Review: MedBridgeGO Patient HEP app

Patient compliance is an integral piece of the rehabilitation puzzle. Patients being consistent with their prescribed home exercise program depends on several factors, however there are two aspects that stand out beyond the rest.

  1. Forming a Therapeutic Alliance with the patient and getting buy-in that their program will help them achieve THEIR goals
  2. Providing a thorough, efficient, and easy to use resource so that they can feel confident in the performance of their program.

While the first aspect of the puzzle relies on the clinician and their ability to educate and coach their patient, the second aspect can be accomplished with the correct technology. Recently, Medbridge came out with their MedBridgeGO app to compliment their growing Home Exercise Program. I have been using both the HEP and app for the past month and below are my thoughts…

How it Works:

1. You use MedBridge’s VERY easy to use home exercise program

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2. The patient downloads and accesses MedbridgeGO, then inputs their access code (provided by their PT)

3. Their session begins…

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Additional Features:

1. Patient education resources that are modifiable are also available to be accessed via the MedbridgeGO application. This allows the patient easy access to information regarding their condition.

2. The ability to set a reminder in order to improve patient compliance.

This feature gives your patients the ability to set an alarm that will automatically sync with their phone’s alarm system. This allows for the patient to have continual reminders that they need to do their homework. In theory, this eliminates the, “I forgot” excuse.

1. Ease of Use

The program is very easy to use and I have been able to utilize it with patients in their teens (much more successfully) and my geriatric population (with a bit more coaching). There will always be patients that prefer a paper home exercise program whether because they prefer that medium or they do not feel comfortable with the technology. All menus and screens spell out what needs to be done and it is presented in a very clear, simple manner.

2. Accuracy of Program

With over 4,000 exercises and 150 patient education resources, there is ample to choose from when making your patient’s home exercise program. That being said, if something has not found its way into their database yet, you do have the ability to add your own exercises/patient education or modify existing content. All exercises chosen in the HEP transferred seamlessly to the MedbrdgeGO app throughout my use to this point.

3. Patient Compliance

The added benefit in this system is being able to see when patients actually performed their HEP… Some patients can be a but ‘misleading’ in their responses. Outside of this additional checks and balances, I have found that giving my patients an easy to perform and easy to access home exercise program has led to increased compliance and accuracy of exercise performance throughout my time using the program.

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4. Overall

This program gives the therapist all of the tools needed to provide a simple, effective home exercise program. The program itself is not for everyone because it does require a requisite comfort level with technology, however this has been a much smaller population than I had expected.

As great as the program is, there are a few areas that do need addressed moving forward. The exercise program is based on a timer that is calculated based on the sets and reps chosen by the therapist. However, as we know, patients perform movements with varying levels of ease and speed. This can make some patients feel as though they are lagging behind throughout the program. Additionally, this issue especially comes through when giving patients a hold time during their exercise (i.e. hold a bridge for 5 seconds or long duration isometrics for 30 seconds) since the current time calculation does not account for this. By having the patient ‘pause’ their program, this issue can be worked around.

The MedbridgeGO app gives the clinician and patient the ability to ensure that they are 100% on the same page with regards to exercise performance and frequency of performance. It has a few small areas that need addressed (and I am sure they will be), but overall adding this program has been incredibly beneficial to my patient care and I will continue to utilize it moving forward.

Conservative Management of Femoroacetabular Impingement

The following is an article written for the online, video-based physical therapy continuing education company MedBridge

FAI Prevalence

As mentioned in my previous post on differential diagnosis of femoroacetabular impingement (FAI), hip pain is an all too common occurrence among older adults and adolescents.1

    • Older adults. According to a survey and subsequent study of 2,221 German respondents (predominantly female and > 40 years old), 15.2% reported hip pain and 3.5% reported bilateral hip pain.2
    • Adolescents. Spahn et al found that 6.5% of German adolescents reported hip pain. Women were more likely to be affected, along with individuals that consumed alcoholic beverages.3

A multitude of different pathologies and medical conditions explain the hip pain, but the more common cause is FAI. Young, active individuals with hip pain generally have very high incidence of FAI (as high as 87%).4

Is Conservative Care Effective for FAI?

