Often considered one of the most functional forms of exercise an athlete can perform, pulley systems coordinate balance and core recruitment with motions of the arm and hand. You can start your patients with isolated movements early in a program to very functional full-body motions that generate force from the foot through the hand in a coordinated fashion. It's a great way to evaluate any weakness that may be present along the chain of movement, especially at the hip, core, and scapular muscles.

There are plenty of alternatives to the pulleys, such as bands and free weights. However, this article will highlight the benefits and advantages unique to using pulley systems to treat shoulder injuries. Here we will explore the variety of reasons why PTs use pulley system machines, how they work, and the shoulder injuries they are used to treat.

THE MECHANICS

In general, most pulley systems are a simple machine made up of an upper and lower platform, a fixed cable column, pulley wheels, and a rope or cable line. The rope or cable is wrapped around the wheels, and the wheels are attached to brackets on the sides so that they can turn freely. The brackets are attached to a fixed cable column. The rope has a handle attached to one end and, when pulled, the cable makes its way through the pulleys and lifts the weight stack on the other end.

The more pulleys that are used, the less effort is needed to lift the object. However, if more pulleys are used, then more rope must be pulled to move the object as far. Therefore, a standard pulley has two pulleys and a 1:1 ratio—meaning 1 foot of pull causes the weight stack to move up the column at an equal distance. A speed pulley has to be pulled 6 feet to move the weight stack 1 foot due to a 6:1 ratio.

"We start all patients—day 1—on the pulley system," says Derek Lagemann, PT, DPT, FAAOMPT, Ortho Rehab Physical Therapy in Little Rock, Ark. "Once the tissue of lesion is determined, we develop a medical exercise program entailing specifics of repetitions, sets, ROM, etc. The patient always starts in a pain-free ROM and in the loose packed position for maximal joint mechanoreceptor recruitment," he explains. "As the patient progresses into the later stages of rehabilitation, we adjust the repetitions accordingly and move them to a more dynamic approach on the speed pulleys," he says.

Lagemann says they have utilized a variety of different pulley manufacturers in the past and just recently purchased equipment from Endorphin Rehabilitation Fitness Solutions in Pinellas Park, Fla, to furnish a start-up clinic. Endorphin manufactures rehabilitation and fitness products for hospitals, rehabilitation, and long-term care facilities especially designed to meet the special, adapted needs of users with physical limitations, physical disabilities, or mobility impairments.

"We bought a standard pulley (1:1 ratio), a combination high/low pulley (2:1 ratio), a speed pulley (6:1 ratio), a couple of training benches, and a quad cage to attach all pulleys together in a 5-foot square," he says. "With the standard pulley you can perform all regular exercises; the combination pulley is a standard pulley with a high lat bar attachment that allows deweighting and gantry work, and the speed pulley is a high-functioning system which allows complete motion patterns at varying velocity. The speed pulley has a 30-foot line of pull for your dynamic activity."

"We use the Response dual-cable column machine," says Mike Fox, PT, SCS, MTC, owner of Sports Therapy and Rehabilitation Physical Therapy (STAR) in New York City. He is a board-certified sports clinical specialist and a certified manual therapist. He is also an adjunct professor at New York University and a clinical supervisor at the State University of New York/Stony Brook.

Fox has four machines in the clinic's hand and upper extremity center, and these are manufactured by Brookdale Medical Specialties Ltd, Toronto. Brookdale offers a wide variety of equipment and supplies in all therapy categories, including electrotherapy, fitness and rehab, hydrotherapy, hot and cold therapy, treatment tables and traction systems, work hardening, diagnostic equipment, orthopedics, and mobility aids.

The 390 Series Tri-Pulley is from
Endorphin Rehabilitation &
Fitness Solutions.

"The mechanics are simple," Fox explains. "The height can be adjusted from ankle height to 7 feet high. This allows a good variety of angles and directions to challenge the various muscles of the upper and lower extremities." The dual cable allows the PT to address the body in a more symmetrical fashion, working both upper extremities at the same time.

The Response dual cable column rehab pulley facilitates upper-, middle-, and lower-extremity exercises. Specs:

• Low initial starting weights;
• A vertical pulley that travels from 8 to 80 in 3-inch increments;
• Adjustable pulley handles that have 180° pivot articulation; and
• Upper-body stabilization support grips.

"I use the Steens (SABA) pulley system," notes Art Webb, PT, of Gerdez Professional Services in San Diego. It is wall-mounted and has a quick release adjustment that allows a swift change in the angle of exercise and length of the rope. "There are various attachments to modify the type of exercise and small weight increments for resistance from a half pound up to 30 pounds," he says.

According to Brad Wilhelm, president, N-K Therapy Products Inc, Lake Elsinore, Calif, the SABA products were incorporated in the Medical Exercise Therapy (MET) Program developed by Odvar Holten in Norway.

Webb attended some early seminars back in the 1980s, where he learned the MET concepts and purchased some of the original SABA equipment for a clinic he held in Riverside, Calif, at the time.

