Download Using Neutrality To Increase Shoulder Strength

Using Neutrality To
Increase Shoulder
Strength
SUSAN M. T. McKAY, OTR/L
[email protected]
GOAL
Look at shoulder rehab in a different
way. Strength can come from
increasing flexibility and placing a joint
in proper alignment. Conversely,
strengthening a shoulder in improper
alignment can cause injury.
WHY PICK ON THE
SHOULDER?
 Impairs function/limits ADL’s
 Pain in shoulder
 Compensatory patterns can lead to back
pain
 Elderly rely on upper body to
move/ambulate
 The sooner issues are treated, the less
physiological damage there is
SHOULDER ANATOMY
 Muscles and how they move
 A basic review and more
 Important to know…
SHOULDER ANATOMY
 Supraspinatus
 Initiates and assists deltoid in abduction of
arm and acts with other rotator cuff muscles.
SHOULDER ANATOMY
 Infraspinatus
 Laterally rotate arm; helps to hold humeral
head in glenoid cavity of scapula
SHOULDER ANATOMY
 Subscapularis
 Medially rotates arm and adducts it; helps to
hold humeral head in glenoid cavity of
scapula
SHOULDER ANATOMY
 Teres Minor
 Laterally rotate arm; helps to hold humeral
head in glenoid cavity of scapula
SHOULDER ANATOMY
 Deltoid
 Anterior part: flexes and medially rotates
arm; Middle part: abducts arm; Posterior
part: extends and laterally rotates arm
SHOULDER ANATOMY
 Latissimus dorsi
 Extends, adducts, and medially rotates
humerus; raises body toward arms during
climbing
SHOULDER ANATOMY
 Teres Major
 Adducts and medially rotates arm
SHOULDER ANATOMY
 Pectoralis major
 Adducts and medially rotates humerus;
draws scapula anteriorly and inferiorly;
Acting alone: clavicular head flexes humerus
and sternocostal head extends it
SHOULDER ANATOMY
 Pectoralis Minor
 Stabilizes scapula by drawing it inferiorly
and anteriorly against thoracic wall
SHOULDER ANATOMY
 Coracobrachialis
 Helps to flex and adduct arm
SHOULDER ANATOMY
 Rhomboid Major and Minor
 Retract scapula and rotate it to depress
glenoid cavity; fix scapula to thoracic wall
SHOULDER ANATOMY
 Serratus Anterior
 Draws scapula forward and upward; abducts
scapula and rotates it; stabilizes vertebral
border of scapula
SHOULDER ANATOMY
 Trapezius
 Elevates, retracts and rotates scapula; superior fibers
elevate, middle fibers retract, and inferior fibers depress
scapula; superior and inferior fibers act together in
superior rotation of scapula
SHOULDER ANATOMY
 Levator Scapula
 Elevates scapula and tilts its glenoid cavity
inferiorly by rotating scapula
CLAVICLE AND SCAPULA
 Things you may or may not know
 Very important to address when
addressing the shoulder
 May be the primary reason limiting the
shoulder
CLAVICLE
 Looking from the front, the medial 2/3 is convex and
lateral 1/3 is concave- only long bone that is horizontal
in the body
 Acts as a “strut” to hold the arm away from the body
and allows space for veins and nerves
 Muscles/Ligament attached:
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Trapezius muscle
Deltoid Muscle
Coracoclavicular ligament
Sternocleidomastoid muscle
Pectoralis major muscle
Subclavius muscle
CLAVICLE
 Sternoclavicular (SC) Joint Structure
 Articulation of clavicle with the sternum
 Only direct attachment of the upper extremity to the
skeleton
 Clavicle moves in 3 planes (3 degrees of freedom)
 Elevation and Depression of SC
 Protraction and retraction of SC
 Axial Rotation of clavicle
 All shoulder girdle movements start at the SC joint, if it is
fused not only the clavicle and scapula would be limited
but the entire shoulder!
CLAVICLE
 The Acromioclavicular Joint (AC) allows motion in all 3
planes, allowing the scapula to maintain contact with
the posterior thorax:
 Upward rotation and downward rotation
 Rotation in the horizontal plane
 Rotation in the sagittal plane
 Acromioclavicular Ligament
 Joins clavicle to acromion, prevents dislocations of
the scapula
CORACOLCLAVICULAR
LIGAMENT
 Attaches twice on clavicle and the
coracoids process of scapula
 It is responsible for bearing most of the
weight of the hanging arm. Without this
ligament, the arm is unable to hang from
the body
CORACOCLAVICULAR
LIGAMENT
SCAPULA
 The scapula is only attached to the thorax by
 ligaments at the AC joint
 suction mechanism provided by
 serratus anterior
 subscapualaris
 Main stabilizers of the scapula:
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Serratus anterior
Rhomboid major and minor
Levator scapulae
Trapezius
SCAPULOHUMERAL
RHYTHM
 The first 30 degrees of
shoulder joint motion is
pure glenohumeral joint
motion
 •After that, for every 2
degrees of shoulder flexion
or abduction that occurs,
the scapula must upwardly
rotate 1 degree
 •This 2:1 ratio is known as
scapulohumeral rhythm
SCAPULAR DYSKINESIS
 Winging
 Posterior movement of the medial border of the scapula,
Rotation about a vertical axis
 Long Thoracic nerve injury
 Weak serratus anterior
 Usually from poor posture, especially when stress is carried in
their neck- rhomboid and levator scapulae muscles are shortened
SCAPULAR DYSKINESIS
 Tipping
 Posterior movement of the inferior angle of
the scapula, Rotation about a transverse
axis
 Pectoralis minor is shortened
RELAX
You made
It though
The hard
Part
SHOULDER POSITION
 Different for everyone
 Side view, ears should be in alignment
with shoulders
 Shoulders should be in alignment with
hips
 May not be able to achieve due to
bony/soft tissue changes and congenital
deformities
SHOULDER
POSITION/PHYSICS
 Levers
 The humerus is a complicated class 3 lever when
the elbow is straight. (Reminder on a class 3 lever:
Effort is in the middle (muscle): the resistance is on
one side of the effort (whatever a person is lifting)
and the fulcrum is located on the other side
(shoulder girdle))
 Fulcrum is set best when the shoulder girdle is at
neutral. When shoulder girdle is no longer at
neutral, the “lever” loses effectiveness
CLASS 3 LEVER
fulcrum effort
resistance
EVALUATION IS
IMPORTANT
 This will mostly design how the person is treated
 In my experience, most people do not have
optimal strength unless they have over 150
degrees of shoulder flexion without
compensation
 Most people are upwardly rotated and abducted
 Pain-where is it specifically?
