Exercise No. 11

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Related compounds such as theophylline are also potent ergogenic aids. Caffeine may act synergistically with other drugs including ephedrine and anti-inflammatory agents. It appears that male and female athletes have similar caffeine pharmacokinetics, i. In addition, exercise or dehydration does not affect caffeine pharmacokinetics. The limited information available suggests that caffeine non-users and users respond similarly and that withdrawal from caffeine may not be important.

The mechanism s by which caffeine elicits its ergogenic effects are unknown, but the popular theory that it enhances fat oxidation and spares muscle glycogen has very little support and is an incomplete explanation at best. These patients either received physical therapy only, combined acromioplasty and physical therapy, or combined rotator cuff repair, acromioplasty and physical therapy.

Solutions for Exercise no. 11

Of the shoulders evaluated at one year, no differences were reported between any of the groups. Operative treatment was no better than conservative therapy with regard to management of non-traumatic supraspinatus tears, suggesting conservative treatment may be a worthy primary treatment method. Moosmayer et al 5 compared non-operative treatment to surgical repair of rotator cuff tears less than 3cm in size. Moosmayer et al 78 in another study, observed the natural history of 50 patients with asymptomatic rotator cuff tears for three years. Eighteen tears developed symptoms during the period, and comparisons were made between tears that developed symptoms and those that did not.

Their results showed a significant increase in the mean tear size, a higher progression rate of muscle atrophy, a significant rate of fatty degeneration, and a higher rate of pathology of the long head of the biceps tendon in the symptomatic group in comparison to patients with no clinical problems. These findings suggest that while non-operative treatment programs and patient education may be a viable initial option and alternative to surgery for many patients, tear size progression and structural deterioration over time may occur, predisposing these patients to symptom recurrence and functional depreciation.

This emphasizes the importance of ongoing monitoring and surveillance. Itoi 41 proposed that those pursuing conservative treatment should consider both the potential responsiveness of the specific patient to conservative treatment as well as the potential for symptom recurrence. Better understanding of who will, or will not, respond well to conservative treatment prior to embarking on a course of conservative rehabilitation is of benefit to both the clinician and the patient.

Some authors have described pertinent factors related to a successful outcome following conservative treatment for full-thickness rotator cuff tears.

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Itoi and Tabata 79 have previously demonstrated that patients who responded well to conservative therapy exhibited good range of motion and abduction strength at initial examination. As mentioned previously, tears spreading into the posterior cuff disrupt the balance of muscular forces, impacting GHJ stability and affecting optimal function. Currently, the duration of shoulder symptoms is used as an indication for the surgical treatment of full-thickness rotator cuff tears.

This research would suggest that using duration of symptoms might not be the best clinical feature when deciding an appropriate treatment approach for patients with atraumatic, full-thickness rotator cuff tears. A commonly held view is that patients with chronic rotator cuff tears may develop symptoms when they are more active, or that a higher activity level contributes to the development of rotator cuff lesions. In patients electing initial non-operative treatment, Brophy et al 81 demonstrated that while shoulder activity level is correlated with age and gender in patients with symptomatic, atraumatic rotator cuff tears, it does not correlate with the size or severity of the tear, suggesting it may be possible that increased activity helps patients develop compensatory kinematics and strength, which may prevent or minimize symptoms.

The influence of tear size on the success of conservative management is not known. Bartolozzi et al 82 undertook a study of patients managed conservatively with symptomatic rotator cuff disease, and identified that full-thickness tears greater than 1cm 2 combined with symptoms persisting more than one year, and functional impairment and weakness were associated with a worse outcome.

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Some tears continued to increase in size, whereas many others remained dormant and did not show signs of propagation. Nevertheless, some patients with massive tears reported functional and pain improvement with conservative treatment The primary aim in treating a rotator cuff tear through conservative management is to reduce pain and improve function, and exercise rehabilitation is usually the cornerstone of this conservative management plan.

In a systematic review of conservative treatments for rotator cuff tendinopathy undertaken by Littlewood et al, 7 it was reported that exercise, whether completed at home or in a clinical setting, offered superior outcomes over no treatment or placebo, and did not differ in outcomes compared to surgery or multi-modal physiotherapy.

This suggests that the exercise component of physical therapy is fundamental in the treatment of these tears, and most exercise protocols should demonstrate clinically important change in patient-reported outcomes by 12 weeks.

While it is unknown exactly why exercise was beneficial, they postulated that the effect of exercise may be multi-factorial. This may include its potential influence on pain modulation, providing a therapeutic effect on the structurally damaged rotator cuff muscles and tendons, placebo, muscular compensation for deficient movement strategies, and reducing kinesiophobia and the patient's uncertainty if the arm should be moved.

