Therapeutic Exercise for the Shoulder

Introduction

The primary goals of treating shoulder disease through conservative management are pain relief and improved function, and exercise rehabilitation is often the cornerstone of this conservative management program. As part of physical therapy management, the goal of exercise is to correct modifiable Physical impairment is thought to cause pain and dysfunction rather than treat pathology. Therapeutic exercises are commonly used to treat and manage a range of shoulder conditions and are often advocated to address movement postural muscle activation dysfunction Proprioception and strength, backed by extensive research.

The Evidence

Exercise can have a beneficial effect, and incorporation with weight-bearing exercise is safe and does not adversely affect results [1]. In rotator cuff tendinopathy, both home and supervised exercise programs were found to be more effective than no intervention or placebo and as effective as the minimal comparison Such as functional scaffolds or active comparators such as multimodal physiotherapy surgery [1].

More recently, there has been increased attention to exercise rehabilitation as a means of managing partial and full-thickness rotator cuff tears by specifically addressing weakness and functional deficits. Recent research has shown that patients who choose physical therapy have demonstrated High satisfaction with improved function and success in avoiding surgery [2][3].

There is no consensus on acceptable pain tolerance between-exercise activity levels and dosing frequency approaches for specific exercise inclusion. [4][5][6][7]. Optimal parameters of exercise and load have not been determined, nor has the mechanism by which response to treatment occurs [1].

Principles of Therapeutic Exercise

Principles of Therapeutic Exercise [8]

Effect of Therapeutic Exercise

The exact reasons why exercise is beneficial are unknown, and it has been suggested that the effects of exercise may be multifactorial [2]. This may include:

• Influence on pain modulation
• Provides therapeutic effect on structurally damaged rotator cuff muscles and tendons
• Insufficient muscle compensation for exercise strategies
• Psychological benefits, such as reduced fear of exercise
• Placebo

Exercise Prescription

It is well known that training and educating patients to improve scapular stability, proper neuromuscular control of the shoulder girdle, and chest posture is critical to a well-designed rotator cuff exercise program [2]. Scapular Rhythm Kinematic Interactions between the Scapula and Scapula The humerus is important for optimal function of the shoulder [9]. Changes in the position of the scapula relative to the humerus may be secondary to pain, soft tissue tightness, altered intensity of muscle activation, muscle fatigue, and imbalance in chest posture, which may lead to scapular abnormalities Kinematic dysfunction of the scapular rhythm and may lead to shoulder pain [2]. The scapular stabilizer muscles ensure that the scapula maintains a stable base, and the rotator cuff muscles can adjust the stable base of the glenoid fossa relative to the humeral head during upper extremity procedures sports. Alterations in the position and control of the scapula provided by the scapular stabilizing muscles are thought to disrupt the stability and function of the glenohumeral joint [9][10][11], resulting in acromial instability, subacromial and rotator cuff-related shoulder pain [2][12]. Changed Changes in muscle activity or strength and temporal properties of the upper and lower serratus anterior trapezius muscles are frequently observed in individuals with subacromial-related shoulder pain and/or rotator cuff tears. [2]

Recent EMG studies have shown that the rotator cuff muscles are recruited in a direction-specific interactive pattern during shoulder flexion and extension exercises. Wattanaprakornkul et al. [13][14] demonstrated that during flexion, the posterior externally rotated cuff muscles (supraspinatus and Infraspinatus) was significantly more activated than the anterior internal rotator cuff (subscapularis) and the opposite was true during extension. This muscular contraction in a mutually specific direction supports the role of the rotator cuff as the dynamic force of the shoulder joint A stabilizer that balances anterior-posterior translational forces, and the rotator cuff provides shoulder support by preventing flexion and extension of the humerus prime movers, such as the deltoid muscle that translates the humeral head from the glenoid socket. This EMG knowledge gives us more Information specific to the rotator cuff muscles in different positions and ranges of motion.

Retraining and strengthening of the anterior deltoid has also been a focus of attention in patients with massive cuff tears. The Torbay protocol was developed and tested by Roberta Ainsworth, initially as a pilot study and then in an RCT to develop a rehabilitation program for patients diagnosed with mass irreparable rotator cuff tears [3], and provides guidelines for physical therapy rehabilitation in these patients based on a progressive strengthening program targeting the anterior deltoid and teres minor. The plan is based on observations of patients with a large rotator cuff Tears utilize the anterior portion of the deltoid to achieve elevation without shearing up the humeral head.

