Conference of the Tense Active Motor Control in the Shoulder. XIVth Federation of European Societies for Surgery of the Hand, FESSH Congress 3rd to 6th of June 2009 Poznan, Poland. The author explain how the connective system is determinant to control the motions in the shoulder, an special joint deeply dependent of the tissue deformation of the connective and sof tissues to build the adequate movements. Are the connective tissues a passive sub system? Dr. López proposed a new vision how understand the role of Fascias, ligaments, Capsules and other connective tissues during the movements and posture.

1. Shoulder Dysfunction:
A Tense Active Analysis
David López Sánchez, P.T., D.C.
XIVth FESSH Congress
3rd to 6th of June 2009
Poznan, Poland

2. Shoulder Pain
 The shoulder pain represent the third
most common cause of
musculoskeletal consultation in
primary care. BMJ 2005;331:1124-1128
 Near 40 to 50% of people who consult
with a new episode of shoulder pain in
primary care report persistent
symptoms after 6 to 12 months.
Rheumatology 1999, 38:160-3.
 The severity of the impingement
syndrome affects the diagnostic values
of the commonly used clinical tests
and those shows low specificity.
Rheumatology 2008;47:679–683

3. The cervicothoracic spine function & head posture have
been related to shoulder dysfunction.
 Forward Head
 Diminished Suboccipital Space &
increased thoracic kyphosis
 Bruxism
 Cervicothoractic Hypomobility
 Forward Shoulder (Scapular Protraction)
 Humeral Internal Rotation
•Lewis JS, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder
Elbow Surg. 2005;14:385–392.
•Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin mounted
electromagnetic tracking sensors. Arch Phys Med Rehabil. 2003;84:563–568.
•Kebaetse M, McClure P, Pratt NA. Thoracic position effect on shoulder range of motion, strength, and three-dimensional
scapular kinematics. Arch Phys Med Rehabil. 1999;80:945–950.
Shoulder Dysfunction and Posture
Dysfunctions?

4. Integrated TenseActive Model
Andry Vleeming PhD
&
David López DC
Poland, November 2008
MOTOR
CONTROL
Tense-Activity
Passive- Dynamic
Neural Activity
Moto-Activity
Voluntary, in Resting
and Automatic
(Reflex)
Tense - Length
Variation

5. Functional Sensory-Motor Integration, propioceptive & kinesthetic
Journal of Athletic Training 2002; 37(1):71–79.
The Sensorimotor System, PartI:ThePhysiologic Basis of Functional Joint
Stability. BryanL.Riemann; Scott M. Lephart

6. Fascies-capsules-tendons-ligaments-perineural layers-
cartilages, conective tissues (Static & Dynamic Behavorial)
TENSEACTIVE SYSTEM
Muscle Activity Neural Activity
Functional Sensory-Motor Integration, propioceptive & kinesthetic
Joint Movement
David López Sánchez
XII Latinoamerican
Congress of Physiotherapy
& Kinesiology CLAFK,
Bogotá, Colombia. 2006
TenseActive Concept
Spinal Motor Control
FUNCTIONAL MOTOR COMPLEX

7. Integrated TenseActive Model
The connective tissue damage could produce corruption
of the propioceptive and kinestethic afferents signals
Manohar Panjabi: XVI Chilean Congress of Kinesiology, Sept. 2005

8. The Passive Sub System: it is?
 The main stimulus for the
mechanoreceptors is deformation
of their differentiated
microarchitecture by compression
for the lamellated bodies and
traction and torsion for the spray-
like type.
 My conviction is No: “The
Connective System actually is a
TenseActive System totally
integrated to the Sensory Motor
Function”. D.L.

9. The Assessment of the
Anterior Head Translation
The suboccipital space distance, Cobb’s method, craniovertebral
angle, sagittal shoulder posture and anterior head translation line are
commonly used by clinicians assess the anterior head translation.
Harrison, 2002: AHT 15 mm (10mm or up to 1.0 inch) and found that
30 mm of AHT will increase the compressive and bending loads
acting on the lower cervical spine by a factor of 1.25- 4.25.
Spine 2000, 25(16):2072–2078; Eur Spine J (2007) 16:669–678; Australian Journal of Physiotherapy 2001, Vol. 47
;

10. Shoulder TenseActive CORE
The optimal kinetic chain alignment is necessary for optimal
movement. The function of the coracoclavicular ligaments is to
stabilise the clavicle at the scapula.
•The conoid ligament primarily prevents the anterior and superior
clavicular displacement.
•The trapezoid ligament is the primary constraint against
compression of the distal clavicle into the acromion.

