Can clinical observation differentiate individuals with and without scapular dyskinesis?

Background:

Altered scapular rotation and position have been named scapular dyskinesis. Visual dynamic assessment could be applied to classify this alteration based on the clinical observation of the winging of the inferior medial scapular border (Type I) or of the prominence of the entire medial border (Type II), or by the excessive superior translation of the scapula (Type III).

Objective:

The aim of this study was to determine if there were differences in scapular rotations (Type I and II) and position (Type III) between a group of subjects with scapular dyskinesis, diagnosed by the clinical observation of an expert physical therapist, using a group of healthy individuals (Type IV).

Method:

Twenty-six asymptomatic subjects volunteered for this study. After a fatigue protocol for the periscapular muscles, the dynamic scapular dyskinesis tests were conducted to visually classify each scapula into one of the four categories (Type IV dyskinesis-free). The kinematic variables studied were the differences between the maximum rotational dysfunctions and the minimum value that represented both normal function and a small dysfunctional movement.

Results:

Only scapular anterior tilt was significantly greater in the type I dyskinesis group (clinical observation of the posterior projection of the inferior angle of the scapula) when compared to the scapular dyskinesis-free group (p=0.037 scapular and p=0.001 sagittal plane).

Conclusions:

Clinical observation was considered appropriate only in the diagnoses of dyskinesis type I. Considering the lower prevalence and sample sizes for types II and III, further studies are necessary to validate the clinical observation as a tool to diagnose scapular dyskinesis.     

Alternative Methods for Measuring Scapular Muscles Protraction and Retraction Maximal Isometric Forces

Background

The importance of the scapular stabilizing muscles has led to an increased interest in quantitative measurements of their strength. Few studies have measured isometric or concentric isokinetic forces. Additionally, limited reports exist on the reliability of objective measures for testing scapular protraction and retraction muscle strength or scapular testing that does not involve the glenohumeral joint.

Objective

To determine the reliability of four new methods of measuring the maximal isometric strength of key scapular stabilizing muscles for the actions of protraction and retraction, both with and without the involvement of the glenohumeral (GH) joint.

Methods

The Isobex® stationary tension dynamometer was used to measure the maximal isometric force (kg) on thirty healthy females (ages 22–26 years). Three measures were taken for each method that was sequentially randomized for three separate testing sessions on three nonconsecutive days.

Results

Intraclass correlations (ICC2,3) for intrasession reliability and (ICC3,3) for intersession reliability ranged from 0.95 to 0.98, and 0.94 to 0.96 respectively. The standard errors of measurement (95% confidence interval [CI]) were narrow. Scatter grams for both protraction and retraction testing methods demonstrated a significant relationship, 0.92 for protraction (95% CI 0.83 to 0.96) and 0.93 for retraction (95% CI 0.87 to 0.97). Bland-Altman plots indicated good agreement between the two methods for measuring protraction strength but a weaker agreement for the two methods measuring retraction strength.

Discussion/Conclusion

The four new methods assessed in this study indicate reliable options for measuring scapular protraction or retraction isometric strength with or without involving the GH joint for young healthy females.     

THE ROLE OF THE SCAPULA

Previously, the scapular musculature was often neglected in designing a rehabilitation protocol for the shoulder. In the past two decades a significant amount of research has been performed in order to help identify the role of the scapula in upper extremity function. Weakness of the scapular stabilizers and resultant altered biomechanics could result in: 1) abnormal stresses to the anterior capsular structures of the shoulder, 2) increased possibility of rotator cuff compression, and 3) decreased shoulder complex neuromuscular performance. This clinical commentary presents facts about the anatomy and biomechanics of the scapula and surrounding musculature, and describes the pathomechanics of scapular dysfunction. The focus is upon the assessment of dysfunction and retraining of the scapular musculature.

Level of Evidence:

5     

VALIDATION OF A NEW METHOD FOR ASSESSING SCAPULAR ANTERIOR‐POSTERIOR TILT

Background:

Electromagnetic tracking systems have enabled some investigators and clinicians to measure tri‐planar scapular motion; yet, they are not practical and affordable options for all clinicians. Currently, the ability to affordably quantify scapular motion is limited to monitoring only the motion of scapular upward rotation, with use of a digital inclinometer.