 Additional extension, limited internal and/or external
rotation
COMPENSATION
 When a person has lost range of motion,
they learn to compensate
 The job must be done!!!!
 Compensatory patterns will give you
clues as to areas that need to be
addressed
TYPICAL COMPENSATION
PATTERNS
 Shoulder flexion- abduction of the
shoulder, lordosis of cervical/thoracic
spine
 Shoulder abduction- lateral flexion of
torso/spine, shoulder flexion, protraction
of scapula
TYPICAL COMPENSATION
PATTERNS
 Shoulder internal rotation- protraction of
scapula, rotation of trunk, kyphosis of
thoracic/cervical area
 Shoulder external rotation- retraction of
scapula, rotation of trunk, lordosis of
thoracic/cervical area
ASSESSING RANGE OF
MOTION
 How is reduced shoulder ROM limiting
ADL’s
 Limited shoulder flexion: brushing/washing
hair, donning/doffing shirt/jacket, reaching
into cabinet
 Limited horizontal adduction:
Donning/doffing clothing, hair care, kitchen
tasks, peri care
ASSESSING RANGE OF
MOTION
 Limited internal rotation: washing back,
hooking bra, pulling up pants, peri
care, cooking, mowing the
lawn/starting mower
 Limited external rotation: brushing
teeth, brushing/washing hair, using a
walker, cooking
ASSESSING RANGE OF
MOTION
 Is functional ROM causing deformity?
 Does that person really have functional
movement?
 Need to look at the entire body
 Watch for compensatory movement
 Look for pain cues (wincing, grunting, etc.)
ASSESSING RANGE OF
MOTION
 Where is the block? Eg. Shoulder flexion
 Look at straight flexion without allowing any
other movement, you will feel a slight “stop”
in the movement if there is a restriction
 Where is the compensatory movement?
 Limited shoulder flexion can cause
compensation
 Cervical, thoracic, lumbar vertebrae
 Spillover into abduction and external rotation
ASSESSING RANGE OF
MOTION
 Long term effects
 Pain
 Arthritis
 Impingement
 Decreased strength
 Destruction of structures of the shoulder
 Biceps
 Coracobrachialis
 Ultimately loss of function
TREATMENT FOR
SCAPULAE
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Mostly upwardly rotated and abducted
Mobilizations and soft tissue release
We must… and scapular squeeze
Tell person to try to touch shoulder
blades together and towards bottom
AIR SPLINT
AIR SPLINT
CONTRAINDICATIONS
ANY ROM RESTRICTIONS
BACK/SHOULDER/CLAVICLE/ARM
FRACTURES
DIALYSIS PORTS
PICC LINES
POOR ARTERIAL/VENOUS FLOW TO
ARM/DVT
AIR SPLINT CONCERNS/
CONSIDERATIONS
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Recent fractures
Cardiac history
Osteoporosis
Muscle tears
Pain tolerance
Recent back
surgeries
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Vascular issues
Skin integrity
IV’s
Contractures
Mastectomy/
Lumpectomy
 Severe arthritis
AIR SPLINT EXERCISES
 Please see additional handout
 Works better initially in supine, gravity pulls
shoulder into a more neutral position breaking
habitual pattern of kyphosis and other
compensatory patterns
 Can use towel for better positioning or to grade
activity
 Move into sitting once patient’s shoulder girdle
becomes more stable
MOBILIZATIONS
PRECAUTIONS AND
CONTRAINDICATIONS
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Any condition that has not been fully evaluated
Joint ankylosis
Joint hypermobility, if techniques that take the joint through its end range
are being considered, unless a positional fault is being treated
Joints that are infected
Malignancy in area treated
Fractures
Inflammatory arthritis, especially if it is exacerbated
Metabolic bone diseases (Paget’s, TB, etc)
Debilitating diseases that compromise periarticular tissue (advanced DM)
Long term use of corticosteroids
Swelling- it takes up some of the slack in the capsule making it difficult to
evaluate the joint mobility correctly
Excessive joint irritability or pain
Coagulation impairments
Skin rashes or open/healing skin lesions
Protective muscle spasms to the point mobility in the area treated is
unable to be evaluated
MOBILIZATIONS
 Joint mobilizations are used when
ligament or capsule resistance is
encountered
 Many different ones to use
 See sheet for helpful ones
Thank you!!!!!
 Many thanks to those
who helped me:
 Heather Barnes,
OTR/L
 Terry Giese, OTR/L
 Nancy Joneth,
OTR/L
 Howard Whitfield,
OTR/L
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Scott McKay, PAC
Chad Randolph, PT
Tim Kisner, PT
My model: Beth
Kohler-Rausch,
OTR/L
 My Photographers:
Diwi Ymson, PT and
Tanvi Desai, OTR/L