rehab A Cools 2014 - Smertebehandling.info

Transcription

Physiotherapy treatment
of shoulder pain:
REHABILITATION
PRINCIPLES
Ann Cools, PT, PhD
Ghent University - Belgium
Dept of Rehabilitation Sciences & Physiotherapy
Rehab A Cools 2014
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[email protected]
« Today’s Topics …. »
Which exercises/manual techniques to
prescribe for
– Rotator cuff pathology
– Instability
– GIRD
– Scapular dyskinesis
Kinetic chain approach in shoulder
rehab
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Rehabilitation of rotator cuff
tendinopathy
1.
2.
3.
4.
Rotator cuff exercises: Which
exercises?
Eccentric exercises: how can we
focus on eccentric phase?
Eccentric exercises: training
intensity?
Scientific evidence?
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1
1. Which exercises activate rotator
cuff muscles?
(Jobe 1987, Donatelli 2004, Ellenbecker 2006, Townsend 1991, Reinold 2004)
1.
2.
3.
4.
Internal rotation
External rotation
Full can
Horizontal abduction
with external rotation
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1. Which exercises activate rotator
cuff muscles?
Werner JSES 2006: ER vs IR regarding Subacromial
pressure? ER decreases subacromial pression compared
to rest, IR increases subacromial pressure.
Boettcher et al. Med Sci Sports Exc 2009: external rotation
and prone external rotation exercises are more valid than
the "can" and prone elevation exercises for supraspinatus
strengthening
Reinold et al. 2004: towell significantly increases IS activity
Anju Jaggi, London 2011: supine RC strengthening to
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focus on both internal and external rotators
(Anju Jaggi London 2011
Karen Ginn, Goth 2012)
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2
2. Eccentric exercises
supraspinatus
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(Cools & Walravens 2007, Maenhout et al. KSSTA 2012)
Eccentric exercises
External rotators
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3. Eccentric exercises: intensity and reps?
3x15 daily, discomfort after exercises, min 6w,
pain-monitoring model
Maenhout et al. 2012 (KSSTA): RCT sign increase in RC
strength after eccentric training program, full can exc,
however no differences on function and pain.
Holmgren et al. BMJ 2012: RCT: specific exercise program
(ecc + scapular excercises) reduces the need for surgery
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3
4. Scientific evidence?
Kuhn JSES 2009, Gebremariam BJSM 2013, VD dolder BJSM 2014
(systematic reviews), Rhon Ann Int Med 2014
Exercise improves symptoms (effect size >15%)
– Exercise + manual therapy better than exercise
alone, however only in case of ROM deficits
(Conroy 1998, Bang 2000)
– Home program = supervised exercise (Walther
2004, Werner 2002)
Soft tissue massage is effective for improving pain
SA corticosteroid injection = physiother,
however PT group is better 1y follow up
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Practice
1.
Eccentric exercice SS
2.
Eccentric exercise IS
3.
Eccentric exercise ER in ABER
4.
Total rotation
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Rehabilitation of shoulder
instability
1.
2.
3.
Training progression
Focus on proprioception and motor
control
TUBS/AIOS versus AMBRI
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4
Paradigma functional Instability
(Lephart et al. 1995)
INJURY
Proprioceptive
deficits
Mechanical
instability
Spinal muscle
Reflex ↓
Functional
instability
Neuro-muscular
coordination ⇓
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Power
Strength
Endurance
Coordination
Proprioception
Muscle control
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Muscle control =
activating the appropriate muscle
on the appropriate moment in the
appropriate intensity
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Conscious muscle control:
Rotator cuff (TUBS + AIOS)
Deltoid (AMBRI/MDI)
(Wilk et al. 2002, Barden 2005)
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AMBRI
TUBS/AIOS
Rotator cuff
From CKC to OKC
Stretching posterior
capsule (GIRD)
Deltoid (ant-post)
A lot of CKC
No stretching
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Power
Strength
Endurance
Progression
Coordination
in exercise
modalities:
↑(50→80%)
Muscle control
Functional relevance ↑
Resistance
Proprioception
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6
Rotator cuff strengthening:
functional perspective
IR
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ER
19
“Throwing program”
TUBS and AIOS
Everybody who wants to trow a ball…
(also non-athletic population)
Not only for instability patients, also
cuff problems, SLAP, scapular
dyskinesis, post op.….)