Hypothesis/Purpose:

The objective of this study was to determine the criterion‐related validity of a modified digital inclinometer when used to measure the motion of scapular anterior‐posterior (AP) tilt.

Materials & Methods:

Thirteen volunteers, free from any history of shoulder injury, reported for a single testing session. Each subject underwent a brief shoulder and posture examination in order to confirm the absence of pathology. Subjects actively performed clinically relevant amounts of humeral elevation in the scapular plane while in a seated position. An electromagnetic tracking system (Ascension Technology, Burlington, VT) and a modified inclinometer (Pro 360, Baseline®, Fabrication Enterprises, White Plains, NY) were used to acquire scapular AP tilt over the same shoulder motions. Criterion‐related validity was determined using Pearson Product Moment correlations.

Results:

Correlation analyses revealed significant moderate to good associations (r = 0.63 to 0.86, p < 0.01) between scapular AP tilt measures obtained with a digital inclinometer and an electromagnetic tracking system.

Conclusions

A modified digital inclinometer is a moderately valid device to use for the quantification of scapular AP tilt. Further study is warranted to establish reliability and to validate use of the device in patients with shoulder injury or pathology. The modified inclinometer expands the clinician''s ability to quantify scapular kinematic motion during the clinical evaluation and rehabilitation process.

Level of Evidence:

Level 3     

THE RELIABILITY OF REHABILITATIVE ULTRASOUND IMAGING IN THE MEASUREMENT OF INFRASPINATUS MUSCLE FUNCTION IN THE SYMPTOMATIC AND ASYMPTOMATIC SHOULDERS OF PATIENTS WITH UNILATERAL SHOULDER IMPINGEMENT SYNDROME

Background:

Rehabilitative ultrasound Imaging (RUSI) is increasingly used in the management of musculoskeletal conditions as it provides an objective measure of muscle function while being less invasive than needle electromyography. While research has documented the ability to reliably measure trunk muscles in patients with back pain, no study to date has used RUSI to quantify infraspinatus muscle function in patients with shoulder impingement syndrome (SIS).

Hypothesis/Purpose:

The purpose of this study was to examine the intra‐rater and inter‐rater reliability of measuring infraspinatus muscle thickness with RUSI and to compare such measures during resting versus contracted muscle states and in the symptomatic versus asymptomatic shoulders in patients with SIS.

Study Design:

Cross‐sectional, measurement study

Methods:

Fifty‐two participants with unilateral SIS underwent a standard baseline examination to include RUSI of the infraspinatus muscle bilaterally. Images were acquired at rest and during a submaximal isometric contraction, by two novice examiners. The isometric contraction was elicited by having prone participants externally rotate their shoulder from a position of 90° abduction into a dynamometer and hold a static force of 20 mmHg (approximately 20‐30% maximal voluntary contraction). Images were captured using a standardized placement of the transducer placed just inferior to the spine of the scapula along the medial scapular border and measured off‐line using Image J software (V1.38t, National Institutes of Health, Bethesda, Maryland).

Results:

Estimates (ICCs) for thickness measurements ranged between 0.96 and 0.98 for intra‐rater reliability and between 0.87 and 0.92 for inter‐rater reliability. Reliability was substantially lower (ICC = 0.43 to 0.79) for calculations of percent thickness change. The infraspinatus muscle was significantly thicker when contracted (19.1mm) than during rest (16.2mm) in both shoulders (p < 0.001). There was also a statistically significant interaction between contraction state and shoulder (p = 0.026), indicating that the change in thickness that occurred during contraction was significantly smaller in the symptomatic shoulder than in the asymptomatic shoulder.

Conclusion:

RUSI measurements of infraspinatus muscle thickness appear to be highly reliable, both within the same examiner and between different examiners, in patients with SIS. Moreover, such measurements were different in rested and contracted states of the infraspinatus, as well as, between the symptomatic and asymptomatic shoulders of patients with unilateral SIS.

