Physiotherapy Treatment of Shoulder Pain - REHABILITATION PRINCIPLES. Today S Topics. Rehabilitation of Rotator Cuff Tendinopathy

Physiotherapy treatment
of shoulder pain:
REHABILITATION
PRINCIPLES
Ann Cools, PT, PhD

Ghent University - Belgium
Dept of Rehabilitation Sciences & Physiotherapy
Rehab A Cools 2014 Ann.Cools@UGent.be1
« Today’s Topics …. »
Which exercises/manual techniques to

prescribe for
– Rotator cuff pathology
– Instability
– GIRD
– Scapular dyskinesis
Kinetic chain approach in shoulder
rehab
Rehab A Cools 2014 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?
4. Scientific evidence?
1
1. Which exercises activate rotator
cuff muscles?
(Jobe 1987, Donatelli 2004, Ellenbecker 2006, Townsend 1991, Reinold 2004)
1. Internal rotation
2. External rotation
3. Full can
4. Horizontal abduction
with external rotation
1. Which exercises activate rotator

cuff muscles?
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
(Anju Jaggi London 2011 Rehab A Cools 2014 6

Karen Ginn, Goth 2012)
2
2. Eccentric exercises
supraspinatus
(Cools & Walravens 2007, Maenhout et al. KSSTA 2012)
Eccentric exercises
External rotators
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
3
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
Practice
1. Eccentric exercice SS
2. Eccentric exercise IS
3. Eccentric exercise ER in ABER
4. Total rotation
Rehabilitation of shoulder
instability
1. Training progression
2. Focus on proprioception and motor
control
3. TUBS/AIOS versus AMBRI
4
Paradigma functional Instability
(Lephart et al. 1995)
INJURY
Mechanical Proprioceptive
instability deficits
Spinal muscle
Reflex ↓
Functional
instability
Neuro-muscular
coordination ⇓
Power
Strength
Endurance
Coordination
Proprioception Muscle control
Muscle control =
activating the appropriate muscle
on the appropriate moment in the
appropriate intensity
5
Conscious muscle control:
Rotator cuff (TUBS + AIOS)
Deltoid (AMBRI/MDI)
(Wilk et al. 2002, Barden 2005)
TUBS/AIOS versus AMBRI
TUBS/AIOS AMBRI
Rotator cuff Deltoid (ant-post)

From CKC to OKC A lot of CKC
Stretching posterior No stretching
capsule (GIRD)
Power
Strength
Endurance
Progression
in exercise modalities:
Coordination
Resistance
Proprioception ↑(50→80%)
Muscle control
Functional relevance ↑
6
Rotator cuff strengthening:
functional perspective
IR Rehab A Cools 2014

ER 19
“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
IR Rehab A Cools 2014

ER 21
7
Functional diagonal
high load in ABER
IR ER
Plyometrics in ABER

IR ER
Acceleration & deceleration

phase throwing
IR ER
8
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
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
Advanced program for

“throwers”
Eccentric high load exercises for
posterior cuff
Plyometrics using plyoball, flexbar,
Xco…
Sportspecific positions
Attention to the kinetic chain
9
Eccentric diagonals
Plyometrics IR & ER

(Ellenbecker & Cools 2010)
Plyometrics IR & ER in
ABER
10
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
11
Thrower’s program: Kinetic Chain
Wrist
F Elbow
O
Shoulder
R
C Trunk
E and Back
Legs
0
TIME Rehab A Cools 2014 34
(Kibler, Gent 2003)
Wrist
F Elbow
O
Shoulder
R
C Trunk
E and Back
Legs
0
TIME Rehab A Cools 2014 35
(Kibler, Gent 2003)
“Thrower’s program”
sportspecific: kinetic chain
12
Integration Kinetic Chain into open
chain shoulder rehabilitation exercises
Results: EMG activity scapular

muscles: unilateral squat versus
other exercise modalities
* *
*
* *

*= significant main effect “exercise”
(De Mey & Cools, 2012 )
Sportspecific program:
swimming
13
Practice
4
1 1. Eccentric ER diagonal
2. Plyoball neutral position
3. Plyoball 90° forw flex 5
4. Plyoball 90°-90°
5. Flexbar + tubing neutral
2 6
6. Xco/flexbar 90°-90°
7. W-V ex swissball
3 7
TUBS/AIOS versus AMBRI
TUBS/AIOS AMBRI
Rotator cuff Deltoid (ant-post)

