Download - Robertson EBP Shoulder Update
Shoulder Update 2014 University of Texas at El PasoCentennial Lecture Series
Evidence-based Management Speaker
Eric Robertson PT DPT OCS FAAOMPT
Objectives
bull Attendees will accurately describe diagnostic and prognostic criteria for patients with various should conditions
bull Attendees will integrate predictors of response into examination of patients with shoulder pain
bull Attendees will review evidence supporting manual therapy interventions for patients with shoulder pain
bull Attendees will integrate information about psychologically informed practice into their management of patients with shoulder pain
bull Attendees will review best-evidence interventions for patients with shoulder pain
Shoulder Pain Incidence and Costs
bull $7 Billion annually in US (2000)bull 20-30 of the populationbull Poor perceived recovery rate lt50bull Prognosis is Fair to Poor for incidence of non-specific
shoulder pain
Our PathThings that donrsquot move enoughbull Subacromial Impingementbull Adhesive Capsulitisbull Evidence for Manual Therapy
Things that move too muchbull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Impingement Syndrome Concept
Neer 1972bull Altered cuff mechanicsbull Compromised or constricted
bull coracoacromial archbull Stage I II III
The SIS Continuum Neer Classification
Stage I Edema amp Hemorrhage
lt 25 reversible conservative treatment
Stage II Fibrosis amp Tendinopathy
25-40 recurrent pain consider SAD
Stage III Bone Spurs amp Tendon Rupture
gt40 progressive disability sx repair
Impingement Classification
bull Mechanical glenohumeral impingement
bull Alteredreduced sub-acromial space
bull Associated AC joint problems
bull Think ldquoblockrdquo
Primary
bull Uncertain glenohumeral positioning
bull Inherently unstable shoulderbull Mechanicallybull Functional
bull Think Instability
Secondary
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Primary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weakness or inflammation (also of bursa)
bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Secondary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or
neuromuscular inhibitionbull Scapular dyskinesia
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Objectives
bull Attendees will accurately describe diagnostic and prognostic criteria for patients with various should conditions
bull Attendees will integrate predictors of response into examination of patients with shoulder pain
bull Attendees will review evidence supporting manual therapy interventions for patients with shoulder pain
bull Attendees will integrate information about psychologically informed practice into their management of patients with shoulder pain
bull Attendees will review best-evidence interventions for patients with shoulder pain
Shoulder Pain Incidence and Costs
bull $7 Billion annually in US (2000)bull 20-30 of the populationbull Poor perceived recovery rate lt50bull Prognosis is Fair to Poor for incidence of non-specific
shoulder pain
Our PathThings that donrsquot move enoughbull Subacromial Impingementbull Adhesive Capsulitisbull Evidence for Manual Therapy
Things that move too muchbull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Impingement Syndrome Concept
Neer 1972bull Altered cuff mechanicsbull Compromised or constricted
bull coracoacromial archbull Stage I II III
The SIS Continuum Neer Classification
Stage I Edema amp Hemorrhage
lt 25 reversible conservative treatment
Stage II Fibrosis amp Tendinopathy
25-40 recurrent pain consider SAD
Stage III Bone Spurs amp Tendon Rupture
gt40 progressive disability sx repair
Impingement Classification
bull Mechanical glenohumeral impingement
bull Alteredreduced sub-acromial space
bull Associated AC joint problems
bull Think ldquoblockrdquo
Primary
bull Uncertain glenohumeral positioning
bull Inherently unstable shoulderbull Mechanicallybull Functional
bull Think Instability
Secondary
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Primary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weakness or inflammation (also of bursa)
bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Secondary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or
neuromuscular inhibitionbull Scapular dyskinesia
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Shoulder Pain Incidence and Costs
bull $7 Billion annually in US (2000)bull 20-30 of the populationbull Poor perceived recovery rate lt50bull Prognosis is Fair to Poor for incidence of non-specific
shoulder pain
Our PathThings that donrsquot move enoughbull Subacromial Impingementbull Adhesive Capsulitisbull Evidence for Manual Therapy
Things that move too muchbull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Impingement Syndrome Concept
Neer 1972bull Altered cuff mechanicsbull Compromised or constricted
bull coracoacromial archbull Stage I II III
The SIS Continuum Neer Classification
Stage I Edema amp Hemorrhage
lt 25 reversible conservative treatment
Stage II Fibrosis amp Tendinopathy
25-40 recurrent pain consider SAD
Stage III Bone Spurs amp Tendon Rupture
gt40 progressive disability sx repair
Impingement Classification
bull Mechanical glenohumeral impingement
bull Alteredreduced sub-acromial space
bull Associated AC joint problems
bull Think ldquoblockrdquo
Primary
bull Uncertain glenohumeral positioning
bull Inherently unstable shoulderbull Mechanicallybull Functional
bull Think Instability
Secondary
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Primary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weakness or inflammation (also of bursa)
bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Secondary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or
neuromuscular inhibitionbull Scapular dyskinesia
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Our PathThings that donrsquot move enoughbull Subacromial Impingementbull Adhesive Capsulitisbull Evidence for Manual Therapy
Things that move too muchbull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Impingement Syndrome Concept
Neer 1972bull Altered cuff mechanicsbull Compromised or constricted
bull coracoacromial archbull Stage I II III
The SIS Continuum Neer Classification
Stage I Edema amp Hemorrhage
lt 25 reversible conservative treatment
Stage II Fibrosis amp Tendinopathy
25-40 recurrent pain consider SAD
Stage III Bone Spurs amp Tendon Rupture
gt40 progressive disability sx repair
Impingement Classification
bull Mechanical glenohumeral impingement
bull Alteredreduced sub-acromial space
bull Associated AC joint problems
bull Think ldquoblockrdquo
Primary
bull Uncertain glenohumeral positioning
bull Inherently unstable shoulderbull Mechanicallybull Functional
bull Think Instability
Secondary
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Primary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weakness or inflammation (also of bursa)
bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Secondary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or
neuromuscular inhibitionbull Scapular dyskinesia
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Impingement Syndrome Concept
Neer 1972bull Altered cuff mechanicsbull Compromised or constricted
bull coracoacromial archbull Stage I II III
The SIS Continuum Neer Classification
Stage I Edema amp Hemorrhage
lt 25 reversible conservative treatment
Stage II Fibrosis amp Tendinopathy
25-40 recurrent pain consider SAD
Stage III Bone Spurs amp Tendon Rupture
gt40 progressive disability sx repair
Impingement Classification
bull Mechanical glenohumeral impingement
bull Alteredreduced sub-acromial space
bull Associated AC joint problems
bull Think ldquoblockrdquo
Primary
bull Uncertain glenohumeral positioning
bull Inherently unstable shoulderbull Mechanicallybull Functional
bull Think Instability
Secondary
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Primary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weakness or inflammation (also of bursa)
bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Secondary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or
neuromuscular inhibitionbull Scapular dyskinesia
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
The SIS Continuum Neer Classification
Stage I Edema amp Hemorrhage
lt 25 reversible conservative treatment
Stage II Fibrosis amp Tendinopathy
25-40 recurrent pain consider SAD
Stage III Bone Spurs amp Tendon Rupture
gt40 progressive disability sx repair
Impingement Classification
bull Mechanical glenohumeral impingement
bull Alteredreduced sub-acromial space
bull Associated AC joint problems
bull Think ldquoblockrdquo
Primary
bull Uncertain glenohumeral positioning
bull Inherently unstable shoulderbull Mechanicallybull Functional
bull Think Instability
Secondary
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Primary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weakness or inflammation (also of bursa)
bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Secondary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or
neuromuscular inhibitionbull Scapular dyskinesia
