 

Raja M. Al Nasrallah
 Researchers:Falk Morl,PhD, Andreas Matkey,
PT, Susanne Bretschneider, Annette Bernsdorf,
MD, Ingo Bradl, PhD
 Published in Journal of Bodywork & Movement
Therapies
 Received 20 January 2010; received in revised
form 17 May 2010; accepted 25 June 2010
Design: Randomized trial.
Setting: Ambulatory care in University Hospital
Jena in Germany
 Thecoordinative capabilities of the shoulder are
important to ensure the precise movement of the
humerus.
 Spatialcoordination does not just affect single
bones articulating with each other.

 Without the compensatory motions of adjacent

joints, incorrect motions of the shoulder as the
root in a segmented body part like the arm will
be propagated to the forearms and the hands.
 Lack of coordination of the shoulder may affect
every day-life activities like picking up a pencil
or moving a cup to the mouth.

 Shoulder pain is often linked to:

• Poor motor function
• Miss-coordination
• Biomechanical stress
 Studies of exercise therapy for the shoulder-neck
region claim all kinds of correlations between
training, pain relief and a significant
enhancement in physical parameters like
strength and range of motion.

 Studies justify their achievement in therapy only

in terms of pain relief.
 Functional parameters have been reasoned only
partly, using questionnaire methods (disability index
etc.).
 At the moment there is no clear evidence for a main
physical measure in correlation to pain relief.

 only one study so far has investigated the effect of

physical training on proprioception and kinesthesia
of the shoulder (Swanik et al., 2002)
 lack of information about changes in coordinative
abilities from therapeutic intervention.
 Is physiotherapy able to change
proprioceptive abilities such as the
capability to reproduce a specific angle
of the glenohumeral joint?

Is there a connection between pain

reduction and change of ability to
reproduce an angle?
 to evaluate the effect of different training
methods in physiotherapy on pain relief and
change in proprioception and kinesthesia of the
shoulder.
 Further, the connections between pain relief and
change in motor function of the shoulder will be
investigated.
 Shoulder
Training

Motor
Pain Relief
Function
 Shoulder patients were recruited with the co-
operation of the State Ministry of the
Environment.

 All patients were examined medically and

orthopedically by an orthopedist in order to
exclude subjects who did not fulfill the inclusion
criteria.
Inclusion Criteria Exclusion Criteria

• Unspecific pain of at • Common contraindications

least one shoulder in like;
combination with • Diseases of the
orthopedically-assessed cardiovascular system
functional deficits. • High blood pressure
• Post-surgical conditions;
• Acute prolapse of an
intervertebral disc (4
months)
• Neurological symptoms
• Rotator cuff tear.
 n=30
non-symptomatic
Unspecific Shoulder Pain
subjects

Group 1 Group 2 Group 3

n=12 n=10 n=8

Flexible Foil Flexible Bands

 The training course was subdivided into 24
workouts and extended over at least 12 weeks,
with 2 workouts per week.

 When there was loss of a workout because of

holiday or illness the workout was carried out in
the following week.
 Every workout was individual (there were no
group-workouts) and coached by a
physiotherapist or a sports therapist.
 Shoulder pain patients usually have higher tonicity
in upper trapezius, which may reduce the benefit of
the training (e.g. the patient would not be able to
exercise as instructed by the therapist).

 To reduce muscle tone, the region of the upper

trapezius was treated randomly through
physiotherapy techniques such as myofascial release
or a hot rolled towel (5-10 min) at the beginning of
every workout.
 The flexible foil aims mainly at stabilizing the
shoulder.
 At this time, there is no evidence for its
efficiency.
 Resemble Body blade
 All exercises were done
in standing position
 Suitable to patients' ability
 Training using flexible bands mainly affects the
force production of muscles surrounding the
shoulder.
 Evidence is rare
 Bands in different colors were used for different
force exertion according
to gender, the weight and
the strength of the patient.
 Female patients usually trained with yellow or
red bands whereas male patients trained with
red or green bands.
 An exception was made for patients suffering
from severe pain or restrictions. These patients
used white bands.
 4 exercises
 3 sets
 5-10 repetitions
 Both training groups showed comparable data in
age, height and weight. An exception is gender: the
flexible-foil group having more female patients.

 To obtain values of a non-restricted capability to

reproduce angles of the shoulder for comparison to
the patients’ data, a group of young subjects without
a history of shoulder pain or injury was recruited
and measured using the angle-replication-test.
 Outcome
Measure

Proprioceptive
Pain
& Kinesthetic ability

Constant- Active-active Angle-

Murley Score Replication Test
 The CMS is a 100-point functional shoulder-
assessment tool in which higher scores reflect
increased function. It combines four separate
subscales:
1. Subjective pain (15 points)
2. Function (20 points)
3. Objective clinician
assessment of ROM(40 points)
1. Strength (25 points)
 Because the test did not discriminate the force
levels depending on the subject’s gender, they
also showed data without strength information.

