Effectiveness of Therapeutic Exercise in Musculoskeletal Risk Factors Related to Swimmer’s Shoulder
Abstract
:1. Introduction
2. Materials and Methods
2.1. Eligibility Criteria
2.2. Information Sources
2.3. Search Strategy
2.4. Selection Process
2.5. Data Collection Process
2.6. Data Items
- Strength and endurance: peak torque (PT) or peak force (PF), time to PT or PF, PT or PF to body weight ratio, torque decrement, amortization time, conventional and functional agonist–antagonist PT or PF ratios, and fatigue index.
- Shoulder posture: acromial distance, forward head angle, total scapular distance, and pectoralis minor length.
- Proprioception: joint position sense (JPS), kinesthesia, and force sense.
- Glenohumeral instability: inferior, anterior, and posterior displacement of the humeral head.
- Shoulder ROM: physiological shoulder ROM of internal rotation (IR), external rotation (ER), flexion (FLX), extension (EXT), adduction (ADD), abduction (ABD), horizontal adduction (HADD), and horizontal abduction (HABD); glenohumeral internal rotation deficit (GIRD), total rotational range of motion (TRROM), posterior shoulder tightness (PST), and humeral torsion (HT).
- Scapular dyskinesia: mean difference in the position of the scapula evaluated in: IR and ER, elevation and depression, protraction and retraction, anterior and posterior tipping, and upward and downward rotation.
2.7. Study Risk of Bias Assessment
2.8. Effect Measures
2.9. Certainty Assessment
3. Results
3.1. Study Selection
3.2. Study Characteristics
3.3. Risk of Bias in Studies
3.4. Results of Individual Studies
3.4.1. Strength Program vs. No Intervention
3.4.2. Strength and Stretching Program vs. No Intervention
3.4.3. Strength Program vs. Strength Program
3.4.4. Shoulder Posture
3.4.5. Proprioception
3.4.6. Shoulder ROM
3.4.7. Shoulder Dyskinesia
3.5. Certainty of Evidence
4. Discussion
Summary of Evidence
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Type | Risk Factors |
---|---|
Musculoskeletal | Strength and endurance [2,5,7,8], shoulder posture [1,2,5,8], proprioception [1,2], glenohumeral instability [1,2,7], shoulder range of motion [1,2,5,8], scapular dyskinesia [1,2,8]. |
Training | Load [2], volume [2,3,8], intensity [2], style [2,5], distance [2,6], technique [7,8], years of experience [2], breathing side [2], training equipment [2], competitive level [2,8], cross training [2], stretching [2]. |
Epidemiological | Previous injuries [2,3], sex [2], age [2,3]. |
Psychological | Subjective pain perception and beliefs [3,8]. |
Lifestyle | Social status [2]. |
Database | Applied Criteria | Descriptors |
---|---|---|
PubMed | #1 and #2 without MeSH terms and #3 with MeSH terms. | #1: (“swimming” OR “swimmer”) AND (“shoulder” OR “shoulder injury” OR “swimmer’s shoulder”) |
#2: (“swimming” OR “swimmer”) AND (“shoulder” OR “shoulder injury” OR “swimmer’s shoulder”) AND (“prevention” OR “injury prevention” OR “injury risk factors” OR “risk factor”) | ||
#3: (“swimming”) AND (“shoulder pain” OR “shoulder injuries”) AND (“exercise” OR “exercise therapy” OR “exercise movement techniques”) AND (“muscle strength” OR “range of motion, articular” OR “joint instability” OR “proprioception” OR “posture”) | ||
Cochrane Library | Limited on study design: Cochrane reviews and trials. | #4: “swimming” AND “shoulder” |
#5: “swimming” AND “shoulder pain” | ||
Science Direct | Limited on study design: review and research articles and in research area: medicine and dentistry and nurse and health professions. | #6: (“swimming”) AND (“shoulder pain”) AND (“exercise” OR “exercise therapy”) AND (“risk factor OR prevention”) |
