exercises that target the scapula: scientific rationale ... rehab y fortems jan... · exercises...
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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
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)
5Ann Cools Gothenborg 2012
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)
6Ann Cools Gothenborg 2012
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)
7Ann Cools Gothenborg 2012
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)
8Ann Cools Gothenborg 2012
STRETCHING PECT MINOR: literature versus reality
(Borstad JOSPT 2006, Reeser PM&R 2010, Ellenbecker & Cools BJSM 2010)9Ann Cools Gothenborg 2012
Ann Cools Gothenborg 2012 10
PM lengthMeasurement 2
PM lengthMeasurement 3
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
PM lengthMeasurement 1
Adolescent swimmers (N=29, mean age = 14y)
3x 30” stretching,
PM length measurement (Borstad et al. 2005)
Ann Cools Gothenborg 2012 11
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)
Ann Cools Gothenborg 2012 12
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)
13Ann Cools Gothenborg 2012
� 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)
14Ann Cools Gothenborg 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
Ann Cools Gothenborg 2012
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
Ann Cools Gothenborg 2012 18
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)
19Ann Cools Gothenborg 2012
Ann Cools Gothenborg 2012
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
Ann Cools Gothenborg 2012
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
Ann Cools Gothenborg 2012 22
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)
23Ann Cools Gothenborg 2012
Ann Cools Gothenborg 2012
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
Ann Cools Gothenborg 2012 25
SCAPULAR STRENGTH TRAINING:Scientific evidence healthy people
6 month program of scapular retraction exercises improvesRC strength (infraspinatus) in volleyball players
Ann Cools Gothenborg 201226
SCAPULAR STRENGTH TRAINING:Scientific evidence patients
Scapular exercises improve muscle strength, symptoms and relative muscle activity in overhead athletes with impingement symptoms
Ann Cools Gothenborg 2012 27
Ann Cools Gothenborg 2012
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 movements
Conscious musclecontrol
Conscious musclecontrol
- Manual stretching- home stretching- soft tissue rechniques- manual mobilisations (accessory movements)
(Ellenbecker & Cools, BJSM 2010)
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
Ann Cools Gothenborg 2012 29
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%
Ann Cools Gothenborg 2012 30
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
Ann Cools Gothenborg 2012
« 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
Ann Cools Gothenborg 2012
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