Dynamic Evaluation and Early Management of Altered Motor Control Around the Shoulders Complex

Masterclass

Dynamic evaluation and early management of altered motor control around the

shoulder complex

M.E. Magarey, M.A. Jones

Discipline of Physiotherapy, School of Health Sciences, University of South Australia, Adelaide, Australia

SUMMARY. Altered dynamic control appears to be a significant contributing factor to shoulder dysfunction.

The shoulder relies primarily on the rotator cuff for dynamic stability through mid-range. Hence, any impairment

in the dynamic stabilizing system is likely to have profound effects on the shoulder complex. The rotator cuff

appears to function as a deep stabilizer, similar to the transversus abdominus and vastus medialis obliquus, with

some evidence of disruption to its stabilizing function in the presence of pain. Similarly, serratus anterior appears to

function as a dynamic stabilizer, also demonstrating altered function in painful shoulders. Examination of dynamic

control begins with a detailed examination of posture, evaluation of natural movement patterns and functional

movements and assessment of the specific force couples relevant to shoulder function. One useful strategy in

management of altered motor control related to these force couples is that of training isolated contraction of the

rotator cuff prior to introduction of loaded activity, together with facilitation and training of appropriate scapular

muscle force couples – serratus anterior and trapezius, in relation to arm elevation.

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INTRODUCTION

The focus of this paper is assessment and manage-ment of dynamic control of the shoulder complex.The shoulder is a mobile joint that relies heavily formid-range stability on muscle control (Schenkman &Rugo de Cartaya 1987, 1994; Lippitt & Matsen 1993;Lippitt et al. 1993; Souza 2000; Ciullo 1996; Kibler1998a; David et al. 2000). Therefore, evaluation ofsuch control and treatment directed at its improve-ment should form an integral part of management ofall shoulder disorders. The programmes suggested areyet to be subjected to the rigours of scientificevaluation but follow principles demonstrated to be

effective in other areas of the body (Richardson &Jull 1995; O’Sullivan et al. 1997a, b, 2000; Richard-son et al. 1999). They are based on research onmuscle function and control (Hodges & Richardson1996; O’Sullivan et al. 1997a, b, 2000; Richardsonet al. 1999; Cowan et al. 2000, 2001; Shumway-Cook& Woollacott 2001), reports from other experiencedclinicians (for example, Wilk & Arrigo 1992; Kibler &Chandler 1994; Wilk 1994; Kibler 1998a, b; Chmie-lewski & Snyder-Mackler 2001; McConnell 2001)coupled with extensive clinical experience within aframework of sound reflective reasoning (Jones et al.2000) and knowledge of patterns of presentation ofshoulder disorders (Magarey 1999).Panjabi’s (1992) now familiar concept of a ‘‘neutral

zone’’ for the lumbar spine as a zone in whichtranslatory movements are available can equally beapplied to the glenohumeral joint (Hess 2000). Thecapsulolabral structures (passive restraints) are re-sponsible for setting the limits of passive movement(Jobe 1990; O’Brien et al. 1990; O’Driscoll 1993;Pagnani & Warren 1994) with the muscles, influencedin their activity by their neural control, responsiblefor maintaining the humeral head centred in the

ARTICLE IN PRESSManual Therapy (2003) 8(4), 195–206r 2003 Elsevier Ltd. All rights reserved.1356-689X/03/$ - see front matterdoi:10.1016/S1356-689X(03)00094-8

Received: 1 November 2001Revised: 7 March 2003Accepted: 4 July 2003

Mary E Magarey Dip Physio, Grad Dip Advanced Manip Therapy,

PhD, Mark A Jones, BS(Psychology), RPT, Grad Dip Advanced

Manip Therapy, MAppSc (Manipulative Physiotherapy), Disciplineof Physiotherapy, School of Health Sciences, University of SouthAustralia, North Terrace, Adelaide, South Australia 5153,Australia.Correspondence to: Tel.: +61-8-8302-2768; Fax: +61-8-8302-

2766.

