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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

Treatment of Scapular Dyskinesis with Reflexive Neuromuscular 
Stimulation: A Case Report  
Alli Z. Powell, DAT, AT1 & Russell T. Baker, PhD, DAT, AT2 
1Colorado Mesa University, Grand Junction, CO; 2University of Idaho, Moscow, ID 
 

 
ABSTRACT 

Scapular dyskinesis is an abnormal movement of the scapula 
due to poor motor control of the surrounding musculature and 
can lead to other glenohumeral pathologies. The pathology 
results in the lateral tilting of the scapula during many 
glenohumeral joint movements and weight-bearing activities 
of the upper extremity (i.e., plank). The typical conservative 
treatment protocol focuses on strengthening surrounding 
musculature and is often a lengthy protocol. A weakness of 
strengthening protocols is the failure to address the motor 
function of targeted muscles at the level of the central nervous 
system (CNS) to restore dynamic stability and motor control. 
Reactive Neuromuscular Stabilization (RNS) is a novel 
treatment that targets the CNS to address motor control 
impairments to restore the normal muscular and joint stability 
and function. Purpose: The purpose of this case study was to 
demonstrate the efficacy and the outcomes of using RNS as 
a treatment for dysfunctions such as scapular dyskinesis. A 
20-year-old female intercollegiate swimmer presented with 
significant mid-back pain that failed to resolve without 
treatment. The patient was diagnosed with scapular 
dyskinesis as well as presented with a number of postural 
concerns, trigger points, and pain with multiple activities. The 
initial protocol for treatment for this patient was a standard 
conservative treatment protocol focused on strengthening. 
After six weeks of treatment without improvement, the 
clinician modified care to include RNS. Following three 
treatments across seven days, the patient’s symptoms 
decreased significantly and the patient met discharge 
criteria. At an eleven-month follow-up, the patient’s 
improvements were maintained. The patient in this case 
report demonstrates the effectiveness of RNS while treating 
scapular dyskinesis and the importance of recognizing the 
cause of the dysfunction early within the evaluation. 
Key Phrases 
Diagnostic testing and physical examination, upper 
extremity, patient-reported outcomes, manual techniques 
 
Correspondence 
Dr. Alli Powell, Colorado Mesa University, 1100 North Ave. 
Grand Junction, CO. 
E-mail: azeigel@gmail.com  
 
Full Citation 
Powell A & Rusty BT. Treatment of Scapular Dyskinesis with 
Reflexive Neuromuscular Stimulation: A Case Report. Clin 
Pract Athl Train. 2019;2(3):35-47. 
https://doi.org/2019/0003.3.     

Submitted: February 21, 2019 Accepted: October 21, 
2019 

 

INTRODUCTION 

Scapular dyskinesis (SD) is defined as irregular 

motion of the scapula.1-2 Scapular dyskinesis is 
often evaluated visually by the clinician from a 
posterior view with the patient performing active 
glenohumeral (GH) motions.1-5 The scapula 
provides stability to the GH articulation through 
the contraction of the surrounding muscles to 
centralize the rotation of the GH joint.1-2 The 
position of the scapula adjusts to overhead 
activity by moving in the following motions: 
protraction, retraction, elevation, depression, and 
rotation. When the scapula fails to move 
synergistically with the GH joint, compensatory 
and dysfunctional movement patterns are 
created.1 Most abnormal movement patterns of 
the scapula have been suggested to result from 
poor functioning of the stabilizing muscles of the 
scapula.1,3 Increased protraction at the medial 
border of the scapula during GH motion, such as 
horizontal adduction, flexion, and abduction are 
some of the most common signs of SD.3 The 
abnormal movement, when not caused by long 
thoracic nerve damage, is typically thought to 
result from hyper-activation of the upper 
trapezius in conjunction with decreased activation 
of the lower trapezius and serratus anterior.6 
Though nerve damage to the long thoracic and 
spinal accessory nerves may result in decreased 
muscular function, the commonality of these 
pathologies as the cause of the dyskinesis is less 
than 5%.1 Other common causes include thoracic 
kyphosis, clavicular fracture nonunion, high-grade 
AC joint instability, or soft tissue inflexibility.2 

Conservative treatment is the most commonly 
recommended course of action in cases of SD; 

https://doi.org/2019/0003.3


Treatment of Scapular Dyskinesis with Reflexive Neuromuscular Stimulation: A Case Report 
 

 

