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Rehab A Cools 2014
Ann Cools, PT, PhDGhent University - Belgium
Dept of Rehabilitation Sciences & [email protected]
Physiotherapy treatment of shoulder pain:REHABILITATION PRINCIPLES
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Rehab A Cools 2014
« Today’s Topics …. »
� Which exercises/manual techniques to prescribe for– Rotator cuff pathology
– Instability
– GIRD
– Scapular dyskinesis
� Kinetic chain approach in shoulderrehab
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Rehab A Cools 2014
Rehabilitation of rotator cuff tendinopathy
1. Rotator cuff exercises: Which exercises?
2. Eccentric exercises: how can we focus on eccentric phase?
3. Eccentric exercises: training intensity?
4. Scientific evidence?
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1. Internal rotation
2. External rotation
3. Full can
4. Horizontal abduction with external rotation
(Jobe 1987, Donatelli 2004, Ellenbecker 2006, Townsend 1991, Reinold 2004)
1. Which exercises activate rotator cuff muscles?
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� Werner JSES 2006: ER vs IR regarding Subacromialpressure? ER decreases subacromial pression comparedto rest, IR increases subacromial pressure.
� Boettcher et al. Med Sci Sports Exc 2009: external rotation and prone external rotation exercises are more valid than the "can" and prone elevation exercises for supraspinatusstrengthening
� Reinold et al. 2004: towell significantly increases IS activity
� Anju Jaggi, London 2011: supine RC strengthening to focus on both internal and external rotators
1. Which exercises activate rotator cuff muscles?
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Rehab A Cools 2014 6(Anju Jaggi London 2011Karen Ginn, Goth 2012)
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� supraspinatus
2. Eccentric exercises
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(Cools & Walravens 2007, Maenhout et al. KSSTA 2012)
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� External rotators
Eccentric exercises
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3. Eccentric exercises: intensity and reps?3x15 daily, discomfort after exercises, min 6w,pain-monitoring model
� Maenhout et al. 2012 (KSSTA): RCT sign increase in RC strength after eccentric training program, full can exc, however no differences on function and pain.
� Holmgren et al. BMJ 2012: RCT: specific exercise program (ecc + scapular excercises) reduces the need for surgery
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4. Scientific evidence?Kuhn JSES 2009, Gebremariam BJSM 2013, VD dolder BJSM 2014 (systematic reviews), Rhon Ann Int Med 2014
� Exercise improves symptoms (effect size >15%)
– Exercise + manual therapy better than exercisealone, however only in case of ROM deficits (Conroy 1998, Bang 2000)
– Home program = supervised exercise (Walther 2004, Werner 2002)
� Soft tissue massage is effective for improving pain
� SA corticosteroid injection = physiother, however PT group is better 1y follow up
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Practice
1. Eccentric exercice SS
2. Eccentric exercise IS
3. Eccentric exercise ER in ABER
4. Total rotation
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Rehabilitation of shoulder instability
1. Training progression
2. Focus on proprioception and motorcontrol
3. TUBS/AIOS versus AMBRI
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INJURY
Functionalinstability
Spinal muscleReflex ↓↓↓↓
Neuro-muscularcoordination ⇓⇓⇓⇓
Mechanical instability
Proprioceptive deficits
Paradigma functional Instability(Lephart et al. 1995)
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Muscle control
Endurance
Power
Strength
Proprioception
Coordination
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Muscle control =
activating the appropriate muscleon the appropriate moment in the appropriate intensity
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Conscious muscle control: Rotator cuff (TUBS + AIOS)Deltoid (AMBRI/MDI)(Wilk et al. 2002, Barden 2005)
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TUBS/AIOS versus AMBRI
TUBS/AIOS
� Rotator cuff
� From CKC to OKC
� Stretching posterior
capsule (GIRD)
AMBRI
� Deltoid (ant-post)
� A lot of CKC
� No stretching
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Muscle control
Endurance
Power
Strength
Proprioception
Coordination
Progression in exercise modalities:
Resistance ↑(50→80%)Functional relevance ↑
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Rotator cuff strengthening: functional perspective
19IR ER
“Throwing program”
� TUBS and AIOS
� Everybody who wants to trow a ball… (also non-athletic population)
� Not only for instability patients, alsocuff problems, SLAP, scapulardyskinesis, post op.….)