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glenoid fossa during mid-range movements, thusstiffening the joint (Schenkman & Rugo de Cartaya1987, 1994; Lippitt & Matsen 1993; Lippitt et al.1993; Wilk 1994; Burkhart 1996; Ciullo 1996; Davidet al. 1997, 2000; Kibler 1998a). Any disruption tothose mechanisms can lead to abnormal translationof the humeral head during active movement. Inrelation to the scapula, muscle and neural influencesare very important to its stability as its ligamentousattachments are limited to those of the acromiocla-vicular joint (Kibler 1998b).The balance of muscle activity within force couples

is often more important to normal function thanisolated strength of individual muscles (Kibler 1998a,b; Kibler & Chandler 1994). Such balance isdetermined by the length of muscle and associatedfascial tissue and the pattern of recruitment. Whentested in isolation in a classic isometric manualmuscle test, a muscle may test strongly, but performpoorly during functional activity.Kibler (1998a) used the term, the ‘length-depen-

dent pattern’ of muscle activity to describe co-contraction force couples which operate locallyaround a joint, controlled by feedback from musclespindle receptors and responding to perturbations ofjoint position. The primary function of such forcecouples is maintenance of joint stability.One key force couple relevant to stability of the

glenohumeral joint is that between the lower elementsof the rotator cuff – subscapularis anteriorly andinfraspinatus/teres minor posteriorly (Saha 1971;Poppen & Walker 1978; Kapandji 1982; Soderberg1986; Schenkman & Rugo de Cartaya 1987, 1994;Norkin & Levangie 1988; Burkhart 1994, 1996; Wilk1994) (Fig. 1). These muscles are ideally placed todraw the humeral head into the glenoid and maintainits axis of rotation, so that they can perform their roleof concavity compression (Saha 1971; Lippitt &Matsen 1993; Lippitt et al. 1993; Sharkey & Marder1995; Wuelker et al. 1995, 1998). Failure of functionof these muscles in their stabilizing role will lead tocreation of an abnormal axis of rotation (Poppen &

Walker 1978; Howell & Galinat 1987; Schenkman &Rugo de Cartaya 1987, 1994; Howell et al. 1988;Souza 2000) and abnormal translation of the head ofhumerus (Burkhart 1994, 1996).In the scapulothoracic area, the force couples

associated with movement overhead alter throughrange, as the axis of rotation changes with increasingelevation and plane of movement (Inman et al. 1944;Poppen & Walker 1978; Dvir & Berme 1978;Schenkman & Rugo de Cartaya 1987, 1994; Bagg &Forrest 1988; Culham & Laprade 2000; Abelew2001), but the primary contributors are serratusanterior and trapezius (Inman et al. 1944; Basmajian1963; Kapandji 1982; Bagg & Forrest 1986, 1988;Schenkman & Rugo de Cartaya 1987, 1994; Norkin& Levangie 1988; Souza 2000). In the early part ofrange, when the axis of rotation is at the root of thescapular spine, the principal rotators are the upperfibres of both serratus anterior and trapezius (Bas-majian 1963), whereas when the axis of rotationmoves towards the acromioclavicular joint, therelative contribution of upper trapezius lessens whilethat of lower trapezius increases, together with thelower fibres of serratus anterior (Basmajian 1963;Schenkman & Rugo de Cartaya 1987, 1994) (Fig. 2A,B). Serratus anterior is, therefore, a significantcomponent of the force couple throughout range(Bagg & Forrest 1986).David et al. (2000) demonstrated consistent activa-

tion of the rotator cuff prior to the more superficialdelto-pectoral muscles during isokinetic rotation innormal shoulders, confirming their role as dynamicstabilizers for the glenohumeral joint. Similarly,analysis of activation during rotation in the normalshoulder revealed that at least one component of theantagonist rotator cuff was always active (David et al.2000), providing evidence of their stabilizing role.Strong evidence is available that pain alters the

timing of contraction in stabilizing muscles –transversus abdominis and multifidus in relation tothe lumbar spine (Hides et al. 1994, 1996; Richardson& Jull 1994, 1995; Hodges & Richardson 1996, 1998;Hodges et al. 1996; O’Sullivan et al. 1997a, b, 2000),vastus medialis obliquus in relation to the knee(Cowan et al. 2001). Preliminary continuation of ourshoulder stabilization research (David et al. 2000)with unstable shoulders has shown widely differingpatterns of onset of muscle activity, with failure ofthe rotator cuff and biceps to be activated prior to thedelto-pectoral group and, in some instances, failureto fire until after the onset of movement – thusdemonstrating a similar disruption to stabilizingfunction as found in the knee and lumbar spine.Kibler (1998b) considered that serratus anterior

and lower trapezius are susceptible to inhibition inpainful shoulders. This inhibition is seen early as anon-specific response to any painful condition in theshoulder, presenting as a disorganization of the

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Fig. 1—Pictorial representation of the transverse and coronal planeforce couples of the rotator cuff, demonstrating the role of theinfraspinatus posteriorly and subscapularis anteriorly to draw thehumeral head into the glenoid fossa. Reproduced with kindpermission of Williams & Wilkins, Baltimore, from Burkhart(1996).