Not for MDI as basic program, only
when overhead sports is the goal
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Functional diagonal
limited load in ABER
IR
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ER
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7
Functional diagonal
high load in ABER
IR
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ER
22
Plyometrics in ABER
IR
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ER
23
Acceleration & deceleration
phase throwing
IR
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ER
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8
In summary:
Internal Rotation progression:
1.
2.
3.
4.
5.
IR in neutral
Diagonal with limited ABER load
Diagonal with high ABER load
Plyometrics in ABER
Throwing against resistance
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In summary:
External Rotation progression:
1.
2.
3.
4.
5.
ER in neutral
Diagonal with limited ABER load
Diagonal with high ABER load
Plyometrics in ABER
Eccentric loading external rotators during
deceleration
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Advanced program for
“throwers”
Eccentric high load exercises for
posterior cuff
Plyometrics using plyoball, flexbar,
Xco…
Sportspecific positions
Attention to the kinetic chain
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Eccentric diagonals
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Plyometrics IR & ER
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(Ellenbecker & Cools 2010)
Plyometrics IR & ER in
ABER
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Scapular muscle recruitment during
plyometric exercises? (2014)
A Cools EUSSER London Symp 2014
Goal of the exercise:
1. MT & LT ↑
2.
SA ↑ and UT ↓
3.
UT ↓
4.
Overall scap muscles↑
“Thrower’s program”
sportspecific: shoulder
position
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11
Thrower’s program: Kinetic Chain
Wrist
F
Elbow
O
Shoulder
R
C
Trunk
and Back
E
Legs
0
TIME
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(Kibler, Gent 2003)
Wrist
F
Elbow
O
Shoulder
R
C
Trunk
and Back
E
Legs
0
TIME
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(Kibler, Gent 2003)
“Thrower’s program”
sportspecific: kinetic chain
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Integration Kinetic Chain into open
chain shoulder rehabilitation exercises
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Results: EMG activity scapular
muscles: unilateral squat versus
other exercise modalities
*
*
*
*
*= significant main effect “exercise”
*
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(De Mey & Cools, 2012 )
Sportspecific program:
swimming
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Practice
4
1.
1
2.
3.
4.
5.
2
6.
7.
Eccentric ER diagonal
Plyoball neutral position
Plyoball 90° forw flex
Plyoball 90°-90°
Flexbar + tubing neutral
Xco/flexbar 90°-90°
W-V ex swissball
5
6
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7
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AMBRI
TUBS/AIOS
Rotator cuff
From CKC to OKC
Stretching posterior
capsule (GIRD)
Deltoid (ant-post)
A lot of CKC
No stretching
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General Guidelines AMBRI/MDI
Low Load
static
dynamic
Moderate Load
static
dynamic
High Load
static
dynamic
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Diagonals in CK exercises
Semi closed chain SA exc
(elevation)
Semi closed chain trap exc
(rowing)
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Case: gymnast with chronic shoulder pain based on instability
6 modalities of the push-up plus exercise
2
3
5
6
(N=32)
4
7
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(Maenhout & Cools BJSM 2009)
Results: EMG-activity and muscle
balance ratios
Highest SA activity (44%MVC) en best
UT/SA ratio (0.40) when ipsilateral leg is
extended
3
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Results: EMG-activity and muscle
balance ratios
Highest activity in MT & LT, when
contralateral leg is extended
(LT=20%MVC)
2
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Rehab A Cools 2014
stretching and mobilisation
techniques in the
rehabilitation of G.I.R.D.
1.
Angular stretching
a.
b.
2.
Translation mobilisations in end-range (dorsal
glides)
a.
b.
3.
Internal rotation: « sleeper’s stretch »
Horizontal adduction: « cross-body stretch »
Internal rotation
Horizontal adduction
Mobilization with movement – dorsal glides
1.
