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Superficial and Deep Scapulothoracic Muscle Electromyographic Activity During Elevation Exercises in the Scapular Plane: Controlled Laboratory Study
JOSPT March 2016Choosing the appropriate exercise progression for patients with scapular dyskinesia can be challenging. It can be difficult to determine the best position or movement to target the most appropriate muscle groups to improve scapulothoracic rhythm. Studies have documented lower activation of the middle and lower trapezius and serratus anterior in patients with scapular dyskinesia. Minimal evidence shows the activation pattern of the pec minor, levator scap and rhomboids during shoulder elevation.
This study looks at scapulothoracic superficial muscle activity (upper trap, middle trap, lower trap, serratus anterior), as well as deep muscle activity (pec minor, levator scap, rhomboid major) differences with various typs of rehabilitation exercises with an elevation component. The authors investigate how different exercises with elevation in the scapular plane may alter muscle activation.
Subjects:
21 participants ranging from 21-55 years old, mean age of 32, 11 male and 10 female. All subjects did not have current or a history of neck or shoulder pain.Design:
EMG data on muscle groups listed above in the dominant UE during 3 different arm elevation tasks in the scapular plane: 1) elevation in the scapular plane; 2) towel wall slide; 3) elevation with an external rotation component with a Thera-Band. Data was collected again with additional load.Results:
The article has a nice graph illustrating the results of the different exercises and the muscle groups involved.During scaption, the upper trap was significantly more active than during the wall slide and elevation with ER and upper trap and serratus anterior activity increased significantly. If the exercise was performed without additional load, the middle and lower trap generated the most activity during elevation with Theraband ER compared to the other two exercises. With the addition of load from a dumbbell, scaption and elevation with ER showed significantly higher middle and lower trap activity.
For the deeper muscle groups, elevation with band ER without additional load showed significantly higher levator scap (LS) activity than the wall slide. No differences found in levator scap activity in the unloaded condition between scaption and the other two exercises. When load was added, scaption and elevation with ER showed higher LS activity than the wall slide. Elevation with ER with additional load did not significantly increase the activity of the levator scap, as did the other exercises with additional load. It’s not a surprise that the wall slide demonstrated significantly higher pec minor activation.
Discussion:
This study provided valuable data applicable to clinical practice. Knowing muscle activation patterns for normal subjects could help us be more specific in our exercise prescriptions to achieve our intended goal. For instance, let’s say you have a patient that you feel demonstrates dominance of the upper trap to achieve scapular upward rotation and your goal is to decrease upper trap activation and facilitate middle and lower trap activity. I have often attempted to use verbal and tactile cues with scaption in attempt to achieve this goal (scapular assist), with minimal success. I realize that with the data from this study, this approach may be counter-productive if I’m performing an exercise that would normally facilitate high upper trap activation.Serratus anterior is an important muscle for scapulothoracic rhythm and often targeted with exercise. Take note in Figure 4 of the high serratus anterior activation under load with all three exercises, and then look at the high pec minor activation with the wall slide. I have often prescribed weight bearing activity, such as quadruped and closed chain elevation to target serratus anterior; however, if I want to calm down the pec minor, it’s good to know that I can achieve roughly the same level of serratus anterior activation with scaption and elevation with ER with additional load.
Question:
1) Can you give an example of a patient you have seen with scapulothoracic movement dysfunction and a functional exercise or strategy you provided to facilitate or inhibit a particular muscle group? What is in your toolbox? Was it successful? Why or why not?
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only to a moderate degree. I hope to believe I choose exercises that promote an appropriate movement pattern and also that engage certain muscle groups based on my biomechanical knowledge of the what the muscle action is; I also want to make sure the patient feels relatively comfortable with the exercise.
For instance, I use the wall slide semi-regularly with cuing for scap protraction and upward rotation, and in doing so for SA contraction. Yes, pec minor does perform scap protraction as well, and therefore had higher EMG performance with this exercise. However, I am not sure I would back off the use of that exercise for that reason alone.
