlete Rehabilitation Goals (Phases and Goals) – (2017).pdf
Shoulder – Nonoperative – Scapular Muscular Training Protocol – (2017).pdf
Shoulder – Nonoperative – Shoulder Impingement Protocol – (2017).pdf
Shoulder – Nonoperative – Subacromial Impingement Protocol – (2017).pdf
Shoulder – Nonoperative – Traumatic Anterior Shoulder Instability Protocol – (2017).pdf
Shoulder – Other – Acromioclavicular Joint Reconstruction for Athletes – Accelerated – (2017).pdf
Shoulder – Other – BIcep Tenodesis Open – Arthroscopic Biceps Tenodesis – (2017).pdf
Shoulder – Other – Hemi Cap Humeral Head Replacement Protocol – (2017).pdf
Shoulder – Other – Pectoralis Major Open Repair – (2017).pdf
Shoulder – Other – Proximal Biceps Tendon Repair Protocol – (2017).pdf
Shoulder – Other – SAD Pre Operative Protocol – (2017).pdf
Shoulder – Other – Subacromial Decompression Protocol – (2017).pdf
Shoulder – Other – TACS with MDI – (2017).pdf
Shoulder – Other – TACS with Overhead Athlete – (2017).pdf
Shoulder – Other – TACS with SAD Protocol – (2017).pdf
Shoulder – Other – Total Shoulder (Reverse) – (2017).pdf
Shoulder – Other – Total Shoulder Arthroplasty Protocol – (2017).pdf
Shoulder – Other – Triceps Repair Protocol – (2017).pdf
Shoulder – Other – TSA with Tissue Deficiency Protocol – (2017).pdf
Shoulder – Rotator Cuff – Arthroscopic Partial Thickness Transtendinous RTC Repair – (2017).pdf
Shoulder – Rotator Cuff – Arthroscopic RTC Repair (Medium to Large Tears) Type II – (2017).pdf
Shoulder – Rotator Cuff – Arthroscopic RTC Repair (Small Tears) Type I – (2017).pdf
Shoulder – Rotator Cuff – Arthroscopic RTC Repair (Small to Medium Tears) in Overhead Athletes – (2017).pdf
Shoulder – Rotator Cuff – Arthroscopic RTC Repair and or Glenoid Labrum Debridement for Overhead Thrower – (2017).pdf
Shoulder – Rotator Cuff – Arthroscopic RTC Repair (Large to Massive Tears) Type III – (2017).pdf
Shoulder – Rotator Cuff – Arthroscopic RTC Repair (Small to Medium Tears) with Anterior Bankart Repair – (2017).pdf
Shoulder – Rotator Cuff – Arthroscopic RTC with PRP Injection (Medium to Large Tears) Type II – (2017).pdf
Shoulder – Rotator Cuff – Arthroscopic SUBSCAPULARIS Repair – (2017).pdf
Shoulder – Rotator Cuff – Mini Open Repair (Large – Massive tear) Protocol – (2017).pdf
Shoulder – Rotator Cuff – Mini Open Repair (Medium – Large tear) Protocol – (2017).pdf
Shoulder – Rotator Cuff – Mini Open Repair (Small – Medium tear) Protocol – (2017).pdf
Shoulder – Rotator Cuff – Open and Mini-Open RTC Repair – (2017).pdf
Shoulder – Rotator Cuff – Open Subscapularis Repair with Biceps Tenodesis – (2017).pdf
Shoulder – Rotator Cuff – Repair Pre Operative – (2017).pdf
Shoulder – Shoulder Rehab Program Post Operative – (2017).pdf
Shoulder – SLAP – Arthroscopic Debridement (Type I and III) and or Partial RTC Debridement Protocol – (2017).pdf
Shoulder – SLAP – Arthroscopic SLAP Repair (Type II) in Overhead Thrower – (2017).pdf
Shoulder – SLAP – Arthroscopic SLAP Repair (Type II) Protocol – (2017).pdf
Shoulder – SLAP – Arthroscopic SLAP Repair (Type II) with Bursectomy in Overhead Thrower – Accelerated – (2017).pdf
Shoulder – SLAP – Arthroscopic SLAP Repair (Type IV) with BIceps Tenodesis (SLAP Lesion Debridement not Repair) – (2017).pdf
Shoulder – SLAP – Arthroscopic Type II Repair with SAD – (2017).pdf
Shoulder – TACS with SLAP Repair (Type II) Protocol – (2017).pdf
Shoulder – Throwers Ten Exercise Program – (2017).pdf

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