UPPER QUARTER: SHOULDER SENMOCOR TM

12/10/20

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UPPER QUARTER: SHOULDERSENMOCORTM

MUSCULOSKELETAL MANAGEMENT OF SHOULDER PAIN

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TOUCHPOINTS

• (PS)• (BD)• (PS)• SOMATOSENSORY EVIDENCE (PS)• UPPER QUARTER (PS)• (BD)•IAOM-US

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INTENTIONS

•

••

IF IT WORKS, USE ITIAOM-US

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The manual therapy is only as good as the sensorimotor control training that follows it

PainGenera

tor

Motio

n Segm

ent

Malfliet A, Kregel J, Coppieters I, De Pauw R, Meeus M, Roussel N, Cagnie B, Danneels L, Nijs J. Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain: A Randomized Clinical Trial. JAMA Neurol. 2018 Jul 1;75(7):808-817. doi: 10.1001/jamaneurol.2018.0492. Erratum in: JAMA Neurol. 2019 Mar 1;76(3):373.

Moreside JM, McGill SM. Improvements in hip flexibility do not transfer to mobility in functional movement patterns. J Strength Cond Res. 2013 Oct;27(10):2635-43.

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IAOM-US

System Function

Trunk Lumbar: Grand StabilizerCervicothoracic: Supporter

Shoulder Supporter / Placer

Elbow Attenuator

Forearm, Wrist, Thumb, Hand

Effector

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IAOM-US

”YOU CAN’T FIRE A CANNONFROM A CANOE” •

https://en.wikipedia.org/wiki/Iowa-class_battleship

Lee BC, McGill SM. Effect of long-term isometric training on core/torso stiffness. J Strength Cond Res. 2015 Jun;29(6):1515-26.

Lee B, McGill S. The effect of short-term isometric training on core/torso stiffness. J Sports Sci. 2017 Sep;35(17):1724-1733.

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IAOM-US

Somatosensory Neuromotor

Rectus Abdominis

External Oblique

Transverse Abdominis

Multifidus

Erector Spinae

Wikimedia Commons

Splenius Capitis & Cervicis

Scalenes

SCM

Longus Colli

Internal Oblique

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Who 55 y/o male electrician

What & Where

• Right shoulder pain (C5)• Right shoulder tightness

IAOM-US

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IAOM-US

Why Original MOI: 1 week ago that began after shovelingsnow after chopping wood

When Aggravating Factors: • Right arm elevation• Lifting• Reaching• Pulling• Carrying• Driving• Right Side lying Relieving Factors: • Mild AROM exercises • Rest (not too much)

To What Extent

Pain: 1/10 through 7/10. Difficulties w/ overhead and lifting activities. May lose job.

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IAOM-US

Test Result ProvocationCervical screening Grossly WNL 0/10

Active shoulder girdle motions

Grossly WNL 0/10

Scapulothoracic Dyskinesis Tests

Active flexion R: Conc & Ecc Elevation Dysfunction

Active Abduction R: Downward Rotation

Hands on Hips R: Winging

Inspection: Mild thoracic kyphosis, rounded shoulders, forward head

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IAOM-US

Arm Elevation Result ProvocationActive Abduction R: Painful arch (80-110o) Yes

Active Flexion R: Painful arch (80-110o) Yes

Active Scaption R: Painful arch (80-110o) Yes

Passive GHJ Motions

External Rotation Not limited NilAbduction Not limited Nil

Internal Rotation Not limited Nil

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IAOM-US

Passive Elevation Result Provocationw/ Contra Fixation R: 10-degree limit R: 3/10 pain

w/ Ipsi Fixation: Medial OP

Nil R: 5/10 pain

w/ Ipsi Fixation: Posterior OP

Nil R: 7/10 pain

Resistive Testing Strength ProvocationAdd R: 5/5 Nil

Abd R: 5/5 5/10

ER R: 4/5 5/10

IR R: 5/5 Nil

Elbow Flex / Ext R: 5/5 Nil

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IAOM-US

Extra Tests ResultPull Test Abd Pain Free

Pull Test ER Improved strength & less pain

ACJ Mobility Hypomobile glide (Pain free)

SCJ Mobility Normal

Palpation Infraspinatus insertional tenderness

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IAOM-US

Clinical Syndromes

Pain Generating

Tissues

Tissue Dysfunctions

Neuromotor Dysfunctions

• External Impingement Syndrome

• Upper Crossed Syndrome

• Infraspinatus tendinopathy

• Subacromial Bursitis

Elevation chain limits• ACJ stiffness

Myofascial (need to assess)• Pec Minor?• Posterior

Shoulder?

