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Toni Talks about PT Today

The CPM Saga

Published December 16, 2008 11:37 AM by Toni Patt
We're having drama on the ortho unit of my hospital. An orthopedic doc is angry at the PT department. He believes we're not following his TKR CPM orders. He wants a CPM on every patient set at 120 degrees the day of surgery. He says he writes the orders but it doesn't always happen. He's right. It doesn't always happen. We're not ignoring his orders. We're listening to our patients who say that setting is too painful. They refuse to allow us to set the CPM that high.

I can see why the doctor believes we're not following his orders. It's not that we don't want to set the CPMs at 120 degrees.  We're trying. But instead of forcing that setting on the patient, we're setting the CPMs at patient tolerance.  Once we get the CPM going we try to increase to the 120 goal. We usually get there, but it's not the first day. Dr. L, the ortho doc, says that isn't good enough. He told us to have nursing increase the pain medicine.  Dr. L believes his outcomes will be worse if the CPM setting is obtained and maintained on every patient.

Dr. L is forgetting something. Patients have rights. One of them is to refuse treatment. The treatment could be a medicine, a test or therapy. Patients refuse things that hurt. If a CPM at 120 degrees is painful, the patient will not allow us to set it there. As therapists, we are respecting the right to refuse the higher setting if it is too painful. The point of developing the list of patient rights was to prevent health care providers from forcing them to do things against their will.  If I'm working bedside and a patient doesn't want to get up, I can't drag the patient out of bed. It works the same way with CPMs. If the patient doesn't tolerate 120 degrees, I can't force it.

Dr. L suggested setting the CPMs at 120 degrees and keeping the control away from the patient. Obviously we can't do that. I'm not sure how many patient rights that would violate. As a result, the PT department is caught in the middle.  We can't follow Dr. L's orders if the patient won't let us set the CPM that high. This isn't a new problem.  It has happened before. It will happen again.

I'm using Dr. L as an example. In reality, patients refuse all kinds of things. As a rule, doctors don't like that. This isn't the dark ages when whatever the doctor said was law. Patients have become more knowledgeable and aware about their treatments. This problem isn't whether the PTs are following the doctor's orders. The problem is that the patients are refusing to follow the orders. Dr. L needs to realize that. Maybe he should be mad at himself for not educating his patients on what to expect post-operatively.  Or, maybe he should be mad at the patients who are refusing the settings. There's nothing like an ortho doc yelling to inspire compliance.  The people he shouldn't be mad are the PTs who are trying to walk a thin line between patient desires and doctor orders.

I don't have a solution to this problem. As a department we can make a greater effort to get those CPMs to 120 degrees the first day.  We now call the department manager as soon as we have a problem with a CPM. He, in turn, calls Dr. L. Maybe Dr. L needs to put a few CPMs and try getting 120 degrees right away. Maybe he needs to experience patients refusing to follow his orders. That might help, but it won't happen.

posted by Toni Patt


I just had a total knee replacement  and I was never given an option to have CPM. My surgeon and PT informed me that it does not make a difference after 3 months of PT the end is the same. I requested for it still since reading from other review of literature it still offers benefits so as not to have manipulation done under analgesia. On 15the day of my PT, the day I was supposed to be discharged there was infection on my knee and had to irrigate and do arthroplasty again. This time my recovery is very tough. I still want to have CPM done since my knee is stiff and my PT progression is slow due to pain. My surgeon is still adamant about not having the CPM despite my request and I ended up having blood transfusion as well. My surgeon said they will do manipulation if my progression is not very good which I really do not like to do. Do I have the right to request the treatment for CPM? Can my knee infection be treated sooner knowing i was febrile up to 102 F even on the 4th day post-op? I am planning to just rent the CPM but will it still make a difference now that I am 5weeks  day post-op on the first surgery and3 weeks after they opened it again due to infection.

David February 5, 2009 6:11 PM
anaheim CA

When a patient refuses, it is easy to let it pass when we agree the refusal is in their best interest.  The question to ask ourselves is, if I thought the treatment they are refusing was beneficial (if in their place I would not refuse, but would accept the treatment), what additional information might I give to make sure they were making the right decision for them?

