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Rehabilitation Protocols and Physical Therapy

PHYSICAL THERAPY PROTOCOLS

The use of protocols has been around for years in the rehabilitation world. There has been a recent trend on social media attacking the use of protocols and the clinicians that utilize them. A theme of those complaining about their use is that physical therapists should rely more upon the education they have received vs. the piece of paper that instructs them on how to do the therapy. As a physical therapist we have been trained for years to better understand the human body, how it functions, and its response to different healing stimuli. It is absolutely necessary to individualize programs that are specific to different patient needs and the type of injury.

Rehabilitation protocols are designed to better help a physical therapist make sound clinical decisions that are consistent with the clinical expertise and secular education received.

Cookie Cutter?

It has been known to happen in the rehabilitation world where a physical therapist can become too dependent on the information in the protocol, and fail to use their clinical brain to make appropriate decisions and problem solve. 

The real purpose of the protocol is to help establish goals, clarify any precautions, and give timelines how to apply optimal loading to injured tissue. They are designed based on the science of healing specific tissue and through experience of the application of evidence based medicine.

There exists a fine line of what is NEEDED and what is NOT NEEDED for a patient during therapy. 

Just like making your own pizza at the restaurant, we all have to start with the pizza dough. Now to the toppings, this depends on the type of person, what your taste buds like, and your experiences in the past. You will have your own wants and needs, as will a patient in rehabilitation.

We will often perform different techniques that are not found on the protocol but are based on recent emerging evidence, clinical expertise, and on how the patient prefers their “pizza”.  An example is working the soft tissue of the hamstrings in the early phases of ACL rehabilitation.  A great clinician knows that just because it isn’t found on the protocol doesn’t mean you can’t perform it. 

Guidelines Following Injury

Many people think protocols are set in stone rules that don’t vary, instead of guidelines.  All protocols that we have incorporated and created over the years are intended to help guide patients through sequential steps of returning from an injury in a safe and quick manner.

Many protocols focus on specific criteria that need to be met vs arbitrary timelines of recovery. See the example of what a few goals would be when rehabilitating an ACL reconstruction.

Phase 1: Restore full passive knee extension, Diminish joint swelling and pain.

Phase 2: Gradually increase knee flexion, Muscle control and activation, Normalize gait. 

Phase 3: Restore full knee range of motion (5- 0 to 125 degrees) symmetrical motion.

Phase 4: Return to sport progression, Achieve maximal strength and endurance.

In the example above, when the criteria is met in each phase this allows the patient to then progress 

to the next phase in the healing process with confidence. The therapist needs to determine what is 

and is not needed in order to achieve the necessary criteria. 

PROTOCOLS AND SURGERY 

Postoperative rehabilitation is a whole different animal and using the best evidence based programs are important in successful recovery.  Standards of care following surgery need to be communicated from surgeon to physical therapist to assure patients progress appropriately.

A physical therapist must respect the guidelines from the operating surgeon since they know the ins and outs of the surgery performed. Many variations exists in the types of surgery done and the patients response to it.  We often teach clinicians that the “rehabilitation must match the surgery” for optimal gains.  

“Random” therapy and not following the surgical protocol can often lead to sub-optimal outcomes. A well designed and carried out postoperative protocol will set the patient up for best success in returning to prior level of function. 

IN SUMMARY 

Physical Therapists should not follow a rehabilitation protocol without thinking, that is not the care deserved. The expert clinician will combine the guidelines of a solid rehabilitation protocol with clinical expertise, evidence based research, and patient preference for optimal outcomes. 

We have several non-operative, pre-operative, post-operative protocols 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 many specific procedures and concomitant surgeries.  If you are interested in learning more about our protocols and how we implement them in our treatment approach please call us at one of our clinic locations (wrightpt.com).