Effect of Scapular Stabilization on Frozen Shoulder Syndrome

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction

Adhesive Capsulitis or Frozen Shoulder Syndrome is characterized by pain and stiffness of the glenohumeral joint. However, knowledge on its disease progression, and optimal therapy timing is currently limited. Additionally, most research addresses the direct limitations of the glenohumeral joint. This randomized control trial seeks to address the abnormal rhythm of the scapula through functional scapular stabilization training. Researchers hypothesized that those participating in functional scapular stabilization training would show more improvement in pain and function compared to standard physical therapy, focusing on GH mobilization and increasing range of motion.

Methods

The study includes 86 patients (between the age of 40 and 65) who were diagnosed with non traumatic frozen shoulder syndrome and demonstrated more than 50% loss in external rotation range of motion and limitations in other directions. Each participant was randomized and allocated into two groups: intervention (functional stabilization training) and control (standard physical therapy: mobilizations, stretching). Exercise compliance and pain levels were monitored throughout the study. The main difference in exercises was activating scapular stabilizers vs rotator cuff muscles. The primary measures used were the SPADI and Numeric Pain Scale.

Results

Seventy-six out of 86 participants completed the treatment/study (38 in each group). By the end of 12 weeks, there was a significant difference in SPADI score, the NPRS, and external rotation between the intervention vs control group.

Discussion

Those within the scapular stabilization group showed greater improvement in self-reported function, pain and external rotation when compared to those who received standard physiotherapy over 12 weeks. This is one of the first studies comparing functional scapular stabilization treatment protocol to standard physical therapy for those with adhesive capsulitis of the shoulder. The thought is that focusing on retraining scapulohumeral rhythm will result in improvements in function due to reducing the stress on the GH joint.

Conclusion

The study suggests that a combination of standard physical therapy and functional scapular stabilization training is effective in reducing pain and improving function and external rotation ROM of the shoulder for those with frozen shoulder syndrome.

References

Karnawat, S., Harikesavan, K., & Venkatesan, P. (2023). Effect of Functional Scapular Stabilization Training on Function and Pain in Frozen Shoulder Syndrome: A Randomized Controlled Trial. Journal of Manipulative and Physiological Therapeutics, 46(2), 86-97. https://doi.org/10.1016/j.jmpt.2023.05.008

Pelvic Floor Disorders and Low Back Pain: Innovative Approaches to Physical Therapy

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction

Pelvic floor dysfunction (PFD) and chronic low back pain (CLBP) often coexist due to overlapping biomechanical, neuromuscular, and pain mechanisms.1 These conditions affect movement patterns, core stability, and quality of life, presenting a unique challenge for physical therapy. While traditional pelvic floor muscle (PFM) exercises, such as Kegels, remain a cornerstone for treating PFD, emerging research suggests that functional and specialized exercises may offer superior engagement and adherence.2,3 This review integrates findings from recent studies exploring the connection between PFD and CLBP while proposing alternative exercise methods to enhance pelvic floor rehabilitation outcomes.

 Pelvic Floor Dysfunction and Low Back Pain: Shared Pathways

A study by Algudairi et al. highlighted the prevalence of PFD among women with CLBP, with 43% reporting at least one pelvic floor symptom and 52% exhibiting neuropathic pain (NP). NP was strongly associated with greater pelvic floor distress, as measured by the Pelvic Floor Distress Inventory.1 The findings suggest that PFD exacerbates CLBP through mechanisms such as central sensitization and impaired core stability. This highlights the importance of addressing both pelvic and lumbar dysfunctions in a comprehensive rehabilitation plan.

 Functional Exercises for Pelvic Floor Muscle Activation

Traditional PFM exercises, such as Kegels, rely on isolated contractions to strengthen the pelvic floor. However, Díaz-Mohedo et al. demonstrated that functional movements like trunk stability push-ups (PU) achieve PFM activation levels comparable to or exceeding those of Kegel exercises.2 Using electromyography (EMG), the study revealed that PUs produced high PFM activation (112% of maximal voluntary contraction), highlighting the benefits of functional exercises in training the pelvic floor indirectly. Such exercises, which simultaneously target core and pelvic floor stability, offer a practical alternative for individuals struggling with adherence to isolated PFM exercises.2 Similarly, Crawford et al. compared traditional Kegel exercises to specialized movements designed to naturally engage the pelvic floor. Using wireless surface EMG sensors, the study analyzed ten dynamic movements, including lunges, squats, and bridges. Results showed that all ten movements significantly increased PFM activation compared to isolated Kegels. For example, bridges produced a 56% greater activation; while hovering exercises achieved a 49% increase.3 These findings suggest that incorporating PFM contractions into functional and dynamic tasks can enhance motor unit recruitment and improve training efficiency.

