Student Session: Selected Manual Therapy Interventions and Functional Exercises for the Shoulder

Transcription

1 Student Session: Selected Manual Therapy Interventions and Functional Exercises for the Shoulder

2 Dr Bob Boyles, PT, DSC, OCS, FAAOMPT Associate Professor, University of Puget Sound, Tacoma, WA Dr Danny McMillian, PT, DSc, OCS, CSCS Assistant Professor, University of Puget Sound, Tacoma, WA

3 Puget Sound. What is that?

4 In 1792 George Vancouver gave the name "Puget's Sound" to the waters south of the Tacoma Narrows, in honor of Peter Puget, then a lieutenant accompanying him on the Vancouver expedition. The name later came to be used for the waters north of Tacoma Narrows as well

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7 Agenda Brief evidence review Selected thoracic interventions Selected shoulder manual interventions Selected functional rehab interventions

8 Structure and Function a surprising lack of consensus as to even the most fundamental aspects of shoulder function Bigliani et al. Clin Orthop 1996

9 Function The primary function of the shoulder girdle is placement of the hand to manipulate our environment The most mobile joint in the body: "sacrifices stability for mobility" Optimal function of the shoulder also depends on adequate motion or stabilization of the trunk

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11 Think Regional

12 Physiotherapy Interventions for Shoulder Pain 26 RCTs included Two broad categories of shoulder pain: Rotator cuff tendonitis disease Adhesive capsulitis Results Exercise is effective for short- and long-term recovery in rotator cuff disease Manual therapy provides added benefit to exercise No evidence of US effectiveness in shoulder pain No evidence that physiotherapy alone is of benefit for adhesive capsulitis Green et al, Cochrane Database of Systematic Reviews, 2003

13 Design: Multi-site RCT Population: N=150, painful shoulder girdle Outcomes: Baseline, during & end of treatment (6 &12 wks), follow-up (26 & 52 wks) Primary - patient perceived recovery Secondary - severity of main complaint, shoulder disability, additional care received Bergman et al, Annals of Internal Medicine, 2004

14 Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain 150 patients w shoulder girdle dysfunction Usual medical care Information, advise and therapy (2 weeks of NSAIDs) Up to 3 corticosteroid injections if therapy ineffective If no improvement after 6 weeks, physiotherapy began consisting of exercise, massage and physical agents Usual medical care plus manipulative therapy ( 6 sessions over 12 weeks) Manipulative therapy consisting of manipulation (thrust) and mobilization techniques to shoulder girdle, cervical and thoracic spines and ribs. No other PT methods allowed. Bergman, Ann Int Med, 2004

15 Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain Outcomes: patient-perceived recovery, severity of pain, shoulder pain, shoulder disability, and general health. 6 and 12 weeks (during and after treatment) 26 and 52 weeks (follow-up) No difference at 6wks 12 weeks: 43% intervention & 21% control reported full recovery 52 weeks: same recovery rate as 12 weeks All times consistent between-group difference in severity, shoulder pain and disability and general health favored MT Conclusion: Manipulative therapy for the shoulder girdle in addition to usual medical care accelerates recovery. Bergman, Ann Int Med, 2004

16 Comparison of Physiotherapy, Manipulation, And Corticosteroid Injection For Treating Shoulder Complaints In General Practice Subjects: (N= 198; 58 shoulder girdle group, 114 synovial group) Treatment conditions: Group 1: Manipulation Cx and Tx spine, ribs, AC and GH joints Group 2: Classic Physiotherapy therex, massage, modalities Group 3: Corticosteroid Injection (1-3 injections) Results: Manipulation was superior to Physiotherapy for the shoulder girdle group improved pain and lower drop-out rates Injections were superior to Physiotherapy and Manipulation for the synovial group improved pain and lower drop-out rates Conclusion: Manipulation seems to be preferred for shoulder girdle disorders; Injections are preferred for synovial joint disorders (Winters et al, BMJ, 1997)

