Printer Friendly

A literature review of studies evaluating rotator cuff activation during early rehabilitation exercises for post-op rotator cuff repair.

INTRODUCTION

Therapeutic exercises for rotator cuff dysfunction are an essential treatment tool used by rehabilitation professionals in a variety of healthcare settings that range from hospitals to outpatient clinics (2,4,7,16,21,38). These exercises can be powerful tools to improve the healing of compromised tissues by increasing blood flow to the tissues while also increasing strength and/or motor control to promote patient function (7,16,38). Exercise prescription and progression requires a systematic approach to enable the therapist to achieve a safe and effective contraction of the muscular tissue relative to the patient's needs and capabilities. The clinician must take into account numerous factors that include the plane of the movement, the speed of the movement, the position of the extremity, the level of assistance, and the type of resistance used (15). Exercises are prescribed along a continuum respecting healing tissues and progressed or regressed based on individual responses (3).

Electromyography (EMG) is a common method of evaluating skeletal muscle activity and function through the capture of electrical activity by either collecting a signal via electrodes placed on the skin overlying the intended muscle (surface EMG) or by fine-wire electrodes placed directly into the muscle (intramuscular EMG) (48). While the EMG provides information on when, how much, and how often a muscle is active throughout a range of motion (ROM), the clinician is careful not to equate the EMG with muscle or joint force (12). Understanding therapeutic EMG amplitudes assists the clinician in prescribing safe and appropriate exercises, and in making modifications without overloading the healing tissues. An appreciation of the anatomy and function of the rotator cuff is essential for therapeutic application of appropriate exercises.

Rotator Cuff Anatomy and Function

The rotator cuff is composed of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles (29). This musculotendinous complex is referred to as a cuff because the inserting tendons of each muscle envelope the head of the humerus to reinforce the stability of the glenohumeral joint. Their role in controlling the direction, degree, and quality of motion of the humeral head during upper extremity movements is required for optimal shoulder function to occur (29,37). The rotator cuff helps to elevate the arm while compressing the humeral head within the glenoid fossa and, therefore, resists translations of the humeral head due to deltoid activity (8,12,49).

The supraspinatus is the most superior located rotator cuff muscle. It originates from in the medial two-thirds of the supraspinous fossa of the scapula. The tendon of the supraspinatus passes under the acromion process, over the glenohumeral joint, and inserts on the superior facet of the greater tubercle (11). Unlike the other three muscles of the rotator cuff that produce an inferior translatory component to counteract the pull of the deltoid, the action line of the supraspinatus produces a superior translatory moment (29).

The supraspinatus is primarily considered an abductor of the humerus that functions in all planes of elevation, although it can also contribute to small amounts of medial and lateral rotation torques depending on the position of the arm (12,29). The supraspinatus peaks in activity at approximately 30 to 60[degrees] of glenohumeral abduction due to a pattern of decreasing mechanical advantage of the muscle that accompanies an increase in the abduction angle of the arm (29). The secondary functions of the supraspinatus include compression of the glenohumeral joint, "steering" of the humeral head, and maintenance of the stability of a dependent arm. However, it is less of a contributor to joint approximation than the other three rotator cuff muscles (29).

The posterior rotator cuff is composed of the infraspinatus and teres minor muscles. The infraspinatus originates from the infraspinous fossa below the spine of the scapula. Its tendon passes posteriorly to the glenohumeral joint to insert on the middle facet of the greater tubercule of the humerus (11). The teres minor is a cord-like muscle that originates from a flattened area of the scapula immediately adjacent to its lateral border below the infraglenoid tubercle. Its tendon inserts on the inferior facet of the greater tubercule of the humerus (11). The action line of the infraspinatus and teres minor in combination with the subscapularis result in an inferior translatory pull on the head of the humerus to counteract the superior translatory pull of the deltoid and supraspinatus (29).

The infraspinatus and teres minor are most commonly known for their roles as the primary external rotators of the GH joint (11,12). Functionally, this action is necessary as it indirectly contributes to abduction of the arm by providing the external rotation that is coupled with elevation of the arm. This coupled movement is necessary for clearance of the greater tubercle from beneath the acromion and lack of external rotation can contribute to subacromial impingement (11,29). The ability of the infraspinatus to provide external rotation to the glenohumeral joint is most effective at 0[degrees] abduction and decreases with an increasing angle of abduction due to a reduction of its moment arm (34). In comparison, the teres minor does not seem to be affected by the abduction angle of the glenohumeral joint. The muscle provides a constant external rotation torque throughout arm abduction (34).

Both the infraspinatus and teres minor also function to horizontally abduct the arm due to their location posterior to the glenohumeral joint (12). The secondary role of the posterior rotator cuff is to create glenohumeral joint compression to promote stability and function of the force closed joint (29,41). In addition to compression, the posterior rotator cuff contributes to the creation of the functionally necessary inferior translatory pull of the humeral head on the glenoid fossa during shoulder elevation. This arthrokinematic component must occur to prevent the humeral head from colliding with the acromion which creates subacromial impingement, which is associated various pathologies (29,41). Also, the teres minor has been defined as a weak adductor of the glenohumeral joint but its contradictory action against arm elevation is negligible. This is due to its small moment arm that ranges from 0.2 cm to 0.1 cm depending on the degree of internal and external rotation at the glenohumeral joint (12,34).

The anterior rotator cuff is comprised of the subscapularis muscle, which forms the largest component of the posterior wall of the axilla (11). It originates from the subscapular fossa to insert on the lesser tubercle of the humerus. Thus, the tendon crosses directly anterior to the joint capsule of the glenohumeral joint (11). Due to its large size, it has been divided into two sections that include upper and lower portions. Each part is independently innervated and activated during movement (9,12,34). The action line of the subscapularis promotes its role of inferior translation of the humeral head during elevation of the arm (29). The primary function of the subscapularis is to stabilize and rotate the shoulder joint to allow the arm to inwardly rotate. Internal rotation produced by the subscapularis peaks when the arm is at 0[degrees] abduction. The upper subscapularis appears to produce similar activation levels for internal rotation throughout increasing ranges of glenohumeral abduction, but the literature is still unclear regarding a difference in activation of the lower portion of the subscapularis. The lower portion has been shown to produce both higher and lower activation levels at 0[degrees] compared to 90[degrees] of abduction (12). When the arm is extended, the subscapularis has been shown to play a significant role in drawing the humerus forward and downward (9).

Rotator Cuff Pathology

Although the prevalence of rotator cuff tears in the general population is not completely clear, it has been established by a combination of magnetic resonance imaging (MRI), cadaveric, and ultrasonographic studies (28,42,54). While one narrative review reported an inconsistent prevalence in the general population to be anywhere from 7 to 40%, a more clear prevalence can be established when the patient's age is taken into account (28). An MRI based study found asymptomatic partial and full-thickness rotator cuff tears to occur in 4% of individuals <40 yrs of age and in more than 50% of individuals >60 yrs of age (42). Though a consistent prevalence is not entirely clear, this appears to be a common condition that increases in frequency with age. Many individuals with a full thickness tear present as asymptomatic and demonstrate no limitations to function. However, it is important to point out that the individuals who are asymptomatic demonstrate a 50% chance of developing pain within 5 yrs (28,53). This is a significant consideration that should be factored into the management of the patient with rotator cuff pathology.