From CKC to OKC A lot of CKC
Stretching posterior No stretching
capsule (GIRD)
General Guidelines AMBRI/MDI

Low Load static dynamic
Moderate Load static dynamic
High Load static dynamic
14
Diagonals in CK exercises
Semi closed chain SA exc Semi closed chain trap exc
(elevation) (rowing)
Case: gymnast with chronic shoulder pain based on instability
6 modalities of the push-up plus exercise (N=32)
2 3 4
5 6 7
(Maenhout & Cools BJSM 2009)
Results: EMG-activity and muscle

balance ratios
Highest SA activity (44%MVC) en best
UT/SA ratio (0.40) when ipsilateral leg is
extended
3
15
Results: EMG-activity and muscle
balance ratios
Highest activity in MT & LT, when
contralateral leg is extended
(LT=20%MVC)
2
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 (Cools et al. BJSM 2008,
2. Forward flexion Ellenbecker 2006,
Ellenbecker & Cools 2010, BJSM
3. Abduction Wilk JOSPT 2009, Cools et al.
Rehab A Cools 2014 Shoulder & Elbow 2011)47
1a: Angular stretching :

« Sleeper’s stretch »
16
Sleeper’s stretch supine +
caudal glide

(John Borstad, ICSET Edinburgh 2010, JOSPT 2011)
1b: Angular stretching into

horizontal adduction: “cross
body stretch”
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. Rehab A Cools 2014 51
17
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
2a: Mobilisation: dorsal

glide in endrange
Dorsal glides in
moderate internal
rotation
18
2b: non-angular stretching
into horizontal adduction
3a. Mobilisation with

movement: ER + dorsal
glide
3b-c. Relocation of the

humeral head during
Forward flexion abduction
19
Practice manual mobilisations
(accessory movements & MWM) :
1
1. End-range dorsal glide in IR
2. Dorsal glide in moderate IR (hand from neutral 2

to belly)
3. Mobilization with movement: ER + dorsal glide

3
– Change shoulder position (to ABER)
– Passive / resistance ER
4. Mobilization with movement: forward flexion 4

with dorsal glide
5. Mobilization with movement: abduction with

dorsal glide 5
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
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
20
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
(Cools et al. BJSM 2013)
Scapular Rehab Algorithm

Lack of Lack of
Soft-tissue flexibility Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae - infraspinatus - co-contraction - lower/middle trap

- pectoralis minor - posterior capsule - force couples - serratus anterior
NEUROMUSCULAR STRENGTH
STRETCHING & MOBILISATION
COORDINATION TRAINING
Conscious muscle Conscious muscle

- Manual stretching control control
- home stretching
- soft tissue techniques Advanced control
Balance -ratio
- manual mobilisations During basic activities
(accessory movements) Rehab A Cools 2014
Advanced control 63
-MWM Endurance/strength
During sports
21

Lack of Lack of


- home stretching
Balance -ratio
Advanced
control 64
During sports

Lack of Lack of


- home stretching
Balance -ratio
Advanced
control 65
During sports

Lack of Lack of


- home stretching
Balance -ratio
Advanced
control 66
During sports
22

Lack of Lack of
Stretching
Pectoralisminor

- home stretching
Balance -ratio
Advanced control 67
During sports
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)Rehab
bestA Cools results,
2014
however… 68
Stretching pectoralis
minor: clinical experience
23
Lack of Lack of


Scapular
control orientation exercise
control
- Manual stretching
- home stretching
- soft tissue rechniques Advanced control
Balance -ratio
(accessory movements)
- taping Rehab A Cools 2014 70
Advanced control
Endurance/strength
During sports movements
Enhancing lower trapezius

muscle control: literature
Scapular Orientation Exercise
- Scapular upward rotation and
posterior tilting
- Increased scapular muscle
activity
(Mottram et al. Man Ther 2009)
Learning conscious lower trapezius

muscle recruitment: clinical
experience
24
Learning conscious lower trapezius
muscle recruitment: clinical
experience