Level of evidence:

Level 2     

A COMPARISON OF CHANGE IN 3D SCAPULAR KINEMATICS WITH MAXIMAL CONTRACTIONS AND FORCE PRODUCTION WITH SCAPULAR MUSCLE TESTS BETWEEN ASYMPTOMATIC OVERHEAD ATHLETES WITH AND WITHOUT SCAPULAR DYSKINESIS

Background

The significance of scapular dyskinesis is being challenged due to a lack of the association with pain and ability to predict injury in athletic populations. However, it is unknown whether asymptomatic overhead athletes with dyskinesis cope by normalizing scapular position with higher demand activities.

Hypothesis/Purpose

The purpose of this study was to compare change in scapular kinematics from an active unweighted contraction to a maximal isometric contraction in asymptomatic overhead athletes with and without scapular dyskinesis. Secondarily, force generated with manual muscle tests were explored for differences and relationships with kinematics.

Study Design

Cross‐sectional laboratory study

Methods

Twenty‐five matched asymptomatic overhead athletes with (n=14) and without (n=11) scapular dyskinesis, defined with a reliable and validated clinical method, participated in this study. Three‐dimensional scapular kinematics were evaluated in an active unweighted condition, and during maximal isometric contractions at 90 ° of shoulder flexion. Isometric force produced with lower trapezius and serratus anterior manual muscle tests were assessed with a dynamometer. Changes in scapular kinematics were compared between groups. Differences in force generated with manual muscle tests between groups and relationships with kinematics were explored.

Results

Athletes with dyskinesis demonstrated greater deficits in scapular upward rotation with maximal contraction (p=<0.001), less external rotation (p=0.036) and weaker lower trapezius manual muscle test strength (p=0.031). Lower trapezius (p=0.003;r=0.57) and serratus anterior (p=0.042;r=0.41) manual muscle test strength deficits were fair to moderately associated with a lack of scapular upward rotation during maximal contraction.

Conclusion

Small to moderate changes in scapular kinematics are normal responses to a maximal contraction, but with scapular dyskinesis this response is accentuated. Athletes with dyskinesis generate less force with lower trapezius manual muscle testing compared to athletes without dyskinesis. Decreased strength with lower trapezius and serratus anterior manual muscle testing was also related to a lack of upward rotation in all athletes.

Level of Evidence

3     

RELIABILITY OF THE SITTING HAND PRESS-UP TEST FOR IDENTIFYING AND QUANTIFYING THE LEVEL OF SCAPULAR MEDIAL BORDER POSTERIOR DISPLACEMENT IN OVERHEAD ATHLETES

Background:

The lack of proper scapular kinematics can limit the function of the entire shoulder complex.^1,3 Many forms of scapular dyskinesis have been proposed along with tests to measure for the position and motion associated with those positional and movement faults (2,4-6). While scapular internal rotation has been listed among the forms of scapular dyskinesis there has not been a reliable test documented in the literature that examines this motion. The purpose of this study was to determine whether an innovative scapular medial border posterior displacement measurement device has adequate inter-rater and intra-rater reliability when used at rest and during the sitting hand press up test.

Methods:

16 male Division III baseball players free of upper limb injury for the previous 12 months participated in the study. Posterior scapular displacement measures were taken on each subject in a resting static posture and while performing a sitting hand press up test. Subjects were tested twice within 24 hours by two separate examiners. Intraclass correlation coefficients (ICC) were calculated to determine intra-rater and inter-rater reliability.

Results:

The intra-rater reliability for rater 1 was .97 (95% confidence interval [CI]= .91-.98), for the rest position and .95 (95% CI= .86-.98) for the sitting hand press-up position. Intra-rater reliability for rater 2 was .99 (95% CI= .97-.99) for the rest position and .98 (95% CI=. 95-.99) for the sitting hand press-up position. The ICCs for inter-rater reliability of the scapular medial border posterior displacement measurement in at the rest position and the sitting hand press-up position were .89 (95% CI= .81-.96) and .89 (95% CI= .80-.96) respectively.

Conclusions:

The findings of this study indicate that the measurement of medial border posterior displacement using this device demonstrates good to excellent inter-rater and intra-rater reliability.     

