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Role of the kinetic chain in shoulder rehabilitation: does incorporating the trunk and lower limb into shoulder exercise regimes influence shoulder muscle recruitment patterns? Systematic review of electromyography studies
  1. Eleanor Richardson1,2,
  2. Jeremy S Lewis3,4,5,
  3. Jo Gibson6,7,
  4. Chris Morgan8,
  5. Mark Halaki9,
  6. Karen Ginn9,
  7. Gillian Yeowell2
  1. 1Department of Physiotherapy, BMI The Alexandra Hospital, Cheadle, UK
  2. 2Faculty of Health Psychology and Social Care, Manchester Metropolitan University, Didsbury, Manchester, UK
  3. 3School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
  4. 4Therapy Department London, Central London Community Healthcare NHS Trust, London, UK
  5. 5Department of Physical Therapy and Rehabilitation Sciences, Qatar University, Doha, Qatar
  6. 6Department of Physiotherapy, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
  7. 7The School of Health Sciences, University of Liverpool, Liverpool, UK
  8. 8High Performance Unit, Medical Department, Arsenal Football Club, London, UK
  9. 9Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Eleanor Richardson; ellierichardson44{at}


Objective To investigate the influence of trunk and lower limb motion on electromyography (EMG) muscle activity and recruitment patterns around the shoulder.

Design Systematic review.

Data sources MEDLINE, CINAHL, PEDro, AMED, PubMed, Cochrane Central Register of Controlled trials, Cochrane Database of Systematic reviews, SportsDiscuss and PROSPERO.

Eligibility criteria Studies investigating both multiregional kinetic chain (KC) shoulder exercises and localised non-kinetic chain (nKC) shoulder exercises in healthy subjects under the same experimental conditions were included in this review.

Results KC exercises produced greater EMG activation levels in 5 of 11 studies for the lower trapezius. Of the remaining studies, five found no difference between the exercise types and one favoured nKC exercises. KC exercises produced greater EMG activation levels in 5 of 11 studies for the serratus anterior. Of the remaining studies, three reported the opposite and three found no significant difference between the exercise types. nKC exercises produced greater EMG activation in infraspinatus in three of four studies. KC exercises produced the lowest trapezius muscle ratios in all studies. Studies investigating the upper trapezius, middle trapezius, supraspinatus, subscapularis, biceps brachii, latifissimus dorsi, pectoralis major, deltoid, and trapezius and serratus anterior ratios showed inconsistency.

Conclusion This review found evidence that integrating the KC during shoulder rehabilitation may increase axioscapular muscle recruitment, produce lower trapezius muscle ratios and reduce the demands on the rotator cuff. Stepping appears preferable to squatting.

PROSPERO registration number CRD42015032557, 2015.

  • shoulder
  • rehabilitation
  • exercise rehabilitation
  • evidence based review
  • sports rehabilitation programs

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  • Twitter @Els_Richardson, @JeremyLewisPT, @Shouldergeek1, @ChrisMorgan10, @HalakiMark

  • Contributors All those involved in this systematic review met the criteria for coauthorship, and therefore no Contributorship statement was required.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement statement Patients were not involved in this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.