Over my years of practicing I’ve realized that many clinicians have no criteria for progressing/regressing their post-surgical patients rehab programs. They seem to do it randomly or “just because.” And if you’re anything like me, the “just because” reason doesn’t fly.
So here are the thoughts, criteria, etc. that go through my head when deciding on when/how to progress (or regress) patients rehab programs. I’m not saying these criteria are the only way to do things or set in stone, rather they are guidelines I use to safely progress my treatments. Anything has to be better than nothing.
The two main areas I will touch upon are range of motion and ther-ex (i.e. strengthening, neuromuscular, dynamic stability, etc).
Range of Motion
First, let me say that if a surgeon wants certain ROM limitations, then you follow them. And yes, I’m well aware many surgeons are behind the times and put silly, many times counterproductive, limitations on their patients.
If you feel that it would be detrimental to the patient if you follow the limitations, then I highly recommend speaking with the surgeon. Maybe there was a reason you weren’t aware of as to why the restricted ROM. And if there isn’t a good reason and they’re just stuck in the 90’s, I’ll leave that up to you to make the call. I know that in those instances, many of us “obey” the limitations appropriately with our patient’s best interest in mind.
If there are no restrictions placed on the patient by the surgeon, then the #1 thing I use to gauge ROM progression is end-feel. It’s really that simple (and complex at the same time). When assessing someone’s motion, it’s not only important to quantify the amount, but also the quality of the movement and the type of end-feel.
The type of end-feel you get will dictate how you go about your ROM work for that session. Here are common end-feels and how they affect my progression. For some joints these end-feels are normal and for others they aren’t - the following rationales are for when that particular end-feel is abnormal for a joint:
Hard (bony) and Springy: don’t push into these end-feels or try to go past it. It’s hard or springy for a reason that you can’t “fix.” Instead you can just make it worse and cause more pain for your patient by going ham on them. It’s like trying to slam a door that has a rock in the way. You can’t progress this type of end-feel unless the underlying physical restriction is removed. Example - bone chip(s) in a joint limiting motion, meniscal fragment in the knee.
Soft tissue approximation: the only times I’ve thought of this as “abnormal” for a joint is in obese people. That extra mass ain’t goin’ anywhere anytime soon, so no sense in trying to progress that motion. I know some people will put motion limited by edema in this category but I think of that as more firm. Example - hip flexion limited by their gut.
Firm: due to increased tone, soft tissue (capsule, ligament, tendon) shortening; decreased tissue mobility (i.e. from incision). Many patients will have this type of abnormal end-feel once that initial surgical pain subsides.
This end-feel is where you can perform your manual therapy magic and improve motion, many times without actually stretching them into the limited motion - i.e. myofascial work, IASTM, PNF, MET, repeated motions, etc. I will “stretch” and progress these joints up to (and sometimes a little past) the firm end feel - making sure to never cause pain. Example: doing some myofascial work on the pecs, then ranging their shoulder into external (or internal) rotation until you hit the new end-feel, then repeating/or switching to another technique, ranging again, etc.
Empty: this is where the vast majority of post-op patients fall, especially in the early phase after surgery and the end-feel that many clinicians have a hard time progressing. Mechanically there is no limitation, rather it’s the pain preventing the joint from going farther. So if you push through the empty-end feel and crank away, you might get some temporary increase in motion, but it will come with the costly trade-off of increased pain/soreness (and probable fear of movement). And that increased pain/soreness and fear of movement typically causes the patient to not use the joint, guard it, etc - thereby negating the “gains” you just got.
The way to improve motion with an empty end-feel is to modulate the pain and address any underlying restrictions (i.e. joint mobility, increased tone) and then guide the joint through its pain-free range - stopping at the new end-feel. It sounds simple and cheesy, but use pain as your guide when progressing this end-feel. Example - using something like IASTM or rocktape or Gr I/II joint mobs to modulate shoulder pain and then guiding it through the new pain-free motion, stopping when it starts to hurt again.
Important Note: Early on in my career, I use to do aggressive joint mobs and crank the shit out of some patients, thinking that “no pain, no gain” method was the way to go. After a few years of that, I realized that that method wasn’t as effective as I thought it was and in many cases it was actually making people worse...not to mention me tired. I have gotten to the point now where I don’t want to cause pain with my manual treatments - some discomfort I’m ok with. If you’re one of those clinicians who is sweating after working on a patient and that patient is near tears during the treatment and super sore afterwards, I challenge you to improve their ROM without ever “stretching” them into that motion - it’s easily doable and, in my opinion, more effective.
Look for part 2 - Ther Ex next week!
via Dr. Dennis Treubig, DPT - Modern Sports PT
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