ELECTROMYOGRAPHIC ACTIVITY OF SCAPULAR MUSCLES DURING DIAGONAL PATTERNS USING ELASTIC RESISTANCE AND FREE WEIGHTS

Purpose/Background:

Abnormalities in glenohumeral rhythm and neuromuscular control of the upper trapezius (UT), middle trapezius (MT), lower trapezius (LT) and serratus anterior (SA) muscles have been identified in individuals with shoulder pain. Upper extremity diagonal or proprioceptive neuromuscular facilitation (PNF) patterns have been suggested as effective means of activating scapular muscles, yet few studies have compared muscular activation during diagonal patterns with varying modes of resistance. The purpose of this study is to determine which type of resistance and PNF pattern combination best elicits electromyographic (EMG) activity of the scapular muscles.

Methods:

Twenty one healthy subjects with no history of scapulohumeral dysfunction were recruited from a population of convenience. Surface electrodes were applied to the SA, UT, MT and LT and EMG data collected for each muscle as the subject performed resisted UE D1 flexion, UE D1 extension, UE D2 flexion and UE D2 extension with elastic resistance and a three pound weight.

Results:

No significant differences were found between scapular muscle activity during D1 flexion when using elastic resistance and when using a weight. UT, MT and LT values were also not significantly different during D2 flexion when using elastic resistance vs. using a weight. The activity of the SA remained relatively the same during all patterns. The LT activity was significantly greater during D2 flexion with elastic resistance than during the D1 flexion and D1 extension with elastic resistance. MT activity was significantly greater during D2 flexion with elastic resistance as compared to all other patterns except D2 flexion with a weight. UT activity was significantly greater during flexion patterns than extension patterns.

Conclusions:

The upper extremity PNF pattern did significantly affect the mean UT, MT and LT activity but was not found to significantly affect SA activity. The type of resistance did not significantly change muscle activity when used in the same diagonal patterns.     

THE RELIABILITY AND CONCURRENT VALIDITY OF SHOULDER MOBILITY MEASUREMENTS USING A DIGITAL INCLINOMETER AND GONIOMETER: A TECHNICAL REPORT

Purpose/Aim:

This study investigated the intrarater reliability and concurrent validity of active shoulder mobility measurements using a digital inclinometer and goniometer.

Materials/Methods:

Two investigators used a goniometer and digital inclinometer to measure shoulder flexion, abduction, internal and external rotation on 30 asymptomatic participants in a blinded repeated measures design.

Results:

Excellent intrarater reliability was present with Intraclass Correlation Coefficients (ICC- 3,k) for goniometry ≥ 0.94 and digital inclinometry ≥ 0.95. The concurrent validity between goniometry and digital inclinometry was good with ICC (3,k) values of ≥ 0.85. The 95% limits of agreement suggest that the difference between these two measurement instruments can be expected to range from 2° to 20°.

Conclusions:

The results cautiously support the interchangeable use of goniometry and digital inclinometer for measuring shoulder mobility measurements. Although reliable, clinicians should consider the 95% limits of agreement when using these instruments interchangeably as clinically significant differences are likely to be present.

Level of evidence:

2b     

Reliability of scapular positioning measurement procedure using the Palpation Meter (PALM)

Background and objectives

Observation and measurement of the static position of the scapula is important for investigating both shoulder and neck pathology. Measurement of scapular position is complex and lacks a clinically useful instrument. The objective of this study was to investigate the reliability of the Palpation Meter (PALM) for measuring scapular position when the glenohumeral joint is held in various positions.

Methods

Thirty normal subjects were recruited for a test-retest reliability study. Three raters conducted measurements on two different occasions to estimate intra- and inter-rater reliability. The scapular positions evaluated in this study were: (1) the horizontal distance between the scapula and the spine in the scapular resting position and during elevation of the arm in the scapular plane; and (2) the vertical distance between C₇ and the acromion (C₇-A). Intraclass correlation coefficient (ICC), standard error of measurement (SEM) and Bland and Altman limits of agreement were calculated.

Results

Reliability values for measurements of the horizontal distance between the scapula and the spine were generally good for both intra-rater (ICC 0.81 to 0.89; SEM 0.56 to 1.17 cm) and inter-rater (ICC 0.67 to 0.89; SEM 0.59 to 0.98 cm) evaluation. Reliability values of measurement of depression of the acromion were also good for both intra-rater (ICC 0.72 to 0.78; SEM 0.66 to 0.79) and inter-rater (ICC 0.76; SEM 0.64) evaluation. No systematic bias was observed with Bland and Altman analysis.