It is proposed that cells can respond to mechanical stimuli and convert the stimulus into a cellular response to promote tendon healing. While the pathology of shoulder impingement syndrome and rotator cuff tears differ, the clinical presentation of both pathologies remains the same. Symptomatic rotator cuff tears are generally characterized clinically by pain with abduction painful arc , as well as physical impairments including rotator cuff and scapular muscular weakness and dysfunction, tightness of the posterior capsule and other soft tissues, and postural abnormalities.

The neck and the elbow should also be examined to exclude the possibility that the reported shoulder pain is referred from a pathologic condition in either of these regions. Restoration of full, pain-free range of motion, flexibility, muscle balance, and scapulothoracic and glenohumeral muscular control and stability, are all important goals of the rehabilitation. Initially, patients should be well educated on provocative postures and movements such as reaching overhead, 87 and appropriate advice and re-training be undertaken in avoiding or minimizing the occurrence of any aggravating activities.

Exercises to improve shoulder girdle and GHJ range of motion are generally required to facilitate optimal motor patterning. Active-assisted supine elevation, using the the non-affected arm to generate movement. Active-assisted external rotation using a bar powered by the non-affected arm to generate movement. It is well accepted that training and educating patients on improving scapular stability, proper neuromuscular control of shoulder girdle and thoracic posture is essential in a well designed rotator cuff exercise program.

Potential contributing mechanisms to abnormal scapular kinematics include pain, soft tissue tightness, altered muscle activation or strength imbalances, muscle fatigue, and thoracic posture. Tightness of the pectoralis minor and posterior glenohumeral capsular stiffness has been described in relation to abnormal scapular position. Altered scapulohumeral rhythm, due to either fatigue or weakness of the scapular stabilizers, can induce shoulder dysfunction with an associated decrease in rotator cuff strength.

Exercise rehabilitation programs aimed at restoring scapulohumeral rhythm have frequently targeted the serratus anterior, middle and lower trapezius, while reducing the muscle activity of upper trapezius to enhance neuromuscular control and synchronised movement during elevation. A moderate level of muscle activation is adequate to retrain neuromuscular control for scapula and glenohumeral musculature, especially in the initial phases of rehabilitation.

Understanding the impact that cuff tears have on shoulder complex function and muscle activation patterns can contribute to designing a restorative exercise rehabilitation program. Strengthening of the rotator cuff muscles is important to provide accurate positioning and stabilization of the humeral head in the glenoid fossa, preventing excessive elevation of the humerus, which may cause impingement and compression of the tendon against the coraoacromial arch. Translation of the humeral head relative to the glenoid fossa occurs in healthy shoulders and is maintained within normal limits by the coordinated activity of the rotator cuff muscles.

Increased activity of the scapula stabilizers and elbow flexor muscles has been reported representing a tactic within proximal and distal segments to reduce demand on the GHJ. They specifically demonstrated increased activation of the latissimus dorsi and teres major muscles, as a partial compensation for the deficient rotator cuff by balancing the destabilizing forces of the deltoid. This has led to the hypothesis that alternative muscle activation strategies can compensate for the deficient rotator cuff to limit the superior migration of the humeral head and establish a stable glenohumeral fulcrum for arm movement.

Strength-based exercises for rotator cuff tears should appropriately target the remaining intact cuff musculature, initiated with low load activities and progressing as patient comfort permits. In massive rotator cuff tears whereby the supraspinatus and infraspinatus are deficient, the teres minor becomes important in maintaining active external rotation, and should be a focus for the rehabilitation in massive cuff tears. Retraining and strengthening of the anterior deltoid has also been a focus for massive cuff tear patients.

In a pilot study, Ainsworth et al proposed a progressive strengthening program for massive rotator cuff tear patients aimed at the anterior deltoid and teres minor muscles, and demonstrated improvements in pain and function after 12 weeks of training.

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The program was based upon the observation that patients with massive rotator cuff tears utilized the anterior portion of deltoid in order to achieve elevation without upward shearing of the humeral head. Patients progress from supine shoulder flexion Figure 10 , to inclined shoulder flexion Figure 11 to upright shoulder flexion Figure Furthermore, the authors observed that patients who had active external rotation, fared better than those who struggled to activate lateral rotation, despite dysfunction of the infraspinatus, and hypothesized teres minor was recruited better in these patients in order to improve their external rotation function enough to enable the greater tuberosity of the humerus to clear the undersurface of the acromion during elevation.

