Late stage rehab tanya mackenzie

Functional/final stage rehab

& clinical applications to guide this stage

Essential Elements for DS• Proprioceptive awareness and NM control of the entire kinetic chain

• GHJ dynamic stability to provide adequate compressive forces GHJ

• Scapular mobility and dynamic stability

• NM control in whole KC for job/sport specificity activities

Jaggi and Lambert 2010; Lephart and Henry 1996; Rogol et al 1998; Ubinger et al 1999; Henry et al 2001; Ginn and Cohen 2005;Swanik et al 2002

Essential Element- GHJ dynamic stability

The Principle is:

For successful rehab of the unstable shoulder requires

• cuff recruitment

• Will facilitate glenohumeral approximation

Downar et al 2006; Reinold et al 2009

Literature reports…motor control alterations in RC with GH instability

• ↓ supraspinatus-subscapularis co-activation

• ↓ biceps brachii activation

• ↓ Inf Sp activation

• ↑pec activity

• ↑lats activity

Glousman et al 1988; Kelly et al 2005; Kronberg et al 1991; McMahonet al 1996; Myers et al 2004;Malone et al 2004; Moraes 2008; Ginn et al 2007

Practical implications …

Aim is to control adverse HOH translation in

glenoid

which m group controls HOH translation and in

which direction?

If we know the answer to this then know which m

group should we target in rehab?

See previous slide…

Practical implication• all of the m surrounding the GHJ… we are not retraining strength we are

retraining synergy between agonist and antagonist muscles groups / synergy within a muscle group/ and synergy in all ranges of the muscle.

• Can’t prioritise one muscle groups activity over another

• The same approach will not work in every patient

• Lig static structures… when taught give afferent input only at extremes of mvt… Need dynamic factors throughout the range of motion.

Clinical application…

Can use sign/symptom modification to guide which m group to target in rehab

• Can the patient with instability maintain the HOH centring through rotation range during an intervention?

• Can the intervention modify the ‘click’ /feeling of apprehension? (can still be present post surgery)

• Key is rehab in controlled positions of vulnerability

May be able to do this activating one m group @ a timeWeight bearing stimulus to guide approx. of joint - CKCVisual stimulationManual stimulation

cuff ..function changes according arm position i.e. spsp can be an ER

The Essential Element-scapular mobilityand dynamic stability

Principle

• Dynamic positioning of the glenoid fossa relative to the humeral axis

• Minimizes GH shear & maximizes GH compression

• Stable base of origin for muscles - Length dependent activation patterns

Subjects with GH Instability •Significant increases scapular

protraction and anterior tilt. •Activity of the lower trap and

serratus delayed during first part of elevation•Alters humeral head and

glenoid alignment predispose shoulder instability

Marias and Pascoal 2006

Literature …

In clinical cases of scapular winging the Standard Pushup Plus is an optimal exercise

Push-up with plusDynamic hugSerratus punch 120

Cools et al 2007

to promote LT and MT activity with minimal activation of the UT part.

Ludewig et al 2004

Reinold et al 2009

Practical implications…for late rehab stage

Most ex reported in literature to target scap DS

• are mid range ex...which may be appropriate

• Are not necessarily functionally or sport appropriate…previous slide

• How to decide which scapula ex is appropriate in instability patients ?

Clinical application…get the glenoid to support the HOH

• No standardised ideal scapula posture

• what position does the pt need the arm in to function and in that position where does the glenoid need to be and rehab them in this position.

• With attention to what needs correcting…post tilt or upward rotation or scap retraction (pertinent to each individual pt)

Clinical approach to include

• Work into controlled positions of vulnerability – re-educate muscle synergy in these position.

• Address GHJ DYNAMIC stability

• Address scapular DYNAMIC stability

Clinical peals to guide end stage rehab

•use modification of the ‘click’ /feeling of apprehension - this can guide you to target the correct muscle groups and alter movement patterns and (principle) correct GHJ neuromuscular control

•get the glenoid to support the HOH – this will guide (principle) scapular dynamic stability in the functional position pertinent to that patient

•rehab in controlled positions of vulnerability – this will guide activity specific rehab

.

In summary

While targeting GHJ and Scap dynamic stability need to build in the following

• Integrated techniques that are reproducible

• Then build the endurance

• Then build strength on this base

• Maintain conditioning

With end result of optimal biomechanical function and return to performance.

Thank you – any questions