Physiotherapy treatment of shoulder pain: REHABILITATION PRINCIPLES. «Today s Topics.» Rehabilitation of rotator cuff tendinopathy

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Rehab A Cools 2014

Ann Cools, PT, PhD Ghent University - Belgium Dept of Rehabilitation Sciences & Physiotherapy Ann.Cools@UGent.be

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 shoulder

rehab

2

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?

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1. Internal rotation

2. External rotation

3. Full can

4. Horizontal abduction

with external rotation

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

1. Which exercises activate rotator

cuff muscles?

4

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Werner JSES 2006: ER vs IR regarding Subacromial

pressure? ER decreases subacromial pression compared

to 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 supraspinatus

strengthening

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

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(Anju Jaggi London 2011 Karen Ginn, Goth 2012)

(3)

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supraspinatus

2. Eccentric exercises

7

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

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External rotators

Eccentric exercises

8

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.

(4)

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4. Scientific evidence?

Kuhn JSES 2009, Gebremariam BJSM 2013, VD dolder BJSM 2014

(systematic reviews), Rhon Ann Int Med 2014

Exercise

improves symptoms (effect size >15%)

– Exercise +

manual therapy

better than exercise

alone, 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

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Rehabilitation of shoulder

instability

1. Training progression

2. Focus on proprioception and motor

control

3. TUBS/AIOS versus AMBRI

(5)

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INJURY

Functional

instability

Spinal muscle

Reflex

↓↓↓↓

Neuro-muscular

coordination

⇓

Mechanical

instability

Proprioceptive

deficits

Paradigma functional Instability

(Lephart et al. 1995)

Muscle control

Endurance

Power

Strength

Proprioception

Coordination

14

Muscle control =

activating the appropriate muscle

on the appropriate moment in the

appropriate intensity

(6)

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Conscious muscle control:

Rotator cuff

(TUBS + AIOS)

Deltoid

(AMBRI/MDI)

(Wilk et al. 2002, Barden 2005)

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TUBS/AIOS versus AMBRI

TUBS/AIOS

Rotator cuff

From CKC to OKC

Stretching posterior

capsule (GIRD)

AMBRI

Deltoid (ant-post)

A lot of CKC

No stretching

Muscle control

Endurance

Power

Strength

Proprioception

Coordination

Progression

in exercise modalities:

Resistance ↑(50→80%)

Functional relevance ↑

18

(7)

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Rotator cuff strengthening:

functional perspective

19

IR

ER

“Throwing program”

TUBS and AIOS

Everybody who wants to trow a ball…

(also non-athletic population)

Not only for instability patients, also

cuff problems, SLAP, scapular

dyskinesis, post op.….)

Not for MDI as basic program, only

when overhead sports is the goal

Functional diagonal

limited load in ABER

(8)

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Functional diagonal

high load in ABER

22

IR

ER

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Plyometrics in ABER

23

IR

ER

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Acceleration & deceleration

phase throwing

24

(9)

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In summary:

Internal Rotation progression:

1. IR in neutral

2. Diagonal with limited ABER load

3. Diagonal with high ABER load

4. Plyometrics in ABER

5. Throwing against resistance

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In summary:

External Rotation progression:

1. ER in neutral

2. Diagonal with limited ABER load

3. Diagonal with high ABER load

4. Plyometrics in ABER

5. Eccentric loading external rotators during

deceleration

26

Advanced program for

“throwers”

Eccentric high load exercises for

posterior cuff

Plyometrics using plyoball, flexbar,

Xco…

Sportspecific positions

Attention to the kinetic chain

(10)

Eccentric diagonals

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Plyometrics IR & ER

29

(Ellenbecker & Cools 2010)

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Plyometrics IR & ER in

ABER

(11)

Scapular muscle recruitment during

plyometric 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

↑

“Thrower’s program”

sportspecific: shoulder

position

(12)

Thrower’s program: Kinetic Chain

Legs Trunk and Back Shoulder Elbow Wrist 0 F O R C E TIME

(Kibler, Gent 2003) Rehab A Cools 2014 34

Legs Trunk and Back Shoulder Elbow Wrist 0 F O R C E TIME

(Kibler, Gent 2003) Rehab A Cools 2014 35

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“Thrower’s program”

sportspecific: kinetic chain

(13)

