Mary E. Magarey

Dynamic evaluation and early management of altered motor control around the shoulder complex.

Altered dynamic control appears to be a significant contributing factor to shoulder dysfunction. The shoulder relies primarily on the rotator cuff for dynamic stability through mid-range. Hence, any impairment in the dynamic stabilizing system is likely to have profound effects on the shoulder complex. The rotator cuff appears to function as a deep stabilizer, similar to the transversus abdominus and vastus medialis obliquus, with some evidence of disruption to its stabilizing function in the presence of pain. Similarly, serratus anterior appears to function as a dynamic stabilizer, also demonstrating altered function in painful shoulders. Examination of dynamic control begins with a detailed examination of posture, evaluation of natural movement patterns and functional movements and assessment of the specific force couples relevant to shoulder function. One useful strategy in management of altered motor control related to these force couples is that of training isolated contraction of the rotator cuff prior to introduction of loaded activity, together with facilitation and training of appropriate scapular muscle force couples--serratus anterior and trapezius, in relation to arm elevation.

Specific evaluation of the function of force couples relevant for stabilization of the glenohumeral joint

Two clinical evaluation procedures for assessment of dynamic stability of the glenohumeral joint are presented in this paper, together with the biomedical evidence on which they are based. They are the Dynamic Rotary Stability Test (DRST) and the Dynamic Relocation Test (DRT). The purpose of the tests is presented and the technique required to perform the tests are described in detail.

Clinical diagnosis and management of minor shoulder instability

The term minor instability refers to a condition in which chronic microtrauma involving the stabilising mechanisms of the glenohumeral joint leads to subluxation of the humeral head. The condition is commonly associated with athletes involved in repetitive high-velocity activities such as throwing or swimming. Minimal signs are found on physical examination of the shoulder joint but the patient presents with vague pain, catches of pain, apprehension with overhead movement or an impingement-like condition which appears resistant to treatment. The clinical examination findings which might alert the physiotherapist to the potential diagnosis of minor instability are reviewed. Following this, an approach to management with emphasis on establishing muscular control in the early stages of rehabilitation is presented.

Physiotherapy, a responsible profession to use cervical manipulation. Response to Refshauge et al

Results from recent randomised controlled trials conducted by physiotherapists are contributing to the increasing evidence of the benefits of cervical manipulative therapy for the management of cervical musculoskeletal disorders (Boline 1995, Bronfort et al 2001, Hoving et al 2002, Jull et al 2002). It is known that there is a risk, albeit very slight, of devastating side effects of cervical manipulation. Issues of safety of use of high velocity cervical manipulation and risk/benefits of this procedure are of concern to all practitioners of manipulative therapy. Refshauge and colleagues (2002) have presented their views of the issues around cervical manipulation to stimulate debate amongst those professions which use cervical manipulation. The debate is welcome within the physiotherapy profession. Refshauge et al raise and present argument around four questions. It is our contention in this response that many of the arguments presented by Refshauge et al do not support their recommendations.

High prevalence of dysfunctional, asymmetrical, and painful movement in elite junior Australian Football players assessed using the Functional Movement Screen.

OBJECTIVES The purpose of this study was to describe the prevalence of dysfunctional, asymmetrical, and painful movement in junior Australian Football players using the Functional Movement Screen (FMS). DESIGN Cross-sectional study. METHODS Elite junior male Australian Football players (n=301) aged 15-18 years completed pre-season FMS testing. The FMS consists of 7 sub-tests: deep squat, hurdle step, in-line lunge, shoulder mobility, active straight leg raise, trunk stability push-up (TSPU) and rotary stability. The shoulder mobility, TSPU, and rotary stability tests were combined with an accompanying clearing test to assess pain. Each sub-test was scored on an ordinal scale from 0 to 3 and summed to give a composite score out of 21. Composite scores ≤14 were operationally defined as indicating dysfunctional movement. Players scoring differently on left and right sides were considered asymmetrical. Players reported whether they missed any games due to injury in the preceding 22 game season. RESULTS Sixty percent of players (n=182) had composite scores ≤14, 65% of players (n=196) had at least one asymmetrical sub-test, and 38% of players (n=113) had at least one painful sub-test. Forty-two percent of players (n=126) missed at least one game in the previous season due to injury. Previous injury did not influence composite score (p=0.951) or asymmetry (p=0.629). Players reporting an injury during the previous season were more likely to experience pain during FMS testing (odds ratio 1.97, 95% confidence interval 1.23-3.18; p=0.005). CONCLUSIONS Junior Australian Football players demonstrate a high prevalence of dysfunctional, asymmetrical, and painful movement during FMS testing.