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Impingement Classification
bull Mechanical glenohumeral impingement
bull Alteredreduced sub-acromial space
bull Associated AC joint problems
bull Think ldquoblockrdquo
Primary
bull Uncertain glenohumeral positioning
bull Inherently unstable shoulderbull Mechanicallybull Functional
bull Think Instability
Secondary
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Primary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weakness or inflammation (also of bursa)
bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Secondary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or
neuromuscular inhibitionbull Scapular dyskinesia
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Primary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weakness or inflammation (also of bursa)
bull RC tendinopathybull Posterior capsule tightnessbull Morphology of acromionbull Postural dysfunction
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Secondary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or
neuromuscular inhibitionbull Scapular dyskinesia
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Secondary Impingement
bull RC tendonsbull Long head of bicepsbull GH joint capsulebull Subacromial bursabull Subacromial archspace
Structures
bull RC weaknessbull RC tearbull Capsular laxitybull Multidirectional instabilitybull Functional instability or
neuromuscular inhibitionbull Scapular dyskinesia
Causes
(Andrews 1993 Kamkar A et al JOSPT Vol17 No5 p212-224 May 1993)
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Diagnosis of Primary SIS
bull Historical Factorsbull Pain at night pain with overhead activities
complaints of stiffness
bull Test-item Cluster for SISbull +LR=1056 -LR=017 (all 3)
bull Hawkins-Kennedy Testbull Painful Arc Signbull Infraspinatus Muscle Test
Park et al 2005
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Diagnosis of Primary SIS
bull Another Perspectivebull A larger test-item cluster
3 or more 5 tests rules in SIS 3 or less 5 rules out SIS
Test SensSpect
+LR-LR
Neer Sens -035
Painful Arc Both +225 -038
Ext Rot Resistance Both +439
Hawkins-Kennedy Both ~1
Empty Can Spec +390
Michener et al APMR 2009
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Diagnosis of Secondary SIS
bull Historical Factorsbull Young history of instability pain with overhead
activities hypermobility overhead athlete
bull Objective Findingsbull Observation of scapular dyskinesisbull Weakness of scapular stabilizersbull + Instability tests (Jobes Relocation lateral
scapular slide test for example)
McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train 200944(2)160-164
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Upper Extremity Y-Balance Test
bull A measure of UE stabilitybull ldquois a body relative quantitative analysis of a personrsquos ability to reach with the free upper
limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
P Plisky
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
bull Numeric Pain Rating Scalebull Andor 3 pain items from the Penn
Shoulder Scale pain at rest normal amp strenuous activities
NPRSbull Disability of Arm Shoulder and
Handbull Quick DASH also goodDASH
bull Shoulder Pain and Disability IndexSPADI
MCID 10-15 points
Outcome Measures for SIS
MCID 8-13 points
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
General Treatment PrinciplesType of SIS Presentation Guiding Principle Management
PrimaryStage I
Stage II
Stage III
Young pain with activity Rest restore mechanics
MT and Exercise
26-40 pain at night prolonged symptoms
Restore sub-acromial space
MT and Exercise possible surgery
Older chronic associated with RC tears
Manage conservatively unless sx indicated
RC strengthening Jt mob surgical
Secondary Multi-directional instability
Stabilize Proprioceptive neuromuscular strengthening
Internal Young impingement in specific range
Strengthen cuff muscles
Rehab or labral repair
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Treatment Non-surgical vs Surgical
bull Emphasize preventionbull Current Best Evidence Summary
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Bang amp DeyleJOSPT 2000
Bottom Line While both groups improved the MT+Ex
group had greater improvements including strength gains
Considerations MT + Ex group received treatment reinforcing HEP
Design RCTPop N=52 impingement syndromeOutcomes
Baseline 1 amp 2 mo
Strength Pain Functional Assessment Questionnaire (FAQ)
Interventions 6 sessions 3-4 wksbullExercise Group (Ex)
bullStretching amp Cuff Ex bullManual Therapy amp Exercise Group (MT+Ex)
bullEx as abovebullMan Ther Upper Quarter
ResultsbullPain amp Function
MT+Ex with significantly more improvement
bullStrengthOnly MT+Ex group with significant improvement
Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Bergman et al Annals of Internal Medicine 2004
Bottom Line MT + UMC was the winner for achieving ldquofull
recoveryrdquo at 12 wks (43 vs 21) Same difference in recovery rate (17) observed at
52wks
Considerations Perceived recovery 6 amp 26 Wks ndash CIs included 0 Other interventions
UMC 28 CSI 27 PT MT+UMC 25 CSI 23 PT 38 MT visits
Design Multi-site RCT
Pop N=150 painful shoulder girdle
Outcomes Baseline 6 12 26 52 wksPrimary - patient perceived recoverySecondary - severity of main complaint shoulder disability additional care received
InterventionsbullUsual Medical Care (UMC)
Adviceinformation therapy NSAIDSanalgesics amp CSIs
bullManipulative Therapy (MT) + UMCMT to neck tx-spine amp ribs shoulder girdlele 6 sessions (in 12 wks)
ResultsbullAt 12 26 52 Wks
ldquoFull Recoveryrdquo MT gtUMCSeverity of main complaint amp disability ndash MTgt UMC
Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder
Dysfunction and Pain
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
McClatchie et alManual Therapy2008
Bottom Line bull Changes in shoulder from treating the
asymptomatic C-spine beyond placebo
Considerations Suggestive of a neurophysiologic effect that treatment
of this area may facilitate recovery in distant regions Not an impairment-based approach
Design RCT cross-over design
Pop N=21 pts with shoulder pain painful arc and no Hx of neck pain
Outcomes Pain (VAS) Painful Arc
Interventionsbull1 session 2 min of seated cervical lateral glide at C567 (Mulligan Grade IV+) or placebo mobilization
Mobilization of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Tate et alJOSPT 2010
Bottom Line bull Strong study describing treatment approach
Considerations No cause and effect
Design Case SeriesPop N=10 pts with SIS
Outcomes DASH (50 improvement) GROC
InterventionsbullStandardized treatment program including exercise and manual techniques
Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Other Interventions
Bottom Line bull Usual Medical Care Arthroscopy Passive Interventions
Pharmaceutical Management even usual PT all seem to be ineffective
1 PT = Arthroscopic debridement + PT (Brox 1993)
2 CSI may only be beneficial for a sub-group (Bergman et al 2004)
3 Passive Interventions and Modalities not effective (Leduc et al 2003)
4 NSAIDs no meaningful changes (Green at al 2003 Petri et al 2004)
5 CSI only short term effect and only prior to 12 weeks (Crashaw 2010)
How does the evidence look for other interventions for SIS
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Musculoskeletal
Somatovisceral
Biopsychosocial
Neurophysiological
Regional Interdependence
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
SIS A Regional Perspective
Cervical Spine forward head muscle tightness
Ribs first and second rib dysfunction
Thoracic Spine attachment for many scapula stabilizers
CNS neuromotor control pain processing core synergies and stabilization
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Eccentric Exercise
bull Degenerative Process = Chronic Changesbull Tendonosisbull Eccentric strength training to the rotator cuff
bull Holmgren et al 2012 Reduced need for surgery with ecc
Treatment Control
0
20
40
60
80
Subsequent Surgery
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
SIS Conclusions
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Adhesive Capsulitis
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
What is it
bull Effects 2-5 of the general population and 10-38 of the population with diabetes or thyroid disease
bull Primarily effects those 40-65 yrsbull Females gt Malesbull Primary (idiopathic)bull Secondary
bull Intrinsic vs extrinsic
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Differential Diagnosis
bull May present similarly to other common shoulder conditions seen in PT
-Rotator cuff tears
-tendonitis
-osteoarthritis
-labral tear
-subacromial bursitis
Diagnostic imaging usually unnecessary but may be used to rule out other conditions
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Kelley MJ et al JOSPT 39 (2) 2009
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Kelley MJ et al JOSPT 39 (2) 2009
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Natural History