Integration Kinetic Chain into open

chain shoulder rehabilitation exercises

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Results: EMG activity scapular

muscles: unilateral squat versus

other exercise modalities

* *

*

* *

*= significant main effect “exercise”

(De Mey & Cools, 2012 )

38

Sportspecific program:

swimming

(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

Rehab A Cools 2014 40 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

Rehab A Cools 2014 42 Low Load dynamic dynamic static Moderate Load

High Load static

dynamic static

(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

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6 modalities of the push-up plus exercise

(N=32)

2 5 4 7 6 3

(Maenhout & Cools BJSM 2009)

44

Results: EMG-activity and muscle

balance ratios

Highest

SA

activity (44%MVC) en best

UT/SA ratio (0.40) when

ipsilateral

leg is

extended

(16)

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Results: EMG-activity and muscle

balance ratios

Highest activity in

MT & LT

, when

contralateral

leg is extended

(LT=20%MVC)

2

(Maenhout & Cools BJSM 2009)

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stretching and mobilisation

techniques in the

rehabilitation of G.I.R.D.

1.

Angular stretching

a.

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 glides

1. External rotation

2. Forward flexion

3. Abduction

(Cools et al. BJSM 2008, Ellenbecker 2006, Ellenbecker & Cools 2010, BJSM

Wilk JOSPT 2009, Cools et al.

Shoulder & Elbow 2011)47

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1a: Angular stretching :

« Sleeper’s stretch »

(17)

Sleeper’s stretch supine +

caudal glide

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(John Borstad, ICSET Edinburgh 2010, JOSPT 2011)

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1b: Angular stretching into

horizontal adduction: “cross

body stretch”

50

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.

(18)

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Practice angular stretching:

1.

2.

3.

4.

5. Cross body stretch

– Work together with patient

6. “Reversed” Cross body stretch

7. Reversed cross body stretch + hold relax

8. Home-sleeper’s stretch

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2a: Mobilisation: dorsal

glide in endrange

53

Dorsal glides in

moderate internal

rotation

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2b: non-angular stretching

into horizontal adduction

55

3a. Mobilisation with

movement: ER + dorsal

glide

3b-c. Relocation of the

humeral head during

(20)

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Practice manual mobilisations

(accessory movements & MWM) :

1.

End-range dorsal glide in IR

2.

Dorsal glide in moderate IR (hand from neutral

to belly)

3.

Mobilization with movement: ER + dorsal glide

– Change shoulder position (to ABER)

– Passive / resistance ER

4.

Mobilization with movement: forward flexion

with dorsal glide

5.

Mobilization with movement: abduction with

dorsal 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 stretching

program, cross body stretch & sleeper’s

stretch

Manske et al. Sports Health 2010: angular

stretching (home program) + joint

mobilisation (dorsal glide) slightly better

than stretching only.

Tyler et al. 2010: ROM improvement is

related to symptom relief.

Cools et al. Shoulder & Elbow 2011: equal

results from angular stretch versus dorsal

glide

Maenhout et al. 2012 JSM: stretching

increases the size of the subacromial space

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Joint mobilization and Mobilization

With Movement?

Hsu et al. (2001), Yang et al. (2007):

Caudal glide mobilisation improves

abduction ROM, but only in endrange

Hsu et al. (2002): both caudal and dorsal

glides (indirect mobilisations) improve

abcuction ROM

Yang et al. (2007): MWM superior effects

with respect to scapulohumeral rythm

Johnsson JOSPT 2007: Posterior glide is

superior to anterior glide in external

rotation ROM

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Rehabilitation of scapular

dyskinesia

1. Summary of factors determining

scapular 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 control

61

Scapular Rehab Algorithm

Lack 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 & MOBILISATION NEUROMUSCULAR COORDINATION STRENGTH TRAINING Conscious muscle control Conscious muscle control - Manual stretching - home stretching (Cools et al. BJSM 2013)

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Scapular Rehab Algorithm

STRETCHING & MOBILISATION NEUROMUSCULAR 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 64 Rehab A Cools 2014 (Cools et al. BJSM 2013)

