Cardiac Rehabilitation and Return to Unsupervised Exercise

Cardiac Rehabilitation is a medically based, professionally supervised program that assists people in recovering from heart attacks, heart surgeries, and other coronary interventions such as PTCA (angioplasty) and stenting.

Cardiac rehab intervention, most often prescribed by doctor referral, has been shown to reduce rates of re-hospitalization, lower mortality rate, decrease the need for cardiac medications, and increase the rate at which people return to work.

In cardiac rehabilitation, clients are carefully monitored and under the supervision of a cardiac registered nurse and other medical professionals. There is a crash cart present in the facility for if an emergency arises. Clients are taught to self monitor and connect with their body through Rate of Perceived Exertion (RPE) and other means in order to listen to their body, monitor symptoms, and to exercise safely and appropriately.

Special medical training and equipment is required in cardiac rehabilitation. Although clients may want to skip a long drive to go into town to go to cardiac rehab, or it may not be at convenient times, it is important that cardiac rehab be completed and they are cleared to join/participate in a community setting. It is very unwise to allow clients to participate in community programs without proper participation and clearance from cardiac rehabilitation. Physician’s consent for participation in a group fitness class, personal training, or small group training is strongly advised and initial (preferably ongoing) communication with the cardiac rehab team is encouraged.

Phases of Cardiac Rehabilitation
Phase Description
Phase I (Inpatient)
  • Provide patient education concerning lifestyle changes (heart healthy food choices, regular exercise and risk factor modification)
  • Provide education on intervention or surgery when hospitalized (signs/symptoms or heart attack, CHF, stent placement, CABG, PAD, etc.)
  • Ambulate patient if possible and provide information on home exercise program.
  • If patient has had open heart surgery, ROM exercises and/or ambulation daily, incentive spirometry, coughing/splinting and home activity guidelines especially for post discharge care.
Phase II (Outpatient)
  • Post-intervention patients
  • Physician referral needed
  • All patients monitored by telemetry units during individualized exercise program.
  • Patients taught how to monitor heart rate, RPE (rate of perceived exertion) and symptoms during exercise
  • Exercise sessions include ~30+ minutes of cardiovascular activity, moderate strength training (approval needed), and cardiovascular risk factor modification education on at least 3 days/week
  • Number of exercise sessions depends on condition and physical response to exercise
Phase III
  • Non-monitored, supervised maintenance program
  • Can be located in hospital or other fitness facility
  • Exercise guidelines provided by progress in Phase II, physician recommendations, and patient’s needs/goals
Phase IV
  • Home exercise guidelines given
  • May exercise at community facility
  • Encouraged to monitor Intensity (HR, RPE, symptoms, etc.)
  • Focus on making positive lifestyle changes
  • Some programs are Phase III/IV combined

Working with clients that have heart disease in a group or individual setting requires fitness professionals to follow safe guidelines and recommendations. It is important to understand these exercise guidelines especially for those who have heart disease and have attended cardiac rehabilitation phase 2. Educate yourself, seek advice, and consider shadowing an experienced professional when creating a client base for those who have been cleared to exercise in cardiac rehabilitation phase 3 and 4 programs.

The information in this course is from the FLS continuing education course “Healthy Heart for a Healthy Life” by Tina Schmidt-McNulty.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

The Development of Atherosclerosis Leading to Heart Disease

Inflammation and irritation of the coronary (heart) artery inner lining can be caused by years of smoking and uncontrolled hypertension and diabetes. These inflamed areas can start to collect cholesterol from the blood stream and begin to form plaque. This plaque begins to grow and decreases the diameter of the artery which compromises blood flow. This decrease can then potentially cause angina (chest pain) symptoms.

In certain situations, this plaque in the artery may rupture or break open which can lead to a formation of a clot in the coronary artery. The clot can block part of the artery preventing the oxygen-rich blood from being delivered to the heart muscle. Part of the heart can then die.

This is known as a heart attack or myocardial infarction. If action is not taken immediately and the condition treated, the part of the heart muscle not receiving oxygen may not be revived and is replaced with scar tissue. Over time, this scar tissue may hinder the ability of the heart to pump effectively and can lead to ischemic (lack of oxygen) cardiomyopathy. It can also lead to electrical conduction irregularities causing abnormal heart rhythms such as ventricular tachycardia or ventricular fibrillation which are associated with sudden cardiac death.