Does physiotherapy diagnosis of shoulder pathology compare to arthroscopic findings

Aims To explore the ability of a physiotherapist, using a standardised musculoskeletal physiotherapy assessment protocol, to accurately identify the structures potentially responsible for shoulder symptoms against a standardised arthroscopic shoulder diagnostic assessment, and to determine the physiotherapists’ ability to influence post-test diagnostic accuracy. Study design Consecutive case-based cohort study. Subject selection All participants were selected by two orthopaedic surgeons for arthroscopic investigation during a 6-month period. Setting Private orthopaedic clinic. Method All consenting participants selected for arthroscopic investigation were examined by the physiotherapist prior to arthroscopy. Presence and priority of impairments/diagnoses were recorded on a standardised form. Inter and intra-rater reliability and diagnostic accuracy were tabulated. Statistical analysis Proportional agreement on diagnostic incidence (broad) and priority (strict) using 2×2 contingency tables for sensitivity, specificity, positive and negative predictive value and positive and negative likelihood ratios were calculated. Post-test probabilities were analysed to determine the influence of a positive or a negative finding. Results 211 participants, aged 14–79 years were included. Overall prevalence of subacromial pathology was (77%) and, disorders of the passive restraints (29%). For both negative and positive findings, post-test probabilities were not notably altered; although positive findings yielded greater value in the decision-making modelling. The physiotherapists ability to identify individual pathology (eg, tendon rupture vs tendinopathy, capsular vs labral) was lower than recognition of pathology within the broader diagnostic category. Conclusions The physiotherapists ability to diagnose individual pathologies was inconsistent. Indirectly, this raises the issue of whether signs and symptoms identified under arthroscopic surgery are reflective of a lesion/pathology reflective of a specific tissue.

The Musculoskeletal Physiotherapy of Australia position on pre-manipulative testing for the cervical spine.

The MPA undertook a survey of its members in 1997 to determine their compliance with and opinion of the APA Protocol for Pre-Manipulative Testing of the Cervical Spine (Magarey et al 2000a, Magarey et al submitted-a). As a result of that survey and a comprehensive literature review, the MPA developed a new set of guidelines for premanipulative procedures for the cervical spine (Magarey et al 2000b, Magarey et al submitted-b).

Muscular load to the therapist's shoulder during three alternative techniques for trigger point therapy

AIM To compare the muscular load (level of muscle activity) to the shoulder during alternative approaches to trigger point therapy (TPT). METHOD Massage therapy students (n=7) applied a predetermined level of force to an artificial contact surface. Changes in five pairs of superficial shoulder muscles (indicated by surface electromyography) were recorded while the student performed the single-arm technique (SAT), the double-arm technique (DAT) and the treatment-tool technique (TTT) using TriggerMate, a new treatment tool. RESULTS For the contact arm, muscle activity was significantly decreased using the TTT compared to the SAT (p<0.05) but was not significantly different between the TTT and DAT. For the non-contact arm, none of the test techniques led to significant differences in muscle activity. CONCLUSIONS While there is evidence that the TTT decreases the muscular load to the shoulder of the contact arm, there is no indication of where this load is redistributed.

Klinische diagnose en behandeling van functionele schouderinstabiliteit

Functionele schouderinstabiliteit staat hier voor de Engelse benaming ‘minor shoulder instability ’. Andere benamingen zijn verborgen instabiliteit (occult instability ’ Garth et al., 1987)) en verborgen recidiverende glenohumerale subluxatie (‘occult recurrent glenohumeral subluxation’ ’ Jobe & Kvitne, 1989). De term verwijst naar een toestand waarbij chronische microtraumata van het stabilise rende mechanisme van het glenohumerale gewricht aanleiding geven tot subluxatie van de humeruskop (OBrien et al., 1987; Pappas et al., 1987<; Protzman, 1980; Schwartz et al., 1987; Warren, 1983).