Scapular Rehab Algorithm

STRENGTH TRAINING

Scapular Rehab Algorithm

STRENGTH TRAINING

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Scapular Rehab Algorithm

STRENGTH TRAINING

Endurance/strength Balance -ratio Advanced control During sports Conscious muscle control Conscious muscle control - Manual stretching - home stretching - soft tissue techniques - manual mobilisations (accessory movements) -MWM Stretching Pectoralis minor (Cools et al. BJSM 2013) 67

Stretching pectoralis minor: literature

Borstad et al. JOSPT 2005: short PM

influences scapular kinematics and induces

changes similar to impingement related

dyskinesis

Cools & Johansson BJSM 2010: significant

decrease PM length in elite junior (11-17yr)

tennis players

Reeser PM&R 2010: tight PM is associated

with history of shoulder pain in volleyball

players

Borstad et al. JSES 2006: unilateral self

stretch (in 90° ABER) best results,

however…

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68

Stretching pectoralis

minor: clinical experience

(24)

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Scapular Rehab Algorithm

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 & MOBILISATION NEUROMUSCULAR_COORDINATION STRENGTH _TRAINING

Endurance/strength Balance -ratio

Advanced control During sports movements

Conscious muscle control Conscious muscle control - Manual stretching - home stretching - soft tissue rechniques - manual mobilisations (accessory movements) - taping

Scapular orientation exercise

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Scapular Orientation Exercise

-

Scapular upward rotation and

posterior tilting

-

Increased scapular muscle

activity

(Mottram et al. Man Ther 2009)

Enhancing lower trapezius

muscle control: literature

71

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Learning conscious lower trapezius

muscle recruitment: clinical

experience

(25)

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Learning conscious lower trapezius

muscle recruitment: clinical

experience

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Scapular Rehab Algorithm

STRENGTH TRAINING

Endurance/strength Balance -ratio

Advanced control During sports movements

Conscious muscle control Conscious muscle control - Manual stretching - home stretching - soft tissue rechniques - manual mobilisations (accessory movements) - taping Muscle control Basic activities 74

Purpose: increase scapular dynamic control

during various exercises and movements:

some examples…

(26)

Scapular muscle balance during

shoulder exercises

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External rotation

component: increasing

lower and middle trap

activity

Functional elevation

plane

76

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

Scapular muscle balance during

shoulder exercises

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Semi-closed chain:

safe for instability

patients and to unload

the cuff

High elevation: LT as a

prime mover

Diagonal pattern:

better scapular muscle

recruitment

(Kibler 2008, Uhl 2010, Johansson 201277

Cools 2013)

UT ↓

SA =

Lev Scap

↓

Rhomb

↓

UT ↓

SA =

MT & LT ↑

Rhomb

↑

(27)

Scapular muscle balance during

shoulder exercises

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Hip-abduction activity:

increasing diagonal

kinetic chain activity?

Core-stability challenge

Perform ER or

elevation

79

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

PRACTICE

Scapular Rehab Algorithm

STRETCHING & MOBILISATION NEUROMUSCULAR COORDINATION STRENGTH TRAINING Conscious muscle control Conscious muscle control - Manual stretching - home stretching

(28)

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Rehabilitation muscle balance

UT/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 balance

UT/MT & UT/LT

83

(29)

Scientific evidence:

De Mey et al. JOSPT 2009: scapular exercises promote

early activation of LT and late activation of UT

Vandevelde et al. JAT 2010: scapular training (12w)

increases scapular strength and endurance in healthy

swimmers

Merolla et al. JAT 2010: scapular program (6mo)

increases Infraspinatus strength in volleyball players

De Mey et al. JOSPT 2012: Pre-setting during

exercises increases muscle activity in trapezius

De Mey et al. AJSM 2012: scapular exercises reduce

EMG ativity in UT during functional movement

Practice

UT/SA

UT/MT & UT/LT

Scapular Rehab Algorithm

STRETCHING & MOBILISATION NEUROMUSCULAR COORDINATION STRENGTH TRAINING Conscious muscle control Conscious muscle control - Manual stretching - home stretching