• Scapular Dyskinesia

• Posterior Rotator Cuff Imbalance / Inhibition

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Pain Genera

tor

Motio

n Segment

NeuroM

otor

Control

Somato

senso

ry

Control Adva

nced

Perform

anceFu

nctional

Advance

ment

Fundam

ental

Perform

ance

Active 55 y/o Electrician

• Shovel• Chop Wood• Overhead work• Prolonged mid-arc

work

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PREPARATORY�

�

�

STIFFER

UNCONCIOUS

Lephart SM, Riemann BL, Fu FH. Introduction to the sensorimotor system. In: Lephart SM & Fu F, eds. Proprioception and Neuromuscular Control in Joint Stability. Champaign, IL: Human Kinetics; 2000.

Neuromuscular Control

REACTIVE (REFLEXIVE)

• FEEDBACK CONTROL (FB)

• CONSTANT ADJUSTMENT

• POSTURE AND “SLOW”

MOVEMENT

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ScapulothoracicInitial

Activation

Stabilizer TrainingObjective

Program Surface EMG BioFB

Pain Genera

tor

Motio

n Segment

NeuroM

otor

Control

RUSI

Fundamental Activation

HistoryInstability Checklist

ExaminationMRI XSA & Fatty Infiltration

Rehab Ultrasound Imaging (RUSI) Isometric Dynomometry

Electromyography

Qualitative Activation Assessment

VPAC & DNF’s

Rotator Cuff

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VOLITIONAL PRE-EMPTIVE ABDOMINAL CONTRACTION(VPAC)

IAOM-US

ADIM

Local Brace

Global Brace Sturdiness Compression

O’Sullivan et al 1992, Robison et al 1992, Tokuno et al 2011, Hodges et al 1987, 1997a, b, Foster et al 1999,Grenier et al 2007, Vera-Garia et al 2007

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PainGenerator

MotionSegment

NeuromotorControl

VPAC Strategies§ Abdominal Drawing In

Maneuver (ADIM)§ Abdominal Bracing

Maneuver (ABM)§ Multifidus Activation (Mf)§ Pelvic Floor Muscle

Activation (PFM)

Volitional Pre-emptive Abdominal Contraction

IAOM-USSenMoCorTM

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PainGenerator

MotionSegment

NeuromotorControl

DNF ActivationProposed Mechanism: CORInstruction: § Think “LOOK DOWN”§ Think “LOOK DOWN & TO THE RIGHT”§ Think “LOOK DOWN & TO THE LEFT

Deep Neck Flexors

Jull et al, 2005; O'Leary S, Jull G, Kim M, 2007

Precedence: Personal Communication with G. Jull & M. Sterling

IAOM-USSenMoCorTM

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UE CONTROL?

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LS Spine-Stability CT Spine-Vision & BalanceShoulder-Placement ControlElbow-Guides & AttenuatesFAWTH-Responder

Control considerations: STJ, Girdle & GHJ

Scapular Control

• Key role in kinetic chain• THE link between the upper & Lower Extremitiess

Scapular Motions

Motions:

• vs Rot, Ant vs Post Tilting, IR vs ER

Normal STJ motion during elevation:

• Rot, ER, vs Post Tilts

• Post Tilt Primarily > 90o

McClure PW, 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg. 2001;10:260-277.

Michner LA, Sennett BJ, Karduna AR. Direct McClure P, Greenberg E, KarehaArthrosc Rev. 2012;20:39-48.S. Evaluation and management of scapular dysfunction. Sports Med

McClure PW, Michner LA, Sennett BJ, Karduna AR. Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg. 2001;10:260-277.

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STJ REQUIREMENTS

•

•

•

RESULT-

ELEVATION: •

1.

2.3.


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PASSIVE VS. ACTIVE MOVEMENT

•

•

•

•

Ebaugh DD, McClure PW, Karduna AR. Three-dimensional scapulothoracic motion during active and passive arm elevation. Clin Biomech. 2005;20:700-709.

Depression & Ant Tilt Pec Minor & Serratus Ant

Depression & Post Tilt Low Trap

Scapular Abd Serratus Ant & Pec Minor

Scapular Add Rhomboids & Mid & Low Trap

Scapular Control

Eckenrode BJ, Kelley MJ, Kelly JD. Anatomic and biomechanical fundamentals of the thrower shoulder. Sports Med Arthorsc Review. 2012;20:2-10.

