TEAM TALK Boehme Workshops 8642 N 66 St Milwaukee. WI 53223 Ph 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 alignment and mobility. Active stabilization of the scapula during reach and weight bearing is the accomplishment of many Interrelated groups of muscles. However, the most direct activity is provided by the, serratus anterior and the external abdominal obliques. The serratus anterior Fig. I - 2 originates on the outer surface of the upper 8 ribs and inserts on the vertebral border of the scapula. In addition to abducting and upwardly rotating the Scapula during reach, it holds the scapula against the chest wall to provide a point of stability for muscles acting on the humerus. The lower fibers originating on the ribs, interdigitate with the external abdominal obliques (Figure 3). The obliques provide an important connection between the rib cage and the pelvis.

Without this rib cage stability, serratus activity tends to elevate the ribs rather than hold the scapula on the ribs. When scapular instability (winging) interferes with arm function in reach and weight bearing, treatment intervention is necessary. Keep in mind, there are many normal children and adults who have scapular winging. Consequently, scapular instability, in and of itself, is not a problem unless it impacts on function.

Treatment involves elongation of the rib cage. Slowly guide the ribs toward the pelvis in order to lengthen the serratus anterior and realign the rib cage in preparation for abdominal activity. Maintain this alignment for at least five minutes while the patient functions in prone (Figure 4). Position your hands as if they were the abdominals connecting the rib cage to the pelvis. This will allow the serratus to activate off the stability provided by your hands. Activity in the serratus will stimulate activity in the abdominals and vice versa. Figure 4

Weight bearing in a three-point position inhibits the patient's use of hip flexion as a static fixation point for the hips and low back. It also maintains spinal and shoulder girdle alignment (Figure 5). Here the therapist provides light support to the abdominals as a reminder to stay active.

Figure 5

You can also maintain rib cage alignment as the patient uses her arms in function (Figure 6). In this diagram, the therapist stabilizes the rib cage on the side of the reaching arm. With the other hand she maintains head and shoulder alignment of the arm in weight bearing.

Figure 6

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 is often the lack of scapular stability on the chest wall. S capular stability is essential for the control of the rotator cuff muscles acting on the arm. I use rotator cuff muscles to refer to the smaller rotator muscles that connect humerus to scapula (Figure 7). One important job of the rotator cuff muscles is to 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 to the humerus, instead of adducting the humeral head toward the glenoid fossa. The patient will rotate the humerus in either an internal or external direction to gain stability in the glenohumeral joint. Long term use of this fixation pattern will create shortening in the muscles along with scapulohumeral immobility.

Treatment will initially focus on gaining mobility of the scapula on the chest wall as the arm is moved through various ranges in space (Figure 8). My suggestion is to move the scapula until you feel resistance and hold it there until the muscles and tissue relax and the scapula moves further into its potential range. Follow this with five minutes of weight bearing in either prone or quadruped. Light support at the rib cage will encourage abdominal activity. This will help stabilize the scapula on the chest wall.

Figure 8

I then work for mobility of the humeral head within the glenoid fossa. I guide the rotation of the humeral head as the patient reaches (Figure 9). In this way, the scapula is active on the trunk as you elongate rotator cuff muscles. Take the humerus into the desired direction of rotation until you feel resistance. Maintain this alignment until the rotators relax. Then, take the humerus further into its new range and wait until the muscles relax again. Repeat this process as the patient 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 our profession is independent function. We guide patients toward (1) personal autonomy (the ability to care for self), (2) economic autonomy (the ability to contribute to society which begins with an education) 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 treatment goals. Our goals, then, reflect function such as specific physical performance of vision, reach, grasp, release and 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 control and full body weight shifting with balance. The strategy is not the goal, but merely a tool utilized to reach the occupational therapy goal. We may approach treatment from a framework of neuro-developmental treatment, myofascial release, sensory integration, splinting, visualization or a blend of treatment principles. In addition, the occupational therapist offers many gifts to the patient beyond physical control. We have an understanding of the mental aspects of disability and can therefore help our patients develop the ability to organize their sensory systems for the integrative learning that ultimately leads to optimum economic performance. The occupational therapist is well-versed in psychosocial function where the emotional aspects of disability are a vital component in the healing process. We are sensitive to the patient's feeling of isolation. We are aware of the feelings of sadness or loss connected to living in a body that is not perfect. We have the background to help parents face their unique challenges. In terms of the NDT framework, occupational therapists utilize the information found in normal development as guidelines for evaluation and treatment planning. We use direct hands-on sensory motor input to alter physical structure, to stimulate postural control and prepare the patient's central nervous system for more efficient ways to function. We help patients discover their ultimate potential.