Saxion Hogeschool Enschede Academy of Physiotherapy

Optimization of scapular control by a specific exercise program

from Andrea Bernau and Sonja Mnzebrock

Enschede, April 10, 2008

Table of contents
Table of contents.............................................................................................. 1 Foreword ........................................................................................................... 3 Introduction ...................................................................................................... 4 Social Relevance ............................................................................................ 4 Physiotherapeutic relevance........................................................................... 5 Function of the Scapula .................................................................................. 5 Scapular dyskinesis ........................................................................................ 6 The Scapula ...................................................................................................... 7 Normal position of the scapula at rest............................................................. 7 Movement possibilities of the scapula............................................................. 8 What is a force couple? ................................................................................. 11 Function of the different muscle components of the force couple ................. 12 The impact of the scapulohumeral rhythm by the force couple..................... 13 Appropriate training of the force couple ........................................................ 13 Proprioception................................................................................................ 15 Proprioceptive receptors ............................................................................... 15 Conversion of the input from the receptors ................................................... 16 Proprioceptive training .................................................................................. 17 Rehabilitation strategies................................................................................ 20 Kinetic chain ................................................................................................. 21 Motor learning............................................................................................... 22 Progression protocol..................................................................................... 24 Exercise program ........................................................................................... 28 EMG values .................................................................................................. 28 Setup and performance of the exercise program.......................................... 32 Joint position sense and kinesthesia ......................................................... 33 Dynamic joint stabilization ......................................................................... 35 Reactive neuromuscular control................................................................ 43 Functional everyday activities ................................................................... 46 Limitations of the script................................................................................. 48 Conclusion...................................................................................................... 49 Appendix ......................................................................................................... 51 References ................................................................................................... 51 1

Table of figures ............................................................................................. 54 Affirmation ...................................................................................................... 56

Foreword
For the purpose of our study of physiotherapy at the Saxion Hogeschool Enschede Academy of Physiotherapy we have to create a bachelor thesis. We were more attracted by the option to write a literature analysis of an appropriate topic than a participation in a scientifical research. Both of us have followed the shoulder course by Donald van der Burg during the minor Masterclass Physiotherapy. This course aroused our interest in shoulder problems and thereby created the basis for our bachelor thesis. Donald van der Burg inspired us to create an exercise program for physiotherapist in which the patient can learn to control his scapula. The need of such an exercise program is composed of global shoulder exercises and the unfamiliar approach to stabilize the scapula at first by many physiotherapists. Physiotherapists mostly will achieve a greater range of motion of the glenohumeral joint to reinsert the arm in functional activities. But often a longterm result is not achieved, as the scapula remains unstable by the use of their approach. That motivated us to create a CD-ROM with a specific exercise program to optimize the scapular control which can be used by physiotherapists as an example. The background knowledge will be described in our thesis Optimization of scapular control by a specific exercise program. We have developed this topic from many well-known studies. In studies from Ann Cools or Sarah Mottram a so-called force couple consisting of the serratus anterior and trapezius muscle was approached. The force couple aroused our interest to start our search of further literature about this topic. At this point we would first of all like to thank Donald van der Burg, our instructor in the minor and tutor of this thesis. He assisted us in finding a topic for our thesis and he accompanied us while creating the thesis. Secondly our thanks go to Markus de Brn, Carolyn Grace Flores. They helped us to phrase our thesis in presentable English. Furthermore we would like to thank Mike Mnzebrock who allocates himself for the pictures and for the short videos. For the technical assistance we would like to thank Marius Bernau, Oliver Flores and Stefan Neubert. We are also indebted to Uwe Juch who made his fitness center Sportzentrum crocodiles available to us and to Rainer Glawe who has borrowed us his video camera. At last we thank all people who supported us in this stressful time. 3

Introduction
In this script we discuss exercises which improve scapular control. The goal is to develop a rehabilitation approach for the physiotherapist targeted at scapular muscle coordination.

Social Relevance
"In the Netherlands, musculoskeletal disorders, of which shoulder complaints constitute the second largest group after low back pain, account for the second largest share of the healthcare budget."15. "The 1-year prevalence of shoulder complaints in the Dutch general population is estimated at 30%. Approximately 50% of all patients who visit their general practioner about a new episode of shoulder problems report persistent symptoms after 6 months, and up to 40% have symptoms lasting up to 12 months."15. In the past years the stake of the scapula and scapular muscles in shoulder disorders has become articulate. Correlations between abnormalities in scapular position and motion with impingement symptoms, rotator cuff dysfunction, and instability have been identified in numerous studies6,7,8,9,12,13,21,29,31,32,37. Authors like Cools, Kibler, Ludewig, Mottram, or Ekstrom are concerned with this topic. In the last eight years they have published around eleven studies dealing with the context of the scapula and scapular muscle activity in conjunction with shoulder dysfunction. Even the abundance of recently published studies on this subject reflects the therapeutic relevance. When analyzing these surveys it becomes clear that there is a need for guidance in the rehabilitation management of shoulder patients. This affiliates to the declaration of Burkhart et al in the study from 2003:The best exercise programme has not yet been established.3. We will combine this thesis with a CD-ROM. The thesis contains the background information and will answer the following three questions: (1) What is the correct scapular position at rest and how the scapular movement possibilities looks like?, (2) In which way can the muscular imbalance of serratus anterior and the trapezius muscle be compensated?, and (3) How does the optimal rehabilitation approach looks like?. The CD-ROM will depict a rehabilitation program, which is predicated on evidence based conclusions from many well-known studies, to optimize the 4

scapular functioning. The rehabilitation program clarifies the selected exercises and can be beneficial as an example for physiotherapists.

Physiotherapeutic relevance
According to Cools et al, () shoulder pain and dysfunction are common complaints among individuals seeking care from physical medicine and rehabilitation specialists.9. Scapular muscle training is an essential component of shoulder rehabilitation. This conclusion is supported through current exercise protocols. Exercises to retrain force, mobility, coordination, and function are routinely used by physiotherapists. Also other authors agree that this parish belongs to the physiotherapy3,5,6,7,8,12,20,21,32. Due to the fact that evidence based practice is forward-looking in the physiotherapeutic approach the statements in this script were taken from recent literature.

Function of the Scapula

The extreme complexity of the shoulder joint results from the coordinated activity of five different articulations and the supporting soft-tissue girdle. It is a mobile joint that relies on muscle control. Any perturbation of this system has deleterious biomechanical consequences for the shoulder muscular girdle integrity and will eventually lead to pain and functional limitations6,7,8,9,12,18,21,25,32,37. The scapula has several functions in the shoulder girdle complex. It provides the proximal part of the articulatio glenohumerale and facilitates an optimal contact to the humeral head to increase joint congruency. Furthermore, the scapula contributes to stability and mobility in the shoulder complex. It is a pivotal mediator of large forces and high energy to the arm and the hand in the kinetic chain20,21,37. Again, the scapula acts as a stable base for muscle attachments and is in state to optimize the length-tension relationship through its position. Some of these muscles act as scapular rotators and others are concerned with glenohumeral movement. The functional role of these muscles changes throughout the range of shoulder motions due to constant changes in the axis of rotation and lines of action. They are crucial in providing shoulder function and stability and use length-tension activation patterns1,3,5,6,7,8,9,12,16,20,21,25,30,31,32,37. 5

Dysfunctional scapular muscle performance contributes to scapular dyskinesis. The ability to position and control movements of the scapula is essential for normal upper limb function.32. Abnormalities in posture and scapular motion are considered to be important risk factors for developing shoulder pathologies. A functional diagnosis of the lesion will always be a prerequisite for a targeted conservative therapy. Evaluation of shoulder control and a treatment that is intended to improve this should form an integral part of the management of all shoulder disorders6,28.

Scapular dyskinesis
The exact etiology of scapular dyskinesis is not defined. There is no accepted or validated operational definition and no standard clinical method for identifying abnormal scapular movement29. Kibler described a test based on linear measurements of the distance between the scapula and the vertebral column with defined arm positions. Moreover he described a rating system for scapular dyskinesis which is based on visual judgments. Thereby it is simple enough for routine clinical use and appears to have promise, although the initial reliability is disputable29. The resulting biomechanical alterations of the scapular dyskinesis increase glenohumeral angulation and thus, tensile strain in the glenohumeral ligaments and decrease the rotator cuff activation3,6,25,26,28,32,37. In this paper we will further discus scapular dyskinesis in the chapter of Movement possibilities of the scapular but we focus on the correct scapular position and kinematic.

