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1 s2.0 S1356689X03000948 Main PDF
1 s2.0 S1356689X03000948 Main PDF
Masterclass
Dynamic evaluation and early management of altered motor control around the
shoulder complex
SUMMARY. Altered dynamic control appears to be a signicant contributing factor to shoulder dysfunction.
The shoulder relies primarily on the rotator cuff for dynamic stability through mid-range. Hence, any impairment
in the dynamic stabilizing system is likely to have profound effects on the shoulder complex. The rotator cuff
appears to function as a deep stabilizer, similar to the transversus abdominus and vastus medialis obliquus, with
some evidence of disruption to its stabilizing function in the presence of pain. Similarly, serratus anterior appears to
function as a dynamic stabilizer, also demonstrating altered function in painful shoulders. Examination of dynamic
control begins with a detailed examination of posture, evaluation of natural movement patterns and functional
movements and assessment of the specic force couples relevant to shoulder function. One useful strategy in
management of altered motor control related to these force couples is that of training isolated contraction of the
rotator cuff prior to introduction of loaded activity, together with facilitation and training of appropriate scapular
muscle force couples serratus anterior and trapezius, in relation to arm elevation.
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196 Manual Therapy
glenoid fossa during mid-range movements, thus Walker 1978; Howell & Galinat 1987; Schenkman &
stiffening the joint (Schenkman & Rugo de Cartaya Rugo de Cartaya 1987, 1994; Howell et al. 1988;
1987, 1994; Lippitt & Matsen 1993; Lippitt et al. Souza 2000) and abnormal translation of the head of
1993; Wilk 1994; Burkhart 1996; Ciullo 1996; David humerus (Burkhart 1994, 1996).
et al. 1997, 2000; Kibler 1998a). Any disruption to In the scapulothoracic area, the force couples
those mechanisms can lead to abnormal translation associated with movement overhead alter through
of the humeral head during active movement. In range, as the axis of rotation changes with increasing
relation to the scapula, muscle and neural inuences elevation and plane of movement (Inman et al. 1944;
are very important to its stability as its ligamentous Poppen & Walker 1978; Dvir & Berme 1978;
attachments are limited to those of the acromiocla- Schenkman & Rugo de Cartaya 1987, 1994; Bagg &
vicular joint (Kibler 1998b). Forrest 1988; Culham & Laprade 2000; Abelew
The balance of muscle activity within force couples 2001), but the primary contributors are serratus
is often more important to normal function than anterior and trapezius (Inman et al. 1944; Basmajian
isolated strength of individual muscles (Kibler 1998a, 1963; Kapandji 1982; Bagg & Forrest 1986, 1988;
b; Kibler & Chandler 1994). Such balance is Schenkman & Rugo de Cartaya 1987, 1994; Norkin
determined by the length of muscle and associated & Levangie 1988; Souza 2000). In the early part of
fascial tissue and the pattern of recruitment. When range, when the axis of rotation is at the root of the
tested in isolation in a classic isometric manual scapular spine, the principal rotators are the upper
muscle test, a muscle may test strongly, but perform bres of both serratus anterior and trapezius (Bas-
poorly during functional activity. majian 1963), whereas when the axis of rotation
Kibler (1998a) used the term, the length-depen- moves towards the acromioclavicular joint, the
dent pattern of muscle activity to describe co- relative contribution of upper trapezius lessens while
contraction force couples which operate locally that of lower trapezius increases, together with the
around a joint, controlled by feedback from muscle lower bres of serratus anterior (Basmajian 1963;
spindle receptors and responding to perturbations of Schenkman & Rugo de Cartaya 1987, 1994) (Fig. 2A,
joint position. The primary function of such force B). Serratus anterior is, therefore, a signicant
couples is maintenance of joint stability. component of the force couple throughout range
One key force couple relevant to stability of the (Bagg & Forrest 1986).
glenohumeral joint is that between the lower elements David et al. (2000) demonstrated consistent activa-
of the rotator cuff subscapularis anteriorly and tion of the rotator cuff prior to the more supercial
infraspinatus/teres minor posteriorly (Saha 1971; delto-pectoral muscles during isokinetic rotation in
Poppen & Walker 1978; Kapandji 1982; Soderberg normal shoulders, conrming their role as dynamic
1986; Schenkman & Rugo de Cartaya 1987, 1994; stabilizers for the glenohumeral joint. Similarly,
Norkin & Levangie 1988; Burkhart 1994, 1996; Wilk analysis of activation during rotation in the normal
1994) (Fig. 1). These muscles are ideally placed to shoulder revealed that at least one component of the
draw the humeral head into the glenoid and maintain antagonist rotator cuff was always active (David et al.