11. SubAcromial Space & its Tenseactive
Relationships with forward shoulders
 The increased tenseactive coupling
action to either the conoid and
trapezoid ligaments in forward
shoulders avoid the coracoclavicular
separation during the arm elevation
and limit the clavicular posterior
rotation
 The superior coracoclavicular ligament
is more tense in forward shoulder
increasing the closing forces and the
joint friction in the AC-C

12. The Acromioclacivular Angle & Scapular
Orientaton
Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Arch Phys Med Rehabil. 2002;83:
60–69
Lukasiewicz AC, McClure P, Michener L, et al. Comparison of 3-dimensional scapular position and orientation between subjects with and
without shoulder impingement. J Orthop Sports Phys Ther. 1999;29: 574–583
Normally the pectoralis minor muscle elongates during arm
elevation.
Kebatse et al. 1999 have shown that excessive scapular protraction,
decreases maximum rotator cuff activation by 23%. (Arch Phys Med
rehab).

13. Shortened Pectoralis Minor
The coupling forces created by
trapezius, Serratus and Pectoralis Minor
are neccessary to positioning the scapula
on the thoracic wall.
The adaptative shortening of the pectoralis
minor would increase the opposite &
passive tension forces during arm
elevation.
Smith et al. 2006 reported that maximal
rotator cuff strength is optimal when the
position is “neutral of scapular
retraction/protraction” (Jour, Elb Should
Surgery)
Physical Therapy . Volume 86 . Number 4 . April 2006

14. Whiplash and Shoulder Impingement
Abbasian et Als examined 220 patients who
reported whiplash injury. Only the 5%
presented impingement syndrome. Journal of
Orthopaedic Surgery and Research 2008, 3:25
Chauhan and colleagues examined 102 cases
of shoulder pain after whiplash and found to be
22% syntomatic but only 9% had subacromial
impingement. J Bone Joint Surg Br 2003, 85(3):408-10.
Direct seatbelt trauma to the shoulder is one
possible explanation for its aetiology. Acta Orthop.
Belg., 2005, 71, 385-387

15. Influences on the fusimotor-muscle spindle system from
chemosensitive nerve endings in cervical facet joints in the cat:
possible implications for whiplash induced disorders.Thunberg
J, Hellström F, Sjölander P, Bergenheim M, Wenngren B,
Johansson H. Pain. Mar;91(1-2):15-22, 2001
Capsular, Facetary & Ligamentous Damage
Related To Motor Dysfunction % Cervical Pain

16. Kinematic Alterations and Muscle
Dysfunctions in the Shoulder
The decreased serratus anterior muscle
function in the subjects with shoulder
impingement have been demonstrated
by a deficitary control of the inferior
angle of the scapula against the thorax.
Ludewig and Cook , Physical Therapy . Volume 80 .
Number 3 . March 2000
In other pathologies as idiopatic
shoulder frozen the humeral ROM
deficits relative to the trunk and scapula
have been confirmed but this was not
determinant in relation to a pattern of
muscle dysfunction. Rundquist P. et Als. Arch
Phys Med Rehabil Vol 84, October 2003

17. Posture Changes and
muscle activation
(1) Mc Lean L, 2005 and (2) Schuldt 1996 coincidently found that the
corrected posture in sitting produce a statistically significant
reduction in muscle activation amplitudes in the neck and
shoulder regions compared to forward head posture and,
Corrected posture in standing required more muscle activity than
habitual or forward head posture.
(1)The effect of postural correction on muscle activation amplitudes recorded from the cervicobrachial region. Linda McLean Journal
of Electromyography and Kinesiology, 2005 Vol. 15, 527-535
(2)Effects of changes in sitting work posture on static neck and shoulder muscle activity. Kristina Schuldt el Als. Ergonomics, Vol. 29,
1986, 1525 - 1537
Villanueva M. Found similar findings
Industrial Health 1997, 35, 330-336.
Ceneviz and other authors have related the
cervical muscle activation to the
mandibular position Cranio. 2006
Oct;24(4):237-44.

