Paula R. Camargo

Scapular and rotator cuff muscle activity during arm elevation: a review of normal function and alterations with shoulder impingement

OBJECTIVE: The purpose of this manuscript is to review current knowledge of how muscle activation and force production contribute to shoulder kinematics in healthy subjects and persons with shoulder impingement. RESULTS: The middle and lower serratus anterior muscles produce scapular upward rotation, posterior tilting, and external rotation. Upper trapezius produces clavicular elevation and retraction. The middle trapezius is primarily a medial stabilizer of the scapula. The lower trapezius assists in medial stabilization and upward rotation of the scapula. The pectoralis minor is aligned to resist normal rotations of the scapula during arm elevation. The rotator cuff is critical to stabilization and prevention of excess superior translation of the humeral head, as well as production of glenohumeral external rotation during arm elevation. Alterations in activation amplitude or timing have been identified across various investigations of subjects with shoulder impingement as compared to healthy controls. These include decreased activation of the middle or lower serratus anterior and rotator cuff, delayed activation of middle and lower trapezius, and increased activation of the upper trapezius and middle deltoid in impingement subjects. In addition, subjects with a short resting length of the pectoralis minor exhibit altered scapular kinematic patterns similar to those found in persons with shoulder impingement. CONCLUSION: These normal muscle functional capabilities and alterations in patient populations should be considered when planning exercise approaches for the rehabilitation of these patients.

Effects of strengthening and stretching exercises applied during working hours on pain and physical impairment in workers with subacromial impingement syndrome

This study evaluated the effectiveness of a rehabilitation program performed during working hours on function and pain in workers with subacromial impingement syndrome. Fourteen male workers (31.93 ± 5.86 years) in the school supply industry were assessed. The duration of their shoulder pain was 28.50 ± 33.64 months, and their amount of time in this industry was 9.07 ± 3.68 years. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire evaluated function of the upper limbs. The Mc Gill Pain Questionnaire quantified the pain by the number of words chosen and the pain rating index (PRI). Subjects completed an 8-week rehabilitation program, twice a week, consisting of cryotherapy, strengthening, and stretching exercises. Subjects’ outcome data were collected pre- and post-intervention. The results showed that DASH scores improved (p<0.05) and the number of words chosen and PRI decreased (p<0.05) on the McGill Pain Questionnaire at post-intervention. Results should be interpreted cautiously, considering the lack of a control group in the investigation. In conclusion, it is suggested that an intervention program consisting of cryotherapy, strengthening, and stretching applied during working hours and twice a week may be effective to decrease pain and physical impairment in male workers with subacromial impingement syndrome.

Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: a blinded, controlled study.

Objectives:To identify the presence of myofascial trigger points (TrPs) and pressure pain threshold (PPT) levels in the shoulder muscles of both involved and uninvolved sides in patients with unilateral shoulder impingement syndrome (SIS). Methods:Twenty-seven patients with SIS and 20 matched control patients participated in this study. TrPs of 10 shoulder muscles and 8 PPTs, including tibialis anterior PPT, were assessed. Results:SIS group showed a greater number of TrPs (t=−2.697; P=0.010) than the control group. The muscles of the uninvolved side of the SIS group also presented some active TrPs. PPTs showed small differences between involved and uninvolved sides of patients with SIS and higher differences between both sides of the SIS group and dominant side of controls although with significant difference only in the supraspinatus PPT (F=3.239; P=0.045). The muscle PPTs of the patients presenting TrPs in each muscle of the involved side were lower than the PPTs of the patients without TrPs in the same muscle for both involved and uninvolved sides with few significant differences. Discussion:The high number of TrPs in the involved side of patients with SIS suggests the presence of peripheral sensitization. The results reject the presence of central alterations. Finally, the patients with unilateral SIS may present bilateral deficits related to myofascial pain.

Scapular Kinematics Pre– and Post–Thoracic Thrust Manipulation in Individuals With and Without Shoulder Impingement Symptoms: A Randomized Controlled Study

