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Abstract

The many structural problems slouching causes include forward migration
of head and rounding of shoulders. The migration of head and rounding of
shoulders is then found to cause muscle imbalances between force
couples, manifesting through pain and dysfunction of the shoulder.
Whether imbalances in other part of the body may have caused the
symptom or vice versa, conventional exercise programs and therapies
often overlook the importance of conditioning the body as a whole, only
focusing on the muscles responsible; rotator cuff muscles.

This paper discusses the structure of shoulder girdle and the spine on a
functional continuum and how BASI Pilates block system, when applied as
a holistic exercise system, can contribute to achieving neck and shoulder
girdle stabilization, and improving functional strength for a client
diagnosed with functional shoulder impingement.
#

Table of contents

1. Abstract
2. Shoulder Anatomy
3. Shoulder pathology
4. Rationale for holistic approach
5. Case study
a. Assessment and goal setting
b. Exercise Plan
c. The program
d. Phase 1 - releasing tension and core stabilization
e. Phase 2 - addressing the shoulder mechanism
6. Conclusion

$
Anatomy of shoulder

Shoulder joint is made up of the clavicle, the
scapula, and the humerus (fig.1) and complex
layers of muscles and ligaments across the entire
upper body. (fig.2) Of the 4 joints of shoulder,
Glenohumeral joint, commonly referred to as
shoulder joint, has the ball shaped superior head
of humerus, the arm bone, loosely fitted into the
shallow socket-shaped lateral edge of scapula,
the shoulder blade. The glenohumeral joint is
held in place by surrounding ligaments and
muscles (fig.2). Scapula can slide along the
posterior ribcage to further facilitate the arm
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movement.

Among the muscles of shoulder complex, a group of four muscles called
rotator cuffs, Supraspinatus, infraspinatus, teres minor, and subscapularis
is identified as being responsible for the stability and movement in
shoulder (fig.3).













Shoulder pathology

Shoulder impingement is the irritation or compression of one or more of
the rotator cuff muscles in between the socket and the ball, creating
inflammation, pain, and decreased function of shoulder. Primary
impingement is structural and due to overcrowding of subacromial space
due to bony abnormality or thickening of tendon through repeated
injuries. Secondary, or functional impingements results from
uncoordinated manner of arm bone movement or due to overuse when
arm bone slides forward during abduction and external rotation of the
shoulder.

Rationale for holistic approach

While rotator cuff muscles are often singled out as being responsible for
shoulder health, shoulder is a complicated structure requiring an
advanced sense of proprioceptive capacity due to its multiple joint
mechanism and the dependence of its stability on the supporting muscles.
These muscles, in turn, have their origins and insertions spanning the
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entire torso, front and back. For example, pectoralis minor connects
upper ribs of chest to coracoid process, and overactive pectoralis minor
draws scapula forward which then pulls the shoulder into forward and
rounded position. In a controlled study, Borstad and Ludewig found that
short pectoralis minor demonstrated scapular kinematics similar to the
kinematics exhibited in earlier studies by subjects with shoulder
impingement, support the theory that an adaptively short pectoralis minor
may influence scapular kinematics and is therefore a potential mechanism
for subacromial impingement.

Similarly, overactive muscles of elevation and flexion such as upper
trapezius and levator scapulae may pull the pectoral girdle superiorly,
then anteriorly, leaving the antagonist muscles of depression and
extension deconditioned. Contrary to popular belief, Latissimus dorsi is
another dominant player in multiple shoulder and arm movements, due to
its position covering the entire lower vertebrae from T6, as well as the
iliac crest of hip bone and the lower three to four ribs, which then has
impact or are affected by the mechanisms of lower extremities.
When we consider that scapula glides against the ribcage which are
attached to thoracic vertebrae, study results showing a significant
relationship between thoracic spine and scapula kinematics are not
surprising either (figure 4; Kebaetse M, McClure P, Pratt NA, 1999).
Holding the pelvis in fatigue posture, as well as excessive foot pronation
may all contribute to shoulder health as these maybe cause compensating
effect on the entire structures integrity. This maybe a reason behind the
persisting pathologies even after localized approach to repetitive
rehabilitation efforts.

As such, conditioning
clients with shoulder
pathology must take
more global approach
addressing the whole body
posture and muscular
imbalances, instead of
working locally around the
pain.

'




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Case study
Dominique, 45 years old, is a corporate marketing professional who has
always been tall and slim. He is a long time runner and cyclist, with love
for motorcycle and photography.

