physiotherapy treatment of shoulder pain: … cools 2015.pdf · dept of rehabilitation sciences...

1

Rehab A Cools 2014

Ann Cools, PT, PhDGhent University - Belgium

Dept of Rehabilitation Sciences & [email protected]

Physiotherapy treatment of shoulder pain:REHABILITATION PRINCIPLES

1

Rehab A Cools 2014

« Today’s Topics …. »

� Which exercises/manual techniques to prescribe for– Rotator cuff pathology

– Instability

– GIRD

– Scapular dyskinesis

� Kinetic chain approach in shoulderrehab

2

Rehab A Cools 2014

Rehabilitation of rotator cuff tendinopathy

1. Rotator cuff exercises: Which exercises?

2. Eccentric exercises: how can we focus on eccentric phase?

3. Eccentric exercises: training intensity?

4. Scientific evidence?

3

2

Rehab A Cools 2014

1. Internal rotation

2. External rotation

3. Full can

4. Horizontal abduction with external rotation

(Jobe 1987, Donatelli 2004, Ellenbecker 2006, Townsend 1991, Reinold 2004)

1. Which exercises activate rotator cuff muscles?

4

Rehab A Cools 2014

� Werner JSES 2006: ER vs IR regarding Subacromialpressure? ER decreases subacromial pression comparedto rest, IR increases subacromial pressure.

� Boettcher et al. Med Sci Sports Exc 2009: external rotation and prone external rotation exercises are more valid than the "can" and prone elevation exercises for supraspinatusstrengthening

� Reinold et al. 2004: towell significantly increases IS activity

� Anju Jaggi, London 2011: supine RC strengthening to focus on both internal and external rotators

1. Which exercises activate rotator cuff muscles?

5

Rehab A Cools 2014 6(Anju Jaggi London 2011Karen Ginn, Goth 2012)

3

Rehab A Cools 2014

� supraspinatus

2. Eccentric exercises

7

(Cools & Walravens 2007, Maenhout et al. KSSTA 2012)

Rehab A Cools 2014

� External rotators

Eccentric exercises

8

Rehab A Cools 2014

3. Eccentric exercises: intensity and reps?3x15 daily, discomfort after exercises, min 6w,pain-monitoring model

� Maenhout et al. 2012 (KSSTA): RCT sign increase in RC strength after eccentric training program, full can exc, however no differences on function and pain.

� Holmgren et al. BMJ 2012: RCT: specific exercise program (ecc + scapular excercises) reduces the need for surgery

9

4

Rehab A Cools 2014

4. Scientific evidence?Kuhn JSES 2009, Gebremariam BJSM 2013, VD dolder BJSM 2014 (systematic reviews), Rhon Ann Int Med 2014

� Exercise improves symptoms (effect size >15%)

– Exercise + manual therapy better than exercisealone, however only in case of ROM deficits (Conroy 1998, Bang 2000)

– Home program = supervised exercise (Walther 2004, Werner 2002)

� Soft tissue massage is effective for improving pain

� SA corticosteroid injection = physiother, however PT group is better 1y follow up

10

Practice

1. Eccentric exercice SS

2. Eccentric exercise IS

3. Eccentric exercise ER in ABER

4. Total rotation

Rehab A Cools 2014 11

Rehab A Cools 2014

Rehabilitation of shoulder instability

1. Training progression

2. Focus on proprioception and motorcontrol

3. TUBS/AIOS versus AMBRI

12

5

Rehab A Cools 2014

INJURY

Functionalinstability

Spinal muscleReflex ↓↓↓↓

Neuro-muscularcoordination ⇓⇓⇓⇓

Mechanical instability

Proprioceptive deficits

Paradigma functional Instability(Lephart et al. 1995)

13

Rehab A Cools 2014

Muscle control

Endurance

Power

Strength

Proprioception

Coordination

14

Rehab A Cools 2014

Muscle control =

activating the appropriate muscleon the appropriate moment in the appropriate intensity