bull Little agreement in the literaturebull ldquoeven the most severe cases recover with
or without treatment in about 2 yearsrdquo Codman ndash 1934
bull ldquo20-40 of cases do not respond to conservative treatmentrdquo Castellarin ndash 2004
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Duration of the Disease(with conservative treatment)
bull Reeves ndash 1975bull Prospective study n = 41bull Average duration 301 months
bull Shaffer et al ndash 1992bull Retrospective study n = 62 bull Average duration 12 months
bull Miller et al ndash 1996bull Retrospective study n = 50bull Average duration 14 months
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Long Term Effectsbull Reeves ndash 1975
bull At 5 yr fu 54 with limited ROMbull 7 with functional limitation
bull Shaffer et al ndash 1992bull At 7 year fu 43 with limited ROMbull 11 had functional limitation
bull Miller et al ndash 1996bull At 10 year fu 100 regained lsquofunctional
ROMrsquo
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Long Term Effects
bull Summary Full PLOF is not a given
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Treatment Optionsbull Wait and seebull PT directed rehabbull MD directed rehabbull Oral corticosteroidsbull Steroid injectionsbull Capsular distensionbull Long lever MUAbull Arthroscopic releasebull Translational MUA
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Oral steroidsCochrane Review Buchbinder 2009
bull One trial reported significant short-term benefits of oral steroids versus placebo 48 reported success overall improvement in pain 27 on a 0 to 10 point scale total shoulder abduction increased by 233 degrees Shoulder Pain and Disability Index (SPADI) score improved by 181 But benefits were not maintained at 6 weeks
bull A second trial reported no significant differences between oral steroid and placebo in pain or range of movement
bull A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months
bull Conclusion oral steroids provides significant short-term benefits in pain
range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Steroid InjectionsCochrane Review Buchbinder 2009
bull For adhesive capsulitis two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term
bull Conclusion Despite many RCTs of corticosteroid injections for shoulder pain their small sample sizes variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Capsular DistensionCochrane Buchbinder 2009
bull Distension methods air air w steroid injection saline and saline w steroid injection
bull Undergoing distension with steroid and saline solution compared to placebo (fake distension)
- May improve pain at three weeks
- May improve disability at three six and 12 weeksbull Undergoing distension with steroid and saline solution compared to ordinary
injection with steroid
- May not lead to any difference in pain and disability
bull Conclusion arthrographic distension with saline and steroid provides short-term benefits in pain range of movement and function in adhesive capsulitis It is uncertain whether this is better than alternative interventions
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Traditional Manipulation long-lever techniques
bull Common practice in some centers for patients who have failed conservative Rx
bull Sandor ndash 2000
bull MUA is a useful way to treat frozen shoulderbull Kivimaki et al ndash 2001
bull Traditional manipulation risks fracture especially in osteoporotic patients
bull Hannifan - 2000
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
bull Markus et al ndash 2005bull 30 consecutive cases of recalcitrant AC received MUAbull ldquounequivocal acute intrarticular lesions were found in 12 jointsrdquo
bull 4 Ant labrum detachments- with 1 osteochondral fragmentbull 3 SLAP tearsbull 2 Partial ruptures of GH ligamentsbull 2 Partial tears of subscapularis tendons
bull ldquothe joint should not be mobilized by force In resistant shoulders controlled endoscopic release is preferablerdquo
Traditional Manipulation long-lever techniques
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis A Case Series
bull Subjects (N= 4)bull Average Symptom Duration = 75 mo
bull Treatmentbull Interscalene block followed by impairment-based
mobilizationsmanipulationsbull Post manipulation Rx mobilization ROM
strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits)
bull Outcome Measuresbull PROM and SPADIbull Video fluoroscopy recordings for 2 patientsbull Taken pre-rx immediately post-rx 6- and 12-week
(Boyles et al Manual Therapy 2005)
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Patient 1 Patient 2 Patient 3 Patient 40
100
200
300
400
500
600
Pre-Rx
Immediate
Final
De
gre
es
of
PR
OM
Total Passive ROM
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Patient 1 Patient 2 Patient 3 Patient 40
10
20
30
40
50
60
70
Pre-RX
Final
SP
AD
I sc
ore
(0
-10
0)
SPADI Scores (Pre-manipulation to final)
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Results
Post ER
Post AbdPre Abd
Pre ER
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Video Fluoroscopy
6 wk Post- ManipulationPre-Manipulation
Case Studies Arthroscopic findings following translational MUAHando B article in write up
bull Arthroscopy performed immediately following translational manipulations
bull Patient 1 42 yo diabetic male 14 month history of labral tear impingement AC x 7 months
bull Patient 2 42 yof secondary AC sp humeral neck fracture AC x 14 months
Patient 1 Diabetic male AC x 7 months
Humeral
head
Torn Scar tissue
Glenoid
Patient 1 Diabetic male AC x 7 months
Humeral head
Scar Tissue
Labrum
Patient 2Secondary AC x 14 months
Humeral head
lsquoVeilrsquo of scar tissue
Patient 2Secondary AC x 14 months
Humeral head
Scar tissue
Glenoid
Intra-articular Findings
bull In both shouldersbull No acute intra-articular
lesions were found
Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition
Translational Manipulation Theory
bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo
bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo
bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus
Placzek et al Amer J of Orthondash 2004
Prognosis
bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion
bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with
conservative treatment and require more aggressive management
bull Spontaneous recovery may occur up to 2 years post-onset
bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term
bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis
bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs
Clinical Bottom Line
Patient 1 Diabetic male AC x 7 months
Humeral
head
Torn Scar tissue
Glenoid
Patient 1 Diabetic male AC x 7 months
Humeral head
Scar Tissue
Labrum
Patient 2Secondary AC x 14 months
Humeral head
lsquoVeilrsquo of scar tissue
Patient 2Secondary AC x 14 months
Humeral head
Scar tissue
Glenoid
Intra-articular Findings
bull In both shouldersbull No acute intra-articular
lesions were found
Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition
Translational Manipulation Theory
bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo
bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo
bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus
Placzek et al Amer J of Orthondash 2004
Prognosis
bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion
bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with
conservative treatment and require more aggressive management
bull Spontaneous recovery may occur up to 2 years post-onset
bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term
bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis
bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs
Clinical Bottom Line
Patient 1 Diabetic male AC x 7 months
Humeral head
Scar Tissue
Labrum
Patient 2Secondary AC x 14 months
Humeral head
lsquoVeilrsquo of scar tissue
Patient 2Secondary AC x 14 months
Humeral head
Scar tissue
Glenoid
Intra-articular Findings
bull In both shouldersbull No acute intra-articular
lesions were found
Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition
Translational Manipulation Theory
bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo
bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo
bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus
Placzek et al Amer J of Orthondash 2004
Prognosis
bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion
bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with
conservative treatment and require more aggressive management
bull Spontaneous recovery may occur up to 2 years post-onset
bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term
bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis
bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs
Clinical Bottom Line
Patient 2Secondary AC x 14 months
Humeral head
lsquoVeilrsquo of scar tissue
Patient 2Secondary AC x 14 months
Humeral head
Scar tissue
Glenoid
Intra-articular Findings
bull In both shouldersbull No acute intra-articular
lesions were found
Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition
Translational Manipulation Theory
bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo
bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo
bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus
Placzek et al Amer J of Orthondash 2004
Prognosis
bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion
bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with
conservative treatment and require more aggressive management
bull Spontaneous recovery may occur up to 2 years post-onset
bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term
bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis
bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs
Clinical Bottom Line
Patient 2Secondary AC x 14 months
Humeral head
Scar tissue
Glenoid
Intra-articular Findings
bull In both shouldersbull No acute intra-articular
lesions were found
Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition
Translational Manipulation Theory
bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo
bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo
bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus
Placzek et al Amer J of Orthondash 2004
Prognosis
bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion
bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with
conservative treatment and require more aggressive management
bull Spontaneous recovery may occur up to 2 years post-onset
bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term
bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis
bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs
Clinical Bottom Line
Intra-articular Findings
bull In both shouldersbull No acute intra-articular
lesions were found
Rotator cuff biceps tendon subscapularis tendon glenoid labrum and humeral surfaces were found in perfect condition
Translational Manipulation Theory
bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo
bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo
bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus
Placzek et al Amer J of Orthondash 2004
Prognosis
bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion
bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with
conservative treatment and require more aggressive management
bull Spontaneous recovery may occur up to 2 years post-onset
bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term
bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis
bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs
Clinical Bottom Line
Translational Manipulation Theory
bull ldquoTranslational manipulation attempts to restore the normal movements associated with angular GH motionrdquo
bull ldquohellipthe applied force moves the humeral head in a linear direction parallel to the glenoid fossardquo
bull Advantages over long-lever MUA includebull Minimizing GH joint compressionbull Improved operator controlbull Increased subacromial spacebull Isolates manipulative force to GH jointbull Minimizes stress to brachial plexus
Placzek et al Amer J of Orthondash 2004
Prognosis
bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion
bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with
conservative treatment and require more aggressive management
bull Spontaneous recovery may occur up to 2 years post-onset
bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term
bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis
bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs
Clinical Bottom Line
Prognosis
bull In most cases conservative treatment is successful in relieving pain and restoring pre-condition motion
bull Some patients may never regain full motionbull Estimated 10 of patients unsuccessful with
conservative treatment and require more aggressive management
bull Spontaneous recovery may occur up to 2 years post-onset
bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term
bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis
bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs
Clinical Bottom Line
bull Little evidence to support modalities oral or injectable steroids or capsular distension All may have some short term relief but none reported for the long term
bull Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis
bull Perhaps patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard less effective programs
Clinical Bottom Line
MANUAL THERAPY FOR THE SHOULDER
Green et al Cochrane Database of Systematic Reviews 2003
Physiotherapy Interventions for Shoulder Pain
bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis
bull Resultsbull Exercise is effective for short- and long-term recovery in
rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for
adhesive capsulitis
Green et al Cochrane Database of Systematic Reviews 2010
Physiotherapy Interventions for Shoulder Pain
bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis
bull Resultsbull Exercise is effective for short- and long-term recovery in
rotator cuff diseasebull Manual therapy provides added benefit to exercise
bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease
bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis
Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review
bull Systematic review of 12 RCTsbull Results
bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery
bull Adding MT to therex provides favorable outcomes compared to therex alone
bull Does not support the use of US as a beneficial treatment
bull Conflicting results in use of acupuncture
Michener LA et al J Hand Ther 2004
Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010
Identifying Prognostic Factors for Successful Short-Term Outcomes in
Individuals with Shoulder Pain Receiving Cervicothoracic
Manipulation
5 Variables in the CPR
bull Painfree shoulder flexion lt 1270
bull Shoulder IR lt 530 at 900 abduction
bull Negative Neer test
bull Not taking medications
bull Symptoms lt 90 days
Prognostic Factors for MT
Mintken et al Physical Therapy Jan 2010
The Rule
Pre-test Probability of
Dramatic Success with Manipulation
61
3 or more present
bullPainfree shoulder flexion lt 1270
bullShoulder IR lt 530
bullNegative Neer test
bullNot taking medications
bullSymptoms lt 90 days
89
Post-test Probability of
Dramatic Success with Manipulation
+LR = 53
Prognostic Factors Risk of Persistent Pain
Kuijpers et al Pain J2006
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Green et al Cochrane Database of Systematic Reviews 2003
Physiotherapy Interventions for Shoulder Pain
bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis
bull Resultsbull Exercise is effective for short- and long-term recovery in
rotator cuff diseasebull Manual therapy provides added benefit to exercisebull No evidence of US effectiveness in shoulder painbull No evidence that physiotherapy alone is of benefit for
adhesive capsulitis
Green et al Cochrane Database of Systematic Reviews 2010
Physiotherapy Interventions for Shoulder Pain
bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis
bull Resultsbull Exercise is effective for short- and long-term recovery in
rotator cuff diseasebull Manual therapy provides added benefit to exercise
bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease
bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis
Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review
bull Systematic review of 12 RCTsbull Results
bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery
bull Adding MT to therex provides favorable outcomes compared to therex alone
bull Does not support the use of US as a beneficial treatment
bull Conflicting results in use of acupuncture
Michener LA et al J Hand Ther 2004
Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010
Identifying Prognostic Factors for Successful Short-Term Outcomes in
Individuals with Shoulder Pain Receiving Cervicothoracic
Manipulation
5 Variables in the CPR
bull Painfree shoulder flexion lt 1270
bull Shoulder IR lt 530 at 900 abduction
bull Negative Neer test
bull Not taking medications
bull Symptoms lt 90 days
Prognostic Factors for MT
Mintken et al Physical Therapy Jan 2010
The Rule
Pre-test Probability of
Dramatic Success with Manipulation
61
3 or more present
bullPainfree shoulder flexion lt 1270
bullShoulder IR lt 530
bullNegative Neer test
bullNot taking medications
bullSymptoms lt 90 days
89
Post-test Probability of
Dramatic Success with Manipulation
+LR = 53
Prognostic Factors Risk of Persistent Pain
Kuijpers et al Pain J2006
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Green et al Cochrane Database of Systematic Reviews 2010
Physiotherapy Interventions for Shoulder Pain
bull Two broad categories of shoulder painbull Rotator cuff tendonitis diseasebull Adhesive capsulitis
bull Resultsbull Exercise is effective for short- and long-term recovery in
rotator cuff diseasebull Manual therapy provides added benefit to exercise
bull No evidence of US effectiveness in shoulder pain AC rotator cuff disease
bull No evidence that physiotherapy alone is of benefit for adhesive capsulitis
Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review
bull Systematic review of 12 RCTsbull Results
bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery
bull Adding MT to therex provides favorable outcomes compared to therex alone
bull Does not support the use of US as a beneficial treatment
bull Conflicting results in use of acupuncture
Michener LA et al J Hand Ther 2004
Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010
Identifying Prognostic Factors for Successful Short-Term Outcomes in
Individuals with Shoulder Pain Receiving Cervicothoracic
Manipulation
5 Variables in the CPR
bull Painfree shoulder flexion lt 1270
bull Shoulder IR lt 530 at 900 abduction
bull Negative Neer test
bull Not taking medications
bull Symptoms lt 90 days
Prognostic Factors for MT
Mintken et al Physical Therapy Jan 2010
The Rule
Pre-test Probability of
Dramatic Success with Manipulation
61
3 or more present
bullPainfree shoulder flexion lt 1270
bullShoulder IR lt 530
bullNegative Neer test
bullNot taking medications
bullSymptoms lt 90 days
89
Post-test Probability of
Dramatic Success with Manipulation
+LR = 53
Prognostic Factors Risk of Persistent Pain
Kuijpers et al Pain J2006
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Effectiveness of Rehabilitation for Patients with Impingement Syndrome A Systematic Review
bull Systematic review of 12 RCTsbull Results
bull Therex more effective in reducing pain and increasing function than placebo Mixed results when compared to surgery
bull Adding MT to therex provides favorable outcomes compared to therex alone
bull Does not support the use of US as a beneficial treatment
bull Conflicting results in use of acupuncture
Michener LA et al J Hand Ther 2004
Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010
Identifying Prognostic Factors for Successful Short-Term Outcomes in
Individuals with Shoulder Pain Receiving Cervicothoracic
Manipulation
5 Variables in the CPR
bull Painfree shoulder flexion lt 1270
bull Shoulder IR lt 530 at 900 abduction
bull Negative Neer test
bull Not taking medications
bull Symptoms lt 90 days
Prognostic Factors for MT
Mintken et al Physical Therapy Jan 2010
The Rule
Pre-test Probability of
Dramatic Success with Manipulation
61
3 or more present
bullPainfree shoulder flexion lt 1270
bullShoulder IR lt 530
bullNegative Neer test
bullNot taking medications
bullSymptoms lt 90 days
89
Post-test Probability of
Dramatic Success with Manipulation
+LR = 53
Prognostic Factors Risk of Persistent Pain
Kuijpers et al Pain J2006
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Paul Mintken Josh Cleland Kristin Carpenter Mel Bieniek Mike Keirns Julie WhitmanPhysical Therapy January 2010
Identifying Prognostic Factors for Successful Short-Term Outcomes in
Individuals with Shoulder Pain Receiving Cervicothoracic
Manipulation
5 Variables in the CPR
bull Painfree shoulder flexion lt 1270
bull Shoulder IR lt 530 at 900 abduction
bull Negative Neer test
bull Not taking medications
bull Symptoms lt 90 days
Prognostic Factors for MT
Mintken et al Physical Therapy Jan 2010
The Rule
Pre-test Probability of
Dramatic Success with Manipulation
61
3 or more present
bullPainfree shoulder flexion lt 1270
bullShoulder IR lt 530
bullNegative Neer test
bullNot taking medications
bullSymptoms lt 90 days
89
Post-test Probability of
Dramatic Success with Manipulation
+LR = 53
Prognostic Factors Risk of Persistent Pain
Kuijpers et al Pain J2006
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
5 Variables in the CPR
bull Painfree shoulder flexion lt 1270
bull Shoulder IR lt 530 at 900 abduction
bull Negative Neer test
bull Not taking medications
bull Symptoms lt 90 days
Prognostic Factors for MT
Mintken et al Physical Therapy Jan 2010
The Rule
Pre-test Probability of
Dramatic Success with Manipulation
61
3 or more present
bullPainfree shoulder flexion lt 1270
bullShoulder IR lt 530
bullNegative Neer test
bullNot taking medications
bullSymptoms lt 90 days
89
Post-test Probability of
Dramatic Success with Manipulation
+LR = 53
Prognostic Factors Risk of Persistent Pain
Kuijpers et al Pain J2006
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Prognostic Factors for MT
Mintken et al Physical Therapy Jan 2010
The Rule
Pre-test Probability of
Dramatic Success with Manipulation
61
3 or more present
bullPainfree shoulder flexion lt 1270
bullShoulder IR lt 530
bullNegative Neer test
bullNot taking medications
bullSymptoms lt 90 days
89
Post-test Probability of
Dramatic Success with Manipulation
+LR = 53
Prognostic Factors Risk of Persistent Pain
Kuijpers et al Pain J2006
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
The Rule
Pre-test Probability of
Dramatic Success with Manipulation
61
3 or more present
bullPainfree shoulder flexion lt 1270
bullShoulder IR lt 530
bullNegative Neer test
bullNot taking medications
bullSymptoms lt 90 days
89
Post-test Probability of
Dramatic Success with Manipulation
+LR = 53
Prognostic Factors Risk of Persistent Pain
Kuijpers et al Pain J2006
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Prognostic Factors Risk of Persistent Pain
Kuijpers et al Pain J2006
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
In the workshellip
Validation of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation A randomized clinical trial
Mintken P Boyles R Cleland J Michener L Strunce J Burns S Carpenter K McDevitt A
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
In the workshellipIn data collection phase
Manual physical therapy versus subacromial corticosteroid injection for the treatment of shoulder impingement syndrome a randomized clinical trial
Rhon Boyles amp Cleland
VS
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
SHOULDER INSTABILITYThings that move too muchhellip
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Epidemiology
66-100 of individuals lt 20 years of age
13-63 of individuals between 20 and 40 years age
0-16 of individuals older than 40 years of age
Instability is defined as a clinical syndromethat occurs when shoulder laxity produces symptoms
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Epidemiology
bull Primary Dislocationsbull Most common in 2nd amp 6th decadesbull ~92-98 are anterior dislocations (remainder are posterior)bull 95 of first-time dislocations result from traumatic forcebull 5 are atraumatic (sleep minor movements)
bull Recurrent Dislocationsbull 70 of first-time dislocations dislocate again within 2 yearsbull Younger patients more likely to have recurrence
Shoulder Dislocation
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Laxity vs Instability
bull Laxity ndash the extent to which the humeral head can be translated on the glenoid
bull Instability ndash an abnormal increase in GH translation that causes symptoms (subluxation or dislocation)
Schenk J Am Acad Orthop Surg 1998
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Shoulder StabilityA Result of Multiple Components
bull Bony Congruencybull Enhanced by labrum
bull Negative pressurebull at side amp at rest
bull Muscles amp tendonsbull static and dynamic
bull Ligaments amp capsuleGlenohumeral Elevation
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Shoulder Function
bull G-H joint has uarr mobility but at loss of stability
bull 25 of humeral head contacts glenoid fossa
bull Static Soft tissue constraints bull Capsule G-H ligaments labrum
bull Dynamic constraints consist ofbull Neuromuscular system (proprioceptive
mechanisms and scapularhumeral muscles
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Labrum Anatomy
Putz et al Ascopy 1999
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Neuromuscular Stabilization
bull The glenoid moves like a sealrsquos nose to remain in the right spot to control the ball (head)
The Shoulder A Balance of Mobility and Stability
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Classifying Instability
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Classifying Instability
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Classifying Instability
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Instability Spectrum
TUBS AMBRI
Born LooseTorn Loose
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Clinical Presentation
Traumatic Injury
bull Position of dislocationbull Anteriorposterior shoulder
painbull Apprehensive to moving
arm out from body
Nontraumatic Injury
bull General multi-joint hypermobility
bull Anteriorposterior shoulder pain
bull Loose inferior capsule
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Physical Examination
bull Observationbull ldquoprotectiverdquo posturebull Anterior tipping of scapulae
bull Painpalpationbull Diffuse pain over anterior and posterior shoulderbull Humeral head position at rest
bull Motionbull Unableunwilling to move into endranges of ABD amp ER
bull Strengthbull Limited by pain weak ABD amp ERbull Ability to co-activate dynamic stabilizers likely diminishedbull Check RC and scapular muscles
bull SensationProprioceptionbull Sensation generally intact check Axillary nbull ProprioceptionKinesthetic deficits may be noticeable
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Physical Examination
Special testsApprehension test Relocation test
Load amp Shift test Sulcus test
