Treatment Toolbox: Rhythmic Stabilization

 

PT Blog   •   October, 2018

“Any structure must have a strong foundation. The cornerstones anchor the foundation.”   – John Wooden

John Robert Wooden was the head basketball coach for the UCLA Bruins from 1948-1975. Known as the “Wizard of Westwood,” Coach Wooden won 10 NCAA Division I men’s basketball titles in a 12 year span, including 7 in a row (which is a record that still stands today), was awarded 7 ‘Coach of the Year’ awards, and was the first person to be inducted into the Basketball Hall of Fame as both a player and a coach. It is no surprise that he is regarded as one of the greatest coaches of all time; moreover, Wooden is revered as a great leader and influencer of business and organizational leadership due to his own philosophical belief system known as his “Pyramid of Success.” His Pyramid of Success consists of building blocks of success not only in basketball but also in life. These building blocks established a stable foundation, which supported consistent success and achievement.

This concept of a stable foundation transfers easily from the hardwood to the human body. A foundation of stability is essential to ensure optimal human movement with respect to all areas of normal life, from reaching overhead to grab a plate from the cabinet, to pushing yourself up from the bed first thing in the morning, to throwing a baseball with your child. As my neuromuscular professor loved to repeat, “proximal stability creates distal mobility.” Regrettably, injury and surgery are unfortunate speed bumps on the road of a full life limiting or inhibiting optimal biomechanics and movement patterns. These temporary pitfalls require rehabilitation and retraining to ensure a complete recovery. This blog post will discuss a specific intervention that focuses on restoring joint stability and optimal movement strategies: Rhythmic Stabilization.

To appreciate the importance of implementing rhythmic stabilization drills into your practice, one must first have an appropriate understanding of normal joint anatomy and biomechanics. [This post will focus on rhythmic stabilization drills of the shoulder, acknowledging that other peripheral joints can also benefit from stability training.] The glenohumeral joint is composed of two bony landmarks: the head of the humerus (ball) and the glenoid fossa of the scapula (socket). Many think of this joint as a true ball-and-socket joint, but the structure is more analogous to a ‘golf ball on a tee.’ This configuration allows for the glenohumeral joint to be the most mobile joint in the body, permitting a wide range of functional movement patterns. This inherent mobility concordantly requires an equal amount of joint stability, and the body achieves this with two main mechanisms: static and dynamic stabilizers. Static stabilizers include inert structures of the shoulder, most notably the glenoid labrum, joint capsule, and ligamentous restraints. These are inherent to the joint and not modifiable. Dynamic stabilizers include the four muscles of the rotator cuff: the supraspinatus, infraspinatus, teres minor, and subscapularis. This dynamic stability is essential to allow for optimal human movement as it “compresses and centers the humeral head within the glenoid fossa during shoulder movements and provides a counterforce to superior humeral head translation resulting from deltoid activity (minimizing subacromial impingement).”

 The goal of implementing rhythmic stabilization drills into a comprehensive rehabilitation program is to stimulate joint receptors and facilitate coordinated muscle contraction of shoulder force couples. The end product is enhanced neuromuscular control, which is defined as an “unconscious trained response of a muscle to a signal regarding dynamic joint stability” or more simply, “efferent (motor) output in response to afferent (sensory) stimulation.” Heightened sensitivity within joint proprioceptors allows for more coordinated movement, especially when load or speed is applied.

 How to incorporate rhythmic stabilization drills into clinical practice?

Rhythmic stabilization drills involve placing the joint in varying positions and creating multidirectional perturbations in a rhythmic fashion. Progression should be made according to the patient’s symptoms and baseline dynamic stability prior to interventions. Below is a list of parameters that can be modified to modulate difficulty: [the example listed second is more difficult]

  • Degrees of freedom: supine 90/90 position of the arm has 2 (internal rotation, external rotation v. supine shoulder flexion to 90 has 4 (flexion/extension, horizontal abduction/adduction
  • Location of perturbations: therapist can place hands close to the target joint (proximal) or further away from the joint (distal)
  • Speed of perturbations: slower, more predictable perturbations v. a quicker, randomized application.
  • Joint position: joint placement in the mid-range of motion v. joints placed at the end-range of motion.
  • Joint approximation: joints placed in an open-kinetic chain (OKC) position require less joint stability than closed-kinetic chain (CKC) positions. Unstable surfaces can also be used with CKC positions to further challenge proprioceptive input.

Rhythmic stabilization drills are an essential part to all comprehensive rehabilitation programs. Whether a 55-year-old factory worker with an overuse injury or a professional baseball pitcher recovering from labral surgery, all can benefit from a well-designed, individualized treatment plan highlighting dynamic stabilization training.

Contributing Author Credit: W. Evan Stringfellow, PT, DPT, CSCS, Cert. DN

Edited by: Ashley Theobald, DPT

Photo by:  Diego PH on Unsplash

References

  1. https://www.ortho.wustl.edu/content/Patient-Care/3127/Services/Shoulder-Elbow/Overview/Shoulder-ArthroscopyInformation/The-anatomy-of-the-shoulder.aspx
  2. Reinold M, Escamilla R, Wilk K. Current concepts in the scientific rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009; 39(2): 105-117.
  3. Reinold M, Gill J, Wilk K, Kevin, Andrews J. Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 2. Sports health. 201;2: 101-115. 10.1177/1941738110362518.
  4. Lephart SM, Warner JJP, Borsa, PA, Fu FH. Proprioception of the shoulder joint in healthy, unstable, and surgically repaired shoulders. J Shoulder Elbow Surg. 1994;3:371–380
  5. Wilk K, Macrina L, Reinold M. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. N Am J Sports Phys Ther. 2006; 1(1): 16-31.
2018-10-09T16:39:44+00:00

About the Author:

Ashley Theobald, D.P.T. – Ashley was born and raised in a small town in Alabama. She attended the University of South Alabama and was an advanced undergraduate student completing her Bachelor of Science degree in pre-professional health sciences in 2012. She then graduated with her doctorate in physical therapy in 2014. During her first year of PT school she met and married her husband, Ben. They moved to Nashville, TN where she worked for 3 years in an outpatient clinic full time and at Vanderbilt Stallworth Rehabilitation Hospital PRN. She is now working for ATI Physical Therapy full-time in Greenville, SC. She has been an avid health and fitness fan playing softball growing up, tennis in high school, and completing 2 half-marathons in college. She enjoys traveling overseas and has completed 2 short-term medical mission trips for physical therapy in the Dominican Republic (2013) and Haiti (2015), with intentions of returning yearly.
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