"Two of the most important additions [to the SABA equipment] were the S-B Angle Bench and the Multi-Purpose Training Bench. Both benches can be used with or without pulley units to do a multitude of shoulder (and other) joint-range-specific exercises," Wilhelm adds.

COMMON INJURIES

The Triad Cable and Pulley System is part of the Response line of equipment manufactured by Brookdale Medical Specialties Ltd. For more exercises like the ones below, see Brookdale's Cable Column Exercises pdf.

Fox uses the cables for all shoulder injuries—ie, rotator cuffs, labral repairs, and simple mechanical impingement and instability. "I also use it to strengthen the trunk and hip muscles," he adds. It is used to treat a lot of rugby players because their injuries are usually traumatic in nature with labral tears and dislocations. "Throwing is probably the most traumatic activity the shoulder will be exposed to," he says. "Throwers and tennis players may present with rotator cuff injuries or labral injuries, especially SLAP tears."

The most common shoulder diagnosis Webb treats with the pulley system is stable rotator cuff injury/impingement. "Sports/activities that require a high level of overhead activity of the arms are the riskiest for shoulder injury," Webb adds. "After the age of 40, many of my patients don't report any excessive use to the shoulder or a specific trauma event as a cause of their injury."

"The riskiest activities/sports for patients suffering with shoulder pathology are generally any movement or activity which requires motion above shoulder height," Lagemann says. "This is problematic due to the coupling requirements placed on the rotator cuff and the surrounding scapular musculature. Another determining factor on the risk of injury is the exact tissue in lesion and the specific joint involved. An acromioclavicular and sternoclavicular joint lesion will have different stresses and compressive forces opposed to a glenohumeral or scapulothoracic joint.

"Furthermore," he continues, "a lesion to the anterior glenohumeral joint capsule will have different pathological ROMs or positions compared to a cartilage lesion of the same joint. A physical therapists's job is to thoroughly assess the patient and determine the correct course of treatment while avoiding pathological ROMs."

Additionally, the pulley system offers the versatility required to adapt to any pathology associated with the shoulder. "Primarily, I see patients with impingement syndromes and instabilities of the glenohumeral joint due to a capsule laxity anteriorly/inferiorly or a hypomobility posteriorly," Lagemann adds. "These instabilities cause motion to occur around a nonphysiological axis, leading to dysfunction of the biomechanics of the entire shoulder complex, which affects how the rotator cuff controls the movement of the humeral head in the glenoid fossa."

BENEFITS

"We use the cables to strengthen the muscles of the rotator cuff and periscapular region. We also have a Response rotator cuff machine, which localizes the muscles of the cuff more specifically," Fox notes. In the final stages of rehab, sport-specific motions are performed on the cables such as eccentric loading of the external rotators in the "slot" position (90° of abduction and external rotation). "Simply adjusting the location in relation to the machine will adjust the range of motion and length of the cable," he says.

The advantage of cables over free weights is that the therapist can achieve stress to targeted muscles throughout the entire shoulder range of motion when using cables. Free weights are reliant on gravity for stressing the muscles. As the upper extremity moves through a full range with free weights, the changes in the lever arm will alter the stress on the muscles of the shoulder, according to Fox.

"Exercise bands give increased resistance as the band is stretched," he says. "This is not optimal for the external rotators, which become weaker at the end range (as the muscle shortens). Cables give constant resistance through the entire range." Fox tries to encourage his patients to replace at least one of their weight training sessions with a cable session.

"The benefit of using our particular pulley system is the ability to make small objective increases in resistance," Webb explains. "In addition to the safety of adding resistance, there seems to be more patient satisfaction as they see themselves making gradual improvements in strength. Patients still require close supervision while on the pulley system," he stresses.

"The ability to modify a pulley system is one of its greatest attributes," Lagemann states. "Physical therapists versed in medical exercise training will have the ability to modify specifics such as ROM, the type of muscle contraction, speed, length tension, angle of pull, and starting/ending positions," he explains. In addition, repetitions, sets, frequency, resistance, and resting intervals can be altered, depending on the functional quality of exercise you are attempting to achieve.

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"The benefits of using a pulley system are numerous. Besides the aforementioned ability to modify specifics of treatment, the pulley system can be used on just about any body part through a controlled ROM. The resistance is consistent through the full ROM, and there is an ability to dose the resistance from as little as one-half pound to 100 pounds. This ability to dose exercise according to the patient's needs is what sets physical therapists apart from our competitors," Lagemann says.

Universal application is another benefit of a pulley system. "I am truly sold on the functional qualities of a pulley system," Lagemann says. "I cannot imagine practicing without one. Pulley principles can be applied on the novice to elite athlete, the sedentary to working man, or the young to the geriatric population. With a little training, research, and clinical reasoning skills, a physical therapist can utilize a pulley system on any patient and enhance outcomes and patient satisfaction," he concludes.

Nina Silberstein is a contributing writer for Physical Therapy Products. For more information, contact .