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Non-surgical Management
bull Older patients have lower recurrence therefore better candidates vs younger patients
bull Immobilization has been standard componentbull Traditionally 6 weeks in ADDIR (sling) positionbull More recently immobilize in ABERbull Neither approach give optimal outcomes recurrence rates of ~ 30
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Non-surgical Management
bull Role of Exercise bull Few studies investigating outcomesbull Aronen et al (1984) advocated strengthening program emphasizing
adductor and internal rotation motionsbull Yoneda et al (1982) used similar approach but included
strengthening in higher positions of abductionbull Both studies had re-dislocation rates in the 15-25 rangebull Gibson et al 2004 Cochrane Review Low evidence 6 weeks of
immobilization and 12 weeks of structured rehab including scap stability Surgical approach may be superior
Traumatic Instability
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Non-surgical Management
bull Role of Exercise bull Again few studies investigating outcomes
bull Progressive strengthening of rotator cuff deltoid and scapular stabilizers
bull Functional coordination exercisebull Lifestyle modification
General Instability Rehabilitation Principles
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Exercise for Selected Shoulder Disorders
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Essential Elements for Dynamic Stability of the Shoulder Complex
bull Adequate compressive forcesbull RC doing its job
bull Scapular basebull Mobilitystability
bull Proprioception and NM control of the entire kinetic chain
bull Muscular endurancebull Train to jobsport specificity
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Shoulder Flexibility Requirements
bull Pectoralis Muscles bull Associated with excessive scapular protraction
and downward rotation both disturbing optimal glenohumeral mechanics
bull Posterior-Inferior G-H Capsule bull Associated with SLAP tears amp internal
impingement syndrome in throwing athletes
bull Latissimus Dorsi and Teres Majorbull Associated with resistance to UE elevation
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Andersen et al Phys Ther 2010 Apr90(4)538-49
bull RESULTS Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude with increasing resistance
bull CONCLUSIONS bull Therapists can choose either
resistance method in clinical practice
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
How do we load the shoulder
Myth
bull We must limit the amount of weight used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and not larger compensatory muscles
Evidence
bull EMG signal amplitude of the smaller RC muscles and larger deltoid muscles increased linearly in relation to the amount of weight
bull Larger muscle groups do not overpower smaller groups such as the rotator cuff
bull Load should be based on the individual goals requirements
Alpert et al (J Shoulder Elbow Surg 2000947-58)Dark et al (Phys Ther 2007871039-1046)
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Baechle TR Essentials of Strength and Conditioning Human Kinetics 2008
Strength Continuum
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
SCAPULArsquoS ROLE IN SHOULDER STABILITY
bull Dynamic positioning of the glenoid fossa relative to the humeral axis (~300)bull Minimizes GH shear amp maximizes GH compressionbull Optimal muscle activation (minimized RTC activation
requirements)
bull Stable base of origin for muscles bull Responsible for function and stability
bull Length dependent activation patternsbull Deltoid biceps triceps and RTC
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Evidence Based Scapular Interventions
bull Serratus anterior strengthening or retraining
bull Upper trapezius activation reduction
bull Pectoralis minor stretching
bull Thoracic extension posture and exercise
bull Posterior shoulder stretching
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Scapular Retraining Exercises
bull Scapular Punches bull Isometric Scapular Retractionsbull Scapular Clocks bull Rotations on a ballbull Prone Yrsquos Trsquos Wrsquosbull Seated push-upsbull Rows
bull Integrate hiptrunk strengthening and stretching throughout rehab
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
What are the best exercises for Muscles around the shoulder
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Recommended Exercises for Rotator Cuff
bull Supraspinatusbull 1 Full can bull 2 Prone full can
bull Infraspinatus and teres minorbull 1 Side-lying ERbull 2 Prone ER at 90deg abductionbull 3 ER with towel roll
bull Subscapularis bull 1 IR at 0deg abductionbull 2 IR at 90deg abduction (less pec)bull 3 IR diagonal exercise
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
20 participants performed full can and empty can exercises and 3D scapula kinematics were captured
Increased scapular internal rotation and anterior tipping decreased the volume of the supraspinatus outlet during the EMPTY CAN
exercise When maintenance of the subacromial space is important use of the FULL CAN exercise seems most appropriate for selective strengthening of the
supraspinatus
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Infraspinatus and subscapularis activityhellip
bull Infraspinatus and subscapularis activity have generally been reported to be higher in the lsquofull canrsquo compared with the lsquoempty canrsquo
bull Posterior deltoid activity is higher in lsquoempty canrsquo ex
Escamilla et al Sports Med 2009 39 (8) 663-685
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Best Exercise for the Serratus
Ludewig et al Am J Sports Med 2004 32 484-93
SUGGESTED SEQUENCEbull Plus phase Wall Pushup Plusbull Elbow Pushup Plusbull Knee Pushup Plus bull Standard Pushup Plus
In clinical cases of scapular winging the Standard
Pushup Plus is an optimal exercise
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Recommended Exercises for Serratus
Serratus anterior bull 1 Push-up with plus
bull 2 Dynamic hug
bull 3 Serratus punch 120deg
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Recommended Exercises for Trapezii
bull Lower trapezius bull 1 Prone full can bull 2 Prone ER at 90deg abductionbull 3 Prone horiz abd at 90deg with ERbull 4 Bilateral ER (best LTUT ratio)
bull Middle trapezius bull 1 Prone row bull 2 Prone horiz abd at 90deg with ER
bull Upper trapezius bull 1 Shrugbull 2 Prone rowbull 3 Prone horiz abd at 90deg with ER
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Best Exercises to Minimize Upper Trap
bull Exercises promoting lower trapezius (LT) middle trapezius (MT) and serratus anterior (SA) activation with minimal activity in the upper trapezius (UT) are recommended
bull Examined 12 commonly used trapezius exercises and looked for low ratios of UTLT UTMT or UTSA
bull No exercise optimized UTSA ratio bull This is the first study calculating balance ratios of
trapezius activity during these exercises
Cools et al Am J Sportsmedicine200735(10)1744-51
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Conclusions THESE are good trapezius exercises but they are NOT good Serratus Anterior Ex
bull sidelying external rotation bull side-lying forward flexion bull prone horiz abduction with
external rotation and bull prone extension exercises
hellipto promote LT and MT activity with minimal activation of the UT part
bull Based on our results we suggest the use of
Cools et al Am J Sportsmedicine200735(10)1744-51
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Recommended Exercises for Rhomboids and Levator
bull Rhomboids and levator scapulaebull 1 Prone row bull 2 Prone horiz abd at 90deg with ERbull 3 Prone extension with ER
Escamilla et al Sports Med 2009 39 (8) 663-685
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
General thoughts on therex for shoulder
bull Initial phasebull Pain control edema reduction gentle PROM address
functional problems
bull Sub-acutebull Progress PROM as tolerated possibly add in AAROM
address functional problemsbull Progress to AROM followed by strengthening
bull Return to functional statebull Progress strengthening agility dynamic stabilization sport-
specific exercises
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
bull 10 Patients with Impingement receivedbull Manual Therapy (Using a regional interdependence approach)bull 3 Phase Exercise Protocol by Tate et al JOSPT 2008bull Motor controlstrengthening (phases I-III)bull Stretchingbull Patient Education
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Program Summaryand Outcomes
Tate et al JOSPT 2010 40(8)
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Instructions
bull Begin with band under very mild tensionbull Progress to next strongest elastic band when able to do 3 sets
of 10 reps without substantial pain or fatiguebull T-band standard 35ft long
bull Longer for taller people doing scaption
bull Avoid or modify position of any exercise producing significant symptoms
Tate et al JOSPT 2010 40(8)
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Tate
