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Facilitating the upward rotators of the scapular. A simple exercise
2013 ASICS Conference / Journal of Science and Medicine in Sport 16S (2013) e2–e38
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12 month results of a randomised controlled trial comparing subgroup specific physiotherapy against advice for people with low back disorders
Facilitating the upward rotators of the scapular. A simple exercise
A. Chan 1,∗ , J. Ford 1 , A. Hahne 1 , L. Surkitt 1 , S. Slater 1 , R. Hinman 2 , N. Taylor 1 1 Musculoskeletal Research Centre, Department of Physiotherapy, Faculty of Health Sciences, La Trobe University, Australia 2 Department of Physiotherapy, The University of Melbourne, Australia
Introduction: Low back disorders (LBD) affect athletes and non-athletes alike. Although multiple guidelines recommend the provision of advice for the treatment of acute-subacute LBD, few treatments have demonstrated clinically meaningful benefits. It has been proposed that clinical heterogeneity in randomised controlled trials (RCTs) may reduce the likelihood of demonstrating treatment effects. The Specific Treatment of Problems of the Spine (STOPS) trial attempted to minimise heterogeneity by evaluating the effectiveness of specific physiotherapy treatment compared to physiotherapy advice in people with LBD classified into one of five homogenous subgroups. Methods: In a multi-centred randomised controlled trial, noncompensable participants with low back pain (≥6 weeks, ≤6 months) and/or referred leg pain were classified into one of five subgroups. They were then randomly allocated to receive either physiotherapy advice or specific physiotherapy treatment over 10 weeks at private practice clinics. The primary outcome measures included back pain and leg pain (0–10 numerical pain rating scale) and activity limitation (Oswestry Disability Index). Data were analysed using linear mixed models for continuous outcomes. Results: Analysis of 300 participants (153 men, 147 women) showed a mean(SD) age of 44(12) years and a duration of back and leg symptoms of 15(10) and 11(10) weeks respectively. Linear mixed model analyses of primary outcomes showed that between group differences for Oswestry favoured specific physiotherapy at 10-weeks (4.7; 95% CI 2.0–7.5), 26 weeks (5.4; 95% CI 2.6–8.2) and 52 weeks (4.3; 95% CI 1.4–7.1). Similarly, back and leg pain were significantly lower in the specific physiotherapy group relative to the advice group at 10 weeks (Back: 1.3; 95% CI 0.8–1.8, Leg: 1.1; 95% CI 0.5–1.7) and 26 weeks (Back: 0.9; 95% CI 0.4–1.4, Leg: 1.0; 95% CI 0.4–1.6) time points. Discussion: Subgroup specific physiotherapy leads to greater reduction in activity limitation across a 52-week follow-up period, and faster reduction in back and leg pain, relative to guideline-recommended advice. These differences are clinically important. This is the first specific physiotherapy RCT targeting pathoanatomical factors as a means of minimising the impact of sample heterogeneity in LBD. Provided physiotherapists in clinical practice adopt the described treatment integrity measures, clinical outcomes are likely to be superior compared to guideline recommended advice. http://dx.doi.org/10.1016/j.jsams.2013.10.022
e9
T. Pizzari 1,∗ , J. Wickham 2 , L. Watson 3 , S. Balster 3 , C. Ganderton 1 1
La Trobe University, Australia Charles Sturt University, Australia 3 Lifecare Prahran Sports Medicine, Australia 2
Introduction: Scapula dyskinesia, characterised by drooping scapulae and reduced upward rotation, has been implicated in the presentation of a number of shoulder disorders. Traditionally, in shoulder rehabilitation programs, the shrug exercise has been prescribed to strengthen the upper trapezius muscle and facilitate upward rotation of the scapula. The aim of this research was to compare muscle activation levels during the standard shrug and the upward rotation shrug in a normal and pathological population. Methods: Surface electrodes recorded EMG activity from upper trapezius, middle trapezius, lower trapezius and serratus anterior muscles in 23 normal participants and 14 participants with