 Pelvic Floor Training and Chronic Low Back Pain Management

Functional exercises that engage PFMs indirectly, such as lunges, squats, and push-ups, not only strengthen the pelvic floor but also address core stability deficits commonly observed in CLBP patients. Additionally, incorporating specialized movements that synchronize PFM contractions with dynamic tasks—such as bridges and cat-cow stretches—provides a more comprehensive approach to improving lumbopelvic stability. Neuropathic pain, often associated with PFD, can further complicate CLBP treatment. Algudairi et al. emphasized the importance of addressing NP through multimodal interventions, including pain education, graded motor imagery, and myofascial release. Combining these strategies with dynamic PFM training offers a pathway to manage both pelvic and lumbar dysfunctions effectively.

Conclusion and Implications for Physical Therapy

The integration of functional and dynamic PFM exercises represents a shift in the management of PFD and its associated low back pain. Studies by Díaz-Mohedo et al. and Crawford et al. demonstrate that functional movements like bridges, squats, and push-ups can significantly enhance PFM activation, outperforming traditional Kegels in many cases. These exercises also promote broader neuromuscular adaptations, addressing core stability deficits and improving adherence by embedding pelvic floor training into everyday movement patterns.

Physical therapists can leverage these findings to develop individualized rehabilitation programs that address both PFD and CLBP. Functional PFM training can be incorporated into standard protocols, complemented by interventions targeting neuropathic pain and compensatory movement patterns. This comprehensive approach not only optimizes pelvic and lumbar health but also enhances overall functional outcomes, reducing the risk of recurrence and improving quality of life for patients.

References

  1. Algudairi G, Aleisa E, Al-Badr A. Prevalence of neuropathic pain and pelvic floor disorders among females seeking physical therapy for chronic low back pain. Urol Ann. 2019;11(1):20-26. doi:10.4103/UA.UA_123_18
  2. Díaz-Mohedo E, Odriozola Aguirre I, Molina García E, Infantes-Rosales MA, Hita-Contreras F. Functional Exercise Versus Specific Pelvic Floor Exercise: Observational Pilot Study in Female University Students. Healthcare (Basel). 2023;11(4):561. doi:10.3390/healthcare11040561
  3. Crawford B. Pelvic floor muscle motor unit recruitment: Kegels vs specialized movement. American Journal of Obstetrics & Gynecology. 2016. Accessed January 25, 2025. https://www.ajog.org/article/S0002-9378(16)00035-1/fulltext

Utilizing Scapular Stabilization Exercises in a Patient with Medical Epicondylalgia

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction/Background

Goldfard et al., presents a case study on the application of scapular stabilization exercises to treat medial epicondylalgia. In 2013, Bhatt et al proposed a case study proposing that improving scapular stability could lead to reduced loading of forearm musculature during functional tasks. They mentioned previous studies that have demonstrated positive outcome using scapular stabilization exercises in patients with lateral epicondylalgia. This case report aims to describe the utilization of a scapular stabilization program for a patient with medial epicondylalgia.

Case Presentation and Treatment

A 52-year-old female patient presented to physical therapy with medial elbow pain. Pt reported gradual, insidious onset that was worse with activities that involved elbow flexion, such as lifting and swimming. The patient underwent an 8-week scapular stabilization program. Assessments included a shortened form of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) score, pain levels, and manual muscle testing (MMT) of the elbow, wrist, and forearm, all measure baseline, discharge, and 1-month follow-up. Elbow, forearm, except for wrist flexion (4/5) was determined to be (5/5) on MMT. Valgus stress, valgus overhead, and varus stress tests examined ligamentous integrity, and all were found to be negative.

