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Papers by Lyn Watson

Research paper thumbnail of Quantifying ‘normal’ shoulder muscle activity during abduction

Journal of Electromyography and Kinesiology, 2010

The purpose of this experiment was to obtain electromyographic (EMG) activity from a sample of he... more The purpose of this experiment was to obtain electromyographic (EMG) activity from a sample of healthy shoulders to allow a reference database to be developed and used for comparison with pathological shoulders. Temporal and intensity shoulder muscle activation characteristics during a coronal plane abduction/adduction movement were evaluated in the dominant healthy shoulder of 24 subjects. Surface and intramuscular fine wire electrodes recorded EMG activity from 15 shoulder muscles (deltoid x 3, trapezius x 3, subscapularis x 2, latissimus dorsi, pectoralis major, pectoralis minor, supraspinatus, infraspinatus, serratus anterior and rhomboids) at 2000 Hz for 10 seconds whilst each subject performed 10 dynamic coronal plane abduction/adduction movements from 0 to 166-° to 0-° with a light dumbbell. Results revealed that supraspinatus (-.102 sec before movement onset) initiated the movement with middle trapezius (-.019 sec) and middle deltoid (-.014 sec) also activated before the movement onset. Similar patterns were also found in the time of peak amplitude and %MVC with a pattern emerging where the prime movers (supraspinatus and middle deltoid) were among the first to reach peak amplitude or display the highest % MVC values. In conclusion, the most reproducible patterns of activation arose from the more prime mover muscle sites in all EMG variables analysed and although variability was present, there emerged "invariant characteristics that were considered "normal for this group of non pathological shoulders. The authors believe that the methodology and certain parts of the analysis in this study can be duplicated and used by future researchers who require a reference database of muscle activity for use as a control group in comparisons to their respective pathological shoulder group.

Research paper thumbnail of Intrarater and interrater reliability of a hand-held dynamometric technique to quantify palmar thumb abduction strength in individuals with and without carpal tunnel syndrome

Journal of Hand Therapy, 2017

Study Design: Clinical measurement. Introduction: Individuals with carpal tunnel syndrome (CTS) s... more Study Design: Clinical measurement. Introduction: Individuals with carpal tunnel syndrome (CTS) sometimes exhibit weakness of palmar abduction strength (TAS). Reliable assessment of this strength in both subjects with and without CTS with the commonly available Microfet 2 is not known. Purpose of the Study: The purpose of this study was to determine the intrarater and interrater reliabilities of a handheld dynamometric (HHD) method to assess TAS in individuals with and without CTS using the commercially available MicroFET2 and to examine the association between TAS in individuals with CTS and the Carpal Tunnel Symptom Questionnaire (CTSQ) scores. Methods: In 2 different study phases, individuals with and without CTS were assessed for TAS by 2 different examiners. The CTSQ was administered to the individuals with CTS. Results: Intrarater and interrater reliability coefficients (0.89-0.93 and 0.82-0.90, respectively) were excellent in individuals with and without CTS. Weak negative correlations were found between TAS and overall CTSQ and symptom severity subscale scores, and a moderate negative correlation was found between TAS and functional Status Subscale score. Discussion: This HHD method of reliably assessing TAS better quantifies deficits and progress than traditional manual muscle testing for muscle grades greater than 3/5. Conclusion: This method of HHD reliably quantifies TAS but is more reliable with the same than different raters.

Research paper thumbnail of The effects of a conservative rehabilitation program for multidirectional instability of the shoulder

Journal of Shoulder and Elbow Surgery, 2017

Background: Conservative management is commonly recommended as the first-line treatment for multi... more Background: Conservative management is commonly recommended as the first-line treatment for multidirectional instability (MDI) of the shoulder. Despite this, the evidence for efficacy of treatment is limited, and until recently, guidance for clinicians on conservative rehabilitation programs has been inadequate. This study evaluated the effectiveness of a physiotherapy-led exercise program for participants with MDI. Methods:: In a single-group study design, 43 participants (16 male, 27 female; mean age, 19.8 years, standard deviation, 4.9 years) diagnosed with MDI undertook a 12-week exercise program. Primary outcome measures were the Melbourne Instability Shoulder Score, Western Ontario Shoulder Instability Index, and Oxford Shoulder Instability Score. Secondary outcomes were strength and scapular position. All measures were taken at baseline and repeated at the conclusion of the program. Test differences before and after rehabilitation were evaluated with dependent t tests and single-group effect size calculations (standardized mean difference [SMD]) to provide a measure of the magnitude of the difference. Results: Large effects were found between pre-and postrehabilitation scores on all functional instability questionnaires, with the Western Ontario Shoulder Instability Index demonstrating the largest effect (SMD,-3.04). Scapular upward rotation improved significantly in the early ranges of abduction (0°-60°), with moderate to large effects (SMDs, 0.54-0.95). All strength measures significantly improved, with large differences identified (SMDs, 0.69-2.08). Conclusion: The identified improvement in functional status, shoulder muscle strength, and scapular positioning after rehabilitation allows greater confidence in the value of conservative management of MDI and informs further research by way of clinical trials in the area.

Research paper thumbnail of The variable roles of the upper and lower subscapularis during shoulder motion

Clinical Biomechanics, 2014

The varied roles of the subscapularis muscle as an internal rotator of the humerus, a shoulder ab... more The varied roles of the subscapularis muscle as an internal rotator of the humerus, a shoulder abductor, a humeral head depressor and an anterior stabiliser may be a result of differing innervation and lines of torque between its superior and inferior components. The aims of the study were to investigate the differences in the level of muscle activation between the upper and lower subscapularis during abduction, flexion, internal and external rotation movements, and temporal characteristics during abduction and flexion. Intramuscular electrodes recorded electromyographic muscle activity from the upper and lower subscapularis muscles of the dominant throwing arm of twenty-four normal subjects. Participants completed ten repetitions of four shoulder movements - abduction, flexion, internal rotation and external rotation. Muscle activity was expressed as a percentage of maximum voluntary isometric contraction. The lower subscapularis was found to activate at a higher level than the subscapularis during abduction, flexion and external rotation movements and this was significant during concentric and eccentric phases of abduction and flexion (<0.001). During internal rotation, upper subscapularis muscle activity mirrored that of lower subscapularis, with a mean difference of 1.14%. Neither upper nor lower subscapularis had onset data commencing prior to the abduction movement; however upper subscapularis activated significantly later than lower subscapularis (P=0.018). The lower subscapularis has significantly higher muscle activity during shoulder elevation and this might reflect its greater role as a humeral head depressor and anterior stabiliser.