The Scapula
This chapter describes the important role of the scapula in the whole shoulder complex including the scapula position at rest and its possibilities during movement. The shoulder is an unstable joint due to its insufficient passive stability composed of the labrum glenoidale, the capsule, and the shoulder ligaments. Because of the adverse relationship of head and socket of the glenohumeral joint, which differs from the hip joint where the socket encloses the femurhead, the shoulder needs a high active stability component. Thereby the scapula plays a crucial role. At first, it is important to mention that the scapula is one of the connecting pieces which connect the shoulder complex with the trunk in the kinetic chain. In this kinetic chain connection it acts as a stable base for the origins of muscles that stabilizes the glenohumeral joint and allows these muscles for an initial tension. Only if the scapula is optimally aligned by the muscles it generates an optimal congruence between head and socket so that the shoulder can function without provocation of other structures. Therefore, the glenoid fossa of the scapula has to stand in an angle of 30 anteriorly rotated from the frontal plane maintained dynamically by the surrounding muscles of the glenohumeral joint21,37. This angle guarantees not only a proper bony alignment () but also facilitates muscular constraint by maintaining proper lengthtension relationships for efficient contraction of the rotator cuff muscles, thereby compressing the humeral head into the fossa.37.

Normal position of the scapula at rest

Because of the convex shape of the thorax the scapula rests in a position which presses against the ribcage. This posture is characterised by a light anterior tilt, internal rotation, and upward rotation. That means that the scapula is a few degrees inclined in an anterior position so that the angulus inferior comes more towards posterior. Furthermore, the cavitas glenoidalis points slightly in cranial and anterior direction6.

Movement possibilities of the scapula

The scapula is able to move in the shoulder complex around three different axes (Figure 1). It can turn in the frontal plane around a sagittal axis to make an upward or downward rotation. During an upward rotation, also known as lateral rotation, the angulus inferior moves laterally and slightly cranial over the thorax. Downward rotation or medial rotation is the opposite direction. The angulus inferior swings medially. In our script we decided to use the term upward and downward rotation. In the sagittal plane there is a posterior and anterior tilt around a horizontal axis possible. The scapula slides over the thorax in posterior or anterior direction. Looking at the back, the angulus inferior becomes more apparent during anterior tilt and it disappears during posterior tilt. Finally, there is the possibility of scapular external and scapular internal rotation around the longitudinal axis in the transversal plane. The cavitas glenoidalis align either during external rotation posteriorly or during internal rotation anteriorly6.

Figure 1. Local coordinate systems and axis orientation for the scapula and trunk. XS= horizontal axis, AT= anterior tilt, PT= posterior tilt. YS= sagittal axis, UR= upward rotation, DR= downward rotation. ZS= longitudinal axis, ER= external rotation, IR= internal rotation.

The study from Ludewig et al6,25 states that the scapula demonstrates a pattern of progressive upward rotation, decreased internal rotation, and movement from an anteriorly to posteriorly tipped position as humeral elevation angle increases. This is a rough description of scapula movement but there is a discussion about this topic: what is the normal movement? If the scapula cannot provide this pattern then you talk about scapular dyskinesis or scapulothoracic dysfunction. 8

Scapulothoracic dysfunction was defined by Cools et al as alterations in the resting position or dynamic motion of the scapula, and changes in scapular muscle recruitment can affect many aspects of normal shoulder function6,9, which can be impingement syndromes, rotator cuff dysfunction or instability. For the evaluation of movement dyskinesis you have to compare both sides of the shoulder. Otherwise, it is impossible to distinguish between normal and abnormal movement regarding the observed person. Less upward rotation is the most common dysfunction with shoulder problems. The consequences of insufficient upward rotation are a decreased elevation of the acromion, shoulder shrug movement, and at last pain in the shoulder. During arm elevation the acromion has to elevate. Otherwise, the humerus will bounce against it which causes pain and further elevation movement will be limited. Additionally, the tendinous structures of the rotator cuff can be irritated with decreased space under the acromion leading to painful disorders (impingement syndrome). The shoulder shrug phenomenon will occur when the activity of the upper trapezius is increased and the serratus anterior is weak. Therefore the scapula cannot neatly rotate upwards. Instead of this movement the trapezius ensures a pure cranial movement of the scapula. Kibler noted Scapular dyskinesis, or alterations in scapular position and motion in arm activity, is common in both traumatic and microtraumatic glenohumeral instability.21. One can only speculate about the causes of scapular dyskinesis, because the etiology is still unknown. However, before we think about which reasons can be responsible for dyskinesis or dysfunction, we have to think about how the scapula moves during the elevation of the arm. But at first we want to define the following glenohumeral movements to obtain a uniform picture of it. Important for this script is abduction, elevation/flexion of the arm, and elevation in the plane of the scapula. The abduction is a movement in the frontal plane. Elevation/flexion takes place in the sagittal plane and the elevation in the plane of the scapula is a movement between these two planes. It is a plane which is located 30 from the frontal plane towards the sagittal plane. It is also called the coronal plane. Ekstrom et al discovered that the scapula usually finds a position of stability within the first 30-60 of glenohumeral elevation or abduction where negligible upward rotation occurs. The scapula then rotates a substantial amount upwards 9

during the midrange (80-140 ) of the elevation. At the end of the whole movement the rotation decreases13. A different view described by Voight et al states that the scapula already rotates upwards in the space of 30-50 of humeral abduction. If motion continues, the scapula rotates another 65 reaching full elevation level37. The findings of Voight et al militate in favor of the scapulohumeral rhythm which was defined as 2:1 by authors such as Cools6, Inman, Mottram32, Voight37, etc.. Despite this, Mottram supports in her study the opinion of Ekstrom that the scapula does not move remarkable in the first 60 of flexion and 30 of abduction. Generally speaking the scapula moves from its resting position 60 upward during the full range of elevation. This clarifies the scapulohumeral rhythm, because during 180 elevation proceeds 120 only in the glenohumeral joint and 60 rotates the scapula upwards. This discussion shows the importance of a stable scapula during the first degrees of elevation. However, in the course of movement the major difficulty is to keep the scapula relatively stable while it has to rotate upwards to allow a full range of elevation and abduction32.

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What is a force couple?

This chapter gives information about how the scapula can be stabilized and moved in order to maintain a stable joint socket creating an optimal functioning for the arm movement. The questions that arise in this connection are which muscles have a stabilizing and which a moving function for the scapula. The primary muscles are the serratus anterior and the trapezius muscle which together create a force couple (Figure 2). According to Cools et al, a force couple is composed of two or more muscles which have at first sight an opposing function on the moving scapula. But if these muscles work together a fluid rotation movement from this segment is caused. This means in cooperation the serratus anterior and trapzius muscle produce a fluid upward rotation of the scapula6. Therefore, one should be conscious that the quality of motion depends in equal measures on every part of the force couple. Gibson estimates that the serratus anterior and lower trapezius muscles are mostly involved in early stages of shoulder disorders16.

Figure 2. Force couple of serratus anterior (SA), upper trapezius (UT), middle trapezius (MT), and lower trapezius (LT) during upward rotation.

One of the most important functions of this force couple is to stabilize the scapula prior to the real movement using the feedforward system. These muscles () are highly developed and are quick to drop out with injury or 11

disuse.21. Otherwise, to prevent an impingement syndrome, it is important for the force couple to produce a steady upward rotation while raising the arm because the deltoid muscle creates a powerful downward rotation force during elevation and abduction. If the downward rotation force is not suppressed the
32 acromial arc will blockade a raising movement of the arm until 180 .

Function of the different muscle components of the force couple

As already mentioned in the introduction of this chapter the force couple is composed of muscles which have a stabilizing or a moving function. The serratus anterior and the upper trapezius have a movement giving function for the scapula. The serratus anterior muscle is in charge to prevent scapular winging which implies a stick out of the medial border of the scapula. Furthermore, this muscle can produce an upward rotation and posterior tilt movement. In many studies the serratus anterior is actually characterized as the prime mover of the scapula11,14,26,27,28. The upper trapezius has the ability to elevate the scapula. It is most active during the first 60 of abduction. In contrast to the upper trapezius, the lower trapezius bundle has a tonic function. Therefore it stabilizes the scapula. For example, it decelerates the excessive elevation produced by the upper trapezius, or the excessive protraction by the serratus anterior. In addition, it can also assist the scapular upward rotation. The middle part of the trapezius plays a minor role in the interaction of the force couple. In some studies it is actually not mentioned in combination with the force couple. Normally, it produces a retraction movement of the scapula. But the middle part also assists the upward rotation movement. At 90 of abduction all muscle parts of the trapezius work together to antagonize a too huge pull of the serratus anterior. On the one hand, the intramuscular precondition for a good cooperation between all parts of the force couple have to comprise adequate muscular strength, endurance, and flexibility. If the conditions are not good enough patients are, for instance, unable to hold the arm above 90 because of decreased muscular strength of the serratus anterior. On the other hand, intermuscular preconditions such as neuromuscular coordination, like timing of the muscular activity, and the muscular equilibrium have to exist. An example 12

for this condition includes a satisfying muscular strength of the serratus anterior muscle but the coordination with the other muscle parts is insufficient so that problems with raising the arm also occur6.

