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Teaching Home Exercises for the Rehabilitation of Upper Extremity Problems Scapular Dyskinesis, Impingement, and Adhesive Capsulitis

UCSF DEPARTMENT OF SPORTS MEDICINE Jessica Dominguez, MS, ATC Kathryn Elston, MA ATC Justine Li, ATC

What is an Athletic Trainer? Objectives

. Unique and multi-skilled health care professionals who . Understand the importance of a Home Exercise Program collaborate with to optimize activity of physically (HEP) for upper extremity chronic issues active patients.

. Provide simple instructions on how to teach home exercise . Provide preventative services, emergency care, clinical programs for common and elbow assessment, therapeutic intervention and rehabilitation of injuries and medical conditions. . Recognize red flags for orthopedic referral

. ATs improve functional outcomes and specialize in patient education to prevent and re-injury.

. Employed in a variety of settings.

1 What is a Home Exercise Program? Why use HEP?

. A program detailing a range of therapeutic exercises and the . Accessibility amount of time each exercise should be performed - Cost effective - Designed for the home . General enough to be used by a wide range of patients with environment upper extremity . Immediacy - may not be available immediately . Little to no special equipment needed other than household items . Simplicity

. Online Access

Improve HEP Effectiveness Causes of Upper Extremity Pain

. May be due to: . Patient Compliance - Traumatic injury Only 35% of patients adhered fully to HEP - - Lack of flexibility . Only 19% adherence if chronic illness present (Kravitz 1993) - Weakness of shoulder and back . 76% followed regimen partly (Sluijs 1993) musculature . Best if used in addition to formal PT - Overuse - Biomechanical issues - Impingement . Posture related factors of shoulder pain - Rolled forward - Poor posture (sitting at computer, reading, writing) - Tight pectoralis/weak stabilizers - Repetitive overhead motions (Ludewig and Borstad 2003)

2 Shoulder Pain

. 3rd most common musculoskeletal condition presenting in primary care (Urwin 1998)

. 5th most common injury among high school athletes (Powell 1999) . Approximately 13.7 million people in the US seek treatment from a for a shoulder problem each year (Hing 2005) . Impingement Syndrome is the most common shoulder disorder accounting for 44-65% of all physician visits for shoulder pain (Van Der Wint 1995)

Lifestyle Effects of Poor Posture

. Ergonomic Solutions for . Muscle Weakness: Postural Issues - Rotator cuff weakness will lead to unbalanced motion that can - Ergonomic Evaluation cause migration of the humeral head (Ludewig and Borstad 2003) - Standing Desk - Weak scapular stabilizers can result in altered biomechanics (Voight and Thompson 2000, Kibler 2008) - Extendable Keyboard . Abnormal stresses to the anterior capsular structures - Laptop Stand . Possibility of Rotator Cuff compression . Decreased performance . Extrinsic Solutions - Postural Tape - Sling - Digital Sensors

3 What Happens Without Exercises Scapular Dyskinesis

. Scapular Control Issues . Scapular dysfunction or dyskinesis is a result of an increase . Postural Changes in anterior tilt, increase of scapular internal rotation, and a decrease in scapular upward rotation (Kibler 2012) . Long Term Motor Control Issues - Results in a decrease in serratus anterior activation and . Connective Tissue Changes— reduction of strength (Kibler 2012) Fibrosis . Causes . Chronic Substitution Patterns - Muscular Imbalances - Over-recruitment upper - Weakness of scapular stabilizers - Underused middle and lower Tightness in anterior musculature trapezius - - Poor posture . PT Needed to Retrain Motor Control Patterns

Anatomy of the Scapula Identifying Scapular Dyskinesis

. Bony . Scapular Dyskinesis Test (McClure 2009) - 17 different muscles - 5 repetitions of bilateral, active, weighted shoulder flexion - Superior Border - 5 repetitions of bilateral, active, weighted shoulder abduction - Medial Border . Dumbbells are selected according to their body weight - Lateral Border - 3lbs for <150 lbs . Musculature - 5lbs for >150 lbs - Serratus Anterior - Trapezius - Rhomboids

4 Scapular Dyskinesis Test Scapular Dyskinesis Test Results

. Observation - Normal (A) . Dyskinesis (B) - Right: subtle - Left: obvious

Prolonged Scapular Dyskinesis HEP: Strengthening

. Decrease in subacromial space (Ludewig and Borstad 2003) . Increase in strain to the joint capsule (Kibler 2012) . Increase in postural defects (Voight and Thompson 2008) . Increase in muscular imbalance (Kibler 2008)

. Increase in pain (Kibler 2012) Scapular Retraction (Shoulder Blade Squeezes)

Frequency: 1 set x 10-12; 3 times per day Goal: Increase scapular stabilization

5 HEP: Strengthening Rotator Cuff Impingement

. Subacromial space - - - Coracoacromial

- Supraspinatus - Biceps Tendon

Angel Wings -

Frequency: 3 sets x 10; 2 times per day Goal: Increase scapular stabilization/ strength

