August 3, 2023
The Struggle Is Real
One of the most frustrating aspects of patient care is getting consistent results. Unfortunately what works for one patient, may not work for another. This means that one treatment method or technique that worked really well to treat hip impingement or adhesive capsulitis in one patient is wildly ineffective in the next. As a "green" clinician, I struggled to find some stable ground for patients with various types of conditions because of this, making it very difficult to know where to start and progress a patient that presented with the same issue. I often felt like I was throwing the "kitchen sink" at a patient with everything that worked for a previous patient in the past, without a solid method of timing, dosage, or treatment path.
I'm the kind of person that searches for more answers or training when faced with frustration. Arguably it could be a perfectionist tendency, but I hated that I could create a consistent outcome in a given patient population. For instance, non-operative shoulder pain was my nemesis in my first year of practice. I searched for more training to get better, just like many of you.
Getting Consistent Results in Rehab
While my outcomes with individual diagnoses improved, I still felt shaky with conditions that didn't match the presentation of other people in that same group. Not every partial thickness rotator cuff tear presents the same in every patient. Not every hip impingement patient reports the same symptoms. And not every baseball player looks the same post-season. Furthermore, the specific treatment methods that are used across the field of Physical Therapy vary widely. Preferred interventions between therapists can be significantly different, yet their outcomes may be the same at the end. At this point, I decided it came down to my over-arching methods, rather than the individual interventions.
I've been using this treatment session model for many years and it has made a significant difference in the work my patients are able to accomplish in a single treatment session, their independence with their exercises, and the consistency they use after they've discharged. Most importantly, this model of treatment was responsible for more consistent results than any individual treatment technique that I applied.
I follow the same 4 steps in every treatment session- no matter the diagnosis. The piece that changes is how much of each treatment session is dedicated to each category. Let's dive in and use a few examples along the way. Keep in mind these are examples and by no means should be considered an all-inclusive list of options for your patient; rather, these are intended to illustrate the treatment session model.
1. Restore Mobility
Restoring mobility of the affected area and the adjacent tissues/joints always comes first for me in any treatment session. In order to make meaningful gains in a patient's symptoms, we must first address any mobility limitations before applying a loading progression. Most mobility restrictions have an underlying motor control deficit, which has resulted in abnormal neuromuscular firing patterns. This means certain tissues get overloaded, while others atrophy. So my first step in a patient's treatment session is applying self mobilization to soft tissues- this could be working with a foam roll, a lacrosse ball, self-applied belt mobilizations, or other mobility drills. This category involves ANY activity, manual treatment, or modality that can be used to restore mobility.
I've detailed a few examples here:
Partial Thickness Rotator Cuff Tear
Step 1: Self-Mobilization. Remember these mobilizations should only be held for 1-2 seconds in order to appropriately prep tissues. This can take many forms, but a few of my favorites are:
Rolling a lacrosse ball over the upper trapezius, infraspinatus, thoracic paraspinals, and pectoralis minor against a wall.
Foam rolling the thoracic spine
Thoracic Spine Bench Mob
Windmill stretching
Step 2: Passive ROM Assessment. I look at specific motions to tell me what I need to know about the tissues involved in limiting motion. Those motions might look like:
Horizontal adduction with the lateral scapular border secured
Flexion with the lateral scapular border secured
Internal and external rotation at 90 degrees abduction
Step 3: Targeted Soft Tissue Treatments. This is addressing any stubborn tissue that hasn't responded to the generalized self-mobilization earlier. When passive motion is limited, I palpate the suspected tissues for significantly different tone between sides. Some of these targeted treatments might be (this list could go on for days):
Upper trapezius pin & stretch
Latissimus dorsi mobilization with movement
Infrared light therapy to the teres minor
Instrument Assisted Soft Tissue Mobilization to the scapula
Cupping of the triceps or upper trapezius
Dry Needling for pectoralis minor
Hip Impingement
ACL Reconstruction with Quadriceps Tendon Autograft
Again, the specific interventions in this category can very widely dependent on the therapist's experience and training. The list above is not all-inclusive. I'm not saying anything goes, but almost. The goal here is to achieve further mobility, reduce swelling/inflammation, or improve soft tissue pliability. You have to gain the motion, then you can train the motion.