et
al
JO
SP
T 2
010
40
(8)
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Tate et al JOSPT 2010 40(8)
Phase I
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Tate et al JOSPT 2010 40(8)
Phase II
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Tate et al JOSPT 2010 40(8)
Phase III
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Clinical Bottom Line Exercise for SIS
bull Conservative treatment is recommended over surgerybull Exercise is effective at improving pain and function bull Improve scapular motion and clear subacromial space
bull Correct posturebull Strengthen shoulder stabilizers
bull Rhomboidsbull Serratus anteriorbull Mid and Lower trapezius
bull Strengthen rotator cuffbull Stretch tight structures
bull Pec major and minorbull Upper trapeziusbull Posterior capsule
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Exercise for Rotator Cuff Tears
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
bull Results bull 4 studies were specific to massive rotator cuff tears
bull 1 study had a sub-group with massive cuff tears bull 5 studies were not specific on size of the full
thickness tear bull Due to the heterogeneity of outcome measures used
it was not possible to combine resultsbull In all studies an improvement in outcome scores
was reportedbull The findings suggest that some evidence exists to
support the use of exercise in the management of full thickness rotator cuff tears
Ainsworth amp Lewis Br J Sports Med 200741200ndash210
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
bull 20 patients with full-thickness rotator cuff tears [RCTs] bull Treatment activity modification NSAIDs physical modalities and
a specific exercise program
bull Statistically significant improvements were obtained in bull ROMbull Pain bull Function scores according to ASES Constant score SF-36 scores
and isokinetic strength (P lt 005)
At the 6-month evaluationbull 11 patients (55) reported that they were ldquomuch betterrdquobull 9 patients (45) ldquobetterrdquo
bull Conservative treatment of full-thickness RCTs yields satisfactory results both subjectively and objectively
Baydar et al Rheumatol Int (2009) 29623ndash628
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
bull Conclusion Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive
Seida et al Ann Intern Med 2010 Aug 17153(4)246-55 Epub 2010 Jul 5
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Exercise for Instability
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
bull Functional rehab following shoulder dislocationbull Increase proprioceptive awarenessbull Increase dynamic stabilizationbull Elicit preparatory and reactive muscle activationbull Restoration of functional movement patterns
bull (Lephart and Henry 1996)bull Open and closed chain exercises improve proprioception
bull (Rogol et al 1998)bull Closed chain activities increase functional joint stability
bull (Ubinger et al 1999 Henry et al 2001)bull Exercises that enhance coactivation improve recovery
bull (Ginn and Cohen 2005)
bull Shoulder plyometric training increases proprioceptionbull (Swanik et al 2002)
Shoulder Instability Rehab
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Motor Control Alterations with GH Instabity
bull Decreased supraspinatus-subscapularis coactivation
bull Slower biceps brachii activationbull Decreased pectoralis major amp
biceps brachii recruitmentbull Suppressed scapular stabilization
by Trapezius and Serratusbull (Glousman et al 1988 Kelly et al 2005 Kronberg et
al 1991 McMahonet al 1996 Myers et al 2004)
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
bull 6 Subjects with GH Instability bull Significant increases scapular protraction and
anterior tilt bull Activity of the lower trap and serratus delayed
during first part of elevationbull Altered humeral head and glenoid alignment
predispose shoulder instability bull Scapular changes are perhaps due to an inadequate
scapular muscular activitybull Evidence to suggest that the sensorimotor
contributors to joint stability can be restored
The unstable shoulder in arm elevation A three-dimensional and electromyographic study in
subjects with glenohumeral instability Matias R Pascoal AG
Clinical Biomechanics 21 (2006) S52ndashS58
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Naughton J et al Upper-body wobbleboard training effects on the post-dislocation shoulder Phys Ther In Sport 2005 631ndash37
bull 15 uninjured control bull 15 dislocatedsubluxed within 1 yearbull Assessed movement discriminationbull 4 wk training period Trunk Lying on
Swiss ball balancing UE on wobbleboard 10 min daily
Significant improvement movement discrimination
with dislocators ( plt0001)
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
bull Rehab success for shoulder instabilitybull Requires cuff recruitmentbull Facilitate glenohumeral approximation
bull Concavity-Compression Retrainingbull (Similar to Dynamic Relocation Test)
Neuromuscular retraining for multidirectional instability of the shoulder -- a case study
Darlow B
NZ J Physiother 200634(2)60-65
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Instability Rehabilitation Implications
bull Restore normal function of rotator cuff musculaturebull Strengthen infraspinatus and teres minor (ERs) to avoid anterio-
inferior instability
bull Avoid rehabilitation exercises combining abduction and external rotation
bull Serratus anterior and trapezius strengthening exercises can begin early in rehab process
bull Begin with isometric exercises with manual resistance progress to dynamic strengthening bull Eventually plyometric exercises for highly active populations
bull Include proprioceptive exercises to combat loss due to tissue damage
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Advanced phase functional rehabilitation
bull Focus on continued strength and endurancebull Retraining patterns of movement biased
towards functional tasksbull Repetition speed and load may be varied
facilitating feedforward processingbull Dynamic stabilization challenged by pushups
on a ball or throwing and catching a ballbull Plyometric drills such as two-hand chest
passes overhead soccer throw and side-to-side throws
bull Bouncing balls off trampoline bull Global upper-limb strengthening
bull Kibler et al Clin Sports Med 2008
Jaggi and Lambert Br J Sports Med 2010445 333-340
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
bull Integrate LEtrunk wloadsbull Push-press to single-arm squatbull Lunge and Reach Progression
Integrating the Shoulder
Return to Function Phase
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Return to sport
bull Sport specific goal-orientated tasksbull Throwing at a specific targetbull Bouncing a ball around an obstacle course bull Shooting into a basketballnetball hoop
bull Patient should regain 5 key components
prior to return to sport1 Flexibility
2 Strength
3 Balance
4 Proprioception
5 CONFIDENCEbull If confidence is lacking patient at risk of
compensation reinjury and recurrence of instability
Jaggi and Lambert Br J Sports Med 2010445 333-340
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Upper Extremity Y-Balance Test
bull ldquoY Balance test is a body relative quantitative analysis of a personrsquos ability to reach with the free upper limb while maintaining single-limb weight-bearing on the contralateral upper limbrdquo
bull Test-retest reliability 080 to 099bull Interrater reliability 100 bull Average composite scores rightleft (Limb Length)
bull Men 817823 bull Women 807 807
Gorman Butler Plisky and Kiesel J Strength Cond Res 2012 Jan 5 Epub
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Our Path
Things that donrsquot move enough
bull Subacromial Impingementbull Adhesive Capsulitis
bull Evidence for Manual Therapy
Things that move too much
bull Shoulder Instabilitybull Evidence-supported exercise
Irsquom getting Emotionalhellip
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Irsquom getting Emotionalhellip
bull Catastrophizing fear avoidance self-efficacy all important for shoulder dysfunction like so many MSK conditionsbull COMT phenotypes
Evidence for risk factors for chronic pain
bull Measure these fine thingsbull TSK FDAQ FABQ
Kinesiophobia
bull Graded ExposureGraded Exercisebull Pain Science Educationbull Fewer manual technqiuesbull Focus on function
Remember to acknowledge and treat chronic conditions as chronic pain
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Pain Phenotypes you say
bull Genetic expressions for inflammation (IL1B TNFLTA region IL6 single nucleotide polymorphisms SNPs)
bull and Psychological factorshellip
bull Combine to predict shoulder pain phenotypes specifically pain level duration and disability
George et al 32014
Inflammatory Genes and Psychological Factors Predict Induced Shoulder Pain Phenotype
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Genetically Predisposed
bull Strong associations between type of COMT (catechol-o-methyl-transferase) phenotype and catastrophizing
bull Are predictive of upper extremity disability and depressive symptoms related to pain