Although the supraspinatus is the most commonly torn rotator cuff muscle, injuries often extend to the infraspinatus and/or subscapularis. When this happens, the injury produces a more extensive deficit (29). Management of a rotator cuff tear can either be conservative or surgical, or it can be both. Conservative treatments that are typically performed include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoid injections, and physical therapy. The surgical route is usually reserved for those who fail to respond to the conservative approach (16). Surgical procedures for the rotator cuff are often a combination of acromioplasty for subacromial decompression, excision of the subacromial bursa, removal of bony spurs at the acromioclavicular level, and cuff debridement, cuff repair, or both (18). Surgeons will choose to take either an open or closed (arthroscopic) approach to perform the repair depending on the training and surgical expertise of the surgeon as well as the wishes of the patient (6).

Despite the modern advancement of surgical repair equipment and techniques, many rotator cuff repairs do not clinically heal (5,13,22,24-26,39,40,44,52). Recent literature has produced rates of retear ranging from 10% in small tears (<2 mm) to 57% in large tears (>6 cm) (5). Many factors play a role in the success or failure of repairs that include patient related factors, surgery related variables, and rehabilitation variables (15). Controversy presently exists regarding the type, volume, and intensity of rehabilitative exercises that should be used in the first 6 wks following surgery to facilitate optimal healing of the repair and prevention of adhesions (15). Prescribed rehabilitative exercises must appropriately load the repaired muscle-tendon complex to promote healing without damaging the repair (15). This study examines the available literature that addresses electromyographic measurements of the rotator cuff muscles during commonly prescribed rehabilitation exercises.

The purpose of this study is to synthesize the current EMG research in order to rank the therapeutic exercises from least to most demanding on the rotator cuff muscle-tendon complex, and to prioritize the exercises that are considered most appropriate during the first 6 wks following rotator cuff repair. It is anticipated that this information will help physical therapists, occupational therapists, athletic trainers, and other orthopedic specialists to have a better idea of what exercises are most suitable for use in the early phase of rehabilitation to protect the repair and promote optimal healing of the muscle-tendon complex. To our knowledge, no study has looked at rotator cuff EMG activation levels in this way. Hence, this study is believed to be a unique review that will contribute to the scientific body of evidence pertaining to post operation rotator cuff rehabilitation.

METHODS

A literature search was completed for available experimental studies, randomized controlled trials, systematic reviews, narrative reviews, and meta-analyses on the topic of this study. The databases utilized were PubMed (1990 to 08/2015), CiNaHL (1990 to 08/2015), Pedro (1990 to 08/2015), Cochrane (1990 to 08/2015), and Sports Discus (1990 to 08/2015). The search terms included shoulder, shoulder muscle, rotator cuff, rotator cuff muscles, supraspinatus, infraspinatus, teres minor, subscapularis, electromyography (EMG), EMG activity, exercises, maximum voluntary isometric contraction (MVIC), and all combinations. Reference lists from relevant articles were also used to scan for additional articles.

Articles returned from the search were compared to identify the relevance of information and potential for inclusion. Primary inclusion criteria were studies that investigated EMG activity for the supraspinatus, infraspinatus, teres minor, or subscapularis. If EMG analyses were not performed for any of these muscles, the articles were excluded. To maximize homogeneity of studies, additional exclusion criteria were established including: (a) studies and exercises that did not normalize EMG activity to a MVIC; (b) studies that reported peak %MVIC and not mean %MVIC; (c) studies that used patients with current shoulder pathology; (d) exercises that are not practical to use as rehabilitation exercises; (e) exercises that used exercise machines with variable resistance; (f) studies that examined EMG activity without exercises; (g) exercises that created >20% MVIC on EMG recordings; and (h) studies and exercises that lacked detailed information to discern proper inclusion/exclusion criteria.

RESULTS

The search found that 13 studies met the inclusion criteria for the infraspinatus (1,8,10,14,17, 19,20,23,30,45,46,49,51), 12 for the supraspinatus (8,10,14,17,20,23,30,33,45,46,49,51), 5 for the subscapularis (17,20, 23,49,50), and 2 for the teres minor (17,31). The EMG levels have been previously described and categorized in the literature as follows: (a) low-level muscle activation at 0 to 20% MVIC; (b) moderate-level activation at 21 to 40% MVIC; (c) high-level activation at 41 to 60% MVIC; and (d) very-high level activation at greater than 60% (12). These categories were used to make meaningful comparisons between exercises. While exercise that fit into all of these categories were present, this study examined only the exercises in the low-level muscle activation category (given that they would be the most appropriate exercises to be performed during the first 6 wks of shoulder rehabilitation post rotator cuff repair) (15).

The EMG activity of the 4 rotator cuff muscles was summarized and ranked from lowest to highest activation to allow for a meaningful comparison of activities. The results are depicted in Figures 1 to 6. For exercises that were only examined in a single study the individual mean and standard deviation (when available) were reported. For exercises that were examined in more than one study, the pooled mean and its 95% confidence interval (CI) were reported.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

[FIGURE 6 OMITTED]

Details of all the exercises that were included in this study are illustrated in Figure 7. The EMG activity and measurement reliability are included when available.

DISCUSSION

The primary goal of post-surgical rehabilitation for rotator cuff tears is to allow for healing of the repaired rotator cuff tendon while minimizing stiffness and muscle atrophy (15,47). The standard of care for the rehabilitation protocols is divided into a series of progressive phases that begins with maximum protection and progresses to minimum protection. Each phase dictates a specific level of rotator cuff loading that attempts to match the patient's stage of healing. Electromyographic studies that examine the rotator cuff during specific activities have been an integral part of establishing these protocols (15,47). The earlier phases used therapeutic activities that resulted in minimal EMG activity to avoid stress to the repair, which helped to ensure tendon integrity and reduced the risk for gapping. Strengthening exercises, classified as exercises that produce >40% EMG activity, are withheld until later phases when repair integrity is ensured (12). The following sections provide an explanation for muscle activation levels [less than or equal to] 20%, as delineated in Figures 1 to 6 for the supraspinatus, infraspinatus, teres minor, and subscapularis.

Our review identified 47 low-level exercises for supraspinatus activation, 53 low-level exercises for the infraspinatus, 13 low-level exercises for the subscapularis, and 5 low-level exercises for the teres minor. These finding far exceed the typical exercise quantity generally described in rotator cuff repair protocols for the maximum phase of protection, which is usually <10 (27,32,43). With adequate clinical reasoning and consideration, these exercises may have clinical implications in the maximum protection phase of rotator cuff rehabilitation.

Many of the passive range of motion (PROM) exercises were determined to be low-level activation. This finding is consistent with the maximum protection phase for rehabilitation protocols (27,32,43,47). The data from the present review does not simply identify but rather delineates the degree to which these passive exercises activate the rotator cuff muscles. Data returned for the pendulum (a very commonly prescribed post-operative rotator cuff repair exercise) was ranked 25th (11% MVIC) out of 47 for supraspinatus activation. This finding makes it the highest activation level relative to all other passive interventions for this muscle group. Activity levels for the infraspinatus and subscapularis were also >10% when performing the pendulum. The reason for this finding may stem from the difficulty of the patient attaining true passive movement through "arm swinging" during the pendulum. It is common for patients attempting the pendulum to actively move the shoulder (that results in unwanted rotator cuff activity) instead of allowing for the shoulder to be moved via the trunk (30). Considering how frequently and early this exercise is prescribed in rehabilitation programs, it is imperative that the patient is properly educated when prescribing the exercise for a rotator cuff repair. Otherwise, the patient may not achieve a proper therapeutic effect.

