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PART 4 • The Shoulder Region in Upper Extremity Pain Syndromes
33
Chapter
Therapeutic Exercises for the Shoulder Region
Johnson McEvoy, Kieran O’Sullivan, Carel Bron
CHAPTER CONTENTS selection of muscles, without focusing on one specific clinical
population.
Introduction
Clinical acground Clinical Background
Shoulder exercise eidence
Principles o exercise
Posture Essential to an understanding of therapeutic exercise is an
Stretching in-depth knowledge of anatomy, physiology and function,
Isometric exercise o the shoulder specifically related to the neuromuscular and musculoskeletal
Isotonic exercises o the shoulder systems (Kendall 2002. he shoulder is a complex functional
Supraspinatus muscle system producing moement of the arm on the trunk and
Inraspinatus and teres minor muscles allowing the upper lim and hand to e dynamically moed
Suscapularis muscle and positioned for function. he shoulder consists of the
scapula, claicle and humerus, giing rise to the sternocla-
Trape
ius muscle icular, claicular, humeral and scapulothoracic oints, and
Serratus anterior muscle has a close relationship to the neck, thorax and ris. he
unctional exercises shoulder is supported y capsular, ligamentous and muscular
Conclusion systems with complex neuromuscular processing that offer a
wide range of motion, ut with a suseuent compromise in
oint staility. his trade-off in staility makes the shoulder
potentially ulnerale to dysfunction and inury, and staility
is often the main focus of therapeutic exercise for the shoulder
complex. eaders should refer to the appropriate chapters
Introduction of this ook and other texts for a comprehensie reiew of
shoulder anatomy, iomechanics, kinesiology and pathome-
chanics (onatelli 200a atis 200. urther, knowledge of
herapeutic exercise is a cornerstone of physiotherapy prac- connectie tissue properties, force applications, tissue inury
tice and was initially referred to as medical gymnastics. he (one, ligament, tendon, muscle, fascia, nere, etc. and tissue-
deelopment of medical gymnastics in physical therapy has healing concepts and timelines (inflammation, proliferation,
had many dierse influences including r rancis uller, maturation is an important precursor to the deelopment of
author of Medicina gymnasticia (0, wedish gymnast er a suitale and safe therapeutic exercise programme (ippet
enrik ing (– and the utch physical education oight aris ouert ouglum 200.
teacher and physician r ohann eorg eger (–0 rior to the deelopment of a rehailitation programme for
(arclay erlouw 200. ore recently Kendall (2002 the shoulder complex a comprehensie assessment and physi-
summed up the role of therapeutic exercise in physical cal examination should e performed with reference to the
therapy ‘¡entral to the practice of physical therapy is the principles of physical therapy practice so as to ascertain per-
preention of moement dysfunction and the rehailitation tinent information and physical characteristics of the indi-
through restoration and maintenance of actie moement – in idual patient. ndications for therapeutic exercise of the
other words, therapeutic exercise in its roadest sense’. he shoulder are listed in ox . and are dierse they include
focus of this chapter is to introduce general principles of specific and non-specific musculoskeletal, orthopaedic, surgi-
therapeutic exercise for the shoulder, and to stimulate cal and neurological conditions and dysfunctions, and also
clinical reasoning and rational rehailitation. he chapter will postural and performance enhancement and inury preen-
riefly discuss posture, stretching and strengthening of a tion strategy.
PART 4 • • Therapeutic exercises or the shoulder region
33
Box 33.1 Indications or theraeutic shoulder inection (¥inters et al , uchinder et al 200.
exercises here is also eidence that comining corticosteroid inection
with physiotherapy including therapeutic exercise results in
• Glenohumeral joint lesions, dysfunctions and instability greater improement than either treatment in isolation
• Rotator cuff lesions and dysfunctions (¡arette et al 200.
• Subacromial impingement syndrome he use of therapeutic exercise in the management of
specific disorders including suacromial impingement syn-
• Acromioclavicular joint lesions and dysfunctions drome (£ and rotator cuff lesions is supported y much
• Sternoclavicular joint lesions and dysfunctions research (ang eyle 2000 esmeules et al 200 reen
• Superior labrum anterior-to-posterior (SLA lesions et al 200 ichener et al 200 ickens et al 200 onsson
• Adhesive capsulitis (froen shoulder et al 200 rampas Kitsios 200 enursa et al 200
• Arthropathies arthrosis, arthritis, rheumatoid arthritis omardi et al 200 aydar et al 200 ¡hen et al 200 Kuhn
• ost fracture and trauma 200 oy et al 200. urthermore, outcomes following con-
• Soft tissue injuries and syndromes seratie treatment (incorporating therapeutic exercise
• Sports injuries appear to e similar to those after surgical interention in
£ and rotator cuff lesions (aahr £ndersen 200
• yofascial pain and dysfunction from trigger points orrestin et al 200. his key role of therapeutic exercise in
• ypermobility syndromes shoulder rehailitation is emphasied y the fact that good
• ostural dysfunction clinical outcomes hae een associated with normaliation of
• ovement disorders scapular kinematics ( oy et al 200 and recoery of strength
• erformance enhancement and performance optimiation (¤ho et al 200.
