Shoulder Dysfunction:

A Tense Active Analysis

Shoulder Dysfunction:

A Tense Active Analysis

David López Sánchez, P.T., D.C.

XIVth FESSH Congress 3rd to 6th of June 2009

Poznan, Poland

David López Sánchez, P.T., D.C.

XIVth FESSH Congress 3rd to 6th of June 2009

Poznan, Poland

Shoulder Pain

Shoulder Pain

The shoulder pain represent the third most common cause of musculoskeletal consultation in primary care. BMJ  2005;331:1124-1128

Near 40 to 50% of people who consult with a new episode of shoulder pain in primary care report persistent symptoms after 6 to 12 months. Rheumatology 1999, 38:160-3.

The severity of the impingement syndrome affects the diagnostic values of the commonly used clinical tests and those shows low specificity. Rheumatology 2008;47:679–683

The cervicothoracic spine function & head posture have been related to shoulder dysfunction.The cervicothoracic spine function & head posture have been related to shoulder dysfunction.

Forward Head Diminished Suboccipital Space & increased

thoracic kyphosis Bruxism Cervicothoractic Hypomobility Forward Shoulder (Scapular Protraction) Humeral Internal Rotation

• Lewis JS, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg. 2005;14:385–392.

• Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin mounted electromagnetic tracking sensors. Arch Phys Med Rehabil. 2003;84:563–568.

• Kebaetse M, McClure P, Pratt NA. Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular kinematics. Arch Phys Med Rehabil. 1999;80:945–950.

Shoulder Dysfunction and Posture

Dysfunctions?

Shoulder Dysfunction and Posture

Dysfunctions?

Integrated TenseActive Model

Andry Vleeming PhD &

David López DC

Poland, November 2008

MOTOR

CONTROL

Tense-Activity Passive- Dynamic

Neural Activity

Moto-Activity

Voluntary, in Resting and Automatic

(Reflex)

Tense - Length Variation

Functional Sensory-Motor Integration, propioceptive & kinesthetic Functional Sensory-Motor Integration, propioceptive & kinesthetic

Journal of Athletic Training 2002; 37(1):71–79.The Sensorimotor System, PartI:ThePhysiologic Basis of Functional Joint

Stability. BryanL.Riemann; Scott M. Lephart

Fascies-capsules-tendons-ligaments-perineural layers- cartilages, conective tissues (Static & Dynamic Behavorial)

TENSEACTIVE SYSTEM

Muscle ActivityMuscle Activity Neural ActivityNeural Activity

Functional Sensory-Motor Integration, propioceptive & kinesthetic Functional Sensory-Motor Integration, propioceptive & kinesthetic

Joint MovementJoint Movement

David López Sánchez

XII Latinoamerican Congress of Physiotherapy & Kinesiology CLAFK, Bogotá, Colombia. 2006

TenseActive ConceptSpinal Motor Control

FUNCTIONAL MOTOR COMPLEX

Integrated TenseActive Model

The connective tissue damage could produce corruption of the propioceptive and kinestethic afferents signals

Manohar Panjabi: XVI Chilean Congress of Kinesiology, Sept. 2005

The Passive Sub System: it is?

The main stimulus for the mechanoreceptors is deformation of their differentiated microarchitecture by compression for the lamellated bodies and traction and torsion for the spray-like type.

My conviction is No: “The Connective System actually is a TenseActive System totally integrated to the Sensory Motor Function”. D.L.

The Assessment of the

Anterior Head Translation

The Assessment of the

Anterior Head Translation

The suboccipital space distance, Cobb’s method, craniovertebral angle, sagittal shoulder posture and anterior head translation line are commonly used by clinicians assess the anterior head translation.

Harrison, 2002: AHT 15 mm (10mm or up to 1.0 inch) and found that 30 mm of AHT will increase the compressive and bending loads acting on the lower cervical spine by a factor of 1.25- 4.25.

Spine 2000, 25(16):2072–2078; Eur Spine J (2007) 16:669–678; Australian Journal of Physiotherapy 2001, Vol. 47;

Shoulder TenseActive CORE Shoulder TenseActive CORE

The optimal kinetic chain alignment is necessary for optimal movement. The function of the coracoclavicular ligaments is to stabilise the clavicle at the scapula.

• The conoid ligament primarily prevents the anterior and superior clavicular displacement.