17 Effectiveness of Rehabilitation for Patients with Impingement Syndrome: A Systematic Review Systematic review of 12 RCTs Results: Therex more effective in reducing pain and increasing function than placebo. Mixed results when compared to surgery Adding MT to therex provides favorable outcomes compared to therex alone Does not support the use of US as a beneficial treatment Conflicting results in use of acupuncture Michener LA et al, J Hand Ther, 2004

18 Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement Syndrome Subjects (N= 52) Treatment conditions Group 1: Manual therapy (upper quarter) and exercise Group 2: Exercise alone; stretches and strengthening 3-week intervention biw for 6 Rx s Results Function: significantly more improvement in MT group (35% vs 17%) Pain: significantly less pain in MT group (70% vs 35%) Strength: significant increase for MT group (16%) Conclusion: MT and exercise is superior to exercise alone for improving strength, function, and pain in patients with impingement syndrome (Bang and Deyle, JOSPT, 2003)

19 Adhesive Capsulitis

20 Natural History Little agreement in the literature even the most severe cases recover with or without treatment in about 2 years, Codman % of cases do not respond to conservative treatment Castellarin 2004

21 Duration of the Disease (with conservative treatment) Reeves 1975 Prospective study, n = 41 Average duration; 30.1 months Shaffer et al Retrospective study, n = 62 Average duration; 12 months Miller et al Retrospective study, n = 50 Average duration; 14 months

22 Long Term Effects Reeves 1975 At 5 yr. f/u: 54% with limited ROM 7% with functional limitation Shaffer et al At 7 year f/u: 43% with limited ROM 11% had functional limitation Miller et al At 10 year f/u: 100% regained functional ROM

23 Treatment Options Wait and see PT directed rehab MD directed rehab Oral corticosteroids Steroid injections Capsular distension Long lever MUA Arthroscopic release Translational MUA

24 Traditional Manipulation (long-lever techniques) Common practice in some centers for patients who have failed conservative Rx.» Sandor M.U.A. is a useful way to treat frozen shoulder.» Kivimaki et al Traditional manipulation risks fracture, especially in osteoporotic patients.» Hannifan

25 Traditional Manipulation (long-lever techniques) Markus et al consecutive cases of recalcitrant AC received MUA unequivocal acute intrarticular lesions were found in 12 joints 4 Ant. labrum detachments- with 1 osteochondral fragment 3 SLAP tears 2 Partial ruptures of GH ligaments 2 Partial tears of subscapularis tendons the joint should not be mobilized by force. In resistant shoulders, controlled endoscopic release is preferable.

26 GH Gliding Manipulation Following Scalene Block Subjects (N=8) Average symptom duration = 7 mo (3-16 mo) Treatment Slow progressive sustained hold Translational small amplitude high velocity thrust Post manipulation Rx: HVGS x 20 with ice, US, contralateral AAROM flexion 3-5 min/hr (daily PT for ~ 16 visits) Results PROM and Wolfgang s functional score VAS pain No complications (Roubal et al, JOSPT, 1996)

27 Long Term Effectiveness of Translational Manipulation Subjects (N= 31) Average symptom duration = 7.8 ± 2 mo Treatment Slow progressive sustained hold Translational small amplitude high velocity thrust Post manipulation Rx: HVGS x 20 with ice, US, contralateral AAROM flexion 3-5 min/hr (daily PT for ~ visits) Results 5.3 ± 3.2 wks and at 14.4 ± 7.3 mo PROM and Wolfgang s functional score VAS pain No complications (Placzek et al, Clin Orthop, 1998)

