Context An Exercise Progression from for Shoulder Therapeutic - - PowerPoint PPT Presentation

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An Exercise Progression from for Shoulder Rehabilitation based on Rehabilitation based on the available EMG Literature

Ti L Uhl PhD ATC PT FNATA Tim L. Uhl PhD ATC PT FNATA Department of Rehabilitation Sciences College of Health Sciences University of Kentucky

Context

• Therapeutic exercises are prescribed along

a continuum a continuum

• A common goal to increase neuromuscular

activity

• In order to stimulate neuromuscular &

musculotendinous adaptations musculotendinous adaptations

• Thereby allowing the patient to return to

“normal” physical

Context

• Better understanding the neuromuscular

activity levels of therapeutic exercise allows y p us to match the exercise selected to the patient’s state of healing

• This knowledge also allows us to titrate the

exercises prescribed up or down the continuum based on the patient’s response continuum based on the patient’s response

Objectives

• Describe Electromyography data collection and

interpretation

• Outline an exercise progression through a phased

rehabilitation process keeping physiological healing response and tissue reactivity in mind

– Higher EMG activity greater muscular recruitment

• Rehabilitation exercises are often selected based on

EMG research to facilitate specific muscle activation

– Therapeutic exercises rarely isolate

“The whole of science is nothing more than a refinement of everyday thinking.”

– Albert Einstein (1879 - 1955), Physics and Reality 1936

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Electromyography (EMG)

• A technique to
• A technique to

evaluate and record electrical activity from skeletal muscle

– EKG/ECG – cardiac muscle muscle

• Device is

electromyograph

• Generates an

electromyogram

Electromyography

• The recording and

l i f l t i l analysis of myoelectrical signals derived from motor unit activity

• Motor Unit

– Nerve cell body in the spinal cord – The motor nerve (axillary) – The muscle fibers that the nerve innervates

When a Muscle Contracts

• Action potential travels

d t t down motor nerve to neuromuscular junction

• ACh causes breakdown
• f membrane to produce

motor action potential (endplate potential) (endplate potential)

• Potential is propagated

along sarcolemma

Set-up for collecting EMG data

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Set up for Indwelling Electrodes (Fine Wire) Action Potential Propagation

• The recording

electrodes (surface or electrodes (surface or indwelling) placed in parallel to the muscle fibers detect the relative voltage difference between the two electrodes as the action potential propagates along the muscle fibers

Utilization of EMG in Rehabilitation and Research

• Initiation of muscle activation (Onset)
• How long is a muscle activated (Duration)
• Amount of muscle activation (Amplitude)
• Measures level of fatigue occurring in a

muscle (Frequency shifts)

Which Muscle Turned on First?

0 .0 0 m s e c . 1 0 0 .0 0 to rq u e (2 0 4 8 x ) v e lo c ity (3 2 0 x ) s u p ra (0 .5 x ) i f (0 5 ) (3 2 x ) (3 2 x ) (3 2 x )

Force

Velocity

Supraspinatus

2 0 0 .0 0 m s e c . in fra (0 .5 x ) p o s td e lt(3 2 x ) (2 5 x ) (3 2 x )

Infraspinatus Posterior Deltoid

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Utilization of EMG in Rehabilitation and Research

• Measure of EMG Amplitude

T d t i h h l ti it – To determine how much muscular activity was recruited for a particular exercise

• EMG activity is translated from Volts to

percentage of muscle activity

– MVC – maximal voluntary contraction y – RVC – reference voluntary contraction (task, set load)

Relative Amount of Muscular Activity

• Normalization of EMG signal to an event or to a

specific task

• Allows for comparison between subjects, days,

muscles or studies

– Soderberg & Knutson, Phys Ther 2000

Normalization

• Specific positions identified for

shoulder or MMT positions

• Rotator cuff
• Rotator cuff

– Kelly, J Ortho Res 1996

• Scapular musculature

– Michener, Phy Ther 2005

• 100% isometric contraction (MVIC)

– Most commonly used – Need to perform for 3-5 sec duration with 2 3 repetition with at least 30 90 sec rest 2-3 repetition with at least 30-90 sec. rest

– Hagberg. Am J Phys Med 1981

• The highest amplitude obtained

during time interval is considered 100% (1 or ½ second)

• EMG data is expressed as a %MVIC
• r %RVC

EMG Amplitude Categorization

• 0 – 20% Low activity
• 21 – 40% Moderate activity
• 15%MVIC= 30N force

conservative estimate to

y

• 41 – 60% High activity
• >61% Very High activity

– DiGivone, JSES 1990

– 0 – 5% Minimal EMG activity (background noise)

