Birgit Castelein

Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete

The scapula functions as a bridge between the shoulder complex and the cervical spine and plays a very important role in providing both mobility and stability of the neck/shoulder region. The association between abnormal scapular positions and motions and glenohumeral joint pathology has been well established in the literature, whereas studies investigating the relationship between neck pain and scapular dysfunction have only recently begun to emerge. Although several authors have emphasised the relevance of restoring normal scapular kinematics through exercise and manual therapy techniques, overall scapular rehabilitation guidelines decent for both patients with shoulder pain as well as patients with neck problems are lacking. The purpose of this paper is to provide a science-based clinical reasoning algorithm with practical guidelines for the rehabilitation of scapular dyskinesis in patients with chronic complaints in the upper quadrant.

Evidence for the Use of Ischemic Compression and Dry Needling in the Management of Trigger Points of the Upper Trapezius in Patients with Neck Pain: A Systematic Review.

ABSTRACTThe aim of this review was to describe the effects of ischemic compression and dry needling on trigger points in the upper trapezius muscle in patients with neck pain and compare these two interventions with other therapeutic interventions aiming to inactivate trigger points. Both PubMed and Web of Science were searched for randomized controlled trials using different key word combinations related to myofascial neck pain and therapeutic interventions. Four main outcome parameters were evaluated on short and medium term: pain, range of motion, functionality, and quality-of-life, including depression. Fifteen randomized controlled trials were included in this systematic review. There is moderate evidence for ischemic compression and strong evidence for dry needling to have a positive effect on pain intensity. This pain decrease is greater compared with active range of motion exercises (ischemic compression) and no or placebo intervention (ischemic compression and dry needling) but similar to other therapeutic approaches. There is moderate evidence that both ischemic compression and dry needling increase side-bending range of motion, with similar effects compared with lidocaine injection. There is weak evidence regarding its effects on functionality and quality-of-life. On the basis of this systematic review, ischemic compression and dry needling can both be recommended in the treatment of neck pain patients with trigger points in the upper trapezius muscle. Additional research with high-quality study designs are needed to develop more conclusive evidence.

Analysis of scapular muscle EMG activity in patients with idiopathic neck pain: A systematic review

It is proposed that altered scapular muscle function can contribute to abnormal loading of the cervical spine. However, it is not clear if patients with idiopathic neck pain show altered activity of the scapular muscles. The aim of this paper was to systematically review the literature regarding the differences or similarities in scapular muscle activity, measured by electromyography ( = EMG), between patients with chronic idiopathic neck pain compared to pain-free controls. Case-control (neck pain/healthy) studies investigating scapular muscle EMG activity (amplitude, timing and fatigue parameters) were searched in Pubmed and Web of Science. 25 articles were included in the systematic review. During rest and activities below shoulder height, no clear differences in mean Upper Trapezius ( = UT) EMG activity exist between patients with idiopathic neck pain and a healthy control group. During overhead activities, no conclusion for scapular EMG amplitude can be drawn as a large variation of results were reported. Adaptation strategies during overhead tasks are not the same between studies. Only one study investigated timing of the scapular muscles and found a delayed onset and shorter duration of the SA during elevation in patients with idiopathic neck pain. For scapular muscle fatigue, no definite conclusions can be made as a wide variation and conflicting results are reported. Further high quality EMG research on scapular muscles (broader than the UT) is necessary to understand/draw conclusions on how scapular muscles react in the presence of idiopathic neck pain.

Evidence-based rehabilitation of athletes with glenohumeral instability.

AbstractPurposeTo give an overview of current knowledge and guidelines with respect to evidence-based rehabilitation of athletes with glenohumeral instability.MethodsThis narrative review combines scientific evidence with clinical guidelines based on the current literature to highlight the different components of the rehabilitation of glenohumeral instability.Results Depending on the specific characteristics of the instability pattern, the severity, recurrence, and direction, the therapeutic approach may be adapted to the needs and demands of the athlete. In general, attention should go to (1) restoration of rotator cuff strength and inter-muscular balance, focusing on the eccentric capacity of the external rotators, (2) normalization of rotational range of motion with special attention to the internal rotation ROM, (3) optimization of the flexibility and muscle performance of the scapular muscles, and (4) gradually increasing the functional sport-specific load on the shoulder girdle. The functional kinetic chain should be implemented throughout all stages of the rehabilitation program. Return to play should be based on subjective assessment as well as objective measurements of ROM, strength, and function.ConclusionsThis paper summarizes evidence-based guidelines for treatment of glenohumeral instability. These guidelines may assist the clinician in the prevention and rehabilitation of the overhead athlete.Level of evidenceExpert opinion, Level V.

