PREVIEW ONLY 6/06/2013. Andrew Ellis PRINCIPLES OF SHOULDER REHABILITATION AND RETURN TO SPORT. Joel Werman

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address associated with this webinar account Say I m a webinar attendee I don t have an account Andrew Ellis BSc (Ex. Sci), M.

(Sports Physio) Specialist Sports Physiotherapist Will commence LIVE from Sydney, Australia at 7:30pm AEST Be sure to convert to

Select Telephone and call in toll - FREE to hear the presentation Specialist Sports Physiotherapist and Fellow of the Australian

Specialized in the treatment of shoulders for over 23 years Founding member of the Shoulder and Elbow Physiotherapists of Australia

1 Need technical support for this live event? Please call , then press 1 Be sure to convert to your own time zone at NOTE: You will be initially asked for the address associated with this webinar account Say I m a webinar attendee I don t have an account Andrew Ellis BSc (Ex. Sci), M. Phty PRINCIPLES OF SHOULDER REHABILITATION AND RETURN TO SPORT World Health Webinars CEO World Health Webinars (Australia/NZ) Host Presented by: Joel Werman B.App.Sc. (Physio), Grad.Dip.Sc. (Sports Physio) Specialist Sports Physiotherapist Will commence LIVE from Sydney, Australia at 7:30pm AEST Be sure to convert to your own time zone at Click red button to minimise Joel Werman Dodgy computer speakers? Select Telephone and call in toll - FREE to hear the presentation Specialist Sports Physiotherapist and Fellow of the Australian College of Physiotherapy. Specialized in the treatment of shoulders for over 23 years Founding member of the Shoulder and Elbow Physiotherapists of Australia group You will be muted during every webinar. Make as much noise as you like :) Questions? We ll answer them all at the end Specialist Sports Physiotherapist Lectured extensively on the subject of the shoulder covering a wide range of subjects Through extensive clinical experience has devised own approach to assessment and treatment of the shoulder which is based on a structured clinical reasoning model. Need technical support? Please call , then press 1 You will need to tell them that you are a webinar attendee and do not have an account with Citrix. 1

PRINCIPLES OF SHOULDER REHABILITATION AND RETURN

Combination Joel Werman APA Specialist Sports

notes available to radiological after purchase

LISTEN to the history was there a significant

2 PRINCIPLES OF SHOULDER REHABILITATION AND RETURN TO SPORT 1. Structural 2. Functional 3. Combination Joel Werman APA Specialist Sports Physiotherapist Fellow of The Australian College of Physiotherapists It is imperative to determine which category the patient falls into so as to establish appropriate goals, expectations and management outcomes. 1. Structural 1.Structural Should you proceed immediately Full notes available to radiological after purchase from investigations and/or specialist referral? LISTEN to the history was there a significant trauma or incident? has this built up over many years? unable to sleep at night due to the pain You can t make These a silk notes purse are a preview. out of a sow s ear LOOK at the patient Severe pain and disability 2

socket throughout a full range of movement. 3.

combined with (often) secondary/ compensatory functional deficits.

expectations of the patient to determine the management options.

general muscle tone, Signs of hyper-mobility Active range of motion- assess quality of

3 2. Functional Timing and tuning. The objective of the shoulder is for the ball to stay centered in the middle of the socket throughout a full range of movement. 3. Combination (structural and functional): The existence of some structural issues combined with (often) secondary/ compensatory functional deficits. You must understand the extent of the structural concerns together with the needs and expectations of the patient to determine the management options. The objective examination will directly dictate the rehabilitation Posture, symmetry, general muscle tone, Signs of hyper-mobility Active range of motion- assess quality of movement with respect to scapular dyskinesia, pain and end range. Passive range of motion. Is the restriction These notes of active are range a preview. the same passively? Can the arm go Slides further are when limited. performed passively? 3

Re-assess restricted or painful active movement with techniques to manually These reposition notes the are scapular, a preview.

Scapular dumping : support under the inferior angle of the scapular and reassess active forward elevation &/or active range of external rotation in neutral

you strengthen it ( Ian Collier These - 1988 notes ) are a preview.

objectives WHAT DOESN T WORK: Electrotherapy: interferential ultrasound laser short wave RESEARCH / EVIDENCE : The Cochrane Collaboration - Cochrane Reviews

Methodological quality was variable and trial populations were generally small (median sample size = 48, range 14 to 180).

32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86).

Laser therapy was demonstrated to be more effective than placebo (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator cuff tendinitis.