2.
3.
External rotation
Forward flexion
Abduction
Rehab A Cools 2014
(Cools et al. BJSM 2008,
Ellenbecker 2006,
Ellenbecker & Cools 2010, BJSM
Wilk JOSPT 2009, Cools et al.
Shoulder & Elbow 2011)47
1a: Angular stretching :
« Sleeper’s stretch »
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Sleeper’s stretch supine +
caudal glide
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(John Borstad, ICSET Edinburgh 2010, JOSPT 2011)
1b: Angular stretching into
horizontal adduction: “cross
body stretch”
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Practice angular stretching:
1.
Sleeper’s stretch side-lying
– Ask for pain ant versus post
2.
Sleeper’s stretch supine
Sleeper’s stretch + caudal glide
Sleeper’s stretch + hold-relax
3.
4.
5.
6.
7.
8.
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17
Practice angular stretching:
1.
2.
3.
4.
5.
6.
7.
8.
Cross body stretch
– Work together with patient
“Reversed” Cross body stretch
Reversed cross body stretch + hold relax
Home-sleeper’s stretch
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2a: Mobilisation: dorsal
glide in endrange
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Dorsal glides in
moderate internal
rotation
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2b: non-angular stretching
into horizontal adduction
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3a. Mobilisation with
movement: ER + dorsal
glide
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3b-c. Relocation of the
humeral head during
Forward flexion
abduction
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Practice manual mobilisations
(accessory movements & MWM) :
1
1.
End-range dorsal glide in IR
2.
Dorsal glide in moderate IR (hand from neutral 2
to belly)
3.
Mobilization with movement: ER + dorsal glide
– Change shoulder position (to ABER)
– Passive / resistance ER
4.
Mobilization with movement: forward flexion
with dorsal glide
5.
Mobilization with movement: abduction with
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dorsal glide
3
4
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5
Stretching posterior structures?
Mc Clure (JOSPT 2005): improvement IR
ROM after 4-weeks home stretching
program, cross body stretch & sleeper’s
stretch
Manske et al. Sports Health 2010: angular
stretching (home program) + joint
mobilisation (dorsal glide) slightly better
than stretching only.
Tyler et al. 2010: ROM improvement is
related to symptom relief.
Cools et al. Shoulder & Elbow 2011: equal
results from angular stretch versus dorsal
glide
Maenhout et al. 2012 JSM: stretching
increases the size of the subacromial space
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Joint mobilization and Mobilization
With Movement?
Hsu et al. (2001), Yang et al. (2007):
Caudal glide mobilisation improves
abduction ROM, but only in endrange
Hsu et al. (2002): both caudal and dorsal
glides (indirect mobilisations) improve
abcuction ROM
Yang et al. (2007): MWM superior effects
with respect to scapulohumeral rythm
Johnsson JOSPT 2007: Posterior glide is
superior to anterior glide in external
rotation ROM
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Rehabilitation of scapular
dyskinesia
1.
2.
3.
Summary of factors determining
scapular dyskinesis?
Treatment of flexibility deficits
Treatment of muscle performance
problems
1.
2.
3.
4.
