As mentioned many times in the previous article, the shoulder joint is the most complex joint in the human body. Compensatory exercises are therefore definitely not among the simple ones due to its complexity. From the point of view of the therapist or trainer, however, there is a very wide field for creativity and sophistication of the exercise itself. Ideally, the exercises will include exercises aimed at a large number of body segments that may not be associated with the shoulder at first sight.
In the following, we will review together very important types of exercises that can be used in shoulder compensation exercises while activating the muscles of the trunk, where - among other things - simultaneous global coordination of the whole body is extremely important. For the purposes of complex shoulder joint compensation exercises, we have found the most useful holistic approach and the choice of exercises according to the Dynamic Neuromuscular Stabilization concept by Professor Pavel Kolář (DNS). However, the complexity of the DNS concept itself is so extensive that it is beyond the scope of this communication to describe it in detail. Therefore, for a better understanding of the essence of the concept itself, we recommend to visit the website of the official method see: https://www.rehabps.com .
Shoulder and trunk stabilisation
Compensatory exercises for the shoulder joint go hand in hand with training in the activity of adequate trunk stabilization or the so-called "core" or the center of the body. It should be obvious from the previous article (Problematic of Shoulder Joint) that movements in the shoulder joint (including the muscles that provide this movement) are linked through muscle chains to more distant body segments such as the neck, chest, ribs, trunk and pelvis. The closest functional connection to the trunk in this case is the m. serratus anterior muscle. This muscle begins at the 1st-9th rib and attaches to the inner edge of the scapula (Čihák, 2004). Functionally, it then enters the stabilization of the trunk through the oblique abdominal muscles and thus forms one of the main connections of the pelvis-trunk-shoulder axis. A publication that supports the idea of the need to work with trunk stabilization for proper compensation in athletes is a study by Davidek et al. (2018). In the study, probands completed a 6 week program involving specific trunk stabilization exercises in developmental positions. Within the results of the study, kayakers experienced improvements in both trunk and shoulder joint stability. In addition, the improvement in trunk stabilization also led to an increase in paddling force.
In order to perform shoulder joint flexion correctly, or to achieve the maximum physiological range and ideal execution of this type of movement, an individual must have the ability to brace in the thoracic spine. When the thoracic spine is in a flexed position (or kyphotic), the movement into flexion at the shoulder joint cannot be performed correctly and to its maximum possible extent. The movement is then compensated and replaced by movements of other parts of the body, which can often be overloaded. Without thoracic (or thoracic spine) upright, the upper limb is only able to reach a limited position of 120° of flexion at the shoulder joint, only after upright the thoracic spine can the body use its full range, i.e. 180°. We consider this fact to be one of the key messages in understanding the ideal compensatory exercise in the context of whole-body connection to the shoulder joint.
PRACTICAL DEMONSTRATION OF SOME EXERCISES USING TRUNK STABILIZATION
The Dynamic Neuromuscular Stabilization (DNS) method itself is based on basic biomechanical laws in harmony with the principles of developmental kinesiology. It is based on the theory that, under ideal conditions, a gradually developing child develops genetically encoded motor patterns that are automatic and species-specific for humans, allowing the development of the biomechanically most advantageous muscle interactions for the functioning of the human body at rest and in motion. The concept within the therapy uses the different milestones of childhood development as exercises using various modifications to re-establish the aforementioned physiological patterns, not only to eliminate musculoskeletal difficulties but also to prevent their overload.
One of the widely used positions of the DNS concept is the position imitating the supine position of a 3-month-old baby. The 3 month supine position is particularly important in terms of its use as an exercise for the shoulder joint to train the economy of its movement. In this position, the body learns to relax the muscles important for the shoulder joint, such as the musculus pectoralis major or the musculus trapezius, and at the same time to activate the diaphragm in the correct breathing stereotype, which then further activates the muscles of the abdominal wall and pelvic floor, among others. Economization of work in this case means work with activation and relaxation of individual muscles and muscle groups, which we teach the ability to relax at the moment when their activation is not needed and vice versa. Simplistically, we can say that we require adequate activation of the muscles that perform the movement itself without excessive activation of other muscles that do not need to perform the movement at a given moment and their hyperactivity could lead to non-ideal execution of the movement and incorrect movement stereotypes.
The position is also considered to be one of the basic ones for ensuring the activation of intra-abdominal pressure. The ability to activate intra-abdominal pressure is then considered to be an essential function for ideal trunk stabilisation, through which a person can be ideally posturally secured.
