REHABILITATION

BOX 2. KEY FACTORS IN PROPRIOCEPTIVE RE-EDUCATION

● Dynamic stabilisation ● Joint position sense ● Preparatory and reactive muscle activation

● Functional motor patterns

face to facilitate input through the ipsi- lateral side. Simple lateral pelvic move- ment is useful in re educating postural awareness and demonstrating the effect of asymmetrical weight bearing on upper limb function (Fig.18). Patients will often have difficulty transferring weight to the problem side and will shorten their trunk in attempting to do so. Once they are able to transfer weight they are generally astounded how easy it feels to lift their arm. They can then do simple dissociation exercises eg. draw a figure of eight to become more confident and make the correction more automatic.

The literature is clear that this group of patients consistently demonstrate propri- oceptive deficits indicating redundancy in certain aspects of their sensory motor system (26). Proprioceptive re education is key in restoring optimal movement patterns. Lephart and Henry (27) have proposed a functional classification system to serve as a guide for restoring proprioceptive deficits and re-establishing neuromuscular control. This system describes four elements that are necessary to restore functional stability. Each element addresses specific objectives in restoring proprioception and neuromuscu- lar control. The system is designed to integrate all subsystems of movement ie. somatosensory, visual and vestibular and all levels of motor control. The four ele- ments include dynamic stabilisation, joint position sensibility, reactive neuromuscu- lar control and functional movement patterns.

The objective of ‘dynamic stabilisation’ is to promote co activation of the force cou- ples around the shoulder joint. Closed kinetic chain activities are particularly useful to facilitate this. The emphasis at all times is on optimal alignment and recruitment patterns. It is essential not to progress patients too quickly as a stabili- ty challenge that is too great or resistance too high will result in them ‘fixing’ to

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compensate with the patterning muscle. The ball press (Fig.19) in standing facilitates co contraction of the rotator cuff and scapula stabilisers in good postural alignment and is easily progressed to increase both load and the stability challenge. Exercises lying prone over the ball weight bearing through the hands facilitate good scapula control and co-contraction of the rotator cuff togeth- er with facilitation of the gluteals and spinal extensors in maintaining trunk alignment (Fig.20). This reinforces the concept of incorporating the kinetic chain; utilising both local and global stability systems. Rolling back from the start position the patient facilitates optimal upward rotation of the scapula, facilitating dissociation of upper limb from trunk. The therapist can apply rhyth- mic stabilisations to increase the chal- lenge. Similarly weight bearing on one arm, using a wobble board, leg lifts can all be used as ways of progressing.

‘Joint position sensibility’ relates to the restoration of joint position awareness. This is an important component of a mus- cles ability to provide joint stability and refine movement patterns. These patients often overuse their visual input to com- pensate for other deficiencies in their afferent system. Initially exercises can involve balancing the Swiss ball in their hand in different postural positions and with different stability challenges (Fig.21). Ball bouncing is a fun and very useful exercises and can be progressed to include control round obstacles and then with eyes shut to decrease the reliance on visual input and increase the use of other systems.

‘Reactive neuromuscular control’ refers to the stimulation of reflex muscular stabili- sation. This involves re-education of a muscle’s ability to adapt appropriately to sudden alterations in joint position. It is important that these drills are not includ- ed until dynamic stability is restored. Exercises with a plyometric basis are par- ticularly useful during this phase. The Swiss ball can be used for throwing and catching activities. ‘Plyo’ push-ups (Fig.22) on the ball incorporating bounce and speed incorporate core control with reactive stabilisation of the shoulder mus- culature. The patients can also maintain a push up position on the ball while the therapist applies short taps to destabilise

them. Specific plyometric drills are well described in the sporting literature. The only limits in exercise choice are the ther- apist’s imagination!

The use of ‘functional movement patterns’ is central to establishing a relearned motor pattern at a central level. Studies have shown that goal-orientated move- ments are more effective in producing rep- resentational plasticity in cortical motor maps than repetitive active movement alone. In an effort to access automatic processes or central pattern generators the position of the exercises, the speed and movement path are all important. In the initial stages kinetic chain exercises facilitating normal sequential activation patterns from lower limbs through the trunk and into the upper limb are very useful. Ipsilateral or contralateral step- ups with upper limb elevation facilitate gluteal activation and trunk segmental extension with upper limb elevation (Fig.22). Similarly lunges with shoulder protraction or step-and-reach type activi- ties facilitate optimal patterns of sequen- tial activation if appropriately guided by the therapist. Weight transference and stability are key components in facilitat- ing dissociation of the upper limb in func- tional activities. Activities should be both open and closed chain to mimic normal function and wherever possible should relate to the individuals functional requirements. Simple ‘games’ involving hitting a moving target can access ‘motor memories’ making movement more auto- matic due to speed and reflexive compo- nents of the activity. Activities that dis- tract the patient eg. counting backwards while performing a task or bouncing a ball with one hand while drawing a picture with the other challenge the ability of the patient to dissociate shoulder movements and achieve selective control. When con- sidering function we can not ignore gait.

BOX 3. KEY FACTORS IN REHABILITATION

● Education ● Movement pattern correction ● Kinetic chain ● Proprioception/neuromuscular control

● Scapula stability ● Glenohumeral translatory control

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