With such a high prevalence, especially in athletes, clinicians must understand the evidence for conservative management.

To determine the effectiveness of therapy and other conservative care, Wall and colleagues conducted a systematic review of the available literature.5 Unfortunately, only 5 studies met the inclusion criteria due to the significant predominance of surgical interventions versus conservative care.

Benefits of Exercise and Activity Modification

That said, two studies with high-quality evidence found that patients can benefit from physical therapy and activity modification. The physical therapy programs included exercise-based staged rehabilitation focusing on the core hip musculature, education, and advice to help reduce the frequency of impingement.

In the first study, only 4 of 37 patients ended up undergoing surgical intervention.6 The remaining 33 subjects significantly improved their mean Harris Hip Score from 72 to 91 points at the 24-month follow-up.

The second study found no significant differences in pain and function when comparing conservative care to conservative care plus surgical intervention.7 Both groups showed improvement at the one-year follow-up.

Separately from this systematic review, a case report also found promising results for prescribing an augmented home exercise program of standing lateral glides and supine inferior glides of the hip using a belt.8

Interventions

Going back to the systematic review, the successful conservative FAI management programs included the following interventions.

  • An overwhelming emphasis was put on core and gluteal musculature training.
  • Most programs focused on pain-free stretching of the hip flexor muscle group.
  • PROM and stretching at end-ranges of hip flexion and internal rotation were avoided.

Interestingly, only one of the programs included joint mobilization or specific manual therapy interventions. Based on the evidence supporting manual therapy in other hip pathologies, and the general FAI pathomechanics, it would appear that joint mobilization techniques should significantly enhance FAI rehabilitation.9

However, more recently Wright and colleagues investigated the effectiveness of conservative management in the treatment of FAI with favorable results10. In this small pilot study, patients were randomly assigned to receive either manual therapy and supervised exercise or advise and a home exercise program. At the conclusion of the 6 week treatment period, there was not a significant difference between the two groups, however both groups showed significant improvements in pain.

Conservative management of FAI is horribly underrepresented in the literature, but the scarce evidence available does provide some optimism. With the lack of definitive evidence supporting specific interventions, therapists must rely on the remaining two pillars of evidence-based practice: experience and patient beliefs.

Evolution of the Treatment-Based Classification for Low Back Pain

The following is an article written for the online, video-based physical therapy continuing education company MedBridge

The prevalence and economic burden of low back pain (LBP) has reached an epidemic level and continues to put a strain on the U.S. healthcare system. According to Hoy et al, the overall incidence of LBP is between 1.5% and 36% with incidence of first-ever LBP ranging between 6.3-15.3%.

This is a HUGE proportion of the general population and typically makes up a large portion of the therapist’s daily caseload. Through the improvement of medical imaging, physicians are better able to see “what’s going on” inside an individual’s spine, but is this information helpful?

Is Medical Imaging the Answer?

The accuracy of the pathoanatomical model in diagnosing and treating LBP is severely overrated. Multiple imaging studies have proven this model is limited by the high rate of false-positives. For example, a study conducted by Savage et al found that 32% of asymptomatic individuals had ‘abnormal’ lumbar spines (as determined by MRI) and 47% of symptomatic individuals had no evidence of abnormality. Additionally, Jarvik and colleagues found no benefit with regards to patient self perceived disability when imaging was conducted early in their course of care. So, if medical imaging isn’t the answer, then how do we diagnose and treat these patients?

Treatment-Based Classification and Its Evolution

According to the Low Back Pain Clinical Guidelines published by Delitto et al, “The best available evidence supports a classification approach that de-emphasizes the importance of identifying specific anatomical lesions after red flag screening is completed.” Within the physical therapy community, there are several unique classification systems, but only one is backed by a substantial bounty of evidence. This Treatment-Based classification (TBC) system distinguishes 4 sub-groups of patients that are treated with specific interventions depending upon their classification. These sub-groups include:

This system was initially proposed by Delitto et al in 1995 and has evolved over the greater part of two decades. Below is a table created by Fritz et al presenting both both the original criteria and the revision proposed in 2007.