� Not for MDI as basic program, onlywhen overhead sports is the goal
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Functional diagonallimited load in ABER
21IR ER
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Functional diagonalhigh load in ABER
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IR ER
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Plyometrics in ABER
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IR ER
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Acceleration & deceleration phase throwing
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IR ER
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In summary: Internal Rotation progression:
1. IR in neutral
2. Diagonal with limited ABER load
3. Diagonal with high ABER load
4. Plyometrics in ABER
5. Throwing against resistance
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In summary:External Rotation progression:
1. ER in neutral
2. Diagonal with limited ABER load
3. Diagonal with high ABER load
4. Plyometrics in ABER
5. Eccentric loading external rotators duringdeceleration
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Advanced program for“throwers”
� Eccentric high load exercises forposterior cuff
� Plyometrics using plyoball, flexbar, Xco…
� Sportspecific positions
� Attention to the kinetic chain
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Eccentric diagonals
�
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Plyometrics IR & ER
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(Ellenbecker & Cools 2010)
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Plyometrics IR & ER in ABER
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Scapular muscle recruitment duringplyometric exercises? (2014)
A Cools EUSSER London Symp 2014
Goal of the exercise:
1. MT & LT ↑
2. SA ↑ and UT ↓
3. UT ↓
4. Overall scap muscles↑A Cools EUSSER London Symp 2014
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“Thrower’s program” sportspecific: shoulder position
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Thrower’s program: Kinetic Chain
Legs
Trunk and Back
Shoulder
Elbow
Wrist
0
F
O
R
C
E
TIME(Kibler, Gent 2003)
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Legs
Trunk and Back
Shoulder
Elbow
Wrist
0
F
O
R
C
E
TIME(Kibler, Gent 2003)
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“Thrower’s program” sportspecific: kinetic chain
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Integration Kinetic Chain into openchain shoulder rehabilitation exercises
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Results: EMG activity scapularmuscles: unilateral squat versus other exercise modalities
* *
**
*
*= significant main effect “exercise”(De Mey & Cools, 2012 )
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Sportspecific program: swimming
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Practice
1. Eccentric ER diagonal
2. Plyoball neutral position
3. Plyoball 90° forw flex
4. Plyoball 90°-90°
5. Flexbar + tubing neutral
6. Xco/flexbar 90°-90°
7. W-V ex swissball
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TUBS/AIOS versus AMBRI
TUBS/AIOS
� Rotator cuff
� From CKC to OKC
� Stretching posterior
capsule (GIRD)
AMBRI
� Deltoid (ant-post)
� A lot of CKC
� No stretching
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General Guidelines AMBRI/MDI
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Low Load
dynamic
dynamicstatic
Moderate Load
High Load static
dynamicstatic
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Diagonals in CK exercises
� Semi closed chain SA exc
(elevation)
� Semi closed chain trap exc
(rowing)
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Case: gymnast with chronic shoulder pain based on instability
Rehab A Cools 2014
6 modalities of the push-up plus exercise (N=32)
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(Maenhout & Cools BJSM 2009)
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Results: EMG-activity and muscle balance ratios
� Highest SA activity (44%MVC) en best
UT/SA ratio (0.40) when ipsilateral leg isextended
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(Maenhout & Cools BJSM 2009)
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Results: EMG-activity and muscle balance ratios
� Highest activity in MT & LT, when
contralateral leg is extended(LT=20%MVC)
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(Maenhout & Cools BJSM 2009)
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stretching and mobilisation techniques in the rehabilitation of G.I.R.D.
1. Angular stretchinga. Internal rotation: « sleeper’s stretch »
b. Horizontal adduction: « cross-body stretch »
2. Translation mobilisations in end-range (dorsal glides)a. Internal rotation
b. Horizontal adduction
3. Mobilization with movement – dorsal glides1. External rotation
2. Forward flexion
3. Abduction
(Cools et al. BJSM 2008,
Ellenbecker 2006,Ellenbecker & Cools 2010, BJSM
Wilk JOSPT 2009, Cools et al. Shoulder & Elbow 2011)47
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1a: Angular stretching : « Sleeper’s stretch »
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Sleeper’s stretch supine + caudal glide
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(John Borstad, ICSET Edinburgh 2010, JOSPT 2011)49
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1b: Angular stretching intohorizontal adduction: “cross body stretch”
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Practice angular stretching:
1. Sleeper’s stretch side-lying
– Ask for pain ant versus post
2. Sleeper’s stretch supine
3. Sleeper’s stretch + caudal glide
4. Sleeper’s stretch + hold-relax
5.