Conclusions

The PALM is a reliable tool for the measurement of scapular positioning in a healthy sample. Future studies should be conducted to further investigate the clinometric properties of the PALM in patient populations before its clinical usefulness for measuring scapular position can be established.     

The influence of scapular depression on upper limb neurodynamic test responses

Objectives

Upper limb neurodynamic testing (ULNT) can be used clinically to assist in identifying neural tissue involvement in patients with upper quarter pain and dysfunction. Consideration for scapular positioning is a crucial component of ULNT standardization, as variations in positioning may dramatically impact sensory and motor responses. This study aimed to determine if there was a meaningful difference in test outcomes when the ULNT was performed in alternative scapular positions.

Methods

This cross-sectional study included 40 asymptomatic individuals. Repeated ULNT testing was performed on the dominant limb with the scapula blocked in neutral (ULNTb) and in scapular depression (ULNTd). Sensory responses, muscle activity, and range of motion outcomes were compared between the two test variations.

Results

Pre-positioning in scapular depression (ULNTd) led to reduced elbow extension range of motion, provoked greater upper trapezius muscle activity and an earlier onset and broader area of sensory responses compared to ULNTb.

Discussion

During ULNTb, the limbs were taken further into range and elicited reduced muscle activation and more localized sensory response providing a less vigorous version of the test. This study demonstrates that scapular positioning has a meaningful impact on ULNT test outcomes in healthy, asymptomatic individuals. The ULNTd can be considered a more vigorous version that may be appropriate when the cervical motions commonly utilized for structural differentiation are limited or contraindicated.     

RELIABILITY OF THE MYOTONOMETER FOR ASSESSMENT OF POSTERIOR SHOULDER TIGHTNESS

Background/Purpose:

The Myotonometer® is an electronic tissue compliance meter that has been used to quantify the compliance of soft tissues. The Myotonometer® may be a valuable tool to measure the effectiveness of interventions commonly used to increase tissue compliance in individuals with posterior shoulder tightness (PST). Limited data exist on reliability and responsiveness of the Myotonometer® for assessment of soft tissues about the shoulder; therefore, the purpose of this study is to determine the intra‐ and inter‐session reliability and responsiveness of the Myotonometer® in measuring tissue compliance of the posterior shoulder musculature in asymptomatic subjects with PST.

Methods:

Fifteen asymptomatic subjects with unilateral shoulder range of motion deficits attended two measurement sessions to assess the compliance of the tissues overlying the posterior deltoid, infraspinatus, and teres musculature. Analyses of reliability and responsiveness were conducted using intra‐class correlation coefficients (ICCs) and the determination of minimal detectible change (MDC).

Results:

Intra‐session ICC values ranged from 0.69 to 0.91 for all muscles with MDC never exceeding 1.0 mm. Inter‐session ICC values were best for the posterior deltoid, which averaged 0.82, compared to the infraspinatus and the teres complex, which averaged 0.42 and 0.5 respectively. Inter‐session MDC ranged from 0.55 to 1.20 mm across all muscles.

Conclusions:

Clinicians can reliably detect relatively small changes in tissue compliance within a single treatment session utilizing the Myotonometer®. The Myotonometer® can reliably detect changes between sessions for tissues overlying the posterior deltoid; however, observed change in the infraspinatus and teres musculature must be above 1 mm to achieve meaningful change and account for decreased inter‐session reliability.

Level of Evidence:

3     

Reliability of new software in measuring cervical multifidus diameters and shoulder muscle strength in a synchronized way; an ultrasonographic study

OBJECTIVES:

This study was conducted with the purpose of evaluating the inter-session reliability of new software to measure the diameters of the cervical multifidus muscle (CMM), both at rest and during isometric contractions of the shoulder abductors in subjects with neck pain and in healthy individuals.

METHOD:

In the present study, the reliability of measuring the diameters of the CMM with the Sonosynch software was evaluated by using 24 participants, including 12 subjects with chronic neck pain and 12 healthy individuals. The anterior-posterior diameter (APD) and the lateral diameter (LD) of the CMM were measured in a resting state and then repeated during isometric contraction of the shoulder abductors. Measurements were taken on separate occasions 3 to 7 days apart in order to determine inter-session reliability. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and smallest detectable difference (SDD) were used to evaluate the relative and absolute reliability, respectively.