FritzTBC2007

Recently, the TBC approach to the management of low back pain underwent another revision in order to address several limitations that have come to light since its revision in 2007. Alrwaily et al recognized that the current system was lacking in addressing the biopsychosocial aspects of low back pain and that the categorization process was not efficient enough. In order to improve this system, the following areas were updated:
  1. Initial triage process includes all healthcare providers who come in first contact with patients with LBP in addition to the level of the rehabilitation provider
  2. Establishing decision-making criteria for the first contact practitioner to triage patients into one of three approaches: medical management, rehabilitation management, self-care management
  3. Utilizing risk stratification and psychosocial tools to determine which patients require psychologically informed rehabilitation
  4. The treatment based classification categories were broadened in order to prevent misclassification of patients

One of the largest issues with the 2007 TBC system proposed by Fritz et al was an inability to match patients to their appropriate treatment group. An evaluation by Stanton et al in 2011 determined that when a patient did not match a specific intervention, they were broadly lumped into the stabilization category or simply remained unclassified. In addition to this flaw, another study conducted by Stanton and colleagues found that close to 25% of patients met the criteria for at least two of the included treatment categories.

In order to address these limitations, Alrwaily and colleagues once again revised the classification system in 2015. This new system breaks the initial triage process into the level of the first healthcare provider contact (direct access) and rehabilitation provider. At the level of the first provider, the patient is directed either toward medical management, rehabilitation management, or self management. This determination is based on the presence/absence of red flags and neurological deficits. Once the patient has been transitioned to rehabilitation management, the classification categories have been broadened in order to direct patients toward the correct treatment approaches. Instead of breaking the categories into specific interventions, they are now broken into logical groups of interventions (symptoms modulation, movement control, and functional optimization). This alteration will prevent patients from being categorized into multiple groups or not being classified what so ever.

TBC2015

Treatment-Based Classification Yields Better Outcomes

In 2000, Fritz et al published a prospective cohort study looking at short-term patient outcomes after matching patient sub-groups to their corresponding treatment strategies. This study evaluated the outcomes of 120 patients receiving physical therapy for acute LBP. While Fritz’s initial evaluation of this treatment strategy did not compare its effects to standard care, it did give some preliminary support to its efficacy.

Later in 2003, Fritz et al conducted a randomized controlled trial of 78 patients comparing their treatment-based classification system to the current clinical guidelines for patients with acute LBP. Patients with work-related LBP of less than 3 weeks duration were admitted after being cleared of “red flags.”

Guideline Group

Subjects assigned to the Guideline Group (GG) were treated with low-stress aerobic exercise (treadmill walking or stationary cycling), general muscle reconditioning exercises, and advice was given to remain as active as possible within the limits of their pain.

Classification Group

Patients in the Classification Group (CG) were evaluated and assigned to the most appropriate sub-group. Following assignment, they were then treated based on the system proposed by Delitto et al.

Results

At 4 weeks, when compared to the GG, the CG had statistically significant mean improvements within group in:

  • Oswestry (22.5 v. 11.6),
  • SF-36 PCS (-13.6 v. -8.0)
  • Improved median satisfaction with treatment

At the one-year follow-up, mean Oswestry scores approached, but did not meet statistical significance (p= 0.063) in favor of the CG.

In terms of healthcare utilization, of the 20 patients who took up 51% of the total medical costs, 13 were from the GG and only 7 were from the CG. This translated into a relative risk of 2.1 for the guideline group and a number needed to treat of 5.5, or an average number of patients who need to be treated to avoid a ‘high cost’ patient when using the classification system compared to the clinical guideline approach.

Why It Works: Superior Interventions or the Matching Principle?

What if the interventions being provided from the previous clinical guideline standards were simply inferior to the techniques used by the classification group? Would proper pairing of presentation to treatment remain an important factor in outcomes when the same interventions were used throughout the patient population?

Brennan et al published a randomized controlled trial that investigated the impact of pairing interventions to the correct sub-group of patients with non-specific LBP. In evaluation of 123 patients, those individuals who were matched to the correct treatment approach demonstrated greater short- and long-term improvements in disability compared to those who were unmatched. Patients in the matched group achieved significantly greater improvements in mean Oswestry scores at 4 weeks (29.9 v. 23.3) and one year from baseline (33.3 v. 26.1).