15

6

Rehab A Cools 2014

Conscious muscle control: Rotator cuff (TUBS + AIOS)Deltoid (AMBRI/MDI)(Wilk et al. 2002, Barden 2005)

16

Rehab A Cools 2014

TUBS/AIOS versus AMBRI

TUBS/AIOS

� Rotator cuff

� From CKC to OKC

� Stretching posterior

capsule (GIRD)

AMBRI

� Deltoid (ant-post)

� A lot of CKC

� No stretching

17

Rehab A Cools 2014

Muscle control

Endurance

Power

Strength

Proprioception

Coordination

Progression in exercise modalities:

Resistance ↑(50→80%)Functional relevance ↑

18

7

Rehab A Cools 2014

Rotator cuff strengthening: functional perspective

19IR ER

“Throwing program”

� TUBS and AIOS

� Everybody who wants to trow a ball… (also non-athletic population)

� Not only for instability patients, alsocuff problems, SLAP, scapulardyskinesis, post op.….)

� Not for MDI as basic program, onlywhen overhead sports is the goal


Rehab A Cools 2014

Functional diagonallimited load in ABER

21IR ER

8

Rehab A Cools 2014

Functional diagonalhigh load in ABER

22

IR ER

Rehab A Cools 2014

Plyometrics in ABER

23

IR ER

Rehab A Cools 2014

Acceleration & deceleration phase throwing

24

IR ER

9

Rehab A Cools 2014

In summary: Internal Rotation progression:

1. IR in neutral

2. Diagonal with limited ABER load

3. Diagonal with high ABER load

4. Plyometrics in ABER

5. Throwing against resistance

25

Rehab A Cools 2014

In summary:External Rotation progression:

1. ER in neutral

2. Diagonal with limited ABER load

3. Diagonal with high ABER load

4. Plyometrics in ABER

5. Eccentric loading external rotators duringdeceleration

26

Advanced program for“throwers”

� Eccentric high load exercises forposterior cuff

� Plyometrics using plyoball, flexbar, Xco…

� Sportspecific positions

� Attention to the kinetic chain


10

Eccentric diagonals

�


Rehab A Cools 2014

Plyometrics IR & ER

29

(Ellenbecker & Cools 2010)

Rehab A Cools 2014

Plyometrics IR & ER in ABER

30

11

Scapular muscle recruitment duringplyometric exercises? (2014)

A Cools EUSSER London Symp 2014

Goal of the exercise:

1. MT & LT ↑

2. SA ↑ and UT ↓

3. UT ↓

4. Overall scap muscles↑A Cools EUSSER London Symp 2014

Rehab A Cools 2014

“Thrower’s program” sportspecific: shoulder position

33

12

Thrower’s program: Kinetic Chain

Legs

Trunk and Back

Shoulder

Elbow

Wrist

0

F

O

R

C

E

TIME(Kibler, Gent 2003)

34Rehab A Cools 2014

Legs

Trunk and Back

Shoulder

Elbow

Wrist

0

F

O

R

C

E

TIME(Kibler, Gent 2003)


Rehab A Cools 2014

“Thrower’s program” sportspecific: kinetic chain

36

13

Integration Kinetic Chain into openchain shoulder rehabilitation exercises


Rehab A Cools 2014

Results: EMG activity scapularmuscles: unilateral squat versus other exercise modalities

* *

**

*

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

38

Rehab A Cools 2014

Sportspecific program: swimming

39

14

Practice

1. Eccentric ER diagonal

2. Plyoball neutral position

3. Plyoball 90° forw flex

4. Plyoball 90°-90°

5. Flexbar + tubing neutral

6. Xco/flexbar 90°-90°

7. W-V ex swissball


1

2

3

4

5

6

7

Rehab A Cools 2014

TUBS/AIOS versus AMBRI

TUBS/AIOS

� Rotator cuff

� From CKC to OKC

� Stretching posterior

capsule (GIRD)

AMBRI

� Deltoid (ant-post)