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normal firing pattern and a decreased ability toproduce torque and to stabilize the scapula, aphenomenon Kibler (1998b) described as ‘scapulardyskinesis’.

Alteration in activity of serratus anterior in thepainful shoulders of swimmers and throwers has beenfound when compared to that of non-painful athletes(Glousman et al. 1988; Scovazzo et al. 1991; Pink

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Fig. 2—Force couples around the scapula relevant in arm elevation (Adapted from Bagg and Forrest 1986; Kapandji 1982). Depicted is themost common pattern of muscle recruitment reported by Bagg and Forrest (1986). (A) In the first 601, the axis of rotation of the scapula issituated at the root of the spine of the scapula. Primary muscles involved in upward rotation of the scapula are lower fibres of serratusanterior and upper trapezius, working via the clavicle, with lower and middle trapezius functioning eccentrically to control the movement. Inthis range, muscle function is highly variable. (B) In the next 601, the axis of rotation begins to move along the spine of the scapula towardsthe acromioclavicular joint. This means that the emphasis of contribution of the muscles changes, with the fibres of lower trapezius nowbecoming more actively involved in upward rotation, along with those of lower serratus anterior and upper trapezius. (C) By the time thearm reaches 1201 of elevation, the axis of rotation is at the acromioclavicular joint. Upper trapezius is no longer positioned to be able tofunction to upwardly rotate the scapula, whereas lower trapezius is now ideally situated to perform this function, in conjunction with lowerserratus anterior. (D) In the final stages of elevation, lower trapezius and lower serratus anterior are the primary rotators of the scapula, withupper trapezius functioning to rotate the clavicle and middle trapezius working eccentrically to control the degree of upward rotation.

Altered motor control around the shoulder complex 197

Manual Therapy (2003) 8(4), 195–206 r 2003 Elsevier Ltd. All rights reserved.

et al. 1993). Wadsworth and Bullock-Saxton (1997)found significant delay in activation of serratusanterior in the painful shoulders of swimmerscompared with non-painful shoulders, with littlechange in timing of activation of trapezius. All thesestudies highlight serratus anterior as the primarystabilizer of the scapulothoracic region, functioningin a manner similar to other deep stabilizers.The movement of elevation has been used as an

example of the need to consider force couples.Clearly, different considerations must be made ifthe disorder involves other movements and loads.Adduction against resistance needs to be consideredin conjunction with elevation in the throwing orswimming athlete, for example. This function is welldescribed in Schenkman and Rugo de Cartaya (1994)and Souza (2000).

PRINCIPLES OF A DYNAMIC ASSESSMENT

Patients move in a variety of ways, with a wide rangeof what can be called ‘normal’ (Shumway-Cook &Woollacott 2001). Influences on movement patternsinclude avoidance of pain, general health and mood,relative length of tissues, strength and level of activityof muscles and timing of contraction of thosemuscles. Functional demands and habitual activitiesalso contribute to development of particular move-ment patterns (Shumway-Cook & Woollacott 2001).All these factors must be considered during examina-tion of muscle function around the shoulder.Antalgic movement patterns are familiar features

of physical examination – a classic example is the armthat drifts towards the plane of the scapula duringfrontal plane abduction, with prevention of thismovement causing pain. A patient who is unwell ordepressed often demonstrates a hunched posture withslow, heavy movements. Such a posture, if habitual,could lead to learned poor scapular rotation duringarm elevation, with the potential for development ofa subacromial impingement.The concept of relative flexibility or relative