Passive shoulder external rotation using a wall was determined to activate the supraspinatus the least compared to supine passive external rotation with a cane and passive external rotation performed by a physical therapist. However, the difference between activity levels was small and all three produced activity levels lower than the pendulum. Although supraspinatus activity was low for the three passive supine external rotation exercises, they generated higher activity levels in the infraspinatus and, particularly, in the subscapularis. This finding suggests that careful consideration must be taken into account if either of these muscles is involved in the repair. It is also important for the clinician to understand that passive external rotation of the glenohumeral joint produces a passive tension in the supraspinatus tendon that does not contribute to the recorded EMG activity. Cadaver studies examining the rotator cuff determined external rotation increased supraspinatus tension in the anterior tendon region and relaxed the posterior region, thus contributing to increased gap formation anteriorly (35,36). Tension peaked at 30[degrees] of passive external rotation so it may be sensible for clinicians to keep the amount of passive external rotation they perform below this threshold during the maximum protection phase to avoid threatening the integrity of the supraspinatus tendon repair (35,36).

Regarding therapist assisted manual PROM in the scapular and sagittal planes, supraspinatus and infraspinatus activation was found to be lower when the therapist moved the shoulder in the scapular plane. Movement in the scapular plane may feel more comfortable for the patient and result in reduced muscle guarding, which can commonly occur when the shoulder is moved through the sagittal plane. This activity also produced subscapularis activity levels close to 20%. Continuous passive motion (CPM) was examined in one study and found to generate very little activity in the supraspinatus and infraspinatus when it was used for combined elevation with external rotation (9). Passive forward bowing resulted in activity levels <10% for the supraspinatus, infraspinatus, and subscapularis. To achieve the lowest activation possible with this movement, it was crucial for the resultant movement produced at the shoulder to be created by using the trunk and not by actively moving the UE. Similar exercises that involved the patient actively performing a towel slide on a table resulted in increased supraspinatus and infraspinatus activity.

Weight bearing through the repaired upper extremity (UE) is generally contraindicated in the maximum protection phase of commonly prescribed rotator cuff repair rehabilitation protocols (27,32,43). Our study reviewed 6 weight bearing positions for the UE; all of which produced EMG activity of [less than or equal to] 20% for the supraspinatus and 3 of the 6 produced EMG activity of [less than or equal to] 10%. This indicates that these may be safe for early implementation due to the potential benefit of performing structured weight bearing activities in the maximum protection phase. The weight bearing in prayer position produced the lowest (i.e., 2% MVIC) supraspinatus activity all exercises. However, these positions tended to result in elevated activity of the infraspinatus and reached levels >20% in the pointer and tripod position. The weight bearing exercises made use of scales in a manner similar to that used for weight bearing activities of the lower extremity (LE) for those with post-surgical weight bearing precautions. This use of scales can allow the clinician to better control the amount of force going through the patient's affected UE.

While active-assisted range of motion (AAROM) exercises are generally withheld until the moderate phase of protection after week 6, EMG activities for a variety of different AAROM shoulder exercises were analyzed in this study and produced rotator cuff activity levels [less than or equal to] 20%. The AAROM exercises attempt to aid the affected UE through its available ROM. Our review analyzed exercises that were performed with the aid of cane or dowel, a t-bar, pulleys, a towel, a slide board, an exercise ball, or the non-affected UE. All of these exercises promoted assistive elevation of the UE, but the range of rotator cuff activity observed across modalities was varied. When the patient performed AAROM in sidelying with a board or performed sagittal flexion with a dowel or non-affected hand, the supraspinatus and infraspinatus activity was closer to 10%, which is similar to the pendulum activation levels. Activation levels in the subscapularis and teres minor were [less than or equal to] 20% but higher than both the supraspinatus and infraspinatus. When pulleys or a t-bar was used to assist in elevation of the upper extremity, the activity of the supraspinatus, subscapularis, and teres minor was closer to 20% while the infraspinatus activity remained closer to 10%. The pulleys and t-bar assisted exercises might make it more difficult for the patient to achieve true relaxation of the assisted upper extremity, thus resulting in the higher activation levels. Due to this finding of increased activity, the exercises closer to 20% MVIC may not be appropriate for use in the maximum protection phase for patients with repairs involving rotator cuff musculature other than the infraspinatus.

Active range of motion and resistive exercises are contraindicated in the maximum protection phase. Our review returned few exercises that measured at [less than or equal to] 20% MVIC, but there were some exceptions worth noting. One study examined variations on chest press ups in the supine position using a wash cloth or an aerosol can with various hand and body positions (46). These exercises produced activities in the supraspinatus that ranged from 3 to 8% MVIC and 7 to 11% MVIC for the infraspinatus. The washcloth exercises produced lower activity levels than the aerosol can for the supraspinatus and vice versa for the infraspinatus. The activity produced in the supraspinatus and infraspinatus for these activities was similar to the activity of the passive interventions described earlier and may occur due to the supine position of the patient. In this position, the effect of gravity on the glenohumeral joint is reduced and the shoulder range of motion is reduced. Although the data for the low intensity press ups was limited to one study, these exercises may prove useful in the maximum protection phase as an adjunct to the more passive interventions and help patients feel more involved with their treatment. Other active range of motion (AROM) activities such as standing flexion in the scapular or sagittal plane with or without the support of a wall or slide board produced activity in the supraspinatus closer to 20%, although they produced values in the infraspinatus closer to 10%. Multiple overhead movements, one with an aerosol can and one with no weight produced infraspinatus activation levels <20% while the supraspinatus levels were >20%. If the supraspinatus is involved in the repair, these movements should be avoided in the maximum protection phase.

Exercises that targeted joints other than the glenohumeral joint were limited in this study, particularly in regards to the supraspinatus muscle activity. Standing elbow flexion produced a low level of activation of the supraspinatus, infraspinatus, and subscapularis even though the activity was higher than all passive interventions mentioned previously. However, one study (20) demonstrated that it was possible to decrease supraspinatus and subscapularis activity during elbow flexion if the upper portion of the arm was supported by the contralateral hand. Wrist extension produced low levels of activation for the infraspinatus that were <5% with both a dumbbell and elastic band, but the supraspinatus activity was not measured during these activities. No scapular exercises were found that met the criteria for inclusion in this study, though they are commonly used in the maximum protection phase of rotator cuff repair rehabilitation protocols (27,32,43).

The EMG activity levels during common activities of daily living were also examined in this study. Although these activities would not be prescribed to the patient following surgery, it is likely that the activities will occur during a patient's episode of care. Hence, it would benefit the clinician to understand the degree to which these activities influence the rotator cuff. Some ADLs were examined with the patient wearing a sling while others were performed without a sling. Most activities carried out with a sling resulted in relatively low activity of the rotator cuff compared to activities performed without a sling. One exception to this was drinking a bottle of water while wearing a sling, which resulted in 19% activity for the infraspinatus and >20% activity for the supraspinatus. Walking without a sling and donning and doffing a button up shirt without a sling produced similarly elevated activity at [greater than or equal to] 20% for the supraspinatus. Typing and teeth brushing activity while wearing a sling were also examined for the supraspinatus and infraspinatus. While supraspinatus activity remained close to 10% for both activities, infraspinatus activity ranged from 12% to 20% (20). Although rehabilitation exercises are performed at a low frequency, ADLs such as walking can occur at high frequency and pose a significant threat to rotator cuff repair integrity. Sling compliance and education should become a critical component of patient care. If patients are adequately informed of the proper use of the sling to reduce unnecessary stress to the repair, optimal tendon repair healing during the maximum protection phase can be ensured.

