Kabat Training Program in Diagonal Pattern With Elastic Bands for Shoulder in Amateur Swimmers. A Randomized Controlled Clinical Trial
Phase: NA
Conditions: Healthy
Sponsor: Universidad Europea de Madrid

 
 
 
 
 
 
 
 
 
 
 
 
 
 
KABAT TRAINING PROGRAM IN DIAGONAL PATTERN WITH ELASTIC 
BANDS FOR SHOULDER IN AMATEUR SWIMMERS. A RANDOMIZED 
CONTROLLED CLINICAL TRIAL 
 
THERA2020 
 
NCT ID NOT YET ASSIGNED 
 
MAY 2023 
 
 
 

ABSTRACT 
Introduction. The aim of the application of proprioceptive neuromuscular facilitation 
(PNF) stretching techniques with Theraband is to improve muscle strength, the range 
of movement, and the muscular balance of the shoulder in swimmers. The training helps 
balancing the strength differences between external rotators and internal rotators 
muscles of the shoulder. 
Aim. Analyze the efficacy of the proprioceptive neuromuscular facilitation training with 
Theraband on muscle strength, range of movement and muscular balance of rotator 
cuff in male swimmers. 
Study design. Randomized clinical trial, prospective, single blind. 
Methods. All 30 patients will be randomly divided into two groups, experimental and 
control, through a blinded process with opaque envelopes. The treatment will last 8 
weeks with two sessions per week of 4 minutes each. The analyzed variables will be 
muscle strength (Manual Dynamometer) and the range of motion ( goniometer ). A 
descriptive statistical analysis will be performed, calculating the main statistical 
characteristics. Through the Kolmogorov – Smirnof analysis the normality will be 
calculated, and through the Pearson correlation test will be calculated the correlation 
between variables. 
Expected results. After the treatment period the intention is to observe an improvement 
of the external rotator muscles strength of the shoulder as so of the range of motion and 
muscular balance of the shoulder joint. 
 
Keywords. swimming; Strength; Proprioceptive Neuromuscular Facilitation; Rotator 
Cuff; Elastic Bands.  
 

1. INTRODUCTION 
 
1.1.INTRODUCTION 
In swimming, the upper limbs, and more precisely the rotator cuff, are responsible 
for adduction and internal rotation movements, allowing the movement of the 
swimmer's body in the aquatic environment. This overuse of the internal rotators and 
adductors causes an imbalance of forces in these athletes compared to the external 
rotators and abductors of the shoulder. Imbalances between these antagonistic muscle 
groups are responsible for the incidence of rotator cuff injuries or "swimmer's shoulder" 
(1). 
Strength exercises, as well as muscle stretching exercises, have always been 
integrated into the training of different disciplines to improve the performance of 
athletes (2). It would therefore be advisable to develop protocols for the prevention of 
shoulder injuries due to these muscular imbalances, strengthening the muscles 
responsible for external rotation and abduction of the shoulder (1). 
 
1.2.ETIOLOGY, PREVALENCE AND INCIDENCE 
The shoulder is the joint with the greatest degree of movement in the whole body, 
consequently, the incidence of injuries is very high. In the so-called “ overhead athletes 
”, which include swimmers, among others, injuries to this joint complex have a high 
prevalence rate (3). 
Swimmer's shoulder pain has an incidence rate of 38%. Between 29% and 91% of 
these athletes have suffered from this symptom throughout their sporting life (4). This 
data is easily explained since in the water the propulsion forces are based on the impulse 
through the upper limbs, unlike sports practiced on land where the lower limbs are used 
preponderantly. The overuse of the shoulder muscles during weekly training sessions, 

which can be up to 6 or 7 per week, leads to muscular imbalances between the rotators, 
which, without preventive treatment, can later lead to injury (3). 
 
