Upper Extremity Balance


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Presentation for WATA Symposium about Upper Extremity Balance and Stability Training

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Upper Extremity Balance

  1. 1. Upper Extremity Balance and Stability Training Patrick Hills-Meyer, MA, LAT, CSCS
  2. 2. Purpose <ul><li>A brief overview on balance and stability </li></ul><ul><li>Discuss current research in upper extremity (UE) balance and stability training </li></ul><ul><li>Discuss current research in core stability </li></ul><ul><li>Discuss core stability and how it relates to shoulder (UE) stability </li></ul><ul><li>Discuss how to train UE balance and stability </li></ul><ul><li>Demonstrate UE exercise progressions both OKC and CKC </li></ul>
  3. 3. Balance <ul><li>The body’s ability to maintain an equilibrium by controlling the body’s center of gravity over its base of support. (Houglum) </li></ul><ul><li>Proprioception </li></ul><ul><ul><li>The body’s ability to transmit position sense, interpret the information, and respond consciously or unconsciously to stimulation through appropriate execution of posture and movement. (Houglum) </li></ul></ul>
  4. 4. Proprioception <ul><li>Joint position sense </li></ul><ul><ul><li>Appreciation and interpretation of information concerning one’s position and orientation in space </li></ul></ul><ul><li>Kinesthesia </li></ul><ul><ul><li>The ability to appreciate and interpret joint motions </li></ul></ul><ul><li>Sensation of force </li></ul><ul><ul><li>The ability to appreciate and interpret force applied to or generated within a joint </li></ul></ul>
  5. 5. Proprioception  SMS <ul><li>The sensory motor system (SMS) is responsible for providing awareness, coordination, and feedback to maintain form and stability, thereby serving as a major component of injury free athletic performance. (Tripp) </li></ul><ul><li>Research has shown that endurance and SMS control exercises should not focus on single joints. (Tripp) </li></ul><ul><li>Joint injury compromises SMS function </li></ul>
  6. 6. Shoulder Balance <ul><li>Range of motion </li></ul><ul><ul><li>Flexion/extension </li></ul></ul><ul><ul><li>Abduction </li></ul></ul><ul><ul><li>External rotation/internal rotation </li></ul></ul><ul><li>Strength </li></ul><ul><ul><li>Periscapular muscles (pec minor, serratus, levator, rhomboids, trapezius) </li></ul></ul><ul><ul><li>Rotator cuff muscles </li></ul></ul><ul><ul><li>Large muscles (deltoids, biceps, triceps) </li></ul></ul><ul><li>Proprioception </li></ul><ul><ul><li>Joint position sense </li></ul></ul><ul><ul><li>Kinesthesia </li></ul></ul><ul><ul><li>Sensaton of force </li></ul></ul>
  7. 7. Stability <ul><li>The state of remaining unchanged even in the presence of forces that would normally change the state or condition. (Myers) </li></ul><ul><li>Glenohumeral stability is the state of the humeral head remaining or promptly returning to proper alignment within the glenoid fossa through an equalization of forces. (Myers) </li></ul><ul><li>Joint stability is mediated by both mechanical and dynamic restraints </li></ul><ul><li>Mechanical </li></ul><ul><ul><li>GH joint capsule and ligaments, labrum, bony geometry, intra-articular pressure </li></ul></ul><ul><li>Dynamic </li></ul><ul><ul><li>Activation and force productions by the muscles </li></ul></ul>
  8. 8. Shoulder Stability <ul><li>There is an inherent lack of bony stability in the glenohumeral joint </li></ul><ul><li>Glenoid fossa is 1/3 to 1/4 the surface area of the humeral head. (Borsa) </li></ul>
  9. 9. Stability <ul><li>Dynamic Stability </li></ul><ul><ul><li>During overhead activities, the scapular stabilizing and rotator cuff muscles function in a balanced manner to maintain a centered relationship between the humeral head and the glenoid fossa. (Borsa) </li></ul></ul><ul><li>Functional joint stability </li></ul><ul><ul><li>Possessing adequate stability to perform functional activity and results from the interactions between the mechanical and dynamic restraints. (Myers) </li></ul></ul>
  10. 10. Training with Instability <ul><li>The advantage of an unstable training environment would be based on the importance of neuromuscular adaptations with increases in strength. (Behm) </li></ul><ul><li>A strong stable core provides a solid foundation for the torques generated by the limbs. </li></ul><ul><li>The greatest contribution of instability training is to improve core stability rather than limb strength. (Behm) </li></ul>