Research paper thumbnail of The Specific AC Score (SACS): a new and validated method of assessment of isolated acromioclavicular joint pathology

Journal of Shoulder and Elbow Surgery, 2018

Background: Acromioclavicular (AC) joint (ACJ) pathology is a common cause of shoulder dysfunctio... more Background: Acromioclavicular (AC) joint (ACJ) pathology is a common cause of shoulder dysfunction, and treatment recommendations vary. When the efficacy of treatment is evaluated, the ability to measure outcomes specific to the population is essential. The aim of the current research was to develop and validate a specific ACJ questionnaire. Methods: Items for the "Specific AC Score" (SACS) were generated through the use of an expert panel, existing questionnaires, and patient feedback. Preliminary data analysis identified redundancy of items resulting in the questionnaire being refined. The final SACS was evaluated in 125 patients requiring surgical intervention of the ACJ. Internal consistency (the Cronbach α and corrected item-total correlation), content validity, criterion validity, responsiveness, and test-retest reliability (intraclass correlation coefficient) were examined and compared with the Shoulder Pain and Disability Index, Oxford Shoulder Score, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. The minimum detectable change score was calculated. Results: The Cronbach α for the total scale preoperatively and postoperatively was high (preoperatively = 0.91, postoperatively = 0.93). All 3 domains (Pain, Function, Quality of Life) demonstrated acceptable internal consistency (α > 0.70), and the correlation between items in each domain was satisfactory. The responsiveness was excellent (effect size, −2.32; standard response mean, −1.85) and was higher than the other general shoulder questionnaires. There were no relevant floor or ceiling effects. Reliability was high (intraclass correlation coefficient, 0.89) and the minimum detectable change was 6.5 points. Discussion: This new ACJ-specific questionnaire has been robustly developed, has good measurement properties, and has excellent responsiveness. The SACS is recommended for measuring outcomes in ACJ patients.

Research paper thumbnail of Functional improvements and electromyographic (EMG) changes in multidirectional instability of the shoulder after conservative rehabilitation

Journal of Science and Medicine in Sport, 2010

Research paper thumbnail of Evidence-Based Review of Clinical Diagnostic Tests and Predictive Clinical Tests That Evaluate Response to Conservative Rehabilitation for Posterior Glenohumeral Instability: A Systematic Review

Sports Health: A Multidisciplinary Approach, 2018

Context:Posterior glenohumeral instability is poorly understood and can be challenging to recogni... more Context:Posterior glenohumeral instability is poorly understood and can be challenging to recognize and evaluate. Using evidence-based clinical and predictive tests can assist clinicians in appropriate assessment and management.Objective:To review evidence-based clinical diagnostic tests for posterior glenohumeral instability and predictive tests that identify responders to conservative management.Data Sources:A comprehensive electronic bibliographic search was conducted using Embase, Ovid MEDLINE, PEDro, and CINAHL databases from their date of inception to February 2017.Study Selection:Studies were included for further review if they (1) reported on clinical diagnostic tests for posterior or posteroinferior instability of the glenohumeral joint, (2) assessed predictive clinical tests for posterior instability of the glenohumeral joint, and (3) were in English.Study Design:Systematic review.Level of Evidence:Level 4.Data Extraction:Data were extracted from the studies by 2 independe...

Research paper thumbnail of What is the reliability of clinical measurement tests for humeral head position? A systematic review

Journal of Hand Therapy, 2017

Study Design: Systematic review. Introduction: Physiotherapists routinely assess the position of ... more Study Design: Systematic review. Introduction: Physiotherapists routinely assess the position of the humeral head (HH) in patients with shoulder pain. Purpose of the Study: To conduct a systematic review to determine the quality and content of studies that evaluated the reliability of clinical measurement methods for assessing the HH position. Methods: Five databases and gray literature were searched for studies fitting the eligibility criteria. After abstract and full-text review, the included studies were appraised using the Quality Appraisal of Reliability Studies checklist. Articles were considered of high quality if 8 was achieved on the checklist, and the overall quality of evidence was classified using prespecified criteria. Multiple raters extracted and performed quality ratings; a consensus process was used to finalize the reliability data that were synthesized and presented in a narrative synthesis. Reliability was classified as excellent if the intracorrelation coefficients or intercorrelation coefficients (ICCs) reported exceeded 0.75. Results: Fifteen studies on the reliability of ultrasound (US) and 3 studies on palpation were included. The methodologic quality was moderate in 17 of 18 studies. The intrarater reliability for all studies was excellent (ICC, 0.76-0.99) with the exception of the 90 abduction in internal rotation position (ICC, 0.48) for palpation. The inter-rater reliability tended to be lower (ICC, 0.48-0.68) for palpation and higher (ICC, 0.66-0.99) for US. Physiotherapists demonstrated excellent intrarater reliability across different levels of training in ultrasonography. Discussion: Our study found a moderate overall level of evidence to support the use of US for assessing HH position in symptomatic or asymptomatic subjects. Conclusion: A moderate overall level of evidence exists for the use of US to reliably assess the HH position. Limited research supports the methods used for palpation within a clinical setting. Level of Evidence: 2a.