Ainsworth et al followed this up with a prospective randomized controlled trial, comparing outcomes between patients with diagnosed massive rotator cuff tears who underwent physiotherapy combined with a comprehensive exercise program, versus physiotherapy without exercise. The exercise program focused on active anterior deltoid strengthening, teres minor strengthening for active external rotation, scapular stability and control exercises, patient education, adaptation, proprioception, and a home exercise program. Both groups demonstrated an overall improvement; however, patients receiving exercise reported a greater and faster improvement compared to those who did not receive exercise.

These results were supported by Levy et al, who found that a deltoid muscle rehabilitation regimen was effective in improving function and pain in 17 elderly patients with massive cuff tears, up to at least nine months after starting rehabilitation. While efficacy of exercise has been demonstrated, optimal dosage remains unknown. Studies reporting favorable outcomes with exercise in people complaining of shoulder pain, generally utilized three sets of repetitions completed twice per day as the recommended dose.

Tendinopathy and tears of the rotator cuff are age-related and commonly degenerative pathologies that can impact an individual's quality of life, and lead to surgical intervention. The economic and social burden associated with symptomatic rotator cuff tears is substantial, and population trends indicate this burden will progressively worsen. The role of exercise in treating rotator cuff tears has become increasingly popular as a means to treat and manage partial and full thickness tears of the rotator cuff, by addressing weakness and functional deficits that are commonly present in patients with symptomatic shoulders.

Prolonged exercise rehabilitation and non-operative treatment should be considered in patients with rotator cuff tendinopathies, partial-thickness tears and potentially small full-thickness tears. When opting for conservative treatment, it is important to understand that the responsiveness of patients and symptom recurrence will determine the potential for a successful outcome of exercise rehabilitation. Evidence-based exercise protocol for the conservative management of rotator cuff tears. National Center for Biotechnology Information , U.

Int J Sports Phys Ther. Gev Bhabra 3 St. Conflict of Interest Statement: No benefits in any form have been received or will be received from a commercial party related to the subject of this article. This article has been cited by other articles in PMC. Level of Evidence Level 5. Conservative management, exercise rehabilitation, physical therapy, rotator cuff tear.

Open in a separate window. Group I Patients over 60 years of age with chronic full-thickness rotator cuff tears, and individuals of any age with large or massive rotator cuff tears with chronic, irreversible rotator cuff changes already present, are thought to benefit from an initial course of conservative treatment. Group II Patients with either acute tears, or chronic full-thickness tears greater than 1—1. Group III Prolonged exercise rehabilitation and non-operative treatment should be considered in patients with rotator cuff tendinopathies, partial-thickness tears, and potentially small full-thickness tears, due to the limited risk for irreversible, chronic rotator cuff changes.

Low row exercise as described by Kibler et al SUMMARY Tendinopathy and tears of the rotator cuff are age-related and commonly degenerative pathologies that can impact an individual's quality of life, and lead to surgical intervention.

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Appendix 1 Evidence-based exercise protocol for the conservative management of rotator cuff tears. Anterior capsule pectoralis minor stretch Supine bear hugs.

Anterior deltoid strengthening Isometric deltoid contractions. Full-thickness rotator cuff tear prevalence and correlation with function and co-morbidities in patients sixty-five years and older. J Shoulder Elbow Surg. Conservative management of rotator cuff tears: Muscles Ligaments Tendons J.

Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: Tissue Eng Part B Rev. Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A randomised controlled study of patients with one-year follow-up.

J Bone Joint Surg Br. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease stage II impingement syndrome: Exercise for rotator cuff tendinopathy: Natural history of asymptomatic rotator cuff tears: Shoulder disorders in general practice: Shanahan EM Sladek R. Shoulder pain at the workplace. Best Pract Res Clin Rheumatol. Maffulli N Furia JP. JP Medical Ltd; Partial-thickness rotator cuff tears: The demographic and morphological features of rotator cuff disease.

A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. Substantial differences within species and within the vasculature appear to exist. In humans, exercise training improves endothelium-dependent vasodilator function, not only as a localised phenomenon in the active muscle group, but also as a systemic response when a relatively large mass of muscle is activated regularly during an exercise training programme.

Individuals with initially impaired endothelial function at baseline appear to be more responsive to exercise training than healthy individuals; that is, it is more difficult to improve already normal vascular function. While improvement is reflected in increased NO bioactivity, the detail of mechanisms, for example the relative importance of up-regulation of mediators and antioxidant effects, is unclear. Optimum training schedules, possible sequential changes and the duration of benefit under various conditions also remain largely unresolved.

In summary, epidemiological evidence strongly suggests that regular exercise confers beneficial effects on cardiovascular health. Shear stress-mediated improvement in endothelial function provides one plausible explanation for the cardioprotective benefits of exercise training.

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