The 4 Steps of Atherosclerosis Development

Step 1:
Injury to inner cell lining

Inside of the artery consists of a single layer of cells called the endothelium, which protects the other layers from interacting with blood. Agents such as smoking, hypertension, elevated LDL levels and stress can potentially cause injury to the endothelium causing atherosclerotic

Step 2:
Relocation of inflammatory cells

When atherosclerotic lesions develop, the endothelial cells (inner layer of cells) cells start to bind to monocytes and other inflammatory cells that start atherosclerotic lesions. Once in these lesions, the monocytes start to travel between the inner lining of the artery and localize in the next layer (intima) where they transform into macrophages and start to engulf mainly LDL.

Step 3:
Accumulation and Smooth Muscle Cell Production

Smooth muscle cells move into the intima and divide. The macrophages that digest the lipids ultimately transform into foam cells that is protective in that it removes excess lipids from circulation. However, this accumulation eventually leads to the progress of the lesion. Active macrophages tarnish (oxidize) LDL and digest them to become foam cells. Macrophages and smooth muscle cells release collagen and other proteins.

Step 4:
Plaque structure

The plaque is now mature and is a collection of foam cells, proteins, smooth muscle cells, and cholesterol debris. This plaque can then harden, crack, cause blood clots to form, and even occlude (block) the vessel.

The information for this course is taken from the FLS continuing education course “Healthy Heart for a Healthy Life” by Tina Schmidt-McNulty.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.


7 Essential Guidelines for Exercise for Diabetics

There are several precautions a client can take to not only prevent hypoglycemia, but to also have a safe exercise experience. Use these Guidelines to help your client avoid complications during exercise.

  1. Inject insulin in a part of the body that will not actively be used for exercise. The abdomen is recommended.
  2. Check blood glucose levels before, during and after exercise the first couple of exercise sessions and/or if trying a new activity.
    1. Activity type, intensity, and duration may affect glucose levels.
    2. Typically, 1 hour of exercise = additional 15 g of carbohydrates either before or after exercise.
  3. During exercise, a quick source of carbohydrates (that does not also contain fat) should be readily available such as orange juice or candy.
  4. Be aware of a delayed post-exercise hypoglycemia in those who take insulin.
    1. Metabolism may remain elevate for several hours post-exercise especially during the night.
    2. Check glucose at bedtime and again couple hours after (~1-2AM) especially on a day of increased activity.
  5. Adequate fluids before during and after exercise are recommended.
  6. Wear proper shoes with polyester or blend socks as well as inspecting feet after exercise to practice good foot care.
  7. Carry medical identification.

For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

6 Important Things to Know when Working with Cancer Patients and Survivors

Cancer is the second leading cause of death in the United States. Today, survival trends are improving, however the number of deaths caused by cancer has increased. More than one-third of yearly cancer deaths are related to diet and physical activity habits. Ironically, the same behaviors that contribute to decreasing the risk of cardiovascular disease such as being physically active, maintaining a healthy weight, and consuming a healthy diet can also significantly reduce the risk of developing cancer.

Exercise provides a significant role in prevention and control of cancer. The U.S. Department of Health and Human Services recommends that those with cancer should be as active as possible considering their current health and capacity, but to avoid inactivity. As with any chronic disease, approval from a physician is recommended before any exercise program prior to, during, or after treatment. Recent data supports that exercise may increase survival rates for both breast and colon cancer survivors, and there is evidence that the risk of cancer reoccurrence may be decreased when physically active during and after treatment. Exercise also plays a significant role in recovery and long-term health.

Overall, exercise comes highly recommended before, during, and after treatment to benefit the cardiovascular system and assist with muscle and bone strength; all of which can be challenged with treatments.

The most frequent cancer site is the skin. If you see moles or abnormal skin spots on your client, encourage them to see their physician immediately. Skin cancer can be deadly.

Here are 6 things to know when working with cancer patients and survivors:

  1. Exercise is not recommended if the client is on intravenous chemotherapy days or within 24 hours of treatment.
  2. No exercise prior to a blood draw.
  3. No exercise if the client has a tissue reaction to radiation therapy.
  4. No exercise if there is any bone, back, or neck pain of recent origin or any unusual muscular weakness.
  5. No exercise if fever greater than 101°F or nausea, vomiting, or diarrhea within 24-36 hours.
  6. Avoid high intensity resistance training for muscles located under or near a port or a PICC line. (A port is an implanted venous access port or totally implanted port used to insert treatments like chemotherapy into the blood stream and a PICC line is a permanently inserted flexible tube for long term intravenous medicine or treatments.) A PICC line is inserted in the upper arm or the fold in the elbow.  The port is normally implanted under the skin in the upper chest (pectoralis area), but can be inserted in the back of the upper arm (triceps area) or in the abdominal area.