CONCLUSIONS

The purpose of this review was, first, to analyze the current EMG research on the rotator cuff muscles and, second, to rank the therapeutic exercises from least to most demanding on muscle-tendon complex so clinicians may better determine the most appropriate therapeutic interventions for their patients during the first 6 wks following a rotator cuff repair. Our findings indicate that there are many therapeutic interventions not commonly prescribed in rehabilitation protocols that may prove beneficial during the maximum protection phase after repair. The EMG activity of the involved muscles ranged from 2 to 20%, which placed them all in the low-level activation category as has been described to be clinically meaningful in the literature.

Our findings clarified the pendulum, which is a commonly prescribed maximum protection exercise, by indicating that it produced a highly variable rotator cuff activity that exceeds many other passive interventions. Also, our findings examined the dangers posed by sling non-compliance and activities of daily living (ADLs) on repair integrity. Most importantly, by following a gradual progression based on EMG activity, therapeutic exercises can be advanced in a systematic fashion that takes into account the plane of the movement, speed of the movement, the position of the extremity, the level of assistance, and the type of resistance used. If the clinician can correctly use a gradual progression of therapeutic activities based on clinical expertise combined with the knowledge of rotator cuff EMG activity, rotator cuff repairs will be better protected during the inflammation and proliferative phase when repaired tissue remains immature and vulnerable to retear.

This study included only individuals without rotator cuff pathology that may decrease the generalizability to a patient population that has rotator cuff pathology. Future studies may also benefit from investigating the pathological population as well as examining therapeutic exercises and activities that elicit >20% EMG activity to help aid clinicians in the successful rehabilitation of their post-operative rotator cuff repair patients.

Address for correspondence: A. Burke Gurney, PT, PhD, OCS, Department Chief, Division of Physical Therapy, University of New Mexico Health Sciences, Albuquerque, NM 87131. Email: bgurney@salud.unm.edu

REFERENCES

(1.) Andersen LL, Andersen CH, Mortensen OS, Poulsen OM, Bjornlund IBT, Zebis MK. Muscle activation and perceived loading during rehabilitation exercises: Comparison of dumbbells and elastic resistance. Phys Ther. 2010; 90(4):538-549.

(2.) Baumgarten KM, Vidal AF, Wright RW. Rotator cuff repair rehabilitation: A level i and ii systematic review. Sports Health Multidiscip Approach 2009; 1 (2):125-130.

(3.) Bolgla L, Malone T, Nitz A, Shaffer S, Uhl T. Exercise progression for the upper and lower extremity: What does the EMG say? APTA Combined Sections Meeting. Anaheim, CA, Feb, 2015.

(4.) Chan K, MacDermid JC, Hoppe DJ, Ayeni OR, Bhandari M, et al. Delayed versus early motion after arthroscopic rotator cuff repair: A meta-analysis. J Shoulder Elbow Surg. 2014; 23(11):1631-1639.

(5.) Choi S, Kim MK, Kim GM, Roh Y-H, Hwang IK, Kang H. Factors associated with clinical and structural outcomes after arthroscopic rotator cuff repair with a suture bridge technique in medium, large, and massive tears. J Shoulder Elb Surg. 2014; 23 (11):1675-1681.

(6.) Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. In: Cochrane Database of Systematic Reviews, The Cochrane Collaboration. Chichester, UK: John Wiley & Sons, Ltd: January 23, 2008.

(7.) Cricchio M, Frazer C. Scapulothoracic and scapulohumeral exercises: a narrative review of electromyographic studies. J Hand Ther. 2011 ; 24(4):322-334.

(8.) Dark A, Ginn KA, Halaki M. Shoulder muscle recruitment patterns during commonly used rotator cuff exercises: An electromyographic study. Phys Ther. 2007; 87(8): 1039-1046.

(9.) Decker MJ, Tokish JM, Ellis HB, Torry MR, Hawkins RJ. Subscapularis muscle activity during selected rehabilitation exercises. Am J Sports Med. 2003; 31(1):126-134.

(10.) Dockery ML, Wright TW, LaStayo PC. Electromyography of the shoulder: An analysis of passive modes of exercise. Orthopedics. 1998; 21 (11):1181-1184.

(11.) Drake RL, Vogl W, Mitchell AWM. Gray's Anatomy for Students. (2nd Edition). Philadelphia, PA: Elsevier, 2009.

(12.) Escamilla RF, Yamashiro K, Paulos L, Andrews JR. Shoulder muscle activity and function in common shoulder rehabilitation exercises. Sports Med Auckl. NZ 2009; 39 (8):663-685.

(13.) Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Jt Surg. 2004; 86-A(2):219-224.

(14.) Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010; 2(5):424-432.

(15.) Gaunt BW, Uhl TL. The challenge of rotator cuff repair rehabilitation--progressing exercises safely: Understanding healing and using EMG evidence as a guide. APTA Combined Sections Meeting, Anaheim, CA. Feb, 2015.

(16.) Gomoll AH, Katz JN, Warner JJP, Millett PJ. Rotator cuff disorders: recognition and management among patients with shoulder pain. Arthritis Rheum. 2004; 50(12): 3751-3761.

(17.) Gurney B, Mermier C, LaPlante M, Majumdar A, O'Neil K, et al. Shoulder electromyography measurements during activities of daily living and routine rehabilitation exercises. J Orthop Sports Phys Ther. May, 2016 (in print).

(18.) Hata Y, Saitoh S, Murakami N, Seki H, Nakatsuchi Y, Takaoka K. A less invasive surgery for rotator cuff tear: Mini-open repair. J Shoulder Elbow Surg. 2001; 10(1):11-16.

(19.) Herrington L, Waterman R, Smith L. Electromyographic analysis of shoulder muscles during press-up variations and progressions. J Electromyogr Kinesiol. 2015; 25(1): 100-106.

(20.) Jung M-C, Kim S-J, Rhee J-J, Lee D-H. Electromyographic activities of the subscapularis, supraspinatus, and infraspinatus muscles during passive shoulder and active elbow exercises. Knee Surg Sports Traumatol Arthrosc. 2015; 1-6.

(21.) Kang M-H, Oh J-S, Jang J-H. Differences in muscle activities of the infraspinatus and posterior deltoid during shoulder external rotation in open kinetic chain and closed kinetic chain exercises. J Phys Ther Sci. 2014; 26(6):895-897.

(22.) Keener JD, Galatz LM, Stobbs-Cucchi G, Patton R, Yamaguchi K. Rehabilitation following arthroscopic rotator cuff repair: A prospective randomized trial of immobilization compared with early motion. J Bone Joint Surg. Am. 2014; 96(1):11-19.

(23.) Kelly BT, Roskin LA, Kirkendall DT, Speer KP. Shoulder muscle activation during aquatic and dry land exercises in nonimpaired subjects. J Orthop Sports Phys Ther. 2000; 30(4):204-210.

(24.) Kim JR, Cho YS, Ryu KJ, Kim JH. Clinical and radiographic outcomes after arthroscopic repair of massive rotator cuff tears using a suture bridge technique: assessment of repair integrity on magnetic resonance imaging. Am J Sports Med. 2012; 40(4):786-793.