� A lot of CKC

� No stretching

41

General Guidelines AMBRI/MDI


Low Load

dynamic

dynamicstatic

Moderate Load

High Load static

dynamicstatic

15

Diagonals in CK exercises

� Semi closed chain SA exc

(elevation)

� Semi closed chain trap exc

(rowing)


Case: gymnast with chronic shoulder pain based on instability

Rehab A Cools 2014

6 modalities of the push-up plus exercise (N=32)

2

5

4

76

3

(Maenhout & Cools BJSM 2009)

44

Rehab A Cools 2014

Results: EMG-activity and muscle balance ratios

� Highest SA activity (44%MVC) en best

UT/SA ratio (0.40) when ipsilateral leg isextended

3


45

16

Rehab A Cools 2014

Results: EMG-activity and muscle balance ratios

� Highest activity in MT & LT, when

contralateral leg is extended(LT=20%MVC)

2


46

Rehab A Cools 2014

stretching and mobilisation techniques in the rehabilitation of G.I.R.D.

1. Angular stretchinga. Internal rotation: « sleeper’s stretch »

b. Horizontal adduction: « cross-body stretch »

2. Translation mobilisations in end-range (dorsal glides)a. Internal rotation

b. Horizontal adduction

3. Mobilization with movement – dorsal glides1. External rotation

2. Forward flexion

3. Abduction

(Cools et al. BJSM 2008,

Ellenbecker 2006,Ellenbecker & Cools 2010, BJSM

Wilk JOSPT 2009, Cools et al. Shoulder & Elbow 2011)47

Rehab A Cools 2014

1a: Angular stretching : « Sleeper’s stretch »

48

17

Sleeper’s stretch supine + caudal glide

Rehab A Cools 2014

(John Borstad, ICSET Edinburgh 2010, JOSPT 2011)49

Rehab A Cools 2014

1b: Angular stretching intohorizontal adduction: “cross body stretch”

50

Rehab A Cools 2014

Practice angular stretching:

1. Sleeper’s stretch side-lying

– Ask for pain ant versus post

2. Sleeper’s stretch supine

3. Sleeper’s stretch + caudal glide

4. Sleeper’s stretch + hold-relax

5.

6.

7.

8. 51

18

Rehab A Cools 2014

Practice angular stretching:

1.

2.

3.

4.

5. Cross body stretch

– Work together with patient

6. “Reversed” Cross body stretch

7. Reversed cross body stretch + hold relax

8. Home-sleeper’s stretch

52

Rehab A Cools 2014

2a: Mobilisation: dorsal glide in endrange

53

Dorsal glides in moderate internalrotation


19

Rehab A Cools 2014

2b: non-angular stretchinginto horizontal adduction

55

3a. Mobilisation withmovement: ER + dorsalglide


3b-c. Relocation of the humeral head during

Rehab A Cools 2014

Forward flexion abduction

57

20

Rehab A Cools 2014

Practice manual mobilisations(accessory movements & MWM) :

1. End-range dorsal glide in IR

2. Dorsal glide in moderate IR (hand from neutralto belly)

3. Mobilization with movement: ER + dorsal glide

– Change shoulder position (to ABER)

– Passive / resistance ER

4. Mobilization with movement: forward flexionwith dorsal glide

5. Mobilization with movement: abduction withdorsal glide

58

1

2

3

4

5

Rehab A Cools 2014

Stretching posterior structures?

� Mc Clure (JOSPT 2005): improvement IR ROM after 4-weeks home stretchingprogram, cross body stretch & sleeper’sstretch

� Manske et al. Sports Health 2010: angularstretching (home program) + joint mobilisation (dorsal glide) slightly betterthan stretching only.

� Tyler et al. 2010: ROM improvement is related to symptom relief.

� Cools et al. Shoulder & Elbow 2011: equalresults from angular stretch versus dorsal glide

� Maenhout et al. 2012 JSM: stretching increases the size of the subacromial space

59

Rehab A Cools 2014

Joint mobilization and MobilizationWith Movement?