– Perry, Gait Analysis 1992

conservative estimate to protect repair

– Long, JOSPT 2010

– Assumptions: fraction of MVIC, CSA, specific tension, & fiber pennation

Perry, Gait Analysis 1992

• <20% = Minimal activity
• 20-50% = Moderate activity
• >50% = Marked activity

– McCann, Clin Orth Rel Res 1993

– 44±15N load for 206 ±88 cycles generated 50% loss of rotator cuff repair

– Bicknell, Arthroscopy 2005

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Limitations of EMG

• Sources of interference

– Movement artifact – External electrical noise (electrical outlets, ECG) – Possibility of “cross-talk” from other muscles (surface)

• Reducing interference by use good

equipment, small electrodes, and careful electrode placement electrode placement

• Not a measure of force or strength

– Moderate correlation in an isometric conditions

– Inman, EEG Clin Neurophysiol 1952

Rotator Cuff Tendon Rupture

• Not typically traumatic
• Degenerative overuse
• Degenerative overuse

mechanism most common

• Combination of

compression and p eccentric overload

– Lin et al., J Biom 2004

Biomechanical Properties of Healing Tendon

• Human tendon maximal

strength ranges from 50 – 150MPa

– Gelberman et al., Injury and Repair Musculoskeletal Soft Tissues 1987

• Rat maximal tensile load

=25 + 9 MPa

6wks = 8% – 6wks = 8% – 12 wks = 12% – Repaired supraspinatus post-

• p does not approach intact

values

– Carpenter et al., JSES 1998

Rehabilitation Implications

• Following tendon repair first 3- 6

wks loads across the tendon have to be minimal

• Animal model suggest

Immobilization is beneficial over early mobilization

– Increased organization – Less scar formation – Mechanically stronger – Mechanically stronger

– Thomopoulos, J Biom Eng, 2003

• Gradual introduction of stresses

during the maturation process

– Lower EMG activity

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Rehabilitation Progression

Sport S ifi Functional Specific Recovery Strength Endurance Power Kinetic Chain breakage

Kibler, Functional Rehabilitation

Acute Rest Modalities Injection ROM Wound care Neuromuscular Control Bracing

Rehabilitation 1998

Immobilization ≠ Inactivity

• EMG activity is present in

immobilizer

• Caution for certain activities to

protect of rotator cuff

– Bimanual tasks increases Biceps (7- 16%) [SLAP] – Pulling open door activated Supraspinatus (10-20%) [Rot Cuff Repairs] Repairs] – Pushing open a door quicky activate

• Infra. (60±45%) [Rot Cuff Repairs]

– Reaching task with contralateral limb facilitate scapular musculature (20-60%)

in the immobilized limb

– Smith, J Sh Elb Surg 2004

Quick Motions of Contralateral Arm Increase Activity Other Precautions in Sling

• Post-operatively to
• Post-operatively to

protect healing rotator cuff avoiding drinking with involved side while in sling

– Long, JOSPT 2010

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Acute Phase Rehabilitation

• For proper healing need some

period of immobilization period of immobilization

• Initiate ROM within physiological

healing restraints and pain tolerances

• Can we find a balance

Hugh Owen Thomas Father of Immobilization

Adhesions

Communication

Respect Physiological Healing when Prescribing Exercises

80 90 100 10 20 30 40 50 60 70 % MVIC 10

What level of muscle activity is associated with PROM?

• Pendulum
• Pendulum
• Supine Passive

elevation

– w/ or without therapist

• Forward Bow
• CPM

Pendulum

• Small vs large circle
• Small vs large circle
• Correct vs incorrect
• 13 Healthy subjects
• Concluded small

circles (20cm) circles (20cm) generated lowest EMG activity

– Long, JOSPT 2010

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Passive Exercises

• Surface EMG on 10

healthy subjects C f

Supra. Infra.

• Ant. Delt.