Presentation Differential Diagnosis

. Bicep Tendinitis . A patient with rotator cuff impingement will have: - Isolated bicep activation - Superior shoulder pain, especially with overhead movements . Subacromial - Poor scapulothoracic stability - Rule out rotator cuff and bicep - Poor posture tendinitis - Night pain . Labral Tear - Mechanical symptoms such as . Stages of Impingement Syndrome (Neer 1972) clicking, popping, or catching - Stage 1 (<25 y.o.): Overuse . Adhesive capsulitis Stage 2 (25-40 y.o.): Fibrosis - . Calcification or tendinosis - Stage 3 (>50 y.o.): Tendon rupture

23 Presentation Title

6 HEP: HEP: Stretching

Doorway Stretch Sleeper Stretch

Frequency: 3 sets x 1 minute; 2-3 times per Frequency: 3 sets x 10 reps; 2-3 times per day day Goal: Increase pectoralis flexibility and Goal: Improve posterior capsule mobility improve posture

HEP: Strengthening HEP: Strengthening

Horizontal Rows

Frequency: 3 sets x 10 reps; 2-3 times per day Goal: Increase strength of scapular stabilizers

External Rotation

Frequency: 3 sets x 10 reps; 2-3 times per day Goal: Increase strength of scapular stabilizers and rotator cuff

7 Adhesive Capsulitis aka “Frozen Shoulder” Adhesive Capsulitis aka “Frozen Shoulder”

• Synovial & . Causation capsular fibrosis - Gradual loss of active and passive ROM • Leads to of the - Most common in women 40-60 years old capsule - Affects about 2% - 5% of the population • Etiology not clearly understood - Strong association with Diabetes Mellitus . 3 stages of Frozen Shoulder: 1. Painful stage 2. Frozen/Adhesive 3. Thawing stage

Adhesive Capsulitis aka “Frozen Shoulder” Differential Diagnosis

. Full duration of disease is 1-3.5 years . Impingement, , and – PROM . Presents unilaterally but will often affect the contralateral is not painful/restricted in these conditions shoulder . Initial treatment of HEP combined with OTC analgesia/anti- inflammatory meds is the most effective to treat this condition (Hsu 2011) . NSAIDS not effective when compared to placebos

8 HEP: Stretching HEP: Stretching

Passive Shoulder Flexion Passive Shoulder Abduction

Frequency: 3 sets x 1 minute; 2-3 times per day Frequency: 3 sets x 1 minute; 2-3 times per day Goal: Increase range of motion Goal: Increase range of motion

HEP: Stretching HEP: Strengthening

Passive Shoulder External Rotation Passive Shoulder Flexion

Frequency: 3 sets x 1 minute; 2-3 times per day Frequency: 3 sets x 1 minute; 2-3 times per day Goal: Increase range of motion Goal: Increase range of motion

9 HEP: Strengthening References

. Fongemie AE, Buss DD, Rolnick SJ. Management of Shoulder Impingement Syndrome and Rotator Cuff Tears. Am Fam Physician. 1998;57(4):667-674. . Hing E, Cherry DK, Woodwell DA, et al. National Amubulatory Medical Care Survey: 2003 Summary. CDC Advance Data. 2005; 365: 1-48. . Hsu, JE, et al. Current Review of Adhesive Capsulitis. Journal of Shoulder and Elbow Surgery. 2011. 20(3): 502 – 514 . Kibler WB, Sciascia AD, Uhl TL, et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am J Sports Med. 2008; (36)9:1789–179. . Kibler W, Sciascia A, & Wilkes T. Scapular dyskinesis and its relation to shoulder injury. Journal of the American Academy of Orthopaedic Surgeons. 2012; 20, 364-372. . Kravitz RL, Hays RD, Sherbourne CD, et al. Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med. 1993; 153(16):1869-78. . Ludewig PM, Borstad JD. Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occupational and Environmental Medicine. 2003; 60: 841-849. . McClure, P, Tate,A, Kareha S, et al. A Clinical Method for Identifying Scapular Dyskinesis, Part 1. Journal of Athletic Training. 2009; 44(2): 160-164. . Neer, C. Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder: A Preliminary Report, JBJS. 1972; 54(1): 41-50. . Powell, JW, Barber-Foss, KD. Injury Patterns in Selected High School Sports: A Review of the 1995-1997 Seasons. J Athl Train. 1999; 34(3): 277–284. Isometrics: Flexion/ Abduction . Sluijs EM, Kok GJ, Van der Zee J. Correlates of Compliance in Physical Therapy. Physical Therapy. 1993; 73(11): 771-782. . Van der Windt DA, Koes BW, de Jong BA, et al. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis.1995;54:959–64. Frequency: 3 sets x 1 minute; 2-3 times per day . Voight ML, Thompson BC. The Role of the Scapula in the Rehabilitation of Shoulder Injuries. Journal of Athletic Training. Goal: Increase range of motion 2000; 35(3): 364-372. . Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis. 1998; 57(11):649-55.

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