Additionally, 78% of subjects in the matched group achieved progression to stage II of treatment, while only 60% of the unmatched patients achieved this milestone (p= 0.039). This study gave continued credence to the application of a treatment-based approach in the management of acute LBP.

Do the Outcomes Depend on a Clinician’s Experience?

The above studies give the treatment-based classification system solid evidence-based support, but is it reliable enough for widespread utilization by clinicians?

Fritz et al evaluated the inter-rater reliability of individual examination characteristics related to the treatment-based classification system in clinicians with varying levels of experience.

The evaluation included:

  • 10 ‘novice’ physical therapists (< 5 years of experience, no experience using the classification system)
  • 10 ‘experienced’ physical therapists (5+ years of experience, no experience using the system)
  • 10 ‘expert’ physical therapists (used the system clinically and participated in research involving the system)

Patients were evenly distributed to each clinician category with between 24-25 patients seen by each group. In terms of individual examination characteristics, the inter-rater reliability coefficients were at least moderate for all range of motion measurements, the prone instability test, and judgments of centralization/peripheralization with flexion and extension ROM. However, reliability of centralization/peripheralization with repeated or sustained extension movements and judgments of aberrant movements were fair or poor.

The ultimate agreement among clinicians on patient placement within the classification decision-making algorithm was 75.9%, which correlated to a kappa value of 0.60 (moderate agreement). Additionally, there was no significant difference in kappa value depending on experience of the examining therapist.

Earlier this year, Henry et al conducted a similar study with 12 therapists evaluating 24 total patients. This small cross-sectional reliability study produced total agreement on classification of 80.9% and a kappa value of 0.62 (moderate-good agreement), which agrees with the previous study by Fritz et al.

The Most Effective Evidence-Based Tool for Low Back Pain

This classification system has been rigorously evaluated and has come out with moderate to good inter-rater reliability regardless of clinician experience or expertise. This goes along with the improved clinical outcomes and decreased healthcare costs seen in two large randomized controlled trials. Currently, this is the most consistent and effective evidence-based tool to evaluate and treat LBP and should be considered a viable option for any therapist.

Additionally, as new evidence comes to light, the system continues to evolve in order to accommodate the growing body of evidence with regards to the evaluation and treatment of low back pain. During clinical practice, not every patient will fit nicely into a specific subgroup, but having this framework aids clinicians in making more informed, evidence-based treatment decisions.

VMO: An Update

The following is an article written for the online, video-based physical therapy continuing education company MedBridge

Patellofemoral pain syndrome (PFPS) is among the most common sports injuries and yet the current treatment protocols are not optimal. In particular, the latest research questions our ability to selectively recruit vastus medialis obliquus (VMO) and affect its timing and suggests that VMO may have nothing to do with the PFPS.

Prevalence of Patellofemoral Pain Syndrome

PFPS has an astounding prevalence according to a retrospective case-control analysis by Taunton et al. They analyzed 2,002 running-related injuries seen at a primary care sports injury facility – and 42.1% (842/2,002) were knee injuries. Of these knee injuries, 39.3% (331/842) were due to patellofemoral pain syndrome (PFPS), which made PFPS by far the most common diagnosis found in this large-scale study.

Similarly, in an older study (1984), Devereaux et al found that over a five year period, 137 patients presented with PFPS – accounting for 25% of all knee injuries seen at this sports injury clinic.

These two studies were conducted 17 years apart, giving support to the consistently high prevalence of this disorder. Now the most important question is, how are we treating these patients?

How are we treating patients with PFPS?

Imbalance of LV and VMO

The biomechanical study by Lieb et al made the VMO the mainstay of most physical therapy protocols and treatment approaches for PFPS.

Conducted in 1968, the study found that VMO’s fibers are oriented at 55° from the longitudinal axis of the femur. This orientation alone makes VMO the primary restraint to lateral subluxation of the patella. The study further postulated that VMO was able to counterballance the pull of the much larger vastus lateralis (VL) due to the discrepancy in mechanical advantages.

As a result of this study, an insufficient balance between the VL and VMO has long been considered the primary contributing factor in developing patellar subluxation, or maltracking.