Again, with scaption I tend to focus on movement pattern vs. muscle activation. I think its quite alright if upper trap is active during scaption (as it is supposed to be assisting upward rotation); what I try and cue against is the excessive elevation component that is often seen. I frequently use mirror feedback for this. I feel I have had mild success with this.
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If the patient is weak I’ll have them in sidelying scaption on a ball while assisting scapular glide. Then progress eventually to standing Ys against the wall and standing scaption. If the patient has a reactive pec minor then I try to decrease tone hoping that will help with movement. I’ve found that decreasing excessive tone and then progressing with movement has been helpful.
Sean- I also a lot of quadraped and “push to your heels and bring yourself back up” cues. I’m not sure what’s really being inhibited and articles such as what you provided are helpful.
Nick- The excessive elevation drive me crazy which is why I go to sidelying scaption/ elevation while supported on a ball. Have you found anything else that has been helpful to decreased the excessive elevation? -
Nick – great point with scaption/UT activation. In most of these patients I focus more on the motor control aspect. I haven’t tried a whole lot of mirror feedback but that’s a great call.
Oksana – I like your notion of decreasing tone followed by movement. Over the last few months I’ve gone from trying to avoid movements that involve hypertonic musculature like the pec minor (or iliopsoas in LBP patients) to attempting to address hypertonicity manually and using exercises involving those muscles with improved motor control/movement patterns. It’s hard to say whether that’s right or wrong, but it seems to work pretty well.
I wouldn’t avoid an exercise just because it increases activation of a specific muscle, as long as the movement pattern/motor control aspect doesn’t suffer. However, it is good to have studies like these that help target some of these other muscles more specifically.I’m curious about the elevation + ER. I’ll have to try that myself tomorrow.
One exercise I’ve used with more advanced patients is a modification of scarecrow in prone, in which I have the patient separate thoracic extension, scap retraction, shoulder ER and UE elevation in sequence to focus on the motor control aspect. I’ve never seen any research on that, it’s just something that’s worked for myself. -
I realize that somehow part of my post got cut off here.
Alex – “I wouldn’t avoid an exercise just because it increases activation of a specific muscle, as long as the movement pattern/motor control aspect doesn’t suffer.” Yes – my exact thoughts.
Oksana – I am certainly still trying to figure out the best way to prevent excessive scap elevation. I think we are going to have a very hard time preventing that if there is GH motion loss – the brain is going to find a way to get the arm at the same level, which it will almost certainly do through scap compensation if GH ROM is insufficient. Nevertheless, in patients for whom passive GH passive and accessory seems sufficient, and yet they are still excessively elevating, another tactic would be to manually inhibit and/or stretch the scap elevators. I have seen Eric do this a couple of times on patients and incorporate movement with it – kind of a soft tissue mobilization (or inhibition) with movement technique. It seems to work well.
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I am just thinking out loud here (so to speak), but we have talked/read a decent bit lately on external cuing vs. internal cuing. Almost certainly all of us are cuing the excessive elevation prevention, or any and all scap motion for that matter, internally (e.g., don’t let your shoulder blade rise up too far, keep your shoulder blade tipped back, etc…) Is it even possible to provide an external cue that might be more effective?
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I like the concept of “sequencing” and using kinetic chains. The exercise that Alex mentioned follows the use of global, functional motor patterns with thoracic extension, scapular retraction, and shoulder external rotation, then elevation. I like the third exercise used in this article more than the first two because it follows more of this concept. Squat and rows, step ups and elevation, side lunge and unilateral row were all examples of global exercises that were presented during our shoulder lecture and within the article by McMullen, et al. Of course, I think that isolated exercises have their place but I think the goal should be to use them to correct muscle imbalances to perform the global movements with a proper motor pattern.
I like using prone positioning for facilitating scapular strengthening, either on the table, on an incline bench, half-kneeling on a flat bench, or over a physioball. The more control and strength they have, I like to take away stability so they have to use their whole body to create the movement. I’ve even been trying out some upper extremity exercises while standing on an airex for an increased challenge.
I’m sure there are ways to incorporate external cues into scapular training. Mirror use for visual feedback is a great option for minimizing shoulder girdle elevation. What about placing your hand above the patient’s shoulder over their upper trap (not touching) and asking them to lift their arm without touching your hand?
