Rehabilitation protocols are something that we think are very important to assure people are progressing as quickly and safely as possible after a surgery.
But sometimes the protocol you get from the physician seems too conservative.
In this episode, we talk about some reasons why that may occur, and what you can do about it.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 298: Working with Conservative Rehabilitation Protocols
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Show Notes
- Rehabilitation Protocols from Wilk, Reinold, and Andrews
- Is it Time to Finally Ditch Using Rehabilitation Protocols?
Transcript
Jeff Hatam:
Today we have a question.
Mike Reinold:
That’s Michael.
Jeff Hatam:
With conservative rehab protocols. So this is David from Austin, Texas. He’s asking, “what do you do when you have a post-op protocol that’s very limited in detail, that seems excessively conservative, when you feel like you should be loading earlier? For example, I have a post-op ACL who was told non-weight bearing for four weeks.”
Mike Reinold:
That’s a great example. And again, lucky, nobody can see what Lenny’s doing right now. Right?
Lenny Macrina:
Exactly. I’m more entertaining you guys.
Dave Tilley:
Out of your scope of practice would be ripping up the protocol and doing that.
Mike Reinold:
Yeah. Lenny’s ripping up the protocol, which I don’t think is the best approach.
Lenny Macrina:
No, I’m kidding.
Mike Reinold:
To really like unwrap this question, I think there’s a few things in here that I liked. I liked a limited and detailed protocol. We see that all the time which I think the majority of us would prefer that, right? The limited detail one, meaning saying, “just give me your, your number one things you do or don’t want us to do and let us fill in the gaps. Like we’re the ones that can, that can paint between the lines.” I like that. But the excessively conservative one I thought was interesting. And I also like that he put, “I want to load earlier”. Is that not the big buzzword in our profession from Instagram, like load, load, load, look, loading’s amazing, and we probably have under loaded, but I don’t know, sometimes you shouldn’t load right away. I mean, they just had surgery, but who wants to tackle this one first? Dave, you want to jump in?
Dave Tilley:
Only because Dan and I literally are talking about this as we go through this week, so we both have patients that have like hip labral repairs and to the point of confusion, I think, Dan, we might have different surgeons, I forget, but the protocol that I got from the surgeon is just check boxes. It’s definitely like, don’t do this, these precautions, whatever, don’t extend or rotate for these amount weeks, which is really helpful. But one is that the check boxes are contradicting themselves. So he didn’t have a micro fracture, so it says you can weight bear earlier, and then the protocol says, start weightbearing off the crutches on week three, then the doctor told him, wait till four.
Dave Tilley:
But then in his protocol he has weight shifting without crutches. So it’s like, I’ll get, “What are we doing here, man?” It’s very overwhelming sometimes because sometimes obviously they don’t look great and you’re like, “okay, we’ll slow down a little bit”. But when you literally have protocols that the doctor says one thing, the protocols written on the sheet for weight bearing say something different and the check boxes say something different, it’s very hard to try to make a program for these people. And the second piece to that is that you definitely, you didn’t have a microfracture check. Okay. We can probably move this along a little bit, we can get off these crutches, we can do some more weight bearing exercises, but it’s very blank that they don’t want him doing anything. It’s hard sometimes to not go forward.
Dave Tilley:
I think the advice to give is like, you have to kind of use your overview of the entire literature of, what does the literature say on these things like micro-fractures, makes sense, it’s cartilage issue. Let’s not be a knucklehead with that, but for an ACL or someone who has just a straight up labral repair, you can probably test the waters a little bit and just get these people going and just talk with the surgeons if you have concerns about emailing them or trying to get in contact, like, “Hey, six weeks might be a long time to not be doing weight bearing for this. Do you think it’s okay if we do some of this or try this?”
Dave Tilley:
I think the worst thing you can do is just go ahead and blow right through it and don’t talk to the surgeon at all, because it gets you in a little bit of hot water, one, if things don’t go well and they get a little flare up, but two is obviously legality wise, you don’t want to be like, “no, we just ignored the protocol, ripped it up. And we just started doing squats, like week two.” So yeah, I think it’s challenging sometimes, but I think the more you can over communicate, call the office, call the PA, leave something with their email, if you can, that’s probably the best approach to take rather than just ignoring it.
Mike Reinold:
Yeah. I agree. What do you think, Mike?
Mike Scaduto:
Yeah, I would say for me, if I’m in this situation, I think step one is really trying to understand the details of the surgical procedure. So I’ll probably try and get an op report. Maybe they did do something in the surgery that the patient isn’t aware of or can’t communicate, which may be reflected in the protocol. So maybe with the ACL, maybe they did a meniscus repair or something and they’re being a little conservative because of that. So I think step one is get the op report. Step two is obviously call the doctor’s office and try and get some clarification. And sometimes that can lead to more confusion because then the doctor will tell you something completely different than the protocol. And then you’re in between the protocol and what the doctor’s telling you. And then step three, is just communicating with your coworkers or your mentors and trying to make sense of it all.