28 Manipulation Following Interscalene Block for Shoulder Adhesive Capsulitis: A Case Series Subjects (N= 4) Average Symptom Duration = 7.5 mo Treatment Interscalene block followed by impairment-based mobilizations/manipulations Post manipulation Rx: mobilization, ROM, strengthening exercises and ice (qd for one week then tiw for 2 weeks ~ 10 visits) Outcome Measures PROM and SPADI Video fluoroscopy recordings for 2 patients Taken pre-rx, immediately post-rx, 6- and 12-week (Boyles et al, Manual Therapy, 2005)

29 Total Passive ROM 600 Degrees of PROM Pre-Rx Immediate Final 0 Patient 1 Patient 2 Patient 3 Patient 4

30 SPADI Scores (Pre-manipulation to final) SPADI score (0-100) Pre-RX Final 0 Patient 1 Patient 2 Patient 3 Patient 4

31 Results Pre Abd Post Abd Pre ER Post ER

32 Video Fluoroscopy Pre- Manipulation 6 wk Post- Manipulation

33 Case Studies: Arthroscopic findings following translational MUA. Arthroscopy performed immediately following translational manipulations Patient #1: 42 y.o. diabetic male. 14 month history of labral tear, impingement. AC x 7 months. Patient #2: 42 y.o.f., secondary AC s/p humeral neck fracture. AC x 14 months.

34 Patient #1 Diabetic male, AC x 7 months Humeral head Torn Scar tissue Glenoid

35 Patient #1: Diabetic male, AC x 7 months Scar Tissue Humeral head Labrum

36 Patient #2: Secondary AC x 14 months. Humeral head Veil of scar tissue

37 Patient #2: Secondary AC x 14 months. Humeral head Glenoid Scar tissue

38 Intra-articular Findings In both shoulders: No acute intraarticular lesions were found. Rotator cuff, biceps tendon, subscapularis tendon, glenoid, labrum and humeral surfaces were found in perfect condition.

39 Translational Manipulation Theory Placzek, et al, Amer J of Ortho 2004 Translational manipulation attempts to restore the normal movements associated with angular GH motion. the applied force moves the humeral head in a linear direction, parallel to the glenoid fossa. Advantages over long-lever M.U.A include: Minimizing GH joint compression Improved operator control Increased subacromial space Isolates manipulative force to GH joint Minimizes stress to brachial plexus

40 Adhesive Capsulitis Conclusions Mounting and compelling evidence exists that translational manipulation following interscalene block is safe and effective treatment for the management of shoulder adhesive capsulitis. Patients should be offered this option early in the course of care rather than waiting out the pain and added expense of standard, less effective programs.

41 RI: UE Associations Association between rib impairment and shoulder pain/impairment Boyle, Man Ther, 1999 Association between lateral elbow pain and shoulder impairment Abbott, Man Ther, 2001 Possible associations between upper quarter and CTS Davis et al, JMPT, 1998 Possible association between upper quarter and de Quervain s Disease Anderson & Tichenor, Phys Ther, 1994

42 Targeted Thoracic Spine for Shoulder Pain The Short Term Effects of Thoracic Spine Thrust Manipulation on Patients with Shoulder Impingement Syndrome Manual Therapy Boyles et al, 2008, Manual Therapy The Immediate Effects of Thoracic Spine Manipulation on Patients with Primary Complaints of Shoulder Pain. Strunce et al, 2008, in review

43 Results: SPADI Mean SPADI Scores α =.05; p < Baseline 48-Hours N=60

44 Results Mean NPRS 5 Score Neer e Hawkins Empty Can α =.05; p <.003 IR ER ABD Baseline 48-Hours

45 Results Mean Change Clinically Meaningful Change* (n) SPADI 6.9 a 20 Neer 1.1 b 21 Hawkins 1.23 c 23 Empty Can 1.07 a 25 IR 0.68 a 17 ER 1.04 a 24 ABD 0.84 a 19 GRCS n/a 13 a p <.001, b p =.001, c p =.003 * SPADI = 10, NPRS = 2, GRCS = 4