18. Shoulder Pain:
¿Motor Control reorganization?
Falla D. et Als. Below experimental muscle
nociceptive stimuluation Differents responses
among trapezius muscle subdivisions during
repetitive shoulder flexion. (1)
Recently Diederichsen L. et Als, 2009 confirmed
that induced pain in the supraspinatus muscle
caused a significant decrease in activity of the
anterior deltoid, upper trapezius and the
infraspinatus and an increase in activity of lower
trapezius and latissimus dorsi muscles. (2)
After the subacromial injection they observed also an increased
muscle activity in the lower trapezius, the serratus anterior and the
latissimus dorsi muscles. (2)
(1)Experimental Brain Research, Volume 178, Number 3 / 2007
(2) Experimental Brain Research Volume 194, Number 3 / 2009

19. Cognitive problems
Associated to Shoulder Pain
Zanette G. et Als. (1997) found reversible
changes of motor cortical outputs following
immobilization of the upper limb. (1)
Exist abundant evidence that cortical
representation of body parts is
continuously modulated in response to
activity, behavior and skill acquisition. (2)
Reorganization of the sensory and motor
systems following peripheral injury occurs
in multiple levels including the spinal cord,
brainstem, thalamus and cortex. (2)
(1) Electroencephalography and Clinical Neurophysiology / Electromyography and Motor Control Volume 105, Issue 4,
August 1997, Pages 269-279
(2) Neuroscience Volume 111, Issue 4, 6 June 2002, Pages 761-773

20. Evidenciated Functional Plasticity By
Neuroimaging
Where are we?
M.E.P.s (EMG)

21. Synapsis
Dendritic Spines
CONDUCT

22. Trained
Hand
Control
Hand
Work Memory (WM)
The amount of WM is directly related to
excitable cortex.
Pascual-Leone 2005. While increase
the difficulty task increase also the
Motor Evoked Potentials (MEPs/EMG)
signal in the working hand.
The Plastic Human Brain Cortex. Alvaro Pascual-Leone, Amir Amedi, Felipe Fregni, and Lotfi B. Merabet.
Annu Rev Neurosci 28: 377-401, 2005

23. Cognitive ability must be qualified with respect to elicited task
employed. The mental exercise practice increased similarly the motor
cortex (MEPs/EMG) representation of the trained hand.
Then Could be the motion a cortical meaning?.
The Plastic Human Brain Cortex. Alvaro Pascual-Leone, Amir Amedi, Felipe Fregni, and Lotfi B. Merabet.
Annu Rev Neurosci 28: 377-401, 2005

24. A,Areas activated during listening to the untrained-same-notes-
music contrasted against rest (p < 0.05, FDR corrected). B,
Contrasted image of group mean activation is presented in areas
that were significantly more active during listening to trained-
music compared with untrained-same-notes-music.
The Journal of Neuroscience 10 January 2007 vol. 27 no. 2 308-314

25. Motion Process: A Motor Meaning
The movement is an experience, an acquired
motor meaning.
The somatosensory information as space,
length, and velocity of the muscles, tension
and pressure acting over the joints, tendons
and ligaments, etc. are fundamental to build up
the motor action.
• In summary we are moving based in the
assimilated sensation along all the life in ours
cognitive-levels.
• Clinical Application: The erectus posture is
developed according our normalized concept
of the erectus position, according our feel and
experiences, our beliefs, emotions and fears,
etc. David López PT, DC.

26. Shoulder Muscle Strengthen Without Tense Length
Normalization and Whatever Posture?
Hides: Spine 2001; Mannion: Spine 2001; Solomonow: Spine 98; O”sullivan: Spine 97; Hodges: J. Spinal Disord. 98;
Richardson et al: Spine, 96-97; Magnusson: Eur.Spine J. 96; Panjabi et al: J. S. Disorders 90,92.

27. Cognition and Emotion Substrate
(Motor learning & adaptative motor strategies , fear to pain,
beliefs, affective experiences, etc.)
Motor Control
(specific timing of neuromuscular function & strength,
& tense-length variation)
Shoulder Dysfunction:
Applied
Tense Active Approrach
XIVth FESSH Congress
3rd to 6th of June 2009
Poznan, Poland
Moto-Tense-Active
Coupling
(muscle forces and its vectiorial action)
Elastic-
Tense-active
Coupling
(connective structures
& joint shapes)

28. Thank You
consultas@dolordeespalda.cl
David López Sánchez PT DC
XIVth FESSH Congress
3rd to 6th of June 2009
Poznan, Poland