exercises that target the scapula: scientific rationale ... rehab y fortems jan... · exercises...

Exercises that target the scapula:

scientific rationale and clinical

relevance

Dr Ann Cools, PT, PhDDept Rehab. Sciences & PhysiotherapyGhent University, Belgium 1Ann Cools Gothenborg 2012

Ghent University, Faculty of Medicine & Health Sciences, Dept of Rehabilitation Sciences & Physiotherapy

Supervisor: Prof dr Ann Cools

Researchers:

- Kristof De Mey (Drs)

- Annelies Maenhout (post-doc)

- Annemie Van de Velde (ass)

- Maarten Van Herzeele (Drs)

- Fredrik Johansson (Drs - Sweden)Ann Cools Gothenborg 2012 2

Implications of scapulardyskinesis on daily activities….

Ann Cools Gothenborg 2012 3

Need for science-based scapularrehab program….

Scapular Rehab AlgorithmLack of

Soft-tissue flexibilityLack 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 & MOBILISATIONNEUROMUSCULARCOORDINATION

STRENGTH TRAINING

Advanced controlDuring basic activities

Endurance/strength

Balance -ratio

Advanced controlDuring sports

Conscious musclecontrol

Conscious musclecontrol- Manual stretching

- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM

(Ellenbecker & Cools, BJSM 2010)

4Ann Cools Gothenborg 2012



Muscle performance







STRENGTH TRAINING


Endurance/strength

Balance -ratio







STRETCHING PECT MINOR: literature versus reality

(Borstad JOSPT 2006, Reeser PM&R 2010, Ellenbecker & Cools BJSM 2010)9Ann Cools Gothenborg 2012


PM lengthMeasurement 2


Swim training session

ANGULAR STRETCHING

DIRECT MANUAL

STRETCHING

Annemie Van de Velde, Karen D’Huyvetter, Céline Dufour, Ann Cools: Effect of two stretching techniques on the length of the pectoralis minor in adolescent swimmers . Paper in progress, 2012


Adolescent swimmers (N=29, mean age = 14y)

3x 30” stretching,

PM length measurement (Borstad et al. 2005)


Annemie Van de Velde, Karen D’Huyvetter, Céline Dufour, Ann Cools: Effect of two stretching techniques on the length of the pectoralis minor in adolescent swimmers . Paper in progress, 2012

STRETCHING PECT MINOR: Scientific evidence

Angular self stretch and direct manual stretchinghave similar effect on pectoralis minor length.

(Annemie Van de Velde, Karen D’Huyvetter, Céline Dufour, Ann Cools, Effect of two stretching techniques on the length of the pectoralis minor in adolescent swimmers . paper in progress, 2012)




Muscle performance







STRENGTH TRAINING


Endurance/strength

Balance -ratio







� Sleeper’s stretch & cross body stretch improve ROM (Mc Clure2005)

� Improvement ROM is related to reduction of symptoms (Tyler 2010)

� Additional manual mobilisationsimprove ROM (Manske 2010, Cools 2011)

� Stretching has a positiveinfluence on the subacromialspace (Maenhout 2012)


POSTERIOR SHOULDER STRETCHING

Ann Cools Gothenborg 2012

Angular stretching Translation mobilisation

(patients with GIRD: n=30, healthy shoulders with GIRD: n=30)

(Cools et al. Shoulder & Elbow 2011)

15

RESULTS:

� Significant increase in ROM after 3w

� Equal results both techniques

� Significant pain reduction in patientgroup


angular stretching

20

40

60

80

before after 3wlater

degr

ee D patients

D controls

ND patients

ND controls

translation mobilisations

20

40

60

80

before after 3wlater

degr

ee

D patients

D controls

ND patients

ND controls

(Cools et al. Shoulder & Elbow 2011)

VAS BeforeBeforeBeforeBefore----afterafterafterafter

AfterAfterAfterAfter----3w 3w 3w 3w laterlaterlaterlater

Pain/movement p= 0,001p= 0,001p= 0,001p= 0,001 p= 0,042

Hawkins’ test p= 0,001p= 0,001p= 0,001p= 0,001 p= 0,116

Neer’s test p= 0,002p= 0,002p= 0,002p= 0,002 p= 0,223

Apprehension p= 0,022 p= 0,755

Modified Rowe p= 0,001p= 0,001p= 0,001p= 0,001 p= 0,125

16

STRETCHING G.I.R.D.:influence on the subacromial space?

