Ann cools 3 scapular rehab [compatibiliteitsmodus]

The scapula: stabilize or mobilize?

Approaches to achieve scapular control

Dr Ann Cools, PT, PhDDept Rehab. Sciences & PhysiotherapyGhent University, Belgium 1Ann Cools Wrightington Nov 2012

Ghent University, Faculty of Medicine & Health Sciences, Dept of Rehabilitation Sciences & Physiotherapy

Supervisor: Prof dr Ann Cools

Researchers:

- Kristof De Mey

- Annelies Maenhout

- Annemie Van de Velde

- Maarten Van HerzeeleAnn Cools Wrightington Nov 2012 2

Scapular dyskinesis in relation to shoulderpain: scientific evidence

Ann Cools Wrightington Nov 2012

Ludewig 2000, Lukasiewicz 1999, Warner 1992, , McClure 2006, Endo 2001, Hebert 2002, Lin 2006,Laudner 2006, Su 2004, Kibler 2009,Mc Clure 2009, Tate 2009 3

Implications of scapulardyskinesis on daily activities….

Ann Cools Wrightington Nov 2012 4

Need for science-based scapularrehab program….

Scapular Rehab AlgorithmLack of

Soft-tissue flexibilityLack of

Muscle performance

Scapular muscles GH muscles/capsule Muscle Control Muscle Strength

- Levator scapulae- pectoralis minor

- infraspinatus- posterior capsule

- co-contraction- force couples

- lower/middle trap- serratus anterior

STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION

STRENGTH TRAINING

Advanced controlDuring basic activities

Endurance/strength

Balance -ratio

Advanced controlDuring sports

Conscious musclecontrol

Conscious musclecontrol- Manual stretching

- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM

(Ellenbecker & Cools, BJSM 2010)

5Ann Cools Wrightington Nov 2012

Muscle performance

STRENGTH TRAINING

Endurance/strength

Balance -ratio

Muscle performance

STRENGTH TRAINING

Endurance/strength

Balance -ratio

Muscle performance

STRENGTH TRAINING

Endurance/strength

Balance -ratio

Muscle performance

STRENGTH TRAINING

Endurance/strength

Balance -ratio

STRETCHING PECT MINOR: literature versus reality

(Borstad JOSPT 2006, Reeser PM&R 2010, Ellenbecker & Cools BJSM 2010)10Ann Cools Wrightington Nov 2012

PM lengthMeasurement 2

Swim training session

ANGULAR STRETCHING

DIRECT MANUAL

STRETCHING

Annemie Van de Velde, Karen D’Huyvetter, Céline Dufour, Ann Cools: Effect of two stretching techniques on the length of the pectoralis minor in adolescent swimmers . Paper in progress, 2012

Adolescent swimmers (N=29, mean age = 14y)

3x 30” stretching,

PM length measurement (Borstad et al. 2005)

Annemie Van de Velde, Karen D’Huyvetter, Céline Dufour, Ann Cools: Effect of two stretching techniques on the length of the pectoralis minor in adolescent swimmers . Paper in progress, 2012

Muscle performance

STRENGTH TRAINING

Endurance/strength

Balance -ratio

Ann Cools Wrightington nov 2012

Stretching posterior shoulder: clinical experience

� Sleeper’s stretch & cross body stretch improve ROM (Mc Clure2005)

� Additional manual mobilisationsimprove ROM (Manske 2010)

� Improvement ROM is related to reduction of symptoms (Tyler 2010)

� Stretching has a positiveinfluence on the subacromialspace (Maenhout 2012)

POSTERIOR SHOULDER STRETCHING

Scientific Evidence? comparisontranslation – angular stretching

Angular stretching Translation mobilisation

(patients with GIRD: n=30, healthy shoulders with GIRD: n=30)

(Cools et al. Shoulder & Elbow 2011)

RESULTS:

� Significant increase in ROM after 3w

� Equal results both techniques

� Significant pain reduction in patientgroup

angular stretching

before after 3wlater

ee D patients

D controls

ND patients

ND controls

translation mobilisations

before after 3wlater

D patients

D controls

ND patients

ND controls

(Cools et al. Shoulder & Elbow 2011)

VAS BeforeBeforeBeforeBefore----afterafterafterafter

AfterAfterAfterAfter----3w 3w 3w 3w laterlaterlaterlater

Pain/movement p= 0,001p= 0,001p= 0,001p= 0,001 p= 0,042

Hawkins’ test p= 0,001p= 0,001p= 0,001p= 0,001 p= 0,116

Neer’s test p= 0,002p= 0,002p= 0,002p= 0,002 p= 0,223

Apprehension p= 0,022 p= 0,755

Modified Rowe p= 0,001p= 0,001p= 0,001p= 0,001 p= 0,125

Muscle performance

STRENGTH TRAINING

Endurance/strength

Balance -ratio

Conscious muscle control lowertrapezius: Scapular Orientation Exercise

� Subjects are able to perform consistent movements of the scapula into posterior tilt and upward rotation

� Significant increase scapular muscleactivity in trapezius

� High correlation betweenassisted and unassisted(home) exercise

(Mottram 2009)19

Sidelying Forward flexion Sidelying Ext Rotation

Prone Hor Abd + Ext Rot Prone Extension

Scapular Orientation Exercise

Does conscious correction of scapular positioning influence muscle activity during exercises?