Mike Reinold:
I would say step four is document anything that the physician said for your own legality. I mean, I think you’re right though, Mike, because that’s the first thing I thought of from this, I don’t know much about David, who asked the question here, but they have the post-op ACL that was told to non-weight bearing for four weeks and that apparently is bothering David, he doesn’t like that. But my guess is that there’s a very strict reason because I don’t think there’s many physicians in this country that would say non-weight bearing after ACL for four weeks without a reason. So who knows, maybe there’s like a huge osteochondral defect, a meniscus repair or something like that. I think you may be missing something there and don’t jump the gun and don’t immediately say like, “ah, this doctor stinks, this protocol stinks,” there’s probably a reason that communication would clear it up immediately. And look, that’s what’s in the best interest of the patient, is for you getting to the bottom of it. That was the first thing I thought of too, Mike, I like that. What do you think, Dan?
Dan Pope:
Well, I was going to say, coming back on the communication thing, I think oftentimes the surgeon isn’t even aware of what the protocol says and this has happened a lot of times for me with multiple surgeons, basically I ended up contacting the surgeon I say, “Hey, we can start throwing baseball eight weeks after a slap tear”, and they’re like, “no, no, no, no, no”. So there’s a big difference between what the surgeon actually wants and then what the protocol says. So I think that sometimes you see these protocols and you think you have to follow this a hundred percent completely, but it may not be what the surgeon wants at all. So it’s a pretty clear problem with communication and just understanding what the surgeon does want. So that’s important.
Mike Reinold:
Yeah, and it’s funny, there’s another wave of opinion online, obviously that’s like, “oh, protocols are terrible, you can’t script things”. And man, I think that is so ridiculously shortsighted. You absolutely need protocols for certain things. There are certain things you should be avoiding and certain things you should be shooting for. And that’s one thing we tell people is that protocol is almost like your pace card that gets you through a procedure, because if you get a little bit behind, sometimes you’re behind for weeks, so it almost tells you where you should be, but also tells you some things you shouldn’t do. So I think it’s very shortsighted to start saying “we shouldn’t be using protocols or stuff like that”. Post-operative protocols are very important. They’re based on the science of what we know, the biological healing, some of the outcome reports and stuff like that. So Len, as somebody that’s, we’ve utilized protocols our whole lives, we write protocols, we publish protocols and stuff, any thoughts on this from your perspective?
Lenny Macrina:
Yeah, definitely. I like getting a protocol from a doctor. That’s one of the first things I ask for besides an op report from the patient is I want get into the mind of the surgeon and see how they handle these surgeries. If it’s type written out and it’s like their generic protocol, it tells me how conservative or progressive they are with their rehab and it gives me an insight into what they’re thinking. Now if they start handwriting stuff on a script or the protocol, I think that supersedes everything and there’s a reason why they hand wrote stuff. So I would be cautious of the handwritten stuff more so than the generic stuff that they just hand that piece of paper to you and say, this is what I want.
Lenny Macrina:
So it gives me insight and then others have said, I try to contact the office if I have the surgeon directly, which I am slowly obtaining phone numbers and cell numbers and all that, where I can contact them. It’s a neat process and they appreciate that. And hopefully you can get through to him or her and get the information that you need and then they’ll be like, “oh yeah, I don’t know why the protocol even says that, you can do this, this and this, and they’re fine”. And so you’d be surprised, the answers that you get when you call a surgeon’s office and hopefully speak to at least a nurse, or maybe even the surgeon themselves. And like Dan said that they don’t even know half the time what’s on their protocols.
Mike Reinold:
And I think the worst thing is what Dave said, the check boxes? I mean, has anyone ever witnessed a PA or somebody that actually used the check boxes? There’s a lot of blind checking going on. There’s nothing worse than the check boxes, but what’s up Dave?
Dave Tilley:
I just wanted to, something that popped in my mind that was mentioned is to give credit to the surgeons too and not making them seem like they have no idea what’s going on in the protocol. There are times when I’ve talked to the hip surgeons locally, where during the surgery, they do more than they expect. So think of this guy recently, he thought he was going to have a one to two anchor repair and just have a very small debridement, ends up having a four to five anchor repair, a large cam reduction, a lot of borderline chondral issues going on. So in that situation, it wasn’t like he didn’t look at their protocol he just realized during surgery, “whoa, this is a little bit more intense than I think maybe it was going in”.