VL:VMO timing

A study by Cowan et al found that subjects with PFPS have an imbalance of VL:VMO timing. The VL typically begins to fire approximately 15-20 ms prior to the VMO.

Due to this understanding of the biomechanics, the treatment strategy typically involved correcting the potential VMO atrophy, hypoplasia, inhibition, and impaired motor control.

Now, this all seems logical in theory, but can we actually selectively train the VMO? Is this relatively small muscle affected differently than the rest of the quadriceps musculature in the presence of pain?

New research questions…

Does VMO atrophy relative to the rest of quadriceps?

A recent study by Giles and colleagues refutes one of the cornerstones of the VMO theory; namely, that this small muscle tends to atrophy relative to the rest of the quadriceps during or following surgery. They performed a cross-sectional study of 35 participants diagnosed with PFPS.

The results showed atrophy of all portions of the quadriceps muscles – and no selective atrophy of the VMO – present in the affected limb of people with unilateral PFPS.

Can we selectively activate VMO?

Even if the atrophy was present, the literature is not very kind to the ability to preferentially activate this musculature either.

Cerny et al evaluated the ability to preferentially recruit the VMO during 22 different quadriceps exercises. Through electromyographic analysis, they determined that VMO activity was not higher in any exercise compared to VL.

In a randomized controlled trial, Song et al found no evidence that VMO can be activated separately. They compared the change in VMO cross-sectional area after 8 weeks of unilateral leg press and unilateral leg press with subsequent hip adduction. The two groups showed no significant difference between the change in VMO cross-sectional area (the standard leg press actually yielded better results).

Thus, selective isolation of the VMO in everyday clinical practice is highly unlikely. In all reality, if we consider inability to selectively recruit their target, most of the ‘VMO programs’ are merely strengthening the quadripceps as a whole. If we could selectively recruit these fibers, according to Grabiner et al, it would take approximately 60% of maximal voluntary contraction to stimulate hypertrophy of the VMO.

Does VMO training have advantages over general quadriceps strengthening?

In 2010, Bennell et al investigated how VMO retraining compares to a general quadriceps strengthening program in relation to vasti onset.

The VMO retraining group used EMG biofeedback during the following series of exercises:

  • isometric VMO contractions at 90° of knee flexion
  • standing mini squats to 40°
  • isometric contraction of the VMO in combination with hip abduction and hip external rotation during an isometric wall contraction in standing
  • step downs

The quadriceps group performed:

  • isometric quad sets
  • straight-leg raises
  • SAQs
  • side-lying hip abduction

At the conclusion of the training programs, the retraining group actually did create more significant changes in stair descent activation in the short-term. However, at the 8-week follow-up, both values were nearly identical. The initial improvement may have been due to the use of ‘step downs’ in the retraining group, which most closely simulates the functional and muscular demands of stair descent.

During stair ascent, on the other hand, the quadriceps strengthening group caused a much more significant alteration in VMO:VL timing and was the only group that caused the VMO to fire prior to the VL.

A study conducted by Laprade et al showed similar results using isometric exercise. This study compared the EMG activity in individuals with PFPS and asymptomatic controls during 5 isometric exercises. There was no significant difference in the ratio of VMO:VL firing between the two groups.

Given these results, I find it hard to support the use of VMO training in everyday clinical practice.

Does VMO strengthening make a difference for PFPS?

Suppose it was possible to selectively recruit the VMO. Would it reduce patellofemoral contact stress sufficiently to relieve the pain?

Sawatsky et al say no. They conducted a biomechanical study using New Zealand white rabbits. Although this is not a direct human study, the muscular alignment and pull of the quadriceps is very similar: the fibers of the VMO and VL are oriented at 45-50° and 14-19°, respectively, in relation to the longitudinal axis of the femur.

They transected VMO at varying levels of knee flexion (30°, 60°, and 90°), measuring patellofemoral joint contact pressures before and after the transections.

There were no significant differences between peak pressures, average pressures, contact areas, or contact shapes before and after transection.

If the contact area and pressure are not altered when the muscle is removed from the equation, then why do we continue thinking VMO training is the gold standard in PFPS treatment?

