Assessment of dynamic humeral centering in shoulder pain with impingement syndrome: a randomised clinical trial.
Beaudreuil J, Lasbleiz S, Richette P, Seguin G, Rastel C, Aout M, Vicaut E, Cohen-Solal M, Lioté F, de Vernejoul MC, Bardin T, Orcel P.Ann Rheum Dis. 2011 Sep;70(9):1613-8.
Unquestionably, the glenohumeral joint and shoulder girdle as a whole can be one of the most complex and intimidating structures for a sports medicine student and professional. With the interplay between the mobile scapula and humerus there are a lot of issues that can arise, including impingement and decreased joint stability. In this article Beaudreil et al investigated the effect of dynamic humeral centering (DHC), or simply the selective activation of the humeral head depressors, on patients suffering from subacromial impingement and degenerative rotator cuff disease. Over a 6 year period the authors identified 69 individuals that meet the following inclusion criteria: age >30 years of age: pain for longer than 1 month; 2 positive impingement tests (Hawkins, Neer, and/or Yocum), and a Constant score of < 80. Any subject suffering from reduced range of motion, anterior-posterior instability, tendinous calcification, humeral fracture, inflammatory joint disease or having had previous surgery or a corticosteroid injection within the past 30 days were disqualified. The subjects were then blindly randomized into 1 of 2 treatment groups: the DHC group and a control group focusing on non-specific mobilization. Both groups were treated by 1 of 2 physiotherapists that had been trained in DHC techniques. Both groups underwent treatment for a total of 6 weeks, with a total of 15 visits to an outpatient clinic. The DHC group was divided into 2 phases. First, the subjects learned humeral head lowering through passive abduction of the shoulder. This phase also focused on muscular control of the scapula, perception of passive humeral head lowering, active contraction of the pec major and latissimus dorsi, as well as, the perception of the humeral head lowering affect during active co-contraction of the pec major and latissimus dorsi. Phase 2 of the DHC intervention included actively lowering the humeral head via co-contraction during active shoulder abduction under 3 conditions: 1) from 0°to 90° of shoulder abduction with the elbow bent to 90°, 2) full range abduction with the elbow extended, and 3) full abduction with elbow extended while holding a 0.5 kg hand-weight. These subjects also performed a home exercise program of 10 co-contractions 3times/day with the elbow either flexed or extended based upon where they stood in their progression. The control group was divided into 3 phases and the subjects underwent passive mobilization of the shoulder, active mobilization, and active mobilization with light resistance. Each step included a home exercise program progressing from pendulums (for phase 1) to active forward elevation while the humerus was externally rotated (for phases 2 and 3). Co-interventions, such as, prescription medication and other extraneous therapies were logged throughout the intervention by the subjects. While the DHC didn’t show a total decrease in the subjects Constant score, there was a marked decrease in pain and medication use in those sub-scores for the DHC group, at 3 month follow-up. In fact there was a 20% difference in pain when compared to the controls.
Dynamic humeral centering is not a common technique; however, this study presents some interesting findings for clinicians. While the subjects are older and dealing with degenerative rotator cuff pathology, it would be interesting to see this technique studied further in younger more athletic populations. One of the biggest roles of the rotator cuff is to operate as a GH joint dynamic stabilizer. Therefore, patients with subacromial impingement secondary to shoulder instability but with a healthier rotator cuff may have even better outcomes. One item that is especially intriguing is the decrease in the subjects’ pain and medication utilization scores. Future studies should examine this to help patients decrease the amount of pain medication. What are your thoughts, does DHC seem to have some value to us as clinicians or is it too soon to tell? Would you be willing to look into it further and incorporate it into your protocols? Do you believe that there is potentially a place as an injury prevention technique, as well as, a post-operative technique?
Written by: Mark Rice
Reviewed by: Stephen Thomas
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Beaudreuil J, Lasbleiz S, Richette P, Seguin G, Rastel C, Aout M, Vicaut E, Cohen-Solal M, Lioté F, de Vernejoul MC, Bardin T, & Orcel P (2011). Assessment of dynamic humeral centering in shoulder pain with impingement syndrome: a randomised clinical trial. Annals of the Rheumatic Diseases, 70 (9), 1613-8 PMID: 21623001
I believe when evaluating the shoulder, if not a direct trauma the scapular/gh movements should always be screened. Incorporating DHC for subacromial impinegment secondary to gh instability should always be implemented sooner then later. There have been multiple studies comparing manual/surgical techniques to an exercise intervention for subacromial impingement and these have not shown a significant difference between the groups, however there is always a pain reduction score post exercise regiment.
As far as an injury prevention technique, in a perfect world to implement a plan like this would be ideal in accordance to a pre-season screening, but in practicality it depends of your situation as a clinician/ATC.
Jenna, thanks for reading and commenting. I think that you're right on point with your thinking. DHC as an injury prevention technique is intriguing, but as clinicians we are too often put in situations where time is of the essence. I'd love to be able to give it shot, but logistically it might not be feasible. Unless we start cloning ATCs and PTs…..
Great article!! I'm a first year student and it helped me understand how "Dynamic Centralization" works. Its an important interaction between the joint capsule and the rotator cuff muscles.