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

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.

-Chris