Research paper thumbnail of Evidence-based conservative rehabilitation for posterior glenohumeral instability: A systematic review

Physical Therapy in Sport, 2016

Study Design: Systematic review Objectives: To identify the best evidenced-based approach for the... more Study Design: Systematic review Objectives: To identify the best evidenced-based approach for the conservative rehabilitation of patients with posterior glenohumeral instability. Background: Posterior glenohumeral instability is more common than previously thought. Proper management is imperative to control symptoms and maximize function. Methods: We conducted an electronic search, up to November 2014, for Englishlanguage studies involving rehabilitation of posterior shoulder instability. A manual search of reference lists of included articles and previously published reviews was also performed. Results: Five studies met the review inclusion criteria. Most studies demonstrated that rotator cuff and posterior deltoid strengthening could reduce instability recurrence and pain, and increase function, mainly in those with atraumatic posterior instability without previous surgery. These studies were mainly case series or retrospective designs Conclusions: Rotator cuff and posterior deltoid strengthening may help with symptommanagement and functioning in those with posterior glenohumeral instability. Further research is needed to detect statistically significant outcomes from conservative treatment.

Research paper thumbnail of A comprehensive rehabilitation program for posterior instability of the shoulder

Journal of Hand Therapy, 2017

Posterior shoulder instability is recognised as being less prevalent than anterior instability, h... more Posterior shoulder instability is recognised as being less prevalent than anterior instability, however the diagnosis of this pathology is easily overlooked or missed and this may contribute to an underestimation of prevalence. Recently, there has been increasing recognition of this condition and consequently a greater requirement for knowledge of diagnostic procedures and treatment directions. Currently there is limited research into the conservative management of posterior instability, although it is recommended as first-line treatment prior to surgical review, particularly in those with an atraumatic instability mechanism. The aim of this paper is to outline a comprehensive rehabilitation program for the conservative management of posterior instability with a focus on scapular and humeral head control. The information provided includes extensive written information, flowcharts, figures and a table of management parameters that will provide therapists with adequate detail to replicate the program in the clinical setting.

Research paper thumbnail of Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula

Clinical Biomechanics, 2014

Background: Scapular dyskinesis, characterised by drooping scapulae and reduced upward rotation, ... more Background: Scapular dyskinesis, characterised by drooping scapulae and reduced upward rotation, has been implicated in the presentation of a number of shoulder disorders. Traditionally, in shoulder rehabilitation programmes, the shrug exercise has been prescribed to facilitate upward rotation of the scapula by strengthening the upper trapezius muscle. The aim of this research was to compare muscle activation levels during the standard shrug and the upward rotation shrug in a normal and pathological population. Methods: Surface electrodes recorded electromyographical activity from upper trapezius, middle trapezius, lower trapezius and serratus anterior muscles in 23 normal participants and 14 participants with multi-directional shoulder instability. Participants completed 10 trials of the standard shrug exercise at 0°of shoulder abduction and the upward rotation shrug exercise at 30°of shoulder abduction in the coronal plane. Muscle activity was expressed as a percentage of maximum voluntary isometric contraction. Findings: The four muscles tested performed at a higher intensity during the modified shrug than the standard shrug. Upper trapezius and lower trapezius activity was significantly greater (P b 0.05) in both populations. Though for middle trapezius and serratus anterior muscles, the modified shrug was statistically significant only in the normal population, P = 0.031 and P = b 0.001 respectively. Interpretation: The upward rotation shrug is a more effective exercise for eliciting muscle activity of the upper and lower trapezius than the standard shrug in a normal and multi-directional instability population. Clinically, the upward rotation shrug might be useful to address scapular dyskinesis involving drooping shoulders and reduced scapula upward rotation.

Research paper thumbnail of Hydrodilatation (distension arthrography): a long-term clinical outcome series

British Journal of Sports Medicine, 2007

To describe and compare the medium to long-term effectiveness of hydrodilatation and posthydrodil... more To describe and compare the medium to long-term effectiveness of hydrodilatation and posthydrodilatation physiotherapy in patients with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. Methods: Patients with primary and secondary glenohumeral contractures associated with rotator cuff pathology were recruited into a 2-year study. They all underwent hydrodilatation, followed by a structured physiotherapy programme. Patients were assessed at baseline, 3 days, 1 week, 3 months, 1 year and 2 years after hydrodilatation with primary outcome measures (Shoulder Pain and Disability Index, Shoulder Disability Index and percentage rating of ''normal'' function; SD%) and secondary outcome measures (range of shoulder abduction, external rotation and hand behind back). Comparisons in recovery were made between the primary and secondary glenohumeral contracture groups at all timeframes and for all outcome measures. Results: A total of 53 patients (23 with primary and 30 with secondary glenohumeral contractures) were recruited into the study. At the 2-year follow-up, 12 patients dropped out from the study. At baseline, the two contracture groups were similar with respect to their demographic and physical characteristics. The two groups of patients recovered in a similar fashion over the 2-year follow-up period. A significant improvement was observed in all outcomes measures over this period (p,0.01), so that both function and range of movement increased. The rate of improvement was dependent on the outcome measure that was used. Conclusions: Hydrodilatation and physiotherapy increase shoulder motion in individuals with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. This benefit continues to improve or is maintained in the long term, up to 2 years after hydrodilatation.

Research paper thumbnail of Effect of exercise-based management on multidirectional instability of the glenohumeral joint: a pilot randomised controlled trial protocol

BMJ Open, 2016

IntroductionThe most commonly recommended treatment for multidirectional instability (MDI) of the... more IntroductionThe most commonly recommended treatment for multidirectional instability (MDI) of the shoulder is exercise. Despite this recommendation, there is limited evidence to support the effectiveness of exercise. The aim of this paper is to describe a pilot randomised controlled trial comparing the effectiveness of 2 exercise programmes on outcomes of participants with MDI.Methods and analysisConsenting participants between 12 and 35 years, with non-traumatic MDI will be randomly allocated to participate in either the Rockwood Instability programme or the Watson MDI programme. Both programmes involve 1 consultation per week for 12 weeks with a physiotherapist to prescribe and progress a home exercise programme. Outcomes will be assessed at baseline, 6, 12, 24 and 52 weeks. Primary outcome measures include the Melbourne Instability Shoulder Score and Western Ontario Shoulder Index. Secondary outcomes include scapular coordinates, scapular upward rotation angles, muscle strength, ...

