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The rehabilitation renaissance: Raising results and lifting patient expectations
More aggressive, earlier mobilization has led to better ranges of motion, faster return to sports.
The role of rehabilitation is undergoing a renaissance in orthopedic surgery.
With the onset of more precise surgical techniques and better implant fixation, earlier mobilization for patients has become a welcome reality. Earlier mobilization means earlier rehabilitation, thus breathing new life into the role of rehabilitation in orthopedic surgery. Moreover, these techniques and protocols have raised patient expectations about the results of their surgeries.
To help meet those expectations, the rehabilitation process begins even before the surgery. Surgeons have developed preoperative protocols that instruct patients in the types of exercise programs they will take on in the postoperative phase. When patients have an idea of their postoperative regimen ahead of time, the learning curve shrinks and surgeons see better functional results.
Another key contributor to early rehabilitation: a reduction in surgical time and the resultant reduction in blood loss. Anesthesiologists have added to the benefits with improved anesthetic techniques that make the postoperative course smoother than in the past.
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Birth of the renaissance
The rehabilitation renaissance in orthopedic surgery actually started in the late 1960s and early 1970s. Michael Pinzur, MD, has stated, “Salter taught me that motion is life and the AO group taught me immobilization led to ‘fracture disease.’” This realization meant that, in order for patients to have full lives after surgery and to avoid fracture disease, they needed to regain motion as quickly as possible.
The teachings of Sarmiento were also influential during this time. Sarmiento’s mobilization techniques for treatment of lower extremity fractures led to the possibility of earlier mobilization for orthopedic patients. In addition, Kleinert and Kurtz introduced meticulous repair of tendon injuries, followed by post-operative rubber band traction, which also led to earlier mobilization after orthopedic surgery. They, along with other pioneers, promoted and advanced the hallmark concept of early mobilization after orthopedic surgery, thereby highlighting the important role that early rehabilitation would play in recovery.
Rehabilitation has been embraced by subspecialties of orthopedic surgery. Knowing that rehabilitation is an integral step in a patient’s recovery, orthopedic surgeons have developed extensive protocols for the recovery period.
Specialty rehabilitation
In the past, sports medicine protocols for knee ligament injuries, especially cruciate ligament repairs, recommended immobilization in a cast or knee immobilizer for 6 to 12 weeks while ligament replacement tissue was allowed to heal. This practice has now been replaced by early, aggressive range of motion (ROM) exercises to regain full extension and flexion, followed by a vigorous secondary knee-stabilizing strengthening program. These aggressive postoperative management protocols have led to earlier mobilization of patients and thus earlier rehabilitation, which has allowed many professional athletes to return to their previous level of athletic performance.
The rehabilitation renaissance has impacted other orthopedic subspecialties, as well. Trauma surgeons learned the value of early casting to the amputation stump, which then was fitted with a temporary pilon. Early mobilization of the amputated limb has helped patients obtain a good gait pattern sooner, leading to quicker ambulation and the use of rehabilitation sooner in the recovery process.
Total joint surgeons embraced early motion and mobilization with the introduction of the continued passive motion (CPM) machine that was applied to the reconstructed extremity while the patient was still in the immediate postsurgical bed. CPM use hastened a patient’s return to ambulation and the need for appropriate rehabilitation. In total hip arthroplasty, CPM machines played a similar role in quickening the return to mobilization and the commencement of rehabilitation.
Spine surgeons too have come to understand the importance of earlier rehabilitation. Spine surgeons treating degenerative disc disease no longer immobilize patients in bed preoperatively. Cervical and pelvic traction have been abandoned as methods of treatment, which makes mobilization happen sooner.
Accurate spinal diagnosis
Thanks to more accurate diagnoses of disc problems through MRI and less tissue invasion using microdiscectomy, patients are out of the hospital in 24 hours and often return to light work within 2 days following disc surgery. Patients undergoing spine fusion, whether for degenerative disease or for fracture, have a shortened length of hospital stay — usually less than 5 days. Little, if any, postoperative bracing is now required for these patients, thanks to better implant fixation that allows patients to resume activity more quickly than in the past. Patients sustaining multiple traumas get treatment promptly with internal fixation, and thus can be quickly entered into a rehabilitation program for the uninjured areas and early ROM exercises can begin for the injured extremities.
Shoulder surgeons have embraced early rehabilitation, as well. They have benefited from ultrasound and MRI, which have allowed them to evaluate the integrity of rotator cuff repairs. In turn, shoulder surgeons can precisely know when it is safe to begin early range of motion exercises. Early ROM exercises are then followed by rehabilitation, which is usually an aggressive strengthening program.
The seeds for the rehabilitation renaissance in orthopedics were planted in the late 1960s and have come to fruition in the 21st century thanks to improved techniques in diagnoses, surgery, implant fixation, and anesthesia, all of which have led to earlier mobilization of patients. With earlier mobilization came the need for earlier rehabilitation, which has led to more timely and improved clinical results for each patient.
For more information
- David F. Apple Jr., MD, rehabilitation section editor for Orthopedics Today and medical director emeritus at the Shepherd Center, 2020 Peachtree Rd. NW, Atlanta, GA 30309; 404-606-2645; David_Apple@shepherd.org.
- Michael S. Pinzur, MD, professor of orthopedic surgery and rehabilitation, department of orthopedic surgery, Loyola University, 2160 1st Ave., Maywood, IL 60153; 708-216-4993; mpinzu1@lumc.edu.