Trap Mn Sd Mn Sd Mn Sd Mn Sd Pulley

using MVIC for normalization

– Pendulum – Pulley – Therapist assisted PROM

Pulley

18

10

9

5

25

15

15

10 Bar Rise

8

3

5

2

11

7

4

4 PROM

4

2

3

2

8

4

8

3 CPM

5

6

4

2

2

2

5

5

PROM – CPM

• Pulley most activity

(p<.05)

– Dockery, Orthopedics 1998

Passive Exercise

• In 10 healthy subjects
• What level of muscle

activity is associated

• Supine Passive

elevation performed by individual < 10%

• Forward Bow moving

body around

activity is associated with PROM? – Not truly passive – Overall levels below 15% suggests to be a safe estimate to

stationary arm <10%

– Uhl, Phy Med Rehab 2010

safe estimate to protect tissue

• No evidence in post-
• perative cohort

Rehabilitation Progression

Sport S ifi Functional

• Protect weakened

tissues

• Regain motion &

function Specific Recovery Strength Endurance Power Kinetic Chain breakage

Kibler, Functional Rehabilitation

function

• Activate

inhibited/weakened muscles gradually Acute Rest Modalities Injection ROM Wound care Neuromuscular Control Bracing

Rehabilitation 1998

Active-Assisted ROM Exercises

• Critical period to avoid

abnormal movement patterns

• r substitution patterns
• r substitution patterns
• Various assistive devices

(Pulley, Stick, Wall & Water) to minimize loads on healing tissue

• Facilitates muscle activation

and dynamic muscular l f h j i control of the joint

• Caution using long lever

arms may be too much demand for recovering tissues

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Gravity Minimized AAROM Exercises

• Water provides buoyancy

– Slow elevation low demand on muscles <10% F t l ti t d – Fast elevation generated more activity

– Kelly et al. JOSPT 2000

• Wound considerations &

availability to pool

Ex Supra Infra Ant. Delt Sub. Delt. Slow 4 + 4% 2 + 2% 2 + 2% 2 + 1% Fast 17+15% 21+16% 17+13% 11+4%

Incremental Loading ↑ EMG activity

• Neer’s 3 phases demonstrated

a progression a progression

• Supine PROM
• Upright AAROM
• Upright AROM
• Resistive
• RVC 2.25 (5lb) abd. to 150º
• Not all AAROM are equal

Pulley Elevation w/Stick Wall Slide Mn Sd Mn Sd Mn Sd Supra

13

17

19

18

22

23

• Not all AAROM are equal
• Minimal – Moderate levels

– McCann, Clin Ortho Rel Res 1993

p Infra.

20

31

27

20

9

10 Ant. Delt.

21

14

43

18

26

15 Serr. Ant.

14

14

29

20

18

14 Trap.

14

13

9

9

17

14

University of Washington Exercise Program

• Rehabilitation program

which progresses patients which progresses patients from PROM to RROM.

• Similar to Neer’s program

but emphasizes more scapular motion (protraction) and does not (protraction) and does not incorporate as much isometric and elastic resistance exercises.

– Rockwood & Matsen, The Shoulder 1998

Kinetic Chain Exercise Program

• Incorporates legs and
• Incorporates legs and

trunk to initiate and facilitate arm elevation

– Kibler , Med Sci Sport Ex 1998 – McMullen & Uhl JAT 2000

• Utilizes patient’s hand

Ut es pat e t s a d in contact with surface to unload the weight of the arm for AAROM exercises

– Wise, JSh Elb Surg 2004

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EMG Assessment of Passive, Active- Assistive, & Active Exercises

45 50

• Uhl, Phy Med Rehab 2010

10 15 20 25 30 35 40 45 Supraspinatus Infraspinatus Anterior deltoid Upper trapezius Serratus anterior 5 Supine Passive ROM Forward Bow WC press up, hands close WC press up, hands apart Towel slide Scapular protraction on ball Supine press up Wedge press up Standing press-up Passive Active-Assistive Active

Kinetic Chain Active Exercises = Static Standing Press-up

50 20 25 30 35 40 45 Supraspinatus Infraspinatus Anterior deltoid Upper trapezius Lower trapezius Serratus anterior 5 10 15 Ips step up, no ball Standing press-up Serratus anterior

Active Motion Relevance

• Passive = some Active-Assistive

Exercises

• Active exercise in repaired flexor

tendons is necessary to regain neuromuscular control (plasticity)

– Session 1: immediately after immobilization and PROM – Session 2: 6 weeks of active exercise Session 2: 6 weeks of active exercise

– Coert J Hand Surg (EUR) 2009

• Deltoid progression supports the

Reading protocol for massive cuff tears

– Levy, J Sh Elb Surg 2008

Subdividing Active-Assistive Elevation Exercises

50.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00 Supraspinatus Infraspinatus Anterior Deltoid 0.00 5.00 Dusting Sidelying Elevation Supine Forward Elevation (Red Band) Ball Roll Standing T- bar Rope & Pulley Wall walk Standing T- bar w/ active lowering Active forward elevation Graviity Minimized Upright Assisted Upright Active