Research paper thumbnail of Thoracic outlet syndrome part 1: Clinical manifestations, differentiation and treatment pathways

Research paper thumbnail of The effect of exercise based management for multidirectional instability of the glenohumeral joint: A systematic review

Journal of Science and Medicine in Sport, 2013

The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumera... more The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumeral joint is exercise-based management. The primary objective of this review was to evaluate the effectiveness of exercise-based management in patients with MDI. The secondary aim was to observe the types of exercise protocols and outcomes used, as well as any adverse results associated with exercise. The Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro, Current Contents, Allied and Complementary Medicine (AMED), Australasian Medical Index (AMI), Ausport, and Clinical Trials Registers were searched for published and unpublished studies from the inception date to June 2012 using the keywords multidirectional instability, glenohumeral, and exercise. Selection criteria included all study designs (except case reports and case series) and participants with clinically diagnosed MDI using exercise-based management. Inclusion criteria were not limited by outcomes. The authors' own risk-of-bias tool was used for quality assessment of studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to synthesize the evidence. The risk of bias was high in all 7 included studies. For before-and-after comparisons of exercise-based management, GRADE assessment showed very low-quality evidence for improvements in shoulder kinematics, the Rowe score, overall status rating, and peak muscle strength. The effect of exercise-based management on MDI was variable across the included studies because of study heterogeneity and a high level of bias. There is a need for high-quality intervention studies to be undertaken to validate the effect of exercise for MDI.

Research paper thumbnail of Thoracic outlet syndrome Part 2: Conservative management of thoracic outlet

Manual Therapy, 2010

Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and v... more Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet. Classified into several sub-types, conservative management is generally recommended as the first stage treatment in favor of surgical intervention. In cases where postural deviations contribute substantially to compression of the thoracic outlet, the rehabilitation approach outlined in this masterclass will provide the clinician with appropriate management strategies to help decompress the outlet. The main component of the rehabilitation program is the graded restoration of scapula control, movement, and positioning at rest and through movement. Adjunctive strategies include restoration of humeral head control, isolated strengthening of weak shoulder muscles, taping, and other manual therapy techniques. The rehabilitation outlined in this paper also serves as a model for the management of any shoulder condition where scapula dysfunction is a major contributing factor.

Research paper thumbnail of The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1

Shoulder & elbow, 2016

The most commonly recommended initial treatment for multidirectional instability is a rehabilitat... more The most commonly recommended initial treatment for multidirectional instability is a rehabilitation program. Although there is evidence to support the effect of conservative management on this condition, the published literature provides little information on the exercise parameters of such programs. In addition, current published rehabilitation programs for multidirectional instability do not focus on scapula stability or exercise drills into functional and sports-specific positions, which are often important aspects to consider in this patient population. The aim of this paper (Part 1) is to outline the first two stages of a six-stage rehabilitation program for the conservative management of multidirectional instability with a focus on scapula control and exercise drills into functional positions. This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial (Australian New Zealand Clinical Trials Registry #ACTRN12613001240730). The inform...

Research paper thumbnail of Comparison of 2 Exercise Rehabilitation Programs for Multidirectional Instability of the Glenohumeral Joint: A Randomized Controlled Trial

The American journal of sports medicine, 2017

The recommended initial treatment for multidirectional instability (MDI) of the shoulder is a reh... more The recommended initial treatment for multidirectional instability (MDI) of the shoulder is a rehabilitation program, yet there is very low-quality evidence to support this approach. Purpose/Hypothesis: The purpose was to compare the Watson MDI program and Rockwood Instability program among patients with nontraumatic, nonstructural MDI. The hypothesis was that the Watson MDI program would produce clinically and statistically superior outcomes over the Rockwood Instability program. Randomized controlled trial; Level of evidence, 2. Forty-one participants with MDI were randomly allocated to the Watson MDI or Rockwood Instability program. Participants attended 12 weekly physiotherapy sessions for exercise prescription. Outcomes were assessed at baseline and 6, 12, and 24 weeks after randomization. Primary outcomes were the Melbourne Instability Shoulder Score (MISS) and the Western Ontario Shoulder Index (WOSI). Secondary outcomes included the Orebro Musculoskeletal Pain Questionnaire,...

Research paper thumbnail of Hydrodilatation (distension arthrography): a long-term clinical outcome series

British Journal of Sports Medicine, 2007

Objectives: To describe and compare the medium to long-term effectiveness of hydrodilatation and ... more Objectives: To describe and compare the medium to long-term effectiveness of hydrodilatation and posthydrodilatation physiotherapy in patients with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. Methods: Patients with primary and secondary glenohumeral contractures associated with rotator cuff pathology were recruited into a 2-year study. They all underwent hydrodilatation, followed by a structured physiotherapy programme. Patients were assessed at baseline, 3 days, 1 week, 3 months, 1 year and 2 years after hydrodilatation with primary outcome measures (Shoulder Pain and Disability Index, Shoulder Disability Index and percentage rating of ''normal'' function; SD%) and secondary outcome measures (range of shoulder abduction, external rotation and hand behind back). Comparisons in recovery were made between the primary and secondary glenohumeral contracture groups at all timeframes and for all outcome measures. Results: A total of 53 patients (23 with primary and 30 with secondary glenohumeral contractures) were recruited into the study. At the 2-year follow-up, 12 patients dropped out from the study. At baseline, the two contracture groups were similar with respect to their demographic and physical characteristics. The two groups of patients recovered in a similar fashion over the 2-year follow-up period. A significant improvement was observed in all outcomes measures over this period (p,0.01), so that both function and range of movement increased. The rate of improvement was dependent on the outcome measure that was used. Conclusions: Hydrodilatation and physiotherapy increase shoulder motion in individuals with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. This benefit continues to improve or is maintained in the long term, up to 2 years after hydrodilatation.