Differential Diagnosis: Athletic Pubalgia

In the next installment of the Differential Diagnosis Series for MedBridge Education, we are going to take a look at the difficult and complex diagnosis of Athletic Pubalgia…

Pathophysiology and Anatomy

Athletic pubalgia is a catch-all term for soft-tissue pathology in the groin, lower abdominal, pubic, and medial thigh regions. This pathology can be secondary to tendinopathies, osteitis pubis, posterior inguinal wall insufficiency, and nerve entrapments in the inguinal region.3

It can involve the following anatomical structures:3,4,8

  1. Rectus abdominis
  2. Rectus femoris
  3. Sartorius
  4. Internal oblique
  5. External oblique
  6. Transverse abdominal muscles/tendons/sheaths
  7. Inguinal ligament
  8. Adductor group of muscles (adductor longus, adductor brevis, adductor magnus)
  9. Gracilis
  10. Pectineus
  11. Iliopsoas
  12. Pubic symphysis
  13. Pubic ramus

Epidemiology

Athletic pubalgia is a common injury found in athletes and the general population alike.

Athletic pubalgia most commonly occurs in sports requiring cutting, pivoting or frequent acceleration/deceleration (ice hockey, football, rugby). Amongst field-based athletes (soccer, rugby, lacrosse, etc.), roughly 10% of injuries are due to groin pain,6 whereas these injuries account for approximately 2-5% of all sports medicine injuries.7 Chronic groin pain ranks as the fourth most common injury in the Rugby Federal Union.

In ice hockey, groin pain is an all too common occurrence as well. A retrospective case series over the course of six National Hockey League (NHL) seasons found a total of 617 groin/abdominal injuries, with a recurrence rate of 23.5%.1

Subjective Findings

Patients typically report the following symptoms:4

  1. Deep groin or abdominal-related pain with exertion, which is more proximal or intense than an adductor or iliopsoas strain
  2. Point tenderness at the superior-lateral pubis
  3. Pain is typically unilateral, but can advance to bilateral
  4. Pain is typically relieved upon rest, but returns with sports-related activities
  5. Pain is exacerbated by kicking, side-stepping, cutting, or sit-ups
  6. Some patients report pain with coughing and sneezing
  7. Males may report testicular pain

Objective Findings

As to the physical examination, the literature supports several findings:5

  1. A resisted sit-up or crunch with palpation of the inferolateral edge of the distal rectus abdominis may re-create symptoms
  2. The pubic tubercle and pubic symphysis are painful in up to 22% of patients upon palpation
  3. Tenderness to palpation of the proximal adductor musculature (adductor longus, gracilis, pectineus)
  4. Resisted adduction in flexion and extension may elicit discomfort
  5. Limited A/PROM (most often, hip internal rotation, external rotation, and abduction)3

Special Tests

As with most hip pathologies, special testing for athletic pubalgia is not robust enough to significantly change a clinician’s clinical reasoning with regards to diagnosis.

However, a systematic review with meta-analysis conducted by Reiman and colleagues9 has discovered three tests (see table below) that allow to rule in the condition with confidence. As to screening and ruling out the pathology, these tests do not provide enough information due to their low sensitivity and high negative likelihood ratios.

Source: Reiman and colleagues9

Risk Factors

Two recent systematic reviews discuss risk factors for developing athletic pubalgia in an athletic population (see details in a table below).

Previous injury to the groin region is the most predictive factor in developing this disorder.

Modifiable risk factors include reduced gluteal strength (adductor and abductor), which makes sense given the proposed mechanism of injury. Higher levels of competition and less sport-specific training have also been associated with higher incidence of groin pain.

Athletic Pubalgia and FAI

Although a diagnosis of athletic pubalgia is complicated, its presence does not prevent your patient from having any concomitant pathologies.

Econompoulos and colleagues performed a retrospective case series to determine the prevalence of femoroacetabular impingement in athletes undergoing surgical treatment for athletic pubalgia. They found radiographic evidence of FAI in at least one hip in 37 of 43 patients (86%).2

In a prospective case series by Weir et al., 94% of 34 athletes with long-standing adductor related pain had radiological findings consistent with femoroacetabular impingement.11

These findings speak to the need to fully investigate all logical differential diagnoses that may affect the patient’s plan of care or prognosis. Ruling in one condition with confidence, does not preclude that patient from having another condition that may contribute to their pain.