stiffness should be familiar to physiotherapists(Sahrmann 2001). Movement occurs in the pathoffering the least resistance, such that compensationfor a tightened tissue or restricted joint occurs withmovement in a different plane or of a different bodypart. A weakened muscle will also disrupt a normalmovement pattern as its weakness must be compen-sated for by an altered pattern of activity in asubstitute muscle capable of achieving similar action.Altered timing of contraction, as discussed above,

influences movement patterns, such that either thetorque producing muscles tend to be activatedwithout pre-setting by the stabilizers (Hodges &Richardson 1996, 1998; David et al. 1997; Cowanet al. 2001) or the nature of activity of the stabilizers

is converted from one which is direction-independentto one which becomes direction-specific (Hodges &Richardson 1997).To achieve a successful outcome from any dynamic

stabilization programme, rehabilitation must becentred on the patient’s abilities rather than impair-ments. The starting point for progression must becorrect movement patterns and muscle recruitment.Training in an incorrect pattern will only reinforcethe pattern. Therefore, the assessment of musclefunction must reveal the patient’s abilities in additionto impairments. As a simple example, if lowertrapezius is tested in a standard manual muscle testposition (Kendall et al. 1993) and found to be weak,the position in which the muscle is tested, or the loadplaced on the muscle during testing, must beincrementally reduced to a stage where the contrac-tion can be initiated and maintained successfully. Thepoint from which to start re-training of lowertrapezius, if appropriate, is that where the contrac-tion can be successfully achieved. Each of the testsdescribed below is based on this principle.Gentile (1992) advocated that goal-directed func-

tional behaviour should be analysed at three differentlevels: the action itself, the movements that areincorporated in that action and the neuromotorprocesses that drive the movements – for example,the integrity of the motor and sensory systems.

DYNAMIC EXAMINATION

Knowledge of, and the indications for, inclusion ofspecific muscle length (Evjenth & Hamberg 1980) andisolated strength tests (Kendall et al. 1993) is assumedby the reader. In this paper, those components andtechniques that we have found particularly usefulduring dynamic examination will be discussed.

Observation of posture

Altered joint position such that some muscles appeartight or overactive and others lengthened or under-active provides early hypotheses in relation to musclefunction. Observation of the posture of the wholebody is an integral component of postural assessmentof the upper quarter. This should occur in the contextof the patient’s functional demands, so that itincludes evaluation of routine postures used by thepatient. Lower quarter muscle development andspinal posture can indicate whether whole bodyintegrated movement patterns are adequate fornormal upper quarter muscle function.Cervicothoracic posture has considerable influence

on scapular position and mobility and therefore, alsoglenohumeral mobility (Crawford & Jull 1991;Culham & Peat 1993; Solem-Bertoff et al. 1993).Specific analysis of scapular and arm position will

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then provide initial clues to the comparative loadcarried by the glenohumeral and scapulothoracicjoints. Finally, specific analysis of contour and toneof all relevant muscle groups should be made.

Analysis of movement patterns

Particular emphasis is placed on detailed visualanalysis of spontaneous movement patterns. Specificattention is given to recruitment of particular musclegroups related to each movement, visual assessmentof the timing of that recruitment and the relativecontribution of all body parts to the movement.An important part of normal function is the ability

to dissociate different body parts during movement.Our clinical experience has shown us that the inabilityto dissociate trunk from scapular movement, forexample, is often a significant contributor to shoulderdysfunction. In the same way, poor trunk and pelvicstability place considerable stress on the upperquarter during loaded or rapid functional activities(Kibler 1998a,b).Control of the movement, both concentric and

eccentric, is also evaluated, at speeds relevant to thepatient’s presentation. Similarly, if symptoms areonly provoked after repetition or under load, thesecomponents are included. Repetition of arm elevationwhile holding a small weight may demonstrate alteredmovement patterns not detected with a singleunloaded movement.Careful attention is placed on detection of sub-

stitution strategies and provocation of symptoms.Any asymmetries found are corrected actively, ifpossible, and passively to evaluate their effect onsymptom production and performance of the move-ment. Active correction provides some insight tothe patient’s awareness of postural or movementimpairment and the appropriate motor strategy tocorrect it. Postural correction or facilitation of amore normal muscle activation that alters pain onmovement provides a positive indication of arelationship between pain and movement and of thepotential benefit of a dynamic rehabilitation pro-gramme.