Research paper thumbnail of Quantifying ‘normal’ shoulder muscle activity during abduction

Journal of Electromyography and Kinesiology, 2010

The purpose of this experiment was to obtain electromyographic (EMG) activity from a sample of he... more The purpose of this experiment was to obtain electromyographic (EMG) activity from a sample of healthy shoulders to allow a reference database to be developed and used for comparison with pathological shoulders. Temporal and intensity shoulder muscle activation characteristics during a coronal plane abduction/adduction movement were evaluated in the dominant healthy shoulder of 24 subjects. Surface and intramuscular fine wire electrodes recorded EMG activity from 15 shoulder muscles (deltoid x 3, trapezius x 3, subscapularis x 2, latissimus dorsi, pectoralis major, pectoralis minor, supraspinatus, infraspinatus, serratus anterior and rhomboids) at 2000 Hz for 10 seconds whilst each subject performed 10 dynamic coronal plane abduction/adduction movements from 0 to 166-° to 0-° with a light dumbbell. Results revealed that supraspinatus (-.102 sec before movement onset) initiated the movement with middle trapezius (-.019 sec) and middle deltoid (-.014 sec) also activated before the movement onset. Similar patterns were also found in the time of peak amplitude and %MVC with a pattern emerging where the prime movers (supraspinatus and middle deltoid) were among the first to reach peak amplitude or display the highest % MVC values. In conclusion, the most reproducible patterns of activation arose from the more prime mover muscle sites in all EMG variables analysed and although variability was present, there emerged "invariant characteristics that were considered "normal for this group of non pathological shoulders. The authors believe that the methodology and certain parts of the analysis in this study can be duplicated and used by future researchers who require a reference database of muscle activity for use as a control group in comparisons to their respective pathological shoulder group.

Research paper thumbnail of Intrarater and interrater reliability of a hand-held dynamometric technique to quantify palmar thumb abduction strength in individuals with and without carpal tunnel syndrome

Journal of Hand Therapy, 2017

Study Design: Clinical measurement. Introduction: Individuals with carpal tunnel syndrome (CTS) s... more Study Design: Clinical measurement. Introduction: Individuals with carpal tunnel syndrome (CTS) sometimes exhibit weakness of palmar abduction strength (TAS). Reliable assessment of this strength in both subjects with and without CTS with the commonly available Microfet 2 is not known. Purpose of the Study: The purpose of this study was to determine the intrarater and interrater reliabilities of a handheld dynamometric (HHD) method to assess TAS in individuals with and without CTS using the commercially available MicroFET2 and to examine the association between TAS in individuals with CTS and the Carpal Tunnel Symptom Questionnaire (CTSQ) scores. Methods: In 2 different study phases, individuals with and without CTS were assessed for TAS by 2 different examiners. The CTSQ was administered to the individuals with CTS. Results: Intrarater and interrater reliability coefficients (0.89-0.93 and 0.82-0.90, respectively) were excellent in individuals with and without CTS. Weak negative correlations were found between TAS and overall CTSQ and symptom severity subscale scores, and a moderate negative correlation was found between TAS and functional Status Subscale score. Discussion: This HHD method of reliably assessing TAS better quantifies deficits and progress than traditional manual muscle testing for muscle grades greater than 3/5. Conclusion: This method of HHD reliably quantifies TAS but is more reliable with the same than different raters.

Research paper thumbnail of The effects of a conservative rehabilitation program for multidirectional instability of the shoulder

Journal of Shoulder and Elbow Surgery, 2017

Background: Conservative management is commonly recommended as the first-line treatment for multi... more Background: Conservative management is commonly recommended as the first-line treatment for multidirectional instability (MDI) of the shoulder. Despite this, the evidence for efficacy of treatment is limited, and until recently, guidance for clinicians on conservative rehabilitation programs has been inadequate. This study evaluated the effectiveness of a physiotherapy-led exercise program for participants with MDI. Methods:: In a single-group study design, 43 participants (16 male, 27 female; mean age, 19.8 years, standard deviation, 4.9 years) diagnosed with MDI undertook a 12-week exercise program. Primary outcome measures were the Melbourne Instability Shoulder Score, Western Ontario Shoulder Instability Index, and Oxford Shoulder Instability Score. Secondary outcomes were strength and scapular position. All measures were taken at baseline and repeated at the conclusion of the program. Test differences before and after rehabilitation were evaluated with dependent t tests and single-group effect size calculations (standardized mean difference [SMD]) to provide a measure of the magnitude of the difference. Results: Large effects were found between pre-and postrehabilitation scores on all functional instability questionnaires, with the Western Ontario Shoulder Instability Index demonstrating the largest effect (SMD,-3.04). Scapular upward rotation improved significantly in the early ranges of abduction (0°-60°), with moderate to large effects (SMDs, 0.54-0.95). All strength measures significantly improved, with large differences identified (SMDs, 0.69-2.08). Conclusion: The identified improvement in functional status, shoulder muscle strength, and scapular positioning after rehabilitation allows greater confidence in the value of conservative management of MDI and informs further research by way of clinical trials in the area.

Research paper thumbnail of The variable roles of the upper and lower subscapularis during shoulder motion

Clinical Biomechanics, 2014

The varied roles of the subscapularis muscle as an internal rotator of the humerus, a shoulder ab... more The varied roles of the subscapularis muscle as an internal rotator of the humerus, a shoulder abductor, a humeral head depressor and an anterior stabiliser may be a result of differing innervation and lines of torque between its superior and inferior components. The aims of the study were to investigate the differences in the level of muscle activation between the upper and lower subscapularis during abduction, flexion, internal and external rotation movements, and temporal characteristics during abduction and flexion. Intramuscular electrodes recorded electromyographic muscle activity from the upper and lower subscapularis muscles of the dominant throwing arm of twenty-four normal subjects. Participants completed ten repetitions of four shoulder movements - abduction, flexion, internal rotation and external rotation. Muscle activity was expressed as a percentage of maximum voluntary isometric contraction. The lower subscapularis was found to activate at a higher level than the subscapularis during abduction, flexion and external rotation movements and this was significant during concentric and eccentric phases of abduction and flexion (<0.001). During internal rotation, upper subscapularis muscle activity mirrored that of lower subscapularis, with a mean difference of 1.14%. Neither upper nor lower subscapularis had onset data commencing prior to the abduction movement; however upper subscapularis activated significantly later than lower subscapularis (P=0.018). The lower subscapularis has significantly higher muscle activity during shoulder elevation and this might reflect its greater role as a humeral head depressor and anterior stabiliser.