multidirectional shoulder instability. Participants completed 10 trials of the standard shrug exercise at 0◦ of shoulder abduction and the upward rotation shrug. The upward rotation shrug is performed with the arm at 30◦ of shoulder abduction in the coronal plane with an emphasis on the tip of the shoulder moving up towards the back of the ear. Muscle activity was expressed as a percentage of maximum voluntary isometric contraction. Results: The four muscles tested performed at a higher intensity during the modified shrug than the standard shrug. Upper trapezius and lower trapezius activity was significantly greater (p < 0.05) in both populations. Though, for middle trapezius and serratus anterior muscles, the modified shrug was statistical significant only in the normal population, p = 0.031 and p = <0.001 respectively. Discussion: The upward rotation shrug is a more effective exercise for strengthening the upper and lower trapezius than the standard shrug in a normal and multi-directional instability population. Clinically, the upward rotation shrug can be used to address scapula dyskinesis involving drooping shoulders and reduced scapula upward rotation. http://dx.doi.org/10.1016/j.jsams.2013.10.023 20 The effect of exercise based management for multidirectional instability of the glenohumeral joint: A systematic review S. Warby 1,∗ , T. Pizzari 1 , J. Ford 1 , A. Hahne 1 , L. Watson 1,2 1 2
La Trobe University, Australia Life Care Prahran Sports Medicine, Australia
Introduction: The most commonly recommended treatment for multidirectional instability (MDI) of the shoulder is exercise based management. The primary objective of this review was to evaluate the effectiveness of exercise based management in patients with MDI. Secondary aims were to investigate the structure of exercise protocols, the types of outcomes used, and any adverse effects associated with exercise. Method: The Cochrane database of systematic reviews, MEDLINE, EMBASE, CINHAL, PEDro, Current Contents, AMED, AMI, Ausport and the Clinical Trials Register were searched for published and unpublished studies from inception date to June 2012, using the key words and synonyms for “multidirectional instability”, and
18
19
12 month results of a randomised controlled trial comparing subgroup specific physiotherapy against advice for people with low back disorders
Facilitating the upward rotators of the scapular. A simple exercise
A. Chan 1,∗ , J. Ford 1 , A. Hahne 1 , L. Surkitt 1 , S. Slater 1 , R. Hinman 2 , N. Taylor 1 1 Musculoskeletal Research Centre, Department of Physiotherapy, Faculty of Health Sciences, La Trobe University, Australia 2 Department of Physiotherapy, The University of Melbourne, Australia
Introduction: Low back disorders (LBD) affect athletes and non-athletes alike. Although multiple guidelines recommend the provision of advice for the treatment of acute-subacute LBD, few treatments have demonstrated clinically meaningful benefits. It has been proposed that clinical heterogeneity in randomised controlled trials (RCTs) may reduce the likelihood of demonstrating treatment effects. The Specific Treatment of Problems of the Spine (STOPS) trial attempted to minimise heterogeneity by evaluating the effectiveness of specific physiotherapy treatment compared to physiotherapy advice in people with LBD classified into one of five homogenous subgroups. Methods: In a multi-centred randomised controlled trial, noncompensable participants with low back pain (≥6 weeks, ≤6 months) and/or referred leg pain were classified into one of five subgroups. They were then randomly allocated to receive either physiotherapy advice or specific physiotherapy treatment over 10 weeks at private practice clinics. The primary outcome measures included back pain and leg pain (0–10 numerical pain rating scale) and activity limitation (Oswestry Disability Index). Data were analysed using linear mixed models for continuous outcomes. Results: Analysis of 300 participants (153 men, 147 women) showed a mean(SD) age of 44(12) years and a duration of back and leg symptoms of 15(10) and 11(10) weeks respectively. Linear mixed model analyses of primary outcomes showed