36 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

however, if nerve damage is present, surgical 
intervention may be indicated.4 Most non-
operative rehabilitation includes mobility 
exercises of the thoracic spine and shoulder (e.g., 
stretching, joint mobilizations, thoracic mobility 
exercises), closed and open chain strengthening 
exercises (e.g., push up plus, serratus anterior 
ceiling punches), and other reactive exercises 
(e.g., catching and throwing) targeting the 
improvement of motor control. A few concerns 
with conservative rehabilitation of SD is lengthy 
treatment protocols (i.e. weeks to months); and a 
primary focus on strengthening only the 
surrounding musculature of the shoulder girdle 
instead of focusing on neuromuscular reeducation 
and the restoration of dynamic stability and  
functional movement patterns.7 

As a proposed cause for SD is poor motor control 
and a loss of dynamic stability, along with over 
activation of related musculature, a 
neuromuscular re-patterning technique such as 
Reflexive Neuromuscular Stabilization (RNS) 
seems appropriate. This technique was derived 
from a treatment called Reactive Neuromuscular 
Training (RNT). The concept of RNT is to restore 
dynamic stability and motor control post-injury 
with rehabilitation techniques which target the 
central nervous system (CNS). As the CNS reacts 
to a stimulus to create joint stability, there is a 
conversion from conscious thought to unconscious.8 

Rather than cue the patient verbally and have 
discussions regarding what they are doing 
incorrectly, the goal of RNT is to exacerbate the 
dysfunctional movement with an external stimulus 
to bring a more clear perception to the patient 
of the error that is occurring.9 When using RNT, a 
clinician applies an external stimulus to the 
patient’s body to promote an unconscious 
response by the CNS to produce the appropriate 
motor response and correct the faulty movement 
pattern.10 Where RNS deviates from RNT is 
modification to make the process more ‘reflexive’ 
than ‘reactive’ to enhance the unconscious and 
reflexive response that a physically active 
patient needs to produce during activity to 

maintain dynamic stability.11 Let us take for an 
example, when a patient performs a squat they 
have a significant valgus collapse. When using 
RNT we may utilize an elastic band around the 
patient’s knees as a constant force that they are 
pushing against as they squat to force the 
patient to engage appropriate knee and hip 
stabilizers throughout the movement. In contrast, 
when switching to an RNS mindset of treatment, 
the clinician would apply the valgus force at the 
patient’s knees with varying amounts of force 
and at unexpected times to force the patient’s 
reflexes to initiate and correct the faulty 
movement pattern with their reflex to the 
stimulus. Again, the largest difference is having a 
constant and known force they are reacting to 
versus and changing and unexpected force their 
reflexes must engage in to correct the movement 
pattern.  

Currently, there are no studies regarding the 
application of RNS and SD and only a few 
studies have been published on the application 
of RNS or RNT; thus, little is known about the 
application of these techniques in patient care. 
Therefore, the purpose of this case study was to 
report the outcomes of incorporating RNS into 
the rehabilitation program of an intercollegiate 
swimmer diagnosed with SD who had failed to 
improve using traditional conservative methods. 
The patient gave informed consent to participate 
in the study as well as was informed that the 
data collected would be submitted for 
publication. This study was approved by the 
Institutional Review Board. 

PATIENT INFORMATION 

Patient 

The patient was a 20-year-old female Division I 
intercollegiate swimmer who presented with right 
upper back pain and no known mechanism of 
injury. She described experiencing her current 
pain for approximately six months. Her pain was 
isolated to the right medial border of the 
scapula with a gradual onset and no known 



Treatment of Scapular Dyskinesis with Reflexive Neuromuscular Stimulation: A Case Report 
 

 

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All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

mechanism of injury. When the symptoms initially 
began, her primary complaint was experiencing 
pain at the end of inhalation. When the pain 
started, the patient was home for the summer 
(i.e. between spring and fall semesters) and used 
self-treatment consisting of three months of 
complete rest from activity and occasional 
superficial heat without resolution of her 
symptoms.  The patient reported to the Athletic 
Training clinic after four months of unresolved 
symptoms for the start of the fall semester.  