He was diagnosed with shoulder impingement in his 30s and has followed
through shoulder re-education in several occasions.
He never changed his life style except during his recurring episodes of
shoulder tendinitis, which would force him to limit his activities.
In the past 2 years, however, he has completely stopped his running and
cycling due to worsening shoulder condition.
His short-term goal is to rectify his shoulder problem, and long-term
goal is to regain strength and improve general health and energy level.

Posture assessment and goal setting
Static posture assessment reveals forward head position, hyper extended
neck, protracted and upwardly rotated scapulae, internally rotated arms
with hands facing back, ribs showing exaggerated curvature and thoracic
spine in exaggerated posterior curve.
The entire body from his chest down simply hangs from his shoulder
girdle, in a fatigue or sway back position; the anterior curve of lumbar
spine is flattened, pelvis jutted forward with a posterior tilt, hip joints are
extended, knee joints hyperextended, and feet turned out.
From the assessment, upper trapezius, pectoralis major and minor
erector spinae, and hamstrings are identified as shortened or tight but not
necessarily strong. These are the muscles that will need stretching before
strengthening. The rest of the body was deconditioned in general and
needed strengthening.

During forward flexion, the client showed exaggerated thoracic spine
flexion, limited hip flexion and bent knees early on towards the end of
forward bending, suggesting inflexible gluteal, hamstrings and or calf
muscles, confirming the result of static posture assessment.

Exercise plan
*+
Although his ultimate goal is to build back overall strength as quickly as
possible, we came to agree that ignoring his shoulder issue will in the
long run only set him back more than go forward.

During the first phase, the attention will be on improving breathing, and
cervical and thoracic spine alignment and function. While the focus is
working on opening up the rib cage to give more space to the lungs and
other internal organs, the exercise program in phase 1 also introduces
truck and pelvic stabilization as well as foot and knee awareness.

As soon as Dominique can dynamically stabilize and control the lumbo-
pelvic complex, or the core, the exercise will gradually add on
strengthening the deep mid and lower back muscles and re-activating
proper scapula rotation rhythm. Also, more exercises for abdominal
strength will be incorporated into the daily program.


Phase 1 tension release and corrective stretches
Stretch (administered independantly everyday and before each session)
Ladder barrel shoulder stretch 1 and 2
Breathing with chest opening on pilates ball

Warm-up - emphasis on pelvic curl to encourage lower abdominals and
gluteal activation, and to introduce the client to spine articulation.
Traditional chest lift is modified with the Step barrel in order to
encourage opening of the chest muscles and isolation of abdominals,
discouraging upper back flexion
o Pelvic curl
o Side twist supine
o Negative chest lift on step barrel

Foot work series on reformer- giving closed chain feedback to activate
the posterior trunk proprioceptive receptors to re-adjust the thoracic
curvature. Ideally, conscious supine position will provide the mind a
chance to work on releasing the neuromuscular hold on neck and
shoulder tension, and bringing awareness to TA and Latissimus dorsi,
to balance out the natural spine curvature. Having a flat surface on his
**
back (closed chain) to refer to facilitates the mind to focus on
conveying information regarding alignment to the body.

Hundred prep on reformer encourage dynamically controlling
shoulder extensors and build up abdominal strength

Cadillac basic leg spring series while the leg spring series will
increase mobility of hip joint and strengthen the quadriceps and
hamstrings, the main focus will be on stabilizing the pelvis while legs
are in motion. The client will also work on knee and foot alignment in
relation to femur positioning parallel or external rotation. The client
is gently yet consistently encouraged to let go of the tension in his
neck and shoulder.

Arm series supine on reformer - continue giving the support for back
chain while working to stabilize the shoulder girdle, focus on
lengthening of the movement to work on crowded articulation and to
engage intrinsic muscles of shoulder girdle including serratus anterior

Standing lunge stretch while still getting an effective stretch on his
hip flexors and hamstring, by placing hands on the foot bar and
actively pressing down with the entire arm, an upright closed chain
position is created. Dominique is encouraged to imagine his shoulder
girdle expanding 3 dimensionally and upper trapezius melting away,
and to experiment with his body in relation to the space.