• njury prevention
• ost shoulder surgery and arthroscopy
• Shoulder replacement Principles of Exercise
• horacic surgery ith shoulder involvement (eg
mastectomy £ clinical assessment should e completed prior to exercise
• Spinal cord injuries and nerve root syndromes prescription and clinicians should remain cognisant of the
• eripheral nerve injuries arious facets of an exercise programme and suit the needs
• entral nervous system disorders (eg hemiplegia to the indiidual patient posture, flexiility and stretching,
staility, strengthening, proprioception and functional pro-
gression (ippet oight ephart u 2000 £lter
200 onatelli 200, 200 Kraemer atamess 200
Shoulder Exercise: Evidence ¥eerapong et al 200 ouglum 200 Kendall et al 200
acntosh et al 200. t is important for the clinician to gather
information including the suectie history, oectie exami-
£ wide ariety of shoulder disorders hae demonstrated nation, special tests, functional aility, impairment, dysfunc-
alterations in shoulder range of motion (all Eley tions, diagnosis and any other pertinent information. wo-way
ermeulen et al 2002 c¡lure et al 200, scapular kinemat- communication with other team memers (e.g. medical, sur-
ics (ukasiewic et al udewig ¡ook 2000 c¡lure gical, psychological, coach, strength and conditioning, etc.
et al 200 oy et al 200 ate et al 200, scapular and rotator is essential in order to enhance the oerall physical therapy
cuff muscle actiation (udewig ¡ook 2000 ¡ools et al plan of care, and set appropriate and safe goals. ¡linicians
200 oraes et al 200 yers et al 200, humeral translation should employ eidence-ased practice and clinical reasoning
(¡hen et al udewig ¡ook 2002, repositioning sense with respect to current research, and patient-orientated
(¤aughton et al 200 and shoulder strength (c¡lure et al goals as the asis for rational rehailitation (¡icerone 200.
200 omardi et al 200 aydar et al 200 igoni et al afety is of paramount importance and clinicians should
200. herefore, therapeutic exercises are commonly ado- ensure that exercises are suitale and safe for indiidual
cated to address these dysfunctions in moility, posture, patients. urthermore, since painful sensory input may alter
muscle actiation, proprioception and strength. motor output during exercise, reduction of the pain where
erall, the eidence that therapeutic exercise is effectie possile with appropriate physical, pharmacological and ¦ or
for non-specific shoulder pain is mixed (midt et al 200, psychological strategies is an important part of the rehailita-
similar to other approaches including manual therapy (o tion process.
et al 200 and acupuncture (reen et al 200. oweer, here are three phases of a therapeutic exercise pro-
exercise appears to e as effectie for non-specific shoulder gramme, which are worked through progressiely ased on
pain as more expensie treatments such as multidisciplinary the reuirements of the indiidual patient these include (
io-psychosocial rehailitation (Karalainen et al 200. ur- posture, oint range of motion and flexiility, (2 muscle
thermore, when specific shoulder disorders are considered strength and endurance, and ( functional aspects including
there is little eidence that alternatie approaches are supe- proprioception, coordination and agility (ouglum 200.
