Journal of Bodywork & Movement Therapies 37 (2024) 164–169

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Journal of Bodywork & Movement Therapies

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Rotator cuff isometric exercises in combination with scapular muscle

strengthening and stretching in individuals with rotator cuff tendinopathy:
A multiple-subject case report
Denise Dal’Ava Augusto a, Rodrigo Scattone Silva b, João Felipe de Medeiros Filho c, Lori
Ann Michener d, Catarina de Oliveira Sousa a, *
a
Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
b
Faculty of Health Sciences of Trairi, Federal University of Rio Grande do Norte, Santa Cruz, RN, Brazil
c
Department of Surgery, Federal University of Rio Grande do Norte, Natal, RN, Brazil
d
Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA

A R T I C L E I N F O A B S T R A C T

Handling Editor: Dr Jerrilyn Cambron Background and purpose: To assess the effects of a rehabilitation protocol of rotator cuff (RC) isometrics coupled
with traditional shoulder exercises on patient-rated outcomes, muscle strength, and electromyographic activity
Keywords: in individuals with RC tendinopathy. Methods: Eleven individuals (8 women and 3 men, 37.9 ± 5.6 years) with
Case report RC tendinopathy performed isometric RC exercises in combination with scapular muscle stretching and
Exercise therapy
strengthening for 6 weeks. Treatment effects were assessed with patient-rated pain and shoulder function, iso­
Pain management
metric muscle strength, electromyographic activity during arm elevation and internal and external shoulder
Shoulder
rotation, and pain during arm elevation before and at the end of the first session, and after 6 weeks of inter­
vention. Results: There were improvements in pain and shoulder function, increased isometric muscle strength
for arm elevation and internal rotation, increased muscle activity of the infraspinatus and serratus anterior, and
reduced pain during arm elevation after 6 weeks of intervention. Discussion: This case report showed im­
provements on pain and function, increases on isometric strength of the shoulder and on electromyographic
activity of the serratus anterior and infraspinatus muscles, as well as decreases on pain during arm elevation,
after a 6-week intervention of RC isometric exercises associated with scapular muscle stretching and strength­
ening in patients with RC tendinopathy.

1. Background and purpose RC tendinopathies (Lewis et al., 2015). Isotonic exercises of both RC and
scapular muscles are effective for improving pain and function, with no
Shoulder pain is a common problem characterized by limitations in difference between eccentric and concentric exercises for improving
range of motion due to pain which affect functional independence and pain, range of motion (ROM) or muscle strength (Lewis et al., 2015).
quality of life (Lin et al., 2005; Sousa et al., 2015). Individuals with Isometric exercises have emerged as a tool for rehabilitating patellar
rotator cuff (RC) tendinopathy may present with changes in neuro­ tendinopathy, showing superior results compared to isotonic exercises
muscular control during arm elevation, such as reduced posterior tilting for reducing pain and improving quadriceps strength and function (Rio
and upper rotation and increased internal scapula rotation (Ludewig and et al., 2015) with immediate effects (Rio et al., 2015) and after a 4-week
Reynolds, 2009), decreased activation of the serratus anterior, middle trial (Rio et al., 2016). Beyond, a systematic review has concluded that
and lower trapezius, increased upper trapezius activation (Lin et al., isometric exercise results in pain reduction with larger effects than
2005), reduced RC co-activation, and increased activation of the middle others exercises, such as aerobic and dynamic resistance (Naugle et al.,
deltoid (Myers et al., 2009). 2012). Therefore, isometric exercises may be recommended for the
Therapeutic exercise has been the primary intervention for treating management of tendinopathy, especially when isotonic exercises are not

* Corresponding author. Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Av. Sen. Salgado Filho, 3000 – Lagoa Nova, 58078-970,
Natal, RN, Brazil.
E-mail address: [email protected] (C.O. Sousa).

