Therapeutic Exercise for the Shoulder
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]
Rotator cuff tendinopathy
Exercise in the management of rotator cuff tendinopathy, has a useful role to play and incorporating loaded exercises is safe and not detrimental to outcome[1]. 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]. However, optimal parameters of exercise and load have yet to be determined as has the mechanism by which therapeutic response occurs[1].
Rotator cuff tears
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].
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
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.
CAN WE ADDRESS THE IMPORTANCE OF DELTOID?
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?
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.
