What are the latest recommendations for postoperative rehabilitation?

Latest Recommendations for Postoperative Rehabilitation

Begin rehabilitation immediately after surgery with a structured, goal-based progression that prioritizes early mobilization, multimodal pain control, and neuromuscular training, continuing for 9-12 months for high-demand activities. 1

Core Principles of Modern Postoperative Rehabilitation

Immediate Initiation and Duration

• Start rehabilitation on postoperative day one, regardless of surgical procedure 1
• Continue structured rehabilitation for 9-12 months for patients returning to high-intensity sports or physically demanding work 1
• For cardiac surgery patients, initiate comprehensive rehabilitation within the first 2 weeks to reduce complications and hospital length of stay 1
• The traditional 22-week rehabilitation protocols are insufficient; most patients cannot achieve end-rehabilitation goals in this timeframe 1

Goal-Based Progression (Traffic-Light Method)

• Use objective criteria to advance between rehabilitation phases, not time-based protocols alone 1
• Patients progress only when specific measurable goals are achieved and confirmed with objective testing 1
• This patient-tailored approach ensures safer and more effective rehabilitation compared to rigid time-based protocols 1

Early Mobilization Strategy

Weight-Bearing Protocol

• Initiate immediate full weight-bearing if the patient demonstrates: 1
  • Correct gait pattern (with crutches if necessary)
  • No pain during or immediately after walking
  • No joint effusion or temperature increase
• For cardiac surgery, mobilize patients on postoperative day one to reduce pneumonia, atelectasis, and ICU length of stay 1
• Early mobilization improves physical capacity (VO2 max, 6-minute walk test) at discharge 1

Facilitating Early Mobilization

• Remove drains, urinary catheters, and central lines as soon as safely possible to enable mobilization 1
• This is critical for post-cardiac surgery pathways but applies broadly across surgical specialties 1

Multimodal Pain Management

First-Line Analgesic Approach

• Apply cryotherapy in the first postoperative week to reduce pain (Level 1 evidence) 1
• Use acetaminophen 1g every 4-6 hours alternating with NSAIDs (e.g., ketorolac 15mg IV every 6 hours) for baseline analgesia 2
• This combination provides opioid-sparing analgesia and reduces opioid-related side effects 3, 4, 2

Regional Anesthesia Techniques

• Consider continuous peripheral nerve blocks (e.g., lumbar plexus/psoas block for lower extremity surgery) for superior pain control without opioid side effects 2
• Regional techniques facilitate early mobilization and physical rehabilitation 2

Avoiding Common Pitfalls

• Do NOT rely on opioids as primary analgesics; they delay mobilization, cause ileus, and prolong hospital stay 4
• Multimodal analgesia is the cornerstone of enhanced recovery, not an optional adjunct 4

Neuromuscular and Strength Training

Week 1: Muscle Reactivation

• Begin isometric quadriceps exercises on postoperative day one when pain-free (Level 2 evidence) 1
• Add neuromuscular electrostimulation to re-educate voluntary quadriceps contraction during the first 6-8 weeks (Level 1 evidence) 1
• This combination accelerates muscle reactivation better than exercises alone 1

Week 2 Onward: Progressive Loading

• Start closed kinetic chain (CKC) exercises from week 2 1
• Prioritize CKC exercises over open kinetic chain (OKC) to reduce patellofemoral stress 1
• Progress from isometric to concentric, then eccentric exercises as tolerated without effusion or pain 1

Week 4+: Open Kinetic Chain Exercises

• For bone-patellar tendon-bone (BPTB) grafts: Begin OKC exercises at 4 weeks in 90-45° ROM with added resistance allowed 1
• For hamstring (HS) grafts: Begin OKC exercises at 4 weeks in 90-45° ROM but add NO extra weight for first 12 weeks to prevent graft elongation 1
• Progress ROM weekly: 90-30° (week 5), 90-20° (week 6), 90-10° (week 7), full ROM (week 8) 1

Critical Addition: Neuromuscular Training

• Combine neuromuscular training with strength training throughout rehabilitation (Level 1 evidence) 1
• This combination optimizes outcomes and reduces risk of secondary injury 1
• Focus on quality of movement, not just strength metrics, as altered biomechanics increase reinjury risk 1

Prehabilitation Integration

Combined Pre- and Postoperative Programs

• Combine prehabilitation with postoperative rehabilitation to reduce complications and hospital length of stay (Grade 2+ recommendation) 1
• Multimodal prehabilitation (aerobic exercise, resistance training, protein supplementation, relaxation) increases preoperative physiologic reserve 1
• Prehabilitation alone shows modest benefits; the combination with postoperative rehabilitation is superior 1

Target Population

• Prioritize prehabilitation for less fit patients who are more likely to benefit 1
• More than 80% of patients receiving multimodal prehabilitation return to baseline functional capacity by 8 weeks postoperatively 1

Return-to-Activity Criteria

Objective Testing Requirements

• Use objective criteria, not time alone, to determine return to activity 1
• Minimum criteria include: 1
  • No pain or swelling
  • Full range of motion
  • Limb symmetry index (LSI) >90% for strength and hop tests
  • For pivoting/contact sports: LSI of 100%
  • Completion of sport-specific training program

Timeline Expectations

• Most patients are not ready for return to play at 8 months despite feeling subjectively ready 1
• Plan for 9-12 months minimum for high-intensity sports or physically demanding work 1

What NOT to Do

Avoid Routine Bracing

• Do NOT use routine postoperative knee bracing; it is associated with a 2.83-fold increased failure rate and lower quality of life 5, 6

Avoid Continuous Passive Motion

• Do NOT use continuous passive motion devices; guidelines recommend against this modality 1

Avoid Premature Progression

• Do NOT advance rehabilitation phases without meeting objective criteria, even if the timeline suggests progression 1
• Premature return to activity increases reinjury risk due to persistent neuromuscular deficits 1

Surgery-Specific Considerations

Cardiac Surgery

• Postoperative rehabilitation started within 8 weeks reduces medium- and long-term mortality (1 year and 10 years) 1
• Include cardiovascular, respiratory, and mobilization physiotherapy 1

Colorectal Surgery (ERAS Protocol)

• Prehabilitation shows promising results but requires further research before becoming mandatory 1
• Focus on preoperative nutritional screening and optimization 1

Orthopedic Surgery

• Rehabilitation duration and intensity depend on graft type, surgical technique, and concomitant procedures 1, 6
• Direct communication with the operating surgeon is essential to tailor the protocol 6