Ann cools 3 scapular rehab [compatibiliteitsmodus]

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Ann cools 3 scapular rehab [compatibiliteitsmodus]

  1. 1. The scapula: stabilize or mobilize?Approaches to achieve scapular control Dr Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy Ghent University, Belgium Ann Cools Wrightington Nov 2012 1
  2. 2. Ghent University, Faculty of Medicine & Health Sciences, Dept of Rehabilitation Sciences & PhysiotherapySupervisor: Prof dr Ann CoolsResearchers:- Kristof De Mey- Annelies Maenhout- Annemie Van de Velde- Maarten Van Herzeele Ann Cools Wrightington Nov 2012 2
  3. 3. Scapular dyskinesis in relation to shoulderpain: scientific evidence Ludewig 2000, Lukasiewicz 1999, Warner 1992, , McClure 2006, Endo 2001, Hebert 2002, Lin 2006,Laudner 2006, Su 2004, Kibler 2009, Mc ClureAnn Cools Wrightington Nov 2012 2009, Tate 2009 3
  4. 4. Implications of scapulardyskinesis on daily activities….Need for science-based scapularrehab program…. Ann Cools Wrightington Nov 2012 4
  5. 5. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle - Manual stretching control control - home stretching - soft tissue techniques Advanced control Balance -ratio - manual mobilisations During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 Advanced control 5 -MWM Endurance/strength During sports
  6. 6. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle - Manual stretching control control - home stretching - soft tissue techniques Advanced control Balance -ratio - manual mobilisations During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 Advanced control 6 -MWM Endurance/strength During sports
  7. 7. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle - Manual stretching control control - home stretching - soft tissue techniques Advanced control Balance -ratio - manual mobilisations During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 Advanced control 7 -MWM Endurance/strength During sports
  8. 8. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle - Manual stretching control control - home stretching - soft tissue techniques Advanced control Balance -ratio - manual mobilisations During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 Advanced control 8 -MWM Endurance/strength During sports
  9. 9. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle - Manual stretching control control - home stretching - soft tissue techniques Advanced control Balance -ratio - manual mobilisations During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 Advanced control 9 -MWM Endurance/strength During sports
  10. 10. STRETCHING PECT MINOR:literature versus reality(Borstad JOSPT 2006, Reeser PM&R 2010, Ellenbecker & Cools BJSM 2010) Ann Cools Wrightington Nov 2012 10
  11. 11. Annemie Van de Velde, Karen D’Huyvetter, Céline Dufour, Ann Cools: Effect of twostretching techniques on the length of the pectoralis minor in adolescentswimmers . Paper in progress, 2012 ANGULAR STRETCHING PM length PM length PM length Measurement 1 Measurement 2 Measurement 3 DIRECT MANUAL STRETCHING Swim training session Ann Cools Wrightington Nov 2012 11
  12. 12. Annemie Van de Velde, Karen D’Huyvetter, Céline Dufour, Ann Cools: Effect of twostretching techniques on the length of the pectoralis minor in adolescentswimmers . Paper in progress, 2012Adolescent swimmers (N=29, mean age = 14y)3x 30” stretching,PM length measurement (Borstad et al. 2005) Ann Cools Wrightington Nov 2012 12
  13. 13. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle - Manual stretching control control - home stretching - soft tissue techniques Advanced control Balance -ratio - manual mobilisations During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 Advanced control 13 -MWM Endurance/strength During sports
  14. 14. Stretching posteriorshoulder: clinical experience Ann Cools Wrightington nov 2012
  15. 15. POSTERIOR SHOULDERSTRETCHING Sleeper’s stretch & cross body stretch improve ROM (Mc Clure 2005) Additional manual mobilisations improve ROM (Manske 2010) Improvement ROM is related to reduction of symptoms (Tyler 2010) Stretching has a positive influence on the subacromial space (Maenhout 2012) Ann Cools Wrightington Nov 2012 15
  16. 16. Scientific Evidence? comparison translation – angular stretchingAngular stretching Translation mobilisation (Cools et al. Shoulder & Elbow 2011) (patients with GIRD: n=30, healthy shoulders with GIRD: n=30) Ann Cools Wrightington Nov 2012 16
  17. 17. angular stretching translation mobilisations VAS Before- Before- After- After-3w after later Pain/movement p= 0,001 p= 0,042 80 80 D patients D patients Hawkins’ test p= 0,001 p= 0,116de gre e de gre e 60 60 D controls 40 D controls 40 ND patients Neer’s test p= 0,002 p= 0,223 ND patients ND controls 20 20 Apprehension p= 0,022 p= 0,755 before after 3w ND controls before after 3w later later 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) Ann Cools Wrightington Nov 2012 17
  18. 18. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle - Manual stretching control control - home stretching - soft tissue techniques Advanced control Balance -ratio - manual mobilisations During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 Advanced control 18 -MWM Endurance/strength During sports
  19. 19. Conscious muscle control lowertrapezius: Scapular OrientationExercise Subjects are able to perform consistent 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) Ann Cools Wrightington Nov 2012 19
  20. 20. Sidelying Forward flexion Sidelying Ext RotationProne Hor Abd + Ext Rot Prone Extension Scapular Orientation Exercise Ann Cools Wrightington Nov 20 2012