https://doi.org/10.1016/j.jbmt.2023.11.032
Received 20 February 2023; Received in revised form 25 September 2023; Accepted 15 November 2023
Available online 22 November 2023
1360-8592/© 2023 Elsevier Ltd. All rights reserved.
D.D. Augusto et al. Journal of Bodywork & Movement Therapies 37 (2024) 164–169

tolerated due to the pain (Malliaras et al., 2015). (DFS-X1000, Nextech Global Company Limited, Thailand), with the
To our knowledge, only one study used isometric exercises for the RC participants seated on a chair (Michener et al., 2016): for arm elevation,
in patients with acute RC tendinopathy, and an improvement in pain, the shoulder was elevated at 90◦ in the scapular plane, and for rotations,
function and isometric strength was observed. However, this study the shoulder was positioned at 0◦ in abduction, elbow flexed at 90◦ , and
found no differences when comparing this intervention to other in­ wrist in neutral position. Individuals were instructed to push with
terventions such as cryotherapy and cryotherapy associated with iso­ maximum possible strength against the dynamometer, that was attached
metric exercises and the intervention focused exclusively on the external to an immovable apparatus fixed on a column, with their distal part of
rotation muscles and lasted for one week (Parle et al., 2017). Therefore, the wrist (Fig. 1). The strength was collected in Kilogram/Force (Kgf)
the effects of isometric RC training on shoulder tendinopathies remain and normalized against body mass and expressed as a percentage of
uncertain. body weight (BW%). An average of 2 contractions of 5 seconds was
The aim of this case report was to investigate the immediate and 6 performed, with 60 seconds of rest between attempts (Bandholm et al.,
weeks of intervention effects of an isometric exercise protocol for the RC 2006). Pain during contractions was assessed using the numerical pain
muscles, on pain, function, muscle strength, and electromyographic rating scale (NPRS) (0–10). The MDC for NPRS in individuals with
activity of the shoulder in individuals with RC tendinopathy. We hy­ shoulder pain is 1.1 (Mintken et al., 2009).
pothesized that individuals with RC tendinopathy will show improve­ In order to determine the researcher’s relative reliability, prior to the
ment in the evaluated outcomes immediately after the first intervention start of the study, the researcher performed reliability test of the
session as well as after 6 weeks of the protocol. maximum isometric shoulder muscles variables in 12 healthy in­
dividuals who were assessed in the same day 30 minutes apart in order
2. Cases description to determine the intraday reliability, and in two different days seven
days apart for the interday reliability. The intra-class correlation coef­
2.1. Participants ficient (ICC2,1), standard error measurement (SEM), and MDC values for
intraday reliability were 0.95, 0.61BW% and 0.86BW% for elevation,
Eleven individuals who met the inclusion criteria of 18–45 years old, 0.98, 0.58BW% and 0.82BW% for internal rotation, and 0.96, 0.68BW%
shoulder pain ≥3 months (Martinez-Calderon et al., 2017), at least one and 0.96BW% for external rotation, respectively. The ICC, SEM and
positive tests for the diagnosis of RC tendinopathy of the supraspinatus MDC values for the interday reliability were 0.84, 1.05BW% and
and/or infraspinatus (Jobe test and/or resisted external rotation, 1.49BW% for elevation, 0.96, 0.87BW% and 1.24BW% for internal
respectively) and clinical diagnosis seen in imaging of nuclear magnetic rotation, and 0.94, 0.77BW% and 1.08BW% for external rotation,
resonance and/or ultrasonography (Martinez-Calderon et al., 2017) respectively.
were included in this study. The exclusion criteria were: impairment in The electromyographic (EMG) activity of the middle deltoid, infra­
the long head of the biceps; adhesive capsulitis (Martinez-Calderon spinatus, serratus anterior and lower trapezius muscles was measured
et al., 2017); history of glenohumeral dislocation or subluxation or during the isometric strength assessment. Passive electrodes (Miotec®,
fracture (Alburquerque-Sendín et al., 2013) or surgical stabilization Porto Alegre, RS, Brazil) with a 4-channel signal conditioning module
(Martinez-Calderon et al., 2017); signs of partial or complete rupture of (EMG system do Brasil®, São José dos Campos, SP, Brazil) were used
the RC; sports activity with high demands on the shoulder (Bandholm with a digital analog converter (A/D) (CAD, 12/36-60K), 12-bit reso­
et al., 2006); neurological and/or rheumatological disorders (Marti­ lution and sampling frequency of 2,000Hz. The electrodes were posi­
nez-Calderon et al., 2017); use of corticosteroid injections in the past 3 tioned according to Michener (Michener et al., 2016) (Fig. 1D). Root
months, and body mass index >28kg/m2 (Alburquerque-Sendín et al., Mean Square (RMS) was used for analysis, normalized by the peak of the
2013). All individuals provided written consent prior to participation. corresponding maximum contraction performed during the
The study was approved by the University’s Ethics Committee (approval pre-intervention assessment. These EMG measurements have been
number: 3.434.684) and was carried out in the Neuromuscular Perfor­ demonstrated to be reliable and valid tools, with MDC during arm
mance Analysis Laboratory of Federal University of Rio Grande do elevation between 5.2% and 35.4% of reference contraction (Michener
Norte, Brazil, between September 2019 and February 2020. et al., 2016).
Beyond, participants performed three arm elevations in the scapular
2.2. Evaluation procedures plane without weight, and supporting a weight of 1.5 kg (participant ≤
68 kg of body weight) and a weight of 2.5 kg (participant > 68.1kg)
One researcher performed all the procedures of recruitment, selec­ (Michener et al., 2016), and reported their pain (0–10) after each
tion, evaluations, and interventions. Shoulder pain and function, repetition. The number of participants who received a weight of 1.5 kg
strength and electromyographic activity of the shoulder, and arm and 2.5 kg is described on Table 1.
elevation were evaluated 3 times: 1) pre-intervention evaluation (before
the first intervention session); 2) post-immediate evaluation (immedi­ 2.3. Intervention
ately after the first session); and 3) after 6 weeks of intervention
evaluation. The intervention was performed at a frequency of 2 times a week and
Shoulder pain and function were assessed in the pre-intervention and consisted of stretching exercises (upper trapezius and pectoralis minor
6-week post evaluations using the Penn Shoulder Score (Penn) (Napoles muscles and posterior shoulder portion), strengthening the scapular
et al., 2010) and Western Ontario Rotator Cuff Index (WORC) (Diniz muscles (serratus anterior and lower trapezius muscles), and isometric
Lopes et al., 2008). Penn has three domains (pain, satisfaction, and RC exercises (Fig. 2).
function), and total score ranges from 0 to 100 and the minimal Stretches were performed in 3 sets of 30 seconds of support for each
detectable change (MDC) of the questionnaire is 11.4 (Leggin et al., limb with 30 seconds between repetitions, and strengthening exercises
2006). The WORC has five domains regarding life and health quality of the scapular muscles were performed in 3 sets of 10 repetitions with 1
which each item varies from 0 to 100 mm scored on a visual analog minute of rest between sets, with resistance provided by elastic bands
scale. Total score varies from 0 to 2100 mm and is converted into a (TheraBand®, The Hygenic Corporation, Akron, OH) and the progres­
percentage score (0–100%) (Diniz Lopes et al., 2008; Kirkley et al., sion determined by a change in the color of the bands according to the
2003a). The MDC of WORC has been shown to be 245.26 mm (Kirkley participant’s perception (Camargo et al., 2015) (Fig. 2).
et al., 2003b). The isometric protocol was adapted from a study for patellar ten­
The maximum isometric shoulder elevation, internal rotation, and dinopathy (Rio et al., 2015), due to the scarcity of literature examining
external rotation strength were assessed using a Nextech dynamometer isometric exercises for RC tendinopathy. Thus, the protocol consisted of