The initial examination revealed pain along the 
medial aspect of the right scapula during 
inhalation, while sitting in good posture, or while 
wearing a backpack. The patient did not reveal 
any red flags for cancer, chronic illnesses, or 
family history of illnesses. She had experienced 
pain in the upper right back eight months 
previously when she was lifting weights, however, 
the pain resolved without treatment. She 
reported the current episode as “feeling 
different” and unrelated to the current condition.  
She was not taking any medication for the 
discomfort and had no other reports of 
treatment. Her reported worst pain on the 
Numerical Pain Rating Scale (NPRS) was a seven 
out of ten when sitting erect and at the end of an 
inhalation. A zero on the NPRS is classified as no 
pain, whereas a ten is classified as the worst 
pain imaginable.12 Disability was measured using 
the Disablement in the Physically Active (DPA) 
Scale, which is scored from zero (no disability) to 
64 (maximum disability).13-14 The patient 
reported a disability score of 28 on the DPA 
Scale on the initial evaluation. The Patient 
Specific Functional Scale (PSFS) was utilized to 
identify activities within her daily life that were 
causing pain. This scale utilizes a score between 
zero (cannot perform) to ten (no problem 
performing).15 Her three primary painful 
activities were breathing (4 out of 10), sitting up 
straight (4 out of 10) and wearing a backpack 
(6 out of 10).  

The examination did not reveal signs of 
inflammation, ecchymosis, or deformities 
surrounding the area of pain. Her natural posture 
was forward head, forward shoulder, and 
increased kyphosis. The postures were 
exacerbated in a seated position. In a seated 
position, visual evaluation of the patient’s 
breathing revealed all of the motion for 
inhalation stemming from the chest rather than 
from the diaphragm. To test breathing 
functionality, the clinician used a modification of 
the Manual Assessment of Respiratory Motion 
(MARM) test.16 The modification of the MARM 
test was done via palpation and observation to 
assess the 3-Dimensional movement of the trunk 
and chest during inhalation and exhalation. The 
clinician placed their hands along the patient’s 
mid to low back with the thumbs parallel to the 
spine and fingers splaying laterally (Figure 1). 
While the patient completed normal 
inspiration/expiration, the clinician felt for the 
motion of breathing to either be lateral, superior, 
anterior, and/or posterior. A normal pattern 
consists of lateral, anterior, posterior, and limited 
superior motion.17 This patient revealed a 
primary upward motion in breathing, with absent 
posterior and lateral motions with inhalation. 

Tender points (TPs) at the middle portion of the 
insertion of the rhomboid minor, superior portion 
of the insertion of the rhomboid major, middle 

Figure 1. Hand Positioning for Modified MARM 
Test 



Treatment of Scapular Dyskinesis with Reflexive Neuromuscular Stimulation: A Case Report 
 

 

38 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

trapezius superior portion of the insertion and 
superolateral muscle belly, and serratus posterior 
superolateral muscle belly were identified with 
palpation. Differentiation of the musculature was 
determined through active contractions of the 
muscles. In addition to reporting TPs, the patient 
stated that she generally felt “tighter” on the 
right medial aspect of the scapula, compared 
bilaterally. The patient also reported tenderness 
to palpation at the first and second ribs with a 
superior to inferior pressure posterior to the 
clacivle and on the posterior aspect of the 
eleventh and twelfth ribs in a supine position.  

Range of motion testing was performed and 
revealed no limitations or pain with any of the 
following active range of motions (AROM) at the 
shoulder: flexion, extension, internal rotation (IR) 
at a 90-90 position, external rotation (ER) at a 
90-90 position, abduction, horizontal adduction, 
or horizontal abduction. Observation during 
AROM testing revealed the patient had 
substantial SD on the right side that was most 
prominent with flexion, abduction, and horizontal 
adduction (Figure 2). The following passive 
ranges of motion (PROM) at the shoulder were 
equal bilaterally, within normal limits, and non-
painful: flexion, extension, IR, ER, horizontal 

adduction, abduction and horizontal abduction. 
Strength testing of the rotator cuff muscles, 
deltoid, pectoralis major, biceps brachii, and 
triceps brachii were all 5/5 and non-painful 
when compared bilaterally. The right rhomboids 
had decreased strength, 4/5, when compared 
bilaterally.  

The patient displayed a positive sulcus sign 
bilaterally and SD on the right when in a push up 
plus position both in non-weight bearing and 
weight bearing positions. Based on the lateral 
scapula slide test (LSST), the patient met the 
established threshold, 1.5cm to be a positive test, 
of difference during 90 degrees of abduction 
and was .2cm and .3cm from the threshold in the 
positions with hands on hips and at 90 degrees 
horizontal adduction while standing to indicate 
SD (Table 1).1,18-19 Each measurement was taken 
from the spinous process even with the inferior 
angle of the scapula for each motion. The LSST 
was performed with the patient’s hands by her 
side, progressed to hands on the hips, and 90 
degrees of abduction. Though the LSST is 
designed exclusively for those three motions, the 
clinician also measured the differences when the 
patient completed horizontal adduction. The 
Apprehension and Relocation, Empty Can, and 
Gerber Lift Off tests were negative. 
Neurological screening and function was within 
normal limits. Based upon these findings, the 
patient was classified with right SD and 
conservative rehabilitation was initiated without 
limitation in activity levels. 