  21. 21. Does conscious correction of scapular positioninginfluence muscle activity during exercises? Yes, for 2 out of the 4 exercisesDe Mey K., Conscious correction of scapular orientation in overhead athletes performing selectedshoulder rehabilitation exercises: what´s the effect on trapezius muscle activation measured by surfaceelectromyography? JOSPT Under revision July 2012 Ann Cools Wrightington Nov 2012 21
  22. 22. Flexibility versus musclerecruitment problems? Ann Cools Wrightington Nov 2012 22
  23. 23. (Ellenbecker & Cools, BJSM 2010) Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle - Manual stretching control control - home stretching - soft tissue techniques Advanced control Balance -ratio - manual mobilisations During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 Advanced control 23 -MWM Endurance/strength During sports
  24. 24. Sidelying Forward flexion Sidelying External RotationProne Hor Abd + Ext Rot Prone Extension Ann Cools Wrightington Nov 2012 24
  25. 25. SCAPULAR STRENGTH TRAINING:Scientific evidence healthy peopleA 12 week program of scapular exercises improves isokinetic muscle strength, and muscle balance in healthy adolescent swimmers Ann Cools Wrightington Nov 2012 25
  26. 26. SCAPULAR STRENGTH TRAINING:Scientific evidence healthy people6 month program of scapular retraction exercises improves RC strength (infraspinatus) in volleyball players Ann Cools Wrightington Nov 2012 26
  27. 27. SCAPULAR STRENGTH TRAINING:Scientific evidence patientsScapular exercises improve muscle strength, symptoms and relative muscle activity in overhead athletes with impingement symptoms Ann Cools Wrightington Nov 2012 27
  28. 28. Scapular Rehab Algorithm Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength - Levator scapulae - infraspinatus - co-contraction - lower/middle trap - pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle control control - Manual stretching - home stretching - soft tissue rechniques Advanced control - manual mobilisations Balance -ratio During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 28 Advanced control Endurance/strength(Ellenbecker & Cools, BJSM 2010) During sports movements
  29. 29. FUNCTIONAL EXERCISES: literature Integrate kinetic chain into shoulder rehab exercises Focus on open and closed chain exercises Challenge sports specific positions and movements Ann Cools Wrightington Nov 2012 29 (Kibler AJSM 1998, Lintner Sports Med 2008, Cools BJSM 2008)
  30. 30. Background and purpose of thestudies: Maenhout et al. BJSM 2009: lower extremity position influences scapular muscle recruitment and muscle balance ratios in closed kinetic chain exercises De Mey et al. Accepted for publication JSAMS May 2012: trunk & lower extremity position and movement influence scapular muscle recruitment and muscle balance ratios in open kinetic chain exercises Ann Cools Wrightington Nov 2012 30
  31. 31. Results (1): EMG activity scapular muscles: extension contralateral leg versus other modalities UT MT LT SAEx Mean StD Mean SD Mean SD Mean SD1 13,63 7,27 10,37 5,38 11,30 6,33 31,65 19,112 18,31 13,17 14,55 8,28 20,12 10,07 23,43 14,663 16,18 8,32 13,04 7,91 11,80 8,14 44,20 18,674 13,67 8,00 10,11 5,42 10,44 5,90 25,30 15,775 16,69 10,55 13,14 6,00 16,86 9,27 14,27 8,146 14,39 7,67 11,44 6,69 10,75 6,68 30,46 15,607 17,20 10,52 12,30 6,22 10,72 6,53 36,71 15,55 (Maenhout & Cools, BJSM 2009) Ann Cools Wrightington Nov 2012 31
  32. 32. Results (2): EMG activity scapular muscles: unilateral squat versus other exercise modalities 5 4,5 * *Gemiddeld (% MVC) 4 3,5 * 3 * * Bilateraal 2,5 2 Unilateraal 1,5 1 0,5 0 Lunge Unipodale Zit dynamisch dynamisch dynamisch Squat Stand Lunge Squat Squat Uitvoeringsmodaliteiten*= significant main effect “exercise” Wrightington Nov 2012 Ann Cools 32 (De Mey & Cools, JSAMS 2012)
  33. 33. Diagonals in CK exercises Ann Cools Wrightington Nov 2012 33
  34. 34. Scapular Rehab Algorithm (Ellenbecker & Cools, BJSM 2010) Lack of Lack of Soft-tissue flexibility Muscle performance Scapular muscles GH muscles/capsule Muscle Control Muscle Strength- Levator scapulae - infraspinatus - co-contraction - lower/middle trap- pectoralis minor - posterior capsule - force couples - serratus anterior NEUROMUSCULAR STRENGTH STRETCHING & MOBILISATION COORDINATION TRAINING Conscious muscle Conscious muscle control control - Manual stretching - home stretching - soft tissue rechniques Advanced control - manual mobilisations Balance -ratio During basic activities (accessory movements) Ann Cools Wrightington Nov 2012 34 Advanced control Endurance/strength During sports movements
  35. 35. Influence of experimentally induced pain inthe 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 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 Ann Cools Wrightington Nov 2012 35
  36. 36. Level of activity DURING pain Total Concentric Eccentric movement phase phase abduction Increased LT activity 3,52% Scapular Decreased LT elevation activity 1,8% Forward flexion Increased SA Decreased SA activity 17% activity 1,49% 20’ after pain Total Concentric Eccentric movement phase phase abduction Scapular Increased UT elevation activity 1,43% Increased SA activity 2,37%PAIN DOESForward flexion SCAPULAR MUSCLE RECRUITMENT CHANGE Ann Cools Wrightington Nov 2012 36
  37. 37. « Take home message »Manual stretching pect minor has positiveshort term effectsIncreased ROM and symptom relief afterposterior shoulder stretchingAdding conscious scapular correctionincreases muscle activity during exercisesScapular rehab program results in strength gain in scapulaand shoulderTake into account that pain can change muscle recruitment Ann Cools Wrightington Nov 2012 37
  38. 38. Ann Cools Wrightington Nov 2012 38

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