  11. 11. Training with Instability <ul><li>The purpose of training with instability is not for significant strength gains, but to try to improve balance, stability and proprioceptive capabilities. (Behm) </li></ul>
  12. 12. Core: Center of the Kinetic Chain <ul><li>A muscular corset that works as a unit to stabilize the body both with and without movement. (Borghuis) </li></ul><ul><li>All motions are generated from the core and translated to the extremities. (Bliss) </li></ul><ul><li>The core is central to all kinetic chains in sports activities, control of core strength, balance and motion will maximize all kinetic chains of upper (and lower) extremity function. (Borghuis) </li></ul>
  13. 13. Balance and Core Stability <ul><li>Maintenance of balance in upright posture is essential in daily activities and sports as well as to he prevention of injury. </li></ul><ul><li>Stabilization of the trunk is crucial for maintaining static or dynamic balance, especially to provide a solid base when attempting to exert forces upon external objects </li></ul>
  14. 14. Core Stability <ul><li>The ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment in integrated activities. (Hibbs) </li></ul><ul><li>To increase core stability, exercises must be performed that stimulate the movement patterns of a given sport </li></ul><ul><li>Greater core stability provides a foundation for greater force production in the upper (and lower) extremities. (Willardson) </li></ul>
  15. 15. Stability Ball Training <ul><li>Recommended that programs exclude, or limit use of stability ball as they do not appear to provide sufficient stimulus for improving muscular strength or hypertrophy. (Nuzzo) </li></ul><ul><li>Difficult to increase intensity through external loading </li></ul><ul><li>Include structural multi-joint exercises instead </li></ul>
  16. 16. Injury to the shoulder <ul><li>To the stabilizing structures of the shoulder results in mechanical instability </li></ul><ul><li>Injury not only disrupts the mechanical stabilizers, but also causes sensorimotor (SMS) deficits </li></ul><ul><li>The combination of mechanical and sensorimotor alterations contribute to functional instability </li></ul>
  17. 17. Injury Cycle (Tripp)
  18. 18. Injury to the shoulder <ul><li>Studies show that instability of the shoulder lead to harmful effects on proprioception. (Myers) </li></ul><ul><ul><li>Osteoarthritis, increased nocioceptor activity, subacromial impingement </li></ul></ul><ul><ul><li>In addition to proprioceptive deficits, muscle activation alterations are also present leading to further instability </li></ul></ul><ul><li>Evidence for SMS restoration via surgical interventions: </li></ul><ul><ul><li>Tension in the GH joint (capsule and ligaments) leads to mechanoreceptor stimulation </li></ul></ul><ul><ul><li>Repopulation of mechanoreceptors following surgery </li></ul></ul>
  19. 19. Injury Rehabilitation <ul><li>Inflammation, spasm and pain reduction </li></ul><ul><li>Restore ROM (balance) </li></ul><ul><li>Proprioception </li></ul><ul><li>Restore Strength </li></ul><ul><li>Return to functional (sport specific) activity </li></ul>
  20. 20. Restore ROM (balance) <ul><li>Optimal flexibility of the inferior and posterior joint capsule enables the humeral head to roll and spin properly against the glenoid fossa during abduction and flexion. (Ronai) </li></ul><ul><li>Inferior capsule stretch </li></ul><ul><li>Posterior capsule stretch (cross over and sleeper) </li></ul>
  21. 21. Proprioception <ul><li>Dynamic stabilization is paramount in restoring functional joint stability and should focus on restoring both coordinated muscle activation patterns during functional tasks as well as muscle coactivation and the resulting force coupling restraint </li></ul>http://www.ptproductsonline.com/issues/articles/2007-11_01.asp
  22. 22. Proprioception <ul><li>Both open and closed kinetic chain exercises have been shown to cause improvements in joint position sense at the shoulder. (Myers) </li></ul><ul><li>Closed kinetic chain UE activities facilitate coactivation of the muscles around the shoulder increasing functional joint stability. </li></ul><ul><li>An increase in joint stability is obtained by creating greater joint congruency and stimulation of mechanoreceptors. </li></ul>