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Results

• AFE > Assisted Ex’s
• Wall walk exercise was

– Supraspinatus – Anterior Deltoid

• Anterior Deltoid

activity increased at each level most demanding of upright exercises for Supraspinatus

– Reserve for later stage in recovery

S i T B d 90

– Gravity Minimized< Upright assisted< Active

– Gaunt et al., Sports Health (2010)

• Supine T-Band 90 –

150º although using resistive exercise was relative low demand on cuff musculature

Post-operative Subjects

• Previous literature has used healthy subjects Is the

progression similar in post-operative subjects? progression similar in post operative subjects?

• Study Purposes:
• To identify order of exercises of increasing

muscular activation amplitude in post-SLAP

Methods / Subjects

• 20 subjects between 18 - 50 y/o

– healthy group vs. post-SLAP group, 4-6 wk s/p Type II repair Type II repair – No concomitant RC repair

• Muscles

– Supraspinatus – Infraspinatus

Healthy Group Post-SLAP Group

p – Biceps – Serratus – Up. Trapezius – Ant. Delt.

Healthy Group n = 10 Group n = 10 mean ± SD mean ± SD Age (years) 28 ± 6 28 ± 9 Height (meters) 1.77 ± 0.1 1.81 ± 0.1 Weight (kilograms) 84 ± 19 90 ± 20

• Reference Contractions- sub-

maximal

EMG Normalization

maximal

– Yang, APMR 1983

• Shoulder Muscles:

– AFE –McCann, CORR 1993 – 5lb Isometric Forward Elevation @ 45°

• Biceps and Infraspinatus:

p p

– 5 lb Bicep curl – 5 lb Isometric External Rotation @ 45°

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3 PROM Exercises

UE Ranger http://www.ueranger.com/

Active-Assisted (AAROM)

T-bar not illustrated

AAROM & AROM EMG - Results

• No difference between groups for any

l t di d muscle studied

• EMG amplitudes

–Lowest for passive ex’s –Greatest for Active Forward elevation

• Active-Assistive

–Supported Active Assistive = PROM –Wall Walk = AFE

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EMG Levels (%RVC)

120 EMG Activation by Muscle Upper Trapezius Serratus Anterior Anterior Deltoid Biceps Supraspinatus Infraspinatus

• 20

20 40 60 80 100 120 EMG (%RVC) Exercise

PROM AAROM AROM

Rehabilitation Progression

Sport S ifi Functional

• Regain motion &

function

• Regain strength
• Develop endurance

Specific Recovery Strength Endurance Power Kinetic Chain breakage

Kibler, Functional Rehabilitation,

Develop endurance Acute Rest Modalities Injection ROM Wound care Neuromuscular Control Bracing

Rehabilitation, 1998

Progression through Recovery

• Re-establish

coordinated UE coordinated UE movement before adding significant loads

• Enhance strength by

increasing loads g

– Resistance – Speed – Lever arm

• Increase Endurance

Subtle Lever Arm Changes Muscular Activation Levels

• Wise, J Sh Elb Surg 2004
• A. Short

, g

B Long

• B. Long

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Developing Scapular Stabilization Exercises

• Low Row and Inferior Glide

Low Row and Inferior Glide

– Isometric exercises biasing serratus and lower trapezius

• Lawnmower & Robbery

– Dynamic exercises integrating trunk and scapular musculature

• These exercises are

These exercises are appropriate for intermediate phase scapular strengthening

– Kibler, AJSM 2008

Low to Moderate Muscular Demands (20-40%)

• Up. Trap

Low. Serr. Ant. Post.

• Up. Trap

Low. Trap. Serr. Ant Ant. Delt. Post. Delt. Inferior glide 8 + 6 19 + 27 23 + 20 5 + 2 9 + 6 Low row 10 + 8 15 + 12 28 + 21 17 + 13 42 + 23 Lawn mower 22 + 16 31 + 19 26 + 21 6 + 4 16 + 11 Robbery 32 + 17 27 + 21 21 + 17 7 + 6 14 + 9

Lawnmower & Robbery

Increase activation of Lower Trapezius when contralateral hip extensor are activated. This phenomenon is suggested to occur due to tightening of thoracolumbar fascia in the direction of contralateral scapula within the kinetic chain.