(25.) Kim KC, Shin HD, Cha SM, Lee WY. Comparison of repair integrity and functional outcomes for 3 arthroscopic suture bridge rotator cuff repair techniques. Am J Sports Med. 2013; 41 (2):271-277.

(26.) Koh KH, Laddha MS, Lim TK, Park JH, Yoo JC. Serial structural and functional assessments of rotator cuff repairs: Do they differ at 6 and 19 months postoperatively? J Shoulder Elbow Surg. 2012; 21 (7) 859-866.

(27.) Kropf EJ, Sewards MJ, Temple Orthopaedics and Sports Medicine. Arthroscopic rotator cuff repair: Physical therapy protocol. Temple Orthopaedics and Sports Medicine. http://ortho.templehealth.org/content/default.htm

(28.) Lashgari C, Redziniak D. Upper extremity: The natural history of rotator cuff tears. Curr Orthop Pract. 2012; 23(1):10-13.

(29.) Levangie P, Norkin CC. Joint Structure and Function: A Comprehensive Analysis, (4th Edition,). Philidelphia, PA: F.A. Davis, 2009.

(30.) Long JL, Ruberte Thiele RA, Skendzel JG, Jeon J, Hughes RE, et al. Activation of the shoulder musculature during pendulum exercises and light activities. J Orthop Sports Phys Ther. 2010; 40(4):230-237.

(31.) Marta S, Pezarat-Correia P, Fernandes O, Carita A, Cabri J, De Moraes A. Electromyographic analysis of posterior deltoid, posterior rotator cuff and trapezius musculature in different shoulder exercises. Int Sportsmed J. 2013; 14(1):1-15.

(32.) Massachusetts General Hospital Orthopaedics. Rotator cuff repair rehabilitation protocol. Massachusetts General Hospital. http://www.massgeneral.org/ortho/

(33.) Myers JB, Pasquale MR, Laudner KG, Sell TC, Bradley JP, Lephart SM. On-the-field resistance-tubing exercises for throwers: An electromyographic analysis. J Athl Train. 2005; 40(1):15-22.

(34.) Otis JC, Jiang CC, Wickiewicz TL, Peterson MG, Warren RF, Santner TJ. Changes in the moment arms of the rotator cuff and deltoid muscles with abduction and rotation. J Bone Joint Surg Am. 1994; 76(5):667-676.

(35.) Park MC, Idjadi JA, ElAttrache NS, Tibone JE, McGarry MH, Lee TQ. The effect of dynamic external rotation comparing 2 footprint-restoring rotator cuff repair techniques. Am J Sports Med. 2008; 36(5):893-900.

(36.) Park MC, Jun BJ, Park CJ, Ahmad CS, ElAttrache NS, Lee TQ. The biomechanical effects of dynamic external rotation on rotator cuff repair compared to testing with the humerus fixed. Am J Sports Med. 2007; 35(11):1931-1939.

(37.) Reinhold MM, Macrina LC, Wilk KE, Fleisig GS, Barrentine SW, et al. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007; 42(4):464-469.

(38.) Roe C, Brox JI, Bohmer AS, Vollestad NK. Muscle activation after supervised exercises in patients with rotator tendinosis. Arch Phys Med Rehabil. 2000; 8l(1):67-72.

(39.) Russell RD, Knight JR, Mulligan E, Khazzam MS. Structural integrity after rotator cuff repair does not correlate with patient function and pain: A meta-analysis. J Bone Joint Surg Am. 2014; 96(4):265-271.

(40.) Sethi PM, Noonan BC, Cunningham J, Shreck E, Miller S. Repair results of 2-tendon rotator cuff tears utilizing the transosseous equivalent technique. J Shoulder Elb Surg Am Shoulder Elb Surg. 2010; 19(8):1210-1217.

(41.) Sharkey NA, Marder RA. The rotator cuff opposes superior translation of the humeral head. Am J Sports Med. 1995; 23(3):270-275.

(42.) Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995; 77 (1):10-15.

(43.) South Shore Hospital Orthopaedic, Spine and Sport Therapy. Rotator cuff repair rehabilitation protocol. http://www.southshorehospital.org/Workfiles/Medical_Services/ Orthopedics/Rotator_Cuff_Repair.pdf

(44.) Tashjian RZ, Hollins AM, Kim H-M, Teefey SA, Middleton WD, et al. Factors affecting healing rates after arthroscopic double-row rotator cuff repair. Am J Sports Med. 2010; 38(12):2435-2442.

(45.) Uhl TL, Carver TJ, Mattacola CG, Mair SD, Nitz AJ. Shoulder musculature activation during upper extremity weight-bearing exercise. J Orthop Sports Phys Ther. 2003; 33(3):109-117.

(46.) Uhl TL, Muir TA, Lawson L. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM&R. 2010; 2(2):132-141.

(47.) Van der Meijden OA, Westgard P, Chandler Z, Gaskill TR, Kokmeyer D, Millett PJ. Rehabiliation after arthoscopic rotator cuff repair: Current concepts review and evidence based guidelines. Int J Sports Phys Ther. 2012; 7(2):197-218.

(48.) Waite DL, Brookham RL, Dickerson CR. On the suitability of using surface electrode placements to estimate muscle activity of the rotator cuff as recorded by intramuscular electrodes. J Electromyogr Kinesiol Off J Int Soc Electrophysiol Kinesiol. 2010; 20(5):903-911.

(49.) Wattanaprakornkul D, Halaki M, Cathers I, Ginn KA. Direction-specific recruitment of rotator cuff muscles during bench press and row. J Electromyogr Kinesiol. 2011; 21 (6):1041-1049.

(50.) Wickham J, Pizzari T, Stansfeld K, Burnside A, Watson L. Quantifying "normal" shoulder muscle activity during abduction. J Electromyogr Kinesiol. 2010; 20(2):212-222.

(51.) Wise MB, Uhl TL, Mattacola CG, Nitz AJ, Kibler WB. The effect of limb support on muscle activation during shoulder exercises. J Shoulder Elbow Surg. 2004; 13(6): 614-620.

(52.) Wu XL, Briggs L, Murrell GAC. Intraoperative determinants of rotator cuff repair integrity: An analysis of 500 consecutive repairs. Am J Sports Med. 2012; 40(12): 2771-2776.

(53.) Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: A longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elb Surg Am Shoulder Elb Surg Al. 2001; 10(3):199-203.

(54.) Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010; 19(1):116-120.

Disclaimer

The opinions expressed in JEPonline are those of the authors and are not attributable to JEPonline, the editorial staff or the ASEP organization.

Samuel N. Wells [1], Jodi R. Schilz [1], Tim L. Uhl [2], A. Burke Gurney [1]

[1] Deparment of Physical Therapy, University of New Mexico Health Sciences, Albuquerque, NM, [2] Department of Rehabilitation Sciences, University of Kentucky, College of Health Sciences, Lexington, KY
Figure 7. Detail Pictures and Descriptions of all of the Exercises
that were Included in this Study. The EMG Activity and Measurement
Reliability were Included When Available.

Exercise             Description          ENG      Relia    Reference
                                          (%MVI    bility
                                          C)(SD)   (ICC)

Weight bearing       Subject kneels       SP                Uhl TL et
m prayer             with weight          2(2)              al. (45)
position             shifted primarily
                     over ankles, leans   IN
                     forward places       4(3)
                     hands on each
                     analog scale,
                     similar to
                     standing weight
                     shift.