1.3.PHYSIOTHERAPY TREATMENT 
The most used techniques to increase the strength and muscular balance of the 
rotator cuff in overhead athletes include scapulohumeral stabilization exercises, 
plyometrics, maximum strength and electrotherapy application. In recent years, some 
studies have been published demonstrating the efficacy of resistance exercises with 
Theraband elastic bands following a diagonal, PNF type pattern of Kabat, mainly 
analyzing sports that involve biomechanics similar to swimmers´, such as handball, 
volleyball and baseball. Compensatory training with the diagonal Kabat pattern with 
Theraband  has shown positive effects in improving rotator cuff strength. (1, 5, 6, 7, 8, 
9, 10). 
 
1.4.THERABAND TREATMENT 
Scientific evidence demonstrates the effectiveness of Kabat diagonal training using 
the Theraband following a strength training protocol with progression of external 
resistance. The elastic bands used ranged from a minimum resistance that corresponded 
to the yellow color, to the maximum of gold color. In general, the protocols were 6 
weeks long, consisting of 3 series of 10 repetitions, 2 times a week. During the 
execution of the repetitions, the subjective perception of effort (SPE) of each patient 
was evaluated. When the SPE had a value equal to or less than 6, the repetitions were 
increased up to a maximum of 25, subsequently increasing the resistance by changing 
the elastic band. The position of the patients varied according to the studies. In order to 
avoid compensation of the thorax, the sitting position was the most frequent position 

chosen. Regarding the fixation point of the elastic band, this varies in 3 points according 
to the study: head, feet and iliac crest. There is no single consensus in the current 
literature indicating protocols applied exclusively to swimmers, but most studies focus 
on overhead type athletes (1, 5, 6, 7, 8, 9). 
 
1.5. JUSTIFICATION OF THE STUDY 
The rotator cuff has enormous biomechanical importance in the swimmer's sporting 
gesture, also leading to a high incidence of injuries (1,4,5) . Exercises with 
Theraband following a diagonal Kabat pattern to work on strength in all ranges of 
motion that involve external rotation can have compensatory effects for the overuse of 
the antagonist musculature, improving joint range of motion. The evidence shown in 
other overhead sports , with similar biomechanics, supports the idea of benefit in 
preventing injuries in swimmers. If a beneficial effect is demonstrated in athletes, its 
inclusion in the training routine of swimmers would be simple, given the ease of 
application of this technique, the versatility and the short time required to carry out this 
training at a minimum cost of money (1, 5, 6, 7, 8, 9). 
 
 

2. HYPOTHESIS 
 
CONCEPT HYPOTHESIS. 
- 
Theraband training produces significant improvements in external rotator muscle 
strength, range of motion, scapular displacement, and rotator cuff muscle balance in 
amateur swimmers. 
 
NULL HYPOTHESIS. 
- 
Theraband training does not produce statistically significant effects on lateral 
rotator muscle strength, range of motion, scapular displacement, and rotator cuff 
muscle balance in recreational swimmers. 
 
ALTERNATIVE HYPOTHESIS. 
- 
Theraband training produces statistically significant effects on lateral rotator 
muscle strength, range of motion, scapular displacement, and rotator cuff muscle 
balance in recreational swimmers. 
 
 
 
 
 
 

3. OBJECTIVES OF THE STUDY 
 
MAIN GOAL 
- 
To evaluate the effectiveness of the application of Theraband techniques on the 
strength of the external rotator muscles of the rotator cuff of the shoulder in 
amateur swimmers between 18 and 33 years of age. 
 
SECONDARY OBJECTIVES 
- 
To evaluate the effectiveness of the application of Theraband techniques on 
the range of motion of the shoulder in amateur swimmers between 18 and 33 
years of age. 
- 
To evaluate the effectiveness of the application of Theraband techniques on 
the scapular displacement of the shoulder in amateur swimmers between 18 and 
33 years of age. 
- 
 To evaluate the effectiveness of the application of Theraband techniques on 
the muscular balance of the rotator cuff of the shoulder in amateur swimmers 
between 18 and 33 years of age. 

4. METHODOLOGY 
 
4.1.STUDY DESIGN 
randomized controlled clinical trial conducted in amateur swimmers between 18 
and 33 years of age, with the objectives of determining if PNF training with the 
Theraband is effective on increasing shoulder external rotator strength, range of 
motion, and muscular balance of the rotator cuff of the shoulder in these subjects. 
 
