Therapeutic Exercise for the Shoulder: Difference between revisions
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== The Evidence == | == The Evidence == | ||
Exercise has a useful role to play and incorporating loaded exercises is safe and not detrimental to outcome<ref name=":0">Littlewood C, Ashton J, Chance-Larsen K, May S, Sturrock B. [[Exercise for rotator cuff tendinopathy: a systematic review.]] Physiotherapy. 2012 Jun 1;98(2):101-9.</ref>. In rotator cuff tendinopathy, both home and supervised exercise programmes have been found to be more effective than no intervention or placebo and as effective as minimal comparators, e.g. functional brace, or active comparators, e.g. multimodal physiotherapy, surgery<ref name=":0" />. | |||
More recently, there has been increasing interest in exercise rehabilitation as a means to manage partial and full thickness tears of the rotator cuff by specifically addressing weakness and functional deficits. Recent studies have suggested that patients opting for physiotherapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery<ref name=":1">Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827371/ Exercise rehabilitation in the non-operative management of rotator cuff tears: a review of the literature]. International journal of sports physical therapy. 2016 Apr;11(2):279.</ref><ref name=":2">Ainsworth R, Lewis J, Conboy V. [http://onlinelibrary.wiley.com/doi/10.1111/j.1758-5740.2009.00010.x/epdf A prospective randomized placebo controlled clinical trial of a rehabilitation programme for patients with a diagnosis of massive rotator cuff tears of the shoulder]. Shoulder & Elbow. 2009 Jul 1;1(1):55-60.</ref>. | |||
However, optimal parameters of exercise and load have yet to be determined as has the mechanism by which therapeutic response occurs<ref name=":0" />. | |||
== Effect of exercise == | == Effect of exercise == | ||
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Recent EMG studies have indicated that rotator cuff muscles are recruited in a reciprocal, direction-specific pattern during shoulder flexion and extension exercises. Wattanaprakornkul et al<ref>Wattanaprakornkul D, Halaki M, Cathers I, Ginn KA. [https://sro.library.usyd.edu.au/bitstream/10765/143401/2/Wattanaprakornkul_et_al.pdf Direction-specific recruitment of rotator cuff muscles during bench press and row]. Journal of Electromyography and Kinesiology. 2011 Dec 1;21(6):1041-9.</ref><ref>Wattanaprakornkul D, Halaki M, Boettcher C, Cathers I, Ginn KA. A comprehensive analysis of muscle recruitment patterns during shoulder flexion: An electromyographic study. Clinical Anatomy 2011;24:619–26.</ref> demonstrated that during flexion, the posterior externally rotating cuff muscles (supraspinatus and infraspinatus) were activated at significantly higher levels than the anterior internally rotating cuff muscle (subscapularis), while during extension the reverse occurs. This muscle contraction in a reciprocal direction-specific manner supports the role of the rotator cuff as shoulder joint dynamic stabilizers to counterbalance antero-posterior translation forces and that the rotator cuff provides shoulder joint support by preventing flexion and extension prime movers of the humerus e.g. the deltoid, from translating the humeral head on the glenoid fossa. This EMG knowledge gives us more information to specifically target the rotator cuff muscles in different positions and ranges of movement. | Recent EMG studies have indicated that rotator cuff muscles are recruited in a reciprocal, direction-specific pattern during shoulder flexion and extension exercises. Wattanaprakornkul et al<ref>Wattanaprakornkul D, Halaki M, Cathers I, Ginn KA. [https://sro.library.usyd.edu.au/bitstream/10765/143401/2/Wattanaprakornkul_et_al.pdf Direction-specific recruitment of rotator cuff muscles during bench press and row]. Journal of Electromyography and Kinesiology. 2011 Dec 1;21(6):1041-9.</ref><ref>Wattanaprakornkul D, Halaki M, Boettcher C, Cathers I, Ginn KA. A comprehensive analysis of muscle recruitment patterns during shoulder flexion: An electromyographic study. Clinical Anatomy 2011;24:619–26.</ref> demonstrated that during flexion, the posterior externally rotating cuff muscles (supraspinatus and infraspinatus) were activated at significantly higher levels than the anterior internally rotating cuff muscle (subscapularis), while during extension the reverse occurs. This muscle contraction in a reciprocal direction-specific manner supports the role of the rotator cuff as shoulder joint dynamic stabilizers to counterbalance antero-posterior translation forces and that the rotator cuff provides shoulder joint support by preventing flexion and extension prime movers of the humerus e.g. the deltoid, from translating the humeral head on the glenoid fossa. This EMG knowledge gives us more information to specifically target the rotator cuff muscles in different positions and ranges of movement. | ||