The 8-week treatment plan consisted only of exercises targeting the middle and lower trapezius and rhomboid strength and endurance, as well as dynamic scapular motor control during functional exercises. With the primary goal to control scapular anterior tipping during resisted elbow flexion- an underlying factor that contributes to the patient’s medial elbow pain. Exercises were broken into 3 phases staring with exercises done in prone with dumbbells and progressed to standing with resistance bands, ensuring proper form was maintained throughout all repetitions.

Outcome/Follow up

Clinically meaningful improvements in pain (d/c 0, 1-mo f/u 0), the QuickDASH (d/c 9.32, 1- mo f/u 4.55), and wrist strength (d/c 5/5, 1-m0 f/u 5/5) were observed at the 1-month follow-up. The patient was able to perform resisted elbow flexion without demonstrating any compensatory anterior tipping and was also able to return to all her previous activities.

Discussion

The case suggests that scapular stabilization exercises may be beneficial in treating medical epicondylalgia, as evidenced by improvements in pain, wrist flexion strength, and activity tolerance. Consider assessing scapular strength and motor control in patients with medial epicondylalgia and monitor for scapular compensatory movements while assessing upper extremity strength.

References

Goldfard, J., Grimes, J. K., & Bauer, P. (2021). Utilizing scapular stabilization exercises in a patient with medial epicondylalgia: A case report. JOSPT Cases, 1(2), 1-8. https://doi.org/10.2519/josptcases.2021.9980

Well-Tolerated Strategies for Managing Knee Osteoarthritis

Reviewed by Kirsten Hales, SPT

Introduction

 Knee osteoarthritis (OA) is a prevalent musculoskeletal condition, commonly leading to pain, stiffness, and functional limitations, especially in older adults. While pharmacological treatments like pain relievers and anti-inflammatory medications are frequently used, non-pharmacological approaches such as physical therapy are essential for long-term management. The article “Well-Tolerated Strategies for Managing Knee Osteoarthritis: A Manual Physical Therapist Approach to Activity, Exercise, and Advice,” by Deyle and Gill (2012), explores manual physical therapy, exercise, and patient education as effective strategies for managing knee OA symptoms. This review aims to evaluate the article’s key findings and contributions to knee OA management.

Methods

 The article provides a comprehensive overview of evidence-based strategies for managing knee OA. The authors reviewed multiple studies and clinical evidence to support the effectiveness of manual therapy, exercise, and patient education. These strategies were analyzed for their ability to alleviate pain, improve joint mobility, and enhance overall function in individuals with knee OA.The article highlights the best practices for physical therapists, covering exercise recommendations, manual therapy techniques, and behavioral changes.

Results

  • Manual Therapy: The use of joint mobilizations and soft tissue techniques was shown to reduce pain and increase mobility in patients with knee OA. The authors emphasized that manual therapy could provide immediate symptomatic relief and improve range of motion when combined with other interventions.
  • Exercise Therapy: A combination of strengthening exercises for the quadriceps and aerobic activities was identified as crucial for reducing pain and improving functional outcomes. The article mentioned that exercises should be customized to each patient’s needs, with a focus on gradual progression to prevent worsening symptoms.
  • Patient Education: Teaching patients about the importance of staying active, modifying daily activities to minimize joint strain, and incorporating weight management strategies were key components of successful treatment.
  • Progressive Load Management: The article discussed the importance of increasing exercise intensity over time, ensuring patients do not overload the joint but are progressively challenged to improve strength and function.

Discussion

The authors concluded that a combination of manual therapy, exercise, and patient education provides a well-rounded, effective approach to managing knee OA. Manual therapy helps reduce immediate pain and stiffness, while exercise promotes long-term improvements in joint function and strength. The authors also highlighted the critical role of patient education in helping individuals manage their condition, maintain physical activity, and prevent further joint degeneration.

However, the authors also noted some limitations. While the evidence supports the benefits of these interventions, they acknowledged that more research is needed to determine the most effective protocols for specific patient populations, including those with varying levels of severity in OA. The differences in exercise routines and manual therapy techniques across studies makes it challenging to create a standardized treatment protocol.