6.
7.
8. 51
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Practice angular stretching:
1.
2.
3.
4.
5. Cross body stretch
– Work together with patient
6. “Reversed” Cross body stretch
7. Reversed cross body stretch + hold relax
8. Home-sleeper’s stretch
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2a: Mobilisation: dorsal glide in endrange
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Dorsal glides in moderate internalrotation
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2b: non-angular stretchinginto horizontal adduction
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3a. Mobilisation withmovement: ER + dorsalglide
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3b-c. Relocation of the humeral head during
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Forward flexion abduction
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Practice manual mobilisations(accessory movements & MWM) :
1. End-range dorsal glide in IR
2. Dorsal glide in moderate IR (hand from neutralto belly)
3. Mobilization with movement: ER + dorsal glide
– Change shoulder position (to ABER)
– Passive / resistance ER
4. Mobilization with movement: forward flexionwith dorsal glide
5. Mobilization with movement: abduction withdorsal glide
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Stretching posterior structures?
� Mc Clure (JOSPT 2005): improvement IR ROM after 4-weeks home stretchingprogram, cross body stretch & sleeper’sstretch
� Manske et al. Sports Health 2010: angularstretching (home program) + joint mobilisation (dorsal glide) slightly betterthan stretching only.
� Tyler et al. 2010: ROM improvement is related to symptom relief.
� Cools et al. Shoulder & Elbow 2011: equalresults from angular stretch versus dorsal glide
� Maenhout et al. 2012 JSM: stretching increases the size of the subacromial space
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Joint mobilization and MobilizationWith Movement?
� Hsu et al. (2001), Yang et al. (2007): Caudal glide mobilisation improvesabduction ROM, but only in endrange
� Hsu et al. (2002): both caudal and dorsalglides (indirect mobilisations) improveabcuction ROM
� Yang et al. (2007): MWM superior effectswith respect to scapulohumeral rythm
� Johnsson JOSPT 2007: Posterior glide is superior to anterior glide in external rotation ROM
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Rehabilitation of scapular dyskinesia
1. Summary of factors determiningscapular dyskinesis?
2. Treatment of flexibility deficits
3. Treatment of muscle performance problems
1. Muscle control
2. Muscle balance
3. Muscle strength
4. Advanced sport specific muscle control61
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Scapular Rehab AlgorithmLack of
Soft-tissue flexibility
Lack 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 & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
control- Manual stretching
- home stretching
- soft tissue techniques
- manual mobilisations
(accessory movements)
-MWM
(Cools et al. BJSM 2013)
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Scapular Rehab AlgorithmLack of
Soft-tissue flexibility
Lack 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 & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
control- Manual stretching
- home stretching
- soft tissue techniques
- manual mobilisations
(accessory movements)
-MWM64Rehab A Cools 2014
(Cools et al. BJSM 2013)
Scapular Rehab AlgorithmLack of
Soft-tissue flexibility
Lack 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 & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
control- Manual stretching
- home stretching
- soft tissue techniques
- manual mobilisations
(accessory movements)
-MWM65Rehab A Cools 2014
(Cools et al. BJSM 2013)
Scapular Rehab AlgorithmLack of
Soft-tissue flexibility
Lack 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 & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
control- Manual stretching
- home stretching
- soft tissue techniques
- manual mobilisations
(accessory movements)
-MWM66Rehab A Cools 2014
(Cools et al. BJSM 2013)
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Scapular Rehab AlgorithmLack of
Soft-tissue flexibility
Lack 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 & MOBILISATIONNEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING
Advanced control
During basic activities
Endurance/strength
Balance -ratio
Advanced control
During sports
Conscious muscle
control
Conscious muscle
control- Manual stretching
- home stretching
- soft tissue techniques
- manual mobilisations
(accessory movements)
-MWM
Stretching
Pectoralis minor
(Cools et al. BJSM 2013)
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Stretching pectoralis minor: literature
� Borstad et al. JOSPT 2005: short PM influences scapular kinematics and induceschanges similar to impingement relateddyskinesis
� Cools & Johansson BJSM 2010: significant decrease PM length in elite junior (11-17yr) tennis players