Muscle control
Muscle balance
Muscle strength
Advanced sport specific muscle control
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(Cools et al. BJSM 2013)
Scapular Rehab Algorithm
Lack of
Soft-tissue flexibility
Scapular muscles
- Levator scapulae
- pectoralis minor
Lack of
Muscle performance
GH muscles/capsule
- infraspinatus
- posterior capsule
STRETCHING & MOBILISATION
- Manual stretching
- home stretching
- soft tissue techniques
- manual mobilisations
(accessory movements)
-MWM
Muscle Control
- co-contraction
- force couples
NEUROMUSCULAR
COORDINATION
Muscle Strength
- lower/middle trap
- serratus anterior
STRENGTH
TRAINING
Conscious muscle
control
Conscious muscle
control
Advanced control
During basic activities
Balance -ratio
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2014
Advanced
control
During sports
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Endurance/strength
21
Lack of
Scapular muscles
- Levator scapulae
- pectoralis minor
Lack of
Muscle performance
GH muscles/capsule
- infraspinatus
- posterior capsule
NEUROMUSCULAR
COORDINATION
- Manual stretching
- home stretching
-MWM
Muscle Control
- co-contraction
- force couples
Muscle Strength
- lower/middle trap
- serratus anterior
STRENGTH
TRAINING
Conscious muscle
control
Conscious muscle
control
Advanced control
Balance -ratio
Rehab A Cools
2014
Advanced
control
During sports
64
Endurance/strength
Lack of
Scapular muscles
- Levator scapulae
- pectoralis minor
Lack of
Muscle performance
GH muscles/capsule
- infraspinatus
- posterior capsule
NEUROMUSCULAR
COORDINATION
- Manual stretching
- home stretching
-MWM
Muscle Control
- co-contraction
- force couples
Muscle Strength
- lower/middle trap
- serratus anterior
STRENGTH
TRAINING
Conscious muscle
control
Conscious muscle
control
Advanced control
Balance -ratio
Rehab A Cools
2014
Advanced
control
During sports
65
Endurance/strength
Lack of
Scapular muscles
- Levator scapulae
- pectoralis minor
Lack of
Muscle performance
GH muscles/capsule
- infraspinatus
- posterior capsule
- Manual stretching
- home stretching
-MWM
Muscle Control
- co-contraction
- force couples
NEUROMUSCULAR
COORDINATION
Muscle Strength
- lower/middle trap
- serratus anterior
STRENGTH
TRAINING
Conscious muscle
control
Conscious muscle
control
Advanced control
Balance -ratio
Rehab A Cools
2014
Advanced
control
During sports
66
Endurance/strength
22
Lack of
Scapular muscles
Stretching
- Levator
scapulae
Pectoralisminor
minor
- pectoralis
Lack of
Muscle performance
GH muscles/capsule
- infraspinatus
- posterior capsule
- Manual stretching
- home stretching
-MWM
Muscle Control
- co-contraction
- force couples
NEUROMUSCULAR
COORDINATION
Muscle Strength
- lower/middle trap
- serratus anterior
STRENGTH
TRAINING
Conscious muscle
control
Conscious muscle
control
Advanced control
Balance -ratio
Rehab A Cools
2014
Advanced
control
During sports
67
Endurance/strength
Stretching pectoralis minor: literature
Borstad et al. JOSPT 2005: short PM
influences scapular kinematics and induces
changes similar to impingement related
dyskinesis
Cools & Johansson BJSM 2010: significant
decrease PM length in elite junior (11-17yr)
tennis players
Reeser PM&R 2010: tight PM is associated
with history of shoulder pain in volleyball
players
Borstad et al. JSES 2006: unilateral self
stretch (in 90° ABER)Rehab
best
A Cools results,
2014
however…
68
Stretching pectoralis
minor: clinical experience
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23
Lack of
Scapular muscles
- Levator scapulae
- pectoralis minor
Lack of
Muscle performance
GH muscles/capsule
Muscle Control
- infraspinatus
- posterior capsule
- co-contraction
- force couples
NEUROMUSCULAR
COORDINATION
Muscle Strength
- lower/middle trap
- serratus anterior
STRENGTH
TRAINING
Conscious muscle
Conscious muscle
Scapular
orientation exercise
control
control
- Manual stretching
- home stretching
- soft tissue rechniques
- taping
Advanced control
Balance -ratio
Rehab A Cools 2014
Advanced control
During sports movements
70
Endurance/strength
Enhancing lower trapezius
muscle control: literature
Scapular Orientation Exercise
- Scapular upward rotation and
posterior tilting
- Increased scapular muscle
activity
(Mottram et al. Man Ther 2009)
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Learning conscious lower trapezius
muscle recruitment: clinical