RESULTS:

The Sonosynch software has shown to be highly reliable in measuring the diameters of the CMM both in healthy subjects and in those with neck pain. The ICCs 95% CI for APD ranged from 0.84 to 0.94 in subjects with neck pain and from 0.86 to 0.94 in healthy subjects. For LD, the ICC 95% CI ranged from 0.64 to 0.95 in subjects with neck pain and from 0.82 to 0.92 in healthy subjects.

CONCLUSIONS:

Ultrasonographic measurement of the diameters of the CMM using Sonosynch has proved to be reliable especially for APD in healthy subjects as well as subjects with neck pain.     

RELIABILITY OF STRENGTH AND PERFORMANCE TESTING MEASURES AND THEIR ABILITY TO DIFFERENTIATE PERSONS WITH AND WITHOUT SHOULDER SYMPTOMS

Background

Upper extremity physical performance measures exist but none have been universally accepted as the primary means of gauging readiness to return to activity following rehabilitation. Few reports have described reliability and/or differences in outcome with physical performance measures between individuals with and without shoulder symptoms.

Hypotheses/Purpose

The purpose of this study was to establish the reliability of traditional upper extremity strength testing and the CKCUEST in persons with and without shoulder symptoms as well as to determine if the testing maneuvers could discriminate between individuals with and without shoulder symptoms. The authors hypothesized that strength and physical performance testing would have excellent test/re‐test reliability for individuals with and without shoulder symptoms and that the physical performance maneuver would be able to discriminate between individuals with and without shoulder symptoms.

Methods

Male and female subjects 18‐50 years of age were recruited for testing. Subjects were screened and placed into groups based on the presence (Symptomatic Group) or absence of shoulder symptoms (Asymptomatic Group). Each subject performed an isometric strength task, a task designed to estimate 1‐repetition maximum (RM) lifting in the plane of the scapula, and the closed kinetic chain upper extremity stability test (CKCUEST) during two sessions 7‐10 days apart. Test/re‐test reliability was calculated for all three tasks. Independent t‐tests were utilized for between group comparisons to determine if a performance task could discriminate between persons with and without shoulder symptoms.

Results

Thirty‐six subjects (18/group) completed both sessions. Test/re‐test reliability for each task was excellent for both groups (intraclass correlations ≥ .85 for all tasks). Neither strength task could discriminate between subjects in either group. Subjects with shoulder symptoms had 3% less touches per kilogram of body weight on the CKCUEST compared to subjects without shoulder symptoms but this was not statistically significantly different (p=.064).

Conclusions

The excellent test/re‐test reliability has now been expanded to include individuals with various reasons for shoulder symptoms. Traditional strength testing does not appear to be the ideal assessment method for making discharge and/or return to activity decisions due to the inability to discriminate between the groups. The CKCUEST could be utilized to determine readiness for activity as it was trending towards being discriminatory between known groups.

Level of Evidence

Basic Science Reliability Study, Level 3     

CLINICAL EFFECTIVENESS OF KINESIOLOGICAL TAPING ON PAIN AND PAIN‐FREE SHOULDER RANGE OF MOTION IN PATIENTS WITH SHOULDER IMPINGEMENT SYNDROME: A RANDOMIZED,DOUBLE BLINDED,PLACEBO‐CONTROLLED TRIAL

Background:

Kinesiological taping (KT) is commonly used to improve symptoms associated with musculoskeletal disorders. However, review of the literature revealed minimal evidence to support the use of KT in treatment of shoulder disorders and controversy exists regarding the effect of KT in patients with shoulder impingement syndrome (SIS).

Objective:

The purpose of this study was to investigate the effect of KT on pain intensity during movement, pain experienced during the night (nocturnal pain), and pain‐free shoulder range of motion (ROM) immediately after taping, after three days and after one week, in patients with SIS.

Design:

Randomized, Double blinded, Placebo‐controlled design.

Participants:

A total of 30 patients with SIS participated in this study. Patients were assigned randomly to a control (N = 15) and an experimental group (N = 15).