The impact of the scapulohumeral rhythm by the force couple

If the force couple works correctly the scapulohumeral rhythm accounts 2:1 as described in the chapter The scapula. In this part we will answer the question, which impact a dysfunction of the force couple can have on the scapulohumeral rhythm. Abnormal kinematics of the scapula can be linked with an imbalance within the force couple. The reason for a reduced upward rotation of the scapula during the 31-60 phase of elevation is a decreased serratus anterior activity for people with impingement syndromes. This was discovered by Ludewig et al with EMG measurements26. Furthermore, she suggests that the upper and lower fibres of the trapezius will compensate a weak serratus anterior muscle which she reasons with an increasing activity of the upper and lower trapezius. The compensatory role of trapezius is affirmed by Hardwick et al17. Nevertheless, Hardwick underlines the importance of appropriate activity of the serratus anterior maintaining a normal scapulohumeral rhythm. The shoulder-shrug phenomenon is a further abnormality of scapula kinematics. It occurs by the time the upper trapezius is more powerful than the rest of the force couple. Thereby appears an excessive superior translation of the scapula with less efficient upward rotation and decreased posterior tipping27. In one of the most recent studies from 2007 by Cools et al it is said that excess activation of the upper trapezius, combined with decreased control of the lower trapezius and serratus anterior, contributes to abnormal scapular motion9.

Appropriate training of the force couple

Now the question arises how the force couple can adequately be influenced to gain an optimal function of the scapula. For this purpose a stable balance intermuscular and intramuscular has to be reached. As mentioned above the most occurring intermuscular problem is an over activity of the upper trapezius due to a decreased activity of the lower and middle trapezius and the serratus anterior. Therefore, it is important to develop specific exercises with low upper trapezius ratios and high lower and middle 13

trapezius and serratus anterior ratios to compensate the imbalance. These exercises will be further described in the chapter of rehabilitation strategies. It is also important to know that it is harder for the trapezius to compensate a weak serratus anterior muscle activity during flexion than in abduction. As a consequence, it is possible to observe more scapular winging and less scapular control while raising the arm in elevation than in abduction27. The intramuscular problem often relates to an incorrect timing which appears to be late most of the time. The affected muscles cannot act together with the other muscles of the force couple causing an imbalance. Another reason for the intramuscular problem can be a decreased muscular strength or endurance in one of the muscles which lets the force couple work ineffectively. Nowadays, it is crucial not to only train the scapula, but also to include the whole shoulder girdle into a global functional kinetic chain pattern9. This is an important rehabilitation aim to integrate the function of the shoulder into everyday life.

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Proprioception
The proprioception is a specialized variation of the sensory modality of touch. It represents a fragment of the sensorimotor system. The proprioception is responsible for the conscious and unconscious motor control, kinesthesia (the sensation of joint movement), and joint position sense (the sensation of joint positioning). It is a system composed of afferent input via mechanoreceptors and an efferent reaction via the Central Nervous System (CNS). Kinesthesia is assessed by measuring the threshold to detection of passive joint motion. The joint position sense is assessed by measuring the reproduction of passive positioning, maximally stimulating joint receptors, likely selectively Ruffini or Golgi- type mechanoreceptors. It can be further assessed by active positioning which stimulates both joint and muscle receptors and constitutes a more functional approach of afferent pathways Lephart et al23. Vestibular information is considered to be proprioceptive referable to the head. We affiliate to Sherrington who delineated the receptors in the periphery from the labyrinth35. This does not mean that there would be no interaction between these two, but they have different functions. In this script we focus on the receptors lying in the periphery.

Proprioceptive receptors
The proprioceptive receptors are lying in the skin, muscles, joints, ligaments, and tendons. They provide information to the CNS with regard to tissue deformation. The Ruffini endings are located in the joint capsule and ligaments. Because these mechanoreceptors are maximally stimulated at specific joint angles they are thought to mediate the sensation of joint position and changes in position. The Fusiform muscle spindle receptors are lying in the skeletal muscle. They measure the muscle tension over a large extrafusal muscle length. According to Riemann et al36, particularly the gamma motor neurons play an important role in the muscle activity. In response to joint mechanoreceptor stimulation the gamma motor neurons are activated and increases muscle

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spindle sensibility. The alpha motor neurons have been supposed to act out this activity for a long time. Pacinian corpuscule have their location in the joint capsule. Their adaptation rate is quick which leads to the notion that they mediate the sensation of joint motion because they are very sensitive to changes in position. Furthermore, are there unmyelinated free nerve endings which are located in ligaments and related muscles. Their function is to transmit joint pain.

Conversion of the input from the receptors

The feedback of these receptors is channeled to the CNS for integration via cortical and reflex pathway. The released motor response can be a spinal reflex, a brainstem activity, or a cognitive programming using the motor cortex, basal ganglia, and the cerebellum. Cognitive programming is the highest level of motor response regarding CNS function. It refers to a voluntary movement so consciousness of the body position, the movement itself, and the external environment is needed. In order to learn a new exercise the patient utilizes cognitive programming. Kinesthetic and proprioception exercises enhance this function, especially performing joint positioning activities at joint end ranges23. The designated movement is repeated and stored as central commands. Most exercises were developed to get from a conscious performed movement to an unconscious conducted movement. This process belongs to motor learning, a topic which will be discussed later in the script. The spinal reflex is another motor response to mechanoreceptor stimulation. This one mediates the movement patterns from higher levels of the nervous system and has significant implications for the rehabilitation. Reflex neuromuscular control is the keyword in conjunction with the spinal reflex. The ability to realize when it is necessary to react knee-jerk is of particular importance. Exercises which work with sudden perturbations elicit this reflex. For example, unexpected alterations in joint positioning cause muscle reaction, which train the perception and reaction to sudden changes. It has been demonstrated that there is a reflex arc between the glenohumeral joint capsule and the rotator cuff, m. deltoideus, m. trapezius and m. pectoralis major. This arc is mediated by receptors within the capsule (Ruffini endings and Pacinian corpuscule) via afferent fibres to the spinal cord. This finding 16

encourages the relevance of exercises that exploit capsular tension to increase afferent input and facilitate rotator cuff recruitment. Furthermore, there is the brainstem activity. The brainstem receives information from mechanoreceptors, vestibular, and visual centres with the function to maintain body balance and posture. To cause this motor response exercises that release reactive neuromuscular activities are in demand. Through closing the eyes you can detract the brainstem from the visual input. Thereby the input from the vestibular centre and the mechanoreceptors becomes more important. Thus, you train the proprioception/ reaction of mechanoreceptor intake more intensive without the helpful contribution of vision.

Proprioceptive training
Proprioception training should started early in rehabilitation and imply all three categories of motor response to regain dynamic joint and functional stability 23. Trauma to tissues that contain proprioceptive receptors may result in partial deafferentation which can lead to proprioceptive deficits23. The loss of structural stability follows either as a result of partial deafferentation, increased tissue laxity, or both in decreased capsuloligamentous mechanoreceptor stimulation. This alters the proprioceptive input to the CNS and follows in changes in the reflex activity, joint stiffness, and abnormal muscle firing patterns16. Also according to Glousmann et al are proprioceptive deficits in the pathologic shoulder. There are alterations in the cortical pathway and changes in the electromyographic pattern. Surgical intervention partially restores kinesthesia23. To regain the dynamic control of the shoulder is of primary importance for return to functional activity or competition. Intact joint position sense is necessary for normal muscle coordination and timing.4. It has been shown that shoulder joint dysfunction may be associated with deficiencies in joint proprioception. If the muscle coordination is impaired as a result of deficient proprioception a symptomatic shoulder can occur or if a trauma has been, a shoulder predisposed to reinjury. A decreased sensory input from joint receptors leads to abnormal body positioning and diminished postural response23. To get an assessment of the proprioceptive status of the patient kinesthesia and joint position sense can be assessed (see above). Continuing, the therapist can

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carry out the Napoleon test and the Dynamic rotatory stability test by Margarey and Jones16 where the reliability and validity is unknown. Exercises should be focused on the importance of incorporating joint position sensibility and the reflexive contractions to regain the dynamic control. Lephart et al23 and Gibson16 offer a rehabilitative construction. The therapy starts with the training of the joint position sense and the kinesthesia, the optimising of somatosensory input to the glenohumeral joint afferents. This is followed by upper extremity balance training for example through the exercise Dynamic joint stabilisation. Then the progression of the rehabilitation implies the reactive neuromuscular control integrating spinal and cognitive levels. In the following step the patient can start with plyometric exercises. At the end follow functionally specific activities to restore the functional motor patterns. Janwantanakul et al. demonstrated that body orientation significantly influenced subjects ability to replicate a target position and to perceive an imposed movement in the upper limb. The use of functional positions is thus useful in promoting re-education. According to the patients needs, subjects generally perform better in sitting than in supine positions16. An example for an appropriate home work for the patient is that the patient self palpates the margo lateralis of his scapula to get a valuable feedback. The scapula should maintain contact against his/ her thumb. Further, to increase the proprioceptive feedback the patient can apply a gentle pressure to the scapula border in the opposite direction. Theses fundamental elements of functional stability need to be considered. Furthermore, is the use of closed-kinetic chain exercises early in the rehabilitation programme extremely valuable. These exercises facilitate the presetting function of the rotator cuff. They stimulate the co-contraction of the rotator cuff and aid to coordinate upward rotation of the scapula therefore enhancing dynamic stabilisation and reproducing normal proprioceptive stimuli16. Carpenter et al4 analyzed in his study the consequences of muscle fatigue on the proprioceptive sense. The result of the study is that there is a significant reduction of joint position sense by fatiguing exercises. Thus, it is important not to overstrain the muscles during the training of proprioception. Gibson16 also add avoiding muscle fatigue during proprioceptive workout.

