Ben,

Excellent point about level 5 evidence plus thank you for the great resources on evidence levels.

Thank you for adding to the discussion.

Rick Kaselj
http://www.ExercisesForInjuries.com
.

Gord,

Good point about the scope a practice.

If you have concerns contact the team involved in the client’s health or send your program with the client before their next doctor appointment.

Rick Kaselj
http://www.ExercisesForInjuries.com
.

Thanks for adding to the discussion.

Thank you for the reference. The exercises from Reinold 2009 plus his 2007 article have all been included in the Exercise Rehabilitation of the Rotator Cuff, Exercise Rehabilitation of the Shoulder and Save Your Client’s shoulder courses.

Rick Kaselj
http://www.ExercisesForInjuries.com
.

Mike,

I am glad I could help.

Talk to you soon.

Rick Kaselj
http://www.ExercisesForInjuries.com
.

It is not my intention to belittle or self-promote as the readers of my initial note implied, as the exercises provided by Rick are sound stabilization exercises. My concern is that readers can be mislead when direct joint kinematics are not discussed and I have seen too many trainers work with clients where they provide some good exercises but given in the wrong manner. Recurrent subluxations are challenging to stabilize if a complete approach is not taken in context of exercise prescription.

My initial post was referring to the course I teach for Rick’s participants directly and if any promotion was implied, please understand that it is Healing Through Movement that is being promoted. The paper which I encouraged to be read fell in the category Level 5 because it is merely clinical commentary. It is the discussion within that paper that I feel helps readers understand that mixed evaluation of research exists and can lead us to better make our decisions in exercise selection.

What spurred me to write the initial response is that it was a Kinesiologist questioning how to manage a subluxing shoulder for which, if questions such as these have arisen, I would hope they would have support of a therapist to guide their decision making. It was the concern in how they may implement Rick’s exercises and not his suggestions themselves that initiated my response.

My apologies, as such, for the misunderstanding of both my intention and my written comment and thank you to Ben & Gord for stating their concerns.

Well said Gordon, and I would like to add that if one checks out the article cited in the original posters rather cantankerous reply, it is listed at a Level 5 of evidence.

FYI, Level 5 evidence is the weakest on the Evidence-Based Medicine (EBM) levels of evidence scale:

Sources:
http://www.cebm.net/index.aspx?o=1025
http://en.wikipedia.org/wiki/Evidence-based_medicine
http://www.eboncall.org/content/levels.html

Level 5 is Quoted as being:

“Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles”

Level 5 carries a grade of recommendation of ‘D’ which equates to:

“Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.”

That makes the opinion in that article and that which was shared by the original poster, in a most belligerent way I might add, no better than yours as far as objectivity is concerned.

I’m not chiming in to discredit the article itself. It may very well work in many cases, but the point here is that someone is stomping on you acting as a major authority and belittling your opinion while sharing one that has no more validity scientifically than yours.

The reasoning behind the exercises cited in the article might very well be correct, but I offer up my opinion in agreement with Gordon in that if someone feels the need to belittle your opinion and supplement it with theirs, they should at least have the courtesy of using an article with Level 1 or 2 evidence to back them up. The best thing to do is not be rude or insolant in the first place.

Ben

Pay no attention to the negative comments with the obvious self-inflated/promotional intentions. Your exercises are sound, and yes while it is true that there are altered biomechanics within the Rotator Cuff post-subluxation, or that there are altered kinematics with almost any injury in the body because of our natural ability to substitute and compensate, the commenter above makes no mention as to how specifically she would assess the shoulder to ascertain what specific and individual substitution patterns the client is experiencing. Clearly she is a blow hard that is out to promote herself above others and that inspired me to come out of lurk mode to comment as I detest the use of blogs to do such things.

One good piece of advice is to stick within one’s scope of practice and as kinesiologists it is not our scope to provide full orthopedic assessments.

Send them to their physician, orthopedic surgeon or physiotherapist for direction and carry out said exercise program to be safe!

Gord

While you have provided this reader with some good exercises for scapular stabilization I am very disappointed that you have given some simplistic direction and not provided discussion with exercises specific to the capsular stability and strengthening of the rotator cuff. It is known with recurrent subluxations that the kinematics and firing pattern of the rotator cuff are altered and ALL exercise selections should be directed in a manner that will regain normative patterning first and foremost. If your 3 chosen exercises are provided out of the context of the client regaining these normative joint kinematics, I would have grave concern that their subluxations will be mis-managed. The direct discussion of this matter is beyond the scope of this response, so I would like to direct ALL of your readers to the following article which highlights my point and includes not only a comprehensive overview of the research (and mis-guided information that exists), but also includes the exercises that are most effective in this regard. I continue to take this approach in the Corrective Exercise workshops I teach as well as in my clinical management of shoulder injuries:

From the Journal of Orthopaedic & Sports Physical Therapy
http://www.jospt.org/issues/articleID.2290,type.2/article_detail.asp

I urge all Kinesiologists / Trainers to remain within their scope of practice and urge caution when clinical pathology is present. Gaining a detailed understanding of pathology will allow you to continue your work with your client while they work in conjunction with clinicians trained in regaining joint kinematics, as is, in this case, required to avoid recurrent subluxations and prevent surgery in the future.

I will apply this to my right shoulder. I have noticed some additional movement with reduced pain having just used your advice.

Thanks again. ~ Mike