Standing self-       Subject Places       SP                Jung M-C
performed            affected hand on     3                 et al.
passive              the wall with the                      (20)
shoulder ER          elbow bent and       IN
using a wall         gently turns body    18
                     to the opposite
                     direction 1 until
                     a stretch is felt.

Active-assisted      The subject lies     SP                Uhl TL et
washcloth press-     supine and mimics    3(7)              al. (46)
up hands close       a chest press-up
                     holding onto a WC    IN
                     with hands placed    7(5)
                     dose together.

Supine self-         While lying down     SP                Dockery
performed passive    on the hack with a   4(1)              ML et al.
ER using a cane      towel roll or                          (10)
                     pillow under the
                     injured shoulder's   IN                Jung M-C
                     elbow and the        9                 et al.
                     other hand at                          (20)
                     pocket level, the    SB
                     patient will push    15
                     the cane stick of
                     the injured hand
                     backwards over
                     their shoulder.

Therapist-           A Therapist          SP                Dockery
assisted manual      manually moves the   4                 ML et al.
PROM m the           patient's                              (10)
scapular plane       affected shoulder
                     through available    IN
                     ROM in the           3
                     scapular n plane
                     in a manner that
                     is as pain free
                     for the patient as
                     possible.

Therapist-           Therapist manually   SP                Dockery
assisted manual      moves the            4                 ML et al.
PROM for ER          patient's affected                     (10)
and IR               shoulder through
                     available ROM for
                     IR and ER in a
                     manner that is as
                     pain free for the
                     patient as
                     possible.

Active assisted      The subject lies     SP                Uhl TL et
washcloth preta-     supine aud mimics    4(7)              al. (46)
up bancs far apart   a chest press-up
                     holding onto a WC    IN
                     with hands placed    11(14)
                     farther apart.

Active supine        The subject lies     SP                Uhl TL et
press-up with        supine. using the    4(8)              al. (46)
aerosol can          affected upper
                     extremity. an        IN
                     aerosol can is       9(5)
                     pushed from the
                     subject's aide up
                     towards the
                     ceiling with the
                     scapalar being
                     protracred at the
                     end of the
                     exercise.

Combined passive     Patient's arm is     SP                Dockery
elevation and EE.    manually moored      5                 ML et al.
using a CPM          through passive                        (10)
Machine              shoulder elevation   IN
                     and ER ROM with      4
                     the use of a CPM
                     machine.

Passive forward be   Subject places       SP                Jung M-C
tv with table        hard of affected     5(1)              et al.
                     upper excremity or                     (20)
                     a table. The
                     subject then steps   IN                Uhl TL et
                     backward away from   2(1)              al. (46)
                     the stationary
                     hand while           SB
                     simultaneously       10(12)
                     bending at his on
                     her waist, which
                     places the subject
                     into a forward bow
                     position.

Standing IR aim at   Subject holds an     SP                Dark A et
aide, pulley cr      elastic band or      5(7)              al. (8)
rubber tubing        pulley at their
                     side with elbow      IN                Myers JB
                     bent. Starting       17(22)            et al.
                     with the hand away                     (33)
                     from the stomach,
                     the band is pulled
                     towards the
                     stomach. Subject
                     keeps elbow near
                     side the entire
                     time.

Active-assisted      The subject stands   SP                Uhl TL et
standing scapular    astride next to      5(9)              al. (46)
protraction with     stable at waist
ball on table        Level with his or    IN
                     her hand on a bad    >20%
                     at chest level.
                     The subject slides
                     his or her hand
                     over the ball
                     allowing the ball
                     to roll away from
                     their body at a
                     45[degrees] from
                     the frontal plane.

Prone shoulder       Patient lies in      SP                Wattanapra
extension in "full   the prone position   5(7)              kornkul D
can" petition        with the arm is                        et al.
                     hanging off the      IN                (49)
                     side. The entire     6(7)
                     aim is then raised
                     backwards in the
                     entire arm is then
                     slowly lowered
                     back to the
                     starting position.

Weight bearing in    Subject is           SP                Uhl TL et
quadruped slide on   positioned with      6(10)             al. (46)
table                hands and knees on
                     the ground with      IN
                     shoulder flexed to   11(8)
                     90[degrees].

Standing AAROM       The subject stands   SP                Uhl TL et
towel slide on       astride next to a    7(12)             al. (46)
table                table at waist
                     level with his or    IN
                     her hand on a        4(6)
                     towel. The subject
                     slides the towel
                     on the table top
                     away from his or
                     her body at a
                     45[degrees] from
                     the frontal plane.

Side lying           Participant          SP       sp       Gaunt BW
shoulder elevation   instructed to        7(5)     .89      et al.
with towel on        slide towel or                         (14)
board                board with weight    IN       IN
                     of hand resting on   10(7)    .92
                     board, effectively
                     elevating arm
                     overhead to
                     approximately
                     140[degrees] and
                     then lowering hand
                     to starting
                     position.

Supine forward       Exercise started     SP       SP       Gaunt BW
elevation with       with dominant        8(6)     .63      et al.
elastic resistance   shoulder flexed                        (14)
from 90[degrees]     90[degrees] and      IN
                     elbow extended.      >20%
                     Participant
                     actively moved arm
                     into forward
                     elevation of
                     approximately
                     160[degrees],
                     thereby
                     lengthening band.
                     Dominant arm then
                     lowered slowly
                     back to starting
                     position.

Typing in a sling    Patient instructed   SP                LONG JL
                     to type              8(5)              et al.
                     continuously for                       (14)
                     three 4 second       IN
                     sets.                12(13)

Active supine        The subject lies     SP                Uhl TL et
press up on wedge    supine, elevated     8(11)             al. (46)
with aerosol can     on a 45[degrees]
                     wedge, using the     IN
                     affected upper       9(7)
                     extremity, an
                     aerosol can is
                     pushed from the
                     subject's side up
                     towards the
                     ceiling with the
                     scapular being
                     protracted at the
                     end of the
                     exercise.

AAROM using a        In the standing      SP                Dockery ML
dowel, with index    position, patient    9(6)              et al.
fingers touching     holds a wand/cane,                     (10)
each other           index fingers
                     touching, palm       IN                Gurney B
                     down on both side.   7(3)              et al.
                     The wand is raised                     (17)
                     up allowing the      SB
                     unaffected arm to    14
                     perform most of
                     the effort. The      TM
                     affected arm         16
                     should be
                     partially relaxed.

AAROM sagittal       While sitting or     SP                Gurney B
plane with hands     standing patient     9(11)             et al.
together and         grasps affected                        (17)
finger locked        hand with fingers
                     locked and slowly    IN                Uhl TL et
                     raises it up and     8(6)              al. (46)
                     forward towards
                     overhead. The        SB
                     affected arm         17
                     should be relaxed
                     and the other arm    TM
                     performing the       20
                     work.

Weight bearing in    Subject remains in   SP                Uhl TL et
tripod position      the quadruped        10(11)            al. (46)
                     position, the
                     flexes nondominant   IN
                     shoulder to          >20%
                     180[degrees]

AROM elbow flex/     While suporting      SP                Jung M-C
ext while holding    the upper arm of     10(13)            et al.
arm with             the affected side                      (20)
contralateral hand   with the             IN
                     contralateral        9(3)
                     hand, the elbow is
                     slowly flexed and    SB
                     extended through     10(13)
                     available ROM.