experience
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24
Learning conscious lower trapezius
muscle recruitment: clinical
experience
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Lack of
Scapular muscles
- Levator scapulae
- pectoralis minor
GH muscles/capsule
- infraspinatus
- posterior capsule
- Manual stretching
- home stretching
- taping
Lack of
Muscle performance
Muscle Control
- co-contraction
- force couples
NEUROMUSCULAR
COORDINATION
Muscle Strength
- lower/middle trap
- serratus anterior
STRENGTH
TRAINING
Conscious muscle
control
Conscious muscle
control
Muscle
control
Advanced
control
During basic
activities
Basic
activities
Balance -ratio
Rehab A Cools 2014
Advanced control
74
Endurance/strength
Purpose: increase scapular dynamic control
during various exercises and movements:
some examples…
(Kibler 2008, Uhl 2010, Johansson 2012
Cools 2013)
75
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Scapular muscle balance during
shoulder exercises
External rotation
component: increasing
lower and middle trap
activity
Functional elevation
plane
Cools 2013)
76
Rehab A Cools 2014
shoulder exercises
Semi-closed chain:
safe for instability
patients and to unload
the cuff
High elevation: LT as a
prime mover
Diagonal pattern:
better scapular muscle
recruitment
Cools 2013)
Rehab A Cools 2014
UT ↓
SA =
Lev Scap ↓
Rhomb ↓
77
UT ↓
SA =
MT & LT ↑
Rhomb ↑
Pect Min ↓
26
shoulder exercises
Hip-abduction activity:
increasing diagonal
kinetic chain activity?
Core-stability challenge
Perform ER or
elevation
Cools 2013)
Rehab A Cools 2014
PRACTICE
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Lack of
Scapular muscles
- Levator scapulae
- pectoralis minor
GH muscles/capsule
- infraspinatus
- posterior capsule
- Manual stretching
- home stretching
- taping
Lack of
Muscle performance
Muscle Control
- co-contraction
- force couples
NEUROMUSCULAR
COORDINATION
Muscle Strength
- lower/middle trap
- serratus anterior
STRENGTH
TRAINING
Conscious muscle
control
Conscious muscle
control
Advanced control
Muscle
balance
Balance
-ratio
Rehab A Cools 2014
Advanced control
81
Endurance/strength
27
Rehabilitation muscle balance
UT/SA
Elbow push-up
Serratus punch
lying on the
back
Serratus punch
in closed chain
( Ludewig et al. 2004)
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Rehabilitation muscle balance
UT/MT & UT/LT
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Scientific evidence:
De Mey et al. JOSPT 2009: scapular exercises promote
early activation of LT and late activation of UT
Vandevelde et al. JAT 2010: scapular training (12w)
increases scapular strength and endurance in healthy
swimmers
Merolla et al. JAT 2010: scapular program (6mo)
increases Infraspinatus strength in volleyball players
De Mey et al. JOSPT 2012: Pre-setting during
exercises increases muscle activity in trapezius
De Mey et al. AJSM 2012: scapular exercises reduce
EMG ativity in UT during
functional movement
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UT/SA
Practice
UT/MT & UT/LT
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Lack of
Scapular muscles
- Levator scapulae
- pectoralis minor
GH muscles/capsule
- infraspinatus
- posterior capsule
- Manual stretching
- home stretching
- taping
Lack of
Muscle performance
Muscle Control
- co-contraction
- force couples
NEUROMUSCULAR
COORDINATION
Muscle Strength
- lower/middle trap
- serratus anterior
STRENGTH
TRAINING
Conscious muscle
control
Conscious muscle
control
Advanced control
Balance -ratio
Rehab A Cools 2014
Advanced control
87
Endurance/strength
29
Case-presentation
Young elite gymnast, 12 years old, 34
hours/week training
Shoulder pain during sport for 6
months
4 months physiotherapy, scapular
training, muscle control…
Imaging and EMG negative
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30
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Case-presentation
No “conscious” trapezius training
Try to optimise global and subconscious
muscle control?
A lot of closed kinetic chain (cfr sports
activity: pain during weight bearing on
upper limb)
Looking for “ appropriate”
exercises…..
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THANKS!
Ghent, Belgium, July 21th every year......
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rehab A Cools 2014 - Smertebehandling.info

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