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It’d be similar to using a stool in front of someone’s knees to prevent anterior tibial translation during a squat.
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I like the hand use Halley – I am going to try that! Thanks for sharing.
I like the use of mirror feedback, but I guess I have been struggling over whether or not that is truly external feedback. I tend to think putting someone in front a mirror and having them watch their knee position to avoid valgus is still somehow internal cuing, though perhaps less so than merely verbal cuing “don’t let your knee go in.”
Again, I like the hand idea – thanks!
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Oksana-with pts who are unable to produce elevation (scaption or flexion) vs gravity, I also use the SL option but have never used a TBall for extra support during manual cuing but I do like that option too. Laura–I ALWAYS use a mirror for all of my shoulder pts as so many automatically go into an excessive UT dominant pattern and shrug on the affected side due to lack of scap stabilizer activation. Another step I use for those who can’t control this pattern in standing is to have them on an incline bench with a half roll behind them…in front of a mirror and have them then perform the ROM in scaption and then progressive elevate the bench to a more upright position as they gain motor control. it’s amazing that I’ve actually seen a pt go from a 45 degree angle to full upright in one session with the NM re-ed. most don’t retain it btw sessions at first though. Any thoughts on why I use that 1/2 foam roll and not just flat vs. the bench? what is the best way to cue the pt to replicate this type of progression at home?
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Nice! I love these ideas Kristen. Good call Sean! Is resting the neck against a stable surface any part of it as well? I’m thinking that supporting the thoracic spine and head will help posture and get patients out of increased thoracic kyphosis and forward head when performing scaption…
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Here’s a good article to review on cuing with these patients – specific cues for specific movement dysfunction.
What other cues related to some ideas here?
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Nice talking points, I love it. Think about what the foam roller from a mechanical aspect to – what does the thoracic spine need to do in order for scapular muscles like lower trap to be most effective?
With all of this motor relearning remember there are central processes occurring. Do not underestimate the neuroplasticity of some of these patients. Even though this citation discusses post-stroke rehab and those with chronic pain, some of the concepts are important to remember. “Strength training does not achieve the same effect as skilled training” – we are impacting the primary motor cortex with many of our techniques.
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Nick – one cue I use for shoulder elevation is “keep your shoulder away from your ear” or “keep the space between shld/ear open”. I guess that’s not really an external cue, but that seems to work for me.
Eric, Aaron – thanks for the articles! I like the specificity in the first article and will have to try that.
The second article talks about pain being an inhibitor to cortical changes and skill acquisition and how total number of repetitions within a session don’t seem to be as relevant as quality of movement. I’ve found myself prescribing less exercise, but more specific to the pt’s problem, as well as focusing more on motor control and it seems like that’s made quite a difference. It also appears that HEP compliance is much better with less volume and increased specificity to the individual (also discussed in my March article review). I’ll def try to focus more on goal oriented cueing and exercise as discussed in the second article.Aaron – I would say it helps facilitate thoracic extension, scap tilt and improves the length tension relationship of the mid and low trap. It should also allow for more movement of the scapula in general since the scapula isn’t in direct contact with the bench. Close?
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The second article really puts things into perspective and the concepts are important to consider. Neuro patients are ortho patients, and ortho patients are neuro. Focusing on sequencing, orientation towards a goal, and quality vs. quantity of movement. I like the concept of less is more for our sessions as well as our HEP’s.
Both articles have me thinking about use of PNF concepts and how I don’t utilize them enough in the clinic compared to straight plane exercises. With those concepts, I also remember how much they stress tactile cueing and hand placement to optimize muscle activation patterns. With all the cues listed in the first article, I would think that tactile cueing and increasing the patient’s kinesthetic awareness of the task would be of great benefit. For example, using the cue “Gently bring the tip of your shoulder blade towards the spine”, placing your hand on the scapular inferior angle and guiding it towards the spine as the patient attempts to perform the exercise.
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I do like the 1/2 foam roll! I assume it helps assist thoracic extension and posterior tilting of the scapulae during elevation with less influence of gravity! I do not have a incline bench at work, but I’ll try to rig something up with the treatment table.