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CAUSED BY STRUCTURAL OR MUSCULAR COMPONENTS

STRUCTURAL

••

•

•


Endo K, Yukata K, Yasui N. Influence of age on scapulo-thoracic orientation.Clin Biomech. 2004;19:1009-1013.

Borsa PA, Laudner KG, Sauers EL. Mobility and stability adaptations in the shoulder of the overhead athlete: a theoretical and evidence-based perspective. Sports Med 2008;38(1):17-36.

Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med 1998 March;26(2):325-37.

Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg 2003 March;11(2):142-51.

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MUSCULAR

• IMPINGEMENT

•

•

•

••

• INHIBITORY PAINFUL CONDITIONS AROUND THE SHOULDER

Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg 2003 March;11(2):142-51.

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MUSCLE INHIBITION

••

•

Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med 1998 March;26(2):325-37.

Effects of FatigueImpingement:

• SA & LT Activity

• UT Activity

Effects of AfflictionImpingement

• SA & LT Activity

• UT Activity

Szucs K1, Navalgund A, Borstad JD. Scapular muscle activation and co-activation following a fatigue task. Med Biol Eng Comput. 2009 May;47(5):487-95.

Struyf F, Cagnie B, Cools A, Baert I, Van Brempt J, Struyf P, Meeus M. Scapulothoracic muscle activity and recruitment timing in patients with shoulder impingement symptoms and glenohumeral instability. J Electromyo Kinesiol 2014; 24(2): 277-284.

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Found Increased scapular dyskinesia during push-up plus and diagonal shoulder elevation in pts with painful shoulder.

Different muscle activation between middle and lower serratus anterior could represent in group with scapular dyskinesis.

Suggests need for selective activation of the lower serratus anterior in patients with scapular winging and tipping

Park SY, Yoo WG. Activation of the serratus anterior and upper trapezius in a population with winged and tipped scapulae during push-up-plus and diagonal shoulder-elevation. J Back Musculoskelet Rehabil. 2015;28(1):7-12.

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PainGenerator

MotionSegment

NeuromotorControl

Scapular Activation

§ Low Row

§ Inferior Glide

§ Robbers

Kibler BW et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am J Sports Med. 2008;36:1789-98.

IAOM-USSenMoCorTM

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DYNAMIC STABILITY

•••

•

••

•••

•Eckenrode BJ, Kelley MJ, Kelly JD. Anatomic and biomechanical fundamentals of the thrower shoulder. Sports Med Arthorsc Review. 2012;20:2-10.

Borsa PA, Laudner KG, Sauers EL. Mobility and stability adaptations in the shoulder of the overhead athlete: a theoretical and evidence-based perspective. Sports Med 2008;38(1):17-36.Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med 2002 January;30(1):136-51.

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SHOULDER FLEXION

FLEXIONRESULTS-

(FEEDFORWARD).

Wattanaprakornkul et al, 2011b

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SHOULDER FEEDFORWARD

MUSCLES

STIMULI EXPECTED UNEXPECTED

RESULTS- PRE-ACTIVATION

DAY et al, 2012

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SHOULDER FEEDFORWARD

MUSCLESSTIMULI CONCENTRIC ECCENTRIC

RESULTS- PRIOR TOPRIOR TO

REGARDLESS OF DIRECTION

DAVID et al, 2000

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PainGenerator

MotionSegment

NeuromotorControl

Rotator Cuff Reactivation

§ SL ER

§ SL Flexion

§ Ecc Open Can

Reinold MM, Wilk KE, Fleisig GS, Zheng N, Barrentine SW, Chmielewski T, Cody RC, Jameson GG, Andrews JR. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004 Jul;34(7):385-94.

Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17.

Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, Cagnie B, Witvrouw EE. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007 Oct;35(10):1744-51.

IAOM-USSenMoCorTM

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SENSORIMOTOR CONTROL

REACTIVE

•

•

• “SLOW”

PREPARATORY (ANTICIPATORY)� FEEDFORWARD CONTROL (FF)� PREVIOUS EXPERIENCE

� INTEGRATED WITH ONGOINGINFORMATION

STIFFER

UNCONSCIOUS

Lephart SM, Riemann BL, Fu FH. Introduction to the sensorimotor system. In: Lephart SM & Fu F, eds. Proprioception and Neuromuscular Control in Joint Stability. Champaign, IL: Human Kinetics; 2000.