that between group differences for Oswestry favoured specific physiotherapy at 10-weeks (4.7; 95% CI 2.0–7.5), 26 weeks (5.4; 95% CI 2.6–8.2) and 52 weeks (4.3; 95% CI 1.4–7.1). Similarly, back and leg pain were significantly lower in the specific physiotherapy group relative to the advice group at 10 weeks (Back: 1.3; 95% CI 0.8–1.8, Leg: 1.1; 95% CI 0.5–1.7) and 26 weeks (Back: 0.9; 95% CI 0.4–1.4, Leg: 1.0; 95% CI 0.4–1.6) time points. Discussion: Subgroup specific physiotherapy leads to greater reduction in activity limitation across a 52-week follow-up period, and faster reduction in back and leg pain, relative to guideline-recommended advice. These differences are clinically important. This is the first specific physiotherapy RCT targeting pathoanatomical factors as a means of minimising the impact of sample heterogeneity in LBD. Provided physiotherapists in clinical practice adopt the described treatment integrity measures, clinical outcomes are likely to be superior compared to guideline recommended advice. http://dx.doi.org/10.1016/j.jsams.2013.10.022
e9
T. Pizzari 1,∗ , J. Wickham 2 , L. Watson 3 , S. Balster 3 , C. Ganderton 1 1
La Trobe University, Australia Charles Sturt University, Australia 3 Lifecare Prahran Sports Medicine, Australia 2
Introduction: Scapula dyskinesia, characterised by drooping scapulae and reduced upward rotation, has been implicated in the presentation of a number of shoulder disorders. Traditionally, in shoulder rehabilitation programs, the shrug exercise has been prescribed to strengthen the upper trapezius muscle and facilitate upward rotation of the scapula. The aim of this research was to compare muscle activation levels during the standard shrug and the upward rotation shrug in a normal and pathological population. Methods: Surface electrodes recorded EMG activity from upper trapezius, middle trapezius, lower trapezius and serratus anterior muscles in 23 normal participants and 14 participants with multidirectional shoulder instability. Participants completed 10 trials of the standard shrug exercise at 0◦ of shoulder abduction and the upward rotation shrug. The upward rotation shrug is performed with the arm at 30◦ of shoulder abduction in the coronal plane with an emphasis on the tip of the shoulder moving up towards the back of the ear. Muscle activity was expressed as a percentage of maximum voluntary isometric contraction. Results: The four muscles tested performed at a higher intensity during the modified shrug than the standard shrug. Upper trapezius and lower trapezius activity was significantly greater (p < 0.05) in both populations. Though, for middle trapezius and serratus anterior muscles, the modified shrug was statistical significant only in the normal population, p = 0.031 and p = <0.001 respectively. Discussion: The upward rotation shrug is a more effective exercise for strengthening the upper and lower trapezius than the standard shrug in a normal and multi-directional instability population. Clinically, the upward rotation shrug can be used to address scapula dyskinesis involving drooping shoulders and reduced scapula upward rotation. http://dx.doi.org/10.1016/j.jsams.2013.10.023 20 The effect of exercise based management for multidirectional instability of the glenohumeral joint: A systematic review S. Warby 1,∗ , T. Pizzari 1 , J. Ford 1 , A. Hahne 1 , L. Watson 1,2 1 2
La Trobe University, Australia Life Care Prahran Sports Medicine, Australia
Introduction: The most commonly recommended treatment for multidirectional instability (MDI) of the shoulder is exercise based management. The primary objective of this review was to evaluate the effectiveness of exercise based management in patients with MDI. Secondary aims were to investigate the structure of exercise protocols, the types of outcomes used, and any adverse effects associated with exercise. Method: The Cochrane database of systematic reviews, MEDLINE, EMBASE, CINHAL, PEDro, Current Contents, AMED, AMI, Ausport and the Clinical Trials Register were searched for published and unpublished studies from inception date to June 2012, using the key words and synonyms for “multidirectional instability”, and