Athletic pubalgia should typically be considered a diagnosis of exclusion, as there are often concomitant diagnosable pathologies present. It is important to not only rule out FAI (as previously discussed), but also acetabular labral tears and other intra-articular disorders of the hip. The low back cannot be ignored either as it also has the ability to refer pain into this region. Once these other pathologies have been ruled out, knowing the epidemiology, risk factors, and specific special tests associated with AP can improve the accuracy of the clinical diagnosis.

Evidence-Based Strength Training: Scapulothoracic Musculature, Part 2

Scapulothoracic Muscles and Pain

As I mentioned in Part 1, weakness or poor neuromuscular control of the periscapular muscles has been implicated in subacromial impingement1,2, lateral epicondylalgia3-5, cervicogenic headache6, and neck pain7,8.

Specifically, insidious onset of neck pain and whiplash associated disorder (WAD) have been linked with a significant delay in and shorter duration of serratus anterior activity bilaterally during arm elevation9. A similar study found decreased serrates anterior activation in individuals with acromioclavicular osteoarthritis and rotator cuff disease.10

Although a cause-and-effect relationship cannot be confirmed, this preliminary evidence still lends support for targeting the periscapular muscles in individuals with neck or shoulder pain.

EMG Activity and Exercise Goals

According to Reiman et al.11 and Escamilla et al.12, moderate EMG activation (21-40% MVIC) is best used to facilitate endurance and neuromuscular re-education; high activation (41-60+% MVIC) – to promote strength gains.

From Biomechanics to Exercises

Serratus Anterior

Primary Function: scapular upward rotation, external rotation, posterior tilt at the acromioclavicular joint, protraction of the clavicle at the sternoclavicular joint.

Origin: External surfaces of lateral aspect of 1st-8th ribs

Insertion: Anterior surface of medial border of scapula

The SA is often activated with scapular protraction. The exercises yielding the highest MVIC for the serratus anterior include:

  • dynamic hug13
  • push-up plus13
  • scaption with external rotation14
  • diagonal PNF (shoulder flexion, horizontal flexion, external rotation)15
  • shoulder abduction in scapular plane above 120 degrees15

The upper trapezius (UT) often compensates for a weak or inhibited serratus anterior, so it’s beneficial to selectively activate the SA in lieu of the UT. According to Cools and colleagues, the best SA:UT ratio is achieved in:

  • high row
  • forward shoulder flexion
  • scaption with external rotation14
Serratus Anterior
Prone Push Up with Plus
Serratus Anterior
Dynamic Hug with Resistance
[Table] MVIC values for SA exercises

Levator Scapulae

Primary Functions: scapular elevation, glenoid cavity inferior tilt through upward scapular rotation

Origin: Posterior tubercles of transverse processes of C1-C4 vertebrae

Insertion: Medial border of scapula superior to root of scapular spine

These muscles have received little attention in the literature compared the SA or trapezius. In a study, Moseley and colleagues discovered that the levator scapulae achieves the highest activity in:

  • rowing
  • horizontal abduction
  • shrug
  • horizontal abduction with ER
  • prone shoulder extension16
[Table] MVIC values for Levator Scapulae exercises

Rhomboids

Primary Functions: Retraction of the scapula; upward rotation to depress glenoid cavity; scapular attachment to thoracic wall

Origin: nuchal ligament; spinous processes of C7, T1 and T2-T5 vertebrae

Insertion: smooth triangular area at medial end of scapular spine; medial border of scapula from level of spine to inferior angle

The rhomboids achieve the highest MVIC during:

  • ER at 90° of abduction17
  • ER at 0° of abduction17
  • horizontal abduction16
  • shoulder extension17
  • scaption16
Levator Scapulae
Prone Shoulder Row
Rhomboid
Shoulder External Rotation at 90° Abduction with Dumbbell
[Table] MVIC values for rhomboid muscle exercises

Choosing the Best Exercise

These studies give us a glimpse into properly selecting exercises, yet very few exercises have been or will ever be studied.