Specific evaluation of relevant force couples

In an initial examination, more importance is placedby the authors on evaluating the force couplesrelevant to stabilization of the shoulder complexthan on isolated manual muscle testing as knowledgeof the more subtle stabilizing capability of theshoulder complex allows better interpretation ofthe results of the more superficial muscle strengthassessments. Testing of more global musclefunction – termed the ‘force–dependent’ patterns byKibler (1998a) – tends to be addressed at latersessions.

Rotator cuff

The two tests that we have developed and used over anumber of years to determine dynamic control of thehead of humerus in the glenoid are the dynamicrotary stability test and the dynamic relocation test.1. The Dynamic Rotary Stability Test (DRST).

The DRST is used to evaluate the ability of therotator cuff to maintain the normal centring of thehumeral head in the glenoid when loaded throughrotation (Howell & Galinat 1987; Howell et al. 1988).In a frankly unstable shoulder or one in whichrotator cuff dynamic control is lacking, the humeralhead can be felt to translate when the rotator cuff isloaded. In more subtle situations, or where theinstability is more functional than structural, provo-cation of symptoms, alteration in the quality ofcontraction, clicking/clunking and compensation byother muscle groups are often noted, without thesensation of humeral head translation.The DRST is undertaken in different parts of the

range of glenohumeral flexion and abduction fromneutral towards the functional position(s) in whichthe patient has symptoms, whether pain, weakness,apprehension or instability (Fig. 3). The aim is to findthe position(s) in range where the patient has controlof the head of humerus as close as possible to theposition in which control is lost. The test is performedisometrically, isotonically, concentrically and eccen-trically at different speeds and under different loads.The amount of resistance added is usually light tomoderate, as the assessment is one of the ability tostabilize, rather than one of strength of rotation.2. The Dynamic Relocation Test (DRT). The DRT

is a test of the ability of the transverse force couple ofthe rotator cuff to stabilize the head of humerus inthe glenoid against a de-stabilizing load. It ispredicated on the knowledge that, in normal situa-tions, the rotator cuff functions in some degree of co-contraction to stabilize the glenohumeral joint duringdynamic function and this activation precedes that ofthe more superficial torque producing muscles (Davidet al. 1997, 2000). Co-contraction stiffens a joint andis an important feature of early stages of skillacquisition (Shumway-Cook & Woollacott 2001). Inpatients with shoulder pain, the co-contraction andpre-setting appears to be lost. Once the ability toisolate the co-contraction has been determined in theoptimal position (Fig. 4), maintenance of this isolatedcontraction can be evaluated in different positionsand during different tasks.Patients with a dysfunctional shoulder may find

isolation of this contraction to the rotator cuffdifficult without considerable facilitation and prac-tice. Once the patient can master the relocationcontraction, the ability to maintain it during armmovement is evaluated, using any relevant functionalmovement, with progressively increasing difficulty. If

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abnormality were detected in the DRST, the testposition in which loss of control was found can be re-evaluated with facilitation of dynamic relocation. Ifcontrol is improved, dynamic rehabilitation has agood chance of success. The specific techniques forthese tests are outlined elsewhere (Magarey & Jones,2003). To date, research on the reliability and validityand on establishing normative values for these tests isincomplete.

Scapular stabilization and movement

Scapular stabilizing and movement function isevaluated with two methods, using weightbearingassessment of scapular control and with modifiedPNF diagonal patterns in isolation from and inconjunction with arm movements.1. Weightbearing assessment of scapular control.

Weightbearing assessment allows evaluation of anumber of factors. In particular, it is a useful positionfor testing dissociation of spinal movement fromscapular movement and lumbar from thoracic move-ment, in addition to scapular control. Althoughdissociation can be evaluated in many different

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Fig. 3—(A, B) Dynamic rotary stability test, demonstrating two different positions in which humeral head control can be evaluated. Theoperator’s left hand is placed over the humeral head so that he is able to detect any translation that occurs during contraction of therotators. In the example shown, he is resisting isometric lateral rotation in mid-range and near end-range, in a position functionally relevantfor a thrower.