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The ultimate goal of a successful rehabilitation programme is to re-establish functional stability throughout a full pain free active range of motion. A proper neuromuscular control and functional stability of the joint minimize the risk of reinjury and promotes a greater chance of successful return to competition.

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Rehabilitation strategies
In the previous chapters we have characterized which factors have an impact on the function of the shoulder, especially on the scapula. Now we will demonstrate the best approach to regain a functional and sport specific using of the shoulder. We created an approach which is adapted from evidence based conclusions from many well-known studies. Our approach addresses all patients with shoulder problems. The treatment can be preoperative, postoperative, or conservative. For each group of patients, it is necessary to achieve a fully functioning scapula before they can proceed with individual rehabilitation. Before surgery, it is important for preoperative patients to activate kinetic chain patterns in order to enhance the stabilizing effect of the scapular musculature. After the surgery the patients are familiar with how to stabilize the scapula. In this way they can relearn this function very fast. In the group with non-operative treatment belong for example patients with impingement syndrome, instability, and rotator cuff problems. For these patients it is important to acquire the control of how to stabilize the scapula at first. This is necessary as basis to build up on each further treatment. The problems will not be solved for a long time without the scapula as a stable base for movement of the arm. With postoperative patients treatment can be started directly after the operation with the arm in a sling. They can train kinetic chain exercises with use of legs, hips, and trunk. Furthermore, the patient can do scapular retraction exercises20,21. The rehabilitation process in the shoulder complex is often difficult. Because of the complexity of anatomy and biomechanics, there are many starting points which have to bear in mind. Important are the alignment of the scapula, the stabilization of the scapula, and coordinated movement of the scapula. Moreover, the scapula has to play its connective role in the kinetic chain. Normally, the scapula does not move in isolation. There are always other segments which act together with the scapula. For this reason, we decided to train the scapula in our approach in the kinetic chain. If the scapula does not work correctly the energy transfer to distal segments of the chain will be

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disturbed. In the course of time other segments will try to compensate this disturbance6.

Kinetic chain
The scapula is on the one hand linked with the trunk and on the other hand with the arm. Through this position in the kinetic chain the scapula has the task to transfer the energy from the lower extremity via the trunk to the upper extremity. The other way around, the energy will be absorbed, for example by catching a ball, from the arms via the trunk to the legs. To get a better idea of the kinetic chain we use the definition of Kibler et al: The kinetic chain harmonizes the interdependent segments to produce a desired result at the distal segment.20. Kinetic chain is the integrated effort of joints, bones, muscles and the neurologic system to move the body through the space. Functional strength is the ability of that neuromuscular system to move, stop and stabilize the body. Every functional task requires this co-operation. Muscles work concentrically, eccentrically, and isometrically. In functioning, muscle forces are accelerating, decelerating, or stabilizing the body as it moves. In order to develop core strength, you need to involve all of those forces. When moving the body through space, whether running, walking, or stand up from a chair, the body uses a functional kinetic chain and requires core competency for stabilization, acceleration and deceleration. The kinetic chain is an activation sequence that work from proximal segments to the distal ones20,21,37. That means that an optimal shoulder and arm function depends on the harmonized activation of legs, pelvis and trunk. There are two essential preconditions for the functioning of the kinetic chain. The first condition includes a perfect timing and an appropriate posture. At the right moment, the scapula has to be aligned by its stabilizing musculature. In this manner the energy can be caught up from the more proximal segments. Secondly, it is necessary to activate the muscles to give an extra impulse. This is important to get a force progression to the distal segment of the chain6. The integration of multiple muscles and joints requires feedforward sensory information to position these ones in the most effective manner23. Through positioning of the joints the length-tension relationship of the muscles is affected. Experience in an appropriate motion facilitates goal directed movement even if there are unexpected perturbations, which are realized 21

through feedback sensory input. Further explanation of this neurologic system responds to the chapter of motor learning. To reach maximum velocity or force to the shoulder, distant segments need to operate in an overflow coupling. The scapula is a pivotal segment which transfers energy from the trunk to the arm and hand37. Large forces and high energy arise from the proximal segments which speed-up the entire chain. Only up to 40% of the forces necessary for forward shoulder- and arm-acceleration are created by scapular motion21. To gain a functional approach in the rehabilitation program it is necessary to involve the whole body, the proximal and distal segments from the scapula. The goal of rehabilitation is to get the patient back to his ability to function in daily living, work, or even to get him back to competition. For this the patient needs functional motion which operates with the activation of the kinetic chain20,21,37.

Motor learning
In the following part of this chapter we want to explain the motor learning for a better understanding on how people learn a movement. This will make it easier to follow the steps of our rehabilitation approach. Motor learning is the act through which one obtains skills. With birth only a few motor skills exist. Motions can be learned and adapted in various situations. Most of our movements include a prepared motion pattern. Thus, there must be a motor program for the central prearrangement of motion. The motor learning and the motor control have been investigated from different disciplines and with different goals. Therefore, there are different models of explanation from which we present a few in this chapter. The fylogenetic model from Jackson divides the brain into three levels that interact; the archi-, the paleo- and the neo-level. The archi-level is composed of the formatio reticularis, the substantia nigra of the spinal cord, and a part of the cerebellum. This level is the oldest one and responsible for the handling of reflexes. If there is no inhibition from the other levels, one attains a higher reflex-activity of the archi-level. The paleo-level consists of the subcortic limbic system, the basal ganglia, the hypothalamus, and parts of the cerebellum. Its functions are automated movements, the automating of motions, posture control, and the affective part of the sensory motor system. The motor activity 22

guided by the paleo-level embodies an automated and a conscious aspect. An example for such an activity is going. While you are going you can be busy with other impressions or tasks. The neo-level is the youngest one and comprises the cortex cerebri, the corpus callosum, the thalamus and the neo-cerebellum. The neo-level has the function to manage conscious, cognitive, and goal directed motions. This level is active whiles learning new skills. Luria developed the model of the three functional systems (Figure 3). The core in this model is the unit for activation. This unit has its origin in the formatio reticularis. It encloses an afferent part which activates the cortex and an efferent part which controls the muscle tone and the posture. The unit for action and the unit for perception give off activating branches to the unit of activation. This unit regulates the arousal and the body tone. It is a combined mental and physical attention. This means that a mental excitement is reflected in the body arousal and the other way around.

Figure 3. Model of the three functional systems from Luria

Furthermore, there is the reafferentie model by Bernstein. This comprehends a coupling of sensor- and motor-cycles. This model uses the terms knowledge of result and knowledge of performance. Knowledge of result answers the question if the result is obtained or not. The quality of movement, how a motion is carried out, is centralized in the term knowledge of performance. The idea of 23

this model affiliates to the process-controlled model by Mulder. This model uses the terms feedback and feedforward. Feedback gives the possibility to accommodate and correct a motor program through sensor input, thus afferent information. Feedforward is very important for the planning and regulation of a movement. It has a prognostic component. The introduction, planning, and accomplishment over every motion are subject to the motor centres of the CNS (Central Nervous System). The function of these centres is to stimulate the motor neurons of the needed muscles in the way that the muscle contraction conducts to the desired motion. But only if the posture of the body and the extremities is adequate, the desired motion can be accomplished successfully. The basic position is important. If a patient practices to comb his hair, he needs to know how he has to position his legs to attain a stable standing position while using his upper extremities. This simple example articulates the interaction of motor learning and the kinetic chain. It is the interaction between directed motility and the postural motor system. The most effective cooperation of these has to be memorized.

Progression protocol
We designed a progression protocol, based on the study from Lephart et al23 and further discussed by Gibson16, to achieve a well functional shoulder with optimal restored proprioception and neuromuscular control. Our protocol is divided into four steps: (1) joint position sense and kinesthesia, (2) dynamic joint stabilization, (3) reactive neuromuscular control, and (4) functional everyday activities. For postoperative patients the first step consist as mentioned before in this chapter of training the legs, hips, and trunk in the kinetic chain, and trying to integrate the retraction movement of the scapula. After this step postoperative patients can follow the normal progression protocol which will be described below. In the first step of our approach the joint position sense and kinesthesia have to be restored. This phase proceeds on a high cognitive level. The physiotherapist needs to teach the patient how to position the scapula on the thorax. The description of the Normal position of the scapula at rest and the Movement possibilities of the scapula can be found in the chapter The scapula. One can 24

learn these skills with the aid of repositioning and neuromuscular facilitation. At first the physiotherapist demonstrates how the scapula has to be aligned by positioning the scapula of the patient in the right way (Figure 4). Then the patient has to try to position the scapula to the previous shown spot through via manual resistance in the initiation phase. It is also helpful to perform the repositioning with and without visual feedback.

