rehabilitation protocols

The Use of Rehabilitation Protocols in Physical Therapy

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!

rehabilitation protocolsIn 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?


Mike’s Thoughts

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.

SEE ALSO: Rehabilitation Protocols by Kevin Wilk, Mike Reinold, and James Andrews

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.

  • I also couldn’t agree more. Whenever I get a post-operative patient that “comes with a protocol,” I look to see what, if any, ROM/weightbearing restrictions they have, then glance over the entire protocol to get a feel for the doctor (did he write his own protocol or did he just copy it out of a book, is it a horribly outdated protocol, etc.), and then formulate my own treatment plan (isn’t that what we get paid to do!). Many times I find that there are contradicting or seemingly unrealistic statements in the protocol – i.e. for a RTC repair, no active ER, but can begin sidelying ER!?; or something like no AROM for 6 weeks, but by 8 weeks they want 4/5 strength. We have to use our brains to fill in the gaps and develop a full treatment plan.

    In principle, I also have a difficult time with doctors writing a “recipe” for our treatments. I don’t think they would take too kindly to us telling them how to perform surgery. I have the most respect for the doctor that says something along the lines of, “Patient X has the following ROM restrictions, I would like to see them be able to achieve ________ by 6-8 weeks, do what you have to do to get them there.”

    In the future, rather than have doctors write protocols with specific exercises (usually outdated ones) and little use of manual techniques (most of which I am sure they are unaware of), I’d prefer them to write down any specific restrictions and subsequent milestones they’d like to see. For example, for an ACL reconstruction write something like: no ROM restrictions; limit strain on ACL during strength training; discharge brace by 4 weeks; full ROM by 6 weeks; normal gait by 6 weeks; >85% quad strength by 6 months; >85% hop tests by 6 months.

    Thanks for writing this article as it brings to light an issue that is on the minds of many therapists.

  • Great article. Especially about scapula ROM & activation of the scapula musculature in the early post-op phases of the rehab. I will activate the serratus almost immediately, along with the lower trap as they must work together to control the scapula. Scapula PNF & muscle activation is also important in helping to prevent scapula dyskinesis later on, which overlooked will impede the rehab progress. Protocols & guidelines are important, but if you are not really looking at and “feeling” what is going on with your patients you are just going through the motions and following the a “playbook”. Think. Look, feel. Make adjustments. Communicate with your patient, your colleagues and most important your doctors. They will respect you more if you present a well thought out rationale for additional treatment options for their patients.

    I’d also like to thank Mike again for this forum. Great work.

  • As an ATC who works in a PT clinic- I loved this article! Too many times protocols are taken as the end all be all which should not be the case. Very refreshing reminder! Thank you for an awesome article and I loved seeing a fellow TU alum contribute!

  • Jim

    I was just in process of inservicing our PTAs and PTs on this same topic. I completely agree. We have to be autonomous with our practice and assess each time. Too many times, we get referrals that are written by the MD like a receipe to follow (Evaluate and treat: Ultrasound, massage, exercise). I take it under advisement but make a professional clinical judgement on what the patient would most benefit from.

    I agree with the article and all the comments.

    I will use this information during my inservice as well.

  • Megan

    As a PTA, I’ve found that the PTs I work with (ones who really follow evidence based practice) question protocols sent from the MDs. However, it’s hard when you have surgeons who are very hard headed and strict. You don’t want them to question the referral when the patient goes back and explains what they may be performing in therapy. Sometimes to the surgeon, therapy should be very black and white, and despite the knowledge base of the PT, their protocols should be followed to the letter.

  • glendz

    Let protocols direct you, not dictate to you.. very well said, I will always remember that by heart! 🙂

  • Sharon

    Here is the problem I am finding. Many new graduates are following the “No protocol” rule that they are hearing about. They are not even consulting the protocol for contraindications. They believe they know best and unfortunately they did not perform the surgery nor do they have the years of experience to treat a post op patient without some guidelines. I am seeing many procedure being done that are way too early in the rehab. What you are saying is important. They need to not just follow the protocol but they do need to use it as a guide to setting up the proper treatment program. They are being told protocols are bad and I think we need to change that message. They neither bad nor good but a guideline that can help ensure your patient gets the best treatment options available. Use your brain but use the protocol as a guide.

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