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D.D. Augusto et al. Journal of Bodywork & Movement Therapies 37 (2024) 164–169

Fig. 1. Evaluation of isometric strength in the elevation (A), external rotation (B) and internal rotation (C) positions of the shoulder and positioning of the electrodes
to capture the electromyographic signal of the middle deltoid, infraspinatus, serratus anterior and lower trapezius (D) muscles.

dynamometer was also used during the intervention protocol to provide

Table 1
visual feedback, and participants were in the same positions of the iso­
Demographics and clinic characteristics of participants.
metric strength evaluation. The complete protocol lasted approximately
Variables Participants (n = 11) 15 minutes, including exercise and rest times, as well as equipment
Age (years) 37.9 (5.6) adjustments. Assessments on the maximum isometric contractions were
Duration of symptoms (months) 27.0 (28.1) repeated in the third and fifth weeks of intervention in order to adjust
Body weight (kg) 71.5 (13.8) and progress the exercise load throughout the intervention. The protocol
Height (m) 1.6 (0.1)
Body Mass Index (kg/m2) 26.5 (3.8)
was performed twice a week for 6 weeks in a supervised manner.
Sex (F/M) 8 F/3 M Beyond, participants were questioned in each session regarding to
Dominance (R/L) 11 R adverse events, especially pain in the regions of the long head of the
Affected limb (D/ND) 9 D/2 ND biceps, supraspinatus muscle and in the acromioclavicular joint, which
Weight during the arm elevation 6–1.5 kg
may suggest symptoms flare or injuries in the biceps, rotator cuff mus­
5–2.5 kg
Injured tendons 7 – Supraspinatus cles and/or the pectoralis major (Kolber et al., 2010).
4 – Supraspinatus and Infraspinatus