Superficial and Deep Scapulothoracic Muscle Electromyographic Activity During Elevation Exercises in the Scapular Plane

STUDY DESIGN Controlled laboratory study. BACKGROUND In scapular rehabilitation training, exercises that include a humeral elevation component in the scapular plane are commonly implemented. While performing humeral elevation, the scapula plays an important role, as it has to create a stable basis for the glenohumeral joint. However, a comparison of both deep and superficial muscle activity of the scapula between different types of elevation exercises is lacking and would be helpful for the clinician in choosing exercises. OBJECTIVES To evaluate scapulothoracic muscle activity during different types of elevation exercises in the scapular plane. METHODS Scapulothoracic muscle activity was measured in 21 healthy subjects, using fine-wire electromyography in the levator scapulae, pectoralis minor, and rhomboid major muscles and surface electromyography in the upper trapezius, middle trapezius, lower trapezius, and serratus anterior muscles. Measurements were conducted while the participants performed the following elevation tasks in the scapular plane: scaption (elevation in the scapular plane), towel wall slide, and elevation with external rotation (Thera-Band). The exercises were performed without and with additional load. Possible differences between the exercises and the load were studied with a linear mixed model. RESULTS Performing elevation in the scapular plane with an external-rotation component resulted in higher middle trapezius and lower trapezius activity compared to the scaption and wall slide exercises. The upper trapezius was maximally activated during scaption. The pectoralis minor and serratus anterior showed the highest activity during the towel wall slide. The towel wall slide activated the retractors to a lesser degree (middle trapezius, lower trapezius, levator scapulae, rhomboid major). Adding load resulted in higher muscle activity in all muscles, with some muscles showing a different activation pattern between the elevation exercises, depending on the load condition. CONCLUSION Scaption maximally activated the upper trapezius. The addition of an extra external-rotation component may be used when the goal is to activate the lower trapezius and middle trapezius. The towel wall slide exercise was found to increase pectoralis minor activity. Adding load resulted in higher muscle activity. Some muscles showed a different activation pattern between the elevation exercises, depending on the loading condition. The findings of this study give information about which elevation exercises a clinician can choose when the aim is to facilitate specific muscle scapulothoracic activity.

The Relevance of Scapular Dysfunction in Neck Pain: A Brief Commentary

Synopsis Though our understanding of motor disorders and mechanical neck pain has advanced, the role of scapular dysfunction in mechanical neck pain remains enigmatic. The biomechanical interdependence between the neck and scapula and the potentially deleterious consequences of scapular dysfunction in the cervical region are biomechanically plausible. Yet the relevance of observed scapular dysfunction in patients with neck pain is still inadequately explained by research. However, studies investigating the association between scapular function and neck pain are beginning to emerge. The purpose of this paper was to review the current knowledge of this topic and consider the implications for clinical practice. Level of Evidence Therapy, level 5.

The isokinetic rotator cuff strength ratios in overhead athletes: Assessment and exercise effect

OBJECTIVE Muscle strength imbalance in the shoulder region can be considered as a predisposing factor in the development of movement dysfunctions, possibly leading to overuse injuries. Repetitive overhead throwing, performed in sports, may result in muscle imbalance between the external (ER) and internal (IR) rotators. Muscle strength measured with an isokinetic device, is reported as a concentric (CON) or eccentric (ECC) force. The balance between an agonist and an antagonist is mentioned as a ratio (CON/CON or ECC/CON). The aim of this systematic literature review is to provide an overview of the existing evidence considering the isokinetic muscle strength ratios of ER and IR of the shoulder in healthy overhead athletes. In addition, the effect of exercise programs on these ratios was investigated. METHODS Two online databases (Web of Science and PubMed) were consulted using different search strategies. Articles were selected based on inclusion and exclusion criteria. All included articles were assessed on their methodological quality. RESULTS AND CONCLUSIONS There is moderate evidence for a lower functional deceleration ratio (ECC ER/CON IR) at the dominant side. This lower ratio is due to a large overweight of CON IR strength on that side. There is no consensus about which exercise program is the most effective in altering the shoulder isokinetic strength ratios.

