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TEAM TALKBoehme Workshops8642 N 66 StMilwaukee. WI 53223Ph 888-463-4668 www,boehmeworkshops.com

OPEN FORUM . .By Regi Boehme, OT

1. HOW DO I GET SCAPULAR STABILITY IN MY PATIENTS?

Scapular stabilization on the thorax relies, in part, on shoulder girdle, spine and rib cage alignmentand mobility. Active stabilization of the scapula during reach and weight bearing is the

accomplishment ofmany Interrelatedgroups of muscles.However, the most

direct activity isprovided by the,serratus anterior andthe external abdominalobliques. The serratusanterior Fig. I - 2originates on the outersurface of the upper 8ribs and inserts on thevertebral border of thescapula. In addition to

abducting andupwardly rotating theScapula during reach,it holds the scapulaagainst the chest wallto provide a point ofstability for musclesacting on the humerus.The lower fibersoriginating on the ribs,interdigitate with the

external abdominalobliques (Figure 3).The obliques providean importantconnection betweenthe rib cage and thepelvis.

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Without this rib cage stability, serratus activitytends to elevate the ribs rather than hold thescapula on the ribs.

When scapular instability (winging) interferes witharm function in reach and weight bearing, treatmentintervention is necessary. Keep in mind, there aremany normal children and adults who havescapular winging. Consequently, scapularinstability, in and of itself, is not a problem unless it

impacts on function.

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Treatment involves elongation of the rib cage. Slowlyguide the ribs toward the pelvis in order to lengthen theserratus anterior and realign the rib cage in preparationfor abdominal activity. Maintain this alignment for at leastfive minutes while the patient functions in prone (Figure4). Position your hands as if they were the abdominalsconnecting the rib cage to the pelvis. This will allow theserratus to activate off the stability provided by yourhands. Activity in the serratus will stimulate activity in theabdominals and vice versa.

Figure 4

Weight bearing in a three-point position inhibits thepatient's use of hip flexion as a static fixation point for thehips and low back. It also maintains spinal and shoulder

girdle alignment (Figure 5). Here the therapist provideslight support to the abdominals as a reminder to stayactive.

Figure 5

You can also maintain rib cage alignment as the patientuses her arms in function (Figure 6). In this diagram, thetherapist stabilizes the rib cage on the side of thereaching arm. With the other hand she maintains headand shoulder alignment of the arm in weight bearing.

Figure 6

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2. WHAT CAUSES SCAPULOHUMERAL TIGHTNESS AND HOW DO YOU TREAT IT?

Figure 7

Scapulohumeral tightness describes an adaptation to an earlier problem. The original problem isoften the lack of scapular stability on the chest wall. S capular stability is essential for the control ofthe rotator cuff muscles acting on the arm. I use rotator cuff muscles to refer to the smaller rotatormuscles that connect humerus to scapula (Figure 7). One important job of the rotator cuff muscles isto adduct, depress and alter the orientation of the humeral head to ensure mobility during reach.

When the scapula is not stable on the rib cage, the action of the rotators will pull the scapula close tothe humerus, instead of adducting the humeral head toward the glenoid fossa. The patient will rotatethe humerus in either an internal or external direction to gain stability in the glenohumeral joint. Longterm use of this fixation pattern will create shortening in the muscles along with scapulohumeralimmobility.

Treatment will initially focus on gaining mobility of thescapula on the chest wall as the arm is moved throughvarious ranges in space (Figure 8). My suggestion isto move the scapula until you feel resistance and holdit there until the muscles and tissue relax and thescapula moves further into its potential range. Followthis with five minutes of weight bearing in either proneor quadruped. Light support at the rib cage willencourage abdominal activity. This will help stabilizethe scapula on the chest wall.

Figure 8

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I then work for mobility of the humeral head within theglenoid fossa. I guide the rotation of the humeral head as thepatient reaches (Figure 9). In this way, the scapula is activeon the trunk as you elongate rotator cuff muscles. Take thehumerus into the desired direction of rotation until you feelresistance. Maintain this alignment until the rotators relax.Then, take the humerus further into its new range and waituntil the muscles relax again. Repeat this process as thepatient continues to reach or use his hands.

Figure 9

3. WHAT IS THE ROLE OF OCCUPATIONAL THERAPY WITHIN A NEURO-DEVELOPMENTAL

TREATMENT FRAMEWORK

The role of occupational therapy does not change within any treatment framework. The focus of ourprofession is independent function. We guide patients toward (1) personal autonomy (the ability tocare for self), (2) economic autonomy (the ability to contribute to society which begins with aneducation) and (3) social autonomy (the ability to be with others and participate in leisure activity).Our greatest challenge is to stay focused on our role and communicate that role in our treatmentgoals.

Our goals, then, reflect function such as specific physical performance of vision, reach, grasp, releaseand manipulation, self-care and leisure. To help the patient to reach those goals our strategies may

include the development of head and trunk control, gaining scapular mobility, pelvic and hip controland full body weight shifting with balance. The strategy is not the goal, but merely a tool utilized toreach the occupational therapy goal. We may approach treatment from a framework ofneuro-developmental treatment, myofascial release, sensory integration, splinting, visualization or ablend of treatment principles.

In addition, the occupational therapist offers many gifts to the patient beyond physical control. Wehave an understanding of the mental aspects of disability and can therefore help our patients developthe ability to organize their sensory systems for the integrative learning that ultimately leads tooptimum economic performance.

The occupational therapist is well-versed in psychosocial function where the emotional aspects ofdisability are a vital component in the healing process. We are sensitive to the patient's feeling ofisolation. We are aware of the feelings of sadness or loss connected to living in a body that is notperfect. We have the background to help parents face their unique challenges.

In terms of the NDT framework, occupational therapists utilize the information found in normaldevelopment as guidelines for evaluation and treatment planning. We use direct hands-on sensorymotor input to alter physical structure, to stimulate postural control and prepare the patient's centralnervous system for more efficient ways to function. We help patients discover their ultimate potential.