Shoulder Perturbation Exercises in Physical Therapy

Shoulder Perturbation Exercises in Physical Therapy

Manual perturbation exercises are commonly used in the rehabilitation of throwing athletes and overhead athletes as well as in the strength and conditioning programs of these athletes. Manual perturbations can be an effective technique to train athletes in pain free ranges and begin to develop co-contraction for stability. The athlete will benefit most from perturbation exercises that are performed in or near positions of instability that correlate to the desired athletic movement. If the perturbation activity is simply performed at 90° of shoulder flexion there will be activation of the shoulder stabilizers but the transfer to athletic movement will be very low.
Initially, manual perturbations may only be able to be applied in specific ranges but as the athlete heals and develops more strength as well as proprioception the arc over which manual perturbations are applied will need to be enhanced.
Perturbation exercise should follow the same rules as other corrective exercise. It should never be applied in a painful arc of motion, it should not facilitate instability or compensatory movement, it should be applied with specificity, and it should be programmed in a way that maximizes its effectiveness. The second point in the last sentence is extremely important, while many clinicians and coaches apply a standardized perturbation training in just one joint position, others are far too aggressive and as a result place the joint, often the shoulder, in a position of instability that is not able to be adequately controlled and apply perturbations that exacerbate the instability and make the athlete worse off. The most effective manual perturbation exercises are those that are applied in a pain free range only slightly beyond where the athlete has complete control and stability but in a position specific to where the dynamic co-contraction or stability is lacking and required in their movement pattern.
Historically at the OAI we have seen that various perturbation exercises in sport specific positions or movements are not only effective in training the target joint but also in strengthening core and lower extremity musculature teaching the athlete how to stabilize against multidirectional and unilateral forces that maybe near or far from the joint(s) that need to be stabilized. A great example is the role of the core musculature in stabilizing against manual or external perturbations that are applied to the wrist of an athlete while they're in a lunge stance. This will be far more beneficial and specific than a variation performed in a supine position. Contextually, the lower extremities, core, and upper extremities function together to resist environmental perturbations. The more components of a movement that can be incorporated into an exercise while not sacrificing technique or health the better.

Keep in mind that contractile sequence, somatosensory, and contraction type specificities are often absent in manual perturbation training so we must maximize positional specificity to allow for the greatest transfer to contextual movement.