� Hsu et al. (2001), Yang et al. (2007): Caudal glide mobilisation improvesabduction ROM, but only in endrange

� Hsu et al. (2002): both caudal and dorsalglides (indirect mobilisations) improveabcuction ROM

� Yang et al. (2007): MWM superior effectswith respect to scapulohumeral rythm

� Johnsson JOSPT 2007: Posterior glide is superior to anterior glide in external rotation ROM

60

21

Rehab A Cools 2014

Rehabilitation of scapular dyskinesia

1. Summary of factors determiningscapular dyskinesis?

2. Treatment of flexibility deficits

3. Treatment of muscle performance problems

1. Muscle control

2. Muscle balance

3. Muscle strength

4. Advanced sport specific muscle control61


Scapular Rehab AlgorithmLack of

Soft-tissue flexibility

Lack of

Muscle performance

Scapular muscles GH muscles/capsule Muscle Control Muscle Strength

- Levator scapulae

- pectoralis minor

- infraspinatus

- posterior capsule

- co-contraction

- force couples

- lower/middle trap

- serratus anterior

STRETCHING & MOBILISATIONNEUROMUSCULAR

COORDINATION

STRENGTH

TRAINING

Advanced control

During basic activities

Endurance/strength

Balance -ratio

Advanced control

During sports

Conscious muscle

control

Conscious muscle

control- Manual stretching

- home stretching

- soft tissue techniques

- manual mobilisations

(accessory movements)

-MWM

(Cools et al. BJSM 2013)


22



Lack of

Muscle performance


- Levator scapulae

- pectoralis minor

- infraspinatus

- posterior capsule

- co-contraction

- force couples

- lower/middle trap

- serratus anterior


COORDINATION

STRENGTH

TRAINING

Advanced control


Endurance/strength

Balance -ratio

Advanced control

During sports

Conscious muscle

control

Conscious muscle


- home stretching




-MWM64Rehab A Cools 2014




Lack of

Muscle performance


- Levator scapulae

- pectoralis minor

- infraspinatus

- posterior capsule

- co-contraction

- force couples

- lower/middle trap

- serratus anterior


COORDINATION

STRENGTH

TRAINING

Advanced control


Endurance/strength

Balance -ratio

Advanced control

During sports

Conscious muscle

control

Conscious muscle


- home stretching








Lack of

Muscle performance


- Levator scapulae

- pectoralis minor

- infraspinatus

- posterior capsule

- co-contraction

- force couples

- lower/middle trap

- serratus anterior


COORDINATION

STRENGTH

TRAINING

Advanced control


Endurance/strength

Balance -ratio

Advanced control

During sports

Conscious muscle

control

Conscious muscle


- home stretching






23

Rehab A Cools 2014



Lack of

Muscle performance


- Levator scapulae

- pectoralis minor

- infraspinatus

- posterior capsule

- co-contraction

- force couples

- lower/middle trap

- serratus anterior


COORDINATION

STRENGTH

TRAINING

Advanced control


Endurance/strength

Balance -ratio

Advanced control

During sports

Conscious muscle

control

Conscious muscle


- home stretching




-MWM

Stretching

Pectoralis minor


67

Stretching pectoralis minor: literature

� Borstad et al. JOSPT 2005: short PM influences scapular kinematics and induceschanges similar to impingement relateddyskinesis

� Cools & Johansson BJSM 2010: significant decrease PM length in elite junior (11-17yr) tennis players

� Reeser PM&R 2010: tight PM is associatedwith history of shoulder pain in volleyballplayers

� Borstad et al. JSES 2006: unilateral selfstretch (in 90° ABER) best results, however…