Legend: F: women; M: men; R: right; L: left; D: dominant; ND: non-dominant. 2.4. Data analysis
Note: values expressed as mean (standard deviation) and frequency.
A paired t-test (Penn and WORC), analysis of variance (ANOVA) with
3 sets of 30 seconds of support being performed at 70% of the maximum repeated measures and Tukey’s post hoc (muscle strength, EMG activity,
isometric strength, measured in strength assessments (Rio et al., 2015), pain on elevation and external rotation strength and pain during arm
with an 80-s interval between the sets (Naugle et al., 2014). A elevation) and Friedman’s test (pain in internal rotation strength) were
used to verify differences between the evaluations. The post hoc tests

Fig. 2. Intervention: stretching of upper trapezius (A), posterior shoulder portion (B) and pectoralis minor (C); strengthening of the serratus anterior (D) and lower
trapezius muscles (E) with elastic bands; and isometric exercises for shoulder elevation (F), external rotation (G) and internal rotation (H) with dynamometer and
visual feedback.

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were used to compare the results of the pre-intervention evaluation to Table 2

post-immediate and after 6 weeks of intervention evaluations. The Pain and function, isometric strength, and electromyography activity in all the
Statistical Package for the Social Sciences (SPSS) version 20.0 software evaluations.
program was used for all analyses with a significance level of α < 0.05. Variables Evaluations P
The mean difference (MD), the confidence interval (CI) and the effect Pre- Post- After 6
values
size (Cohen’s d) were calculated for the variables with statistical dif­ Intervention immediate weeks
ferences, with the effects interpreted as large (>0.8), moderate (~0.5),
Pain and Function
and small (<0.2) (Cohen, 1988). Penn Shoulder Score 68.3 (15.8) – 84.0 (9.5) <0.001
Total score (0–100)
2.5. Outcomes WORC Total score 965.0 – 554.1 <0.001
(0–2100) (424.8) (364.7)
Maximal Isometric Strength
Eleven individuals (8 women and 3 men, 37.9 ± 5.6 years, 26.5 ± Elevation (%BW) 8.36 (3.21)a 8.07 (2.82)b 11.60 <0.001
3.8 kg/cm2) participated in the study (Table 1). All participants (3.67)ab
completed the entire intervention period, were able to execute the Pain – Elevation 3.27 (2.60) 3.27 (0.13) 2.09 0.27
intervention protocol without any adjustments and reported no adverse (0–10) (2.58)
b
External Rotation (% 10.52 (3.01) 9.99 (2.39) 13.05 0.04
events.
BW) (2.47)b
Results showed decreases in the total Penn (MD = 15.7, CI = Pain – ER (0–10) 3.32 (2.63) 2.41 (2.98) 1.18 0.07
− 27.3–4.1, d = 1.29) and WORC (MD = 410.9, CI = − 76.0–58.8, d = (1.40)
0.46) scores after 6 weeks of intervention (Table 1). In the Penn, im­ Internal Rotation (% 11.57 (3.52)a 11.88 15.55 <0.001
BW) (2.90)b (0.65)ab
provements were seen in pain (MD = 8.60, CI = 4.69–12.50, d = − 1,96),
Pain IR (0–10) 0.00 (3.00) 0.00 (2.00) 0.00 0.57
satisfaction (MD = 3.10, CI = 1.06–5.14, d = − 1.35) and function (MD (5.00)
= 4.00, CI = − 3.78 to 11.78, d = − 0.46) subscales, and the pain at rest Electromyography Activity (% of maximal)
decreased 1.72 (CI = − 2.99–0.44, d = 1.20), pain with normal activities Middle Deltoid – 22.8 (3.2) 27.0 (17.8) 25.0 0.72
decreased 3.80 (CI = − 5.72–1.88, d = 1.76) and pain with strenuous Elevation (14.4)
Middle Deltoid – ER 22.8 (3.5) 23.3 (10.4) 37.6 0.14
activities decreased 3.10 (CI = − 5.02–1.18, d = 1.44). In the WORC, the
(30.7)
domains of pain and physical symptoms (MD = − 148.50, CI = Middle Deltoid – IR 26.8 (6.8) 28.2 (20.3) 26.0 0.99
− 240.01–56.98, d = 1.44), sports and recreation (MD = − 94.0, CI = (13.7)
− 172.81–15.18, d = 1.06) and lifestyle (MD = − 64.20, CI = − 143.22 to
a b
Infraspinatus – 23.9 (4.0) 23.2 (4.3) 32.5 0.02
Elevation (10.9)ab
14.82, d = 0.72) also presented improvements, however, no difference
Infraspinatus – ER 25.4 (3.3) 25.7 (7.8) 27.9 0.69
was observed for the work function (p˃0.05) and emotional function (10.0)
(p˃0.05) domains. Infraspinatus – IR 25.0 (6.9) 26.6 (22.0) 31.4 (9.3) 0.56