INTERVENTION 

The first six weeks of treatment and 
rehabilitation consisted of a combination of moist 
heat packs (MHP), Positional Release Therapy 
(PRT), breathing retraining, Primal Reflex 
Release Techniques (PRRT), instrument assisted 
soft tissue mobilization (IASTM), massage, 
strengthening, and stretching. Treatment sessions 
began with MHPs to stimulate blood flow to the 
affected area, and to help increase patient 
relaxation and comfort. After the application of  

Figure 2. Scapular Dyskinesis Pre-
Treatment 



DISABLEMENT MODEL CASE SERIES 

 

39 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

Table 1. Measurements Taken in the Scapular Slide Test (cm) 
 Left Right Left Right 
Arm Position Day 1 Day 3 
Down by sides 9.5 9.5 9.5 9.5 
Hands on hips 8.9 10.2 8.9 8.9 
90 degrees abduction 10.2 7.6 10.2 10.2 
90 degrees horizontal adduction 12.7 14 12.7 12.7 

the MHPs, PRT was used to release the TPs 
present during the initial evaluation.  Following 
PRT, breathing retraining exercises were used to 
restore normal diaphragmatic breathing. The 
techniques utilized were a combination of 
breathing exercise developed by Michael Grant 
White20 and PPRT techniques developed by John 
Iams, and were selected because of positive 
clinical outcomes experienced by the treating 
clinician during previous patient care.21 The 
breathing exercise was similar to the traditional 
“clam shell” exercise for hip external rotator 
strengthening (Figure 3 and Figure 4). However, 
the breathing component required the patient to 
attempt maximal exhalation (i.e., “blow all your 
air out”) and then move through full hip external 
rotation with the top leg while holding their 
breath throughout the motion. Once the knees 
returned to the starting position, the patient was 
cued to inhale. The length of the count varied by 
the patient’s ability to hold her breath. When the 
patient returned to the starting position, the 
required response was to have the patient take 
a “gasping” breath, meaning the patient felt as 

if she could not hold her breath any longer, thus 
taking a large reflexive inhalation.  

The PRRT technique was then used to address the 
patient reported rhomboid tightness. Initially, a 
facilitation technique was used on the rhomboids 
due to the forward shoulder posture of the 
patient; however, the technique did not produce 
improvement, so the clinician then inhibited the 
rhomboids in an attempt to decrease pain and 
tightness. Next, IASTM and massage were used 
to reduce remaining TPs on the affected side 
rhomboid major, rhomboid minor, upper and 
middle trapezius, and serratus posterior, as well 
as to restore function and ROM. Therapeutic 
exercises were used to improve muscular control 
and strength of the serratus anterior and lower 
trapezius muscles to improve scapular 
stabilization within a functional movement 
pattern (Table 2). Finally, a stretching regimen 
was used to release tight anterior musculature 
and improve posture. 

Over the first six weeks of therapy, the patient 
would complete this therapy protocol 1 time per  

Figure 3. Starting and Ending Position of the 
“Clam Shell” Exercise 

Figure 4. “Clam Shell” Exercise Motion 



DISABLEMENT MODEL CASE SERIES 

 

40 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

 

day and four days per week, on average. 
During this time, the patient reported short-term 
pain relief and TP reduction. The patient 
typically reported a decrease in pain following 
each treatment session; yet, the pain and TPs 
returned without any substantial improvement by 
the end of a two-hour swim practice or by her 
next visit. When a treatment was provided prior 
to practice, the patient reported a resolution of 
her complaint, but it would only remain resolved 
through 50 to 75% of the practice period (~2 
hours). Treatment provided on non-training days 
followed a similar pattern, but usually increased 
the duration of her pain resolution from 
approximately 90 minutes to 3 hours. During 
these six weeks, discernible improvements in the 
patient’s strength and dyskinesis were recorded 
(Table 4).   Due to the lack of consistent and 
long-lasting patient-reported or disease-oriented 
improvement, the clinician re-evaluated the 
patient and decided to add RNS to her 
established rehabilitation protocol. The clinical 
reasoning for this choice focused on the belief 
the patient’s functional motor patterns (i.e., 
stability) were not being addressed at the 
subconscious level, and a more reflexive 
neuromuscular intervention was needed to 
normalize movement patterns and postures at the 
subconscious level.  