4 Re-assess restricted or painful active movement with techniques to manually These reposition notes the are scapular, a preview. or the head of the humerus in the Slides glenoid are limited. Scapular dumping : support under the inferior angle of the scapular and reassess active forward elevation &/or active range of external rotation in neutral Strength testing : manually Hand held dynamometer Re-test with active scapular retraction METHOD continued Where it s tight you stretch it, where it s weak you strengthen it ( Ian Collier These notes ) are a preview. Clinical reasoning : Identify the deficient component parts of the shoulder your objective examination Justify your intervention and prioritize your objectives WHAT DOESN T WORK: Electrotherapy: interferential ultrasound laser short wave RESEARCH / EVIDENCE : The Cochrane Collaboration - Cochrane Reviews 2003 Physiotherapy interventions for shoulder pain Green S, Buchbinder R, Hetrick SE Main results Twenty six trials met inclusion criteria. Methodological quality was variable and trial populations were generally small (median sample size = 48, range 14 to 180). Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more effective than placebo (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43) respectively). There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis. When compared to exercises, ultrasound is of no additional benefit over and above exercise alone. There is some evidence that for rotator cuff disease, corticosteroid injections are superior to physiotherapy and no evidence that physiotherapy alone is of benefit for adhesive capsulitis 4

WHAT DOESN T WORK: Passive joint mobilization RESEARCH / EVIDENCE : Does Passive Mobilization of Shoulder Region Joints Provide Additional Benefit

A Randomized Controlled Trial Ross Yiasemides, Mark Halaki, Ian Cathers and Karen A. Ginn Physical Therapy February 2011 vol. 91 no.

shoulder region joints, to exercise and advice is more effective than exercise and advice alone in the treatment of people with shoulder pain and

WHAT DOESN T WORK: Most other passive interventions, particularly in isolation WHAT DOES WORK: Exercise therapy RESEARCH / EVIDENCE : Physiotherapy

Methodological quality was variable and trial populations Full were notes generally available small (median after sample purchase size = 48, range

5 WHAT DOESN T WORK: Passive joint mobilization RESEARCH / EVIDENCE : Does Passive Mobilization of Shoulder Region Joints Provide Additional Benefit Over Advice and Exercise Alone for People Who Have Shoulder Pain and Minimal Movement Restriction? A Randomized Controlled Trial Ross Yiasemides, Mark Halaki, Ian Cathers and Karen A. Ginn Physical Therapy February 2011 vol. 91 no Conclusion This randomized controlled clinical trial does not provide evidence that the addition of passive mobilization, applied to shoulder region joints, to exercise and advice is more effective than exercise and advice alone in the treatment of people with shoulder pain and minimal movement restriction. WHAT DOESN T WORK: Most other passive interventions, particularly in isolation WHAT DOES WORK: Exercise therapy RESEARCH / EVIDENCE : Physiotherapy interventions for shoulder pain Green S, Buchbinder R, Hetrick SE Main results Twenty six trials met inclusion criteria. Methodological quality was variable and trial populations Full were notes generally available small (median after sample purchase size = 48, range from 14 to 180). Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more effective than placebo (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43) respectively). EXERCISE THERAPY: Addresses: a. Flexibility b. Strength - neuromuscular control - muscle hypertrophy The relevance of an exercise is how it relates to the patient s problem. Clinical reasoning requires the physio to justify the choice of intervention as dictated by the initial examination. 5

OBJECTIVES: Goal of Physiotherapy: EXERCISE THERAPY: a.

centered in the glenoid fossa through a full range of movement a home These program notes of

gently but regularly throughout Full notes the available day.

adjunct ABNORMAL BIOMECHANICS PAIN AND NEUROMUSCULAR CONTROL: Neuromuscular control of

Pain inhibits muscle activation at a central level.

Strength : The scapular provides a dynamic platform for the arm.

to the subacromial space Muscle Imbalance PAIN!

6 OBJECTIVES: Goal of Physiotherapy: EXERCISE THERAPY: a. Flexibility: to normalize the shoulder girdle mechanics to allow the humeral head to stay centered in the glenoid fossa through a full range of movement a home These program notes of are a preview. appropriate stretches Slides are done limited. gently but regularly throughout Full notes the available day. Do one after purchase from minute of stretching 4 to 6 times a day soft tissue massage as an adjunct ABNORMAL BIOMECHANICS PAIN AND NEUROMUSCULAR CONTROL: Neuromuscular control of scapular musculature is diminished in the presence of pathology (Ludewig, 2000). Pain inhibits muscle activation at a central level. Altered mechanics (scapula dyskinesia) Tissue damage Inflammation EXERCISE THERAPY: b. Strength : The scapular provides a dynamic platform for the arm. Alteration of the normal anchoring function of the scapular stabilizers results in compromise to the subacromial space Muscle Imbalance PAIN! EXERCISE THERAPY: Incidence of scapular dyskinesia: Studies have shown dysfunction in scapula position and mechanics in 68% of cases with abnormalities of the rotator cuff and 100% of those with glenohumeral instability (Kibler & McMullen, 2003) EXERCISE THERAPY: Crane analogy: If the base is not anchored securely, the crane is unable to lift the load. 6

4 PHASES OF REHABILITATION Crawl walk run sprint! Would you ask your limping patient to go for a run? Would you expect a crane to lift a load if the base was not securely anchored?