Lateral Flexion and rotation - Side over leaning on to the Step barrel
gives support to pelvis for stabilization and keeping the spine neutral
while oblique muscles go through full ROM

Leg work Gluteals Kneeling series and Adductor Lift are chosen to
activate and strengthen the hip extensors and adductors which are
weakened from holding the sway position for too long. Kneeling with
elbows on the box also reduces the intensity of gravity on upper girdle,
allowing us to work on weakened neck flexors by keeping the head
lifted

*"
Back extension by focusing on keeping the abdominals engaged and
reaching the arms and the legs towards the back of the room,
Dominique is strengthening his entire posterior chain while
eccentrically working the shoulder depressors including serratus
anterior and teres major. The adductor muscles are encouraged to stay
active in order to aid in pelvic floor muscle activation

The client is also given as homework pectorals stretches and a simple
fundamental Mat routine with emphasis on back extension and shoulder
girdle stabilization.

Phase 2 - addressing the shoulder mechanism
After a month of training with 2 private sessions per week and keeping up
20minutes routine everyday, Spine articulation and Full body Integration
blocks are added to previous exercise blocks. Avalon is introduced to add
more strength training. More abdominal work is added with careful
emphasis on avoiding excessive flexion. Strict priority is given to
movement quality over the amount of resistance or flexibility.

Progress from Supine arm work to Sitting arm work on Avalon -
Arms sitting side series are introduced with focus on rotator cuff
muscles while stabilizing the trunk

Sitting side on Cadillac scapula protraction and retraction is
explored before combining the recruiting of shoulder depressor
muscles

Shrug on chair Dominique is encouraged to take as much time
resisting the way up as well as the way down, thus to be in control
of the movement the complete repetition.

Arm work - Triceps Press sitting, Side Kneeling Arm press, Side
Kneeling stretch on Wunda chair: more movements to combine
stabilization of the trunk, and the activation and strengthening of
shoulder depressor muscles. The movements balances out tight
antagonist muscles, namely the upper trapezius.
*#

Full body Integration on reformer Up stretches with emphasis on
scapula stabilization. Down stretch with emphasis on mid back
strength and scapula stabilization

Hip extension and back extension on Avalon in addition to
providing challenges to mind by putting the body in a unfamiliar
position, the back chain exercises on Avalon challenges the client by
freeing up the ROM, allowing supine movements to go from
negative to neutral to positive.


Conclusion

A carefully thought out Pilates exercise program can safely and
successfully improve general fitness of clients with shoulder issues
because its approach is global. Incorporating well-executed Pilates
movements can reverse the faulty movement pattern that causes pain
and deconditioning in other parts of body. While each movement has
different muscle focus and objectives, the underlying principle of holistic
care is constantly present to reinforce the motor learning and adaptation,
and reinforcement of healthy and efficient use of our body be it static or
dynamic.

The client should be reminded that good habits form the same way bad
habits form. Even after the pain is gone, tight muscles relieved and weak
muscles strengthened, and the general balance is brought back to the
body, in order to maintained the balance and the good posture, the
client should be encouraged to continue Pilates or include some form of
mindful and holistic exercise in her life.
*$

Bibliography

Borstad J. D., Ludewig P. M. (2005 April). The effect of long versus short
pectoralis minor resting length on scapular kinematics in healthy
individuals. Retrieved 23 July, from
http://www.ncbi.nlm.nih.gov/pubmed/15901124.

Clark, M. A., Lucett, S. C., & Sutton, B. G. (2012). NASM Essentials of
personal Fitness Training. Fourth edition. Piladelphia, PA:Lippincott
Williams & Wilkins

Feil, C. & Morgan, W. E. (2010 May 6). The Importance of the Thoracic
Spine in Shoulder Mechanics. Retrieved 20 July 2013, from
http://www.dynamicchiropractic.com/mpacms//dc/article.php?id=54622

Franklin, E. (2012). Dynamic alignement through imagery. Champaign,
IL:Human Kinetics.

From FDA reports: Depression and Kyphosis n.d. Retrieved 20 July 2013,
from http://www.ehealthme.com/cs/depression/kyphosis

Isacowitz, R. & Klippinger, K (2011). Pilates Anatomy. Champaign,
IL:Human Kinetics.

Isacowitz, R. (2013). Study Guide. Comprehensive Course. Costa Mesa
CA: Body Arts and Science International

Kebaetse M. & McClure, P. & Pratt N. A. (1999 August) Thoracic position
effect on shoulder range of motion, strength, and three-dimensional
scapular kinematics. Retrieved 20 July 2013, from
http://www.ncbi.nlm.nih.gov/pubmed/10453773

Paterson, J. (2009). Teaching Pilates for Postural faults, Illness & Injury.
A practical guide. Kidlington, Oxford:Butterworth-Heinemann Elsevier



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