� Reeser PM&R 2010: tight PM is associatedwith history of shoulder pain in volleyballplayers
� Borstad et al. JSES 2006: unilateral selfstretch (in 90° ABER) best results, however…
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Stretching pectoralis minor: clinical experience
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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 movements
Conscious musclecontrol
Conscious musclecontrol
- Manual stretching- home stretching- soft tissue rechniques- manual mobilisations (accessory movements)
- taping
Scapular orientation exercise
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Scapular Orientation Exercise
- Scapular upward rotation andposterior tilting
- Increased scapular muscleactivity
(Mottram et al. Man Ther 2009)
Enhancing lower trapezius muscle control: literature
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Learning conscious lower trapezius muscle recruitment: clinical experience
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Learning conscious lower trapezius muscle recruitment: clinical experience
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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 movements
Conscious musclecontrol
Conscious musclecontrol
- Manual stretching- home stretching- soft tissue rechniques- manual mobilisations (accessory movements)
- taping
Muscle control Basic activities
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Purpose: increase scapular dynamic control during various exercises and movements: some examples…
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(Kibler 2008, Uhl 2010, Johansson 2012Cools 2013)
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Scapular muscle balance duringshoulder exercises
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� External rotationcomponent: increasinglower and middle trap activity
� Functional elevationplane
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(Kibler 2008, Uhl 2010, Johansson 2012Cools 2013)
Scapular muscle balance duringshoulder exercises
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� Semi-closed chain: safe for instabilitypatients and to unloadthe cuff
� High elevation: LT as a prime mover
� Diagonal pattern: better scapular musclerecruitment 77(Kibler 2008, Uhl 2010, Johansson 2012
Cools 2013)
� UT ↓� SA =
� Lev Scap ↓� Rhomb ↓
A Cools EUSSER London Symp 2014
� UT ↓� SA =
� MT & LT ↑� Rhomb ↑� Pect Min ↓
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Scapular muscle balance duringshoulder exercises
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� Hip-abduction activity: increasing diagonalkinetic chain activity?
� Core-stability challenge
� Perform ER or elevation
79(Kibler 2008, Uhl 2010, Johansson 2012Cools 2013)
PRACTICE
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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 movements
Conscious musclecontrol
Conscious musclecontrol
- Manual stretching- home stretching- soft tissue rechniques- manual mobilisations (accessory movements)
- taping
Muscle balance
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Rehabilitation muscle balanceUT/SA
� Elbow push-up
� Serratus punch lying on the back
� Serratus punch in closed chain
( Ludewig et al. 2004)82
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Rehabilitation muscle balanceUT/MT & UT/LT
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Scientific evidence:
� De Mey et al. JOSPT 2009: scapular exercises promoteearly activation of LT and late activation of UT
� Vandevelde et al. JAT 2010: scapular training (12w) increases scapular strength and endurance in healthyswimmers
� Merolla et al. JAT 2010: scapular program (6mo) increases Infraspinatus strength in volleyball players
� De Mey et al. JOSPT 2012: Pre-setting duringexercises increases muscle activity in trapezius
� De Mey et al. AJSM 2012: scapular exercises reduceEMG ativity in UT during functional movement
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PracticeUT/SA
UT/MT & UT/LT
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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 movements
Conscious musclecontrol
Conscious musclecontrol
- Manual stretching- home stretching- soft tissue rechniques- manual mobilisations (accessory movements)
- taping 87
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Case-presentation
� Young elite gymnast, 12 years old, 34 hours/week training
� Shoulder pain during sport for 6 months
� 4 months physiotherapy, scapular training, muscle control…
� Imaging and EMG negative
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Case-presentation
� No “conscious” trapezius training
� Try to optimise global and subconscious muscle control?
� A lot of closed kinetic chain (cfr sports activity: pain during weight bearing on upper limb)
� Looking for “ appropriate” exercises…..
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THANKS!Ghent, Belgium, July 21th every year......
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