Upper Extremity Upper Extremity Balance and Balance and

Stability TrainingStability TrainingPatrick Hills-Meyer, MA, LAT, CSCSPatrick Hills-Meyer, MA, LAT, CSCS

Purpose A brief overview on

balance and stability

Discuss current research in upper extremity (UE) balance and stability training

Discuss current research in core stability

Discuss core stability and how it relates to shoulder (UE) stability

Discuss how to train UE balance and stability

Demonstrate UE exercise progressions both OKC and CKC

Balance The body’s ability to maintain an equilibrium by

controlling the body’s center of gravity over its base of support. (Houglum)

Proprioception The body’s ability to transmit position sense, interpret the

information, and respond consciously or unconsciously to stimulation through appropriate execution of posture and movement. (Houglum)

Proprioception Joint position sense

Appreciation and interpretation of information concerning one’s position and orientation in space

Kinesthesia The ability to appreciate and interpret joint motions

Sensation of force The ability to appreciate and interpret force applied to or

generated within a joint

Proprioception SMS The sensory motor system (SMS) is responsible for

providing awareness, coordination, and feedback to maintain form and stability, thereby serving as a major component of injury free athletic performance. (Tripp)

Research has shown that endurance and SMS control exercises should not focus on single joints. (Tripp)

Joint injury compromises SMS function

Shoulder Balance Range of motion

Flexion/extension Abduction External rotation/internal rotation

Strength Periscapular muscles (pec minor, serratus, levator,

rhomboids, trapezius) Rotator cuff muscles Large muscles (deltoids, biceps, triceps)

Proprioception Joint position sense Kinesthesia Sensaton of force

Stability The state of remaining

unchanged even in the presence of forces that would normally change the state or condition. (Myers)

Glenohumeral stability is the state of the humeral head remaining or promptly returning to proper alignment within the glenoid fossa through an equalization of forces.

(Myers)

Joint stability is mediated by both mechanical and dynamic restraints

Mechanical GH joint capsule and

ligaments, labrum, bony geometry, intra-articular pressure

Dynamic Activation and force

productions by the muscles

Shoulder Stability There is an inherent lack

of bony stability in the glenohumeral joint

Glenoid fossa is 1/3 to 1/4 the surface area of the humeral head. (Borsa)

Stability Dynamic Stability

During overhead activities, the scapular stabilizing and rotator cuff muscles function in a balanced manner to maintain a centered relationship between the humeral head and the glenoid fossa. (Borsa)

Functional joint stability Possessing adequate stability to perform

functional activity and results from the interactions between the mechanical and dynamic restraints. (Myers)

Training with Instability The advantage of an unstable training

environment would be based on the importance of neuromuscular adaptations with increases in strength. (Behm)

A strong stable core provides a solid foundation for the torques generated by the limbs.

The greatest contribution of instability training is to improve core stability rather than limb strength. (Behm)

Training with Instability The purpose of training with instability is not for

significant strength gains, but to try to improve balance, stability and proprioceptive capabilities. (Behm)

Core: Center of the Kinetic Chain

A muscular corset that works as a unit to stabilize the body both with and without movement. (Borghuis)

All motions are generated from the core and translated to the extremities. (Bliss)

The core is central to all kinetic chains in sports activities, control of core strength, balance and motion will maximize all kinetic chains of upper (and lower) extremity function. (Borghuis)

Balance and Core Stability

Maintenance of balance in upright posture is essential in daily activities and sports as well as to he prevention of injury.

Stabilization of the trunk is crucial for maintaining static or dynamic balance, especially to provide a solid base when attempting to exert forces upon external objects

Core Stability The ability to control the position and motion of the trunk

over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment in integrated activities. (Hibbs)

To increase core stability, exercises must be performed that stimulate the movement patterns of a given sport

Greater core stability provides a foundation for greater force production in the upper (and lower) extremities. (Willardson)

Stability Ball Training Recommended that programs exclude, or limit use of

stability ball as they do not appear to provide sufficient stimulus for improving muscular strength or hypertrophy. (Nuzzo)

Difficult to increase intensity through external loading

Include structural multi-joint exercises instead

Injury to the shoulder To the stabilizing structures of the shoulder results in

mechanical instability

Injury not only disrupts the mechanical stabilizers, but also causes sensorimotor (SMS) deficits

The combination of mechanical and sensorimotor alterations contribute to functional instability

Injury Cycle

(Tripp)