Therapist-           Therapist            SP                Gurney B
assisted manual      mannually moves      11                et al.
PROM in the          the patient's                          (17)
sagittal plane       affected shoulder    IN
                     through available    5
                     ROM in the
                     scapular plane in    SB
                     a manner that is     18
                     as pain free for
                     the patient as       TM
                     possible.            >20

Pendulum             Patient shifts       SP                Dockery ML
                     body weight in       11(15)            et al.
                     circles to allow                       (10)
                     injured arm to       IN                Gurney B
                     swing in circles     12(3)             et al.
                     freely. Injure arm                     (17)
                     should be fully      SB                LONG JL
                     relaxed.             16                et al.
                                                            (14)
                                          TM
                                          >20

Dustins center       Participant          SP       SP       Gaunt BW
                     positioned sitting   12(7)    .83      et al.
                     in front of an                         (14)
                     adjustable table     IN       IN
                     with table at        8(5)     .91
                     elbow height and
                     elbow at midline
                     of body.
                     Participant placed
                     hand on a towel
                     and then slid
                     towel directly
                     forward and
                     backward in
                     sagittal plane
                     until elbow was
                     fully extended
                     while keeping body
                     still.

Dusting medial       Dusting exercise     SP       SP       Gaunt BW
                     repeated             12(6)    .90      et al.
                     45[degrees] medial                     (14)
                     to first exercise.   IN       IN
                     Glenohumeral joint   7(5)     .96
                     moved through an
                     arc of
                     approximately
                     0[degrees] to
                     45[degrees] for
                     each of first 3
                     exercises.

Weight bearing in    Subject maintains    SP                Uhl TL et
pointer position     same position as     12(13)            al. (45)
                     tripod position
                     and extends          IN
                     contralateral hip    >20%
                     to 0[degrees].

Standing shoulder    While in water and   SP                Kelly BY
elevation in the     standing with your   12(13)            et al.
scapular plane in    thumb facing up,                       (23)
water                raise your arms up   IN
                     towards the          9(11)
                     ceiling with your
                     arms slightly        SB
                     pulled forward at    5(6)
                     about a 30 degree
                     angle.

Brushing teeth in    Subject instructed   SP                Long JL
a sling              to brush             12(10)            et al.
                     continuously for                       (30)
                     three 4 second       In
                     sets.                20(21)

Dusting lateral      Dusting exercise     SP       SP       Gaunt BW
                     repeated             13(7)    .94      et al.
                     45[degrees]                            (14)
                     lateral to first     IN       IN
                     exercise along       9(6)     .92
                     plane of the
                     scapula.

Standing active      Subject instructed   SP                Jung M-C
elbow flexion with   to bend elbow        13(15)            et al.
the arm in neutral   upwards as shown                       (20)
                     and then to lower    IN
                     arm to a             8(2)
                     straighten
                     position.            SB
                                          14(8)

Standing vertical    Subject stands       SP                Wise MB
wail slide,          near wall with one   13(7)             et al.
supported AROM       foot in front of                       (51)
                     the other. The       IN
                     affected hand is     9(5)
                     placed on a
                     sphygmomanometer
                     and then slid up
                     the wall as weight
                     is shifted forward
                     onto the front
                     foot.

Weight bearing in    Subject maintains    SP                Uhl TL et
push-up position     push-up position     14(14)            al. (45)
                     with elbows in
                     full extension and   IN
                     shoulder flexed to   >20%
                     approximately
                     90[degrees].

Standing wall ball   Participant stood    SP       SP       Gaunt BW
roll                 1 arm length from    16(9)    .96      et al.
                     wall with a small                      (14)
                     ball against wall    IN       IN
                     at shoulder          18(11)   .96
                     height.
                     Participant asked
                     to roll ball up
                     and down wall
                     1-hand length
                     (approximately a
                     20[degrees] arc)
                     while keeping
                     elbow-extended.

Standing T-bar       In standing,         SP       SP       Gaunt BW
active assisted      participant          16(9)    .69      et al.
forward elevation    instructed to                          (14)
                     primarily use
                     nondominant arm to   IN       IN
                     raise and lower      13(10)   .72
                     dominant arm into
                     elevation.
                     Dominant arm
                     grasped 1-m. PVC
                     bar with thumb
                     pointing up and
                     moved through an
                     approximately
                     160[degrees] arc.

Standing vertical    Subject stands       SP                Wise MB
wail slide           near wall with one   17(11)            et al.
unsupported AROM     foot in front of                       (51)
                     the other. The       IN
                     affected hand is     10(6)
                     placed 1 inch away
                     from the wall and
                     then slid up the
                     wall as weight is
                     shifted forward
                     onto the front
                     foot.

AAROM using          Using door pulleys   SP                Gaunt BW
pulleys in the       and facing away      18(1)             et al.
sagittal plane       from the door,                         (14)
                     patient slowly
                     pulls down with      IN                Jung M-C
                     the unaffected arm   5(4)              et al.
                     so that the                            (20)
                     affected arm
                     raises forward and   SB
                     up without effort.   11(9)
                     The affected arm
                     should be relaxed.   TM
                     The unaffected arm   16
                     does the work.

Standing ER arm at   Subject holds an     SP                Dark A et
side, pulley or      elastic band at      18(4)             al. (8)
rubber tubing        their side with
                     elbow bent.          IN                Myers JB
                     Starting with the    >20%              el al.
                     hand near the                          (33)
                     stomach the band
                     is pulled away.
                     The elbow is kept
                     at the side the
                     entire time.

Weight bearing in    Subject maintains    SP                Uhl TL et
push-up feet         pushup position      18(16)            al. (45)
elevated position    with feet elevated
                     45 cm. elbows in     IN
                     full extension and   >20%
                     the shoulder
                     flexed to
                     90[degrees]

Standing diagonal    Subject stands in    SP                Wise MB
wall slide.          front of a slide     18(11)            et al.
supported AROM       board angled at                        (51)
                     45[degrees] with     IN
                     one foot in front    10(7)
                     of the other. The
                     affected hand is
                     placed on a
                     sphygmomanometer
                     and then slid up
                     the the board as
                     the weight is
                     shifted forward
                     onto the front
                     foot.

Active standing      The subject stands   SP                Uhl TL et
ipsilateral          astride with the     18(15)            al. (46)
shoulder flexion     ips foot of the
                     affected arm in
                     front. The subject   IN
                     shifts his or her    >20%
                     weight forward and
                     elevates both arms
                     overhead. The
                     motion should be
                     rhythmic with the
                     lower extremity
                     preceding the
                     upper extremity.

Donning and          Patient              SP                Gurney B
doffing a sling      independently puts   19                et al.
                     sling on and                           (17)
                     indecently takes     IN
                     sling off after      15
                     education by
                     therapist            SB
                                          >20

                                          TM
                                          >20

Standing shoulder    Subject stands       SP                Kelly BY
elevation in the     with the thumb       19(3)             et al.
scapular plane       facing up and                          (23)
                     raises the arm up
                     towards the          IN
                     ceiling with the     12(2)
                     arm slightly
                     pulled forward at    SB
                     about a 30 degree    7(1)
                     angle.