One thing I noticed is in your blog is that the doctor and other health care professionals are talking to each other, but not necessarily conveying everything to the patient.  You may be and I'm just not reading between the lines...or maybe today's excessive intake of sweet potato casserole has left me unable to see what is clearly before my eyes:-)  

Specifically what I am talking about is the increase in meds.  In acute care, I would commonly work with the nurses to medicate patients about 45 minutes before bringing them down, especially when I worked burn and ortho rotation...meds were our friends.  That seems a very reasonable suggestion from the doc to help accomplish his goal.  But I don't see where this option is being passed on to the patient.  (Now, I'm not saying I agree with his my years on ortho, I have to agree with Christie...I never saw CPMs at high settings make that much difference.  Regaining range really seemed to be more of an intangible...perhaps some sort of genetic makeup that influenced whether or not motion returned.  I was routinely surprised by patients.  Some who, by all rights, should have done well never got full range back.  Others who should have never made it to 90 degrees of flexion got full range back.  

What if CPM to 120 makes no difference for 99 patients out of 100, but the patient you have who just refused is the one patient whose outcome would be dramatically improved by that protocol?  Did you give them absolutely every piece of information to make an educated decision for them?

You mentioned the doctor needing to prepare his patients more pre operatively as to what would happen post operatively.  Most docs would be wise to follow your counsel there.  And let me add here, from your blog Dr. L sounds like a particularly accomplished pain in the tush.  But this isn't about Dr. L.  This is about doing what is best for the patient.  So since Dr. L is not communicating to the someone from the nursing or PT staff explaining the doctor's orders and his adamant directive for them to be followed, as well as the option he's suggested for increased meds to help tolerate the pain?  You could phrase it in a way to covey the doctor's belief system without stating your agreement or disagreement.  

Then following up on what Christie and Karen said, you document that educated patient on how strongly doc feels about CPM setting of 120 and that he feels that will lead to improved fxnl outcome (expressing the docs beliefs without interjecting yours)...also that you educated pt on doc's suggestion of increased pain meds to help tolerate setting.  Then patient declined or agreed.  You also call the doc's office and let them know how you've educated the pt and what the outcome was and document that as well.

Like I said, the PTs (or nurses) may already be doing this but if they aren't then they are respecting the patient's right to refuse without fulfilling the patient's right to informed consent.  The patient has to know all of his/her options (including increased pain meds to tolerate a tx, even if you think the tx is bogus) for the refusal to be valid.  

Janey Goude December 25, 2008 11:22 PM

In most PT depts. a DOR will institute a protocol as Christie suggested for all hip/knee/wound care/back etc patients.  Why isn't the DOR calling the MD and saying "This is what we do, and this is why we do it" with the articles cited as a reference.  

If that doesn't work then do what the patient is able to tolerate and document everything.  Let the MD balk, in the end what can he/she do about it if there is clear documentation and a protocol in place.  

A strong DOR works wonders in acute and SNF when dealing with MD's and their orders than don't compute with patients.

karen December 20, 2008 3:32 PM

I'd like to first ask the surgeon what evidence he has to be using such a protocol.  I've never heard of such a protocol, but the protcols listed below come close:

Prospective randomized clinical trial of continuous passive motion after total knee arthroplasty.

Source Clinical Orthopaedics & Related Research. (380):30-5, 2000 Nov.

Continuous passive motion with accelerated flexion after total knee arthroplasty.

Source Clinical Orthopaedics & Related Research. (345):38-43, 1997 Dec.

Both of these studies show no long term difference in outcomes.

I think what the surgeon is forgetting is that performing a treatment on a patient, especially one that is painful and against their will is battery...plain and simple.

Start calling the surgeon everytime you can't progress it to 120 degrees (and of course document how you attempted), have the nurse call as well.  After about 20 phone calls, he'll get the message.  

Finally, consider that hostile work environment is a new focus of JC this year.  There should be a protocol in place for you to report physicians and are being abusive and creating a hostile work environment.  I'd suggest you get your team to start utlizing it.

...otherwise, he can get his *ss down there himself and do it.  Let's see who gets hit with a lawsuit first.

Christie, Physical therapist December 16, 2008 9:24 PM
Streamwood IL

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