4.2.SAMPLE RECRUITMENT 
Swimmers will be recruited from the following clubs: Royal Spanish Swimming 
Federation (Madrid) and Universidad Europea de Madrid. After presenting the research 
project to the directors and managers of the clubs, the athletes of the clubs will be 
informed verbally and in writing of the objectives and purposes of the study. 
Subjects who agree to participate in this clinical trial will be evaluated to determine 
whether or not they meet the inclusion criteria, they will be given the informed consent 
form to sign and successively they will be randomized into two groups, the 
experimental and the control group. 
 
4.3.SELECTION CRITERIA 
Subjects with the following characteristics will be included in this study: male 
swimmers, belonging to an age range between 18 and 33 years; and that they are 
training at least two days per week. 
In the same way, those subjects who present acute infections, those who suffer from 
shoulder pathologies and those who have not signed the informed consent document 
will be excluded. 

4.4.SAMPLE SIZE JUSTIFICATION  
sample size with respect to the samples used in studies carried out prior to this 
publication with a similar research objective. 
 
4.5.SAMPLE RANDOMIZATION 
Study participants who have signed the informed consent and who meet the 
inclusion criteria will be randomized. Subjects will be randomly assigned to the 
respective groups through opaque envelopes. 
The athletes belonging to the experimental group will carry out PNF training with 
Theraband, while those in the control group will not carry out any type of training. 
The physiotherapist in charge of carrying out the test measurements (pre and post 
treatment) will be blinded regarding the assignment of the participants to the two study 
groups. 
 
4.6.OUTCOME MEASURES 
After receiving the informed consent signed by the athletes, the pre-treatment 
evaluation will be carried out in the aforementioned centers and included in this study. 
The measurement will be performed by a physiotherapist blinded to the investigation. 
After the treatment period, the study participants from both groups (experimental 
and control) will be assessed again by the same investigator, following the same 
guidelines as the initial assessment. 
In the different study evaluations, 4 variables will be measured: the maximum 
isometric force of shoulder in external rotation, the range of joint movement, the 
scapular displacement and the muscular balance between external and internal rotators 
of the shoulder. The outcome measures used for these variables will be: 

- 
Assessment of the maximum isometric strength of the external and internal rotators 
of the shoulder joint complex. An assessment will be made with the modified 
sphygmomanometer test validated by Chamorro et al. (2021) (11). It will be used 
according to the protocol indicated by Souza et al. (2014) (12). Before starting the 
test, the entire procedure will be explained to the subject, time will be allowed for 
them to familiarize themselves with the dynamometer and they will have 3 minutes 
to warm up before starting with 2 test series at minimal effort (13). The unit of 
measurement of this instrument is the applied force, indicated in Newton (N) (12). 
The subject will be placed in a supine position on a table, with the trunk held by 
velcro straps to ensure stability during the test and avoid possible compensation. 
The subject's upper limb to be evaluated will be placed in a shoulder abduction and 
90° elbow flexion, the forearm will be perpendicular to the floor and to the table. 
The dynamometer will be placed transversely to the distal end of the upper limb, in 
contact with the patient's wrist, requesting 5-6 series of maximum isometric 
contractions, for 5 seconds, with 30 seconds of rest between series, respectively in 
external rotation position and internal. The exerted force will be indicated by the 
dynamometer and the maximum value reached during each series will be recorded. 
If the values reached in the 5 contractions exceed a coefficient of variation of 5% or 
if a pain threshold of 6/10 of the visual analogue scale (VAS) is exceeded, the test 
must be repeated to guarantee its validity. During the execution of the series, the 
physiotherapist will maintain firm contact with the dynamometer, applying a 
resistance parallel to and equal to the force applied by the subject, without allowing 
the upper limb to move. The patient will be verbally stimulated to make maximum 
effort during the 5 seconds and the subject will be instructed not to use the Valsalva 
maneuver during the execution of the test (13). 