Increases in the isometric strength of shoulder elevation (MD = Serratus Anterior – 26.4 (3.9)a 27.3 (12.1) 38.5 0.01
3.24BW%, CI = 0.17–6.31, d = 0.45) and internal rotation (MD = Elevation (11.7)a
Serratus Anterior – 23.9 (6.1) 23.4 (20.6) 30.5 (9.2) 0.35
3.98BW%, CI = 0.31–7.65, d = 0.49) between the pre-intervention and
ER
the after 6 weeks of intervention evaluations were observed (Table 1). Serratus Anterior – IR 24.0 (0.3)a 26.0 (16.7) 39.4 0.05
The intervention did not cause differences in isometric strength between (23.0)a
the pre-intervention and post-immediate evaluations. Lower Trapezius – 25.2 (2.9) 24.4 (3.8) 30.4 0.34
There was an increase in the EMG activity of the infraspinatus (MD Elevation (18.2)
Lower Trapezius – ER 24.0 (3.0) 29.5 (14.5) 33.8 0.16
= 8.6%, CI = 1.30–15.90, d = 0.51) and serratus anterior (MD = 12.1%, (14.1)
CI = 4.34–17.86, d = 0.60) during the elevation and of the serratus Lower Trapezius – IR 26.6 (3.9) 21.3 (8.5) 33.0 0.06
anterior during internal rotation (MD = 15.4%, CI = 0.79–30.0, d = (14.7)
0.79) between the pre-intervention and after 6 weeks of intervention Legend: WORC: The Western Ontario Rotator Cuff Index; %BW: percentage of
evaluations. There was no difference in the EMG activity between pre- body weight; IR: Internal Rotation; ER: External Rotation.
intervention and post-immediate evaluations (Table 2). Notes: Data are expressed as mean (SD) for parametric data and median
Shoulder pain during the arm elevation without weight decreased (interquartile range) for nonparametric data (pain in internal rotation strength).
after 6 weeks of intervention compared to the pre-intervention evalua­ a: Difference between Pre-Intervention and After 6 weeks evaluations. b: Dif­
tion (MD = 1.99, CI = − 3.64–0.33, d = 0.33), with all participants being ference between Post-immediate and After 6 weeks evaluations.
asymptomatic after the 6-week intervention. Regarding shoulder pain
during arm elevation with weight, there was no difference between individuals with patellar tendinopathy. Based on these findings, it
evaluations (p˃0.05). seemed reasonable to assume that using 70% of the maximum isometric
exercises could be a useful protocol prior to activity to reduce pain
3. Discussion without inducing muscle fatigue in individuals with chronic RC ten­
dinopathy. However, our hypotheses were not confirmed, and no dif­
After the 6-week intervention including isometric exercises, there ferences were observed between the pre-intervention and
were substantial improvements in terms of shoulder pain and physical post-immediate assessments for any of our outcomes. The conflicting
function, isometric strength during shoulder elevation and internal results between our study and the study by Rio et al. (2015) and Parle
rotation, and increases in EMG activity of the infraspinatus and serratus et al. (2017) may have occurred due to methodological differences.
anterior muscles in patients with RC tendinopathy. All the improve­ While we conducted the Pre-Intervention assessment immediately
ments had at least moderate effect sizes, that can be considered clinically before the first intervention session, Rio et al. (2015) conducted their
relevant (Armijo-Olivo et al., 2011) with function (Kirkley et al., 2003a; initial evaluation one week prior to the intervention session. The large
Leggin et al., 2006) and pain (Chien et al., 2013) reaching the minimum number of repetitions of the maximum isometric strength tests in the
clinically difference, and strength exceeding our MDC. evaluations of our study may have irritated the tendon, causing
We had hypothesized that individuals with RC tendinopathy would increased discomfort, potentially leading to a smaller therapeutic effect
show improvement in the evaluated outcomes immediately after the of the isometric exercise. Nevertheless, the significant results in pain,
first intervention session based on the findings of Rio et al. (2015) that function, and strength after the 6-week intervention of this study, with
observed significant reductions in pain and increase of strength in