46 Discussion Thoracic thrust manipulations were associated with statistically significant reduction of SPADI & NPRS Our findings may support recent studies that advocate the use of spinal thrust manipulation in the treatment of the upper extremity

47 Techniques

48 Grades of Mobilization P. E. Greenman

49 Grades of Mobilization G. D. Maitland II + I + III ++ IV ++ R2 III + I II III IV + III - IV R1 IV - 1/4 1/2 3/4 L

50 Grades of Mobilization G. D. Maitland GRADE I II III IV DESCRIPTION Small amplitude out of resistance (R1) Large amplitude out of resistance Large amplitude into resistance Small amplitude into resistance III- or IV- performed at 25% into restricted range III or IV performed at 50% into restricted range III+ or IV+ performed at 75% into restricted range III++ or IV++ performed at restricted barrier (R2) Grades I and II used to treat pain prior to reaching resistance Grades III and IV used to treat resistance (joint restrictions) when pain is not a limitation

51 Mobilization Principles G. D. Maitland; P. E. Greenman Patient must be completely relaxed Operator must be relaxed Patient must be comfortable and have complete confidence in the operator s grasp Embrace the joint to be moved, hold around the joint to feel movement Move one joint, one motion at one time Patient must be confident that the joint will not be hurt Operator s position must be comfortable and easy to maintain Operator s position must afford him/her complete control

52 Mid-Thoracic Manipulation Patient seated with back near edge of table Have patient grasp opposite shoulders, ensuring patient s arm is over the other arm Fulcrum the patient s thoracic spine into flexion by grasping the patient s elbows and leaning into the patient with your upper body (Jstroke) Extend knees, lifting the patient vertically while emphasizing flexion and distraction of the thoracic spine

53 Cervico-Thoracic Junction Gapping Manipulation Your chest should be level with patient s CT junction With patient seated, have them interlock their fingers at the base of their neck Weave arms through the patient s arms until your hands are resting slightly below the patient s hands (Patient s elbows should be relaxed) Support patient with compression of forearms Lean patient back until C-T junction is perpendicular to the floor Extend knees, lifting the patient vertically producing a distraction thrust at the C-T Junction

54 Shoulder Techniques GH Physiological Mvmts Flexion (Grade 4) Abduction (Grade 4) External Rotation (Grade 4) Internal Rotation (Grade 4) Horiz. Flexion (Grade 4) GH Accessory Mvmts AP Glides in Abduction Caudal Glides in Abduction Caudal Glides in Flexion AC Accessory Mvmts AC Joint Caudal Glides Clavicle Rotation (Wiggle)

55 Shoulder Flexion Grade IV Patient position: Supine Therapist position Proximal hand: Reach under patient and grasp the upper trapezius muscle; forearm lies along medial border of scapula. Distal hand: Grasp the distal humerus in a position to stabilize the elbow joint. Mobilization technique Use the proximal hand to stablize the scapula and prevent shoulder shrugging. Bring patient s arm into flexion to find resistance (R1 and R2. Apply small amplitude flexion mobilizations (2-3 ) within this resistance.

56 Shoulder Abduction Grade IV Patient position: Supine Therapist position Proximal hand: Reach under patient and grasp the upper trapezius muscle; forearm lies along medial border of scapula. Distal hand: Grasp the distal humerus in a position to stabilize the elbow joint. Mobilization technique Use the proximal hand to stabilize the scapula and prevent shoulder shrugging. Bring patient s arm into abduction to find resistance. Apply small amplitude abduction mobilizations (2-3 ) within this resistance.