At the end of the test, the result obtained will be recorded. A higher score indicates 
a greater application of muscular force (12). 
- 
Joint range of motion in external rotation. The patient will be placed in the supine 
position on a table with the arm stabilized and a towel placed below the humerus to 
maintain a position of the arm 10/15° anterior to the coronal plane (in the scapular 
plane). The patient's arm will be in a 90° shoulder abduction position, the elbow 
outside the table at 90° flexion, the forearm and wrist in a 0° position (perpendicular 
to the table and the floor). To carry out the measurement, a goniometer 
(Tandou_1AA800252®) will be used. The axis will be placed over the central part 
of the acromion. The fixed arm of the goniometer will be positioned aligned with 
the vertical perpendicular to the ground, while its mobile arm will be superimposed 
on the fixed arm, aligned with the longitudinal midline between the ulna and its 
styloid process (14). 
- 
Rotator cuff muscle balance: with the results of the maximum isometric strength 
assessment, we will make a ratio between internal and external rotators of each arm 
(maximum internal rotation isometric force / maximum external rotation isometric 
force), a value closer to 1 will indicate a better muscular balance (15). 
- 
Scapular displacement: in standing position, the horizontal distance between the 
inferior angle of the scapula and the corresponding thoracic spinosa is measured in 
the relaxed position as a baseline measure, and the horizontal displacement of the 
angle at maximum elevation of the arm is measured using the PALM(16) . 
- 
inter-observer reliability analysis will be performed . The principal investigator and 
the evaluator will evaluate the maximum isometric force of the external rotators of 
the shoulder and the angle of optimal application of force in a sample of 5 subjects. 
 

4.7. INTERVENTION 
Each session will last approximately 4 minutes per subject, taking place 2 days a 
week, over a period of 8 weeks. The intervention will be carried out at the beginning of 
the training session. 
Prior to the realization After swimming training, the strength technique with 
Theraband will be applied to the subjects of the experimental group, asking the 
control group to follow their usual routine. 
The Theraband intervention will consist of the application of the protocol 
described by Batahla et al. 2015(1). The objective of the application of the technique is 
to produce an increase in muscle strength in the external rotators and the optimal angle 
of force application. The technique will be performed with the patient in a standing 
position lateral to a wall bar where the elastic band will be fixed at the level of the iliac 
crest. Each repetition will consist of bringing the end of the elastic band following the 
diagonal pattern of Kabat D2 for the flexion. It will start from a position of adduction, 
extension and internal rotation of the shoulder with elbow extension and pronation, 
flexion and ulnar tilt of the wrist until reaching a position of flexion, abduction and 
external rotation of the shoulder with elbow extension and supination, extension and 
radial bend of the wrist. The elastic bands used will have different resistances depending 
on the color. 2 types of bands will be used respectively from lower to higher resistance. 
There will be 3 series, of 10 repetitions each, for each upper limb. At the end of each 
series, the subjective perception of effort of each patient will be evaluated (from 0 to 
10), and in the event that it reaches a value equal to or less than 6, 5 repetitions will be 
added in each series until reaching a maximum. of 20 or SPE greater than 6. When 20 
repetitions are reached, the resistance of the Theraband will be increased by changing 
the elastic band in the next session, starting again with 10 repetitions (1). 

Subjects will be properly instructed in performing the exercises at the start of the 
protocol by physiotherapists and/or qualified trainers previously trained by the authors. 
 
 

5. STATISTICAL ANALYSIS PLAN 
 
Descriptive analysis will be conducted to characterize the sample. Central tendency and 
dispersion data will be reported as mean and standard deviation for normal-distributed 
variables, or as median and interquartile range for non-normal- distributed variables, 
respectively. For the quantitative variables, the independent t-test or the Mann–Whitney 
U test will be carried out to compare the mean groups at the baseline. The 
homoskedasticity and sphericity will be checked. A mixed analysis of variance 
(ANOVA) 3 × 2 was carried out, adjusting multiple comparisons with the Bonferroni 
test. The size of the effect will be estimated with partial eta squared (η 2), interpreting 
values of 0.01, 0.06, 0.14, as small, medium, and large, respectively. 
 
 

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