Situation:
Mrs H is a woman in her early 50’s. She attended physiotherapy for her first appointment last week, 4 weeks post rotator cuff repair. The post op orders stated there is to be no glenohumoral joint movement for 6 weeks. I asked Mrs H about this, according to her she was told not to so take the arm out of the abduction sling or move the arm at all during this time. At this stage she had not even had an appointment to see her surgeon since discharge from hospital.
I am thinking there are a few problems with this situation. This seems a very odd protocol to me. I had thought that most post op treatment protocols called for at least passive range of motion in the first 1-2 weeks of rehab, but was not confident with my knowledge.
I felt conflicted because I got the distinct sense that this lady had been lost in the surgeons system, she had told me that she was meant to have an appointment at two weeks, however when she went to make the appointment she was told she would be contacted to make an appointment when she needed to be. There was no reason I could think of in this lady’s history for such a restrictive post op protocol.
What was my role to be if the only exercises I could give this lady, she had already had on a sheet of paper given to her at discharge.
Task:
1. Try and provide this patient with the best possible treatment given the surgeons restrictions.
2. Find out more about the usual rehabilitation protocol post rotator cuff repair and any possible reasons for this surgeon’s post op orders.
Action:
I spent great deal of time of time talking to this patient regarding her ongoing management, what she needed to do and what would likely happen in the future. She was very distressed at how long the whole process was taking and how she seemed to have been lost in the system.
After reassuring the patient and setting a plan in place, I checked her elbow and wrist stretches as well as adding in a scapula stetting exercise.
After this I went home and did a search on rotator cuff rehabilitation protocols. I did a quick scan of PEDRO and ebsco. I found that in most of the control groups in studies testing various rotator cuff rehab protocols had the patients doing at least passive range of motion from day 2 or so. The experimental groups often had accelerated progression to static contractions and active assisted. Most of the evidence seemed to suggest that there was no difference in approach, also that a generic exercise approach was as good as a specific one.
Some reasons for adhering to a more limited post op program of exercise were specific problems with instability, poor bone strength or repair integrity. To my patients knowledge she had none of these. Perhaps this lady should have received a more accelerated program.
Result:
Hopefully the overall result for the patient will be good. Although her path to full function has been delayed, I convinced Mrs H to take a more active role in ensuring that she was receiving the best care possible. She will see her Dr as soon as possible, hopefully when he sees her he will give her the all clear to go ahead with physio as he was the person who referred her in the first place. Hopefully the surgeon had strong reason for the delay in GHJ ROM.
Seeing this patient has been a positive experience for me as seeing this patient prompted me to do some research. I have acknowledged that there are some holes in my understanding of standard rehabilitation protocols.
Evaluation:
It is important to keep up to date with the latest EBP. One of the positive things about musculoskeletal physiotherapy is that this is one area of physio where there is usually ample resources to keep up to date on the latest research. This experience has brought to my attention that I am not 100% confident with post op protocols of many orthopaedic procedures, (including rotator cuff repair). In order to understand why a surgeon may have given certain orders, or when someone needs further follow up I think it is important for me to have a better understanding of what the surgeon has done in each procedure and the standard path of rehabilitation. Because I wasn’t really sure of the norm compared with what this surgeon had asked, I was not confident with what I was doing.
Strategies:
Set myself the goal of revising general rehab protocols from orthopaedics.- Keep up to date on EBP. Set the goal of choosing at least one case from my patient list each week and research the most up to date information about relevant treatment techniques and prognosis.
- If unsure, in the future try and call the surgeon. I might not get an answer straight away but at least I might get some more understanding about the patient from a surgical perspective.
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