Figure 4. Alignment of the scapula

In the further process, the intensity of the resistance will be gradually reduced. This approach is not only used in the regaining of joint position sense but also in the restoring of the correct movement possibilities of the scapula. Step two is about reaching the ability of dynamic joint stabilization. With exercises in the kinetic chain which have axial loading components, coactivation of muscles will be facilitated. Axial loading components can be found in closed kinetic chain exercises. Closed kinetic chain exercises means that the distal segment is fixed and only proximal segments can move. The distal segment remains in constant contact with the surface such as the ground, the wall, or the exercise equipment. This character of exercises has many advantages6. The main advantage is the enhancement of the neuromuscular coordination between different muscles. Also the stimulation of proprioceptive sensors in the joints is important and the stabilizing muscles will be automatically activated without awareness of the patient. In this way, patients 25

can easy get the feeling to activate the force couple of the scapula. At this moment the therapist also has to choose how the force couple needs to be influenced by specific exercises. He has to use adequate exercises after deciding whether the intermuscular or intramuscular conditions are decreased9,11. Because of the approximative function the exercises are safe for patients with instability. The exercises can be performed in the full range of motion () because of the difference in the afferent response that has been observed at different joint positions.23. The achievement of reactive neuromuscular control is the third step in our approach. Once the patient has reached the skill of dynamic joint stabilization, the scapula has to be able to react automatically on every functional situation. The difference between the second and third step is the level of awareness during the exercises. During the second step the patient trains with thinking about how to stabilize the scapula. In the third step the patient can easily master this task so that the level of exercises can be increased. During the new exercises, for example on an unstable surface, the patient has no time to concentrate on the scapula because he is busy with controlling his balance. The scapula has to stabilize automatically. During the last step functional everyday activities have to be developed. This phase also includes open chain exercises with short or long lever. During the exercise it is of prime importance for the scapula to be stabilized all the time. Once the patient is not able to stabilize the scapula at a certain position, this deficit has to be worked on before going further. At this moment PNF (proprioceptive neuromuscular facilitation) exercises are excellent methods () for re-educating coordinated co-contraction of the scapula stabilisers and rotator cuff musculature through full range of movement with increasing strength and resistance.16. Through training functional everyday activities, the functional motor patterns can be newly created. At this step the therapist should also include plyometrical exercises. They encourage the contraction ability of the neuromuscular system and increase the development of the explosive force and the quick force. Plyometrics are needed in shoulder patient for example during throwing and catching movements. The motion needs to be performed very quick and with maximal force. Furthermore, in this phase the patient can be treated to reach his old level to return to his sport activities. If the patient can

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train at the same level as his team-mates without discomfort and a controlled scapula, a safe, and successful return to competition can be aspired. Generally speaking The more times the technique is repeated and the more different situations in which it is repeated, the quicker the patient is likely to master it.28.

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Exercise program
This chapter provides a discussion part and a part about the setup of exercises. At first we will discuss all important exercises from the well-known studies, we uses in this thesis. We analyze the exercises based on available EMG-values, the possibility of performance, and the functional body alignment of each exercise. Thereafter, follows a discussion which exercises are in our opinion useful for our exercise program. The program is about the setup of the selected exercises and there is described how the exercises have to be performed. However, the CD-ROM which belongs to the thesis will vivid demonstrates our exercise program.

EMG values
For the assortment of exercises it is on the one hand important to know the rehabilitation goal and on the other hand it is important to have knowledge about the exercise itself. In this chapter we will analyse EMG values of exercises discussed in our script. Therefore we use the texts from Decker et al11, Ekstrom et al13, Hardwick et al17, Ludewig et al27, and Moseley et al31, in which EMG values are named. The data of the text from Decker et al11 and Ekstrom et al13 are almost comparable. Both studies use EMG values in percent from MVC11 and MVIC13. MVC is the short cut from maximum voluntary contraction and MVIC from maximum voluntary isometric contraction. So, there is a difference and that means that one has to be carefully in matching these values. The four exercises discussed in the study of Moseley et al31 are state in percent of MMT of peak arc. MMT is the short cut for maximum manual muscle strength test. The value selected during this test was defined as 100% of muscle activity. According to us this adds close to MVC and MVIC. Unfortunately, it is not further described if the MMT was performed in an isometric or static way. In the study from Hardwick et al17 are three exercises discussed with EMG values in percent of MVIC. Sadly, only the data from serratus anterior are mentioned in this size and sadly, this data are only stated at 90 of humeral elevation. The upper and lower trapezius values are denoted in volts. Thus, a direct comparison is not possible with these ones.

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Ludewig et al27 analysed different manner of push-up exercises. She gives EMG values in percent of MCV, but only from the upper trapezius. The upper trapezius-serratus anterior ratio and the serratus anterior activity are mentioned in her study without named EMG data in detail, with some exception. Except in the studies of Ekstrom et al13 and Hardwick et al17, the push-up plus exercise is analysed in every one of these studies. The push-up plus includes an additional full protraction after obtaining elbow extension. According to Ludewig et al27 and Decker et al11 this exercise activates the serratus anterior maximally during the plus- phase, with 66% and 63% MVC respectively. Moseley et al31 divides the serratus anterior in a middle and a lower part. The middle serratus anterior has the function to upward rotate and protract the scapula and shows during the push-up plus an activity of 80% MMT. At this exercise the lower part has the same function as the middle serratus anterior and EMG values of 72% MMT. Hardwick et al17 and Ludewig et al27 analysed the wall push-up plus. In the study of Hardwick17 the serratus anterior reached 31.1% MVIC. In the study of Ludewig27 remains the exact serratus anterior value for this exercise open. The knee push-up plus exercise is although analysed in two studies, in the study of Decker et al11 and in the study of Ludewig et al27. Unfortunately, are these studies not comparable, because Ludewig27 named upper trapezius EMG values and Decker11 values of the serratus anterior and anterior deltoideus. But generally Ludewig notifies that the use of the plus-phase for all push-up exercises activates the serratus anterior above 80% MVC27. The values of the studies of Ludewig et al27 and Hardwick et al17 agree that there is a low upper trapezius activity during these exercises, exact as the standard push-up plus exercise. So, these exercises show a low upper trapezius activity17, 27, thus, a low upper trapezius-serratus anterior ratio. Especially in patients with a shoulder shrug motion during arm elevation, the push-up exercises are of great value. These patients show a high upper trapezius activity17 which can be interrupted during these exercises. The standard push-up plus elicit greater EMG values for the serratus anterior as the wall push-up plus and the knee push-up plus17, 27. For that reason this pushup exercise is the better one to strength the serratus anterior. 29

Scaption is the scapular plane elevation of the arm with the humerus in external rotation. This exercise is subject in the studies of Moseley et al31, Decker et al11, and Ekstrom et al13. Scaption asks the simultaneous activity of the serratus anterior and the trapezius to get an upward rotation of the scapula. Performing this type of exercise may be important in teaching proper motor recruitment of trapezius and serratus anterior if the goal is to improve scapular upward rotation and scapulohumeral rhythm.13. Partially Moseley et al31 and Decker et al11 recorded different muscles, included with this exercise and Ekstrom et al13 used different spots to measure EMG values. So first we will discuss the EMG values of Moseley31 and Decker11. Both studies give us data of the upper trapezius and the serratus anterior. In the study of Moseley31 the upper trapezius has a peak arc of 54% MMT, in the study of Decker11 this value amounts 97.0% MCV with an average data of 43.7% MVC of the increasing force. It is not clear to us why there is such a discrepancy. One reason might be the manner of measuring the 100% muscle force. In the study of Decker et al11 the MMT, the maximum manual muscle strength test is not further described. But according to the name of this test, the force measurement took place with a manual resistance. In the study of Moseley et al31 this force test was performed () in a joint configuration that maximized EMG activity. Resistance was provided by chains mounted to a wall and aligned parallel to the line of pull.31. This manner of testing seems to us more reliable. Thus, maybe the values of Deckers study11 are higher, because the subjective assumed 100% of muscle force were fewer than 100%. This error in measurement could for example arise through testing the muscle force by more than one examiner. As already mentioned the precise design of this test is not known. Or, the data of the study of Moseley31 are lower, because the muscle was during the exercise not in the best joint configuration, so that under these circumstances, the muscle could not perform with his full power. Furthermore, both studies discuss the serratus anterior. Moseley et al31 divides the serratus in a middle and a lower part, with the data of 91% MMT of peak arc and 84% MMT of peak arc respectively. Decker et al11 gives for the increasing force of the serratus anterior during this exercise a peak value of 92.2% MCV and an average value of 37.3% MCV. For the decreasing force he notes the peak data of 85.8% MCV and average data of 24.2% MCV. For this muscle the 30

