REHABILITATION

which we can access the afferent system and effect central motor processes we can effectively re-educate optimal movement patterns in this complex group of patients (Fig.11).

SO WHERE DO WE START? Education is an essential component of successful management. These patients are often frustrated and disillusioned due to inappropriate treatment. Time spent explaining the specifics of their problem and the basis of what rehabilitation aims to achieve will improve compliance. Another aspect of compliance is demon- strating to the patient that correction of their movement pattern with appropriate facilitation will improve their symptoms whether they are subluxation/dislocation or pain. The primary aim of treatment is to regain normal neuromuscular control and sequencing. Often simple facilitation of trunk alignment and the antagonistic muscle group will correct the abnormal patterning. The primary aim of treatment is to regain normal neuromuscular control and sequencing.

A key component of the rehabilitation programme is specific proprioceptive facilitation to aid the patient’s motor relearning and help them relearn what is normal! Tactile cues are used to enhance the patients understanding of the activa- tion pattern required. Verbal cues will influence the performance strategy and generally should be kept as simple as possible. Tactile cues based on ‘central key points’ and established neuromuscular facilitation techniques eg. ‘stroking’ and ‘tapping’ are widely applicable (16). While specific facilitation techniques or cues have to be subtly adapted for individuals there are common strategies that appear effective. Those patients with a postero- inferior bias tend to sublux easily on active elevation movements. Simple postural correction with activation of the external rotators during active elevation in the scapula plane will commonly enable the patient to move the arm above 90 degrees without losing control or without

Figure 12: Activation of external rotators during active elevation

pain (Fig.12). The amount of resistance offered and the direction in which it is applied are crucial. The patient is encour- aged to lead with the hand rather than the elbow and the therapists ‘resistance’ guides them to elevate in the scapula plane rather than directly into the body which will result in them pulling against you in an attempt to ‘fix’ with the pat- terning muscle. An important component of postural correction is facilitating weight transference into the affected side. This then allows the patient to elongate through their lateral trunk and activate trunk segmental extension.

A common feature of patients with pat- terning is that they are unable to dissoci- ate their upper limb from their body. In patterns where pectoralis major is domi- nant the scapula is often observed to retract and tilt anteriorly during initiation of upper limb flexion. Postural correction and weight transfer into the affected side are always precursors to other facilitation cues. One strategy to correct this pattern is to encourage protraction movements of the scapula together with facilitation of the shoulder external rotators preceding upper limb movement. Repeating this ini- tially in the sagittal plane and then pro- gressing to diagonal movements (Fig.13)

TABLE 3: COMMON PATTERNS OF INSTABILITY/FACILITATION Direction of instability

Dominant muscle

Posterior Anterior Inferior

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latissimus dorsi/anterior deltoid pectoralis major /latissimus dorsi pectoralis major/latissimus dorsi

Figure 13: Scapular movement in the diagonal plane

gives the patients’ confidence that they can move the shoulder without it feeling unstable. Verbal cues encouraging move- ment of the hand to a target, change the patient’s point of reference. This simple strategy can stop them ‘fixing’ with the shoulder as they initiate movement. Simple exercises encouraging normal excursion of the scapula can also be very effective ie. protraction/retraction/eleva- tion/depression and facilitation of full movement and reinforcement with visual feedback help the patient regain full functional range, which is essential for optimal movement pattern re-education (25). These very simple exercises help the patient learn to dissociate the scapula from the trunk and appreciate where their scapula is in space.

The Swiss ball is a particularly useful tool in generating intrinsic feedback. Activities using the ball are an effective way of providing vestibular input, somatosensory stimulation of pressure and joint receptors and visual input. The ball’s dynamic properties allow us to reduce verbal and manual cues about movement quality as it is possible to elicit movement more automatically due to ‘facilitation’ of these systems. What’s more the ball introduces an element of fun

Facilitate/cue

trunk + infraspinatus/posterior deltoid trunk + scapular protraction/dissociation trunk + deltoid

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