 

 

The initial treatment goal for utilizing RNS was to 
decrease SD during standing horizontal 
adduction because this was the most difficult 
movement for the patient and movement with the 
most SD. The patient continued to use MHP prior 
to beginning exercises because she felt the MHP 
helped to decrease pain and increase her 
mobility. The treatment protocol was MHP, RNS 
with horizontal adduction in standing, I’s, Y’s, T’s 
in a prone position on two of the days, push up 
plus on a BOSU ball on one day, while the 
patient also continued to stretch the pectoralis 
muscles in a doorway as she had been doing 
daily.  

The clinician first applied an anterior to posterior 
stimulation for RNS to various places on the 
anterior aspect of the patient’s body (i.e., upper 
1/3 of the sternum, middle of the sternum, 
xiphoid process, upper abdomen, lower 
abdomen, and bilateral ASIS) as the patient was 
standing and performing horizontal adduction. 
While the clinician applied the anterior to 
posterior force via hand pressure, the patient 
was instructed to close her eyes and not allow 
the clinician to push her backwards. The response 
the clinician was testing for was the largest 
decrease in the SD during one repetition of 
horizontal adduction with the external 
stimulation. Once the location of pressure that 
was the most responsive in decreasing SD the 
patient was found, she was asked to continue to 

Table 2. Frequency and Duration of Each Rehabilitative Exercise Performed 
Exercise Times per 

Week* 
Weeks 

Performed Duration 

Low row/ scapula pinches with a red resistance band 2-3 2 3x8-10 
Supine Scapular Retraction 1-5 2 2x8 
Standing Scapular Retraction Against Exercise Ball 1-5 3 2x10 
Scapular control exercises (patient holding a weighted ball 
and moving into flexion, horizontal adduction, horizontal 
abduction & abduction) 

2-3 
 4 3x30 seconds 

Push up plus on BOSU  2 3.5 3x8 
I’s, Y’s, T’s 2 3.5 2x8 
Horizontal adduction with 3lb weighted ball with RNS 2 1.5 3x10 
*Times per week varied weekly based on availability and travel 



Treatment of Scapular Dyskinesis with Reflexive Neuromuscular Stimulation: A Case Report 
 

 

41 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
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keep her eyes closed, to react to the stimulus 
without anticipation, and told to not let the 
clinician push her backwards. Once the patient 
reacted, she then performed the active horizontal 
adduction while the stimulus was sustained 
(Figure 5).  

On the first day of treatment with RNS, the 
patient performed two sets of ten repetitions 
with the pressure in the middle of her sternum. A 
third set was completed with the patient closing 
her eyes and imagining the pressure on her chest 
before completing the movement. When the 
patient imagined the pressure, the elimination of 
dyskinesis was consistent with the clinician 
applied force. Days two and three of RNS 
consisted of the same treatment, but on these 
days, the patient performed one set of ten 
repetitions with clinician generated force, while 
the second and third sets were done with the 
imagination of the pressure. The NPRS was 
collected pre and post each treatment, PSFS was 
collected pretreatment, and the DPA Scale was 
collected at day one, at discharge (day three), 
and eleven-months post-discharge. The patient 
denied taking any medications for pain and 
maintained her activity level throughout the 
course of the new treatment protocol. The patient 
was treated two consecutive days, then 6 days 
later for the third treatment. She responded well 
to treatment without increased pain during and 
after treatments. The patient did not return to the 
clinic until 6 days following the third treatment. 
At this time, the patient reported near resolution 
of symptoms, was able to swim throughout an 
entire practice without pain returning, had an 
improved physical exam (e.g., no tender points, 
improved scapular positioning, negative special 
tests), and met established discharge criteria. 
Discharge criteria had been previously 
established as the ability to maintain normal 
scapular stabilization throughout functional 
movements (without RNS), an average NPRS 
score of one out of ten or below,22 and a PSFS 
of a nine out of ten or higher23 with 

intercollegiate swimming and conditioning 
activity. 