values of the two studies are close together. This agreement call the above named critic points into question. Maybe, was the serratus anterior in the study of Decker11 in a fortunate joint configuration tested, which than would become quite close to the manner of testing in the study of Moseley31. But this remains a speculation, so one has to stay conscious while interpret these values. Ekstrom et al13 divided the motion of this exercises in below 80 and above 120 shoulder elevation. He concluded that the maximum EMG activity of the serratus anterior was produced between 80 to 140 , because in this range of motion the majority of upward rotation of the scapula occurs. So in the analyse below 80 of scapular plane elevation the serratus anterior activity was 62 18% MVIC. This value was higher in the measurement above 120 namely, 96 24% MVIC. This data agree mostly to a study of Moseley, named in the text of Ekstrom13, who found out that shoulder elevation exercises from 120 to 150 produce maximum EMG values of the serratus anterior. In the analyse of Hardwick et al17 is the scapular plane shoulder elevation without an externally rotated humerus and thus, not comparable to the others. But it is interesting that the serratus anterior EMG values increase with rising elevation. So Hardwick17 records at 90 of elevation a serratus anterior activity of 41.1% MVIC, at 120 a value of 55.1% MVIC and at 140 an EMG activity of 82.4% MVIC. Thus, also in this exercise is the serratus anterior activity higher as the elevation increases. The press-up exercise is discussed in two of these studies, by Moseley et al31 and by Decker et al11. This exercise is performed out of a seated position with the feet on the floor. The patient places his hand at the level of the buttocks and then pushes himself with his arms above. This exercise elicits pectoralis minor, upper trapezius, and anterior deltoideus activity. Decker11 measured the anterior deltoideus EMG values at different spots of this exercise. Moseley31 measured upper trapezius peak arc, 64% MMT and pectoralis minor peak arc, 89% MMT. Further exercises are not analysed with named EMG data in at least two studies. Thus, other exercises can not be discussed. The necessity of the exercises, and exercises which have been reviewed in one study will be discussed in the following chapter. 31

The analyses of EMG values is not the focus of our script, we want to give the physiotherapist a proposal for the treatment of a shoulder patient. As a matter of course, it is important to know the effect of the exercises. Evaluated EMG values of exercises are one fundamental point of effect. In our script we used a lot of texts in which single values of different studies are summed up to compare. In these texts the established EMG data are not named in detail. But to get a discussion of EMG values one needs detailed rates to check up. That is why we have in fact only five studies and four exercises; push-up plus, wall push-up plus, elbow push-up plus, scaption and press-up, available in this discussion. Further search, and analyse of detailed EMG data would not have been conformable with our time limit. That is why we do not searched outspread in the databases for this subject. A further study of this issue may be relevant.

Setup and performance of the exercise program

This chapter will describe the setup based on the chapter of Rehabilitation strategies, especially the part of the Progression protocol. Furthermore, the performance of all exercises will be explained. At first we want to point at the choice of our exercises. We only include exercises into our program which train the stabilization of the scapula. As already found out an imbalance of the force couple is the most distracting factor of stabilization of the scapula. Most of the time is the strength of the serratus anterior decreased. In return the upper trapezius tries to compensate this weakness. In this way the upper trapezius becomes overactive. In these patients often occurs the shoulder-shrug phenomenon, in which no pure upwards rotation takes place, as described in chapter What is a force couple. On this account it is essential to use exercises which based on a low upper trapezius/ serratus anterior ratio (UT/SA ratio). That means the most effective exercises are these with a high activity of the serratus anterior and with minimal or best without activation of the upper trapezius. We divided the selected exercises into four groups. This division is described in detail in the chapter of Rehabilitation strategies. The four groups are called: (1) 32

joint position sense and kinesthesia, (2) dynamic joint stabilization, (3) reactive neuromuscular control, and (4) functional everyday activities. The arrangement of the exercises is arguable because often the exercises can belong to two groups at the same time.

Joint position sense and kinesthesia

At the beginning of the rehabilitation the intention is to achieve joint position sense and kinesthesia. If the scapula is not immediately ready for action, because of immobilisation after surgery, the program can be started with kinetic chain exercises with focus on legs, hips, and trunk. The possibility of variation in this category is huge, for example exercises such as squats or one leg stability is common. But a proper kinetic chain exercise with slightly integration of the scapula is the scapula dump exercise. At this the patient stands in split stance with the ispilateral leg of the affected scapula site in front. The scapula is positioned in protraction and the spine is flexed. Then the patient moves his spine into extension with ipsilateral trunk rotation and the scapula facilitated by this moves to retraction. Before the scapula will intensively be integrated into the exercise program the patient has to learn how to position the scapula in the right way. Furthermore, he has to reach the function of holding the scapula in this position via scapular stabilizing muscle control. This can the therapist teach the patient by the use of facilitation methods such as tactile feedback, given for example at the sternum as well as at the coracoid process. If the patient has to try bringing the scapula in posterior tilt and external rotation, the therapist can facilitate this movement with the use of manual resistance at the inferior angle (Figure 5). He pushes the scapula in cranial and lateral direction so that the patient has to work against this resistance.

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Figure 5. Positioning of the scapula with manual resistance at the inferior angle

The therapist can also make the patient aware about an optimal scapular position via the sternum (Figure 6). He gives a slight traction at the skin of the sternum and asks the patient to move it a bit upwards. In this way the patient also brings the scapula into posterior tilt and external rotation.

Figure 6. Facilitation at the sternum

Moreover, the patient can practice this scapular position without therapeutic assistance, while palpate with his own fingers the coracoid process. Then he has to try to move the coracoid process away from his fingers. 34

Furthermore, it is often difficult for people to imitate the upward rotation motion. To get the feeling for it a closed kinetic chain exercise on hands and knees is helpful. As the patient moves in this position his spine into flexion he will automatically stimulate an upward rotation movement. Upward rotation will also occur if he places his arms in internal rotation on the ground. An alternative method is to move the patients backside rearwards while he is resting on hands and knees. With this motion the elevation of the arms increase in the glenohumeral joint and the scapula rotates upward. Joint position sense and kinesthesia can be attained with exercises like submaximal isometrics. The physiotherapist applies at first resistance against the scapula. The patient has to hold the scapula in this position. Later the therapist can also give resistance against the arm to make it more difficult through a longer lever.

Dynamic joint stabilization

In the second step of the exercise program dynamic joint stabilization will be trained. Once the patient has learned how to position and move the scapula via exercises of the first group, the therapist has to show him how to hold the scapula stable during movement. In this part we decide in favor of exercises which are mostly in the closed kinetic chain with axial loading components and which are easy in performance. Later, the exercises of group three are more complex in the performance. It makes sense to start with the weight bearing exercise (Figure 7). While practicing this exercise the patient leans with the hands on the treatment couch. It is a closed kinetic chain exercise with an axial loading component. The exercise facilitates the activation of the force couple. But this exercise also appears later in the setup in more difficult variations.

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Figure 7. Weight bearing exercise

The clock exercise increase joint specific motion. It will automatically improve the awareness of the joint. The aim of this exercise is composed of moving the arm in different glenohumeral angles with a controlled scapular movement. At the beginning the patient can practice while standing next to a treatment couch. It is similar as the weight bearing exercise. A different start or further progression is to press the arm against the wall. This can be done at various degrees in different planes. It can be performed in glenohumeral flexion, abduction, or in the scapular plane elevation depending on the standing position in relation of the treatment couch or the wall. The patient moves his extended arm at different time positions on an imaginary clock, for example 3 oclock, or 9 oclock. During the movement to the different time positions the scapula needs to move controlled with the humerus. If the patient is proficient in the performance and able to stabilize greater elevation angles he can do the same exercise against a wall with a towel. In this way the patient obtained more resistance from the towel. At a later date he also can practice with a ball. This can only be done effectively on the treatment couch because against the wall the range of motion will be limited. The unstable surface makes it more difficult of maintaining a stabilized scapula. This degree of difficulty belongs more in the exercise group three. A mirror can support the performance of this type of exercises. The patient gets by it visual feedback. Moreover, one can perform the scapula clock exercise (Figure 8). In this exercise the hand rest on the wall or treatment couch while moving only the scapula towards different time positions. This is more difficult to practice

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because the patient has to move the scapula independently. This needs a high level of consciousness to activate the scapular muscles.

Figure 8. Scapula clock exercise depression, retraction, elevation, protraction

The wall slide (Figure 9) exercise is easy in performing without thinking much about how to orientate the scapula into an upward rotation position. While increasing the glenohumeral elevation angle the serratus anterior activity increases. The patient stands in front of a wall or a door in split stance. His body weight resists on the backmost leg. He contacts the wall with the forearms. Then the patient shift his weight from the backmost leg to the front leg while moving the arms upwards to the highest position of his own possible scapular plane elevation.

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Figure 9. Wall slide starting position and ending position

The hands have to work against the resistance of the rough wall which stimulates following Gibson () optimal recruitment of the scapula stabilizers.16. If one will train the serratus anterior in an appropriate position this exercises is suited for stopping in different positions. In this way one can practice difficult arm elevation positions where the scapula cannot yet be stabilized. The muscle recruitment can be facilitated to give self resistance in the appropriate positions at the inferior scapular angle in the opposite direction (Figure 10).