rior to therapeutic exercise. or example medium- and long- or example, the exercise prescription and goals of a patient
term outcomes after therapeutic exercise in adhesie capsulitis with adhesie capsulitis will differ significantly from those
are similar to those after other treatments including arthro- of a patient with humeral instaility. rinciples for guiding
graphic distension (uchinder et al 200 and corticosteroid rehailitation include aoidance of aggraation, timing of
Principles o exercise
Therapeutic e ercise programme
Patient assessment Rehabilitation principles Phases o e ercise programme –
Patient characteristics ouglum 2 ouglum 2
Clinical information Aoid aggraation
onitor and reassess
Impairments/Dysfunctions/Diagnosis – aapt accoringly
Safety/Suitability/Goals Suitable e
ercise within clinical limits aety
Treatment onitor for aggraation
Communication with team members Timing
Time within clinical limits Range o motion
Anatomy/Physiology Start early as appropriate Posture
Function onitor an progress le
ibility
Biomechanics-pathomechanics ange of motion
Pathology ompliance
Healing pathway ucation emonstration
Set goals
uscle strength
1. Inflammation euce fear aoiance uscle strength an enurance
2. Proliferation oi oere
ertion
. aturation
ndiidualiation Functional
Guiding principles Prescribe iniiual programme Proprioception
iencebase practice elate to specific nees an goals Coorination
Suitability an safety peciic sequencing gility
olff’s law/Dais’s law unction
Specific aptation to Progress as inicate
Impose Demans SID lements of e
ercise programme 1–
Concentric/ccentric ntensity Aggraation–red lags
pen an close chain e
ercise aapte from Tippet oight 1
ress healing pathway
Technique Tippet oight 1 Consier tissues hange in/presence o
Carriage/Confience/Control ee to challenge patient 1. Swelling
2. Pain
Tools Total patient . ange
lastic bans weights machines Inure an uninure boy parts . oss of strength
pulleys mirror an biofeebac Psychology . unction
therapy G auatherapy etc. General fitness an carioascular . Specific clinical tests
igure Principles of therapeutic exercise
exercise, compliance, indiidualiation, specific seuencing, with non-athletes (¥ang et al 200. n the other hand, oer-
intensity and total patient approach (ouglum 200 these loading of one and soft tissue can result in inury such as
principles are presented in igure .. one stress fracture or tendon failure.
Exercise programmes should e progressie and graded he principle of specific adaptations to imposed demands
according to the stage of healing and should not aggraate (£ refers to the ody’s aility to change according to
pain, swelling or result in deterioration in other clinical specific demands placed upon it and therefore has implica-
signs such as range of motion, strength and function (see tions for rehailitation design in that exercises should mimic
ig. . (ippet oight . he aility to perform the expected functional stressors of the indiidual patient as
exercises with appropriate skill should e monitored closely much as possile (ouglum 200. mplementing ariance of
(ippet oight . hese authors referred to the three actiities and rest phases is important so as to allow adapta-
‘¡’s ( carriage – appropriate weight shift, weight accept- tion. £n example of the releance of these principles is when
ance and symmetry of moement, (2 confidence – eral considering the introduction of eccentric strength training
and non-eral communication, speed and delierateness of into the rehailitation programme. Eccentric strength training
exercise performed, and ( control – smooth unrestricted programmes appear to e effectie in the management of
automatic moements with skilled task performance (ippet knee and ankle tendon pathology (£lfredson et al §oung
oight . et al 200. here has een less research on eccentric pro-
one and soft tissues adapt according to the stresses placed grammes for rotator cuff tendon pathology howeer, initial
upon them, which highlights the importance of appropriate results are encouraging (onsson et al 200. Eccentric pro-
loading of tissue in a graded progressie manner to enhance grammes are, howeer, associated with muscle damage
healing, and has een descried y ¥olff’s law and ais’s (¡larkson ual 2002. efore placing such high stresses on
law respectiely (¥olff ippet oight . hese preiously inured tissues, asic isometric and isotonic
principles also apply to the hypertrophy of uninured tissues strength programmes should e already in place. urther, the
for example, it has een demonstrated that aseall athletes introduction of such eccentric training programmes should e
hae thicker iceps and supraspinatus tendons compared progressed.
PART 4 • • Therapeutic exercises or the shoulder region
33
houlder muscle alance ratios hae een reported, includ- pectorals may e felt in the front of the shoulder and arm
ing ratios etween the external and internal rotators of . (imons et al and sometimes een in the upper ack
(¨ for oth fast and slow isokinetic torue arm speed in region (eung et al 200. (ee ¡h for a reiew of these
normal suects (ey et al . atios hae also een pre- mechanisms and muscle referral patterns.