RESULTS 

Prior to using RNS as a treatment, the patient 
had received 26 days of treatment over six 
weeks without substantial or lasting improvements 
then after just three treatment sessions with RNS 
involved in the treatment protocol the patient met 
established discharge criteria  (Table 3 and 
Table 4). At this time, a full re-evaluation was 
performed, intake data was collected, and no 
treatment was performed. The physical exam 
revealed the scapular slide test was equal 
bilaterally. The patient’s primary chest breathing 
pattern was still present in a seated position, but 
diaphragm activation was now present measured 
through modified MARM test. The TPs on the 
insertion of the rhomboid major and insertion, 
muscle belly of the middle trapezius, and 
eleventh and twelfth ribs were no longer present 
during palpation. The TP at the middle portion of 
the rhomboid major was still present, but the 
patient reported tenderness to be mild (2/10)  

Figure 5. Scapular Dyskinesis was 
Eliminated when Pressure was Applied to 
Mid Sternum 



DISABLEMENT MODEL CASE SERIES 

 

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Table 3. Patient Reported Outcomes Prior to RNS with Horizontal Adduction 
 Tx Day 1 Tx Day 11 Tx Day 21 

NPRS - Current 8 7 4 
NPRS - Best 5 7 4 
NPRS - Worst 8 7 5 
NPRS - Average 7 7 4.33 
NPRS –Post 6 6 3 
DPA Scale 28 15* - 
PSFS 7.75 7 7.6 
*Clinically significant difference; Abbreviations: DPA Scale- Disability of the Physically Active Scale; PSFS- 
Patient Specific Functional Scale (0=unable to perform, 10= fully able to perform); NPRS- Numeric Pain 
Rating Scale at current, best within past 24 hours, worst within last 24 hours, average of current, best and 
worst (0=no pain, 10=worst pain); Pre-Tx: Pre-treatment; Post-Tx. Post-treatment; N/A: Not applicable 

Table 4. Outcome Measurements After RNS with Horizontal Assuction 
 RNS Tx 1 RNS Tx 2 RNS Tx 3 6 day F/U 2 wk F/U 11 mon F/U 

DPA Scale 22 N/A 16 N/A N/A 4 
PSFS 8 N/A 7 9.5* N/A 10 

NPRS- Current Pre-Tx 4 4 4 1 2 0 
NPRS-Current Post Tx 2 3 2 N/A N/A N/A 

NPRS- Change 2* 1* 2* N/A N/A N/A 
Scapular Slide Test- 
Horizontal Adduction 1.3 cm N/A N/A N/A 0 cm 0 cm 

*Clinically Significant Difference; DPA Scale- Disability of the Physically Active Scale; PSFS- Patient Specific 
Functional Scale (0=unable to perform, 10= fully able to perform); NPRS- Numeric Pain Rating Scale at 
current, best within past 24 hours, worst within last 24 hours, average of current, best and worst (0=no pain, 
10=worst pain); Pre-Tx: Pre-treatment. Post-Tx. Post-treatment; Scapular Slide Test- Horizontal Adduction: 
Number is different between affected and unaffected; N/A: Not applicable 

compared to initial measures (4/10). The patient 
also continued to experience tenderness at the 
first and second ribs. The patient’s natural sitting 
posture was still forward head, forward 
shoulder, and increased kyphosis; however, these 
postures were not as noticeable as those found 
during the initial exam. The patient also reported 
it was easier to maintain good posture, and she 
could now do so without experiencing pain. 
Additionally, the previous SD that was noted with 
flexion, abduction, horizontal adduction, and in a 
push up plus position was no longer present. 
Based on the physical exam and patient outcome 
findings, the patient was released to full activity 
(i.e., swimming, dryland training, and weight 
lifting) without further treatment, but was 
monitored throughout the remainder of the swim 
season. Follow-up measurements were collected 

at 2 weeks and 11 months post-discharge (Table 
4).  

Detailed evaluation of patient outcomes utilizing 
RNS treatment revealed the patient 
demonstrated a change in pain that met the 
minimal clinically important difference (MCID) on 
the NPRS after Day 1, but it took 3 visits for this 
change to be maintained between treatment 
sessions (Table 4).24 Functional improvement 
followed a similar pattern based on PSFS scores.  
The patient did not report sustained functional 
improvement until after the third treatment. 
However, once this was reached, the patient 
retained her functional improvement all the way 
through the 11 month post-discharge follow-up. 
Additionally, the patient’s scapular winging 
improved. At the initial exam, the patient 



Treatment of Scapular Dyskinesis with Reflexive Neuromuscular Stimulation: A Case Report 
 

 

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displayed a 1.3 cm difference side to side of 
scapular winging with horizontal adduction; at 
discharge, the patient had an even distance from 
medial border of the scapula to spinous process 
with active horizontal adduction (Table 1). As 
with the other measures, this improvement was 
maintained at the 11-month follow-up visit.  