Research paper thumbnail of The Specific AC Score (SACS): a new and validated method of assessment of isolated acromioclavicular joint pathology

Journal of Shoulder and Elbow Surgery, 2018

Background: Acromioclavicular (AC) joint (ACJ) pathology is a common cause of shoulder dysfunctio... more Background: Acromioclavicular (AC) joint (ACJ) pathology is a common cause of shoulder dysfunction, and treatment recommendations vary. When the efficacy of treatment is evaluated, the ability to measure outcomes specific to the population is essential. The aim of the current research was to develop and validate a specific ACJ questionnaire. Methods: Items for the "Specific AC Score" (SACS) were generated through the use of an expert panel, existing questionnaires, and patient feedback. Preliminary data analysis identified redundancy of items resulting in the questionnaire being refined. The final SACS was evaluated in 125 patients requiring surgical intervention of the ACJ. Internal consistency (the Cronbach α and corrected item-total correlation), content validity, criterion validity, responsiveness, and test-retest reliability (intraclass correlation coefficient) were examined and compared with the Shoulder Pain and Disability Index, Oxford Shoulder Score, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. The minimum detectable change score was calculated. Results: The Cronbach α for the total scale preoperatively and postoperatively was high (preoperatively = 0.91, postoperatively = 0.93). All 3 domains (Pain, Function, Quality of Life) demonstrated acceptable internal consistency (α > 0.70), and the correlation between items in each domain was satisfactory. The responsiveness was excellent (effect size, −2.32; standard response mean, −1.85) and was higher than the other general shoulder questionnaires. There were no relevant floor or ceiling effects. Reliability was high (intraclass correlation coefficient, 0.89) and the minimum detectable change was 6.5 points. Discussion: This new ACJ-specific questionnaire has been robustly developed, has good measurement properties, and has excellent responsiveness. The SACS is recommended for measuring outcomes in ACJ patients.

Research paper thumbnail of Functional improvements and electromyographic (EMG) changes in multidirectional instability of the shoulder after conservative rehabilitation

Journal of Science and Medicine in Sport, 2010

Research paper thumbnail of Evidence-Based Review of Clinical Diagnostic Tests and Predictive Clinical Tests That Evaluate Response to Conservative Rehabilitation for Posterior Glenohumeral Instability: A Systematic Review

Sports Health: A Multidisciplinary Approach, 2018

Context:Posterior glenohumeral instability is poorly understood and can be challenging to recogni... more Context:Posterior glenohumeral instability is poorly understood and can be challenging to recognize and evaluate. Using evidence-based clinical and predictive tests can assist clinicians in appropriate assessment and management.Objective:To review evidence-based clinical diagnostic tests for posterior glenohumeral instability and predictive tests that identify responders to conservative management.Data Sources:A comprehensive electronic bibliographic search was conducted using Embase, Ovid MEDLINE, PEDro, and CINAHL databases from their date of inception to February 2017.Study Selection:Studies were included for further review if they (1) reported on clinical diagnostic tests for posterior or posteroinferior instability of the glenohumeral joint, (2) assessed predictive clinical tests for posterior instability of the glenohumeral joint, and (3) were in English.Study Design:Systematic review.Level of Evidence:Level 4.Data Extraction:Data were extracted from the studies by 2 independe...

Research paper thumbnail of What is the reliability of clinical measurement tests for humeral head position? A systematic review

Journal of Hand Therapy, 2017

Study Design: Systematic review. Introduction: Physiotherapists routinely assess the position of ... more Study Design: Systematic review. Introduction: Physiotherapists routinely assess the position of the humeral head (HH) in patients with shoulder pain. Purpose of the Study: To conduct a systematic review to determine the quality and content of studies that evaluated the reliability of clinical measurement methods for assessing the HH position. Methods: Five databases and gray literature were searched for studies fitting the eligibility criteria. After abstract and full-text review, the included studies were appraised using the Quality Appraisal of Reliability Studies checklist. Articles were considered of high quality if 8 was achieved on the checklist, and the overall quality of evidence was classified using prespecified criteria. Multiple raters extracted and performed quality ratings; a consensus process was used to finalize the reliability data that were synthesized and presented in a narrative synthesis. Reliability was classified as excellent if the intracorrelation coefficients or intercorrelation coefficients (ICCs) reported exceeded 0.75. Results: Fifteen studies on the reliability of ultrasound (US) and 3 studies on palpation were included. The methodologic quality was moderate in 17 of 18 studies. The intrarater reliability for all studies was excellent (ICC, 0.76-0.99) with the exception of the 90 abduction in internal rotation position (ICC, 0.48) for palpation. The inter-rater reliability tended to be lower (ICC, 0.48-0.68) for palpation and higher (ICC, 0.66-0.99) for US. Physiotherapists demonstrated excellent intrarater reliability across different levels of training in ultrasonography. Discussion: Our study found a moderate overall level of evidence to support the use of US for assessing HH position in symptomatic or asymptomatic subjects. Conclusion: A moderate overall level of evidence exists for the use of US to reliably assess the HH position. Limited research supports the methods used for palpation within a clinical setting. Level of Evidence: 2a.

