Shoulder Complex需要有協調的acromioclavicular (A-C), sternoclavicular (S-C), glenohumeral (GH), scapulothoracic joints, rotator cuff, 和 scapular stabilizer muscles以便產生適當的功能.
其中glenohumeral (GH) joints需要有muscular system的dynamic stabilization以維持其高度的mobility.
而muscular system 則利用 "force couple" 來控制humerus and scapula 於各種arm movement的位置. 這些force couples (or coordinated contraction)能夠適度的調整scapula 與humerus的相對位置而產生efficient motion.
因此任何joints, 和它週邊的soft tissse (labrum,tendons,bursa); 或muscular system的movement dysfunction都將導致 pain syndromes.
Muscular system如何產生Movement dysfunction.
它的理論包括
1. Postural adaptation to gravity而導致soft tissue 在這個長期的 poor posture下產生shortening.
2. 因為脊椎segmental restriction而對正常的articular reflexes( neuroreflexive) 產生干擾(Wyke).
3. 肌肉系統的agonist and antagonist喪失彼此間的reciprocal interaction between agonist and antagonist.
4. Painful stimulus改變了motor recruitment的sequence(Wyke).
5. Muscular system 的(repetitive) overload產生的fatigue and inhibition.
治療Movement Dysfucntions的原則:(兩位大師的見解很不一樣)
l Janda: 要Reeducate movement patterns預防reoccurring compensatory patterns. 先stretch short muscle再訓練inhibited muscles.
l Sahrmann: 最重要的是Strengthen the antagonist that is too long in its optimal position, 而通常不需去stretch short structures. 強調functional activities的quality of movement.
在shoulder rehabilitation的過程中要思考Structure VS Function. 而Motion Restoration是治療的key. 因為motion loss的主要原因是pain抑制掉肌肉的收縮功能. 當pain減輕後, pain free motion會增加. Motion增加後,要把重點放在strengthening and muscle re-education. 利用"specificity of training" 來恢復適當的motor patterns 和 force couples.
總之, Restoring the proper recruitment patterns 和 sequencing of the muscles 是恢復proper motor patterns的關鍵.
"PRACTICE DOES NOT MAKE PERFECT... PERFECT PRACTICE MAKES PERFECT"
Manual Therapy 的Concepts: (Tsai’s)
1. 在對movement dysfunction做strengthening或stretching時, restore arthrokinematics必須先作,即以mobilization (或manipulation)先恢復shoulder joint的biomechanics.
常見影響shoulder complex的mechanical restrictions:
1. 除了glenohumeral joint外, acromioclavicular joint和 first and second rib motion restriction 是最容易被忽略的問題來源(first and second rib motion也影響S-C joint motion.)特別是我們常見的rotator cuff tendonitis 和 impingement syndromes(Greenman).
2. Tight posterior shoulder capsule (unilateral forward shoulder) 會抑制掉rotator cuff 等external rotator muscles 被有效地recruited.
3. An elevated first rib 會導致 cervical radiculopathy 因為 C8 spinal nerve entrapment between the clavicle and first rib.
4. Acute elevated first rib and inhalation restriction會類似 acute rotator cuff tear 因為病人會因痛而無法抬手而不是 weakness as in rotator cuff pathology.
5. 於extension 時, T7-9 facet restriction會 inhibit lower trapezius recruitment (Bookout).
於flexion時, T3-5 facet restriction 會 inhibit serratus anterior and rhomboid recruitment.
於flexion時, T3-5 facet restriction 會 inhibit serratus anterior and rhomboid recruitment.
6. Flat back posture with decreased kyphosis.
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