The information for this article is taken from the continuing education course “Essential Exercises for Cancer Patients and Survivors” by Tina Schmidt-McNulty.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

6 General Recommendations for Working with Clients with Respiratory Conditions

Knowledge of the respiratory system and pulmonary function is fundamental for training the client with chronic conditions known as pulmonary disorders. These disorders are characterized by airflow obstruction, cardiovascular and muscular impairments, abnormalities of gas exchange, and psychological issues including fear and embarrassment that often accompanies shortness of breath. Properly done exercise can improve musculoskeletal and psychosocial factors that limit clients with pulmonary disease.

  1. It is important to do a longer warm up and cool down for clients with asthma, COPD, and other respiratory issues.
  2. Choose an appropriate, lower demand cardiorespiratory activity for beginner or compromised clients such as cycling or walking.  Switch to a lower demand exercise during periods of respiratory condition flare ups.
  3. Teach the client proper breathing techniques. There are breathing exercises such as “Pursed Lip Breathing” or “Diaphragmatic Breathing” that help with shortness of breath and the anxiety, fear, and embarrassment that may be present.
  4. Do not use continuous overhead arm work. This can cause the client fatigue by making the heart work harder.
  5. Incorporate resistance training, especially in the upper body to help improve stamina and function in the chest, upper back, shoulders, and arms.
  6. Do exercises in a well-ventilated area. Make sure room temperatures are not too low or too high for comfort.  Be aware of humidity and the presence of allergens or respiratory irritants that may be present in the exercise area.  Just opening windows during allergy season can cause an allergy or asthma attack.

The information in this article is from the FLS continuing education course “Respiratory Rescue” by Soraya Cates Parr.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

3 Things to Know When Working with Diabetic Clients

  1. Symptoms of Hypoglycemia
    Prevention of hypoglycemia is important for a safe exercise program for someone who has diabetes. Anyone taking insulin or an oral medication that may cause hypoglycemia should be aware of symptoms and how to manage this situation especially during exercise. Hypoglycemia occurs when glucose levels are < 70mg/dl.  This condition may become worse if not treated. Prevention is the best intervention.


Symptoms may include:

  • sweating
  • shaking
  • dizziness
  • headache
  • confusion
  • irritability
  • hunger
  • personality change
  • weakness
  • vision changes
  • seizures and/or loss of consciousness.
  1. Exercise Blood Sugar Guidelines
    Blood glucose should be checked and treated if the reading is below 70 mg/dl.
    Treatment: It is recommended to follow the “Rule of 15”:
    a. Eat 15 grams of carbohydrate, wait 15 minutes, then eat another 15 grams of carbohydrates if there is no improvement in symptoms. (Lobb-Oyos 2012)
    When exercising, blood glucose levels should be at least 100-110 mg/dl.
    b. If not, a carbohydrate should be consumed and levels can be rechecked before starting to exercise.
    c. Type 1 diabetics using insulin pumps may need to adjust insulin delivery during exercise and basal delivery rates for up to 12 hours post-exercise to avoid hypoglycemia. (ACSM 2017)


  1. Recommended Pre-Exercise Carbohydrate Intake
Exercise Intensity and
Additional Food
<100 mg/dl Low (< 30 min)
Moderate (30-60 min)
Strenuous (> 60 min)
15 grams of carbohydrate
30 grams of carbohydrate
60 grams of carbohydrate
101-170 mg/dl Low (< 30 min)
Moderate (30-60 min)
Strenuous (> 60 min)
No additional food necessary
15 grams of carbohydrate
30 grams of carbohydrate
171-300 mg/dl Low (< 30 min)
Moderate (30-60 min)
Strenuous (> 60 min)
No additional food necessary
No additional food necessary
15 grams of carbohydrate
>300 mg/dl *Blood sugar needs to be under control prior to starting exercise!

*(Type 1 DM Glucose > 250 mg/dl: Check for ketones; if present, notify physician)
(“Diabetes Medications: Guidelines for exercise safety” 2012)

The information in this article is from the continuing education course
“Exercise, Diabetes, and Metabolic Syndrome” by FLS author Tina Schmidt-McNulty.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

What is the difference between Pilates and Yoga breathing?