Medscape | Research carried out in the Medline section | #7: (“swimming” OR “swimmer”) AND (“shoulder” OR “shoulder pain” OR “swimmer’s shoulder”) AND(“exercise” OR “exercise therapy”) |
Study | Sample | Interventions | Name of Exercises | Exercise Program Characteristics | Conclusion |
---|---|---|---|---|---|
K. A. Swanik et al., 2002 [9] | 24 competitive female swimmers with an average of 20.0 ± 1.1 years. | EG: Plyometric exercises. CG: No intervention. | Concentric IR using an elastic tube. Pitchback system: throw and catch a weighted ball. | Duration: 6 wks. Frequency: 2× wk. Sets: 3. Reps: 15. Progressions: 1st 2 wks—elastic band; after—pitchback system (ball weight 2–8 Kg), cycles—1 throwing every 2 s. Moment of realization: No reference. Monitoring: Investigator. | Significant improvement after the plyometric program in kinesthesia and some muscle performance characteristics. |
K. A. Swanik et al., 2002 [15] | 26 swimmers | EG: Functional training. CG: No intervention. | Elastic-tubing exercises: IR at 90°, ER at 90°, HABD and FLX, HADD and EXT. Prone exercises: ER with 120° ABD, ER with 90° ABD. Push-up plus. | Duration: 6 wks. Frequency: 3× wk. Sets: 3. Reps: 15. Progressions: started—2nd resistance level elastic band and 2 Kg prone exercises; progresses when performing all sets without difficulty. Moment of realization: Preseason. Monitoring: Swimming coach. | No differences were found between groups in muscle performance parameters. There was a significant decrease in the incidence of shoulder pain. |
Kluemper et al., 2006 [10] | 39 competitive swimmers with a mean age of 16 ± 2 years. | EG: Strength and stretching exercises. CG: No intervention | Strength exercises: Scapular retraction, ER at 90°, Ys. Stretching exercises: Pectoral minor stretching, pectoralis major stretching. | Duration: 6 wks. Frequency: 3× wk. Strength—Sets: 3. Reps: 15. Stretching—Sets: 2. Duration: 30 s. Progressions: Initial resistance—5 reps of each strength exercise; wk1—3 × 10; wk2—3 × 15; wk3—3 × 20; wk4—3 × 10 + difficult elastic band; wk5—3 × 15; wk6—3 × 20. Moment of realization: After warm-up. Monitoring: Investigators. | The EG significantly reduced the distance from the acromion to the wall in the relaxed standing position compared to the CG. |
Lynch et al., 2010 [11] | 28 competitive swimmers between 17 and 23 years | EG: Strength and stretching exercises. CG: No intervention | Strength exercises: Y to W, L to Y, elbow push-up. Stretching exercises: Pectoralis flexibility, chin tucks. | Duration: 8 wks. Frequency: 3× wk. Strength—Sets: 3. Reps: 10. Stretching—Sets: 10. Duration: 5 s. Progressions: No progressions. Moment of realization: During regular dry-land training. Monitoring: Investigator. | The intervention carried out led to a decrease in head and shoulder forward posture in young competitive swimmers. |
Van de Velde et al., 2011 [16] | 18 swimmers with an average of 14.7 ± 1.3 years. | G1: Strength exercises. G2: Endurance exercises. | Serratus anterior: Dynamic hug movement, elbow push-up. Lower trapezius: ER with a dumbbell, bilateral HABD + scapular retraction with 2 dumbbells. | Duration: 12 wks. Frequency: 3× wk. Strength—Sets: 3. Reps: 10. Endurance—Sets: 3. Reps: 20. Progressions: Loads assessment after 6 wks. Moment of realization: Before water training. Monitoring: Physiotherapist. | Both exercises programs increased absolute strength, but neither had a positive effect on scapular muscle endurance parameters. |
