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Exercise Protocols: Why They Often Work and Why We Must Be Careful

11/3/2014

9 Comments

 
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?
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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.

-Chris
9 Comments
Alex
11/3/2014 03:29:00 am

What is Ellenbecker's protocol? Just curious on what he uses for shoulder pathology.

Reply
Chris link
11/3/2014 11:19:25 am

Several push and pull exercises along with rhythmic stab and scapular mobilizations. That's it haha Oh and a body blade is thrown in there as well.

Reply
AJ
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?

I always reflect on a quote from a fellow I worked with: therapy is like being a good chef/baker. It takes the right amount of each ingredient at the right time and cooked/baked at the right temperature to get the outcome we want - right intervention at the appropriat time in the POC prescribed at the optimal dosage for maximum patient outcome... But good bakers/chefs know how to add their own secret ingredients.

AJ

Reply
Kevin
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.

I had no interest in outpatient physical therapy before my rotation in AZ, but the passion Todd brings to the clinic is inspiring. The amount of information I attained while being in the clinic with Todd was immense, no doubt due to years of research and patient care he has performed. I have yet to come across a physical therapist that performs an evaluation as thorough, efficient, or personal as Todd does. It is truly an art form. In the time I was at his clinic, I did not come across a patient who wasn’t completely satisfied with their experience, which should also be considered a work of art taking into account the amount of patients he has treated.

The beauty in Todd’s approach begins with the eval, which I’ve already explained as being more than adequate. Every current impairment, and potential future impairment is identified, contemplated, and addressed in the prescribed exercise routine. Patient goals and activities are implemented, encouraging self-efficacy. While it is true people who have similar impairments start from the same “exercise bank”, this is for a reason. That reason is called evidence-based practice, which we know is research-backed, a lot of which Todd himself has contributed. His results speak for themselves. While every person is unique, every shoulder dysfunction is not. Many different impairments of the shoulder share common qualities, almost all of which are very effectively treated by Todd’s “cookie-cutter” routine. Patients progress and regress at different rates, and the plan of care must constantly be adjusted. This includes modifying types, frequency, and difficulty of exercises performed. Todd, like any great PT, knows when and how to do this. The spectrum of treatment I witnessed was vast. He also genuinely considers input from those working at the clinic with him, including students like me.

I understand your clinic is also located in Scottsdale, and you may be a bit biased, but from a student standpoint it was hard to refute any of Todd’s policies or results.

Sincerely,
Kevin Hall, SPT (Wichita State University)

Reply
Chris
11/5/2014 04:32:13 am

Hi Kevin,

Thank you for your comments. I fear you misunderstood the purpose of the article. The focus was not on Ellenbeckr himself but on standard protocols. The PT I work with may have misinformed me about her experience with Todd but that was not ye point of the article. I am curious just how many PT'S you have worked around in your years of clinical practice since you are still in school? I don't say this to mock you but because it is all relative. Just because someone is an OCS does not make them a guru. I know A LOT of bad PT'S with their OCS. I almost considered not sitting for it this year because the information they test on is so outdated. Anyways, in reference to your research comment, do you ever look at where the articles stem from? Like which ones the studies cite? Because there are often lots of problems with those. For example, many cite a study for eccentric exercises using 3 sets of 15 reps for tendinopathy. Did you ever ask where that comes from? The results might startle you. Anyways my point is if you live and die by academia and what double blind studies say you can do, you may be disappointed in your outcomes. I hope this clears up some of your concerns about any perceived attacks on todd. He is a great clinician, don't get me wrong. But this was about systematic approaches. By the way, I thought your comment about bias was actually funny. I have never considered him competition. I focus too much on my patients outcomes. Not sure what lead you to that thought.

Chris

Reply
AJ
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.

Reply
David
11/5/2014 06:57:27 am

Chris, do you mind providing the reference for the tendinopathy article? I would love to read it

Reply
Chris link
11/5/2014 07:29:39 am

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.

http://www.ncbi.nlm.nih.gov/pubmed/25133077

http://www.ncbi.nlm.nih.gov/pubmed/18184750

Steve PTA
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

Reply



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