57 Shoulder External Rotation Grade IV Patient position Supine, shoulder abducted and elbow flexed to 90, upper arm resting on plinth Therapist position Proximal hand: Grasp the distal humerus; lay forearm across anterior shoulder for stabilization Distal hand: Grasp wrist and hold in a neutral position Mobilization technique Bring patient s arm into external rotation to find resistance. Apply graded mobilizations (~10 ) within resistance. May be performed in various degrees of abduction based on patient symptoms and response

58 Shoulder Internal Rotation Grade IV Patient position Supine, shoulder abducted and elbow flexed to 90, upper arm resting on plinth Therapist position Proximal hand: Grasp the distal humerus; lay forearm across anterior shoulder for stabilization Distal hand: Grasp wrist and hold in a neutral position Mobilization technique Bring patient s arm into internal rotation to find resistance. Apply graded mobilizations (~10 ) within resistance. May be performed in various degrees of abduction based on patient symptoms and response

59 Shoulder Horizontal Flexion Grade IV Patient position Supine, shoulder and elbow flexed to 90 Therapist position Proximal hand: Place the heel of one hand under the medial border of scapula for stabilization Distal hand: Grasp wrist and hold in a neutral position Tuck patient s elbow into your shoulder crease Mobilization technique Small amplitude mobilizations into HF are applied: 1) Along humeral shaft, or 2) In a direction toward the opposite shoulder. Used independently or together

60 Glenohumeral Joint AP Glides in Abduction (Grades III IV) Patient position Supine, shoulder off plinth in abduction, elbow flexed to 90 Therapist position Distal hand: Grasp the patient s distal humerus and elbow; hold patient s forearm against yours Proximal hand: Heel of hand placed against anterior humeral head Mobilization technique Graded AP mobilization is applied through your mobilizing arm against the humeral head. May be performed in various degrees of GH ABD and HF based on patient symptoms and response

61 Glenohumeral Joint Caudal Glides in Abduction (Grades III IV) Patient position Supine, shoulder off plinth in abduction, elbow flexed to 90 Therapist position Distal hand: Grasp the patient s distal humerus and elbow; hold patient s forearm against yours Proximal hand: 1 st web space or heel of hand placed against head of humerus (adjacent to acromion) Mobilization technique Graded mobilization is applied through your mobilizing hand to glide the humeral head caudally. Elbow may be held stationary, or carried on line with humerus or further distally depending on irritability

62 Glenohumeral Joint Caudal Glides in Full Flexion (Grade IV) Patient position Supine, shoulder off plinth in abduction, elbow flexed to 90 Therapist position Distal hand: Grasp the patient s upper arm with the lateral border of index finger against humeral head and thumb into axilla; hold patient s arm against your side. Proximal hand: Heel of hand placed along the lateral border of scapula Mobilization technique Graded mobilization is applied through your mobilizing hand to glide the humeral head caudally. Scapula is stabilized using firm pressure along the lateral border.

63 Acromioclavicular Joint Caudal Glides Patient position: Supine Therapist position Place the tips of both thumbs on the superior surface of the clavicle adjacent to the AC joint; spread fingers out for stability. Position forearms in line with the caudal movement at the AC joint. Mobilization technique Graded oscillatory mobilization is applied by your arms, acting through stable thumbs. Pad of your outer thumb should feel the joint motion (feel for the stationary acromion process).

64 Clavicle Rotation (Wiggle) Patient position: Supine Therapist position Stand near the patient s shoulder, facing towards the clavicle. Gently grip the mid clavicle using your thumbs on the inferior edge and finger tips superiorly. Mobilization technique Apply a gentle mobilization force using a rocking or wiggling motion through repetitive wrist flexion and extension. Works as a nice easing technique following direct AC and/or SC joint mobilizations.