Motor sequencing is something I’m trying to learn better. As Nick said earlier the brain will do anything it can to get a limb from point A to point B. One exercise that I have found to be helpful is having a patient in sitting with scapular retraction, thoracic rotation and cervical rotation. It may seem simple but I want patients to feel what’s moving and when it’s moving. Once patients can control these motions I try to progress from there. Once again keeping the patient’s goals in mind and progressing towards that direction is something that I try to be aware of instead of my goals.
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I use the full length 1/2 foam roll. Yes, the 1/2 foam roll promotes thoracic extension (or at least promotes neutral or a decrease in the moderate kyphotic posture so many of us are in all day) and promotes clearing of the scapula (not pinned directly vs the bench) while still promoting good spine alignment with better scapular tilt and the mm length tension relationship. I also have pts focus on deep neck flexor activation as most all of these pts will have postural control issues and moderate fwd head posture with non-existent cervical stabilizer activation. Many pts will require a small towel roll behind their head (btw their head and the 1/2 roll) to achieve a neutral cervical lordosis based on the amt of forward head posture they present with. The foam roll gives them the manual cue of a neutral spine while also providing a little support vs gravity depending on the angle of the bench but even with full erect sitting. So many pts require that cuing and support to be successful at all in good postural control. That neutral posture will also help to better clear the GH joint to reduce impingement and promote better cuff activation by reducing the relative IR position poor posture causes.
I have 2 full length mirrors on wheels in my clinic and utilize them with almost every pt for postural education and cuing as well as for feedback for everything…pelvic and spine positioning, cuing for knee positioning during WB and gait activity…etc. The more feedback a pt has verbally, and with visual and tactile cuing, the more they improve their motor patterns and understand the benefit of what we offer them. -
Wow – Great discussion all. I am overlapping with many in my comments but in looking at the three articles and the discussion, I think about a lot of PNF concepts developed in the 1940’s. Aaron’s article makes the point of quality vs. quantity with cognitive effort for best neuroplasticity. Many good points have been made that provide addition facilitation of quality of the movement pattern to the original article. Kudos to all of you. I believe the best outcome occurs when you use as many types of facilitation as necessary to achieve the desired pattern. As the patient improves, less facilitation is needed. Early on, I use more facilitation techniques, including manual resistance . Facilitation techniques include:
Visual: (examples include: mirror, having the patient follow their hand through the entire pattern of movement with their eyes and functional visual goals such as reaching for something),
Verbal: (I think cues work better when they are oriented towards what you want them to do, as in Eric’s posted article, rather than what not to do, as when telling a patient to keep their shoulder away from their ear). Don’t forget to use timing and change in tone of voice with verbal cues to influence the best pattern of movement.
Tactile: Tactile and visual cues influenced the change in emphasis noted in the towel slide in addition to the resistance provided by keeping the towel on the wall.. As noted by Laura, specific tactile feedback on the scapula can be very helpful. I think the actual tactile cues of the foam roller (although the scapula is more free, often, you have some scapula contact by mid-range of the movement pattern) or lying supine are facilatory for the scapular retractors.
Progressing through developmental positions: Starting supine is great when the patient has a hard time stabilizing the scapula, then to sidelying (scapula free, requiring more work), then prone, adding gravity as resistance. Then progressing to more difficult developmental positions…kneel, 1/2 kneel, stand, standing on foam. If the pattern is not good, use moving down this sequence as an important tool.
Resistance: Key here is, as noted in Aaron’s article, not having so much resistance that the patient moves out of the desired quality of the pattern of movement. Also, if you are not satisfied with the movement pattern, think about improving the direction of resistance, whether you are providing manual resistance or pulleys or a band. I recommend using PNF patterns for optimal facilitation. If using manual resistance, stand on the diagonal and sufficiently move out of the way to allow movement through the pattern. Give resistance in ALL components of the pattern. If they need facilitation of weak scapular stabilizers, facilitate with one of your hands on the scapula. Carefully think about your hand placement. If using a pulley, position the patient on the diagonal.
So many tools in your toolbox!
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