This was December’s Journal Club article at the hospital. The point of this article is to make you say, “Hmmm.” So open your mind and let’s dive in!
Scapular stabilization has been a mainstay of shoulder kinematics and therapeutic treatment strategies for who knows how long. Having a bum shoulder and getting physical therapy in the scapular stabilization line of thought is what got me into physical therapy… nearly 20 years ago! So it’s been around a while. But not everything that is old is good, so this article explores what scapular stabilization is and where we go from here.
“Scapular stability has come to imply ‘normal’ scapula movement….” as it relates to the purpose of the scapula which is to provide a stable base on which the arm functions in daily tasks, athletic endeavors, etc. So the opposite of that, dyskinesia, has come to signify an unstable base and an imbalance of the scapulothoracic musculature. That’s where therapy steps in with stabilization exercises, braces and taping techniques. Easy right? WRONG!
Remember our friend individual difference? The core of the article is based on the thought that the varying dyskinesia we visualize and then treat may be just individual difference. So we really need to look at the side we aren’t treating to see what each person’s “normal” is. On top of that, dyskinesia is very subjective, not quantifiable, so we’re relying purely on our ability to describe what we’re seeing, which is another challenge in measuring stability. Also, we need to keep the context in mind as well. Perhaps the weird kinematics a person presents with work for them just fine when they’re washing their hair, but not when they’re playing softball. Then some variability in synergy is probably a good thing. Our muscles make little mistakes all the time and having the ability of one muscle to automatically correct for the little errors of another is beneficial, so that the purpose of the system (functional movement) doesn’t break down and cause pain. On that same beat, having multiple ways to achieve the same functional goal is beneficial as well, so if one way isn’t working for some reason, there’s another way to get it done. This is called “degrees of freedom.” Because of all this, having “scapular stability” maybe not be desirable.
So we’re rethinking “stability.” What is it we’re shooting for then? The article suggests the term “robustness” meaning ability to perform desired functions in multiple contexts, like being able to work fine when washing hair AND playing softball AND carrying in the groceries. To get to “robustness,” the authors suggest looking at the scapulothoracic musculature in a tensegrity or slingshot energy transfer system rather than bones that support muscles. (Click the link to learn more about tensegrity.)
So what do we do in the clinic? Our goal should be to increase “robustness” by increasing the number and intensity of variability that is tolerated by the scapulothoracic system. “Interventions that require the shoulder complex to function as a force absorption and transfer unit and muscle activation in functionally relevant positions should be emphasized…. using various levels of resistance, speed or both…. Adding perturbations… [and] plyometric training [in addition to]…. stretching tight tissues or improving thoracic mobility.” So what does that look like? Functional activities of course designed around each individual client. I was also thinking weight bearing activities. What do you have in your treatment tool box that would work here? Think about it.
On a different note, I’ll be taking a vacation for a couple weeks. This will include a reduction in my time on the blog and a social media detox. I may have a post or two, but I won’t be posting up regularly until the new year. So, as I enjoy my family, I ask you to do the same. I wish you a wonderful holiday season!