The [http://www.bobbyainsworth.com/datafiles/TorbayCuffProtocol.pdf Torbay Protocol], developed and trialled by Roberta Ainsworth initially as a pilot study and then in an RCT for a rehabilitation programme for patients with a diagnosis of massive, irreparable rotator cuff tears of the shoulder<ref name=":2" /> provides guidelines for the physiotherapy rehabilitation of these patients. | |||
See demonstrations of the exercises in the Torbay Protocol here: | |||
* https://www.torbayandsouthdevon.nhs.uk/services/physiotherapy/support-videos/torbay-shoulder-exercise-programme/ | |||
* https://vimeopro.com/rocklandsmedia/torbay-shoulder-exercise-video-series/video/105122462 | |||
'''CAN WE ADDRESS THE IMPORTANCE OF DELTOID?''' | '''CAN WE ADDRESS THE IMPORTANCE OF DELTOID?''' | ||
== Mode of delivery == | |||
Both group and individual physiotherapy interventions which incorporate exercise aim to reduce pain and disability, but a consensus is a lack of evidence for the most effective mode of treatment delivery for people for exercise rehabilitation in musculoskeletal pain. Although it is clear that group and individual physiotherapy interventions that incorporate exercise are better than minimal or no treatment, it remains unclear whether either is better than the other<ref name=":3">O'Keeffe M, Hayes A, Mccreesh K, Purtill H, O'sullivan K. [http://bjsm.bmj.com/content/51/2/126 Are Group-Based And Individual Physiotherapy Exercise Programmes Equally Effective For Musculoskeletal Conditions? A Systematic Review And Meta-Analysis]. Br J Sports Med. 2016 Jun 24:Bjsports-2015.</ref>. O'Keeffe et al<ref name=":3" />, in a broad study of exercise for musculoskeletal pain, found only small, clinically irrelevant differences in pain or disability outcomes between group and individual physiotherapy, and concluded that group interventions may need to be considered more often given their similar effectiveness and potentially lower healthcare costs. Specifically to the shoulder, recent evidence suggests that group exercise classes can improve shoulder pain and disability in people with non-specific shoulder pain<ref>Barrett E, Conroy C, Corcoran M, O'Sullivan K, Purtill H, Lewis J, McCreesh K. An Evaluation Of Two Types Of Exercise Classes, Containing Shoulder Exercises Or A Combination Of Shoulder And Thoracic Exercises, For The Treatment Of Nonspecific Shoulder Pain: A Case Series. Journal Of Hand Therapy. 2017 Dec 4.</ref>. | |||
== What about pain? == | == What about pain? == | ||
Revision as of 17:57, 3 February 2018
Original Editor - Rachael Lowe
Top Contributors - Rachael Lowe, Naomi O'Reilly, Shreya Pavaskar, Kim Jackson, Claire Knott and Wanda van Niekerk
Introduction[edit | edit source]
The primary aim in treating shoulder conditions through conservative management is to reduce pain and improve function, and exercise rehabilitation is usually the cornerstone of this conservative management plan. The goal of exercise as part of the physiotherapy management is to correct modifiable physical impairments thought to contribute to pain and dysfunction, rather than to treat the pathology. Therapeutic exercise is commonly used in the treatment and management of a range of shoulder disorders and is supported by much research.
The Evidence[edit | edit source]
Exercise has a useful role to play and incorporating loaded exercises is safe and not detrimental to outcome[1]. In rotator cuff tendinopathy, both home and supervised exercise programmes have been found to be more effective than no intervention or placebo and as effective as minimal comparators, e.g. functional brace, or active comparators, e.g. multimodal physiotherapy, surgery[1].
More recently, there has been increasing interest in exercise rehabilitation as a means to manage partial and full thickness tears of the rotator cuff by specifically addressing weakness and functional deficits. Recent studies have suggested that patients opting for physiotherapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery[2][3].
However, optimal parameters of exercise and load have yet to be determined as has the mechanism by which therapeutic response occurs[1].
Effect of exercise[edit | edit source]
It is unknown exactly why exercise was beneficial and has been suggested that the effect of exercise may be multi-factorial[2]. This may include:
- influence on pain modulation
- providing a therapeutic effect on the structurally damaged rotator cuff muscles and tendons
- placebo
- muscular compensation for deficient movement strategies
- Psychological benefits such as reducing fear of movement
Exercise prescription[edit | edit source]
It is well accepted that training and educating patients on improving scapular stability, proper neuromuscular control of shoulder girdle and thoracic posture is essential in a well designed rotator cuff exercise program[2]. NEED SOMETHING HERE ON SCAPULOHUMERAL RHYTHM - see Edwards article.