Rehab A Cools 2014

68

Rehab A Cools 2014

Stretching pectoralis minor: clinical experience

69

24

Rehab A Cools 2014


Soft-tissue flexibilityLack of

Muscle performance


- Levator scapulae- pectoralis minor

- infraspinatus- posterior capsule

- co-contraction- force couples

- lower/middle trap- serratus anterior

STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION

STRENGTH TRAINING

Advanced controlDuring basic activities

Endurance/strength

Balance -ratio

Advanced controlDuring sports movements

Conscious musclecontrol


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

- taping

Scapular orientation exercise

70

Rehab A Cools 2014

Scapular Orientation Exercise

- Scapular upward rotation andposterior tilting

- Increased scapular muscleactivity

(Mottram et al. Man Ther 2009)

Enhancing lower trapezius muscle control: literature

71

Rehab A Cools 2014

Learning conscious lower trapezius muscle recruitment: clinical experience

72

25

Rehab A Cools 2014

Learning conscious lower trapezius muscle recruitment: clinical experience

73

Rehab A Cools 2014



Muscle performance







STRENGTH TRAINING


Endurance/strength

Balance -ratio





- taping

Muscle control Basic activities

74

Purpose: increase scapular dynamic control during various exercises and movements: some examples…


(Kibler 2008, Uhl 2010, Johansson 2012Cools 2013)

26

Scapular muscle balance duringshoulder exercises

Rehab A Cools 2014

� External rotationcomponent: increasinglower and middle trap activity

� Functional elevationplane

76

(Kibler 2008, Uhl 2010, Johansson 2012Cools 2013)


Rehab A Cools 2014

� Semi-closed chain: safe for instabilitypatients and to unloadthe cuff

� High elevation: LT as a prime mover

� Diagonal pattern: better scapular musclerecruitment 77(Kibler 2008, Uhl 2010, Johansson 2012

Cools 2013)

� UT ↓� SA =

� Lev Scap ↓� Rhomb ↓

A Cools EUSSER London Symp 2014

� UT ↓� SA =

� MT & LT ↑� Rhomb ↑� Pect Min ↓

27


Rehab A Cools 2014

� Hip-abduction activity: increasing diagonalkinetic chain activity?

� Core-stability challenge

� Perform ER or elevation

79(Kibler 2008, Uhl 2010, Johansson 2012Cools 2013)

PRACTICE


Rehab A Cools 2014



Muscle performance







STRENGTH TRAINING


Endurance/strength

Balance -ratio





- taping

Muscle balance

81

28

Rehab A Cools 2014

Rehabilitation muscle balanceUT/SA

� Elbow push-up

� Serratus punch lying on the back

� Serratus punch in closed chain

( Ludewig et al. 2004)82

Rehab A Cools 2014

Rehabilitation muscle balanceUT/MT & UT/LT

83


29

Scientific evidence:

� De Mey et al. JOSPT 2009: scapular exercises promoteearly activation of LT and late activation of UT

� Vandevelde et al. JAT 2010: scapular training (12w) increases scapular strength and endurance in healthyswimmers

� Merolla et al. JAT 2010: scapular program (6mo) increases Infraspinatus strength in volleyball players

� De Mey et al. JOSPT 2012: Pre-setting duringexercises increases muscle activity in trapezius

� De Mey et al. AJSM 2012: scapular exercises reduceEMG ativity in UT during functional movement


PracticeUT/SA

UT/MT & UT/LT


Rehab A Cools 2014



Muscle performance







STRENGTH TRAINING


Endurance/strength

Balance -ratio





- taping 87

30

Rehab A Cools 2014

Case-presentation

� Young elite gymnast, 12 years old, 34 hours/week training

� Shoulder pain during sport for 6 months

� 4 months physiotherapy, scapular training, muscle control…

� Imaging and EMG negative

88



31


Rehab A Cools 2014

Case-presentation

� No “conscious” trapezius training

� Try to optimise global and subconscious muscle control?

� A lot of closed kinetic chain (cfr sports activity: pain during weight bearing on upper limb)

� Looking for “ appropriate” exercises…..

92


32




THANKS!Ghent, Belgium, July 21th every year......

physiotherapy treatment of shoulder pain: … cools 2015.pdf · dept of rehabilitation sciences...

Documents