Maenhout Br J Sports Med 2010

Elastic Resistance Exercises

• Rubber tubing for shoulder
• Rubber tubing for shoulder

exercises

• Developed for throwing

athletes (on-field)

• Identified 7 exercises that

moderately activated primary moderately activated primary muscle involved in throwing

– (* indicates key exercises)

– Myers JAT 2005

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Elastic Resistance Exercises

High to Very High Category Ant Mid Low Ser Sub- Supr Infra Ant. Delt Mid. Delt Low Trap Ser. Ant. Sub- scap Supr a Infra ER 0

6 ± 6 8 ± 7 48 ±25 18 ±19 72 ±55 20 ±13 46 ±20

ER 90*

22 ±11 50 ±21 88 ±51 66 ±39 57 ±50 50 ±21 51 ±30

90 IR 0

6 ± 6 40± 3 44 ±30 21 ± 4 74 ±47 10 ± 6 32 ±51

IR 90

28 ±18 41 ±21 54 ±39 54 ±32 71 ±43 41 ±30 24 ±21

Elastic Resistance Exercises

Scapular Punch Shoulder extension Shoulder Flexion w/ axial load Low Row

Elastic Resistance Exercises

Ant. Delt Mid. Delt Low Trap Ser. Ant Sub- scap Supra Infra Delt Delt Trap Ant. scap Scap Punc* 45 ±36

36 ±24 32 ±32 67 ±45 69 ±47 46 ±31 35 ±17

Low Row*

19 ±13 34± 23 44 ±32 22 ±14 69 ±50 46 ±38 29 ±16

Sh. Flex*

60 ±41 32 ±14 49 ±35 67 ±37 99 ±37 42 ±22 47 ±34

Sh. Ext*

19 ±15 27 ±16 53 ±40 30 ±21 97 ±55 29 ±21 50 ±57

Elastic Resistance Exercises

Ant. Delt Mid. Delt Low Trap Ser. Ant. Sub- scap Supra Infra Throw Accel*

27±20 22 ± 12 53 ±46 55 ±35 93 ±51 36 ±32 33 ±22

Throw D l*

29±16 44 ±16 63 ±42 48 ±32 69 ±48 64 ±32 45 ±21

Decel*

29±16 44 ±16 63 ±42 48 ±32 69 ±48 64 ±32 45 ±21

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What about Weight Bearing Exercises?

• Fixed Boundary Axial Load
• Fixed Boundary Axial Load

– Lephart & Henry JSR 1996

• Greater joint congruency

thereby decreasing shear forces

• Football & Wrestling – sport

6 + 3 BW%

g p specific

• EMG activity highly correlated

to load R2 = .95

7 Common CKC Exercises

• Prayer
• Quadruped

16% BW + 2%

• Quadruped
• Tripod
• Pointer
• Push-up
• Push-up feet elevated
• One arm push-up

33% BW + 3%

One arm push up

– Uhl et al. JOSPT 2003

Push-up elevated and One Arm Push-up

40% BW + 4% 60% BW + 6% 40% BW 4% 60% BW + 6%

140 160

EMG Activity for Exercise Position

40 60 80 100 120 EMG Activity (% MVIC)

• 20

20 Prayer Quad Tripod Pointer Push-up Push-up elev 1 arm push-up E Supraspinatus Infraspinatus Ant-deltoid Post-deltoid Pec-major

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Scapular Muscular Activation

• Ipsilateral leg ext.

biases Serratus A t i (#3) Anterior (#3)

• Contralateral leg ext.

biases Lower Trapezius (#2)

– Maenhout Br J Sport Med 2010

• EMG low
• EMG low –

moderate 15- 45%

Unstable Surface does not Increase Muscular Activation

120 40 60 80 100 120 Cuff Link Push-up 20 Middle Trapezius Lower Trapezius Serratus Anterior

Tucker et al., JAT 2008

Injury Effects Neuromuscular System

• Serratus Anterior inhibition
• Substitution of upper
• Substitution of upper

trapezius & rhomboids

– Scovazzo et al., AJSM 1991

• 80 ms delay in activation of

Serratus anterior, indicating poor muscular control

Wadsworth & Bullock Saxton Int J – Wadsworth & Bullock-Saxton, Int J Sports Med. 1997

• Increased Upper Trap activity

& decreased Serratus Anterior activity with a load

– Ludewig & Cook, PT 2000

Serratus Progression

• Least to most challenging

based on average amplitude of based on average amplitude of MVIC

• Shoulder Extension (5+3)
• Press-up (32+28)
• Forward Punch (34+15)
• Scaption (38+10)
• Knee Push-up Plus (40+15)
• Knee Push-up Plus (40+15)
• Serratus anterior Punch (44+12)
• Dynamic Hug (50+15)
• Push-up Plus (58+17)

– Decker, AJSM 1999

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Lower Fibers of Serratus Anterior

• Protraction focuses on
• Protraction focuses on

upper fibers

• Elevation above 120

deg is needed to address lower fibers of Serratus Ant. Serratus Ant.