Research paper thumbnail of Evidence-based conservative rehabilitation for posterior glenohumeral instability: A systematic review

Physical Therapy in Sport, 2016

Study Design: Systematic review Objectives: To identify the best evidenced-based approach for the... more Study Design: Systematic review Objectives: To identify the best evidenced-based approach for the conservative rehabilitation of patients with posterior glenohumeral instability. Background: Posterior glenohumeral instability is more common than previously thought. Proper management is imperative to control symptoms and maximize function. Methods: We conducted an electronic search, up to November 2014, for Englishlanguage studies involving rehabilitation of posterior shoulder instability. A manual search of reference lists of included articles and previously published reviews was also performed. Results: Five studies met the review inclusion criteria. Most studies demonstrated that rotator cuff and posterior deltoid strengthening could reduce instability recurrence and pain, and increase function, mainly in those with atraumatic posterior instability without previous surgery. These studies were mainly case series or retrospective designs Conclusions: Rotator cuff and posterior deltoid strengthening may help with symptommanagement and functioning in those with posterior glenohumeral instability. Further research is needed to detect statistically significant outcomes from conservative treatment.

Research paper thumbnail of A comprehensive rehabilitation program for posterior instability of the shoulder

Journal of Hand Therapy, 2017

Posterior shoulder instability is recognised as being less prevalent than anterior instability, h... more Posterior shoulder instability is recognised as being less prevalent than anterior instability, however the diagnosis of this pathology is easily overlooked or missed and this may contribute to an underestimation of prevalence. Recently, there has been increasing recognition of this condition and consequently a greater requirement for knowledge of diagnostic procedures and treatment directions. Currently there is limited research into the conservative management of posterior instability, although it is recommended as first-line treatment prior to surgical review, particularly in those with an atraumatic instability mechanism. The aim of this paper is to outline a comprehensive rehabilitation program for the conservative management of posterior instability with a focus on scapular and humeral head control. The information provided includes extensive written information, flowcharts, figures and a table of management parameters that will provide therapists with adequate detail to replicate the program in the clinical setting.

Research paper thumbnail of Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula

Clinical Biomechanics, 2014

Background: Scapular dyskinesis, characterised by drooping scapulae and reduced upward rotation, ... more Background: Scapular dyskinesis, characterised by drooping scapulae and reduced upward rotation, has been implicated in the presentation of a number of shoulder disorders. Traditionally, in shoulder rehabilitation programmes, the shrug exercise has been prescribed to facilitate upward rotation of the scapula by strengthening the upper trapezius muscle. The aim of this research was to compare muscle activation levels during the standard shrug and the upward rotation shrug in a normal and pathological population. Methods: Surface electrodes recorded electromyographical activity from upper trapezius, middle trapezius, lower trapezius and serratus anterior muscles in 23 normal participants and 14 participants with multi-directional shoulder instability. Participants completed 10 trials of the standard shrug exercise at 0°of shoulder abduction and the upward rotation shrug exercise at 30°of shoulder abduction in the coronal plane. Muscle activity was expressed as a percentage of maximum voluntary isometric contraction. Findings: The four muscles tested performed at a higher intensity during the modified shrug than the standard shrug. Upper trapezius and lower trapezius activity was significantly greater (P b 0.05) in both populations. Though for middle trapezius and serratus anterior muscles, the modified shrug was statistically significant only in the normal population, P = 0.031 and P = b 0.001 respectively. Interpretation: The upward rotation shrug is a more effective exercise for eliciting muscle activity of the upper and lower trapezius than the standard shrug in a normal and multi-directional instability population. Clinically, the upward rotation shrug might be useful to address scapular dyskinesis involving drooping shoulders and reduced scapula upward rotation.

Research paper thumbnail of Hydrodilatation (distension arthrography): a long-term clinical outcome series

British Journal of Sports Medicine, 2007

To describe and compare the medium to long-term effectiveness of hydrodilatation and posthydrodil... more To describe and compare the medium to long-term effectiveness of hydrodilatation and posthydrodilatation physiotherapy in patients with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. Methods: Patients with primary and secondary glenohumeral contractures associated with rotator cuff pathology were recruited into a 2-year study. They all underwent hydrodilatation, followed by a structured physiotherapy programme. Patients were assessed at baseline, 3 days, 1 week, 3 months, 1 year and 2 years after hydrodilatation with primary outcome measures (Shoulder Pain and Disability Index, Shoulder Disability Index and percentage rating of ''normal'' function; SD%) and secondary outcome measures (range of shoulder abduction, external rotation and hand behind back). Comparisons in recovery were made between the primary and secondary glenohumeral contracture groups at all timeframes and for all outcome measures. Results: A total of 53 patients (23 with primary and 30 with secondary glenohumeral contractures) were recruited into the study. At the 2-year follow-up, 12 patients dropped out from the study. At baseline, the two contracture groups were similar with respect to their demographic and physical characteristics. The two groups of patients recovered in a similar fashion over the 2-year follow-up period. A significant improvement was observed in all outcomes measures over this period (p,0.01), so that both function and range of movement increased. The rate of improvement was dependent on the outcome measure that was used. Conclusions: Hydrodilatation and physiotherapy increase shoulder motion in individuals with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. This benefit continues to improve or is maintained in the long term, up to 2 years after hydrodilatation.

Research paper thumbnail of Effect of exercise-based management on multidirectional instability of the glenohumeral joint: a pilot randomised controlled trial protocol

BMJ Open, 2016

IntroductionThe most commonly recommended treatment for multidirectional instability (MDI) of the... more IntroductionThe most commonly recommended treatment for multidirectional instability (MDI) of the shoulder is exercise. Despite this recommendation, there is limited evidence to support the effectiveness of exercise. The aim of this paper is to describe a pilot randomised controlled trial comparing the effectiveness of 2 exercise programmes on outcomes of participants with MDI.Methods and analysisConsenting participants between 12 and 35 years, with non-traumatic MDI will be randomly allocated to participate in either the Rockwood Instability programme or the Watson MDI programme. Both programmes involve 1 consultation per week for 12 weeks with a physiotherapist to prescribe and progress a home exercise programme. Outcomes will be assessed at baseline, 6, 12, 24 and 52 weeks. Primary outcome measures include the Melbourne Instability Shoulder Score and Western Ontario Shoulder Index. Secondary outcomes include scapular coordinates, scapular upward rotation angles, muscle strength, ...

