About a month ago, one of the physical therapists at my clinic did an inservice on the exercises she prescribes for the shoulder. She recently graduated from PT school and had done one of her final clinical rotations with Todd Ellenbecker from whom she basis her shoulder rehab. For those of you unfamiliar with Ellenbecker's treatment approach, each and every shoulder patient gets the exact same shoulder exercises. This was confirmed by my co-worker. The idea that a "cookie-cutter" approach is effective can be frustrating to the diligent therapist. Why take all the strength and ROM measurements if you are going to apply the same exercises anyway?
It's not that these generic approaches don't work, because they often do! If you think about your past cervical, shoulder, or whatever evaluations, you may recall that there exists a common set of impairments. Likely, the scapula are downwardly rotated, the middle and lower traps are weak, there is a hypomobile posterior capsule, and more. Impairments like these are so common, because of the frequency with which we assume certain postures (like FHP) and perform repetitive motions throughout each day. Because of this, many shoulder pathologies present with similar impairments and, thus, can be successfully treated the same way.
But what if they don't fall into the majority? Sure most people have limited occipitoatlantal flexion due to forward head posture (FHP), but not everyone. Most people respond well to repeated lumbar extension, but not everyone. The problem of always treating based on common impairments, instead of actual impairments, is that eventually you will run into the patient that does not fall into the majority. They will not respond to your treatment and not get better. Sure, most of the patients will improve, but not all. Or maybe they won't get 100% better. It is for this reason that we cannot blindly apply the same exercises to everyone we treat. We actually talked about how Ellenbecker is referred to as the shoulder and elbow expert by the APTA. You don't get to that level without some significant success, and the majority of patients improving (based on this approach) will form a large following, but may limit your expertise. Base your treatments off of impairments. If you stretch a lengthened muscle or mobilize a hypermobile joint, you may actually make a patient worse! Physical therapy does not have to be as difficult as we like to make it. The key is keeping an open eye to find all relevant impairments and treat accordingly. Knowing the common patterns may allow you to speed up the process, but if you ignore the exceptions, you will fail to make progress.
11/3/2014 03:29:00 am
What is Ellenbecker's protocol? Just curious on what he uses for shoulder pathology.
11/3/2014 10:36:40 pm
Chris. You bring up a great point and a common pitfall a lot of therapist get trapped into. I couldn't agree more with the impairment based approach and as a new grads I'll be the first to admit I always found myself trying to treat everything. With my residency I really learned to focus my treatment approach in order to ensure I was investing my time in the right areas and actually managing the impairments that were driving the patient complaints. Specifically, I feel we try and treat too much at once: sending a patient with "SIS" presentation home with Tspine ext mobs, a sleeper stretch, and ilpsilateral neck flexibility exercises. Now sure, there are likely those impairments present but without a systematic approach how do we know the next time we see that patient which intervention had either helped or harmed?
11/5/2014 03:16:00 am
Chris, I was referred to your article by one of my classmates who was aware that I also had a rotation in Scottsdale with Todd Ellenbecker. After reading your comments, I couldn’t disagree more. For those who aren’t familiar with Todd Ellenbecker or his credentials, he is a DPT, SCS, OCS, CSCS, and is a certified USPTA tennis teaching professional. Mr. Ellenbecker is the National Director of Clinical Research for the company for which he works, travels often to professional tournaments throughout the world for research and to help treat athletes, and has authored more research, publications, or texts (including some you and I have studied from) than will fit in this comment box. The APTA refers to him as the shoulder guru, because he is just that.
11/5/2014 04:32:13 am
11/5/2014 04:46:33 am
Chris, great point. We have to remember that care is based around a triad and evidence is one piece of it. I'm glad you brought up the OCS exam, it's terrible to think that this distinguishing credential in our profession truly only determines who can study and take a test well. I've heafd many recognized experts in PT speak to this (Flynn, Childs, Wainner) speak to its dysfunction as a measure of skill/care.
11/5/2014 06:57:27 am
Chris, do you mind providing the reference for the tendinopathy article? I would love to read it
Here are just a couple. There are more articles of course on eccentrics. I just think it's odd how the dosage of "3 sets of 15" is used everywhere for tendinopathy. Especially, since the patients typically are chronic pain patients. Patients in earlier stages of tendinopathy have not been examined for this.
11/6/2014 06:06:06 am
Wow. you guys/gals work in health care as physical therapist with a bunch of initials following your names, that mean pretty much nothing if the only reason you are getting then is to do a sternal lift. Why include someones name in a blog post about standard protocols if you don't intend to associate that person with your point? EGO and jealousy abound in ortho PT. always has always will. Go compete go compete..healthcare looses
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