Ann cools 3 scapular rehab [compatibiliteitsmodus]

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

Ghent University, Faculty of Medicine & Health Sciences, Dept of
Rehabilitation Sciences & Physiotherapy
Supervisor: Prof dr Ann Cools

Researchers:
- Kristof De Mey
- Annelies Maenhout
- Annemie Van de Velde
- Maarten Van Herzeele

Scapular dyskinesis in relation to shoulder
pain: 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

Implications of scapular
dyskinesis on daily activities….

Need for science-based scapular
rehab program….

(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


Lack of Lack of




- home stretching
Balance -ratio
Advanced control 6
During sports


Lack of Lack of




- home stretching
Balance -ratio
Advanced control 7
During sports


Lack of Lack of




- home stretching
Balance -ratio
Advanced control 8
During sports


Lack of Lack of




- home stretching
Balance -ratio
Advanced control 9
During sports

STRETCHING PECT MINOR:
literature versus reality

(Borstad JOSPT 2006, Reeser PM&R 2010, Ellenbecker & Cools BJSM 2010)

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 PM length PM length
Measurement 1 Measurement 2 Measurement 3

DIRECT
MANUAL
STRETCHING

Swim training session

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)



Lack of Lack of




- home stretching
Balance -ratio
Advanced control 13
During sports

Stretching posterior
shoulder: clinical experience

Ann Cools Wrightington nov 2012

POSTERIOR SHOULDER
STRETCHING
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)

Scientific Evidence? comparison
translation – angular stretching

Angular stretching Translation mobilisation

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

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= 0,116
de 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)


Lack of Lack of




- home stretching
Balance -ratio
Advanced control 18
During sports

Conscious muscle control lower
trapezius: Scapular Orientation
Exercise
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)

Sidelying Forward flexion Sidelying Ext Rotation

Prone Hor Abd + Ext Rot Prone Extension

Scapular Orientation Exercise

Ann Cools Wrightington Nov 20
2012

Does conscious correction of scapular positioning
influence muscle activity during exercises?

Yes, for 2 out of the 4 exercises

De Mey K., Conscious correction of scapular orientation in overhead athletes performing selected
shoulder rehabilitation exercises: what´s the effect on trapezius muscle activation measured by surface
electromyography? JOSPT Under revision July 2012

Flexibility versus muscle
recruitment problems?



Lack of Lack of




- home stretching
Balance -ratio
Advanced control 23
During sports

Sidelying Forward flexion Sidelying External Rotation

Prone Hor Abd + Ext Rot Prone Extension


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


Scientific evidence healthy people

6 month program of scapular retraction exercises improves
RC strength (infraspinatus) in volleyball players

Ann Cools Wrightington Nov 2012
26

Scientific evidence patients
Scapular exercises improve muscle strength,
symptoms and relative muscle activity in overhead
athletes with impingement symptoms


Lack of Lack of




control control
- Manual stretching
- home stretching
- soft tissue rechniques Advanced control
- manual mobilisations Balance -ratio
During basic activities
(accessory movements)
Advanced control
Endurance/strength
(Ellenbecker & Cools, BJSM 2010) During sports movements

FUNCTIONAL EXERCISES: literature

Integrate kinetic chain into
shoulder rehab exercises

Focus on open and closed
chain exercises

Challenge sports specific
positions and movements


(Kibler AJSM 1998, Lintner Sports Med 2008, Cools BJSM 2008)

Background and purpose of the
studies:
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

Results (1): EMG activity scapular
muscles: extension contralateral
leg versus other modalities

UT MT LT SA
Ex Mean StD Mean SD Mean SD Mean SD
1 13,63 7,27 10,37 5,38 11,30 6,33 31,65 19,11
2 18,31 13,17 14,55 8,28 20,12 10,07 23,43 14,66
3 16,18 8,32 13,04 7,91 11,80 8,14 44,20 18,67
4 13,67 8,00 10,11 5,42 10,44 5,90 25,30 15,77
5 16,69 10,55 13,14 6,00 16,86 9,27 14,27 8,14
6 14,39 7,67 11,44 6,69 10,75 6,68 30,46 15,60
7 17,20 10,52 12,30 6,22 10,72 6,53 36,71 15,55

(Maenhout & Cools, BJSM 2009)

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)

Diagonals in CK exercises


Lack of Lack of




control control
- Manual stretching
- home stretching
- soft tissue rechniques Advanced control
- manual mobilisations Balance -ratio
During basic activities
(accessory movements)
Advanced control
Endurance/strength
During sports movements

Influence of experimentally induced pain in
the 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


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

« Take home message »
Manual stretching pect minor has positive
short term effects
Increased ROM and symptom relief 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


Ann cools 3 scapular rehab [compatibiliteitsmodus]

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