By FLS Authors Naomi Aaronson and Ann Marie Turo

As an Occupational Therapist, many patients come to me who are in pain and are suffering from a variety of issues including breast cancer, repetitive stress injuries, musculoskeletal problems, and back pain. I use both Yoga and Pilates in my practice Integrated Mind and Body in Boston for relaxation, and to help prepare patients physically and psychologically for the treatments that I offer. They are often curious about the breathing and ultimately ask, ” What is the difference between Pilates breathing and yoga breathing?”

Pilates breathing is “ribcage breathing” or three-dimensional breathing (breathing to the back and side of the ribcage). The breath is taken in through the nose, and exhaled through pursed lips. The benefits of this type of breathing are many. It relaxes and releases tension in tight chest and shoulder muscles  as the exhale facilitates contraction of the transverse abdominas, multifidi, and pelvic floor. This in turn, activates the lymphatic system clearing the proximal lymph nodes located in the abdominal region.

Pilates is a great modality in working with breast cancer patient especially those who have received mastectomies, lymph node removal or breast reconstruction. The breathing in Pilates helps my clients and patients to “get back in touch with their bodies” and to recruit the correct muscles. They tell me that they feel more relaxed, yet energized at the same time after Pilates.

Yoga Breathing is “belly breathing.” In Yoga, the breath is taken in through the nose as the belly expands and then one exhales through the nose as the belly contracts. Yoga breathing helps to engage the parasympathetic nervous system, which calms us when we are in ” fight or flight mode.” This promotes the relaxation response and allows muscles to lengthen, stretch and relax as it oxygenates the blood.

Both Yoga and Pilates breathing are forms of diaphragmatic breathing and are useful in my practice. However, they work the body in different ways. I use either Pilates or yoga breathing depending on patient needs and what my treatment goals are for that day.

For more information on Pilates breathing for breast cancer recovery please look for the book “Pilates for the Breast Cancer Survivor: A Guide to Recovery, Healing and Wellness”

Naomi Aaronson OTR/L, CHT, CPI, CET and Ann Marie Turo, OTR/L, certified Yoga and Pilates Instructor

Hard-to-Recognize Heart Attack Symptoms

June Chewning, BS MA

In my 38 year career and 18 years owning a fitness center, I know heart attacks happen.  I have heard about them when members went home, sat up in bed, and dropped dead next to their spouse after a visit to the gym. I have made the ambulance ride to the hospital with them when they thought they just pulled a chest muscle, but their pulse and blood pressure were erratic. When they went back to work after a lunch time work out to look up the symptoms of heat attack on Google and realize it was happening to them right then. When they couldn’t figure out why their calves hurt so bad when they exercised, and when told to stop exercise and consult their physician had triple by-pass surgery the next day.  When my friend’s sister had a massive heart attack at age 40 because they thought she had a bruise instead of a blood clot in her leg.  When a young teacher thought she had the flu from her kids at school and went home early from aerobic class feeling nauseous and dropped dead at the threshold of her apartment.

Health-Fitness professionals, heart disease is the leading cause of death  in the US.  You will encounter it.  Be prepared and get educated. Be aware and vigilant about seeing the tell tale and not so obvious symptoms in your clients.  Save a life…

Healthy Heart, Healthy Life
eLearning Continuing Education Course for
Health-Fitness Professionals

This article is from
the American Heart Association
Go Red for Women Program

Well-known heart attack symptoms can include chest pain and radiating discomfort in the left arm. But, as Dr. Suzanne Steinbaum explains, there are several other ways your body may tell you when something isn’t quite right, potentially with your heart.
Read on for details on four silent heart attack symptoms that women should most definitely be aware of.

Shortness of breath
According to Steinbaum, director of The Heart and Vascular Institute at Lenox Hill Hospital in New York City, women often struggle to breathe a few weeks before experiencing a heart attack.
“If you are used to doing a certain amount of activity and then, all of a sudden, you can’t get enough air, that is when I get concerned,” says Steinbaum.

Back pain
Irregular pain in the lower or upper back can indicate stress to the heart muscle, Steinbaum says.