Conclusion

The article provided strong evidence for the efficacy of manual therapy, exercise, and patient education in managing knee OA. For clinicians, it serves as a valuable resource in developing treatment plans that emphasize non-invasive, well-tolerated interventions. Incorporating these strategies into rehabilitation programs can significantly improve outcomes for patients with knee OA. As a student physical therapist, I have observed the positive impact of combining these approaches in clinical practice. The focus on individualized care is particularly important, as knee OA affects patients in many different ways. However, like the authors, I believe more research is needed to determine optimal exercise protocols and to assess long-term outcomes. In the meantime, the comprehensive approach outlined in this article is an excellent foundation for treating knee OA in clinical settings.

Reference

Deyle, G. D., & Gill, N. W. (2012). Well-Tolerated Strategies for Managing Knee Osteoarthritis: A Manual Physical Therapist Approach to Activity, Exercise, and Advice. The Physician and Sportsmedicine, 40(3), 12–25. https://doi.org/10.3810/psm.2012.09.1976

 

The Effectiveness of Resistance Exercise for Rotator Cuff Tendonitis

Reviewed by Kirsten Hales, SPT

Introduction

Rotator cuff tendonitis (RTC) is a common musculoskeletal condition, often associated with shoulder pain and dysfunction resulting from repetitive motion, aging, or poor posture. Conservative management strategies such as rest, physical therapy, and anti-inflammatory medications, are frequently used. However, the role of resistance exercise (RE) in alleviating pain and improving function in RTC tendonitis is still under investigation. The article “Effect of Resistance Exercise on Pain and Function in Rotator Cuff Tendonitis,” aims to provide insight into the effectiveness of resistance training in addressing pain and functional limitations in individuals with RTC tendonitis.

Methods

This systematic review and meta-analysis included data from 10 randomized controlled trials (RCTs) involving 552 patients diagnosed with RTC tendonitis. The different studies assessed the effects of RE programs on pain reduction, functional improvement, and overall quality of life in patients with chronic shoulder pain related to RTC injuries. Key outcomes analyzed were pain intensity (measured via the VAS) and functional improvement (assessed with the SPADI, and DASH).

Results

● Pain Reduction: Participants who engaged in RE programs demonstrated significant reductions in shoulder pain compared to control groups. Pain intensity scores improved by 35-45% after 6-12 weeks of resistance training.
● Functional Improvement: Functional outcomes, as measured by SPADI and DASH scores, showed that resistance exercise resulted in a 20-30% improvement in shoulder strength and ROM.
● Exercise Protocols: The studies varied in terms of the exercise duration (ranging from 6 to 12 weeks) and frequency (2-3 sessions per week). The most effective programs incorporated moderate to high-intensity exercises targeting both the rotator cuff muscles and scapular stabilizers.
● Long-Term Outcomes: While RE yielded immediate improvements in pain and function, the authors noted that the long-term benefits were less clear. Follow-up data at 3 to 6 months showed some sustained improvements in strength and function, but not all patients maintained pain relief after completing the exercise programs.

Discussion

The authors concluded that RE can be effective in short-term interventions for reducing pain and improving function in patients with RTC tendonitis. By strengthening the muscles around the shoulder joint, RE can help stabilize the joint, reduce strain on the tendons, and promote healing. Additionally, resistance training may enhance neuromuscular control and proprioception, which play a critical role in preventing re-injury and improving overall shoulder function. However, the review also highlighted several limitations. The diversification of the exercise protocols (such as variations in type, intensity, and duration) across studies makes it difficult to determine the most optimal approach for all patients. The absence of high-quality, long-term data leaves the question of long-term benefits unresolved.

Conclusion

The review concludes that RE is a promising intervention for managing pain and improving function in individuals with RTC tendonitis. Based on the article, clinicians are encouraged to incorporate RE into rehabilitation programs, particularly for patients with chronic shoulder pain. They are also encouraged to combine it with other conservative treatment strategies. In my clinical experience as a student PT, I have observed that incorporating RE into treatment plans for patients with RTC tendonitis can significantly improve pain and function in the short term and the long term. While I have witnessed the benefits of RE firsthand, the variability in protocols highlights the need for individualized and carefully tailored programs to meet each patient’s needs. This approach ensures that treatment is not only effective but also adaptable to the unique challenges and goals of each patient. However, similar to the authors’ conclusions, further research is necessary to establish standardized protocols and determine the long-term efficacy of RE in managing RTC tendonitis.