General & Specific Rehab Protocols

I want to discuss the need for general and specific rehab protocols; as well as touch on complications associated with these different approaches. My goal is to facilitate a partnership between two sets of practitioner's that should be collaborating, and not competing.

I would also like to give a few examples of each situation and address why it is important to stay open minded, understand the tools you have, as well as the limitations of your tools.

A general protocol is:

A. Looking past the primary complaint or reason for visit

B. Looking elsewhere to see the potential involvement of muscles/patterns not pulling their weight

C. Assessing static posture from differing angles

D. Assessing single leg balance and noting compensations, shifts, rotations, and tilts

E. Assessing gait

F. Assessing mobility/stability of the spine

G. Assessing left to right imbalances

H. Assessing dynamic movement and noting any body parts that seems sluggish, lazy, off, or lacking movement

A general approach is an approach that is ‘less concerned’ with what is hurting today and more concerned with “how did this problem come to be?”

A general approach is an approach that isn’t hyper focused or zoomed in on the area that is hurting. Instead, the camera pans out, the lens is widened, and we take a look at how the body moves and is oriented in space.

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A specific protocol is:

A. Zooming in on the primary complaint

B. Testing joint mobility, end feel, and stability of the primary complaint

C. Testing the movement mechanics of the primary complaint

D. Treating inflammation of the primary complaint

E. Testing and treating neural structures of the primary complaint

F. Testing and treating vascular components of the primary complaint

G. Testing and treating the mechanoreceptors as well as proprioceptors of the primary complaint

H. Testing and treating any reflex or feedback loops associated with the primary complaint

A specific approach is an approach that is ‘more concerned’ with “how do we solidify and make better this local complaint (problem) as it is today?”

A specific approach gives less attention to structures above and below while zooming in and shining a spotlight on the problem area.

The specific approach understands the “complex & layered nuance of each individual joint’ and ‘has a process to test and treat each structure.’

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Order of Operations - Specific Approach

The specific approach can lead to permanent results faster if the structures treated are the primary cause of dysfunction and pain.

The greatest strength of the specific approach is also its greatest weakness. Specifically, you can spend lots of time treating one area and it not affect the whole organism in a way that increases their ceiling of performance, capacity, & longevity.

This happens when the primary complaint does not have its genesis in the segment that is hurting. If the primary complaint is a manifestation of dysfunction elsewhere then you sooth symptoms instead of fixing the root problem.

The other limitation of the specific approach is that it is possible to produce many hydras (even more true when the specific approach is treating a secondary or tertiary symptom and not the root of the problem.)

Example:

Years ago a very good football player who was a D1 Rb recruit came into our gym for ACL rehab. He was working with a physical therapist offsite, and at our gym with another trainer, for S&C as well as continued rehab. This trainer had been with various pro teams at different times in his career and considered himself a knee specialist.

The athlete and coach worked together 2-3x a week and it was very evident the athlete became very strong and very fast.

The trainer told me that the doctor had tested neurological, mechanical, and vascular structures of the knee and he had been cleared. There was no joint mobility/stability issues present and manual muscle testing revealed nothing out of the ordinary for the knee or discernible by palpation. He was also cleared by his PT.

I said to the trainer “He is not ready.” I was laughed off by the trainer and he reminded me how strong & fast the athlete was. I said to him “Do you agree or disagree that the position of the knee lends itself to certain vulnerabilities?” He agreed.

I said to him a few days later “although your client is very fast and very strong there are still real possibilities of being injured. His knee and ankle joints are nowhere near where they should be to allow for best possible movement.” I wasn't campaigning for perfect alignment - just something better than it currently was.

In the 11th or 12th month he played in his spring game since he had been medically cleared. He took a toss to the outside and made a jump cut, but upon landing he fell and grabbed his knee. He tore his ACL, again.

How could the doctor, PT, and S&C specialist miss or ignore these static, postural, and dynamic clues presented by the body? Why did they deem them unimportant?

This result was the downside of being hyper focused on the knee. The knee was considered the culprit, and not a victim. The knee was considered primary, but it was only primary to a point. The lost sight of the knee’s linking ability from hip to ankle and rotational stress eventually won.

When a door is slightly off its hinges it doesn't take much force to break it. When a door is properly aligned - no amount of slamming it will get it off track. The knee is no different.