Hibberd et al., 2012 [17] | 37 young competitive swimmers. | EG: Strength and stretching exercises. CG: No intervention | Strength: Shoulder FLX, Shoulder EXT, IR at 90°, ER at 90°, throwing acceleration, throwing deceleration, low scapular rows, scapular punches, Ys, Ts, Ws. Stretching: Sleeper stretch, corner stretch. | Duration: 6 wks. Frequency: 3× wk. Strength—Sets: 2. Reps: 15. Stretching—Sets: 2. Duration: 30 s. Progressions: No progressions. Moment of realization: After swimming training. Monitoring: Swimming coach. | There were no significant changes in the strength of the glenohumeral and scapular musculature and scapular kinematics between the groups. |
N. Batalha et al., 2015 [12] | 40 competitive male swimmers aged between 14 and 15 years. | G1: Strength exercises. G2: No exercise. GC: Sedentary youth. | Exercises with TheraBand: Ws, Ys, shoulder press. | Duration: 16 wks. Frequency: 3× wk. Sets: 3, 30 s rest. Reps: 20—1st 2 sets, maximum possible—3rd set. Progressions: TheraBand resistance was increased after 30 reps in the 3rd set. Moment of realization: During training. Monitoring: No reference. | Significant increases in strength of shoulder IR and an improvement in the balance of the rotators, especially at 60°/s speed. |
Manske et al., 2015 [13] | 43 young swimmers under 18 years. | EG: Strength exercises. CG: No intervention | Exercises with TheraBand: Shoulder ABD, shoulder EXT, shoulder IR, shoulder ER. | Duration: 12 wks. Frequency: 2/3× wk. Sets: 2. Reps: 15.Progressions: Initial TheraBand resistance assessment— progressively test of all resistances, athletes referring 0–10 difficulty of execution, ideal resistance when felt > 6; next progression when the athlete felt < 6 after exercises. Moment of realization: Before water training. Monitoring: Investigators. | Swimmers belonging to the EG had a significantly increased strength of shoulder ER compared to the CG. |
N. Batalha et al., 2018 [18] | 25 young swimmers aged between 12 and 15 years. | G1: Dry-land strength exercises. G2: In-water strength exercises. | Dry-land exercises: Ws, Ys, ER at 90°. In-water exercisers: ER with Theraband, ER with hand paddles, sculling. | Duration: 10 wks. Frequency: 3× wk. Dry-land—Sets: 3, 30 s rest. Reps: 20—1st 2 sets, maximum possible—3rd set. Progressions: TheraBand resistance was increased after 30 reps in the 3rd set. In-water—Sets: 3–5, 10 s rest. Progressions: Every 2 wks—wk1—3 × 30 s; wk3—4 × 30 s; wk5—3 × 45 s; wk7—4 × 45 s; wk9—5 × 30 s. Moment of realization: No reference. Monitoring: Swimming coach. | A dry-land strength program was found to be more effective in improving shoulder rotator balance and ER endurance compared to an in-water program. |
Chepeha et al., 2018 [14] | 8 swimmers aged between 18 and 35 years. | EG: Stretching exercise. CG: No intervention | Sleeper stretch. | Duration: 8 wks. Frequency: 7× wk. Sets: 5, 1–2 min rest. Duration: 2 min. Progressions: No progressions. Moment of realization: No reference. Monitoring: Swimming coach— swimmer’s performance, physiotherapist—assessment. | There was an increase in dominant shoulder IR and HADD ROM. |