STUDY DESIGN Randomized controlled trial with immediate follow-up. OBJECTIVES To evaluate the immediate effects of a low-amplitude, high-velocity thrust thoracic spine manipulation (TSM) on pain and scapular kinematics during elevation and lowering of the arm in individuals with shoulder impingement syndrome (SIS). The secondary objective was to evaluate the immediate effects of TSM on scapular kinematics during elevation and lowering of the arm in individuals without symptoms. BACKGROUND Considering the regional interdependence among the shoulder and the thoracic and cervical spines, TSM may improve pain and function in individuals with SIS. Comparing individuals with SIS to those without shoulder pathology may provide information on the effects of TSM specifically in those with SIS. METHODS Fifty subjects (mean ± SD age, 31.8 ± 10.9 years) with SIS and 47 subjects (age, 25.8 ± 5.0 years) asymptomatic for shoulder dysfunction were randomly assigned to 1 of 2 interventions: TSM or a sham intervention. Scapular kinematics were analyzed during elevation and lowering of the arm in the sagittal plane, and a numeric pain rating scale was used to assess shoulder pain during arm movement at preintervention and postintervention. RESULTS For those in the SIS group, shoulder pain was reduced immediately after TSM and the sham intervention (mean ± SD preintervention, 2.9 ± 2.5; postintervention, 2.3 ± 2.5; P<.01; moderate effect size [Cohen d = 0.2]). Scapular internal rotation increased 0.5° ± 0.02° (P = .04; small effect size [Cohen d<0.1]) during elevation of the arm after TSM and sham intervention in the SIS group only. Subjects with and without SIS who received TSM and asymptomatic subjects who received the sham intervention had a significant increase (1.6° ± 2.7°) in scapular upward rotation postintervention (P<.05; small effect size [Cohen d<0.2]), which was not considered clinically significant. Scapular anterior tilt increased 1.0° ± 4.8° during elevation and lowering of the arm postmanipulation (P<.05; small effect size [Cohen d<0.2]) in the asymptomatic subjects who received TSM. CONCLUSION Shoulder pain in individuals with SIS immediately decreased after a TSM. The observed changes in scapular kinematics following TSM were not considered clinically important. LEVEL OF EVIDENCE Therapy, level 4. J Orthop Sports Phys Ther 2014;44(7):475-487. Epub 22 May 2014. doi:10.2519/jospt.2014.4760.

Pain in workers with shoulder impingement syndrome: an assessment using the DASH and McGill pain questionnaires

Objective: This study assessed physical function and pain in male and female workers with shoulder impingement syndrome using the Brazilian Portuguese versions of the Disabilities of the Arm, Shoulder and Hand (DASH) and McGill pain questionnaires. Methods: Twenty-seven assembly line workers (18 men and 9 women; mean age of 33.26 ± 6.49 years) in the school supply industry were evaluated. The duration of the shoulder impingement pain was 31.74 ± 32.92 months and the amount of time of the workers in this industry was 11.08 ± 6.41 years. The DASH questionnaire was used to evaluate functional status and symptoms of the upper limbs of the workers. Using the McGill Pain Questionnaire, the pain was quantified by the number of words chosen and by the pain rating index (PRI). Results: The women presented higher scores (P< 0.05) than the men for both DASH overall and DASH work scores. The women chose more words (17.00 ± 2.59) than the men (13.33 ± 3.16) and also presented the highest total PRI (P< 0.05). Conclusions: The results obtained in this group of Brazilian workers with shoulder impingement identify the most commonly used descriptors of shoulder pain. Further, this study shows that females are more likely than males to refer physical disability and pain. Also, the DASH and McGill pain questionnaires are important and helpful tools in the clinical evaluation of shoulder impingement syndrome.

Reliability and Minimal Detectable Change of 3-Dimensional Scapular Orientation in Individuals With and Without Shoulder Impingement

STUDY DESIGN Clinical measurement. OBJECTIVE To establish trial-to-trial within-day and between-day reliability, standard error of measurement, and minimal detectable change of scapular orientation during elevation and lowering of the arm, and with the arm relaxed at the side, in individuals with and without shoulder impingement. BACKGROUND Electromagnetic devices are commonly used to measure 3-D scapular kinematics during arm elevation in different conditions and for intervention studies. However, there is a lack of studies that evaluate within- and between-day reliability of these measurements. METHODS The subjects were allocated to either a control group or an impingement group. Kinematic data were collected using the Flock of Birds electromagnetic device during elevation and lowering of the arm in the sagittal plane on 2 different occasions, separated by 3 to 5 days. Forty-nine subjects were tested for within-day reliability. Forty-three subjects were reassessed for between-day reliability. RESULTS Intraclass correlation coefficients for within- and between-day assessment of scapular orientation during elevation and lowering of the arm in both groups ranged from 0.92 to 0.99 and from 0.54 to 0.88, respectively. Intraclass correlation coefficients for assessment of scapular orientation with the arms relaxed at the side in both groups ranged from 0.66 to 0.95. The standard error of measurement for between-day measurements ranged from 3.37° to 7.44° for both groups. The minimal detectable change for between-day measurements increased from 7.81° at the lower to 17.27° at the higher humerothoracic elevation angles. CONCLUSION These results support the use of Flock of Birds to measure scapular orientations in subjects with and without impingement symptoms. The measurements showed excellent within-day reliability but were not highly reliable over time.

Comparison of scapular local coordinate systems.