Comparing Trigger Point Dry Needling and Manual Pressure Technique for the Management of Myofascial Neck/Shoulder Pain: A Randomized Clinical Trial

Objective The aim of this study was to investigate short‐term and long‐term treatment effects of dry needling (DN) and manual pressure (MP) technique with the primary goal of determining if DN has better effects on disability, pain, and muscle characteristics in treating myofascial neck/shoulder pain in women. Methods In this randomized clinical trial, 42 female office workers with myofascial neck/shoulder pain were randomly allocated to either a DN or MP group and received 4 treatments. They were evaluated with the Neck Disability Index, general numeric rating scale, pressure pain threshold, and muscle characteristics before and after treatment. For each outcome parameter, a linear mixed‐model analysis was applied to reveal group‐by‐time interaction effects or main effects for the factor “time.” Results No significant differences were found between DN and MP. In both groups, significant improvement in the Neck Disability Index was observed after 4 treatments and 3 months (P < .001); the general numerical rating scale also significantly decreased after 3 months. After the 4‐week treatment program, there was a significant improvement in pain pressure threshold, muscle elasticity, and stiffness. Conclusion Both treatment techniques lead to short‐term and long‐term treatment effects. Dry needling was found to be no more effective than MP in the treatment of myofascial neck/shoulder pain.

Scapular muscle dysfunction associated with subacromial pain syndrome

Study Design: Narrative Review. Introduction: One of the shoulder pain disorders in which the function of the scapula is comprised is the subacromial pain syndrome. Several rehabilitation guidelines and exercises have been proposed to improve scapulothoracic muscle dysfunction. Consideration of muscle activation patterns may help to select the most appropriate rehabilitation exercise in these patients. To date, suggesting rehabilitation exercises is often based upon the knowledge of the superficial lying scapulothoracic muscles’ activity. In the assumption that the deeper lying scapulothoracic muscles’ activity may hinder normal scapular movement in case of tightness or hyperactivity, exercise protocols for patients with altered pattern in scapulothoracic muscles should also integrate knowledge on the deeper lying scapulothoracic muscle activity. Purpose of the Study: To help clinicians choosing the most appropriate exercise in patients with subacromial pain syndrome related to scapulothoracic muscle dysfunction. Methods: First, a summary of key alterations in scapulothoracic (muscle) function in patients with subacromial pain was accomplished. Second, promising practical rehabilitation strategies toward restoring scapulothoracic muscle dysfunction (with a focus on scapulothoracic exercises) were developed, integrating current new research evidence (including information about the deeper lying scapulothoracic muscles) with clinical practice. Conclusion: This review details clinical exercises and their muscular activity to guide clinicians to optimize individualized scapulothoracic training and treatment programs by selecting the most appropriate exercise, based on knowledge from the clinical examination. Level of Evidence: Level 5.

The influence of induced shoulder muscle pain on rotator cuff and scapulothoracic muscle activity during elevation of the arm

BACKGROUND Altered recruitment of rotator cuff and scapulothoracic muscles has been identified in patients with subacromial impingement syndrome. To date, however, the cause-consequence relationship between pain and altered muscle recruitment has not been fully unraveled. METHODS The effect of experimental shoulder pain induced by injection of hypertonic saline in the supraspinatus on the activity of the supraspinatus, infraspinatus, subscapularis, trapezius, and serratus anterior activity was investigated during the performance of an elevation task by use of muscle functional magnetic resonance imaging in 25 healthy individuals. Measurements were taken at 4 levels (C6-C7, T2-T3, T3-T4, and T6-T7) at rest and after the elevation task performed without and with experimental shoulder pain. RESULTS During arm elevation, experimentally induced pain caused a significant activity reduction, expressed as reduction in T2 shift of the IS (P = .029). No significant changes in T2 shift values were found for the other rotator cuff muscles or the scapulothoracic muscles. CONCLUSIONS This study demonstrates that acute experimental shoulder pain has an inhibitory effect on the activity of the IS during arm elevation. Acute experimental shoulder pain did not seem to influence the scapulothoracic muscle activity significantly. The findings suggest that rotator cuff muscle function (infraspinatus) should be a consideration in the early management of patients with shoulder pain.