Dave Tilley:
And I think sometimes given how busy they are, you wish they would update you, but it gets lost in translation about what happens that’s why you get the radiology report or the surgical report or what happened, but sometimes just a quick phone call or a quick email, they’ll hit back like, “oh yeah, four anchors, much more involved. chondral was kind of questionable, didn’t do a micro-fracture, but we were close. And that’s why we’re goings with this”. OK, makes total sense.
Lenny Macrina:
A lot can go wrong during a surgery. How common is it for a surgery to go perfectly well? You take off too much tissue, you discover something you hadn’t seen, you were doing a labor repair of a hip or it’s shoulder and the anchor doesn’t take, the bone is soft. Who knows what can go, I don’t say wrong, but go unexpected in a surgery that will influence the surgeon’s opinion on the rehab afterwards? And we don’t know all that stuff that’s where some of those factors play into what they’re thinking when they’re trying to give us some insight into the rehab.
Mike Reinold:
Yeah. And it’s pretty naive to think a slap repair or even in ACL, they’re all the same. So there’s one protocol for every ACL. There’s so many specific variables based on the patient, the surgical procedure, how they looked on the inside. There’s so many different variables in there. You can’t say that. So Lisa, from when you were, obviously coming from a different place before you came to Champion, I think you had some different experience with protocols and stuff. What can you share from your past?
Lisa Lowe:
That I was probably in the same place as the person asking this question.
Mike Reinold:
Yeah. I think a lot of people are. That’s great.
Lisa Lowe:
In some ways, just because of the primary people that I treat at Champion, rowers, don’t get a ton of surgeries, I feel like I have learned and listened to you all in terms of what you do with your protocols and everything you’ve just talked about more than I’ve actually had the experience and needing to deal with them personally, minus while you all are talking, I have one client right now who you’ve persuaded me that I should reach out to her surgeon.
Mike Reinold:
That’s right. I forgot about that. You’re right.
Lisa Lowe:
She fits this question. She had a really conservative protocol, but then she goes for a follow up and is told, “do whatever you want to with your shoulder, go for a run, do this, do that. It doesn’t matter” but then her protocol doesn’t really match that. So definitely someone that I need to reach out to the surgeon and see why on earth we’re getting two messages.
Mike Reinold:
She’s a classic example of the pace car analogy that I use though, right there where she was doing her therapy elsewhere and she just recently transferred to us, what, four or five months out of surgery? And she was quite behind in a range of motion, and it was that the protocol isn’t just based on their feelings and how they’re feeling, you do sometimes have to push people and the protocol tells you when you can push and when you shouldn’t push in my mind. And that was a good example.
Mike Reinold:
So if she was four plus months out of surgery, so on the inside, we’re like, “okay, she’s healed. There’s no risk.” We know that on that thing, if she can start doing all these activities, we know that, but she’s behind in motion. So you start to say to yourself, “okay, well, should we push, should we be cautious?” And then you, when you put it all together, you’re like, “no, she’s way behind. It’s healed on the inside. The surgeon said she can do a bunch of other things. It’s time to push.” And I think that’s where the protocol can help in that case.
Mike Reinold:
It’s so interesting. So, great question again, David. I mean, the protocols, I think to me are sometimes people get a little too worked up about the complexity of it. I think it comes down to communication and it comes down to doing as best as you can to learn about the why of what you see, and look, don’t get me wrong. Michael, I don’t even remember who it was, I think you and I were working with somebody and we did an eval on somebody recently and the protocol that the physician gave us wasn’t even for the right surgery that they had it was a different surgery. I think it was you Michael but we were like, “all right, geez, this is really conservative. Wait a minute this isn’t even for the right procedure.” And then you talked to the doctor and the doctor was like, “oh yeah, yeah, yeah, don’t do that.” And, you’re like, “Okay, so they just gave them the wrong piece of paper.”
Mike Reinold:
So don’t take things for granted, reach out, communicate, I think that’s the important part. It’s in the best interest of our patients. So, keep that in mind. But remember, oftentimes I think that when we think it’s conservative, there’s probably something going on in the physician’s head, or maybe that’s been communicated between the physician and the patient that is saying that they want to go more conservative. Maybe they’re worried about something down the road. Maybe they’re worried about needing a revision in the future. So don’t just take that for granted and just proceed. I think you got to dig in before you divert from what’s listed on the protocol. So, great question, David, if you have something like that, head to mikereinold.com, click on that podcast link, and you can continue to ask us these questions. As long as we’re getting questions, we’re going to keep answering them. So, please continue to fill out that form and ask us anything you want to talk about and please rate, review, subscribe on Apple, Spotify, wherever you listen to it. And we’ll see you on the next episode. Thanks so much.