• The trapezoid ligament is the primary constraint against compression of the distal clavicle into the acromion.

The optimal kinetic chain alignment is necessary for optimal movement. The function of the coracoclavicular ligaments is to stabilise the clavicle at the scapula.

• The conoid ligament primarily prevents the anterior and superior clavicular displacement.

• The trapezoid ligament is the primary constraint against compression of the distal clavicle into the acromion.

SubAcromial Space & its Tenseactive Relationships with forward shoulders SubAcromial Space & its Tenseactive

Relationships with forward shoulders

The increased tenseactive coupling action to either the conoid and trapezoid ligaments in forward shoulders avoid the coracoclavicular separation during the arm elevation and limit the clavicular posterior rotation

The superior coracoclavicular ligament is more tense in forward shoulder increasing the closing forces and the joint friction in the AC-C

The Acromioclacivular Angle & Scapular Orientaton

The Acromioclacivular Angle & Scapular Orientaton

Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Arch Phys Med Rehabil. 2002;83: 60–69Lukasiewicz AC, McClure P, Michener L, et al. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29: 574–583

Normally the pectoralis minor muscle elongates during arm elevation.Kebatse et al. 1999 have shown that excessive scapular protraction, decreases maximum rotator cuff activation by 23%. (Arch Phys Med rehab).

Shortened Pectoralis Minor Shortened Pectoralis Minor

The coupling forces created by trapezius, Serratus and Pectoralis Minor are neccessary to positioning the scapula on the thoracic wall.

The adaptative shortening of the pectoralis minor would increase the opposite & passive tension forces during arm elevation.

Smith et al. 2006 reported that maximal rotator cuff strength is optimal when the position is “neutral of scapular retraction/protraction” (Jour, Elb Should Surgery)

Physical Therapy . Volume 86 . Number 4 . April 2006

Whiplash and Shoulder Impingement

Abbasian et Als examined 220 patients who reported whiplash injury. Only the 5% presented impingement syndrome. Journal of Orthopaedic Surgery and Research 2008, 3:25

Chauhan and colleagues examined 102 cases of shoulder pain after whiplash and found to be 22% syntomatic but only 9% had subacromial impingement. J Bone Joint Surg Br 2003, 85(3):408-10.

Direct seatbelt trauma to the shoulder is one possible explanation for its aetiology. Acta Orthop. Belg., 2005, 71, 385-387

Influences on the fusimotor-muscle spindle system from chemosensitive nerve endings in cervical facet joints in the cat: possible implications for whiplash induced disorders.Thunberg J, Hellström F, Sjölander P, Bergenheim M, Wenngren B, Johansson H. Pain. Mar;91(1-2):15-22, 2001

Capsular, Facetary & Ligamentous Damage Related To Motor Dysfunction % Cervical Pain

Kinematic Alterations and Muscle Dysfunctions in the Shoulder

The decreased serratus anterior muscle function in the subjects with shoulder impingement have been demonstrated by a deficitary control of the inferior angle of the scapula against the thorax. Ludewig and Cook , Physical Therapy . Volume 80 . Number 3 . March 2000

In other pathologies as idiopatic shoulder frozen the humeral ROM deficits relative to the trunk and scapula have been confirmed but this was not determinant in relation to a pattern of muscle dysfunction. Rundquist P. et Als. Arch Phys Med Rehabil Vol 84, October 2003

Posture Changes and muscle activation

Posture Changes and muscle activation

(1) Mc Lean L, 2005 and (2) Schuldt 1996 coincidently found that the corrected posture in sitting produce a statistically significant reduction in muscle activation amplitudes in the neck and shoulder regions compared to forward head posture and, Corrected posture in standing required more muscle activity than habitual or forward head posture.

(1)The effect of postural correction on muscle activation amplitudes recorded from the cervicobrachial region. Linda McLean Journal of Electromyography and Kinesiology, 2005 Vol. 15, 527-535(2)Effects of changes in sitting work posture on static neck and shoulder muscle activity. Kristina Schuldt el Als. Ergonomics, Vol. 29, 1986, 1525 - 1537

Villanueva M. Found similar findings Industrial Health 1997, 35, 330-336. Ceneviz and other authors have related the cervical muscle activation to the mandibular position Cranio. 2006 Oct;24(4):237-44.

Shoulder Pain: ¿Motor Control reorganization?

Shoulder Pain: ¿Motor Control reorganization?