• Diagonal Flexion /

Adduction / Ext. Rot.

– Ekstrom et al., JOSPT 2003

Serratus Anterior Exercises (%MVIC)

Exercise Mosely ’92 Ekstrom ‘03

Flexion 96 + 45 NT Abduction 96 + 53 NT Abduction 96 + 53 NT Scaption > 120o 91 + 52 96 + 24 Diag Flex/ Horiz Add/ Ext. Rot. NT 100 + 24 Military Press 82 + 36 NT Unilateral shoulder press supine w/plus NT 62 + 19 Push up w/plus 80 + 38 NT Push up w/ hands wide 57 + 36 NT Bilateral scapular protract. NT 57 + 22

Biasing Serratus Anterior (SA) over Upper Trap (UT)

• Push-up plus is better

than wall push-up to than wall push-up to activate SA relative to UT

– Ludewig AJSM 2004

• Exercises favoring early

LT & MT over UT ti ti activation

– Prone Ext – Prone Horiz Abd – Side-lying ER

– De Mey JOSPT 2009

Rotator Cuff Core Exercises

Protect t i anterior capsule

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64 72 83 73 72 74 79 80 80 100 Supraspinatus Subscapularis Infraspinatus Deltoid s c t i

• n

I f i t Deltoid 72 66 60 80 50 56 62 52 80 74 70 67 64 50 20 40 60 EMG Activity (% MVIC) P r

• n

e E R a t 9 S c a p t i

• n

E R F l e x i

• n

P H A 9 ° E R S c a p t i

• n

I R M i l i t a r y p r e s s A b d u c t Supraspinatus Subscapularis Infraspinatus

Rehabilitation Progression

Sport S ifi Functional

• Increase Power
• Integrate specific

functional demands Specific Recovery Strength Endurance Power Kinetic Chain breakage

Kibler, Functional Rehabilitation

Acute Rest Modalities Injection ROM Wound care Neuromuscular Control Bracing

Rehabilitation 1998

Baseball Throwing Tasks

175 200 75 100 125 150 %MVIC Infraspinatus Supraspinatus Subscapularis Deltoid Serratus Anterior Trapezius 25 50 Early Cocking Late Cocking Acceleration Follow Through Phases of Throwing

Plyometrics

• Overhead plyometric simulate and

prepare body to return throwing activities

– Cordasco et al. AJSM 1996

50 60 70 80 90 VIC 10 20 30 40 Infraspinatus Supraspinatus Subscapularis Upper Trap % MV

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20

Plyometrics Posterior Shoulder

• No EMG evidence
• No EMG evidence
• Several studies

indicate benefit

– Injury reduction

– Swanik J Sport Rehab 2002 2002

– Strengthening

– Carter, J Strength Cond Res. 2007 – Swanik, JSES 2002

Key Points: Acute Phase & Early Recovery

• Consistently low EMG activity for PROM

– 15% MVIC appears to be most safe 15% MVIC appears to be most safe

• AAROM exercises can be performed in a

position or with support that equals PROM and requires less activation than AFE

– Establish proper movement with support or in gravity minimized position prior to initiating unsupported upright or resistive exercises

• Neural reorganization

– Upper trapezius activation increases as upright positions

Key Points: Recovery Phase

• Resistance can be advance many ways

– Lever arm Lever arm – Load – Speed

• Many exercises overlap muscular

activations be efficient with exercise selection

– Subscapularis active with several functional exercises

Key Points: Functional Phase

• EMG studies can help you select appropriate

exercise for your patient but must consider / k d d sport/work demands

– Not all tasks or exercise activation levels are known

• There are often multiple variations to

activate the muscle Think along a continuum of exercises –Think along a continuum of exercises

• Design program based:

– Tissue physiology – Your clinical judgment – Available evidence

SLIDE 21

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Thanks Y’all

My Old Kentucky Home Contact: tluhl2@uky.edu