Recent EMG studies have indicated that rotator cuff muscles are recruited in a reciprocal, direction-specific pattern during shoulder flexion and extension exercises. Wattanaprakornkul et al[4][5] demonstrated that during flexion, the posterior externally rotating cuff muscles (supraspinatus and infraspinatus) were activated at significantly higher levels than the anterior internally rotating cuff muscle (subscapularis), while during extension the reverse occurs. This muscle contraction in a reciprocal direction-specific manner supports the role of the rotator cuff as shoulder joint dynamic stabilizers to counterbalance antero-posterior translation forces and that the rotator cuff provides shoulder joint support by preventing flexion and extension prime movers of the humerus e.g. the deltoid, from translating the humeral head on the glenoid fossa. This EMG knowledge gives us more information to specifically target the rotator cuff muscles in different positions and ranges of movement.
The Torbay Protocol, developed and trialled by Roberta Ainsworth initially as a pilot study and then in an RCT for a rehabilitation programme for patients with a diagnosis of massive, irreparable rotator cuff tears of the shoulder[3] provides guidelines for the physiotherapy rehabilitation of these patients.
See demonstrations of the exercises in the Torbay Protocol here:
- https://www.torbayandsouthdevon.nhs.uk/services/physiotherapy/support-videos/torbay-shoulder-exercise-programme/
- https://vimeopro.com/rocklandsmedia/torbay-shoulder-exercise-video-series/video/105122462
CAN WE ADDRESS THE IMPORTANCE OF DELTOID?
Mode of delivery[edit | edit source]
Both group and individual physiotherapy interventions which incorporate exercise aim to reduce pain and disability, but a consensus is a lack of evidence for the most effective mode of treatment delivery for people for exercise rehabilitation in musculoskeletal pain. Although it is clear that group and individual physiotherapy interventions that incorporate exercise are better than minimal or no treatment, it remains unclear whether either is better than the other[6]. O'Keeffe et al[6], in a broad study of exercise for musculoskeletal pain, found only small, clinically irrelevant differences in pain or disability outcomes between group and individual physiotherapy, and concluded that group interventions may need to be considered more often given their similar effectiveness and potentially lower healthcare costs. Specifically to the shoulder, recent evidence suggests that group exercise classes can improve shoulder pain and disability in people with non-specific shoulder pain[7].
What about pain?[edit | edit source]
There is a lot of disagreement in relation to pain with exercises. Should exercises be painful during rehabilitation? If yes, then how much pain is ok? If no, then will our patients who are very irritable be limited in their ability to participate in any exercise program and what impact will that have on their management?
Smith et al[8] suggest that, in the short term, protocols using painful exercises for musculoskeletal conditions offer a small but significant benefit over pain-free exercises, however in the medium and long term the evidence is lacking. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. NEEDS MORE FROM THE ARTICLE
References[edit | edit source]
- ↑ 1.0 1.1 1.2 Littlewood C, Ashton J, Chance-Larsen K, May S, Sturrock B. Exercise for rotator cuff tendinopathy: a systematic review. Physiotherapy. 2012 Jun 1;98(2):101-9.
- ↑ 2.0 2.1 2.2 Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. Exercise rehabilitation in the non-operative management of rotator cuff tears: a review of the literature. International journal of sports physical therapy. 2016 Apr;11(2):279.
- ↑ 3.0 3.1 Ainsworth R, Lewis J, Conboy V. A prospective randomized placebo controlled clinical trial of a rehabilitation programme for patients with a diagnosis of massive rotator cuff tears of the shoulder. Shoulder & Elbow. 2009 Jul 1;1(1):55-60.
- ↑ Wattanaprakornkul D, Halaki M, Cathers I, Ginn KA. Direction-specific recruitment of rotator cuff muscles during bench press and row. Journal of Electromyography and Kinesiology. 2011 Dec 1;21(6):1041-9.
- ↑ Wattanaprakornkul D, Halaki M, Boettcher C, Cathers I, Ginn KA. A comprehensive analysis of muscle recruitment patterns during shoulder flexion: An electromyographic study. Clinical Anatomy 2011;24:619–26.
- ↑ 6.0 6.1 O'Keeffe M, Hayes A, Mccreesh K, Purtill H, O'sullivan K. Are Group-Based And Individual Physiotherapy Exercise Programmes Equally Effective For Musculoskeletal Conditions? A Systematic Review And Meta-Analysis. Br J Sports Med. 2016 Jun 24:Bjsports-2015.
- ↑ Barrett E, Conroy C, Corcoran M, O'Sullivan K, Purtill H, Lewis J, McCreesh K. An Evaluation Of Two Types Of Exercise Classes, Containing Shoulder Exercises Or A Combination Of Shoulder And Thoracic Exercises, For The Treatment Of Nonspecific Shoulder Pain: A Case Series. Journal Of Hand Therapy. 2017 Dec 4.
- ↑ Smith BE, Hendrick P, Smith TO, Bateman M, Moffatt F, Rathleff MS, Selfe J, Logan P. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med. 2017 Jul 12:bjsports-2016.