Yes, for 2 out of the 4 exercises

De Mey K., Conscious correction of scapular orientation in overhead athletes performing selected

shoulder rehabilitation exercises: what´s the effect on trapezius muscle activation measured by surface electromyography? JOSPT Under revision July 2012

Flexibility versus musclerecruitment problems?

Muscle performance

STRENGTH TRAINING

Endurance/strength

Balance -ratio

Sidelying Forward flexion Sidelying External Rotation

Prone Hor Abd + Ext Rot Prone Extension

SCAPULAR STRENGTH TRAINING:Scientific evidence healthy people

A 12 week program of scapular exercises improves isokineticmuscle strength, and muscle balance in healthy adolescent swimmers

SCAPULAR STRENGTH TRAINING:Scientific evidence healthy people

6 month program of scapular retraction exercises improvesRC strength (infraspinatus) in volleyball players

SCAPULAR STRENGTH TRAINING:Scientific evidence patients

Scapular exercises improve muscle strength, symptoms and relative muscle activity in overhead athletes with impingement symptoms

Muscle performance

STRENGTH TRAINING

Endurance/strength

Balance -ratio

Advanced controlDuring sports movements

- Manual stretching- home stretching- soft tissue rechniques- manual mobilisations (accessory movements)

(Ellenbecker & Cools, BJSM 2010)28

FUNCTIONAL EXERCISES: literature

� Integrate kinetic chain intoshoulder rehab exercises

� Focus on open and closedchain exercises

� Challenge sports specificpositions and movements

(Kibler AJSM 1998, Lintner Sports Med 2008, Cools BJSM 2008)

Background and purpose of the studies:

� Maenhout et al. BJSM 2009:

lower extremity positioninfluences scapular musclerecruitment and muscle balanceratios in closed kinetic chainexercises

� De Mey et al. Accepted for publication JSAMS May

2012: trunk & lower extremityposition and movement influencescapular muscle recruitment and muscle balance ratios in openkinetic chain exercises 30

Results (1): EMG activity scapularmuscles: extension contralateralleg versus other modalities

UT MT LT SA

Ex Mean StD Mean SD Mean SD Mean SD

1 13,63 7,27 10,37 5,38 11,30 6,33 31,65 19,11

2 18,31 13,17 14,55 8,28 20,12 10,07 23,43 14,66

3 16,18 8,32 13,04 7,91 11,80 8,14 44,20 18,67

4 13,67 8,00 10,11 5,42 10,44 5,90 25,30 15,77

5 16,69 10,55 13,14 6,00 16,86 9,27 14,27 8,14

6 14,39 7,67 11,44 6,69 10,75 6,68 30,46 15,60

7 17,20 10,52 12,30 6,22 10,72 6,53 36,71 15,55

(Maenhout & Cools, BJSM 2009)31Ann Cools Wrightington Nov 2012

Results (2): EMG activity scapularmuscles: unilateral squat versus other exercise modalities

chUitvoeringsmodaliteiten

Bilateraal

Unilateraal

*= significant main effect “exercise”(De Mey & Cools, JSAMS 2012)

Diagonals in CK exercises

Muscle performance

STRENGTH TRAINING

Endurance/strength

Balance -ratio

Advanced controlDuring sports movements

- Manual stretching- home stretching- soft tissue rechniques- manual mobilisations (accessory movements)

Influence of experimentally induced pain in the supraspinatus on scapular muscle activity(Van Herzeele M, Parlevliet T, HeemanS , Hofman K & Cools A, unpublished data 2012)

- ultrasound-controlled pain induction (hypertonic saline) in supraspinatus muscle (N=23)

- Pain sensation Numeric Rating Scale (NRS) >6/10

- Elevation in 3 planes before and after paininduction- Before pain

- Immediately after pain induction

- 20’ after pain induction (NRS 0,62)

- EMG scapular muscles (Noraxon Myoresearch)- Normalised EMG activity (% MVC)

- Recruitment order

Level of activityDURING pain Total

movementConcentricphase

Eccentricphase

abduction Increased LT activity 3,52%

Scapularelevation

Decreased LTactivity 1,8%

Forward flexion Increased SA activity 17%

Decreased SA activity 1,49%

20’ after pain Total movement

Concentricphase

Eccentricphase

abduction

Scapularelevation

Increased UT activity 1,43%Increased SA activity 2,37%

Forward flexionPAIN DOES CHANGE SCAPULAR MUSCLE RECRUITMENT

« Take home message »� Manual stretching pect minor has positive

short term effects

� Increased ROM and symptom relief afterposterior shoulder stretching

� Adding conscious scapular correctionincreases muscle activity during exercises

� Scapular rehab program results in strength gain in scapulaand shoulder

� Take into account that pain can change muscle recruitment

Ann cools 3 scapular rehab [compatibiliteitsmodus]

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