2. Re-Educate Motor Control
When a given tissue is tonic for long enough, and then finally released with your magical techniques, there is a certain learning curve that happens in figuring out how that tissue should normally behave again. In the therapy world, we call this neuromuscular reeducation. To a patient, I call it muscle memory. The example I give many patients is that if you spend long enough in bed, imagine the sea legs you would have once you finally stood up- and the relearning to walk that would need to happen rather than immediately running a marathon. If we expect a soft tissue to remain pliable, they will likely need to be re-educated on how and when to properly fire in a functional pattern again. Motor control exercises can also significantly impact how much tone returns to these tissues by your next visit. No motor control exercises, no progress next time. This is why stretching your upper trapezius may help for 30 seconds after the stretch, but even applying it 3x/day for 4 weeks doesn't get effective results long term.
Motor control exercises are literally any exercise or movement that encourages appropriate mechanics and firing patterns. This usually means these are the basic of the basic exercises, or the exercises that result in a strong EMG of your targeted structures. For instance, a tight upper trapezius is often a result of relative inactivity of the remaining scapular stabilizers- particularly the lower trap and serratus anterior. So I would apply motor control exercises for these structures, since I don't know too many upper traps that didn't know what they were doing. On the other hand, a patient whose posterior rotator cuff has been tonic, I may release these tissues and then retrain their activation with sidelying external rotation.
I've detailed a few examples here:
Partial Thickness Rotator Cuff Tear Example
I commonly use the following exercises to restore motor control in a shoulder with a torn supraspinatus:
Rhythmic stabilization with the patient in supine and arm elevated to 90 degrees flexion
Reverse Codman's (supine with 50% scapular retraction)
Weightshifting on the edge of a table (transferring marbles, counting, or with shoulder taps)
Neuromuscular Electrical Stimulation (NMES) of the infraspinatus and/or serratus anterior
Rhythmic initiation in a D2 PNF pattern
Rhythmic stabilization with perturbations using a light medicine ball on a wall
Hip Impingement Example
ACL Reconstruction with Quadriceps Tendon Autograft Example
3. Strength and Loading
We all know that strengthening is a necessary part of any rehab plan. The debate is in its application, dosage, and programming- which is highly dependent on the condition you're treating. The following items are principles I follow when making decisions about this section of my treatment session.
Criteria for Strengthening
No pain or inflammation in the tissues/joints you are working
Full mobility
Adequate motor control in basic movement pattern range you are strengthening
Dosage for Hypertrophy and Strengthening
Fatigue Protocol
In a clinical setting, I typically give patients a circuit of exercises that work various muscle groups OR various actions of the same muscle. For instance, you wouldn't put 3 quadricep strengthening exercises back-to-back at the gym, but would rather choose a quadriceps isolating exercise, a hamstring/gluteal exercise, and possibly a core exercise. In another scenario, you can also target the same muscle in two different actions, such as resisted ankle inversion exercise and a balance exercise to work the posterior tibialis. I find that when patients are given circuits, we get A LOT more done in clinic and it keeps things interesting for the patient.
If you're interested in finding out more about periodization in rehab, I would highly recommend Dan Pope, the Prehab Guys, and Sue Falzone.
4. Endurance Training
The fourth step in a given treatment session is endurance training. This takes on many forms depending on the patient, their condition, and the readiness of their tissues. When starting a patient on endurance training, this is typically holding a static position for a given length of time with a short duration of rest between repetitions. For instance, I may have a patient hold a plank on a medicine ball for 30 seconds, rest for 30 seconds, and repeat this 3-4 times. Any opportunity for a teenager to use their smartphone usually goes over well- so I have a patient set a 3 or 4 minute timer, watching the clock to know when to start and stop the exercise.