The deltoid is a three-part pinnate muscle that covers the entire shoulder joint and is recruited to move the humerus relative to the scapula. The front is the primary movement for shoulder flexion and horizontal shoulder adduction, while the lateral/medial Functions during abduction and horizontal abduction, the posterior is recruited during horizontal abduction. An important function of the deltoid is to prevent subluxation or even dislocation of the humeral head, especially when bearing weight, by improving joint stability by Resists low pull forces applied to the upper body. Analysis of the deltoid showed that the anterior deltoid was most likely to cause joint instability. The deltoid is the anterior stabilizer of the glenohumeral joint, which abducts and abducts the arm As the shoulder becomes unstable, the rotation and stabilizing functions of the deltoids become more important [15]. Many strength training exercises have traditionally emphasized the anterior deltoid, which may contribute to the development of muscle imbalances among individuals Part of the deltoid and increases joint instability. Therefore, combining strength training with the mid and posterior deltoids can enhance its role in improving shoulder stability. [16]

Check out a demo 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

Mode of Delivery

Group and individual physiotherapy interventions incorporating exercise are aimed at reducing pain and disability, but the consensus is that evidence is lacking for the most effective treatment modality for exercise rehabilitation in people with musculoskeletal pain. Although it is clear that the group Individual physical therapy interventions combined with exercise are superior to minimal or no treatment, and it is unclear whether one is superior to the other [17]. O’Keeffe et al. [17] found only small clinically irrelevant differences in pain or disability outcomes between group and individual physical therapies, and concluded that group interventions may need to be considered more frequently given their similar effectiveness and likely lower healthcare costs. Especially in the shoulder recent evidence suggests Group exercise classes can improve shoulder pain and disability in patients with nonspecific shoulder pain [18]. how is the pain There is much disagreement about the relationship between pain and exercise. Should Exercise Be Painful During Rehab? If yes, how much pain is ok? If not, then our What impact does this have on the management of very irritable patients who are limited in their ability to participate in any exercise program? Smith et al. [19] suggested that, in the short term, regimens using pain exercises for musculoskeletal disorders can provide small but significant benefits More beneficial than pain-free exercise, but evidence is lacking in the medium to long term. Chronic Musculoskeletal Pain Pain during therapeutic exercise need not be a barrier to successful outcomes. What about fatigue? What role does fatigue play in shoulder pain? What impact When we as physical therapists prescribe exercise to individuals? Recent studies have shown that patients with shoulder pain have significantly increased supraspinatus tendon thickness in response to acute fatigue loads compared with pain-free controls. Reduced subacromial space It was also noted that return to baseline of rotator cuff fatigue was delayed by up to 24 hours due to rotator cuff tendinopathy due to rotator cuff pain. Rehabilitation plan for rotator cuff tendinopathy needs to consider the possibility of tendon gain The thickness and reduction of the subacromial space after loading, so the type and dose of exercise should be adjusted to avoid fatigue from excessive loading, and an appropriate recovery period should be implemented after loading to fatigue [20]. General Movement Interventions for the Shoulder Girdle Here are some Therapeutic Exercise Guidelines – (Book Reference – Kisner C Colby LA Borstad J. Therapeutic exercise: foundations and techniques. Fa Davis; 18 October 2017) Exercise Techniques in the Acute and Subacute Early Phases of Tissue Healing Early Glenohumeral Joints Movement usually involves passive ROM in the painless range. If tolerated, begin active assisted ROM exercises. Wand exercises for flexion/extension/internal rotation/external rotation/abduction/adduction Wand exercises with towels Wall (window) washing movements Circular pendulum (Codman’s) exercises Early PROM/A-AROM Movement of the scapula in lateral recumbency to perform distraction-contraction of the scapula elevation depression. [21] Exercise Techniques to Increase Flexibility and Range of Motion Stretching exercises increase joint capsule mobility and muscle lengthening. Latissimus dorsi pectoralis major stretch The pectoralis minor, levator scapulae, and trapezius muscles are carefully assessed and evaluated, and self-stretching exercises are given to the patient when needed. [21] Exercises to develop and improve muscle performance and functional control These exercises should be started at a minimum and gradually Stress levels are complex. Initially choose exercises that help the patient focus on activating the correct muscles and perform them at the appropriate time and sequence. Isometric contraction of the scapular muscles and glenobrachial muscles can be performed. Stabilization of the scapula can be achieved by opening Chain/closed chain exercises from static to dynamic using hand resistance or a wall. E.g. Push-ups push-ups stand-up push-ups superman exercise etc. Dynamically strengthen the glenohumeral joint using elastic resistance pulleys or hand weights. [21] Agreement of different shoulders Conditions The following are specific shoulder conditions that provide detailed guidance for physical therapy treatments and exercises.