Jaw pain
“I had one patient who would feel her jaw start to hurt every time she got on a treadmill,” Steinbaum says. “But once she stopped, her jaw pain would go away. She went to a dentist, but there wasn’t anything wrong with her teeth.”
This discomfort continued until the woman experienced a heart attack. When she came into Steinbaum’s office after the event, it was evident that the jaw pain was directly linked to what was happening in her heart.
“Sometimes the heart isn’t able to give a good signal and, instead, the pain can radiate to the neck, jaw and back,” she says.

Flu-like symptoms are often reported weeks and days before a heart attack. In fact, as Steinbaum explains, TV personality Rosie O’Donnell reportedly regurgitated a few times before she experienced a heart attack in early 2012.

Advice: Trust Your Gut
If you aren’t feeling normal or are experiencing any of the symptoms above, head to you local emergency room. It is better to take care of yourself and prevent damage to your heart, in the event you are having a heart attack.
“A women’s intuition is a very strong thing; don’t ever discount it,” Steinbaum says.
“Ninety percent of my women patients who’ve just had a heart attack tell me that they knew it was their heart all along. That they just had a feeling.”

Your Brain on Exercise-Critical!

The information provided is adapted from “Alzheimer’s Disease Prevention and Intervention,” a Medical Fitness Specialist Certificate Program authored by Alzheimer’s Research and Prevention Foundation (ARPF) and produced by Fitness Learning Systems.
June M. Chewning MA, BS, AEA

Dementia is a syndrome characterized by a chronic deterioration relating to memory, thinking, behavior, and the ability to perform activities of daily living. Consciousness, however, is not affected. Dementia is not a normal part of aging. The cause may be related to a variety of diseases and injuries that may have affected the brain. The most common form of dementia is Alzheimer’s disease (AD).
There are 47.5 million people suffering from dementia worldwide, with 7.7 million new cases each year. The most common cause of dementia, Alzheimer’s disease, makes up 60-70% of cases. (Dementia 2016) Millions of Americans are challenged by Alzheimer’s disease and other forms of dementia. In 2016, an estimated 5.4 million Americans of various ages are diagnosed with Alzheimer’s disease, and approximately 5.2 million of those are ages 65 and older. (Alzheimer’s Disease Facts and Figures 2016)
Although there are natural physiological changes that occur with age, memory loss is neither normal nor a natural process of aging. It is important to take a proactive role in retaining the strength, resiliency, and vitality of the brain. Research has shown that just as the body needs strength-building exercises to maintain muscle strength, so does the brain.
Physical exercise is identified through recent research as one of the key elements in the ARPF 4 Pillars of Prevention™.  “Although at this time, medications have no proven neuroprotective effect on dementia, an evolving literature documents significant benefit of long-term regular exercise on cognition, dementia risk, and perhaps dementia progression.” (Ahlskog 2011 metanalysis)  Many studies suggest that exercise reduces the effects of dementing neurodegenerative mechanisms.
At this time, research significantly indicates that exercise is associated with a reduced risk of cognitive impairment and dementia. This appears to happen in two ways: (Ahlskog 2011)

  1. A convergence of evidence from both animal and human studies indicate that aerobic exercise seems to reduce the risk of degeneration of brain processes and seems to protect the brain from biological and neurological decline.
  2. The cardiovascular benefits of aerobic exercise reduce vascular risk improving cerebrovascular (carotid and brain artery) health, reducing plaque build-up, and maintaining better circulation to the brain.

As health-fitness professionals, we are in a position more than ever to help people with making healthy lifestyle choices and with maintaining quality of life.  Exercise is critical to the biological and neurological health of the brain and vascular system that feeds the brain.  Learn more about ways to prevent cognitive decline to help your clients live a long, healthy life with vigor and clarity.

Alzheimer’s Research and Prevention Foundation. (2016) Alzheimer’s Disease Prevention and Intervention Medical Fitness Specialist Program. 888.221.1612.
Ahlskog, J. Eric, Yonas E. Geda, Neill R. Graff-Radford, and Ronald C. Petersen. “Physical Exercise as a Preventive or Disease-Modifying Treatment of Dementia and Brain Aging.” Mayo Clinic. Proceedings 86.9 (2011): 876-84. Web.

Alzheimer’s Disease is now the 6th leading cause of death in the U.S. All health-fitness professionals are called to stem this epidemic with prevention and intervention. Get educated and get on board!
Alzheimer’s Disease Prevention and Intervention Medical Fitness Specialist Program. 888.221.1612.