Biopsychosocial influence on exercise-induced injury genetic and psychological combinations are predictive of shoulder pain phenotypes George et al 12014
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
References1 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-137 2 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 200914(4)375-380 3 Kuijpers T van Tulder MW van der Heijden GJMG Bouter LM van der Windt DAWM Costs of shoulder pain in primary care consulters a
prospective cohort study in The Netherlands BMC Musculoskelet Disord 2006783 4 McClure P Tate AR Kareha S Irwin D Zlupko E A clinical method for identifying scapular dyskinesis part 1 reliability J Athl Train
200944(2)160-164 5 Mintken PE Cleland JA Carpenter KJ et al Some factors predict successful short-term outcomes in individuals with shoulder pain receiving
cervicothoracic manipulation a single-arm trial Phys Ther 201090(1)26-42 6 Morse K Davis AD Afra R et al Arthroscopic versus mini-open rotator cuff repair a comprehensive review and meta-analysis Am J Sports Med
200836(9)1824-1828 7 Norlander S Nordgren B Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine Scand J
Rehabil Med 199830(4)243-251 8 Tate AR McClure PW Kareha S Irwin D Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in
overhead athletes J Orthop Sports Phys Ther 200838(1)4-11 9 Tate AR McClure P Kareha S Irwin D Barbe MF A clinical method for identifying scapular dyskinesis part 2 validity J Athl Train 200944(2)165-
173 10 Winters JC Jorritsma W Groenier KH et al Treatment of shoulder complaints in general practice long term results of a randomised single blind
study comparing physiotherapy manipulation and corticosteroid injection BMJ 1999318(7195)1395-1396 11 Crawshaw DP Helliwell PS Hensor EMA et al Exercise therapy after corticosteroid injection for moderate to severe shoulder pain large
pragmatic randomised trial BMJ 2010340c3037 12 Conroy DE Hayes KW The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome
J Orthop Sports Phys Ther 199828(1)3-14 13 Bang MD Deyle GD Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement
syndrome J Orthop Sports Phys Ther 200030(3)126-37 14 Bergman GJD Winters JC Groenier KH et al Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and
pain a randomized controlled trial Ann Intern Med 2004141(6)432-9 15 Winters JC Sobel JS Groenier KH Arendzen HJ Meyboom-de Jong B Comparison of physiotherapy manipulation and corticosteroid injection for
treating shoulder complaints in general practice randomised single blind study BMJ 1997314(7090)1320-5 16 Senbursa G Baltaci G Atay A Comparison of conservative treatment with and without manual physical therapy for patients with shoulder
impingement syndrome a prospective randomized clinical trial Knee Surg Sports Traumatol Arthrosc 200715(7)915-21 17 Boyles RE Ritland BM Miracle BM et al The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement
syndrome Man Ther 2008 Available at httpwwwncbinlmnihgovpubmed18703377 [Accessed September 7 2008] 18 Arslan S Celiker R Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis
Rheumatol Int 200121(1)20-3 19 Vermeulen HM Rozing PM Obermann WR le Cessie S Vliet Vlieland TPM Comparison of high-grade and low-grade mobilization techniques in
the management of adhesive capsulitis of the shoulder randomized controlled trial Phys Ther 200686(3)355-68 20 McClatchie L Laprade J Martin S et al Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults Man
Ther 2008 Available at httpwwwncbinlmnihgovpubmed18752983 [Accessed September 7 2008]
Holmgren Theresa Hanna Bjoumlrnsson Hallgren Birgitta Oumlberg Lars Adolfsson and Kajsa Johansson ldquoEffect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome Randomised Controlled Studyrdquo BMJ (Clinical Research Ed) 344 (2012) e787
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-
Referencesbull Brotzman SC Manske RC Clinical Orthopedic Rehabilitation Elsevier 2011bull Carter T Hall H McIntosh G et al Intertester reliability of a classification system for
shoulder pain Physiotherapy 2012 9840-6bull Hayes K Callanan M Walton J et al Shoulder instability management and rehabilitation
JOSPT 2002 32497-509bull Hegedus EJ Goode AP Cook CE et al Which physical examination tests provide
clinicians with the most value when examining the shoulder Update of a systematic review with meta-analysis of individual tests Br J Sports Med 2012 DOI 101136bjsports-2012-091066
bull Jaggi A Lambert S Rehabilitation for shoulder instability Br J Sports Med 2010 44333ndash340
bull May S Chance-Larsen K et al Reliability of physical examination tests used in the assessment of patients with shoulder problems a systematic review 201090179-190
bull Robinson CM Howes J Murdoch H Will E Graham C Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients J Bone Joint Surg Am 2006 882326-36
bull Wilk KE Reinold MM Dugas JR Arrigo CA Moser MW Andrews JR Current concepts in the recognition and treatment of superior labral (SLAP) lesions J Orthop Sports Phys Ther 200535273-91
- Shoulder Update 2014 University of Texas at El Paso Centennia
- Objectives
- Shoulder Pain Incidence and Costs
- Our Path
- Impingement Syndrome Concept
- The SIS Continuum Neer Classification
- Impingement Classification
- Primary Impingement
- Secondary Impingement
- Diagnosis of Primary SIS
- Diagnosis of Primary SIS (2)
- Diagnosis of Secondary SIS
- Slide 13
- Outcome Measures for SIS
- General Treatment Principles
- Treatment Non-surgical vs Surgical
- Bang amp Deyle JOSPT 2000
- Bergman et al Annals of Internal Medicine 2004
- McClatchie et al Manual Therapy2008
- Tate et al JOSPT 2010
- Other Interventions
- Slide 22
- SIS A Regional Perspective
- Eccentric Exercise
- Slide 25
- Adhesive Capsulitis
- What is it
- Differential Diagnosis
- Kelley MJ et al JOSPT 39 (2) 2009
- Slide 30
- Slide 31
- Natural History
- Duration of the Disease (with conservative treatment)
- Long Term Effects
- Long Term Effects (2)
- Treatment Options
- Oral steroids Cochrane Review Buchbinder 2009
- Steroid Injections Cochrane Review Buchbinder 2009
- Capsular Distension Cochrane Buchbinder 2009
- Traditional Manipulation long-lever techniques
- Traditional Manipulation long-lever techniques (2)
- Manipulation Following Interscalene Block for Shoulder Adhesive
- Total Passive ROM
- SPADI Scores (Pre-manipulation to final)
- Results
- Video Fluoroscopy
- Case Studies Arthroscopic findings following translational
- Patient 1 Diabetic male AC x 7 months
- Patient 1 Diabetic male AC x 7 months
- Patient 2 Secondary AC x 14 months
- Patient 2 Secondary AC x 14 months (2)
- Intra-articular Findings
- Translational Manipulation Theory
- Prognosis
- Clinical Bottom Line
- Slide 56
- manual Therapy for the Shoulder
- Physiotherapy Interventions for Shoulder Pain
- Physiotherapy Interventions for Shoulder Pain (2)
- Effectiveness of Rehabilitation for Patients with Impingement S
- Slide 61
- 5 Variables in the CPR
- Prognostic Factors for MT
- The Rule
- Prognostic Factors Risk of Persistent Pain
- In the workshellip
- In the workshellip In data collection phase
- Shoulder Instability
- Epidemiology
- Epidemiology (2)
- Laxity vs Instability
- Shoulder Stability A Result of Multiple Components
- Shoulder Function
- Labrum Anatomy
- Neuromuscular Stabilization
- Classifying Instability
- Classifying Instability (2)
- Classifying Instability (3)
- Instability Spectrum
- Clinical Presentation
- Clinical Presentation (2)
- Physical Examination
- Physical Examination (2)
- Non-surgical Management
- Non-surgical Management (2)
- Non-surgical Management (3)
- Exercise for Selected Shoulder Disorders
- Essential Elements for Dynamic Stability of the Shoulder Comple
- Shoulder Flexibility Requirements
- Slide 91
- How do we load the shoulder
- Slide 93
- SCAPULArsquoS ROLE IN SHOULDER STABILITY
- Slide 95
- Evidence Based Scapular Interventions
- Scapular Retraining Exercises
- What are the best exercises for Muscles around the shoulder
- Recommended Exercises for Rotator Cuff
- Slide 100
- Infraspinatus and subscapularis activityhellip
- Best Exercise for the Serratus
- Recommended Exercises for Serratus
- Recommended Exercises for Trapezii
- Best Exercises to Minimize Upper Trap
- Conclusions THESE are good trapezius exercises but they are
- Recommended Exercises for Rhomboids and Levator
- General thoughts on therex for shoulder
- Slide 110
- Program Summary and Outcomes
- Instructions
- Slide 113
- Slide 114
- Slide 115
- Slide 116
- Clinical Bottom Line Exercise for SIS
- Exercise for Rotator Cuff Tears
- Slide 119
- Slide 120
- Slide 121
- Exercise for Instability
- Shoulder Instability Rehab
- Motor Control Alterations with GH Instabity
- Slide 125
- Naughton J et al Upper-body wobbleboard training effects on t
- Slide 127
- Instability Rehabilitation Implications
- Advanced phase functional rehabilitation
- Slide 130
- Return to sport
- Slide 132
- Our Path (2)
- Slide 134
- Pain Phenotypes you say
- Genetically Predisposed
- Slide 137
- References
-