its axis of rotation, so that they can perform their role 2000), providing evidence of their stabilizing role.
of concavity compression (Saha 1971; Lippitt & Strong evidence is available that pain alters the
Matsen 1993; Lippitt et al. 1993; Sharkey & Marder timing of contraction in stabilizing muscles
1995; Wuelker et al. 1995, 1998). Failure of function transversus abdominis and multidus in relation to
of these muscles in their stabilizing role will lead to the lumbar spine (Hides et al. 1994, 1996; Richardson
creation of an abnormal axis of rotation (Poppen & & Jull 1994, 1995; Hodges & Richardson 1996, 1998;
Hodges et al. 1996; OSullivan et al. 1997a, b, 2000),
vastus medialis obliquus in relation to the knee
(Cowan et al. 2001). Preliminary continuation of our
shoulder stabilization research (David et al. 2000)
with unstable shoulders has shown widely differing
patterns of onset of muscle activity, with failure of
the rotator cuff and biceps to be activated prior to the
delto-pectoral group and, in some instances, failure
to re until after the onset of movement thus
demonstrating a similar disruption to stabilizing
function as found in the knee and lumbar spine.
Fig. 1Pictorial representation of the transverse and coronal plane Kibler (1998b) considered that serratus anterior
force couples of the rotator cuff, demonstrating the role of the and lower trapezius are susceptible to inhibition in
infraspinatus posteriorly and subscapularis anteriorly to draw the painful shoulders. This inhibition is seen early as a
humeral head into the glenoid fossa. Reproduced with kind
permission of Williams & Wilkins, Baltimore, from Burkhart non-specic response to any painful condition in the
(1996). shoulder, presenting as a disorganization of the
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Altered motor control around the shoulder complex 197
Fig. 2Force couples around the scapula relevant in arm elevation (Adapted from Bagg and Forrest 1986; Kapandji 1982). Depicted is the
most common pattern of muscle recruitment reported by Bagg and Forrest (1986). (A) In the rst 601, the axis of rotation of the scapula is
situated at the root of the spine of the scapula. Primary muscles involved in upward rotation of the scapula are lower bres of serratus
anterior and upper trapezius, working via the clavicle, with lower and middle trapezius functioning eccentrically to control the movement. In
this range, muscle function is highly variable. (B) In the next 601, the axis of rotation begins to move along the spine of the scapula towards
the acromioclavicular joint. This means that the emphasis of contribution of the muscles changes, with the bres of lower trapezius now
becoming more actively involved in upward rotation, along with those of lower serratus anterior and upper trapezius. (C) By the time the
arm reaches 1201 of elevation, the axis of rotation is at the acromioclavicular joint. Upper trapezius is no longer positioned to be able to
function to upwardly rotate the scapula, whereas lower trapezius is now ideally situated to perform this function, in conjunction with lower
serratus anterior. (D) In the nal stages of elevation, lower trapezius and lower serratus anterior are the primary rotators of the scapula, with
upper trapezius functioning to rotate the clavicle and middle trapezius working eccentrically to control the degree of upward rotation.
normal ring pattern and a decreased ability to Alteration in activity of serratus anterior in the
produce torque and to stabilize the scapula, a painful shoulders of swimmers and throwers has been
phenomenon Kibler (1998b) described as scapular found when compared to that of non-painful athletes
dyskinesis. (Glousman et al. 1988; Scovazzo et al. 1991; Pink
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198 Manual Therapy
et al. 1993). Wadsworth and Bullock-Saxton (1997) is converted from one which is direction-independent
found signicant delay in activation of serratus to one which becomes direction-specic (Hodges &
anterior in the painful shoulders of swimmers Richardson 1997).
compared with non-painful shoulders, with little To achieve a successful outcome from any dynamic
change in timing of activation of trapezius. All these stabilization programme, rehabilitation must be
studies highlight serratus anterior as the primary centred on the patients abilities rather than impair-
stabilizer of the scapulothoracic region, functioning ments. The starting point for progression must be
in a manner similar to other deep stabilizers. correct movement patterns and muscle recruitment.