This portion of a treatment session can take on many forms, including other time-based activities like an EMOM (Every Minute On the Minute) or AMRAP (As Many Rounds As Possible)- shout out to Peloton's very own, Jess Sims! These are again timed challenges where a patient completes the required reps and is allowed to rest for the remainder of the 60 seconds until the top of the next minute comes around (EMOM), or is given a timer and asked to complete as many sets of a circuit as possible in the time frame (AMRAP). These have proven very effective for those that are motivated by a challenge.
But also, in an aging population, balance training has been shown to be more effectively conducted AFTER strengthening in a session than before. The neuromuscular requirements here in the presence of fatigue are key for making gains. In a patient population with a knee osteoarthritis, I may use endurance training as an opportunity to work on static or dynamic balance for a given time frame, similiar to a 30 seconds-on, 30 seconds-off setting.
5. Activity-Specific Transition & Training
The fifth step of four. I know, I know, I said 4 simple steps. But once you've summited these 4 steps, eventually some degree of interval training or returning to activity-specific training is necessary to make the transition away from rehab more effective. This also decreases the likelihood that this patient will be revisiting your clinic again in 6 months.
Interval training is not a new concept, but should also be considered across the spectrum of activity levels. A gradual progression back to running, throwing, jumping, swimming, manual labor, prolonged positioning and other job duties should be considered before fully returning without restriction. Specific to throwing athletes, I generally prefer an interval throwing program with soreness rules such as the program from the University of Delaware (Mackler and Axe). These rules look something like this:
Interval Throwing Soreness Rules (Mackler, Axe)
If no soreness, advance one step every throwing day
If sore during warm up but soreness is gone within the first 15 throws, repeat the previous workout. If shoulder becomes sore during this workout, stop and take 2 days off. Upon return to throwing, drop down one step.
If sore more than 1 hour after throwing, or the next day, take 1 day off and repeat the most recent throwing program workout
If sore during warm up and soreness continues through the first 15 throws, stop throwing and take 2 days off. Upon return to throwing, drop down one step.
I strongly recommend using a criterion-based approach to returning an individual to their activity-specific tasks, rather than using a time-based approach. Every rehabilitation process can look different. An individual's readiness to return to prolonged standing, running or contact sports is dependent on the steps 1-3 in this process (ie having full mobility, motor control, and overall strength, endurance, and power). The rehabilitated tissues and the individual as a whole should be adequately prepared for returning to repetitive tasks or explosive movements, otherwise set backs and injury can occur. Graded exposure is key!
It's so easy.... now.
Wrapping my head around this method took some time, because it forced me to really analyze what treatments I was giving a patient and addressing the order as well. The good news, is I've broken down my treatment sessions into a fillable form, that I keep on nearly every patient I see in clinic. The electronic documentation system I use for clinical care does not currently have a feature to track my interventions over time- I can see what I did at the last visit, but it takes far more clicks to find what I did 2 or 4 or 7 times ago. I also have an exercise library that I organized by motor control, strength, and endurance training exercises. This made the process of learning this system a lot easier. If you're interested in a copy of this fillable form, you can download it below for free!
Overall, when I finally learned this method of treating, the interventions were not quite as important as the methodology behind them. And THAT, my friends, made all the difference in the world with my outcomes. What once took 12 weeks, now takes 8. What once took 4 weeks to see improvement in pain and function, now takes 3 visits. I check mobility at every single session. I apply motor control exercises (that may change over time) after full mobility is restored, every single session. Strength and endurance training are then applied using the principles discussed earlier. There is a TON of flexibility of interventions within each of these categories, but the question for me that made all the difference in my patients' outcomes was this: Why are you doing this specific intervention at this specific time?
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