DISCUSSION 

Rehabilitation for SD commonly targets the 
decreased activation of the serratus anterior and 
middle trapezius.25 Worsley et al.26 used a 
general rehabilitation program to retrain 
scapular stabilizers over a course of ten weeks. 
The researchers found the serratus anterior and 
lower trapezius could successfully be retrained 
over ten weeks, and scapular motion was nearly 
equal to a healthy population after the protocol 
was completed.26 The long-term benefits of this 
program are unknown as data was collected 
prior to intervention and immediately post the 
ten week protocol.26 

In this case study, the initial focus was on 
relieving pain through soft tissue treatments, and 
improving scapular motion through increased 
strength and muscle activation of the para-
scapular musculature. After minimal improvement, 
the intervention shifted towards restoring optimal 
movement patterns of the scapula using a 
reflexive neuromuscular approach. Unlike 
exercise-based therapy, RNS may be beneficial 
from an evaluative and treatment standpoint 
because of the immediate restoration of a 
functional movement pattern when the clinician 
applies an external force.27 If the functional 
movement pattern is not restored, either the 
wrong force is being applied (e.g., not enough 
force, wrong location) or RNS is not indicated.9,27 
The location or amount of force may vary from 
patient to patient; though, when indicated, the 
treatment should produce an instantaneous, 
noticeable, and long-lasting improvement in 
movement.27 

The proposed theories behind the success of RNS 
are based on influencing the central nervous 
system (CNS) with subconscious and reflexive 
movement which restores motor control and 
dynamic stability. Reflexive Neuromuscular 
Stabilization was derived from the term RNT, 
which was first proposed by Voight and Cook.28 
The primary objective of the treatment is to 
trigger the subconscious process of recruiting the 
appropriate musculature to establish a proper 
movement pattern(s).8,10,28 

When using an RNS treatment, the external 
stimulus is provided in varying forces at varying 
times throughout a dysfunctional movement. With 
RNS, the goal remains to recruit the CNS to 
establish appropriate recruitment strategies of 
involved musculature in particular movements or 
activities by reflexively re-patterning the 
neuromuscular system. In this case study, the 
treatment was applied to the sternum with a 
varying amount of force and frequency, 
requiring the patient to react more reflexively to 
an unexpected stimulus, as opposed to 
anticipating a consistent resistance, which helps 
the reaction to become subconscious. Borsa et 
al.29 also explained when a motion or stimulus is 
repeated, the brain stores these movements or 
stimuli, and then has the ability to access the 
response unconsciously. Through applying RNS, 
restoring the functional movement, then having 
the patient go through the functional movement 
over a number of repetitions that functional 
movement can now be maintained without 
conscious thought.  

Currently, there are no published studies or case 
reports on utilizing RNS for SD; however, there 
are published reports on the use of RNT or RNS 
to address other dysfunction or pathology. The 
ability to functionally complete a previously poor 
motor pattern without conscious thought was 
elicited in a case study using RNT for apparent 
hamstring tightness.27 The patient in this case was 
tested on a variety of hamstring extensibility 
measurements and was classified with hamstring 



Treatment of Scapular Dyskinesis with Reflexive Neuromuscular Stimulation: A Case Report 
 

 

