SHOULDER INSTABILITY

Figure 14: Flexion dissociation with dynamic feed- back from the ball

Figure 15: Prone position over ball

Figure 16: Use of opposite arm to facilitate weight transfer

Figure 17: Progress Fig.16 to moving ball away from body

Figure 18: Seated arm raise

Figure 19: Wall push up/ball press

Figure 20: Over the top exercise

Figure 21: Joint position sensibility

Figure 23: Ipsilateral or contralateral step-ups with arm elevation

and novelty which help increase compli- ance and facilitate learning in a patient group that have often done the rounds of more traditional cuff re-education programmes.

Patients with muscle patterning tend to fall into two groups. The first includes those in which simply sitting on the ball results in activation of their postural tone such that their movement pattern improves immediately and less facilitation is required to achieve optimal movement patterns. The second group are those who when sitting on the ball demonstrate co contraction rigidity and the patterning

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worsens in an attempt to stabilise them because the stability challenge is too great. In this group the supportive quali- ties of the ball can be employed. Sitting on a plinth with both arms on the ball and encouraging dissociation can be a very effective way of switching off the pat- terning muscle. Patients will often tend to pull the ball down towards them rather than allow movement forward. The dynam- ic feedback qualities of the ball together with appropriate facilitation from the therapist will allow them to elevate the arms without patterning with the support of the ball (Fig.14).

In patients where the glenohumeral joint is persistently subluxed or dislocated or, those that find it difficult to comply with dissociation, exercises prone over the ball can be effective (Fig.15). The ball then offers both support of the trunk and limb and feedback regarding joint position. Furthermore the upper limb is weight bearing (closed kinetic chain) which will facilitate co contraction of the deep sta- bilisers and reduce destabilising shear

Figure 22: Plyo-push up

forces across the joint. Simple rocking exercises will often reduce the patterning muscle activity, modulate pain responses and improve stability at the glenohumeral joint. The patient can also work in sitting where they support the patterning limb on the ball. Initial activities may involve active use of the opposite arm to facili- tate weight transfer (Fig.16) and then progress to moving the ball away from the body in different planes (Fig.17). The therapist facilitates optimal movement patterns at all times with verbal and tac- tile cues. It is important to pay attention to foot position during these activities as sensory input from the foot helps us to locate our centre of gravity relative to our base of support. It therefore plays a piv- otal role in postural adjustment. Often those patients who weight bear to the opposite side will have very little aware- ness of where their ipsilateral lower limb is in space. The therapist must provide appropriate stimulation through the foot, hip and knee (e.g. compression into the hip through the femur) and may have to put the opposite foot on a less stable sur-

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