Analysis study of a scapular orientation exercise and subjects ability to learn the exercise. Manual Therapy. 14 (13-18). 2009. Mottram, S.L., Woledge, R.C., Morrisse, D.

7 4 PHASES OF REHABILITATION Crawl walk run sprint! Would you ask your limping patient to go for a run? Would you expect a crane to lift a load if the base was not securely anchored? Phase 1: Reactivate the scapular stabilizers Phase 2: Add light resistance Phase 3: Muscle hypertrophy Phase 4: Sport specific rehabilitation THEORY: How do you reactivate the scapular stabilizers? Analysis study of a scapular orientation exercise and subjects ability to learn the exercise. Manual Therapy. 14 (13-18) Mottram, S.L., Woledge, R.C., Morrisse, D. Motion Examples of cues included passive/assisted movements into the SOE position, tactile feedback with gentle pressure on the acromion to encourage upward rotation, recognition of a feeling of widening the chest to encourage posterior tilt, demonstration of common wrongly directed movements, demonstration and verbal feedback THEORY: The subacromial impingement syndrome of the shoulder treated by conventional physiotherapy, self-training, and a shoulder brace: Results of a prospective, randomized study Markus Walther, MD, PhDa, Andreas Werner, MD, PhDb, Theresa Full notes Stahlschmidt, available MDc, after Rainer purchase Woelfel, MD, from 2004 Journal of Shoulder and Elbow Surgery Pull the shoulder blades back and push the sternum forward THEORY: Journal of Bodywork and Movement Therapies (2006) 10, Self-management of shoulder disorders Part 3: Craig Liebenson, DC Starting with light resistance perform scapular setting (pulling your shoulder back and down). PHASE 1 Scapular setting: Early rehabilitation focuses on reestablishing normal scapular control. Setting the scapular back and level ( NOT DOWN! ) while raising the arm away from the body. The ability to dissociate movement of the arm from the scapular is the essential building block of restoring normal biomechanics. PHASE 1 The objective is to normalize the mechanics of the scapular at the neuromuscular level by initially over- activating the retractors as static stabilizers (not as prime movers). Through conscious over-activation, subconscious control is restored. Unilateral control initially. 7

PHASE 2 Begin adding external loads to the arm while

All exercises must be performed with the scapular anchored

PHASE 3 (early) Increase loads and begin training in outer

sport specificity All with an emphasis on control All

PHASE 3 (late) After the initial phase of scapular

for more advanced upper body strengthening while the

that they are compatible with the demands of the individual

requirements of the sport PHASE 4 Return to sport: Must be

frequency, duration, environment, equipment and technique

8 PHASE 2 Begin adding external loads to the arm while performing exercises in an inner range of movement. All exercises must be performed with the scapular anchored in it s retracted (back & level ) position. PHASE 3 (early) Increase loads and begin training in outer ranges, working to include aspects of endurance, speed and sport specificity All with an emphasis on control All exercises must be performed without symptoms! PHASE 3 (late) After the initial phase of scapular retraining, progression of the rehabilitation should allow for more advanced upper body strengthening while the scapular is allowed to naturally adopt it s appropriate position. PHASE 4 Return to sport: How do you know when the athlete is ready to return to sport? When the objective findings have normalized to the extent that they are compatible with the demands of the individual s sport Must be able to understand the biomechanical requirements of the sport PHASE 4 Return to sport: Must be graduated with consideration to the variables of intensity, frequency, duration, environment, equipment and technique TREATMENT Establish realistic and explicit goals with the patient in terms of: time frames outcomes (measureable) patient involvement therapist s role determination of success or failure alternative options and when to instigate these 8

EXPECTATIONS / OUTCOMES: Rule of thumb: Initial improvement

of a contract Average patient requires about 4 6 visits over

Make the exercises achievable set the patient up for

diagrams, instructions re repetitions/ frequency PATIENT

Feed-back: These positive notes and negative are a preview.