Figure 10. Wall slide with self resistance at the inferior angle

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The wall slide exercise can also be done unilateral. During this variant the patient can work in closed kinetic chain with axial loading. He can, for example, stand in split stance in front of the wall and move his hands with flexed elbows from shoulder height up to maximal elevation with eventually adduction or abduction. Moseley et al are of the opinion that a combination of four exercises is most effective in shoulder rehabilitation and has to be included in each program31. For them are the scaption, rowing, push-up plus, and press-up exercises important because they effectively use the scapular muscles. But we only concentrate on the force couple which is responsible for the stabilization of the scapula. That is why we exclude the rowing and the press-up such as Moseley et al perform the exercise. During rowing the serratus anterior is not activated. But in the upper trapezius one can find high activation data. This effect we will not create. Otherwise there exist two different forms of rowing in which the serratus anterior is activated. The patient can stand at one end of the treatment couch which is at the same height as the patients hip. The patient gives resistance to the couch. In this way he activates the force couple. We will call this exercise in our program rowing against resistance (Figure 11). While performing the second useful type of rowing the patient faces a pulley system in sitting or standing position. The patient performs a rowing movement with the arms close to the body. He starts with the arms 90 elevated and pulls from this position his arms backwards with flexion in the elbows. This exercise we will call low rowing. These two types of rowing have a high activation potential of lower trapezius with minimal upper trapezius activity. We also excluded the press up exercise, because this exercise only activates for us unimportant muscle groups.

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Figure 11. Rowing against resistance

Based on the study of Decker et al11 the scaption exercise appears to us to be an adequate exercise of the second category. They found out that at this the upper trapezius and the serratus anterior are active and that only this exercise stimulates the activity of the middle trapezius with at least 20% MVC. Moseley et al31 affirms the importance of this exercises with his EMG-values. The patient has to raise his extended arms in the scapular plane with glenohumeral external rotation. While raising the arm until shoulder height a coordinated interaction of the force couple has to take place (Figure 12).

Figure 12. Scaption

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For us the most important exercise for our rehabilitation program is the push-up plus. In many studies it is known to be excellent because of the low UT/SA ratios. It is the exercise where nearly no activation potentials of the upper trapezius occur. In the study of Ludewig et al27 the exercise is described in four variations: standard push-up plus, knee push-up plus, elbow push-up plus, and wall push-up plus. Generally spoken the push-up plus exercise is just performed as the normal push-up exercise. But there is add a plus phase in which one has to make from a position with full extended arms an additional protraction movement of the shoulder. The names of the variation speak for themselves. The standard push-up plus is practiced with the hands and feet on the ground. During the knee push-up plus the knees have contact with the ground. While performing elbow push-up plus the elbows and feet remain on the surface. And, wall push-up plus are trained in standing with the arms against a wall. We advise to use the variations in the following order. Although, this exercise shows the worst UT/SA ratio, it seems to be the best opportunity to start at first with wall push-up plus (Figure 13). The patient does not have to bear his own body weight. He can get the feeling of the course of motions and practice already to stabilize his scapula in an easy way. If the stabilization happens controlled he can go a step further.

Figure 13. Wall push-up plus

The following step is variable with the third step. In our opinion the patient should at first practice on knees (Figure 14). At this he has the same performance as practising against a wall. He just has to bear a bit more body weight. 41

Figure 14. Knee push-up plus

Then he can try this exercise on elbows and feet (Figure 15). This is a bit more complicated because the motion cannot be induced by the normal push-up movement. Now he only can perform the plus phase and he has to bear his full weight.

Figure 15. Elbow push-up plus

At last practising the standard push-up plus (Figure 16) seems to be most difficult. But at the same time it is the most effective variant as described in the study of Ludewig et al27.

Figure 16. Standard push-up plus

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Not only is the low UT/SA ratio relevant in this exercise. But also the stimulation of proprioception by the axial loading component in the closed kinetic chain position Moreover, Ludewig et al points out that while performing these push-up plus exercises the data are actually excellent in the plus-phase. In the concentric and eccentric phase of extending and flexing the arms the upper trapezius plays a greater roll as during the plus-phase. One solution for training selectively the serratus anterior with exclusion of the upper trapezius is elbow push-up plus on the knees. While performing the patient can fully concentrate on the plus-motion and has not bear his full body weight. We will call this variant elbow knee push-up plus (Figure 17). For intensification of this variant the patient can also practice the elbow push-up plus (on feet). This option has to be analysed with EMG in further studies.

Figure 17. Elbow knee push-up plus

Reactive neuromuscular control

The exercises of group three has to facilitate the stabilization muscles of the scapula to react automatically on every functional situation. They can be similar to the exercises of group two but there has to be an attached deflecting element where the patient has to concentrate on. Thereby the concentration of the stabilization process of the scapula has to be faded out. Essential is now to concentrate on, for example, a functional task or an unstable surface. The stabilization has to occur automatically. Furthermore, in this group can be started with open chain exercises which will be expanded in group four.

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At the beginning, to make the patient familiar with the new type of exercises one can start with weight bearing exercises. But now with the use of an unstable surface such as a gym ball or wobble board, the patient has to displace his focus of concentration. He has to react on the perturbations of the unstable surface. The perturbations lead to co-contraction of other muscles. This can also be done on hands and knees. A further aggravation of the exercise is possible by using only one arm to hold the body in the same position (Figure 18).

Figure 18. Weight bearing exercise with unstable surface

In our study of the literature we have found two important open chain exercises for group three: the dynamic hug exercise as well as the SA punch (serratus anterior punch). For both of them are in the study of Decker et al11 very high EMG-values for the serratus anterior in comparison with the upper trapezius mentioned. During the dynamic hug (Figure 19) exercise the patient stands with his back shoulder width apart towards the pulley apparat. The arms are 60 flexed in the glenohumeral joint with 45 of elbow flexion. The shoulders are internal rotated and the patient holds a loop of the pulley in each hand. The patient has to perform a hugging movement until the hands touch each other in front of the patient. At this position he has also reached complete protraction of the shoulder.

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Figure 19. Dynamic hug starting and ending position

The SA punch (Figure 20) is simple in the performance. In the starting position the patient stands again shoulder width apart holding the arms 90 elevated. From this position the patient moves the shoulders into protraction the same way as a punch. This can the patient also practice with dumbbells, theraband, or with the pulley apparat. To make it more functional the SA punch can also be done while the patient makes a step forward.

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Figure 20. SA punch starting and ending position

Functional everyday activities

In functional everyday activities complex PNF exercises and plyometrics have an important function. In this way functional motor patterns can be newly created. PNF exercises will train muscle functioning in full range of motion. Thereby coordinated co-contractions of scapular stabilisers can be facilitated. Furthermore, they are suitable for independently training of increasing strength and coordination with dumbbells, theraband, or pulley apparat. There exist many variations of it. In our program we will describe some of them as an example. Reflex joint stabilization will be attained with the aid of plyometrics. The motion has to be performed very quick and powerful. Useful and very functional for sport activities are throwing (Figure 21) and catching exercises in shoulder patients. There exist so many different throwing forms that we cannot list and describe them all in our thesis. But in every form of throwing and catching the patient has to be aware of an explosive course of motion with use of maximal force.

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Figure 21. Throwing position during handball

Moreover, punching forms are also relevant if they are performed in an explosive way. They can effectively be practiced with dumbbells or with a pulley apparat. In this way the maximal force is elicited. Also in sports like tennis where the ball has to be stroked with a racquet are plyometrics needed. While practicing, a number of repetitions have to ensure a training effect, but also muscle fatigue has to be avoided. Otherwise, the awareness of the joint position and scapular movement will decrease and makes the exercises ineffective. We have created this exercise program in a way which is in our opinion the best setup to get a fully functional scapula on whose basis a further individual exercise program can be designed. It is just one approach of many. But every therapist should think about a logical setup and his aim of such an exercise program. Our strategy can be used as a guideline or as an example for a different setup.

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Limitations of the script

In our thesis some limitations can be found. We did not concentrated on examination techniques to find out the problem of the patient. On the grounds that we included all groups of shoulder patients, it would expand the guidelines of our bachelor thesis. But the reader can use our exercise program as a step before his normal rehabilitation approach at his shoulder patients. Moreover, we do not focus on pain which is an important factor of rehabilitation progress. That can be a relevant point to integrate in future papers. Furthermore, it is difficult to compare different studies with each other. Often, the authors use a different recording of EMG-values or include the EMG data of different muscles for one exercise. Thus, a comparison of the studies is delicate and we cannot always make science-based statements. An outspread discussion about EMG values is a clinically interesting issue and already topic in some reviews. But to affiliate this subject in our script would deflect the focus of it. We tried to choose the exercises based on available EMG-values, the possibility of performance, and the body alignment of each exercise.