Fig. 4—Dynamic relocation test. The patient is positioned suchthat his upper arm is in approximately 60–801 of abduction in thescapular plane, as this position optimizes the line of pull ofthe lower elements of the rotator cuff. The middle finger of theoperator’s left hand is placed over the belly of subscapularis, sothat he is able to detect activity in this muscle during the test. He isalso able to feel activation of the more superficial muscles at thesame time. Alternatively, the operator may palpate subscapularisfrom a posterior approach – particularly useful if the patient has atendency to over-activate the pectorals. With his right hand, theoperator applies a very gentle longitudinal distraction force to thearm and asks the patient to draw his arm into the socket, while hefeels for activation of subscapularis, remembering that this occursin conjunction with activation of infraspinatus/teres minor.

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positions, the steps to evaluate this ability are integralto the scapular assessment and are therefore included.The standard starting position for weightbearing

assessment is four point kneeling, although assess-ment should be undertaken in multiple differentpositions, as a wide variation appears to exist inpeople’s ability to function in weightbearing. Thepositions used include leaning against a wall or table,four point kneeling, prone on elbows and weightbear-ing in the frontal and scapular plane. In the frontalplane, the contribution of the trapezius componentsof the force couple may be stressed more thanserratus anterior as a result of the lesser protractioncomponent (Inman et al. 1944; Schenkman & Rugode Cartaya 1994).In four point kneeling, the patient’s ability to

dissociate pelvic from lumbar, lumbar from thoracicmovement and thoracic from cervical movement isevaluated first. Spinal dissociation and awareness ofnatural posture will facilitate success in scapularcontrol re-training. The next step is to determinewhether the patient can protract and retractthe scapulae without concurrent spinal movement(Fig. 5). If this can be achieved, the scapula’s holdingability in neutral (mid-range) protraction is thenassessed through different stages and types of

loading. If loading in this position fails to demon-strate any impairment, the assessment can beprogressed to more challenging positions or de-mands. Equally, if scapular control is not adequate,positions which require less weightbearing or cogni-tive load should be evaluated.2. Scapular diagonal patterns. One method in

which to assess functional muscle performance isthrough the use of the PNF patterns fromglenohumeral extension/abduction/medial rotation toelevation/adduction/lateral rotation (D1) and fromextension/adduction/medial rotation to elevation/abduction/lateral rotation (D2) (Voss et al. 1953;Knott & Voss 1968; Engle 1994). During thesemovements, the scapula moves from retraction/depression/downward rotation to protraction/eleva-tion/upward rotation and from protraction/depres-sion/downward rotation to retraction/elevation/upward rotation, respectively. Having first deter-mined that the relevant range is available passively,an initial assessment of the patient’s ability toperform these scapular patterns independent of armmovement is undertaken. Without inclusion of thearm, the rotation component of the scapular move-ment is minimal, but the resultant diagonal move-ments are regularly dysfunctional with a painfulshoulder. This may simply relate to lack of familiaritywith the movement, so inclusion of stimulation withpassive, active assisted and resisted movementthrough the patterns is used to determine whetherthis is the case (Fig. 6A,B). If so, repeat assessment ofunassisted active scapular diagonal movement issignificantly improved, whereas in the impairedshoulder, such improvement is not immediatelyevident (Fig. 7).Often, patients and non-symptomatic individuals

will be biased in their un-loaded scapular diagonalpatterns, possibly reflecting learned movements. Forexample, physiotherapists and keyboard operatorsfrequently present with an exaggerated protractioncomponent at the expense of shoulder elevation in theD1 pattern.Finally, the scapula’s ability to rotate upwardly

during arm elevation is evaluated, using similarprinciples to those described for the scapularpatterns. With this assessment, the emphasis is onthe retraction/downward rotation to protraction/upward rotation component with less emphasis ondepression/elevation (Fig. 8).In most instances, the authors have found that, at

initial dynamic assessment, these tests, coupled withappropriate muscle length assessment, are all thatneed to be included for the upper quarter. Specificevaluation of isolated muscle strength may beappropriate, particularly for the athletic population,but frequently, because of impairment in the stabiliz-ing force couples, such evaluation is withheld untilstabilization is improved. However, evaluation of

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Fig. 5—Assessment of scapular function in four point kneeling.(A) The standard starting position, emphasizing spinal neutralposition. (B) A more challenging position for the subject’sright scapular region, in one arm weightbearing.

