Exercises that target the scapula: scientific rationale and clinical relevance. Dr Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy

Transcription

1 Exercises that target the scapula: scientific rationale and clinical relevance Dr Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy Ann Ghent Cools Gothenborg University, 2012 Belgium 1

2 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) 2 - Fredrik Johansson (Drs - Sweden)

3 Implicationsof scapular dyskinesison dailyactivities. Need for science-based scapular rehab program. 3

4 (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Soft-tissue flexibility 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 & MOBILISATION NEUROMUSCULAR COORDINATION STRENGTH TRAINING - Manual stretching - home stretching - soft tissue techniques - manual mobilisations (accessory movements) -MWM During basic activities During sports Balance -ratio Endurance/strength 4

9 STRETCHING PECT MINOR: literatureversus reality (Borstad JOSPT 2006, Reeser PM&R 2010, Ellenbecker & Cools BJSM 2010) 9

10 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 ANGULAR STRETCHING PM length Measurement 1 PM length Measurement 2 PM length Measurement 3 DIRECT MANUAL STRETCHING Swim training session 10

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 Adolescent swimmers (N=29, mean age = 14y) 3x 30 stretching, PM length measurement (Borstad et al. 2005) 11

12 STRETCHING PECT MINOR: Scientificevidence Angular self stretch and direct manual stretching have 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) 12

13 (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Soft-tissue flexibility 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 & MOBILISATION NEUROMUSCULAR COORDINATION STRENGTH TRAINING - Manual stretching - home stretching - soft tissue techniques - manual mobilisations (accessory movements) -MWM During basic activities During sports Balance -ratio 13 Endurance/strength

14 POSTERIOR SHOULDER STRETCHING Sleeper s stretch & cross body stretch improve ROM (Mc Clure 2005) Improvement ROM is related to reduction of symptoms (Tyler 2010) Additional manual mobilisations improve ROM (Manske 2010, Cools 2011) Stretching has a positive influence on the subacromial space (Maenhout 2012) 14

15 Angular stretching Translation mobilisation (Cools et al. Shoulder & Elbow 2011) (patients with GIRD: n=30, healthy shoulders with GIRD: n=30) 15

16 angular stretching translation mobilisations VAS Before- after After-3w later d e g r e e before after 3w later D patients D s ND patients ND s d e g r e e before after 3w later D patients D s ND patients ND s Pain/movement p= 0,001 p= 0,042 Hawkins test p= 0,001 p= 0,116 Neer s test p= 0,002 p= 0,223 Apprehension p= 0,022 p= 0,755 Modified Rowe p= 0,001 p= 0,125 RESULTS: Significant increase in ROM after 3w Equal results both techniques Significant pain reduction in patient group (Cools et al. Shoulder & Elbow 2011) 16

17 STRETCHING G.I.R.D.: influenceon the subacromialspace? Measurements: - Acromiohumeral distance (Echoblaster 128; Telemed, Vilnius, Lithuania) - Glehonumeral ROM (Acumar inclinometer) Quantifying acromiohumeral distance in overhead athletes with glenohumeral internal rotation loss and the influence of a stretching program. Maenhout A, Ann Cools Lexington Van EesselV, Vanraes A, Van Dyck L, Cools A. (Accepted AJSM May 2012)

18 Six week stretching program (sleeper s stretch daily) increases the ROM into IR and increases the subacromial space 18

20 lower trapezius: ScapularOrientation Exercise Subjects are able to performconsistent movements of the scapula into posterior tilt and upward rotation Significant increase scapular muscle activity in trapezius High correlation between assisted and unassisted (home) exercise (Mottram 2009) 20

21 Sidelying Forward flexion Sidelying Ext Rotation Prone Hor Abd + Ext Rot Prone Extension Scapular Orientation Exercise 21

22 Conscious correction of scapular orientation improves scapular muscle activity during exercises 22

24 Sidelying Forward flexion Sidelying External Rotation Prone Hor Abd + Ext Rot Prone Extension 24

25 SCAPULAR STRENGTH TRAINING: Scientificevidencehealthypeople A 12 week program of scapular exercises improves isokinetic muscle strength, and muscle balance in healthy adolescent swimmers 25

26 SCAPULAR STRENGTH TRAINING: Scientificevidencehealthypeople 6 month program of scapular retraction exercises improves RC strength (infraspinatus) in volleyball players 26

27 SCAPULAR STRENGTH TRAINING: Scientificevidencepatients Scapular exercises improve muscle strength, symptoms and relative muscle activity in overhead athletes with impingement symptoms 27

28 Scapular Rehab Algorithm Soft-tissue flexibility (Ellenbecker & Cools, BJSM 2010) 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 & MOBILISATION NEUROMUSCULAR COORDINATION STRENGTH TRAINING - Manual stretching - home stretching - soft tissue rechniques - manual mobilisations (accessory movements) During basic activities During sports movements Balance -ratio 28 Endurance/strength

29 Influenceof experimentallyinducedpainin the supraspinatus on scapular muscle activity (Van HerzeeleM, Parlevliet T, HeemanS, Hofman K & Cools A, unpublisheddata 2012) - ultrasound-led pain induction (hypertonic saline) in supraspinatus muscle (N=23) - Pain sensation Numeric Rating Scale (NRS) >6/10 - Elevation in 3 planes before and after pain induction - Before pain - Immediately after pain induction - 20 after pain induction (NRS 0,62) - EMG scapular muscles (Noraxon Myoresearch) - Normalised EMG activity (% MVC) - Recruitment order 29

30 Level of activity DURING pain Total movement abduction Scapular elevation Forward flexion Increased SA activity 17% Concentric phase Increased LT activity 3,52% Eccentric phase Decreased LT activity 1,8% Decreased SA activity 1,49% 20 afterpain Total movement abduction Concentric phase Eccentric phase Scapular elevation Increased UT activity 1,43% Increased SA activity 2,37% PAIN DOES CHANGE SCAPULAR MUSCLE RECRUITMENT Forward flexion 30

31 «Takehome message» Manual stretching pect minor has positive short term effects Increased acromiohumeral distance after posterior shoulder stretching Adding conscious scapular correction increases muscle activity during exercises Scapular rehab program results in strength gain in scapula and shoulder Take into account that pain can change muscle recruitment 31

32 Future congress: THE SHOULDER IN THE OVERHEAD ATHLETE: CHALLENGES FOR SCAPULAR REHABILITATION AND RETURN TO PLAY AFTER INJURY FRIDAY 29th MARCH 2013 Het Pand, Gent, Belgium

33 (Gent- Belgium) ² 33