Lately I’ve had a new favorite kind of patient. Can you guess what it is? It may come as a little bit of a surprise, but recently I’ve really been enjoying my prehab patients. I’ve had more prehab patients in the last 6 months than probably the last 5 years combined. My workplace has definitely seen improvement in patient outcomes with the use of prehab for total joint replacements. In my opinion, prehab should definitely be the norm. In this week’s post I’ll share the benefits of prehab, why I like it, and what I’m commonly doing with my prehab patients in our sessions.
Research on Prehab
When I dove into the research, it was difficult to get a consensus on the benefits of prehab, especially when looking at total joint replacement. I’d see one study where researchers reported improved outcomes in gait and strength, but not range of motion. Then I’d find another that said range of motion was better, but not strength. I’d also see some where they reported no change in any of these tests or measures. Results were inconclusive with overall health utilization as well. Some studies showed patients who completed prehab required less medical follow up visits, some more, and some no difference. So, if we look at the research on prehab, it’s a bit all over the place to be honest.
I did not see any studies where patients who received prehab did worse than the control group. So it’s at least proven that a little prehab before total joint replacement doesn’t hurt anything. I also came across a couple interesting studies, looking at intriguing or new approaches to prehab.
For example, I’d never thought about this but a couple studies looked at home-based prehab programs and had supportive results. Here’s one from the UK if you want to check it out.
I also saw a few studies looking at the use of blood flow restriction (BFR) in prehab that also had positive results. The BFR studies definitely interested me because our clinic actually just got BFR in the last year and we’ve seen some good results as well. Here’s just one of the few if you want to take a look.
For the sake of consistency and conciseness of this blog post, we’re going to focus mainly on total joint prehab, but I did want to make a quick comment on ACL prehab. The research there gave a much clearer picture. Most studies reported improved outcomes with prehab prior to ACL repair. This is just one of several if you’re interested in looking specifically at ACL prehab.
Why I Like Prehab
Even though the jury is still out on the effectiveness of total joint prehab, I still like it for a lot of reasons.
I think prehab makes patients more physically prepared for surgery. In my opinion, the stronger someone is going into surgery, the better. For example, if someone is already going into TKA with poor quad activation, weak quads, tight hamstrings, or tight gastrocs, the list goes on and on – that’s only gonna be worse after surgery. In prehab we can address those issues so they don’t negatively affect the patient as much immediately after surgery.
I also think prehab prepares people mentally. A lot of patients want to get their knee done, but they have anxiety about it. During prehab I do A LOT of educating on what day of surgery typically looks like, how they can expect to feel in the first week after surgery, and what rehab inpatient and outpatient will look like. Giving patients a clear picture can ease a lot of their worries. I find they are much better at taking their entire course of rehab in stride from post-op day 0 to discharge because they say “well yeah I knew it would be like this because we talked about it.”
Along with easing anxiety, prehab also sets the stage for expectations for rehab and recovery in general. Your inpatient PT friends will thank you for letting the patient know the plan will be to get up the day of surgery. After surgery, I’ve also never had a prehab patient ask “but why does it hurt so much?” because we’ve talked about it in prehab. There is a way to prepare people for pain without scaring them. Knowing it’s going to hurt for a while, but that’s normal, and it will gradually get better can keep a patient from perseverating on it.
Lastly, I like prehab because if you see a patient for prehab it’s likely you’re gonna see them after the surgery too. Prehab gives a great opportunity for you and the patient to build a rapport beforehand. It’s kind of like a “dress rehearsal” for you guys before the big show. You already know how that patient learns, communicates, and is motivated. They have good trust in you since you’ve already prepared them so well for their surgery. In my opinion, a strong patient rapport has the potential to make or break a person’s progress. If they’ve done prehab, you’ve already gotten past the awkward “get to know you phase.”
My Prehab To-Dos
Obviously there are a TON of things you can do with your pre-habers. Here’s the things I do the most or find the most helpful.
Identify musculoskeletal things that could be a problem in recovery
Like I said before, I like prehab because we can get ahead of things that could cause problems in recovery. My first to-do is to find those musculoskeletal deficits. Patient has quad atrophy? That’s gonna be an issue for a lot of reasons. Let’s work on some activation and strengthening ahead of time. Something like hamstring and gastroc tightness might be a problem for extension range of motion. Let’s get it stretched out now. If we catch that stuff early, the patient doesn’t have to start from square one while also dealing with all the other post-surgery things.
Education, education, education
Education is probably the #1 thing I use for my prehab patients. I think it sets the patient up for success more than anything else. How the day of surgery works. What outpatient therapy looks like. How they can expect to feel the first couple weeks. How they can expect to be moving in the first couple weeks. Pain control, activity pacing, and healing time are all on my list. I tend to just spread it out throughout the prehab plan of care and most of the time these topics come up naturally. It’s very cliche of me to say, but knowledge truly is power. The education helps patients “roll with the punches” of total joint rehab better than patients who didn’t get prehab. We’re able to really just double down and focus on the functional aspects after their surgery because we’ve already talked about all that other stuff.
Blood flow restriction
Blood flow restriction isn’t something I use with all prehab patients. However, I have found it extremely helpful when I need it. If you see a lot of prehab patients you’ve probably come across someone who is pretty weak, but just can’t tolerate a lot of load due to the severity of their arthritis. This is where blood flow restriction can make all the difference. The science behind blood flow restriction could be its own separate blog post. If you’re not familiar, basically it can help a patient achieve some of the benefits of traditional strength training, but with lower loads and intensity. So you can see how it would be great for someone with advanced knee OA who may have trouble with weight bearing exercises or a lot of load. We can kind of hack the patient’s musculoskeletal system with BFR and get them ready for surgery.
Dry needling
Dry needling isn’t something I use on every pre-haber. Much like in the situation with blood flow restriction, sometimes these patients are just in A LOT of pain. Yes, prehab is primarily to get the patient ready for surgery, but sometimes some pain control can go a long way. I’ve seen patients who are strong and are very active, but they are looking for something to get them to their surgery. I’ve seen situations where a patient needs pain control so they can keep working up until their surgery. Or even just to participate in the activities they love doing.
A lot of people have strong feelings about dry needling, both bad and good. I’ve found a lot of success with it. I took a course from the American Academy of Manipulative Therapy where we were taught a protocol specifically for knee OA. So far, I haven’t had anyone feel like it didn’t help them. Like blood flow restriction, it isn’t a must, but can certainly be helpful. So don’t worry if you don’t have equipment or training in blood flow restriction or needling. Again, just sharing my personal experiences.
If you also see a lot of prehab patients, what’s on your must-do list? Or what things have you found the most helpful? Obviously I’m a fan of prehab, but what’s your take? Drop it in the comments section! I’d love to hear some other thoughts and perspectives or what you’re doing with your patients. If you’ve missed some posts you can catch up on those by visiting the blog page. If you want to make sure you never miss new stuff to keep up with all things PT, hit that subscribe button below!
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