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Order of Operations - Generalist Approach

The order of operations for the generalist is more investigative followed by copious amounts of testing and observation. The generalist approach is “the body has the answers - I only need to uncover them!” Change and progress move slower for individual parts at first but there is a faster rate of systemic effect head to toe (even if the main problem you set out to fix isn't better).

The preeminent feature of the generalist approach is - investigate, test, observe ad nauseam. Add things in slowly. Be willing to change but not be too quick to change. Give a dose of something and then give it time to work.

It also may be wise to administer a bigger dose of prior regimen before you abort mission and come from a different vantage point.

Trust your intuition and trust what you see. The body isn't fooling you. What you see is the result of what tools the body has available to it.

What is true of the specific approach is still true of the generalist approach - if the primary problem is uncovered and understood then change will happen very fast and at an exponential rate. But, more than that, hydras will not be produced as the organism is solidified at every level.

Example:

Years ago I was working with an athlete and he brought his girlfriend to our session. She was sitting on the chair and telling me about her neck pain, thoracic pain, and low back pain as I was doing soft tissue work on the athlete.

The generalist, like the specialist, never wants to cause pain or hurt someone so we try to pick our methods very carefully.

This was a point of contention I wrestled with for years. How can I not hurt someone but still get all the information I need to do my job effectively? I found myself shying away from certain exercises because of potential downsides. I was taking a safer and more cautious approach out of fear instead of obtaining all the information I needed.

Eventually, rightly or wrongly, I decided that I needed all relevant info. Therefore, if something seemed off to me, and my intuition was saying to try something risky, I would.

I said to her “I’m not sure how your body is wired and its default pattern, and I, nor anyone else, can predict with certainty what is going to happen.“ “Would you like to proceed?” I asked.

She agreed to the exercise. Before the exercises her hips, shoulders, and ears were not in alignment and her knees were locked into hyperextension. She had a pronounced kyphosis with her trunk in flexion and functionally she could not hinge/bend/fold at her hips and touch her toes.

I gave her an exercise for mass extension out of the quadruped position. I made her shift all of her weight forward to where her shoulders were about 6 inches in front of her hands and the bulk of the load was on the scapulas and shoulder's.

This exercise also tips the pelvis into extension with the lumbar spine and that produces a synergistic effect up through the thoracic and cervical spine. The hips and knees are in flexion and there is a very mild load on the hip flexors but it is worth noting because of its linking purpose. It also places 4 of the 8 main load bearing joints onto the same plane and reduces any thoracic and pelvic rotation as long as the ground is firm and level.

After 2 minutes she got up and it seemed like she was 3 inches taller. Her boyfriend goes “holy sh*t!” The systemic effect was immediate. Her cervical spine was positioned correctly on top of her shoulders, the kyphosis was gone, and her knees were no longer hyperextended. Ankles and hip joints were now also in proper alignment.

She had a big smile on her face and felt better immediately. I said to her “try and touch your toes. She quickly found her hands resting flat on the floor.

“I’ve never done that in my life!” she said.

How is it possible that one exercise could arrange all the joints to a more neutral position, reduce pain, as well as improve total body coordination?

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Generalist approach - lessons learned.

That encounter taught me a few things.

1. The body wants to heal and be brought into alignment.

2. The body needs a stimulus to do it.

3. The body will show you quickly if your approach is right or wrong.

4. Sometimes you have to quit thinking and trust your intuition.

5. The body is a unit. Nothing happens in isolation.

6. Our understanding & theory of how something may work is of secondary importance.

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The Specialist & Generalist Need a System: A Lesson on Convergence

I simply want to highlight that it is best to observe what the client shows you. And, you must gather information from all areas to be effective. By having simple test arranged in a system of checks and balances you can better understand how the body is managing its position.

If the body was A(1) + B(2) then it would always = C(3).

But, the body does not work that way. Why not?! Because that logic ignores the timeline in which the body has compensated and then adapted.

That framework also underestimates the layers of dysfunction as well as the synergistic role of other structures.

In addition to that, a body that has dysfunction and rotation is no longer bound to the rules of textbook movement, because the axis of movement will have changed.

The specialist and generalist share a bond in that both have to have a system of checks and balances. Both need to be aware of their limitations of knowledge. Both need to be very observant and diligent in their testing.

When the specialist and generalist work together it is peak efficiency for the client.