sented for professional aseall pitchers (Ellenecker ustained contractions impair normal lood flow in skel-
attalino . ¡linicians should consider these ratios in etal muscles. ptimal posture allows muscles the opportunity
exercise programme design. £ discussion of isokinetics is to relax in etween contractions, which permits and facilitates
eyond the scope of this chapter, ut has een reiewed y recoery of circulation (tten ogaard ogaard
Ellenecker and aies (2000. almerud et al 2000. ¡omining postural exercises with
he following sections will discuss, posture, stretching and myofeedack ¦ E is helpful when teaching patients how to
strengthening (isometric and isotonic and riefly mention use their muscles in an economic and healthy manner (eper
functional exercise. pecific parameters for timing and repeti- et al 200 oerman et al 200. hough there is a wide range
tions of stretching and strengthening will e coered under of postures, clinicians should consider the optimal posture for
each appropriate section. each patient and indiidualie exercise programmes, rather
than focusing on an idealied posture suitale for all. £ssump-
tion of an appropriate upright trunk posture can change
Posture muscle actiation and modify range of motion and symptoms
(ullock et al 200. capular taping can e used as a tempo-
rary means of altering scapular muscle actiation (elkowit
ostural assessment is an important part of the oectie eal- et al 200. urthermore, ucas et al (200 demonstrated that
uation and ideal static postural alignments hae een sug- latent trigger points can alter muscle actiation patterns of the
gested (Kendall et al 200. oweer, it is important to assess shoulder as assessed y E and suseuently reported that
oth static and dynamic postures to ascertain the patient’s dry needling and stretch, when compared with placeo ultra-
functional moement and aility to self-correct a static haitus. sound, was found to improe the muscle actiation patterns
£n example of this is a oxer, who enhances a hyperkyphotic significantly and similar to controls.
and rounded shoulder posture to reduce his target sie for reatment for postural dysfunctions may include manual
strategic adantage, ut when dynamically tested may e ale therapies, including oint moiliation and manipulation,
to self-correct the seemingly poor posture. massage and myofascial trigger point release, myofascial
t is important to assess for muscle length, oint moility release techniues, trigger point dry needling, iofeedack
and muscle control. £ltered posture may e related to muscle and E, stretching, staility and strengthening and cogni-
imalances and altered oint position, which ultimately could tie and ehaioural strategies.
result in moement dysfunction and pain. eiations in
normal upright positions may include a forward head posi-
tion, an exaggerated cure in the thoracic kyphosis, and Stretching
rounded shoulders. eiations in scapular kinematics may
present in multiple planes, including changes in scapular
eleation, protraction, tilt and rotation, affecting the sie of lexiility and stretching is a road topic with conflicting
the suacromial space (olem-ertoft et al , as well as opinions in the literature, and a full discussion of this topic is
oth actiation ( oy et al 200 and mechanical adantage eyond the scope of this chapter. eaders are referred else-
(Kiler et al 200 of muscular structures. t has een demon- where for a comprehensie reiew of stretching (£lter
strated that the sie of the suacromial space is reduced in the ¥eerapong et al 200. £ rehailitation programme of the
presence of thoracic hyperkyphosis ( aine womey shoulder may incorporate a muscle-stretching programme,
umina et al 200 and shoulder protraction (olem-ertoft which is usually employed for muscle lengthening and associ-
et al . t is, howeer, uncertain whether a strong correla- ated clinical implications, pain inhiition and potential inury
tion exists etween narrowing of the suacromial space and preention.
shoulder symptoms (raichen et al 200 oerts et al 2002 t has een reported that alterations in scapular moement
interwimmer et al 200 ewis et al 200 ayerhoefer et al are related to changes in myofascial length (orstad
200. n fact, although it has een assumed that there is a udewig 200 orstad 200. he addition of appropriate
definitie association etween these postural deiations, a manual therapy techniues may increase the effectieness of
study of 0 asymptomatic suects found no such correlation therapeutic exercise (¥inters et al ¡onroy ayes
( aine womey . herefore, although there may e a ang eyle 2000 esmeules et al 200 ergman et al
relationship etween posture and suacromial space, this is 200 ichener et al 200 enursa et al 200 oyles et al
not yet fully understood. 200. hese techniues may include soft tissue techniues,
horacic kyphosis and forward shoulder position influence passie stretching and oint moiliation, and may increase
the length of the upper ack and scapular muscles and place range of motion in suects with shoulder pain (ermeulen
the intererteral oints in an end-range position (riegel- et al 200 ohnson et al 200. herapeutic exercise alone,
orris et al 2. he sustained strain on these soft tissues howeer, may e as effectie as adding passie oint moilia-
may lead to upper ack pain or shoulder pain. n the front of tions to therapeutic exercise (rampas Kitsios 200 ¡hen
the ody the pectoral muscles may shorten (orstad et al 200. (ifferent oint moiliation techniues are
udewig 200 uraki et al 200. ustained muscle shorten- descried in detail in ¡h .
ing may lead to the deelopment or actiation of myofascial £ muscle-stretching programme should e ased on assess-
trigger points (imons et al . eferred pain from the ment of muscle length and end feel. uscles and fascia may
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