REHABILITATION

scapula stabilisers and rotator cuff muscles is required to stabilise the glenohumeral joint (5).

Corrective exercises for protraction of head and neck/thoracic kyphosis 1. Cranio-vertebral flexion - head nods 2. Coulsons postural exercise which also helps to improve overall spinal posture and deep spiral musculature strength.

Cranio-vertebral flexion Objective: commonly used pilates exercise and designed to encourage correct head and cervical spine alignment in relation to the thorax. Technique: Lie on back with knees bent, feet shoulder width apart (crook lying) with head supported on a book/block or pillow. Lengthen back of neck by nodding the head, retracting neck and contracting deep neck flexors (head does not lift, but stays in contact with the block). Tip: Avoid jamming chin into chest, result- ing in over-flexion of cervical spine and pain. Place fist at level of clavicular notch - chin should aim to lightly touch the fist.

Coulsons postural exercise Objective: These exercises are performed in three phases, the concept being that mus- cle action is initially active and then stat- ic, thus strengthening the deep spinal mus- cles (rotators, multifidus). The movement aims to obliterate the natural curves of the spine and place the spine on stretch. Be aware that most patients find these exer- cises difficult at first but once they get the ‘feel’ of the technique they find them most useful. Technique: Crook lying (see above), arms by side at 200

angle, palms facing downwards.

Phase 1: Tighten abdominal area, contract the gluteal muscles and press the small of the back into the mat. Hold this position while progressing to phase 2. Phase 2: Take a maximal deep breath, rolling arms outwards (laterally rotate from palm down to palm up position) pressing shoulders back into the mat. Hold this position while progressing to phase 3. Phase 3: Tuck chin in, pushing back of neck into the mat and stretch the crown of the head away, trying to make yourself as tall as possible. Exercise progression: Long lying (supine, legs straight). This increases the lumbar lordosis curve by tilting the pelvis, thus requiring a stronger contraction through phase 1.

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Figure 1: Anterior compartment stretch

Figure 2: Posterior compartment stretch

Figures 3 and 4: Elimination of gravity in rotation exercises

Figures 5 and 6: Progression to gravity-resisted exercises

It may require practising each phase sepa- rately until the patient becomes accus- tomed to the technique. The whole cycle should take 10-15 seconds with 10-15 sec- onds rest in between. Aim to perform around 10 repetitions.

Stretches The focus is to lengthen the muscles con- tributing to poor posture particularly the internally rotated position of the humeral head in relation to the GH joint. Medial rotators of the GH joint that should be stretched are: ■ teres major ■ pectoralis major/minor ■ anterior deltoids ■ latissimus dorsi ■ subscapularis.

The anterior and posterior capsule should also be stretched (Figures 1 and 2).

ROTATOR CUFF WEAKNESS/ GLENOHUMERAL JOINT STABILITY Focus should primarily be on internal and

external rotation (predominantly external rotation) to train subscapularis, infraspina- tus and teres minor.

Resistance band exercises 1. Internal and external rotation Objective: These exercises are designed to strengthen the rotator cuff and increase GH joint stability. Technique: exercises are first performed at 00

in standing until pain subsides during

and/or post-exercise and when there is more stability in the shoulder. Tip: a towel should be placed between the elbow and the body to prevent abduction of the arm. Exercise progression: ■ The rotation exercises can be progressed to be performed in a more functional, abducted position, with gravity elimi- nated initially (Figures 3 and 4)

■ Progress to and 6)

gravity-resisted (Figures 5

■ Once there is more stability in the shoul- der, progress into a more functional position through range eg. PNF pattern of flexion, adduction with internal rota-

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