  23. 23. Shoulder (UE) Stability Program <ul><li>Improve strength and endurance of the periscapular and rotator cuff muscles </li></ul><ul><li>Good posture and technique </li></ul><ul><li>Proper flexibility </li></ul><ul><li>Proper progressions </li></ul><ul><li>Based on current literature, free weight exercises performed while standing on stable surface should be the primary training modality to develop core stability and enhance sports performance in healthy athletes. (Willardson) </li></ul>
  24. 24. UE Progressions <ul><li>Use both OKC and CKC </li></ul><ul><li>Use sport specific skills </li></ul><ul><li>PNF-Rhythmic Stabilization OKC to CKC </li></ul><ul><li>Co-contraction with out movement to movement on stable, then unstable surfaces </li></ul><ul><li>Eyes open to closed </li></ul><ul><li>Active repositioning </li></ul><ul><li>Body weight to med balls </li></ul><ul><li>Short to long distance </li></ul>
  25. 25. Scapular Stability Exercises (Jeran)
  26. 26. “ The Six Pack” (Jeran)
  27. 27. Basic Rotator Cuff <ul><li>Internal rotation </li></ul><ul><li>External rotation </li></ul><ul><li>“ Full can” </li></ul>
  28. 28. Core Endurance Training (The 5 Endurance Tests) (Bliss)
  29. 29. Closed Chain Exercises <ul><li>Stability ball push up </li></ul><ul><li>Push up with single arm support </li></ul><ul><li>BOSU push up </li></ul><ul><li>BOSU rocking </li></ul>
  30. 30. Closed Chain Exercises <ul><li>Stairmaster Hand Walking </li></ul><ul><li>PB Hand Walk Outs </li></ul>
  31. 31. Closed Kinetic Chain Endurance Test (Schulte-Edelmann)
  32. 32. Closed Chain Exercises
  33. 33. Open Chain Exercises <ul><li>One Arm Shoulder Press </li></ul><ul><li>One Arm Row </li></ul>
  34. 34. Open Chain Exercises <ul><li>Bus Driver, Rock Star </li></ul><ul><li>Triple Extension Press </li></ul>
  35. 35. Open Chain Exercises <ul><li>Hang Clean </li></ul><ul><li>Snatch </li></ul>
  36. 36. Open Chain Exercises <ul><li>Plyo Toss </li></ul><ul><li>Wall Toss </li></ul>
  37. 37. Open Chain Exercises
  38. 38. References <ul><li>Behm D. and Anderson K. The role of instability with resistance training. Journal of Strength and Conditioning Research. 20(3):716-722. 2006. </li></ul><ul><li>Bliss L. and Teeple P. Core stability: The centerpiece of any training program. Current Sports Medicine Reports. 4:179-183. 2005. </li></ul><ul><li>Borghuis J., Hof A., and Lemmink K. The importance of sensory-motor control in providing core stability. Sports Med. 38(11):893-916. 2008. </li></ul><ul><li>Borsa P., Laudner K., and Sauers E. Mobility and stability adaptations in the shoulder of the overhead athlete. Sports Med. 38(1):17-36. 2008. </li></ul>
  39. 39. References <ul><li>Hibbs A., Thompson K., French D., et al. Optimizing performance by improving core stability and core strength. Sports Med. 38(12):995-1008. 2008. </li></ul><ul><li>Houglum P. Therapeutic Exercise for Athletic Injuries. (1 st ed.) Champaign: Human Kinetics, 2001. pp. 268-283, 566-655. </li></ul><ul><li>Jeran J. and Chetlin R. Training the shoulder complex in baseball pitchers: A sport-specific approach. Strength and Conditioning Journal. 27(4):14-31. 2005. </li></ul>
  40. 40. References <ul><li>Myers J., Wassinger C., and Lephart S. Sensorimotor contribution to shoulder stability: Effect of injury and rehabilitation. Manual Therapy . 11:197-201. 2006. </li></ul><ul><li>Nuzzo J., McCaulley G., Cormie P., et al. Trunk muscle activity during stability ball and free weight exercises. Journal of Strength and Conditioning Research. 22(1):95-102. 2008. </li></ul><ul><li>Ronai P. Exercise modifications and strategies to enhance shoulder function. Strength and Conditioning Journal. 27(4):36-45. 2005. </li></ul>
  41. 41. References <ul><li>Schulte-Edelmann J., Davies G., Kernozek T., and Gerberding E. The effects of plyometric training of the posterior shoulder and elbow. Journal of Strength and Conditioning Research. 19(1):129-134. 2005. </li></ul><ul><li>Tripp B., Yochem E., and Uhl T. Functional fatigue and upper extremity sensorimotor system acuity in baseball athletes. Journal of Athletic Training. 42(1):90-98. 2007. </li></ul><ul><li>Willardson J. Core stability training: Applications to sports conditioning programs. Journal of Strength and Conditioning Research. 21(3):979-985. 2007. </li></ul>