Scapulohumeral Rhythm

By: Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

The shoulder is one of the most vulnerable joints in the body due to its vast range of motion and complexity. It is a complex ball and socket joint, uniquely comprised of various connective tissue, supporting structures, including muscles. It is an important joint because functionally, it is involved in most daily and sport activities, such as reaching, lifting, carrying and throwing a ball. Knowledge of the biomechanics of the shoulder can help you with training and aiding in rehabilitation of the shoulder and related injuries.

The shoulder complex involves coordinated movements between the humerus bone and the scapula. The scapula, clavicle, and humerus serve as attachments for most of the muscles in the shoulder. The shoulder is comprised of four primary joints:

  • Glenohumeral joint (GH)
  • Acromioclavicular joint (AC)
  • Sternoclavicular joint (SC)
  • Scapulothoracic joint




Scapulohumeral Rhythm (SHR) is defined as the movement relationship between the humerus and the scapula during both shoulder flexion and shoulder abduction. Arthrokinematics is the movement that takes place between articular surfaces in a joint.

For example, during abduction of the arm at the shoulder (side arm raise) the following happens (See Figure):

  • The glenohumeral joint (concave) is stable (depicted by the vertical arrow), while the humerus (convex) abducts (depicted by the horizontal arrow).
  • There is a sliding down or glide of the convex humerus on the concave glenohumeral joint.
  • The scapula rotates upward (bottom of the scapula moves laterally and upward).


During shoulder abduction, there is 120 degrees of movement that occurs at the glenohumeral joint, while 60 degrees occurs at the scapulothoracic joint, creating a 2 to 1 ratio (2:1). This movement is known as the scapulohumeral rhythm (SHR) of shoulder abduction. The same SHR occurs both during shoulder flexion and shoulder abduction. (See Figure)

The muscle actions that occur when you abduct the arm at the shoulder include: (See Figure)

  • Biomechanically, the supraspinatus muscle raises the arm during the first
    15 degrees of shoulder abduction.
  • Then, from 15-90 degrees of shoulder abduction, the medial deltoid assists to raise the arm biomechanically.
  • There are several muscles within the shoulder that play important roles, specifically at the rotator cuff. The rotator cuff is comprised of four primary muscles known as the S.I.T.S muscles. These muscles include the supraspinatus, infraspinatus, teres minor and subscapularis which pull the bone in different directions due to different attachment points and angle of pull.
  • A force couple can be defined as a pair of muscle forces that act together on a joint to produce rotation. These forces may exert pulls in opposite directions. Force couples may be synergistic pairs or agonist/antagonist pairs of muscles.  In the Figure shown, a force couple occurs between the low trapezius and serratus anterior. During shoulder abduction, the lower trapezius and serratus anterior work together to anterior upwardly rotate the scapula on the thorax.


Abnormal scapulohumeral rhythm is a dysfunction that occurs within the scapulothoracic junction.  There are many causes for this including:

  • A rotator cuff tear where the individual does not have the musculotendinous connection and strength to abduct the arm.
  • Limitations due to joint and capsule hypomobility (restriction) known as adhesive capsulitis (frozen shoulder).
  • Pain and/or muscular weakness that prevent the ability to raise the arm to the side.
  • Occurrence of excessive upper trapezius and scapular elevation which becomes a means of compensation, and provides the individual with an alternative ability to abduct the arm.

Why is this important?

  • Connective tissue (muscles, tendons, ligaments, and fascia) are supposed to move. Joints, as well, have a certain amount of movement and should glide and translate with everyday movement.
  • Muscle imbalances and tightness create dysfunction. If a muscle does not have adequate muscle length to concentrically and eccentrically contract, compensation will occur typically above and below a joint.
  • If this tightness continues, it will result in trigger points. Trigger points are where a muscle shortens and, in essence, has increased sensitivity affecting the muscle’s ability to completely move as it was designed. If trigger points become bigger and more prominent, they can compress the nerve that innervates the respective muscle creating radicular (fuzzy feeling, numbness, or tingling) symptoms.

If the scapula is not able to properly upwardly rotate on the thorax, an individual will compensate using other muscles to perform the work. This compensation will lead to muscle imbalance, pain, and dysfunction affecting activities of daily living and sports movements.

For more information about working with clients with shoulder issues, see the Fitness Learning Systems Human Movement Matrix: Shoulder continuing education course by Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS of Pinnacle Training & Consulting Systems. “Teaching The Science Behind The Movement.” Fitness Learning Systems is an IACET accredited continuing education provider.