Measurements:

- Acromiohumeral distance (Echoblaster 128; Telemed, Vilnius, Lithuania)

- Glehonumeral ROM (Acumar inclinometer)

Ann Cools Lexington 2012 17

Quantifying acromiohumeral distance in overhead athletes with glenohumeral

internal rotation loss and the influence of a stretching program. Maenhout A,

Van Eessel V, Vanraes A, Van Dyck L, Cools A. (Accepted AJSM May 2012)

Six week stretching program (sleeper’sstretch daily) increases the ROM into IR and increases the subacromial space




Muscle performance







STRENGTH TRAINING


Endurance/strength

Balance -ratio








Conscious muscle control lowertrapezius: Scapular Orientation Exercise

� Subjects are able to perform consistent movements of the scapula into posterior tilt and upward rotation

� Significant increase scapular muscleactivity in trapezius

� High correlation betweenassisted and unassisted(home) exercise

(Mottram 2009)20


Sidelying Forward flexion Sidelying Ext Rotation

Prone Hor Abd + Ext Rot Prone Extension

21

Scapular Orientation Exercise

Conscious correction of scapular orientationimproves scapular muscle activity during exercises




Muscle performance







STRENGTH TRAINING


Endurance/strength

Balance -ratio








Sidelying Forward flexion Sidelying External Rotation

Prone Hor Abd + Ext Rot Prone Extension

24

SCAPULAR STRENGTH TRAINING:Scientific evidence healthy people

A 12 week program of scapular exercises improves isokineticmuscle strength, and muscle balance in healthy adolescent swimmers


SCAPULAR STRENGTH TRAINING:Scientific evidence healthy people

6 month program of scapular retraction exercises improvesRC strength (infraspinatus) in volleyball players


SCAPULAR STRENGTH TRAINING:Scientific evidence patients

Scapular exercises improve muscle strength, symptoms and relative muscle activity in overhead athletes with impingement symptoms





Muscle performance







STRENGTH TRAINING


Endurance/strength

Balance -ratio

Advanced controlDuring sports movements



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


28

Influence of experimentally induced pain in the supraspinatus on scapular muscle activity(Van Herzeele M, Parlevliet T, HeemanS , Hofman K & Cools A, unpublished data 2012)

- ultrasound-controlled pain induction (hypertonic saline) in supraspinatus muscle (N=23)

- Pain sensation Numeric Rating Scale (NRS) >6/10

- Elevation in 3 planes before and after paininduction- Before pain

- Immediately after pain induction

- 20’ after pain induction (NRS 0,62)

- EMG scapular muscles (Noraxon Myoresearch)- Normalised EMG activity (% MVC)

- Recruitment order


Level of activityDURING pain Total

movementConcentricphase

Eccentricphase

abduction Increased LT activity 3,52%

Scapularelevation

Decreased LTactivity 1,8%

Forward flexion Increased SA activity 17%

Decreased SA activity 1,49%


20’ after pain Total movement

Concentricphase

Eccentricphase

abduction

Scapularelevation

Increased UT activity 1,43%Increased SA activity 2,37%

Forward flexionPAIN DOES CHANGE SCAPULAR MUSCLE RECRUITMENT


« Take home message »� Manual stretching pect minor has positive

short term effects

� Increased acromiohumeral distance afterposterior shoulder stretching

� Adding conscious scapular correctionincreases muscle activity during exercises

� Scapular rehab program results in strength gain in scapulaand shoulder

� Take into account that pain can change muscle recruitment

31

THE SHOULDER IN THE OVERHEAD ATHLETE: CHALLENGES FOR SCAPULAR REHABILITATION

AND RETURN TO PLAY AFTER INJURY

FRIDAY 29th MARCH 2013

Het Pand, Gent, Belgium

www.europeanshoulderconference.ugent.be

Future congress:

²

(Gent- Belgium)

33


exercises that target the scapula: scientific rationale ... rehab y fortems jan... · exercises...

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