44 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

tissue extensibility dysfunction (TED). After one 
treatment of RNT during multi-segmental flexion, 
for the patient experienced substantial 
improvements in all ROM measurements 
immediately following the intervention. Not only 
were the gains in all ROM testing improved, but 
the gains in motion were enough to be within the 
normative ranges for each ROM measurement 
tested after a single intervention.27 The patient 
also maintained the improvements, which 
exceeded the gains expected from the stretching 
literature, at the five-week follow-up without 
further intervention.27 Similarly, in another case 
study, RNS was used in conjunction with the 
Mulligan Concept for a young patient with 
multidirectional instability of the shoulder, who 
had recently sustained a subluxation.11 In this 
case, the clinician performed a Mulligan Concept 
mobilization with movement followed by RNS to 
restore full pain-free ROM after one visit. The 
patient was discharged in 6 visits, returned to 
football activities, and did not suffer a re-injury 
during that season.11 Additionally, RNT has been 
reported to be beneficial in a case report on 
Anterior Cruciate Ligament (ACL) deficiency.28 
Over the course of eight visits, the patient 
experienced a large increase in strength that 
could only be explained by neuromuscular 
adaptations as opposed to true strength 
increases.28 Traditional strength gains require 
several weeks to occur, whereas neuromuscular 
adaptations within the body occur during the first 
six weeks of training.28 Further, when movement 
patterns changes, or the abolition of patient 
complaint, occur immediately with RNS 
application during a treatment session, it seems 
most likely that the mechanism of action is drive 
by a neurological change. Thus, of the in-
treatment session changes and the overall 
improvement over eight treatment sessions, 
indicate rapid neuromuscular adaptations as 
opposed to traditional drivers of strength 
improvements from exercise.28 While these three 
cases suggest RNS may be an effective 
intervention, reports on the effectiveness of RNS 
on SD could not be identified in the literature.  

In the current case, applying RNS required a 
contraction of anterior chain muscles, in particular 
the abdominal muscles, to initiate stabilization 
before the patient tried to move the arm. The 
reflexive contraction, and subsequent 
stabilization, corrected faulty stabilization 
patterns allowing for more ideal functional 
movements (e.g., shoulder horizontal adduction). 
The serratus anterior and lower trapezius are 
typically the muscles not activating appropriately 
with SD.6 It is hypothesized that activating a 
reflexive stabilization pattern (e.g., spinal 
stabilization) with RNS created the proper 
stability for the serratus anterior and lower 
trapezius to be properly coordinated to stabilize 
the scapula properly. Throughout the three days 
of treatment with RNS, the application of RNS 
immediately produced improvement (e.g., pain, 
scapular positioning), but it took until after the 
third treatment for the motor pattern to become 
ingrained enough for the patient to maintain her 
improvement during and after activity.  

Due to the paucity of research on RNS, the ideal 
treatment parameters (e.g., number of 
treatments, sets, repetitions) required for the best 
treatment results are unknown. In addition, ideal 
locations for stimulus during RNS, or any variance 
across different areas of the body, functional 
movements (e.g., are complex movement patterns 
more difficult to restore), or pathology are also 
unknown. It is quite possible that different 
pathologies or movement patterns will require 
different parameters (e.g., differences in 
treatment time, frequency, duration) to produce 
effective patient outcomes. For example, multi-
segmental flexion, a uniplanar motion, required 
only one treatment to produce maintained 
resolution of a patient who present with a 
hamstring TED.27 In contrast, a patient with a 
deficient ACL completed eight days of treatment 
with RNT, and may have needed more, to fully 
resolve the patient’s condition. In this case, the 
patient did not only have one dysfunctional 
motion, but instead needed to restore functional 
movement through multiple complex movement 



Treatment of Scapular Dyskinesis with Reflexive Neuromuscular Stimulation: A Case Report 
 

 

45 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

patterns. Though the motions that needed 
restoration were complex, only three treatments 
of RNS were necessary for a case of SD to meet 
discharge criteria and maintain these 
improvements at 11-month follow-up (Table 4). 

The presented case provides preliminary 
evidence that RNS may be an effective 
treatment option, at least as an adjunct therapy, 
for patients with SD. Future research needs to be 
completed on RNS to determine the effectiveness 
of the treatment as an adjunct or individual 
treatment. Additionally, future research should 
be performed to determine the appropriate 
dosage of RNS to restore and maintain 
functional movement patterns.  

CLINICAL BOTTOM LINE 

The results of this case study provide initial 
evidence of the potential benefit of utilizing RNS. 
The reflexive nature of RNS, and the description 
of its use in this case study, may help clinicians 
utilize the technique to inform their clinical 
decision-making in determining when or how to 
use RNS or RNT in therapeutic rehabilitative 
programs. In this case, after adjusting the 
treatment protocol to include RNS as the primary 
intervention, the patient reported clinically 
significant improvement in pain and function. The 
patient reported clinically significant 
improvement and did not believe she needed 
additional treatment after three days of RNS 
treatment. She remained fully functional and with 
reduced pain 2 weeks and 11-months post 
conclusion of the treatment after a multi-modal 
conservative rehabilitation program had failed 
to produce meaningful improvement over 6 
weeks. Based on these results, further research on 
the use of RNS with SD is warranted to 
determine effectiveness, but this case may serve 
as a clinical guide for incorporating RNS into 
patient care. 

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All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

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