65 Therapeutic Exercise: The Shoulder Danny McMillian, PT, DSc, OCS, CSCS AAOMPT OCT 09

66 Shoulder Function Integrated not isolated Define integrated GHJ, ACJ, SCJ, Scapula- Thoracic Articulation? Why are there no chairs on a pitcher s mound? Re-define integrated Regional interdependence considerations C-spine to the foot (and everything in between) Functional Movement Screen (FMS) Deep Squat

67 Shoulder Impairment Janda has written extensively on neuromuscular imbalances as they affect function of the upper quarter. Prone to tightness upper trapezius pectoralis major/minor upper cervical extensors Prone to weakness middle/lower trapezius rhomboids serratus anterior deep neck flexors

68 Shoulder Impairment Sahrmann has classified several movement impairment syndromes about the shoulder. Ex: Scapular Downward Rotation Syndrome Dominance, shortness, and/or stiffness of the downward rotators Insufficient activity of the upward rotators

69 Examination Ensure full, 3D view of all segments contributing to motion Death by special tests 35+ Magee/Cleland Let a viewing of integrated motion be your guide to a more focused examination Hx: Consider previous spine or LE problems Loss of power from LE

70 Examination The SICK scapula Scapular malposition Inferior medial border prominence Coracoid pain and malposition dyskinesis of scapular movement Adjunct tests Scapular assistance Assess ROM Scapular retraction Assess Strength Relocation test

71 Regional Interdependence with the SICK scapula Burkhart & Kibler % poor lumbar flexibility 44% exhibited Trendelenburg sign with SLS sequence 39% exhibited decreased hip IR on contralateral side

72 Regional Interdependence with the SICK scapula By altering proximal mobility/stability distal mobility and force production suffer Breaks the kinetic chain What effect does decrease T-Spine extension/rotation have on this player s force production?

73 Regional Interdependence Kinetic link model Proximal to distal stability 50-60% of the force transmitted through the shoulder is generated from the lower extremity and trunk (tennis & baseball) Kinetic Chain Roles Legs/trunk - force generation Shoulder force regulation Arm- force delivery

74 Lower Extremities: Generating drive for overhead lifts Decelerating throws Shoulder Primary Synergists

75 Shoulder Primary Synergists The Core: An unstable core = unstable, length:tension relationships about the shoulder girdle

76 Shoulder Flexibility Requirements Pectoralis Muscles: Tight pectoralis muscles are associated with excessive scapular protraction and downward rotation, both disturbing optimal glenohumeral mechanics. Posterior-Inferior G-H Capsule: Tightness here is associated with SLAP tears & internal impingement syndrome in throwing athletes. Latissimus Dorsi and Teres Major: Tightness can limit upper extremity elevation.

77 Shoulder Flexibility Requirements Thoracic Rotation & Extension: For throwing/punching motions, inability to optimally move the thoracic spine in the transverse plane may create pathological compensations at the shoulder. Hip & Trunk Extension: Lack of extension will result in compensations up the chain to enable continuation of functional performance.

78 Functional Shoulder Exercise Foundational principles guide exercise selection and progression Train movements, not mm* Train in 3D Don t fear speed Challenge proprioception *Discrete mm performance impairments may need isolation first, then integration with more functional movement patterns.

79 Functional Shoulder Exercise Training Considerations Isolated shoulder movement versus integrated activity with the trunk and LEs Both or single arm demand Symmetry of weight distribution Stability of surface and base of support Dynamic versus static demand Repetitive motion or sustained postures

80 Warming up the shoulder Priming the Cannon Light loads through full range Roll-outs on physioball Medicine ball chop/lift Overhead squat Lunge and reach Standing row and rotate Windshield wiper

81 Training considerations: Isolated versus integrated

82 Training considerations: Both or single arm demand

83 Training considerations: Symmetry of weight distribution

84 Training considerations: Stability of surface/bos

85 Training considerations: Static versus dynamic demand

86 Training considerations: Mobility Impairment Pursue full mobility of the shoulder complex GHJ & STJ Spine & Lumbopelvic complex GIRD (posterior shoulder stretch) What is being stretched? Anterior shoulder stretch Various techniques Stretching the right tissue

87 Progression Options galore Amplitude partial to full Speed of movement slow to fast Volume Repetitions or Time Amount of resistance