Figure 1: 3 month supine position
Figure 2: Schematic of intra-abdominal pressure activation during exercise.
Another position that can be used with effect to improve the stability of the shoulder girdle and to train the tension of the thoracic spine is undoubtedly the high bear position. Here the shoulder joint is subjected to the load of supporting the upper limbs, and the shoulder is taught stability in the anteroposterior direction. Under certain modifications of the bear position, the upper limb may also be in a more pronounced flexion in the shoulder joint, and thus we can subsequently very well enter the stabilization of the shoulder joint in its extreme position, which can be much more insufficient than movements outside the extreme position, even in normal movement.
The position itself then places considerable emphasis on correct execution and associated thoracic spine upright/elongation - so here we are able to train stabilization of the shoulder joint in its flexion under ideal muscular coordination and muscle chain activation with simultaneous upright of the thoracic spine and ensuring adequate intra-abdominal pressure.
Figure 3. and 4.: Transition from the low bear position to the high bear position
The last position of the DNS concept that we will introduce in this text is the oblique sitting position with the upper limb supported. Through the position with various modifications, we are able to effectively enter the stability of the shoulder joint even in its rotation, and thus the exercise can be used both compensatively and as a prevention of joint damage. Another positive aspect of this position is the effective possibility of practicing isolated body rotation around the shoulder. In fact, if we lose the ability of isolated movements of individual parts of the body during the movement, it is very easy to overload the musculoskeletal system in the predisposed segments. Repeated overloading of the body segments can then lead, apart from pain, to their structural damage.
Figures 5 and 6: Transition from the high oblique sitting position to rotation around the lower upper limb.
A very good exercise, especially for canoeists, from our point of view is for example the French press position with an improvement by adding components of the 3 month supine pattern (mentioned above). With this modification, we can achieve a more strength training and greater activation of the muscles around the shoulder joint while combining trunk stabilization and upright thoracic spine training. At the same time, we are able to address the musculus latissimus dorsi very well here, which is ranked as a key muscle in canoeing that performs movement on the water.
Figure 7. and 8.: Application of the 3 month supine position within the frenchpress exercise
The shoulder joint in the context of global muscle chains
We feel that this text must also contain a very important sentence, namely that the brain does not think only in the context of individual muscles, but it thinks in the context of the whole movement. This phrase is meant to emphasize the extreme need for complexity in the execution and choice of individual exercises. Thus, muscle groups cannot be strengthened only analytically, but must be taught as a whole movement based on knowledge of the basic biomechanical principles of the human body.
The movements of our body are, among other things, based on the cooperation of muscles in so-called muscle chains. Basically, we can distinguish two types of chains, namely the oblique and lateral (i.e. contralateral and ipsilateral) muscle chains. Based on our knowledge of the interconnectedness and function of these muscle chains in the body, we know that stabilising the right shoulder joint can be a therapeutic way to stabilise, for example, the left hip joint, etc.
Compensatory exercises for the shoulder joint should therefore include, in addition to specific exercises, non-specific exercises leading to an even load on the whole body, or even physical activity dominating muscle groups that are at first sight very distant from the shoulder joint. One such type of physical activity may be running, for example, which is one type of exercise that does not primarily strengthen the brachial plexus but the lower limbs. However, through the biomechanical transfer of forces, we also act on the shoulder joint as such - correct running technique must then be trained to avoid overloading even distant movement segments.
Figure 9: contralateral (left) and ipsilateral (right) muscle chains (istockphoto.com - modified by author)
As we have already mentioned above - based on the knowledge of the existence of muscle chains, we already know that improvements in a certain movement segment can affect more distant body segments, and this fact must be taken into account when choosing the appropriate compensatory exercise for the shoulder joint. This means that regenerative techniques such as massage, foam-rolling, stretching, etc. should also include more distant body segments in order to affect, for example, the shoulder joint.
Written by Jáchym Kolář
Reviewd by Jaylene Pratt
ČIHÁK, Radomír. Anatomie. 2., upr. a dopl. vyd. Ilustroval Milan MED, ilustroval Ivan HELEKAL. Praha: Grada, 2004. ISBN isbn80-7169-970-5.
DAVIDEK, Pavel, Ross ANDEL a Alena KOBESOVA. Influence of Dynamic Neuromuscular Stabilization Approach on Maximum Kayak Paddling Force. Journal of Human Kinetics [online]. 2018, 61(1), 15-27 [cit. 2023-04-17]. ISSN 1899-7562.