Call it as it is Constant Full notes reassessment available

9 EXPECTATIONS / OUTCOMES: Rule of thumb: Initial improvement generally takes as many weeks as it has been months, that the problem has existed. By 12 weeks you will have 80% of your potential improvement behind you. PATIENT COMPLIANCE: How do you get your patients to do their exercises? Appropriate education Goal setting written out in the form of a contract Average patient requires about 4 6 visits over a two to three month period. Make the exercises achievable set the patient up for success, not for failure Write everything down- clear diagrams, instructions re repetitions/ frequency PATIENT COMPLIANCE: Suitable scheduling of follow up appointments Feed-back: These positive notes and negative are a preview. as required. Call it as it is Constant Full notes reassessment available and after comparisons purchase with from the established goals The young athlete: reassure them that the exercises will (hopefully) fix their pain, but also improve their performance EXERCISE THERAPY: Exercise prescription: Which exercise? How many? How often? What force / resistance? Pain? Technique 9

Sports Participation and Humeral Torsion RJ Whitely,KA These Ginn, LL notes Nicholson are a - preview. J Orthop Sports Phys, 2009 - ukpmc.ac.

adults. BACKGROUND: It is hypothesized that humeral retrotorsion develops.

or more degrees of IR or 8 degrees total arc difference), it is known as glenohumeral internal rotation deficit or total arc of motion deficit.

Bennett lesion A/C joint pathology Suprascapular nerve entrapment A detailed consideration must be given to the entire kinetic chain when assessing the

10 Sports Participation and Humeral Torsion RJ Whitely,KA These Ginn, LL notes Nicholson are a - preview. J Orthop Sports Phys, ukpmc.ac.uk Retroversion of the humerus in throwing athletes is a developmental consequence of participation from a young age STUDY Full DESIGN: notes available Cross-sectional after study. purchase from OBJECTIVE: To examine differences between arms humeral torsion in adult and adolescent throwing and nonthrowing athletes, and nonathletic adults. BACKGROUND: It is hypothesized that humeral retrotorsion develops... Glenohumeral internal rotation deficiency (GIRD): When the amount of IR or total arc of motion difference reaches a certain threshold (typically 20 or more degrees of IR or 8 degrees total arc difference), it is known as glenohumeral internal rotation deficit or total arc of motion deficit. Other pathology of the throwing shoulder includes: Internal impingement Anterior instability SLAP lesions Rotator cuff and bicipital tendinopathy Bennett lesion A/C joint pathology Suprascapular nerve entrapment A detailed consideration must be given to the entire kinetic chain when assessing the shoulder of the throwing athlete. Kinetic chain assessment: Foot and ankle range of movement. Previous ankle sprain and loss of dorsiflexion Hip/knee Full notes control. available Single leg after quarter purchase squat from Glute/ hamstring eccentric control Core strength. Eccentric control of trunk flexion on the follow through Adequate flexibility at each segment 10

CONCLUSION Treatment: As previously discussed, the objective of rehabilitation of the throwing shoulder is to identify the deficient biomechanical

Establish an appropriate plan of action with the patient Physiotherapy rehabilitation for shoulder pathology aims to normalize deficient shoulder

muscle control and strength, is essential CONCLUSION THANK YOU Rehabilitation programs must be suitably structured to work in a graduated manner

11 CONCLUSION Treatment: As previously discussed, the objective of rehabilitation of the throwing shoulder is to identify the deficient biomechanical components and set about strategies to correct them Assess issues of flexibility, neuromuscular control and strength as relevant to the thrower Establish an appropriate plan of action with the patient Physiotherapy rehabilitation for shoulder pathology aims to normalize deficient shoulder mechanics A targeted, clinically reasoned approach, determined from the initial objective examination, addressing issues of flexibility and/or muscle control and strength, is essential CONCLUSION THANK YOU Rehabilitation programs must be suitably structured to work in a graduated manner from least to more demanding exercises Use this logical approach to help make treating shoulders easy! Join US on Facebook Live Q & A With Joel Werman 11

12 Coming up next week Live Q & A With Joel Werman Thank you From Joel Werman & World Health Webinars Australia / NZ 12

PREVIEW ONLY 28/07/2013. Andrew Ellis. Jenny McConnell. This webinar will begin in the next few minutes. Multidirectional Instability of the Shoulder

PREVIEW ONLY 28/07/2013. Andrew Ellis. Jenny McConnell. This webinar will begin in the next few minutes. Multidirectional Instability of the Shoulder This webinar will begin in the next few minutes Need technical support for this live event? Please call 1800 006 293, then press 1 NOTE: You will be initially asked for the email address associated with