Lack of Lack of


control control
- Manual stretching
- home stretching
- soft tissue rechniques Muscle
Advancedcontrol
control
Balance -ratio
- manual mobilisations Basic activities
During basic activities
Advanced control
Endurance/strength
Purpose: increase scapular dynamic control

during various exercises and movements:
some examples…
(Kibler 2008, Uhl 2010, Johansson 2012

Cools 2013)
25
Scapular muscle balance during
shoulder exercises
External rotation
component: increasing
lower and middle trap
activity
Functional elevation
plane

Cools 2013)

shoulder exercises
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 2012
Rehab A Cools 2014
Cools 2013)
77
UT ↓ UT ↓
SA = SA =
Lev Scap ↓ MT & LT ↑
Rhomb ↓ Rhomb ↑
Pect Min ↓
26
shoulder exercises
Hip-abduction activity:
increasing diagonal
kinetic chain activity?
Core-stability challenge
Perform ER or
elevation

Rehab A Cools 2014
Cools 2013)
PRACTICE

Lack of Lack of


control control
- Manual stretching
- home stretching
Muscle balance
Balance -ratio
Advanced control
Endurance/strength
27
Rehabilitation muscle balance
UT/SA
Elbow push-up
Serratus punch
lying on the
back
Serratus punch
in closed chain
( Ludewig et al. 2004)

Rehabilitation muscle balance

UT/MT & UT/LT
28
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
UT/SA
Practice
UT/MT & UT/LT

Lack of Lack of


control control
- Manual stretching
- home stretching
Balance -ratio
Advanced control
Endurance/strength
29
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
30
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…..
31
THANKS!
Ghent, Belgium, July 21th every year......
32

Physiotherapy Treatment of Shoulder Pain - REHABILITATION PRINCIPLES. Today S Topics. Rehabilitation of Rotator Cuff Tendinopathy

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Physiotherapy Treatment of Shoulder Pain - REHABILITATION PRINCIPLES. Today S Topics. Rehabilitation of Rotator Cuff Tendinopathy

Uploaded by

Copyright:

Available Formats

Physiotherapy treatment

Ann Cools, PT, PhD

Which exercises/manual techniques to

Rehabilitation of rotator cuff

Rehab A Cools 2014 4

1. Which exercises activate rotator

Werner JSES 2006: ER vs IR regarding Subacromial

(Anju Jaggi London 2011 Rehab A Cools 2014 6

Rehab A Cools 2014 7

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

Rehab A Cools 2014 8

3. Eccentric exercises: intensity and reps?

Maenhout et al. 2012 (KSSTA): RCT sign increase in RC

Holmgren et al. BMJ 2012: RCT: specific exercise program

Exercise improves symptoms (effect size >15%)

3. Eccentric exercise ER in ABER

Rehab A Cools 2014 12

Proprioception Muscle control

Rehab A Cools 2014 14

Rehab A Cools 2014 15

Rehab A Cools 2014 16

TUBS/AIOS versus AMBRI

Rotator cuff Deltoid (ant-post)

Rehab A Cools 2014 17

IR Rehab A Cools 2014

TUBS and AIOS

IR Rehab A Cools 2014

Rehab A Cools 2014 22

Rehab A Cools 2014 23

Acceleration & deceleration

Rehab A Cools 2014 24

Rehab A Cools 2014 25

Rehab A Cools 2014 26

Advanced program for

Rehab A Cools 2014 27

Rehab A Cools 2014 28

Rehab A Cools 2014 29

Rehab A Cools 2014 30

A Cools EUSSER London Symp 2014

Goal of the exercise:

4. Overall scap muscles↑

Rehab A Cools 2014 33

Rehab A Cools 2014 36

Rehab A Cools 2014 37

Results: EMG activity scapular

Rehab A Cools 2014 38

Rehab A Cools 2014 39

TUBS/AIOS versus AMBRI

Rotator cuff Deltoid (ant-post)

Rehab A Cools 2014 41

General Guidelines AMBRI/MDI

Moderate Load static dynamic

High Load static dynamic

Rehab A Cools 2014 42

Rehab A Cools 2014 43

Case: gymnast with chronic shoulder pain based on instability

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

Rehab A Cools 2014 44

(Maenhout & Cools BJSM 2009)

Results: EMG-activity and muscle

Rehab A Cools 2014 45

(Maenhout & Cools BJSM 2009)

Rehab A Cools 2014 46