Injury to the shoulder Studies show that instability of the shoulder lead to

harmful effects on proprioception. (Myers) Osteoarthritis, increased nocioceptor activity, subacromial

impingement In addition to proprioceptive deficits, muscle activation

alterations are also present leading to further instability

Evidence for SMS restoration via surgical interventions: Tension in the GH joint (capsule and ligaments) leads to

mechanoreceptor stimulation Repopulation of mechanoreceptors following surgery

Injury Rehabilitation Inflammation, spasm and pain reduction

Restore ROM (balance)

Proprioception

Restore Strength

Return to functional (sport specific) activity

Restore ROM (balance) Optimal flexibility of the

inferior and posterior joint capsule enables the humeral head to roll and spin properly against the glenoid fossa during abduction and flexion. (Ronai)

Inferior capsule stretch

Posterior capsule stretch (cross over and sleeper)

Proprioception Dynamic stabilization is

paramount in restoring functional joint stability and should focus on restoring both coordinated muscle activation patterns during functional tasks as well as muscle coactivation and the resulting force coupling restraint

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Proprioception Both open and closed kinetic chain exercises have been

shown to cause improvements in joint position sense at the shoulder. (Myers)

Closed kinetic chain UE activities facilitate coactivation of the muscles around the shoulder increasing functional joint stability.

An increase in joint stability is obtained by creating greater joint congruency and stimulation of mechanoreceptors.

Shoulder (UE) Stability Program

Improve strength and endurance of the periscapular and rotator cuff muscles

Good posture and technique

Proper flexibility

Proper progressions

Based on current literature, free weight exercises performed while standing on stable surface should be the primary training modality to develop core stability and enhance sports performance in healthy athletes. (Willardson)

UE Progressions Use both OKC and CKC

Use sport specific skills

PNF-Rhythmic Stabilization OKC to CKC

Co-contraction with out movement to movement on stable, then unstable surfaces

Eyes open to closed

Active repositioning

Body weight to med balls

Short to long distance

Scapular Stability Exercises

(Jeran)

“The Six Pack”

(Jeran)

Basic Rotator Cuff Internal rotation External rotation “Full can”

Core Endurance Training (The 5 Endurance Tests)

(Bliss)

Closed Chain Exercises Stability ball push up Push up with single arm

support BOSU push up BOSU rocking

Closed Chain ExercisesStairmaster Hand Walking PB Hand Walk Outs

Closed Kinetic Chain Endurance Test

(Schulte-Edelmann)

Closed Chain Exercises

Open Chain ExercisesOne Arm Shoulder Press One Arm Row

Open Chain ExercisesBus Driver, Rock Star Triple Extension Press

Open Chain ExercisesHang Clean Snatch

Open Chain ExercisesPlyo Toss Wall Toss

Open Chain Exercises

References Behm D. and Anderson K. The role of instability with

resistance training. Journal of Strength and Conditioning Research. 20(3):716-722. 2006.

Bliss L. and Teeple P. Core stability: The centerpiece of any training program. Current Sports Medicine Reports. 4:179-183. 2005.

Borghuis J., Hof A., and Lemmink K. The importance of sensory-motor control in providing core stability. Sports Med. 38(11):893-916. 2008.

Borsa P., Laudner K., and Sauers E. Mobility and stability adaptations in the shoulder of the overhead athlete. Sports Med. 38(1):17-36. 2008.

References Hibbs A., Thompson K., French D., et al. Optimizing

performance by improving core stability and core strength. Sports Med. 38(12):995-1008. 2008.

Houglum P. Therapeutic Exercise for Athletic Injuries. (1st ed.) Champaign: Human Kinetics, 2001. pp. 268-283, 566-655.

Jeran J. and Chetlin R. Training the shoulder complex in baseball pitchers: A sport-specific approach. Strength and Conditioning Journal. 27(4):14-31. 2005.

References Myers J., Wassinger C., and Lephart S. Sensorimotor

contribution to shoulder stability: Effect of injury and rehabilitation. Manual Therapy. 11:197-201. 2006.

Nuzzo J., McCaulley G., Cormie P., et al. Trunk muscle activity during stability ball and free weight exercises. Journal of Strength and Conditioning Research. 22(1):95-102. 2008.

Ronai P. Exercise modifications and strategies to enhance shoulder function. Strength and Conditioning Journal. 27(4):36-45. 2005.

References Schulte-Edelmann J., Davies G., Kernozek T., and

Gerberding E. The effects of plyometric training of the posterior shoulder and elbow. Journal of Strength and Conditioning Research. 19(1):129-134. 2005.

Tripp B., Yochem E., and Uhl T. Functional fatigue and upper extremity sensorimotor system acuity in baseball athletes. Journal of Athletic Training. 42(1):90-98. 2007.

Willardson J. Core stability training: Applications to sports conditioning programs. Journal of Strength and Conditioning Research. 21(3):979-985. 2007.