Altered motor control around the shoulder complex 201


trunk control, either the ability to isolate the deepstabilizers, as described by Richardson et al. (1999)and control of pelvic and hip muscle function, orthrough control of neutral and later out-of-neutralpostures and movements should be included, asupper quarter stability requires a strong stable baseon which to work (Fleisig et al. 1994; Kibler 1998a,b).

MANAGEMENT OF MUSCLE CONTROL

DYSFUNCTION OF THE SHOULDER

COMPLEX

From the examination findings, a management plancan be made, addressing those aspects of each part ofthe examination found to be impaired and ensuringmaintenance of an appropriate balance betweenfunction of the scapulothoracic and scapulohumeralmuscles. Training for control of one region must notoccur at the expense of the other. Similarly, trainingfor either the glenohumeral joint or scapulothoracicregion must be implemented in positions of totalbody control and stability. In this paper, thedominant features associated with the early stagesof rehabilitation are addressed.Our approach to management of muscle control

impairment of the shoulder complex follows similar

principles to those outlined in other dynamicstabilization programmes (for example, O’Sullivanet al. 1997a, b, 2000; Richardson et al. 1999;Comerford & Mottram 2001; Sahrmann 2001).Progression through the programmes is considered

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Fig. 7—(A) D2 scapular PNF pattern – depression/protractioncomponent. (B) D2 scapular PNF pattern – elevation/retractioncomponent.

Fig. 6—(A) D1 scapular PNF pattern – depression/retractioncomponent. (B) D1 scapular PNF pattern – elevation/protractioncomponent.

Fig. 8—Facilitation of scapular upward rotation. Resistance isprovided to protraction through the patient’s hand between thetherapist’s upper arm and trunk and to upward rotation throughthe lateral aspect of the scapula and through resisted extension ofthe arm. The technique may be performed with the resistance toscapular movement only if resisted arm movement provokes pain.

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in terms of attainment of specific skills and control –a criteria-based protocol (Chmielewski & Snyder-Mackler 2001) – rather than length of time, as inmany shoulder rehabilitation programmes (for ex-ample, Kunkel & Hawkins 1994; Loeb et al. 1994;Souza 2000; O’Brien et al. 1994; Scarpinato &Andrews 1994; Timmerman et al. 1994; Ciullo1996). Our approach also works on the principle ofspecificity of muscle function and the importance offunctional relevance for transfer of training (Kibler &Chandler 1994; Kibler 1998a; Shumway-Cook &Woollacott 2001) so that, as soon as possible, anyre-training occurs in positions relevant to thepatient’s habitual activities.The authors use the concept of re-training by

breaking function into interim steps (Schmidt 1991;Winstein 1991). One goal of any motor controlrehabilitation is to gain awareness of, and the abilityto, activate the deep stabilizers of the region prior toactivation of the, usually, more superficial torqueproducing muscles and to maintain that activationduring activity. Another is retraining of optimalmovement patterns. Both involve motor programmeretraining and therefore, refined, controlled activa-tion of the deep stabilizing force couples, using eitherstrategies of isolation or controlled posture or move-ment facilitated by imagery. Activation of isolatedmuscles is often difficult to conceptualize. Therefore,patient explanation of the reasons for the programmeand the processes required become important aspectsof the management. Similarly, imagery can facilitateunderstanding of the action required. Without thepatient’s understanding and collaboration in theprocess, it is doomed to failure, as perseverance, evenwhen there is little obvious initial change, is essentialto success.Pain inhibition appears to have a powerful

influence on the motor system (Richardson 1987;Hodges & Richardson 1996, 1998; Cowan et al 2001),so palliative treatment may be necessary to decreasepain in the early stages. However, there is no need towait for pain to settle before starting a motor controlprogramme within a pain-free range at a load thatdoes not provoke symptoms, as often, restoration ofcontrol acts as a potent pain inhibitor.Retraining motor programming, or the neural

control in Panjabi’s (1992) model, is dependenton motor learning. Motor learning involveslearning new strategies for sensing as well asmoving, arising from a complex of perception—cognition—action processes (Shumway-Cook &Woollacott 2001). Motor learning can be enhancedby the use of mental imagery, tactile, verbal, visual,taping, weightbearing and movement orientedcues – different cues are effective with differentpeople. Initially, facilitation is undertaken in anoptimal position for the relevant muscles, usuallymid-range.