 The pain of the shoulder during testing was

gathered using a visual analogue scale.
Procedure:
 To get a specific measure of proprioception
 The patients had to move their arms to the test
position themselves during the test.
 The angular location of the shoulder was
visualized on a display located in front of the
subject.
 In this way, the subject was able to correct the
angular location up to the specific angular value
based on the test-protocol.
 the subjects had to close
their eyes and keep the
arm in the pre-defined
position for about 10 s.

 The therapist leading the

test advised the subjects
to sense the position of
the shoulder arm-
complex without visual
feedback .
 With eyes closed, the subject had to change the arm
position to a neutral position e.g. hanging relaxed at
the side of the body. Then, (eyes still closed) the
therapist advised the subject to change the position
of the arm to the instructed position.

 A difference between the pre-adjusted position (with

visual control) and the newly adjusted position
(without visual control) was measurable in the
coordinative ability of the subject
 Both shoulders were tested separately.
 The angle-repetition-test was performed for three
different motions in different angles.

The motions were:

1. Anteversion (sagittal plane)
2. Abduction (frontal plane)
3. inward and outward rotation (transversal plane).
4. Inward and outward rotation of the humerus were
measurable in the neutral position of the upper
arm with the elbow flexed at 90
 Every test was repeated 3 times
 Using the CMS-HS 3D motion
measuring system
 applied on landmark C7 & T12.
 On the shoulder arm- complex,
markers were applied on
acromion, epicondylus lateralis
at the elbow and caput ulna of
the ulna.
 It was thereby possible to
measure the angle between
trunk and humerus as a
measure for all ROM.
Before Training
Halfway
-Constant-Murley
Score After Training
Constant-Murley
-Active-active Score -Constant-Murley
Angle-Replication Score
Test
-Active-active
Angle-Replication
Test

Training period was 12 weeks

 The difference between pre-adjusted and self
adjusted angle without visual control was
calculated using Matlabroutines (The
MathWorks, Inc., NatickMA, USA).

 Significance level for all tests was p = .05.

 A linear correlation analysis was calculated to
get a measure of the coherence of pain relief and
the change in motor function.
Improvement in Functional Pain Assessment:
Pain was reduced in both intervention groups.
 VAS p<.001
 More benefit in pain relief by training using the
flexible foil device.
 Significant improvement in functional pain
assessment was found during both interventions.
 There was significant improvement for both group
in the 1st 6 weeks, later no change 6-12 weeks.
Changes in Motor Function by Physiotherapy:

 After intervention, the patients, in comparison with

the non-symptomatic group, still showed
significantly lower abilities to reproduce the test
angles in abduction and anteversion at 60⁰ (p < .01),
and significantly lower ability to reproduce angles in
anteversion at 90⁰ (p < .05).
Coherence of Pain Relief and Change in Motor
Function:

 There is no statistical coherence of pain relief

and change in motor function (p > .05).
 This means that the improvement in pain of the
shoulder is not associated with good or poor
capability in proprioception.
 Intervention using physiotherapy-driven training
reduces the pain of the shoulder.

 This result was expected and is comparable to other

studies in efficiency of physical interventions.

 A clear deficit in the ability to reproduce angles of

the shoulder as a special part of proprioception was
detected before and after 12 weeks of intervention
for the patients. a very imprecise reproduction of a
specific angle.
 Pain relief and change in motor function of the
affected shoulder joints were not in coherence. This
result is a first sign that shoulder pain is not closely
associated with poor motor function
 Poor motor function of the shoulder may lead to
shoulder pain sooner or later, but this is not the
main reason for pains of the shoulder
 Other parameters like muscle-strength, flexibility,
intra-and intermuscular coordination, or properties
of passive joint structures may also play a role in this
context. of the shoulder.
 In this study, the data of a passive control group,
consisting of young subjects without shoulder pain,
was used to evaluate the data of the patients.

 For future studies, the data of a placebo training

group of patients should be compared to the data of
the active patient group.
 In conclusion, data shows pain relief by
physiotherapy but gives no information about why
pain is relieved.
 Because both devices clearly affect muscles
surrounding the glenohumeral joint and the rotator
cuff, the pain relief may correlate with change in
muscle function.
 Systematic exercises and training affect the
metabolism of passive structures like articular
cartilage and ligaments.
 The intervention may have an effect on painful
processes of such structures.