Shahpar et al., 2019 [19] | 45 competitive male swimmers aged between 18 and 25 years. | G1: Stretching and strength exercises in OKC. G2: Stretching and strength exercises in CKC. CG: No intervention. | Warm-up: Run or cycle. Pendular arm movements, posterior deltoid stretching, passive IR, passive ER, sleeper stretch, corner stretch. Strength in OKC: ER, IR, dumbbell fly, reverse dumbbell fly. Strength in CKC: Push up, scapular push up, scapular dip, crab walk. | Duration: 8 wks. Frequency: 3× wk. Stretching—Sets: 1–3. Reps: 4–10, 30 s rest. Strength in OKC—Sets: 3. Reps: 8–15, 3 min rest. Strength in CKC—Sets: 3. Reps: 6–8, 1–3 min rest. Progressions: Performed regularly over time, strength training load 80–90% of 1RM. Moment of realization: No reference. Monitoring: No reference. | Both exercise programsincreased the strength of shoulder ER and IR in swimmers. The authors also suggested that OKC exercises are more effective compared to CKC exercises. |
Risk of Bias Assessment Criteria—PEDro Scale Item | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 * | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | Final Score | Quality | |
K. Swanik et al., 2002 [9] | • | • | • | • | 3/10 | Low | |||||||
K. Swanik et al., 2002 [15] | • | • | • | • | 3/10 | Low | |||||||
Kluemper et al., 2006 [10] | • | • | • | 2/10 | Low | ||||||||
** Lynch et al., 2010 [11] | • | • | • | • | 4/10 | Low | |||||||
Van de Velde et al., 2011 [16] | • | • | • | • | • | • | 5/10 | Moderate | |||||
** Hibberd et al., 2012 [17] | • | • | • | • | • | • | 5/10 | Moderate | |||||
N. Batalha et al., 2015 [12] | • | • | • | • | • | 4/10 | Low | ||||||
** Manske et al., 2015 [13] | • | • | • | • | • | • | 5/10 | Moderate | |||||
N. Batalha et al., 2018 [18] | • | • | • | • | • | 4/10 | Low | ||||||
** Chepeha et al., 2018 [14] | • | • | • | • | • | • | • | 6/10 | Moderate | ||||
Shahpar et al., 2019 [19] | • | • | • | • | • | 4/10 | Low | ||||||
PEDro Scale Item 1. Eligibility criteria specified 2. Random allocation 3. Concealed allocation 4. Group similar at baseline 5. Subject blinding 6. Therapist blinding 7. Assessor blinding 8. Less than 15% dropouts 9. Intention-to-treat analysis 10. Between-group statistical comparisons 11. Point measures and variability data |
Positive Effects | Risk of Bias | Inconsistency | Indirectness | Imprecision | Certainty of Evidence |
---|---|---|---|---|---|
Strength program on shoulder rotators’ strength/endurance | Downgraded | Not downgraded | Not downgraded | Not downgraded | Moderate |
Strength and stretching programs on shoulder posture | Downgraded | Not downgraded | Not downgraded | Not downgraded | Moderate |
Plyometric program on proprioception | Downgraded | - | Downgraded | Not downgraded | Low |
Stretching program on shoulder ROM | Not downgraded | - | Downgraded | Not downgraded | Low |
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Tavares, N.; Dias, G.; Carvalho, P.; Vilas-Boas, J.P.; Castro, M.A. Effectiveness of Therapeutic Exercise in Musculoskeletal Risk Factors Related to Swimmer’s Shoulder. Eur. J. Investig. Health Psychol. Educ. 2022, 12, 601-615. https://doi.org/10.3390/ejihpe12060044
Tavares N, Dias G, Carvalho P, Vilas-Boas JP, Castro MA. Effectiveness of Therapeutic Exercise in Musculoskeletal Risk Factors Related to Swimmer’s Shoulder. European Journal of Investigation in Health, Psychology and Education. 2022; 12(6):601-615. https://doi.org/10.3390/ejihpe12060044
Chicago/Turabian StyleTavares, Nuno, Gonçalo Dias, Paulo Carvalho, João Paulo Vilas-Boas, and Maria António Castro. 2022. "Effectiveness of Therapeutic Exercise in Musculoskeletal Risk Factors Related to Swimmer’s Shoulder" European Journal of Investigation in Health, Psychology and Education 12, no. 6: 601-615. https://doi.org/10.3390/ejihpe12060044