Falla D. et Als. Below experimental muscle nociceptive stimuluation Differents responses among trapezius muscle subdivisions during repetitive shoulder flexion. (1)

Recently Diederichsen L. et Als, 2009 confirmed that induced pain in the supraspinatus muscle caused a significant decrease in activity of the anterior deltoid, upper trapezius and the infraspinatus and an increase in activity of lower trapezius and latissimus dorsi muscles. (2)

After the subacromial injection they observed also an increased muscle activity in the lower trapezius, the serratus anterior and the latissimus dorsi muscles. (2)

(1)Experimental Brain Research, Volume 178, Number 3 / 2007 (2) Experimental Brain Research Volume 194, Number 3 / 2009

Cognitive problems Associated to Shoulder Pain

Cognitive problems Associated to Shoulder Pain

Zanette G. et Als. (1997) found reversible changes of motor cortical outputs following immobilization of the upper limb. (1)

Exist abundant evidence that cortical representation of body parts is continuously modulated in response to activity, behavior and skill acquisition. (2)

Reorganization of the sensory and motor systems following peripheral injury occurs in multiple levels including the spinal cord, brainstem, thalamus and cortex. (2)

(1) Electroencephalography and Clinical Neurophysiology / Electromyography and Motor Control Volume 105, Issue 4, August 1997, Pages 269-279 (2) Neuroscience Volume 111, Issue 4, 6 June 2002, Pages 761-773

Evidenciated Functional Plasticity By Neuroimaging

Where are we?

Evidenciated Functional Plasticity By Neuroimaging

Where are we?

M.E.P.s (EMG)

Synapsis

Dendritic Spines

CONDUCT

TrainedHand

ControlHand

Work Memory (WM) The amount of WM is directly related to excitable cortex.Pascual-Leone 2005. While increase the difficulty task increase also the Motor Evoked Potentials (MEPs/EMG) signal in the working hand.

The Plastic Human Brain Cortex. Alvaro Pascual-Leone, Amir Amedi, Felipe Fregni, and Lotfi B. Merabet. Annu Rev Neurosci 28: 377-401, 2005

Cognitive ability must be qualified with respect to elicited task employed. The mental exercise practice increased similarly the motor cortex (MEPs/EMG) representation of the trained hand. Then Could be the motion a cortical meaning?.

The Plastic Human Brain Cortex. Alvaro Pascual-Leone, Amir Amedi, Felipe Fregni, and Lotfi B. Merabet. Annu Rev Neurosci 28: 377-401, 2005

A,Areas activated during listening to the untrained-same-notes-music contrasted against rest (p < 0.05, FDR corrected). B, Contrasted image of group mean activation is presented in areas that were significantly more active during listening to trained-music compared with untrained-same-notes-music.

The Journal of Neuroscience 10 January 2007 vol. 27 no. 2 308-314

Motion Process: A Motor Meaning

The movement is an experience, an acquired motor meaning.

The somatosensory information as space, length, and velocity of the muscles, tension and pressure acting over the joints, tendons and ligaments, etc. are fundamental to build up the motor action.

• In summary we are moving based in the assimilated sensation along all the life in ours cognitive-levels.

• Clinical Application: The erectus posture is developed according our normalized concept of the erectus position, according our feel and experiences, our beliefs, emotions and fears, etc. David López PT, DC.

Shoulder Muscle Strengthen Without Tense Length Normalization and Whatever Posture?

Hides: Spine 2001; Mannion: Spine 2001; Solomonow: Spine 98; O”sullivan: Spine 97; Hodges: J. Spinal Disord. 98; Richardson et al: Spine, 96-97; Magnusson: Eur.Spine J. 96; Panjabi et al: J. S. Disorders 90,92.

Cognition and Emotion Substrate(Motor learning & adaptative motor strategies , fear to pain,

beliefs, affective experiences, etc.)

Motor Control(specific timing of neuromuscular function & strength,

& tense-length variation)

Shoulder Dysfunction:Applied

Tense Active Approrach

XIVth FESSH Congress 3rd to 6th of June 2009

Poznan, Poland

Moto-Tense-Active Coupling

(muscle forces and its vectiorial action)

Elastic-Tense-active

Coupling (connective structures

& joint shapes)

Thank You

consultas@dolordeespalda.cl

David López Sánchez PT DCXIVth FESSH Congress 3rd to 6th of June 2009

Poznan, Poland