BACKGROUND Our purposes were to compare between the original and current recommended standard methods of three-dimensional scapular rotation descriptions and to examine the prevalence of gimbal-lock for scapular motion during scapular plane abduction. Additionally we compared these standards to an alternative method and a glenoid based description. METHODS Eleven asymptomatic subjects were studied using electromagnetic sensors secured to bone-fixed pins in the scapula and humerus during two repetitions of scapular plane abduction. Anatomical landmarks defined scapular axes. Scapular angular data were analyzed at humerothoracic elevation angles from initial to maximum elevation. Repeated measures ANOVAs were performed for each variable with a significance level of P<0.05. An anatomical model was used to compare the standards to the alternative and glenoid methods. FINDINGS For scapular upward rotation and tilting, larger differences occurred between standards at higher angles of elevation. The current standard measured 12.4 degrees less upward rotation and 6.1 degrees greater posterior tilting at maximum elevation as compared to the original. The current standard measured 11.6 degrees less scapular internal rotation across all elevation angles. Using the original landmarks, six subjects attained a mean end-range humerothoracic elevation of 147.4 degrees (SD 12.1 degrees ), with a mean end-range scapular upward rotation of 54.4 degrees . The alternative method was more closely aligned to the glenoid method than the current standard. INTERPRETATION Significant differences were found between the two standards. The current standard interprets the same scapular motion with less internal rotation and upward rotation, and more posterior tilting than the original. No subjects reached upward rotation positions nearing gimbal-lock. Axis orientations also affect clinical interpretation. The alternative method appears worthy of further consideration as shoulder kinematic measurement further evolves.

Eccentric training as a new approach for rotator cuff tendinopathy: Review and perspectives

Excessive mechanical loading is considered the major cause of rotator cuff tendinopathy. Although tendon problems are very common, they are not always easy to treat. Eccentric training has been proposed as an effective conservative treatment for the Achilles and patellar tendinopathies, but less evidence exists about its effectiveness for the rotator cuff tendinopathy. The mechanotransduction process associated with an adequate dose of mechanical load might explain the beneficial results of applying the eccentric training to the tendons. An adequate load increases healing and an inadequate (over or underuse) load can deteriorate the tendon structure. Different eccentric training protocols have been used in the few studies conducted for people with rotator cuff tendinopathy. Further, the effects of the eccentric training for rotator cuff tendinopathy were only evaluated on pain, function and strength. Future studies should assess the effects of the eccentric training also on shoulder kinematics and muscle activity. Individualization of the exercise prescription, comprehension and motivation of the patients, and the establishment of specific goals, practice and efforts should all be considered when prescribing the eccentric training. In conclusion, eccentric training should be used aiming improvement of the tendon degeneration, but more evidence is necessary to establish the adequate dose-response and to determine long-term follow-up effects.

Avaliação da amplitude articular do joelho: correlação entre as medidas realizadas com o goniômetro universal e no dinamômetro isocinético

BACKGROUND: The instrument most often used by therapists for measuring joint range of motion (ROM) is the universal goniometer. However, there is a lack of studies analyzing the reliability of knee joint ROM measured by the isokinetic dynamometer. OBJECTIVE: The purpose of this study was to analyze the correlation between the knee joint ROM measurements made using a universal goniometer and an isokinetic dynamometer. METHOD: 38 healthy volunteers (27 women, 11 men) aged 36 ± 11 years were evaluated. All of them had a minimum knee extension ROM limitation of 20°. Three knee ROM measurements were made using the universal goniometer and another three using the isokinetic dynamometer, on each subjects dominant limb. RESULTS: The results showed a high degree of correlation between the knee ROM measurements made using the two instruments (Pearson correlation coefficient = 0.90). CONCLUSION: From the procedures performed, both the universal goniometer and the isokinetic dynamometer can be used to evaluate knee ROM, since they both present reliable measurements.

Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials

Aim To summarise the current evidence regarding the effectiveness of physical therapy on pain, function and range of motion in individuals with subacromial pain syndrome (SAPS). Design Systematic review. Data sources PubMed, Web of Science, CINAHL, Cochrane, Embase, Lilacs, Ibecs and Scielo databases. Eligibility criteria for selecting studies Randomised controlled trials (RCTs) investigating physical therapy modalities for SAPS on pain, function/disability or range of motion were included. Results 64 high-quality RCTs were included. Exercise therapy provided high evidence of being as effective as surgery intervention and better than no treatment or placebo treatment to improve pain, function and range of motion in the short, mid and long terms. The combination of mobilisation and exercises provided high evidence to decrease pain and improve function in the short term. There is limited evidence for improvements on the outcomes with the isolated application of manual therapy. High level of evidence was synthesised regarding the lack of beneficial effects of physical resources such as low-level laser, ultrasound and pulsed electromagnetic field (PEMF) on pain, function or range of motion in the treatment of SAPS. There is limited evidence for microwave diathermy and transcutaneous electrical nerve stimulation. There is moderate evidence to no benefits with taping in the short term. Effects of diacutaneous fibrolysis and acupuncture are not well established yet. Conclusions Exercise therapy should be the first-line treatment to improve pain, function and range of motion. The addition of mobilisations to exercises may accelerate reduction of pain in the short term. Low-level laser therapy, PEMF and taping should not be recommended.