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Examination

Initial Activation

Progressive Program

TTDPM

Angle Reproduction

Balance Testing

Pain Genera

tor

Motio

n Segment

NeuroM

otor

Control

Somato

senso

ry

Control

Postural Control Assessment


Reflex Ensemble

??????

Relocation Training

Balance Ensemble

Postural Training

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SHOULDER COMPLEX AS AN SUPPORTER / PLACER•••

•

The Shoulder Complex is at the BASE of the UQ Sensorimotor Control Universe!!!!

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SHOULDER KINESIS SOMATOSENSORY FUNCTION

Due to its unconstrained nature, the glenohumeral joint must necessarily have several mechanisms to regulate its position in space

Guanche CA, Noble J, Solomonow M, Wink CS. Periarticular neural elements in the shoulder joint. Orthopedics. 1999 Jun;22(6):615-7.

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SOMATOSENSORY (FEEDBACK) SYSTEMS:

SOMATOSENSORY FUNCTION / DYSFUNCTION

••

•

•

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SOMATOSENSORY (FEEDBACK) SYSTEMS:PROPRIOCEPTION

• SALLES ET AL, 2013

• TENG CC, CHAI H, LAI DM ET AL 2007

• SUPRAK, 2011

• WASSINGER F ET AL 2007

Proprioception : Influenced by?ú Neoprene sleeve Ulker et al, 2004

ú CryotherapyWassinger CA, et al 2007

ú Starting Position Ulker et al, 2004

ú Blunt Trauma Morgan & Herrington 2014

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SHOULDER REFLEX REACTIVATION

•• REFLEX ACTIVATION

••

••

Huxel et al, 2008

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SHOULDER IMPINGEMENT

•

•

•

•

SHOULDER PROPRIOCEPTION

Machner et al, 2003

Maenhout et al, 2012Bandholm et al, 2006

Machner et al, 2003

ROTATOR CUFF DISORDERS

•

•

•

Anderson & Wee, 2011

Martins et al, 2012

Anderson & Wee, 2011

Roy et al, 2008

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PainGenerator

MotionSegment

NeuromotorControl

SomatosensoryControl

IAOM-USSenMoCorTM

§ Proprioception

ú TTDPM

ú JRE

§ Reflex

Reactivation

§ Closed Chain Response

§ Balance

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PainGenerator

MotionSegment

NeuromotorControl


IAOM-USSenMoCorTM

§ Proprioception

ú TTDPM

ú JRE

§ Reflex

Reactivation

§ Closed Chain Response

§ Balance

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Pain Genera

tor

Motio

n Segment

NeuroM

otor

Control

Somato

senso

ry

Control

Upper Quarter Functional Examination (UQFE)

IDENTIFY MOVEMENT DYSFUNCTIONS•

•

•

•

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THE UQFE

• STATICTESTS

••••

§ Functionally Available PROMú Supine 90/90 IR-ER

ú Supine Sh Flex & ABD ú Standing Elevation x 3

§ Muscle Length / Elongationú Lateral Rotator Length

ú Pec Minor Lengthú Elbow Flexor Lengthú Lat Length

§ Functional Mvmnt Patternsú A. Sh Flexion (standing)

ú A. Sh ABD (standing)ú A. Sh IR-ER (standing)ú A. Sh IR-ER (prone)

§ Muscle Recruitmentú Posterior Deltoid

ú Lower Traps ú Middle Traps

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THE UQFE

STATIC TESTS

• CERVICAL

• FRONTAL PLANE

• SAGITTAL PLANE

DYSFUNCTIONS:

•

•

•

Static Tests

§ Humeral

ú Translation

ú Rotation

Dysfunctions:

§ Ant vs. Post glide

§ IR’d vs. ER’d

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THE UQFE

STATIC TESTS

• SCAPULA

• FRONTAL

• SAGITTAL

• TRANSVERSE

DYSFUNCTIONS:

••

•••

Static Tests

§ Thoracic

ú Sagittal ú Frontal

Dysfunctions:§ Dec’d or Inc’d Kyph

§ (L) vs. (R) Lat Shift

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THE UQFE

FUNCTIONALLY AVAILABLE PROM

•

DYSFUNCTIONS:

••••

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THE UQFE

FUNCTIONALLY AVAILABLE PROM

•

DYSFUNCTIONS:

••

•

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THE UQFE

FUNCTIONALLYAVAILABLE PROM•

DYSFUNCTIONS:•••••

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THE UQFE

MUSCLE LENGTH / ELONGATION

•

DYSFUNCTIONS:

•

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THE UQFE

MUSCLE LENGTH / ELONGATION

•

•

DYSFUNCTIONS:

••

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THE UQFE

FUNCTIONAL MVMNT PATTERNS

•

DYSFUNCTIONS:

•••

••

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THE UQFEFUNCTIONAL MVMNT PATTERNS

•

DYSFUNCTIONS:

•••

••

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THE UQFE

FUNCTIONAL MVMNT PATTERNS

•

DYSFUNCTIONS:

••

•

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THE UQFE

FUNCTIONAL MVMNT

PATTERNS

•

DYSFUNCTIONS:

•••

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THE UQFE

MUSCLE RECRUITMENT

•

DYSFUNCTIONS:

•

•

•

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THE UQFE

MUSCLE RECRUITMENT

••

DYSFUNCTIONS:

•••

•

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THE UQFE

MUSCLE RECRUITMENT: ALL-4’S SERRATUSACTIVATION

FOUNDATION:

• COMPONENTS:

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Pain Genera

tor

Motio

n Segment

NeuroM

otor

Control

Somato

senso

ry

Control

Upper Quarter Functional Examination (UQFE) Lite

Fundam

ental

Perform

ance

CORRECTIVE STRATEGIES• Mobility• Scapulothoracic• Glenohumeral

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PainGenerator

NeuromotorControl


FundamentalPerformance

IAOM-USSenMoCorTM

Correctives: Mobility Dysfunction

• Thoracic Spine

• Latissimus Dorsi

• Pec Minor

• Posterior Shoulder

M otionSegment

Wilk KE, Hooks TR, Macrina LC. The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete. J Orthop Sports Phys Ther. 2013 Dec;43(12):891-4.

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PainGenerator

MotionSegment

NeuromotorControl



IAOM-USSenMoCorTM

Correctives: Scapular Protraction Training

• All 4’s 2 arms

• All 4’s 1 arm

• Low Plank

• Banded Low Plank

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PainGenerator

MotionSegment

NeuromotorControl



IAOM-USSenMoCorTM

Correctives: Scapulothoracic Integration

• Manual Packing

• SL Packing

• All 4’s Pack/Rot

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PainGenerator

MotionSegment

NeuromotorControl



IAOM-USSenMoCorTM

Correctives: Overhead Training

• Y-Wall Slides• Serratus Ant• Lower

Trapezius

• Landmine

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PainGenerator

MotionSegment

NeuromotorControl


Advanced Performance


IAOM-USSenMoCorTM

Composite MovementsUpper Quarter (UQ)Lower Quarter (LQ)

Fundamental Movements

• Hinge• Squat• Lunge• Push

• Pull• Twist• Ambulation

Whole Body Movement

Patient Specific Rotatory

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PainGenerator

MotionSegment

NeuromotorControl


Advanced Performance


Functional Advancement Log Splitting

§ Maul Swingú Elevation Chainú Thoracic Ext/Rotú Lumbar Neutralú Hinge (drive

w/Hips)

ú Stable BOS

https://www.ochsenkopf.com/en/magazine/chopping-wood-right/

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FUNCTIONAL MANAGEMENTEXAM à PRESCRIPTION

•PROGRESSION:

Structural Mgmnt Functional Mgmnt

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GOAL: PERFORMANCE ENHANCEMENT Preliminary:

Clinical Examination / Structural Diagnosis

Functional Examination / Functional Diagnosis

Manage Pain/Dysfunction


Dx Specific Dx Inclusive Client Specific

OMTBiopsychosocial-Interpersonal Management

GOAL: PAIN MANAGEMENTPreliminary:

Biopsychosocial Assessment

FUNCTIONAL SCREENMEDICAL SCREEN

Composite Training

Corrective Strategies

SenMoCORTM

Pain G

enerato

r M

otion Segm

entNeuro

Moto

r

Control

Somato

senso

ry

Control

Advanced

Perform

ance

Functi

onal

Advance

ment

Fundam

ental

Perform

ance

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•

••

•

•

IAOM-US

QUESTIONS or COMMENTS?

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UPPER QUARTER: SHOULDER SENMOCOR TM

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