Frequent stimulation and repetition improveawareness and the ability to activate far more thanan isolated exercise session once a day (Catalano &Kleiner 1984; Shumway-Cook & Woollacott 2001).Therefore, while learning the activation technique, weencourage patients to practise it for a few minutesseveral times a day. Initially, each region is trained inisolation – that is, the rotator cuff is worked with thescapula in an unchallenged position and vice versa.The muscles are worked in co-contraction in theirrelevant force couples, with the contractions initiallyisometric and isotonic with low load, with a gradualbuild up and release.Once dynamic stability is established, the positions

in which control is emphasized are determined by theexamination findings and functional needs of thepatient. During the DRST, for example, the patientmay have demonstrated good control up to 601 ofabduction in isotonic external rotation, while iso-metric control may have been satisfactory to 1201. Ifthese positions are re-tested with pre-setting of therotator cuff via the DST manoeuvre, better controlmay be found. Training should then be started inthose positions in which the patient has control, butas close to the position where that control is lost aspossible. Isometric and isotonic training can beundertaken concurrently, as long as the patient isaware of the different sensations associated withcontrol and lack of control. Teaching this differencein feel may be time consuming initially, but isessential to success of the programme, as training ina position in which control is lacking may reinforcepoor movement patterns.As control is mastered, the load can be increased

cognitively by asking the patient to maintain controlin one area and work on the other. Once activationcan be achieved in an isometric, stable situation, weencourage the patient to incorporate the activationinto simple tasks of daily living. Deliberate activationof the rotator cuff in the DRT manoeuvre whilewaiting at traffic lights in a car, or prior to reachingto answer the telephone; setting of the scapulae in anoptimal position while at a computer or beforereaching into a cupboard are examples of cognitivechallenge. When such tasks are mastered, physicalload, speed and more complicated, integrated taskscan be progressively added. Progression is made withany particular exercise only when the step before ismastered. The more times the technique is repeatedand the more different situations in which it isrepeated, the quicker the patient is likely to master it.While this intensive training is underway for the

upper quarter, any more general impairment inmotor control should also be addressed. Issues suchas poor dissociation may need to be improved beforescapular work can be initiated and transversusabdominis and gluteal control can be incorporatedand progressed from the first day of treatment. If



control is good, but general strengthening is indi-cated, this can be undertaken in conjunction with theupper quarter control programme. Progression ineach region may be at different rates, depending onthe degree of impairment, so each component mustbe regularly checked and progressed individually.Once this level is mastered, function is re-evaluated

to determine the need for further progression. Formany non-athletic patients, we have found thataddressing the motor control issues and teachingthe patient appropriate strategies to continue mon-itoring and stimulating the control are sufficient for areturn to normal function. However, in the manuallabourer or overhead athlete, further progression isneeded. Whether rehabilitation is ceased at this pointor continued, the authors have found that the patientwho has had pain in the shoulder needs to continuallymonitor their dynamic control and practise itregularly, or the control tends to be lost. A briefself-directed activation session once or twice a weekor deliberate pre-activation during normal function issufficient to maintain the control once mastered tothis level.

CONCLUSION

In this paper, we have presented an approach todynamic evaluation and management of the shouldercomplex that we use in conjunction with detailedpassive examination and management as indicatedfor each patient. The ideas presented here representone set of strategies that we have found to improveshoulder function. A deliberate setting in neutralrather than specific pre-activation can also beeffective with different patients. Interestingly, anumber of researchers have demonstrated that stablemovement patterns become more unstable just priorto a transition to a new movement pattern in bothadults and children (Kelso & Tuller 1984; Gordon1987; Woollacott & Shumway-Cook 1990). Thera-pists should be aware of this possibility whenreassessing patients undergoing a dynamic rehabilita-tion programme such as the one suggested. It isimportant that patients be made aware of thispossibility so that they do not become discouragedthrough this phase of their training.While the dynamic component of our management

approach has not been challenged through clinicaltrial, it is based on similar principles to thosedemonstrated as effective in the cervical and lumbarspine regions (O’Sullivan et al. 1997a,b, 2000; Jull2000; Jull et al. 2002). If the whole process is linkedby sound reflective clinical reasoning (Jones et al.2000), the optimal balance of passive and dynamicmanagement will be included.

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Dynamic Evaluation and Early Management of Altered Motor Control Around the Shoulders Complex

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