When choosing an exercise for your patient, be sure to consider:

  • the biomechanics of the movement,
  • current evidence for or against the exercise,
  • your patient’s presentation, and goals for treatment.
  • aggravating movement(s) or comparable signs

The Most Important Aspect of Patient Care

The following is an article written for the online, video-based physical therapy continuing education company MedBridge

Helping individuals with a chronic pain and significant functional limitations is a remarkably difficult and delicate task. Numerous treatment philosophies are available to clinicians from the overtly biomechanical (Cyriax, Kaltenborn, Sahrmann, etc.) to more patient-response driven (Maitland, Mckenzie, etc.). Unfortunately, no one approach has been proven superior to others. For instance, in one of the only comparison studies, Powers and colleagues1 investigated the acute effects of a common Maitland intervention (posterior-to-anterior mobilization) to a common McKenzie intervention (prone press-up) on patients with non-specific low back pain. The study concluded that both groups improved significantly in pain level and lumbar extension, but without significant differences between the two interventions.

If the approach isn’t the determining factor, what makes one clinician better than another?

Throughout my clinical education and professional career, I have been exposed to expert clinicians with varying interventions, personalities, and clinical reasoning. However, one aspect holds true for all the clinicians who achieve superior outcomes – they form a positive therapeutic alliance (TA) with their patients.

What is a therapeutic alliance?

Leach et al.2 defines a therapeutic alliance as “a trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect”. Moreover, a TA involves working together to define goals and success criteria for the treatment. With trust and mutual understanding, your patients are more confident in the interventions and more positive in their expectations from the treatment, which goes a long way towards achieving positive outcomes3. While every patient and pathology is unique, your patients deserve for a positive TA to be integrated and nurtured within their care.

Is there evidence supporting the importance of a therapeutic alliance?

Quite a bit of literature links a trusting therapeutic relationship to superior patient outcomes. A recent systematic review found that amongst patients with musculoskeletal complaints a positive therapeutic alliance was associated with significant improvements in the patient outcomes, including global perceived effect of treatment and satisfaction with treatment, pain levels, physical function, depression, and general health status4. More recently several randomized controlled trials have found favorable associations between positive alliance and outcomes in patients with chronic low back pain.

Fuentez et al.5 investigated how varying levels of therapeutic alliance impact a single-session treatment of chronic low back pain when combined with interferential electrical stimulation. They found significant improvements when patients received enhanced TA as opposed to limited TA. In a randomized controlled trial, Ferreira and colleagues6 looked into the effect of TA as part of a longer-term treatment with a follow-up at 8 weeks. Once again, therapeutic alliance had a significant influence on patient outcomes. The therapeutic alliance at baseline was a nonspecific predictor for the 4 measures of treatment outcome (global perceived effect, pain, disability, function) regardless of intervention applied by the treating therapist (motor control, general exercise, or spinal manipulative therapy). These two studies give further credence for the importance of forming mutual collaboration and trust with your patients.

Sometimes, techniques or interventions we use play a lesser role than our relationship with the patient. Many therapists downplay one approach in lieu of their chosen technique or approach, however no one approach is effective or ineffective for all patients. Only one aspect of patient care – therapeutic alliance – translates to each and every patient.

References:

1. Powers CM, Beneck GJ, Kulig K, Landel RF, Fredericson M. Effects of a single session of posterior-to-anterior spinal mobilization and press-up exercise on pain response and lumbar spine extension in people with nonspecific low back pain. Phys Ther. 2008; 88(4): 485-93. doi: 10.2522/ptj.20070069.

2. Leach, Matthew J. Rapport: A key to treatment success. Complementary Therapies in Clinical Practice. 2005; 11(4): 262 – 265.

3. Joel E Bialosky, Mark D Bishop, Michael E Robinson, Josh A Barabas and Steven Z George. The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. BMC Musculoskeletal Disorders. 2008; 9-19 doi:10.1186/1471-2474-9-19.

4. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010; 90(8): 1099-110. doi: 10.2522/ptj.20090245.

5. Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross D. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014; 94(4): 477-89. doi: 10.2522/ptj.20130118.

6. Ferreira PH1, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013; 93(4): 470-8. doi: 10.2522/ptj.20120137.