The movement of elevation has been used as an Training in an incorrect pattern will only reinforce
example of the need to consider force couples. the pattern. Therefore, the assessment of muscle
Clearly, different considerations must be made if function must reveal the patients abilities in addition
the disorder involves other movements and loads. to impairments. As a simple example, if lower
Adduction against resistance needs to be considered trapezius is tested in a standard manual muscle test
in conjunction with elevation in the throwing or position (Kendall et al. 1993) and found to be weak,
swimming athlete, for example. This function is well the position in which the muscle is tested, or the load
described in Schenkman and Rugo de Cartaya (1994) placed on the muscle during testing, must be
and Souza (2000). incrementally reduced to a stage where the contrac-
tion can be initiated and maintained successfully. The
point from which to start re-training of lower
PRINCIPLES OF A DYNAMIC ASSESSMENT trapezius, if appropriate, is that where the contrac-
tion can be successfully achieved. Each of the tests
Patients move in a variety of ways, with a wide range described below is based on this principle.
of what can be called normal (Shumway-Cook & Gentile (1992) advocated that goal-directed func-
Woollacott 2001). Inuences on movement patterns tional behaviour should be analysed at three different
include avoidance of pain, general health and mood, levels: the action itself, the movements that are
relative length of tissues, strength and level of activity incorporated in that action and the neuromotor
of muscles and timing of contraction of those processes that drive the movements for example,
muscles. Functional demands and habitual activities the integrity of the motor and sensory systems.
also contribute to development of particular move-
ment patterns (Shumway-Cook & Woollacott 2001).
All these factors must be considered during examina- DYNAMIC EXAMINATION
tion of muscle function around the shoulder.
Antalgic movement patterns are familiar features Knowledge of, and the indications for, inclusion of
of physical examination a classic example is the arm specic muscle length (Evjenth & Hamberg 1980) and
that drifts towards the plane of the scapula during isolated strength tests (Kendall et al. 1993) is assumed
frontal plane abduction, with prevention of this by the reader. In this paper, those components and
movement causing pain. A patient who is unwell or techniques that we have found particularly useful
depressed often demonstrates a hunched posture with during dynamic examination will be discussed.
slow, heavy movements. Such a posture, if habitual,
could lead to learned poor scapular rotation during Observation of posture
arm elevation, with the potential for development of
a subacromial impingement. Altered joint position such that some muscles appear
The concept of relative exibility or relative tight or overactive and others lengthened or under-
stiffness should be familiar to physiotherapists active provides early hypotheses in relation to muscle
(Sahrmann 2001). Movement occurs in the path function. Observation of the posture of the whole
offering the least resistance, such that compensation body is an integral component of postural assessment
for a tightened tissue or restricted joint occurs with of the upper quarter. This should occur in the context
movement in a different plane or of a different body of the patients functional demands, so that it
part. A weakened muscle will also disrupt a normal includes evaluation of routine postures used by the
movement pattern as its weakness must be compen- patient. Lower quarter muscle development and
sated for by an altered pattern of activity in a spinal posture can indicate whether whole body
substitute muscle capable of achieving similar action. integrated movement patterns are adequate for
Altered timing of contraction, as discussed above, normal upper quarter muscle function.
inuences movement patterns, such that either the Cervicothoracic posture has considerable inuence
torque producing muscles tend to be activated on scapular position and mobility and therefore, also
without pre-setting by the stabilizers (Hodges & glenohumeral mobility (Crawford & Jull 1991;
Richardson 1996, 1998; David et al. 1997; Cowan Culham & Peat 1993; Solem-Bertoff et al. 1993).
et al. 2001) or the nature of activity of the stabilizers Specic analysis of scapular and arm position will
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Altered motor control around the shoulder complex 199
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200 Manual Therapy
Fig. 3(A, B) Dynamic rotary stability test, demonstrating two different positions in which humeral head control can be evaluated. The
operators left hand is placed over the humeral head so that he is able to detect any translation that occurs during contraction of the
rotators. In the example shown, he is resisting isometric lateral rotation in mid-range and near end-range, in a position functionally relevant
for a thrower.
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Fig. 6(A) D1 scapular PNF pattern depression/retraction Fig. 7(A) D2 scapular PNF pattern depression/protraction
component. (B) D1 scapular PNF pattern elevation/protraction component. (B) D2 scapular PNF pattern elevation/retraction
component. component.
