This article was written by Danya Sadler, Student Physical Therapist, during her clinical rotation at Nick Rinard Physical Therapy.
What is Prehab?
Many people assume that physical therapy begins only after surgery, but postoperative rehabilitation is just one part of what physical therapists do. The American College of Surgeons defines prehabilitation, or “prehab,” as “a process of improving the functional capability of a patient prior to a surgical procedure so the patient can withstand postoperative inactivity and the associated decline.” Physical therapists accomplish this through targeted exercise, education, and movement strategies tailored to each individual.
What the Research Shows
Prehab is much more than simply “getting ready” for surgery, it gives patients the opportunity to improve strength, mobility, and confidence while working toward their best possible outcome. A growing body of research has shown that prehab is an effective way to make the most of that opportunity. A research article by Konnyu, et al. finds that prehab prior to total knee or total hip surgeries can lead to reduced length of stay in the hospital, increased strength, and decreased stiffness post-operatively. Another article looking at orthopedic surgeries found that “prehabilitation was associated with moderate improvement in several preoperative outcomes (function, 6-minute walk test, knee flexor and hip abductor strength, etc.) among patients undergoing all orthopedic procedures and was also associated with a reduction in back pain among patients undergoing lumbar surgery.” (Punnoose et al., 2023). The research behind this topic has been vastly growing over the years but all other articles shared similar findings. In some cases, the prehab process reveals something patients weren’t expecting: surgery may not be the right next step after all.
When Physical Therapy May Help Avoid Surgery
For many musculoskeletal conditions, current evidence supports physical therapy as a first-line treatment for many musculoskeletal conditions before considering surgery, as many patients achieve similar improvements in pain and function without an operation. This is not to say that surgeries are bad nor never warranted, because they are actually very well researched and helpful in many cases. By using physical therapy first however can help patients find a potential non-surgical way of improving function and reducing pain, or, if symptoms persist despite appropriate rehabilitation, physical therapy can help patients and their healthcare team determine that surgery is the most appropriate next step. Multiple randomized control trials and systemic reviews comparing supervised exercise therapy with arthroscopic surgery for degenerative meniscal tears have found similar improvements in pain and function, while the physical therapy group demonstrated greater improvements in muscle strength early in rehabilitation.
A Closer Look at Low Back Pain
Evidence supporting conservative care extends beyond meniscal injuries. Similar recommendations exist for conditions such as knee osteoarthritis, rotator cuff injuries, and more but I want to present some evidence about its use with patients with low back pain since we see many individuals with this at the clinic. While surgery for back pain is appropriate in certain conditions like progressive neurological deficits or required fusions, most episodes of low back pain improve with conservative care. Current clinical practice guidelines from JOSPT and the American College of Physicians recommend remaining active, participating in exercise-based rehab, and working with a physical therapist before considering surgical intervention when there are no red flags found by your clinician or your physical therapist. Physical therapy can decrease pain, improve mobility, increase strength, and also help patients return to their daily activities while determining whether surgery is truly necessary.
The Right Treatment at the Right Time
Ultimately, the goal of prehab isn’t to avoid surgery at all costs, it is to ensure that each patient receives the right treatment at the right time whether it be surgery on conservative care. If surgery is found to be the best next step, patients will benefit from becoming stronger, more informed, and more active participants in their own care.
Konnyu KJ, Thoma LM, Cao W, Aaron RK, Panagiotou OA, Bhuma MR, Adam GP, Pinto D, Balk EM. Prehabilitation for Total Knee or Total Hip Arthroplasty: A Systematic Review. Am J Phys Med Rehabil. 2023 Jan 1;102(1):1-10. doi: 10.1097/PHM.0000000000002006. Epub 2022 Mar 12. PMID: 35302954; PMCID: PMC9464791.
Punnoose A, Claydon-Mueller LS, Weiss O, Zhang J, Rushton A, Khanduja V. Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis. JAMA Netw Open. 2023;6(4). doi:10.1001/jamanetworkopen.2023.8050
Kise N J, Risberg M A, Stensrud S, Ranstam J, Engebretsen L, Roos E M et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up BMJ 2016; 354 doi:10.1136/bmj.i3740
Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514–530.
George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., Gilliam, J. R., Hendren, S., Norman, K. S., et al. (2021). Interventions for the management of acute and chronic low back pain: Revision 2021. Journal of Orthopaedic & Sports Physical Therapy, 51(11), CPG1–CPG60. https://doi.org/10.2519/jospt.2021.0304
We had a patient this past week with a unique challenge. This patient had been fighting with a serious medical condition for the past couple months and had, a week before seeing us, started experiencing pain on their left lower ribs. This patient had great difficulty sleeping, rolling over, and generally moving around and wanted to see if this new symptom was related to the illness or if it had a mechanical component.
This visit was conducted via telehealth which is a great way for patients to be seen who either are living or travelling far away or people, like our patient in this article, who are homebound due to their illness or injury. This patient was told at the start of the visit that we were going to use this first visit to determine if there was a mechanical component to their rib pain and if there wasn’t, that we were going to help guide them to appropriate medical providers for further evaluation.
