Today’s guest post “The Use of Rehabilitation Protocols in Physical Therapy” comes from my good friend and frequent contributor, Trevor Winnegge. Trevor writes a nice article discussing the use, and often times over-reliance, of rehabilitation protocols by physical therapists. I’ll add some comments at the end of the article as well. Hope you enjoy!
In writing this post, I am going to stray away from the normal educational posts on this blog. I would like to take this opportunity to provide my commentary on the use of orthopedic and sports medicine protocols by physical therapists, and a problem I am seeing more common of late:
Physical therapists are not using their brains!
Too often, I get referrals and phone calls asking to take a second look at a physical therapy patient. Most of them are post operative and have been doing their rehabilitation elsewhere. Upon evaluation, the patient is behind schedule and doing poorly. When I ask the patient what they have been doing in physical therapy, the answers are often all over the map. The patient will say the therapist is “just following the doctor’s protocol.”
It is that statement that inspired me to write this post.
The Use of Rehabilitation Protocols in Physical Therapy
We as physical therapists have gone through a lot of schooling and hard work to earn our degree, pass our board exams, and remain licensed each year. We possess knowledge of anatomy, kinesiology, biomechanics and rehabilitation like no other.
Unfortunately, I see and hear stories of physical therapists not using this knowledge base and simply following a protocol.
Lets use an example of a patient who recently had a medium sized rotator cuff repair. The referring surgeon sends them to physical therapy 10-12 days post operative and the therapist initiates the surgeon’s protocol. The protocol states passive and active assisted range of motion only for six weeks. This patient comes into the clinic twice a week to be stretched and is compliant with his home exercises. The therapist performs passive and active assisted range of motion only, as stated on the protocol.
The therapist took the phrase “range of motion only” literally and did not perform any other aspect of therapy. While this patient may end up with a decent outcome, the therapist is following the protocol and not utilizing their education to the best of their ability.
Don’t Be Afraid to Think!
In addition to the range of motion, there are many beneficial treatments that could be performed to help the patient feel and function better.
You could perform soft tissue mobilizations to areas that are sore or tight from guarding all day, such as the rhomboids, subscapularis, latissimus, and pectoralis. Postoperative patients are often guarded, in a sling, and not moving their arm normally. By performing soft tissue, you can help them relax and increase tissue extensibility.
Ultimately, we should be helping the patient become more comfortable and return to their functional activities.
You can also perform scapular mobilizations to start getting the scapula free of restrictions and allow it move through full range of motion. This patient is not actively moving their arm, therefore the scapular is also not moving through it’s normal range of motion. Think of this as passive range of motion for the scapula, which is absolutely necessary.
In addition to these interventions, you can also perform scapular PNF manual resistance for scapular retraction and depression. The protocol states ROM only, so many therapists won’t perform this technique. However, this is not resistance for the shoulder or rotator cuff.
This PNF pattern works the rhomboids, middle trapezius, and most importantly the lower trapezius. By utilizing my knowledge of anatomy and kinesiology, I know the lower trapezius attaches to the medial border of the scapula, forming a force couple with serratus anterior to upwardly rotate the scapula when elevating the arm above ninety degrees.
Lower traps are a key muscle group to target for a successful rehabilitation program. While we can’t have the patient use their arm to perform lower trap exercises, you can have them get in the sidelying position with the affected arm towards the ceiling. Place your hand over the inferior angle of the scapula and provide manual resistance into depression and retraction, on a diagonal pattern. You can then passively bring them back to the starting position. I will do multiple sets per visit. This starts activating the lower traps without putting any harm or strain on the rotator cuff.
Let Protocols Direct You, Not Dictate to You
None of the above mentioned interventions were written on the protocol. Yet I know all of them are safe, effective, and a much better use of my patient’s time and money. It will allow for a better and faster recovery, while keeping the integrity of the surgery intact.
So I encourage all therapists to start thinking more with your hard earned physical therapy degree. Become less complacent while following a protocol. Challenge yourselves to develop more comprehensive treatment interventions for the post operative patient, whether it is a rotator cuff, ACL, fracture, joint replacement or any other surgery. Approach protocols as guidelines, not all inclusive to what you can do. You will be pleased with the results.
I invite others to comment on this and give feedback on your experiences using protocols. Have you seen therapists simply following the protocol without thinking? Do you think outside the box when developing treatment plans with a post operative population?
Excellent article, Trevor, and much needed! When all is said and done, rehabilitation protocols are very important components of post-operative physical therapy. Certain standards of care following a surgery must be set and communicated to assure patients progress appropriately after surgery.
However, a protocol simply gives you guidelines as to what you can and can NOT do. What you “can” do is not restricted to what is within the protocol. Think of them as guidelines to assure that you are not going too slow or too fast.
Realistically, a protocol does not list every treatment and exercise that should be included. This is where your skill and experience comes into play. You must determine what other interventions you can safely perform to help the patient, while assessing if that chosen intervention fits safely within the protocol restrictions.
We should not follow a rehabilitation protocol without thought, that is not “skilled” physical therapy.
About the Author
Trevor Winnegge PT,DPT,MS,OCS,CSCS has been practicing PT for over 13 years. He graduated from Northeastern University with a Bachelors in PT and a Master of Science Degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He currently practices at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA, where he treats many orthopedic and sports medicine patients.