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Altered motor control around the shoulder complex 203
in terms of attainment of specic skills and control Frequent stimulation and repetition improve
a criteria-based protocol (Chmielewski & Snyder- awareness and the ability to activate far more than
Mackler 2001) rather than length of time, as in an isolated exercise session once a day (Catalano &
many shoulder rehabilitation programmes (for ex- Kleiner 1984; Shumway-Cook & Woollacott 2001).
ample, Kunkel & Hawkins 1994; Loeb et al. 1994; Therefore, while learning the activation technique, we
Souza 2000; OBrien et al. 1994; Scarpinato & encourage patients to practise it for a few minutes
Andrews 1994; Timmerman et al. 1994; Ciullo several times a day. Initially, each region is trained in
1996). Our approach also works on the principle of isolation that is, the rotator cuff is worked with the
specicity of muscle function and the importance of scapula in an unchallenged position and vice versa.
functional relevance for transfer of training (Kibler & The muscles are worked in co-contraction in their
Chandler 1994; Kibler 1998a; Shumway-Cook & relevant force couples, with the contractions initially
Woollacott 2001) so that, as soon as possible, any isometric and isotonic with low load, with a gradual
re-training occurs in positions relevant to the build up and release.
patients habitual activities. Once dynamic stability is established, the positions
The authors use the concept of re-training by in which control is emphasized are determined by the
breaking function into interim steps (Schmidt 1991; examination ndings and functional needs of the
Winstein 1991). One goal of any motor control patient. During the DRST, for example, the patient
rehabilitation is to gain awareness of, and the ability may have demonstrated good control up to 601 of
to, activate the deep stabilizers of the region prior to abduction in isotonic external rotation, while iso-
activation of the, usually, more supercial torque metric control may have been satisfactory to 1201. If
producing muscles and to maintain that activation these positions are re-tested with pre-setting of the
during activity. Another is retraining of optimal rotator cuff via the DST manoeuvre, better control
movement patterns. Both involve motor programme may be found. Training should then be started in
retraining and therefore, rened, controlled activa- those positions in which the patient has control, but
tion of the deep stabilizing force couples, using either as close to the position where that control is lost as
strategies of isolation or controlled posture or move- possible. Isometric and isotonic training can be
ment facilitated by imagery. Activation of isolated undertaken concurrently, as long as the patient is
muscles is often difcult to conceptualize. Therefore, aware of the different sensations associated with
patient explanation of the reasons for the programme control and lack of control. Teaching this difference
and the processes required become important aspects in feel may be time consuming initially, but is
of the management. Similarly, imagery can facilitate essential to success of the programme, as training in
understanding of the action required. Without the a position in which control is lacking may reinforce
patients understanding and collaboration in the poor movement patterns.
process, it is doomed to failure, as perseverance, even As control is mastered, the load can be increased
when there is little obvious initial change, is essential cognitively by asking the patient to maintain control
to success. in one area and work on the other. Once activation
Pain inhibition appears to have a powerful can be achieved in an isometric, stable situation, we
inuence on the motor system (Richardson 1987; encourage the patient to incorporate the activation
Hodges & Richardson 1996, 1998; Cowan et al 2001), into simple tasks of daily living. Deliberate activation
so palliative treatment may be necessary to decrease of the rotator cuff in the DRT manoeuvre while
pain in the early stages. However, there is no need to waiting at trafc lights in a car, or prior to reaching
wait for pain to settle before starting a motor control to answer the telephone; setting of the scapulae in an
programme within a pain-free range at a load that optimal position while at a computer or before
does not provoke symptoms, as often, restoration of reaching into a cupboard are examples of cognitive
control acts as a potent pain inhibitor. challenge. When such tasks are mastered, physical
Retraining motor programming, or the neural load, speed and more complicated, integrated tasks
control in Panjabis (1992) model, is dependent can be progressively added. Progression is made with
on motor learning. Motor learning involves any particular exercise only when the step before is
learning new strategies for sensing as well as mastered. The more times the technique is repeated
moving, arising from a complex of perception and the more different situations in which it is
cognitionaction processes (Shumway-Cook & repeated, the quicker the patient is likely to master it.
Woollacott 2001). Motor learning can be enhanced While this intensive training is underway for the
by the use of mental imagery, tactile, verbal, visual, upper quarter, any more general impairment in
taping, weightbearing and movement oriented motor control should also be addressed. Issues such
cues different cues are effective with different as poor dissociation may need to be improved before
people. Initially, facilitation is undertaken in an scapular work can be initiated and transversus
optimal position for the relevant muscles, usually abdominis and gluteal control can be incorporated
mid-range. and progressed from the rst day of treatment. If
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Altered motor control around the shoulder complex 205
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