Walking              Patient is           SP                Gurney B
approximately 10     instructed to walk   20                et al.
steps without a      normally for 10                        (17)
sling                seconds without      IN
                     any additional       >20%
                     support for the
                     affected shoulder.   SB
                                          >20

                                          TM
                                          >20

AARQM using          Using door pulleys   SP       SP       Dockery
pulleys in the       and facing away      20(5)    .89      ML et al.
scapular plane       from the door,                         (10)
                     patient slowly       IN       IN       Gaunt BW
                     pulls down with      13(4)    .98      et al.
                     the unaffected arm                     (14)
                     so that tire         SB                Gurney B.
                     affected arm         >29               et al.
                     raises forward and                     (17)
                     up at a              TM
                     30[degrees] angle    19
                     without effort.
                     The affected arm
                     should be relaxed.
                     The unaffected arm
                     does the work

Standing T-bar       Exercise performed   SP       SP       Gurney B.
assistive            exactly as           20(11)   .96      et al.
elevation with       standing T-bar                         (17)
active lowering      active-assistive     IN       IN
                     forward elevation    18(13)   .98
                     except upon
                     lowering dominant
                     arm, participant
                     released bar and
                     under volitional
                     control, actively
                     eccentrically
                     lowered dominant
                     aim to starting
                     position keeping
                     elbow extended.

Seated wrist         Participants         IN                Andersen
extension on table   rested then          4(1)              LL et al.
with 2 kg dumbbell   forearm on a table                     (1)
                     while holding the    SP
                     in the same hand     Not
                     using a pronated     tested
                     grip. The starting
                     position was from
                     a flexed wrist.
                     The participants
                     then performed a
                     wrist extension
                     through a full
                     range of motion.

Seated wrist         Participants         IN                Andersen
extension on table   rested their         5(1)              LL et al.
with red tubing      forearm on a table                     (1)
                     while holding the    SP
                     tubing handle in     Not
                     the same hand        tested
                     using a pronated
                     grip. The elastic
                     tubing was
                     prestretched to
                     twice its resting
                     length. The
                     starting position
                     was from a flexed
                     wrist. The
                     participants then
                     performed a wrist
                     extension through
                     a full range of
                     motion.

Two-arm box press    Participants         IN                Herrington
up, stable base      positioned with      9(8)              L et al.
                     knee, hip and                          (19)
                     shoulder flexion     SP
                     at 90[degrees],      Not
                     spine neutral,       tested
                     knees hip width
                     apart and head
                     position
                     maintained. Hands
                     positioned
                     directly beneath
                     and position is
                     held

Standing: vertical   Subject stands in    IN                Wise MB
mall slide.          front of a slide     15(8)             et al.
unsupported AROM     board angled at                        (51)
                     45[degrees] with     SP
                     one foot in front    >20
                     cf the other. The
                     affected hand is
                     placed onboard and
                     then slid up the
                     slide board as the
                     weight is shifted
                     forward onto the
                     front foot.

Standing             Subject gripped      IN                Jung M-C
self-performed       the head of a cane   11(7)             et al.
passive shoulder     with his right                         (20)
flexion using a      hand and the         SP
case                 bottom of the cane   >20
                     with his left hand
                     in a standing
                     position and then
                     passively elevated
                     the right arm unto
                     the shoulder angle
                     reached at leas:
                     170[degrees] by
                     pushing the cane
                     upward with the
                     left arm.

Active spsilateral   The subject stands   IN                Uhl TL et
step up              astride with the     13(10)            al. (46)
                     the ips foot of
                     the affected arm     SP
                     on a standard inch   >20
                     step and the other
                     on the floor. The
                     subject shifts his
                     or her weight
                     forward and rises
                     up onto step as
                     both arms are
                     elevated overhead.

Active standing      He subject it        IN                Uhl TL et
press-up with        standing. using      14(6)             al. (17)
aerosol can          the affected upper
                     extremity, an        SP
                     aerosol can is       >20
                     pushed overhead
                     toward the ceiling
                     from a bent elbow
                     resting position.
                     with the scapular
                     being protracted
                     at the end of the
                     exercise.

Donning and          Patient puts on      IN                Gurney B
doffing a            and tubes off a      16                et al.
button-up-shirt      button up shirt                        (17)
                     using both upper     SP
                     Extremities.         >20

                                          TM
                                          >20

Standing coronal     Participants stood   IN                Andersen
plane abduction      erect holding the    17(0)             LL et al.
with a 2 kg          dumbbells to the                       (1)
dumbbell             side and abducted    SP
                     the shoulder         Not
                     joints until the     tested
                     upper arms were
                     slighltly above
                     horizontal

Active ipsilateral   The subject stands   IN                Uhl TL et
step up with ball    astride with the     18(9)             al. (46)
                     ips foot of the
                     affected arm on a    SP
                     standard inch step   >20
                     and the other on
                     the floor, while a
                     light plastic ball
                     is held in both
                     hands. The subject
                     shifts his or her
                     weight forward and
                     rises up onto step
                     as both arms are
                     elevated overhead.
                     The unaffected
                     upper extremity
                     assists the
                     affected upper
                     extremity through
                     the use of the
                     ball during this
                     exercise.

Drinking in a        While in a sling,    IN                Long JL et
sling                subject was given    18(15)            al. (30)
                     a 0.5 1 bottle of
                     water and asked to   SP
                     take 2 sips of       >20
                     water and place
                     the bottle back on
                     the table between
                     sips.

Wall walk            Participant stood    IN       IN       Gaunt BW
                     20 cm to 40 cm       19(13)   .98      et al.
                     from wall with                         (14)
                     dominant hand        SP
                     resting at           >20
                     shoulder level on
                     wall. Participant
                     instructed to walk
                     hand up and down
                     wall using index
                     and middle Angers
                     into forward
                     elevation within
                     an arc of
                     approximately
                     30[degrees] to
                     160[degrees].
                     Performed taking 4
                     beats to walk up
                     and down at a rate
                     of 40 beats per
                     minute

Standing coronal     Participants stood   IN                Andersen
plane abduction      erect holding the    19(4)             LL et al.
with red tubing      tubing to the side                     (1)
                     and abducted the     SP
                     shoulder joints      Not
                     until the upper      tested
                     arms were slightly
                     above horizontal.
                     During this
                     exercise, the
                     elastic tubing was
                     stretched to
                     slightly more than
                     twice its resting
                     length

Standing ER with a   With the shoulder    TM                Marta S et
4 kg dumbbell        abducted and elbow   17(7)             al. (45)
                     flexed to
                     90[degrees], the     IN
                     exercise began       >20
                     with the subject's
                     shoulder in full
                     internal rotation.
                     The exercise
                     consisted of
                     moving the
                     shoulder into full
                     external rotation
                     with a 4 kg
                     dumbbell and then
                     returning to the
                     starting position
                     while maintaining
                     the
                     shoulder-abduction
                     and elbow-flexion
                     positions.

Prone shoulder       Patient lies m the   SB                Wattanapra
flexion in "full     prone position       10(17)            kornkul D
can" position        with the arm                           et al.
                     hanging off the      SP                (49)
                     side. The entire     >20
                     arm is then raised
                     forwards in the      IN
                     sagittal plane and   >20
                     then slowly
                     lowered back to
                     the starting
                     position.
COPYRIGHT 2016 American Society of Exercise Physiologists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2016 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Wells, Samuel N.; Schilz, Jodi R.; Uhl, Tim L.; Gurney, A. Burke
Publication:Journal of Exercise Physiology Online
Article Type:Report
Date:Jun 1, 2016
Words:9651
Previous Article:Acute effect of resistance exercises performed by the upper and lower limbs with blood flow restriction on hemodynamic responses.
Next Article:Elderly hypertensive subjects have a better profile of cardiovascular and renal responses during water-based exercise.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters