Rehab Protocols are the demise of our profession

or... Don't show up at a nice restaurant with a recipe

Ever watch a great cook in action? You won’t find a recipe propped up on their counter. For them it's "a dash of this, a scoop of that, taste it and adjust". Why can a great cook put together a delicious meal without following a recipe?

You know the answer: they understand the key underlying principles of their craft and can use this knowledge creatively. Want a healthy muffin but don’t have a recipe? Throw in some flour and scatter some wheat bran with it. Want it to rise and be fluffy? Add a spoonful of baking powder. Want to bring out the flavor? A little salt, maybe some zest of lemon. Need to sweeten it but don’t want to use white sugar? Mash up a banana. Understand the principles and you can be a master in the kitchen. Let's bring that idea into our own field:

Understand the principles, and you can be an expert physiotherapist without using rehab protocols.

I have a strong aversion to prescribed treatment regimens written on paper and delivered to me by the patient from their surgeon. That doesn’t mean that if you follow a protocol you are a bad physio. I found protocols quite helpful in the early part of my career. Without them, I may have done harm to my patients, and perhaps I would have missed some important things too. But keep in mind this:

We are therapists trained in clinical reasoning, not technicians trained to follow instructions.

Once you understand why rehab protocols came into existence, and how to scan through them to discover the reasoning behind them, it would be in your patient’s best interest for you to put them aside and figure out how to apply your deep experience to their specific case.

I suppose the first surgeon to write up a post-op protocol thought about it something like this: “I’ve stitched together this patient’s tissues in such and such a way, and while they heal, I can’t have them doing things that will put the success of my surgery at risk.” If I were a surgeon, I’d feel the same way. The idea behind a rehab protocol is sound, when you consider safety and risk management as the only goal.

The trouble with a generic rehab protocol is buried right there in their title.

“Post-Op ACL Reconstruction Protocol, by Dr. So-and-So.”

Now before we even debate the specifics, remember that we don’t treat ACLs, we treat people. People with new ACLs. People with vastly different social situations, medical health, thoughts and beliefs, and physical abilities or impairments.

How do we treat a reconstructed ACL? That's the wrong question.

We should be interested in how we treat our patient, keeping in mind their altered anatomy as one factor, albeit a major one.

When we are at our creative best, the post-op/post-injury rehab plan that we create for our patients should follow a standard pattern.

• Any outright motion restrictions should be plainly stated. This will be determined by us, based on the nature of the injury, or if the case is post-operative, then by the surgeon as they know exactly how robust or fragile the tissue was that they encountered in surgery.

• Next, the general principles of the rehab goals should be indicated. In the case of most joint surgeries, that is a combination of

  • resolving inflammation

  • regaining ROM,

  • regaining strength,

  • mastering proprioception

  • a return of general mobility and fitness.

• Under each of these headings, we should list the treatments or exercises we intend to prescribe to meet each goal. (This is something we learn as part of the Physiotherapy Guild MSK Fellowship program - it's called Impairment Based Treatment Planning, and it's vital to understand.)

  
  

  

  One of the 12 Frameworks used in the Physiotherapy Guild MSK Fellowship program.

This is not an easy thing to do. There are five key categories listed above. Let's think of just one: strength. In that category alone, we have quite a number of body regions and muscle groups to consider. What if we just consider strengthening the hip extensor muscle group itself ? And then we limit ourselves to just supine, closed kinetic chain strengthening of that group. By my account, there are at least 21 different versions of an exercise that could be prescribed. Follow this link for my list:

Bridging.pdf

Download PDF • 720KB

In the end, the specific decision of what exactly to prescribe should rest with the treating therapist and their clinical wisdom, and their understanding of the unique individual that they are treating. This is all the more important when we acknowledge that

there can be harm in strictly following a protocol.

Imagine the standard protocol for a particular joint arthroplasty. These protocols are generic and apply to every patient - we rarely if ever see modified protocols based on a patient’s unique age or fitness level. Should we apply the same protocol to a 78-year-old frail osteoporotic lady as we do to a healthy 49-year-old one with the same surgery? That would be foolish. The protocol may be over-dosed and dangerous for the former, and under-dosed for the latter leading to delayed return to function.

If you have a favorite exercise that you always prescribe for every patient with the same surgical procedure, perhaps you have fallen prey to this fault.

The best approach is to prescribe based on principles. Ask yourself, what does this particular patient need to improve their ROM / strength / proprioception. Oftentimes, you’ll be modifying a standard exercise to be safer, or more vigorous as the need applies. Perhaps pain is a bigger factor than it should be, and that needs to be managed first before getting too much into the rehab. It is our 6+ years of academic training that gives us the expertise to make these decisions, and we shouldn’t defer them to a protocol simply out of laziness.

Can you imagine showing up at a high-end restaurant and handing the chef a recipe you would like them to make?

I try not to be offended when I am presented with a written, detailed rehab protocol to follow. But the truth is, you wouldn’t go to a master chef’s kitchen and demand they make you a soup following your exact recipe, would you? I guess if you did, you might get a fine soup, but a talented rat could do the same thing (subtle reference here to Pixar's wonderfully animated film Ratatouille)

Be encouraged to take your exquisite academic knowledge and your years of clinical wisdom, stir them all up with a big huge whisk of creativity, and come up with something really helpful for your client. They deserve that from you.