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Conclusion
Assumption for a successful rehabilitation is the correct analysis of the patients problem, otherwise no goal-oriented therapy is possible. In this paper therapeutic exercises were the focal point. To get a full-blown rehabilitation programme you have to comprise a basis of proprioception, the kinetic chain approach, motor learning, valid EMG values of muscle activity at certain motions, and investigated trainings principles. Furthermore, the therapist needs to consider individual patient factors and has to respond to someones requirements. In this script we chose a four point rehabilitation progress which is discussed in the study of Lephart et al23. The first goal is to gain joint position sense and kinaesthesia. At this high cognitive level of exercising repositioning of the scapula with manual resistance is one possibility to start with. The second step in rehabilitation is the dynamic joint stabilization. This can be reached with exercises in the closed kinetic chain. The axial loading facilitates the proprioceptive input which enhance inter- and intraneuromuscular coordination. In this phase the therapist has to choose exercises which stimulate the force couple of the scapula in the desired manner. The following rehabilitation point is to stimulate reactive neuromuscular control. This can be trained by included and unexpected perturbations during an exercise. The goal is that the patient develops an unconscious, automatically manner of scapula stabilization. Functional everyday activities form the last spot of the rehabilitation programme. The other steps prior to this are the basics for reaching this goal. The achieved skills are now fit in a functional context. The paragraph of Kinetic chain clarifies that the scapula would never be activated alone in every day life, work, or during sport activities. That is why it is important to integrate other segments of the kinetic chain into the rehabilitation program. Further, it is fundamental that the patient is able to stabilize his scapula automatically during the performance of other tasks. This is trained in the last step of rehabilitation. Particularly this last part should be individual arranged.

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What is the goal of the patient? Clinicians should challenge themselves to be creative and experiment with different forms of every exercise in order to achieve each individual patients rehabilitative goals.37. One has to include the wishes of the patient and the surrounding circumstances of him, concerning functional everyday activities, life situation, work and hobbies. It is not the goal to satisfy the therapist, it is the goal to satisfy the patient.

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Appendix
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12. Ebaugh DD, McClure PW, Karduna AR. 3-dimensional scapulothoracic motion during active and passive arm elevation. Clin Biomech. 2005;20:700-709. 13. Ekstrom RA, Donatelli RA, Soderberg GC. Surface electromyographic analysis of exercise fort he trapezius and serratus anterior muscles. J Orthop Sports Phys Ther. 2003;33; 247-258. 14. Ekstrom RA, Bifulco KM, Lopau LJ, Andersen CF, Gough JR. Comparing the function of the upper and lower parts of the serratus anterior muscle using surface electromyography. J Orthop Sports Phys Ther. 2004;34:235-243. 15. Gerates J. Behavioral graded activity for shoulder pain. Dutch Journal of Physical Therapy Special Issue 2007;3;80-81 16. Gibson JC. Rehabilitation after shoulder instability surgery. Cur Orthop. 2004;18:197-209. 17. Hardwick DH, Beebe JA, McDonnell MK, Lang CE. A comparison of serratus anterior muscle activation during wall slide exercise and other traditional exercises. J Orthop Sports PhysTher. 2006;36;903-910. 18. Jerosch J, Wuestner P. Effekt eines sensomotorischen Trainigsprogramms bei Patienten mit subakrominalem Schmerzsyndrom. Der Unfallchirurg: Organ der Deutschen Gesellschaft fr Unfallheilkund. 2002;105:36-43. 19. Kadefors, Roland, Forsman, Mikael, Zoega, Bjorn, Herberts, Peter. Recruitment of low threshold motor units in the trapezius muscle in different static arm positions. Ergon. 1999;42:359-376. 20. Kibler WB, McMullen J, Uhl T. Shoulder rehabilitation strategies, guidelines and practice. Orthop Clin of North Am. 2001;32:527-538. 21. Kibler WB. Management of the scapula in glenohumeral instability. Tech Should Elbow Surg. 2003;4:89-98. 22. Lehmann GJ, Gilas D, Patel U. An unstable support surface does not increse scapulothoracic stabilizing muscle activity during push up and push up plus exercises. Man Ther. 2007 23. Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997;25:130-137.

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24. Lin J, Lim HK, Soto-quijano DA, Hanten WP, Olson SL, Roddey TS, Sherwood AM. Altered patterns of muscle activation during performance of four functional tasks in patients with shoulder disorders: Interpretation from voluntary response index. J Electromyogr Kinesiol. 2006;16:458468. 25. Ludewig PM, Cook TM. Threedimensional scapular orientation and muscle activity at selected positions of humeral elevation. J Orthop Sports Phys Ther. 1996;24:57-65. 26. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80:276-291. 27. Ludewig PM, Hoff M, Osowski E, Meschke S, Rundquist P. Relative balance of serratus anterior and upper trapezius muscle activity during push-up exercises. Am J Sports Med. 2004;32:484-493. 28. Magarey ME, Jones MA. Dynamic evaluation and early management of altered motor control around the shoulder complex. Man Ther. 2003;8:195-206. 29. McClure PW, Michiner LA, Karduna AR. Shoulder function and 3dimensional scapular kinematics in people with and without shoulder impingementsyndrome. Phys Ther. 2006;86:1075-1090. 30. McQuade KJ, Dawson J, Smidt GL. Scapulothoracic muscle fatigue associated with alterations in scapulohumeral rhythm kinematics during maximum resistive shoulder elevation. J Orthop Sports Phys Ther. 1998;28:74-80. 31. Morseley J, Jobe F, Pink M, Perry J, Tibone J. EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am J Sports Med. 1992;20:128-134. 32. Mottram SL. Dynamic stability of the scapula. Man Ther. 1997;2:123-131. 33. Mottram SL, Woledge RC, Morrissey D. Motion analysis study of scapular orientation exercise and subjects ability to learn the exercise. Man Ther. 2007. 34. Mottram SL. Movement dysfunction- dynamic stability & muscle balance of the cervical spine and shoulder girdle. Comeford & Kinetic Control 2000

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35. Riemann BL, Lephart SM. The Sensorimotor System, Part I: The physiologic basis of functional joint stability. J Athl Train. 2002;37:71-79. 36. Riemann BL, Lephart SM. The Sensorimotor System, Part II: The role of proprioception in motor control and functional joint stability. J Athl Train. 2002;37:80-84. 37. Voight ML,Thomson BC. The role of the scapula in the rehabilitation of shoulder injuries. J Athlet Train. 2000;35:364(9). 38. Wand CH, McClure P. Stretching and strengthening exercises: their effect on three-dimensional scapular kinematics. Arch Phys Med Rehab. 1999;80;923-929.

Table of figures
Figure 1. Local coordinate systems and axis orientation for the scapula and trunk. Ludewig PM, Cook TM. Threedimensional scapular orientation and muscle activity at selected positions of humeral elevation. J Orthop Sports Phys Ther. 1996;24: p.58 ............................................................................................ 8 Figure 2. Force couple. Cools AM, Walravens M. Oefentherapie bij schouderaandoeningen. First print 2005 Standaard Uitgeverij nv, Antwerpen; ISBN: 90 341 9858 8: p.107 ............................................................................. 11 Figure 3. Model of the three functional systems from Luria. Cranenburg B. Neurowetenschappen een overzicht. First print 1997 Uitgeverij Utrecht, De Tijdstroom; ISBN: 90 352 1714 4 ..................................................................... 23 Figure 4. Alignment of the scapula ................................................................... 25 Figure 5. Positioning of the scapula with manual resistance at the inferior angle ......................................................................................................................... 34 Figure 6. Facilitation at the sternum ................................................................. 34 Figure 7. Weight bearing exercise. Gibson JC. Rehabilitation after shoulder instability surgery. Cur Orthop. 2004;18: p.202 ................................................ 36 Figure 8. Scapula clock exercise depression, retraction, elevation, protraction ......................................................................................................................... 37 Figure 9. Wall slide starting position and ending position.............................. 38 Figure 10. Wall slide with self resistance at the inferior angle .......................... 38 Figure 11. Rowing against resistance .............................................................. 40 Figure 12. Scaption .......................................................................................... 40 54

Figure 13. Wall push-up plus............................................................................ 41 Figure 14. Knee push-up plus .......................................................................... 42 Figure 15. Elbow push-up plus ......................................................................... 42 Figure 16. Standard push-up plus .................................................................... 42 Figure 17. Elbow knee push-up plus ................................................................ 43 Figure 18. Weight bearing exercise with unstable surface ............................... 44 Figure 19. Dynamic hug starting and ending position.................................... 45 Figure 20. SA punch starting and ending position ......................................... 46 Figure 21. Throwing position during handball ...................................................... http://www.handballfoto.de/details.php?image_id=1149 .................................. 47

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Affirmation
Hereby we declare that we have created/written the present work independently and unassisted. Also, we have used and documented all sources, tools and internet sites truthfully.

_____________________________ Place, date

__________________ Andrea Bernau

_____________________________ Place, date

__________________ Sonja Mnzebrock

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