Using Movement to Find Answers
During this visit, it was difficult to conclude whether the rib pain was mechanical or visceral. The patient had tenderness around their left lower ribs, but also had right sided tenderness right underneath the ribs dealing more with internal structures. One notable finding was the patient experienced some pain relief when side-gliding to the right and side-bending to the right. Based on this response, we decided to have the patient perform these consistently over the next few days to see if this would relieve symptoms and help us conclude if this rib pain was indeed mechanically based.
An Unexpected Setback—and a Breakthrough
When we followed up with the patient a few days later, they reported an eventful week. Shortly after our initial evaluation, they went to the emergency room with severe rib pain and did not do their PT exercises at all. After testing negative for any illness related cause of her rib pain, she went home and then began performing the assigned movements consistently. They worked! The patient was happy to report that their pain had almost completely gone away! They were very grateful that we were able to provide the tools to reduce their pain and gave them hope even in these really difficult times that they were facing with their illness.
The Power of a Thorough Assessment
This case highlights the value of a thorough physical therapy evaluation, even when symptoms occur alongside a significant medical condition. Rather than making assumptions about the source of the patient’s pain, we used movement testing and symptom response to guide our clinical decision-making and determine the most appropriate next steps. By the patient’s second visit, their rib pain had improved dramatically, allowing them to move, sleep, and function more comfortably. Just as importantly, the patient gained confidence and clarity during a challenging time in their health journey.
A mistake that people often make is waiting too long to start physical therapy treatment for their aches and pains. This commonly occurs because you may be thinking, “this will go away on its own,” or, “it’s just normal for me to feel like this at my age.” I want to clear up some confusion on mechanical pain versus normal muscle soreness that does not require skilled therapy or treatment.
Muscular Pain:
Experienced after a sudden increase in activity or exercise.
Running 6 miles when you typically only run 2 miles
You increased the intensity or length of time to your typical workout
Will be experienced 1-2 days after the increased activity has been performed and will typically begin to dissipate or be gone in 3-5 days after onset.
Is typically vague pain or experienced in a general area. The pain will not be sharp or pin-point to a specific area.
If you’re educated on what muscles perform which actions, the sore muscles will correlate with what activity you were performing.
Does not have increased or decreased pain associated with positions.
Mechanical Pain:
May have a sudden onset without explanation of occurrence (you woke up with pain for no apparent reason).
Will typically have a loss in range of motion. For example: it may be difficult to stand up straight in the morning or after prolonged sitting or driving.
Will have positions that will increase or decrease symptoms. For example: pain increases with sitting, pain is better while lying down.
If you’re experiencing mechanical pain the sooner you seek physical therapy treatment, the better! A good Physical Therapist can determine which exercises will reduce your symptoms and get you back to doing the activities that you love!
Waiting to start PT after an accident can actually INCREASE your healing time
Some people are told to “rest” for 4-6 weeks before starting therapy after an accident. The problem with this? There are many things a person can do immediately after a car accident to facilitate healing and prevent dysfunction.
All too often, we see people 6 months or more after a car accident or motor vehicle accident (MVA).
Without exercises at home, the picture is this: limited, painful movement of the spine or joints, global weakness, and poor posture that becomes painful when corrected.
The same is true for other types of trauma as well! Prolonged rest causes stiffness, and can lead to increased pain.
Nick Rinard Physical Therapy has a very effective treatment protocol that helps patients avoid loss in range in motion, and decrease pain!
Happy Thanksgiving from Nick Rinard Physical Therapy
From everyone at Nick Rinard Physical Therapy – We wish you a happy Thanksgiving.
Nick Rinard Physical Therapy will be CLOSED for Thanksgiving on Thursday, November 23th 2023, Friday November 24th, 2023, Monday 27, 2023 and Tuesday 28, 2023..
Nick Rinard Physical Therapy is very Thankful to have you in our lives! We couldn’t do it without you!
Regular office hours will resume Wednesday November 29 2023.
If you are in need before then please do not hesitate to call 503-244-6232 or email help@rinardpt.com and we will get back to you as soon as possible.
“I thought this was the end of my physical fitness routine (and youth) before coming to Nick Rinard Physical Therapy.
But I feel 100% better and know I have the right tools to address this issue if it should ever come back.
I loved all of the clear explanations I received regarding what was physically happening and causing my pain as well as the explanations for how the exercises help to mitigate and fix the pain.”
Slippery streets, short days, and increase stress can make winter a high-risk season for falls and injuries. How can you help prevent falls at home? One excellent way to avoid falls is to improve your strength and balance. Our team at Nick Rinard Physical Therapy is ready to help you!
Dealing with pain on a daily basis is fatiguing and frustrating. At Nick Rinard Physical Therapy, we empower our patients with individual, customized home exercise programs to help you gain control of your symptoms. We believe in education, and prioritize teaching our patients how to become effective in their daily routines. If you are tired of being a victim to your out of control symptoms, contact us! Our team is dedicated to helping you chart a course to better health.