88 Is there a role for traditional weight training? YES Especially deadlift and its variations Practical lift Neural drive (irradiation) from heavy loads without putting GHJ in vulnerable position However, Beware isolated pressing movements Poor adaptability Increased injury risk Remember: Eventually, you must train movements, not muscles

89 Start proximally Shoulder dump Shoulder Exercises: Acute phase From post-op (in-sling) Sternal lift Scapular clocks* Postural awareness Restore ROM (PROM to AROM) Arthrokinematics, M-T length CKC incorporation reduces load on RTC and aids in proximal recruitment Incorporate LE movement & stability challenges Protect and promote Cx and Tx function

90 Shoulder Exercises: Sub-acute phase Upper Body Ergometer Consider impairment when choosing forward/rearward cycle Unloaded movements Large-amplitude, integrated ROM Pain-free Integrated PNF patterns Throwing patterns Light resistance Isolate PRN

91 Shoulder Exercises: Sub-acute phase Incorporate movement & stability challenges Pushup+ Physioball roll/reach Progressive push-ups PU+ w/rotation Telescoping/Punching Bow Hunter

92 Integrate LE/trunk Step up/down w/single-arm shoulder press Squat w/arms overhead Lunge and Reach Variations MedBall, etc Shoulder Exercise Functional Progression

93 Shoulder Exercise Functional Progression Increase load, speed, and/or complexity of kinetic chain movement Lunge & Reach Overhead squat with unequal load Turkish Get Up Battling Ropes Deadlift

94 Shoulder Exercise Functional Progression

95 Shoulder Exercises: Reconditioning End Stage Finish-Line Functional Training Considerations in this stage must focus on individualspecific occupational or sports goals

96 References Malliou PC, et al. Effective ways of restoring muscular imbalances of the rotator cuff muscle group: a comparative study of various training methods. BJSM 38: , Wise MB, et al. The effect of limb support on muscle activation during shoulder exercises. JSES 13: , 2004 Krabak BJ, et al. Practical nonoperative management of rotator cuff injuries. CJSM 13: , Burkhart SS, et al. The disabled throwing shoulder: spectrum of pathology part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 19: , McMullen J, Uhl TL. A kinetic chain approach for shoulder rehabilitation. JAT 35: , Jonsson P, et al. Eccentric training in chronic painful impingement syndrome of the shoulder: results of a pilot study. KSSTA 2006;14: Smith J, et al. Electromyographic activity in the immobilized shoulder girdle musculature during scapulothoracic exercises. APMR 2006;87:

97 References Bak K, Fauno P. Clinical findings in competitive swimmerss with shoulder pain. AJSM 1997;25(2): Gross ML, et al. Anterior shoulder instability in weight lifters. AJSM 1993;21(4): Scavenius M, Iversen BF. Nontraumatic clavicular osteolysis in weight lifters. AJSM 1992;20(4): Ronai P. Exercise modifications and strategies to enhance shoulder function. Strength and Conditioning Journal 2005;27(4): Sauers EL. Effectiveness of rehabilitation for patients with subacromial impingement syndrome. JAT 2005;40(3): Buss DD, et al. Nonoperative management for in-season athletes with anterior shoulder instability. AJSM 2004;32(6): Kibler WB. The role of the scapula in athletic shoulder function. AJSM 1998;26(2):

98 References Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy. 2003;19(5): Fees M, et al. Upper extremity weight-training modifications for the injured athlete. A clinical perspective. AJSM 1998;26(5): Placzek JD, et al. Shoulder outcome measures. A comparison of 6 functional tests. AJSM 2004;32(5): Reinold MM, et al. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. JOSPT 2004;34: Cools AM, et al. Rehabilitation of scapular muscle balance. Which exercises to prescribe. AJSM 2007;35(10): Kibler WB, et al. Evaluation of apparent and absolute supraspinatus strength in patients with shoulder injury using the scapular retraction test. ASJM 2006;34:

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