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D.D. Augusto et al. Journal of Bodywork & Movement Therapies 37 (2024) 164–169

no adverse events, indicates that adding high intensity isometric exer­ CRediT authorship contribution statement
cises may be a promising treatment for RC tendinopathy patients.
The strength increase after the 6-week intervention was an expected Denise Dal’Ava Augusto: Data curation, Investigation, Methodol­
result and was observed in other studies with isometric exercises in ogy, Validation, Writing – original draft, Writing – review & editing.
patients with both patellar (Rio et al., 2015) and RC (Parle et al., 2017) Rodrigo Scattone Silva: Conceptualization, Data curation, Project
tendinopathy. However, there was no improvement in pain during administration, Supervision, Writing – review & editing. João Felipe de
maximal contractions, suggesting that the increase in strength also Medeiros Filho: Conceptualization, Data curation, Investigation, Su­
increased the muscle tension, which may have masked improvements in pervision, Writing – review & editing. Lori Ann Michener: Conceptu­
pain, since pain is load dependent on tendinopathies (Rio et al., 2015). alization, Formal analysis, Investigation, Supervision, Writing – review
The pain reduction during arm elevation without load after the 6 & editing. Catarina de Oliveira Sousa: Conceptualization, Data cura­
weeks of intervention reflects the functional improvement as well as the tion, Formal analysis, Project administration, Resources, Supervision,
improvement in the self-reported pain assessed by the Penn Shoulder Writing – original draft, Writing – review & editing.
Score, since this questionnaire evaluates pain during daily life activities,
such as arm elevation. The improvement in EMG activation of the Declaration of competing interest
infraspinatus and serratus anterior muscles may have also contributed to
this. I hereby declare, on behalf of myself and my co-authors, that any of
The infraspinatus muscle plays a crucial role in stabilizing the su­ the authors, their immediate family, and any research foundation with
perior translation of the humeral head (Phadke et al., 2009) and in which they are affiliated did not receive any financial payments or other
supporting the posterior shoulder during arm elevation (Yanase et al., benefits from any commercial entity related to the subject of the
2018). Focusing on this muscle is pivotal for enhancing shoulder func­ manuscript “Rotator Cuff Isometric Exercises in Combination with
tion, particularly in cases of shoulder joint disorders (Hoshikawa et al., Scapular Muscle Strengthening and Stretching in Individuals with Ro­
2022; Yanase et al., 2018). The serratus anterior, responsible for scap­ tator Cuff Tendinopathy: A Multiple-Subject Case Report”.
ular upward rotation and posterior tilting, has been associated with
pathological conditions affecting the shoulder complex. Optimizing the Acknowledgments
scapula control during arm elevation is a crucial step in reducing po­
tential stress on the glenohumeral joint (Neumann and Camargo, 2019). Authors are grateful to all the volunteers who contributed to this
Due to their clinical significance, studies have focused on different study.
types of exercise therapy, including the motor control of rotator cuff and
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Acknowledgment of financial support Ha, S.M., Kwon, O.Y., Yi, C.H., Cynn, H.S., Weon, J.H., Kim, T.H., 2016. Effects of
scapular upward rotation exercises on alignment of scapula and clavicle and strength
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Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) - Finance Hoshikawa, K., Yuri, T., Giambini, H., Mura, N., Kiyoshige, Y., 2022. The functional role
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