Research paper thumbnail of Thoracic outlet syndrome part 1: Clinical manifestations, differentiation and treatment pathways

Research paper thumbnail of The effect of exercise based management for multidirectional instability of the glenohumeral joint: A systematic review

Journal of Science and Medicine in Sport, 2013

The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumera... more The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumeral joint is exercise-based management. The primary objective of this review was to evaluate the effectiveness of exercise-based management in patients with MDI. The secondary aim was to observe the types of exercise protocols and outcomes used, as well as any adverse results associated with exercise. The Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro, Current Contents, Allied and Complementary Medicine (AMED), Australasian Medical Index (AMI), Ausport, and Clinical Trials Registers were searched for published and unpublished studies from the inception date to June 2012 using the keywords multidirectional instability, glenohumeral, and exercise. Selection criteria included all study designs (except case reports and case series) and participants with clinically diagnosed MDI using exercise-based management. Inclusion criteria were not limited by outcomes. The authors' own risk-of-bias tool was used for quality assessment of studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to synthesize the evidence. The risk of bias was high in all 7 included studies. For before-and-after comparisons of exercise-based management, GRADE assessment showed very low-quality evidence for improvements in shoulder kinematics, the Rowe score, overall status rating, and peak muscle strength. The effect of exercise-based management on MDI was variable across the included studies because of study heterogeneity and a high level of bias. There is a need for high-quality intervention studies to be undertaken to validate the effect of exercise for MDI.

Research paper thumbnail of Thoracic outlet syndrome Part 2: Conservative management of thoracic outlet

Manual Therapy, 2010

Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and v... more Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet. Classified into several sub-types, conservative management is generally recommended as the first stage treatment in favor of surgical intervention. In cases where postural deviations contribute substantially to compression of the thoracic outlet, the rehabilitation approach outlined in this masterclass will provide the clinician with appropriate management strategies to help decompress the outlet. The main component of the rehabilitation program is the graded restoration of scapula control, movement, and positioning at rest and through movement. Adjunctive strategies include restoration of humeral head control, isolated strengthening of weak shoulder muscles, taping, and other manual therapy techniques. The rehabilitation outlined in this paper also serves as a model for the management of any shoulder condition where scapula dysfunction is a major contributing factor.

Research paper thumbnail of The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1

Shoulder & elbow, 2016

The most commonly recommended initial treatment for multidirectional instability is a rehabilitat... more The most commonly recommended initial treatment for multidirectional instability is a rehabilitation program. Although there is evidence to support the effect of conservative management on this condition, the published literature provides little information on the exercise parameters of such programs. In addition, current published rehabilitation programs for multidirectional instability do not focus on scapula stability or exercise drills into functional and sports-specific positions, which are often important aspects to consider in this patient population. The aim of this paper (Part 1) is to outline the first two stages of a six-stage rehabilitation program for the conservative management of multidirectional instability with a focus on scapula control and exercise drills into functional positions. This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial (Australian New Zealand Clinical Trials Registry #ACTRN12613001240730). The inform...

Research paper thumbnail of Comparison of 2 Exercise Rehabilitation Programs for Multidirectional Instability of the Glenohumeral Joint: A Randomized Controlled Trial

The American journal of sports medicine, 2017

The recommended initial treatment for multidirectional instability (MDI) of the shoulder is a reh... more The recommended initial treatment for multidirectional instability (MDI) of the shoulder is a rehabilitation program, yet there is very low-quality evidence to support this approach. Purpose/Hypothesis: The purpose was to compare the Watson MDI program and Rockwood Instability program among patients with nontraumatic, nonstructural MDI. The hypothesis was that the Watson MDI program would produce clinically and statistically superior outcomes over the Rockwood Instability program. Randomized controlled trial; Level of evidence, 2. Forty-one participants with MDI were randomly allocated to the Watson MDI or Rockwood Instability program. Participants attended 12 weekly physiotherapy sessions for exercise prescription. Outcomes were assessed at baseline and 6, 12, and 24 weeks after randomization. Primary outcomes were the Melbourne Instability Shoulder Score (MISS) and the Western Ontario Shoulder Index (WOSI). Secondary outcomes included the Orebro Musculoskeletal Pain Questionnaire,...

Research paper thumbnail of Hydrodilatation (distension arthrography): a long-term clinical outcome series

British Journal of Sports Medicine, 2007

Objectives: To describe and compare the medium to long-term effectiveness of hydrodilatation and ... more Objectives: To describe and compare the medium to long-term effectiveness of hydrodilatation and posthydrodilatation physiotherapy in patients with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. Methods: Patients with primary and secondary glenohumeral contractures associated with rotator cuff pathology were recruited into a 2-year study. They all underwent hydrodilatation, followed by a structured physiotherapy programme. Patients were assessed at baseline, 3 days, 1 week, 3 months, 1 year and 2 years after hydrodilatation with primary outcome measures (Shoulder Pain and Disability Index, Shoulder Disability Index and percentage rating of ''normal'' function; SD%) and secondary outcome measures (range of shoulder abduction, external rotation and hand behind back). Comparisons in recovery were made between the primary and secondary glenohumeral contracture groups at all timeframes and for all outcome measures. Results: A total of 53 patients (23 with primary and 30 with secondary glenohumeral contractures) were recruited into the study. At the 2-year follow-up, 12 patients dropped out from the study. At baseline, the two contracture groups were similar with respect to their demographic and physical characteristics. The two groups of patients recovered in a similar fashion over the 2-year follow-up period. A significant improvement was observed in all outcomes measures over this period (p,0.01), so that both function and range of movement increased. The rate of improvement was dependent on the outcome measure that was used. Conclusions: Hydrodilatation and physiotherapy increase shoulder motion in individuals with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. This benefit continues to improve or is maintained in the long term, up to 2 years after hydrodilatation.