Methods:

The patients in the experimental group received a standardized therapeutic KT. The standardized, placebo neutral KT was applied for control group. KT was applied two times with a three day interval, remaining on during the 3 day interval. Both groups followed the same procedures. Pain‐free active ROM during shoulder abduction, flexion, and elevation in the scapular plane was measured. Visual analogue scale (VAS) for pain intensity during movement or nocturnal pain and was assessed at baseline, immediately after KT, after three days, and one week after KT.

Results:

The result of repeated measures ANOVA showed a significant change in pain level during movement, nocturnal pain, and pain‐free ROM (p = 0.000) after KT in the experimental group. In the ANCOVA, controlling for pre‐test scores, change in pain level at movement (p = 0.009) and nocturnal pain (p = 0.04) immediately after KT was significantly greater in the experimental group than in control group. There was no significant difference in ROM measures (p > 0.05) between groups immediately after KT. No significant differences were found between the two groups in the after one week measurements of pain intensity and shoulder ROM.

Conclusion:

The KT produces an immediate improvement in the pain intensity at movement and nocturnal pain in patients with SIS.

Level of Evidence:

1     

ULTRASOUND IMAGING MEASUREMENT OF THE TRANSVERSUS ABDOMINIS IN SUPINE,STANDING, AND UNDER LOADING: A RELIABILITY STUDY OF NOVICE EXAMINERS

Background

Military personnel and first responders (police and firefighters) often carry large amounts of gear. This increased load can negatively affect posture and lead to back pain. The ability to quantitatively measure muscle thickness under loading would be valuable to clinicians to assess the effectiveness of core stabilization treatment programs and could aid in return to work decisions. Ultrasound imaging (USI) has the potential to provide such a measure, but to be useful it must be reliable.

Purpose

To assess the intrarater and interrater reliability of measurements of transversus abdominis (TrA) and internal oblique (IO) muscle thickness conducted by novice examiners using USI in supine, standing, and with an axial load.

Study Design

Prospective, test‐retest study

Methods

Healthy, active duty military (N=33) personnel were examined by two physical therapy doctoral students (primary and secondary ultrasound technicians) without prior experience in USI. Thickness measurements of the TrA and IO muscles were performed at rest and during a contraction to preferentially activate the TrA in three positions (hook‐lying, standing, and standing with body armor). Percent thickness changes and intraclass correlation coefficients (ICC) were calculated.

Results

Using the mean of three measurements for each of the three positions in resting and contracted muscle states, the intrarater ICC (3,3) values ranged from 0.90 to 0.98. The interrater ICC (2,1) values ranged from 0.39 to 0.79. The ICC values of percent thickness changes were lower than the individual ICC values for all positions and muscle states.

Conclusion

There is excellent intrarater reliability of novice ultrasound technicians measuring abdominal muscle thickness using USI in three positions during the resting and contracted muscle states. However, interrater reliability of two novice technicians was poor to fair, so additional training and experience may be necessary to improve reliability.

Level of Evidence

2b     

Scapular behavior in shoulder impingement syndrome.

OBJECTIVE: To quantify the contribution of each scapular rotation to the scapular total range of motion (ROM) in both shoulders of persons with a unilateral shoulder impingement syndrome (SIS), to compare 3-dimensional (3D) scapular attitudes of their symptomatic and asymptomatic shoulders in flexion and in abduction, and to characterize the scapular behavior of these subjects by classifying them into subgroups based on scapular tilting differences between their symptomatic and asymptomatic shoulders. DESIGN: Comparisons of 3D scapular attitudes, scapular total ROM, and percentage of contributions of each scapular rotation to the scapular total ROM. SETTING: A motricity laboratory. PARTICIPANTS: Fifty-one subjects, including 41 with a SIS (29 had an asymptomatic contralateral shoulder) and 10 healthy subjects. INTERVENTIONS: The 3D scapular attitudes were calculated with the subjects in a standardized seated position; with the arm at rest; or at 70 degrees, 90 degrees, and 110 degrees of shoulder flexion and abduction. Axial rotation angles were calculated using a fixed set of Cardanic angles. MAIN OUTCOME MEASURES: At 90 degrees of arm elevation, data from 10 shoulders of healthy subjects were used to set up normative values (99% confidence interval of mean 3D scapular attitudes) to compare with 3D scapular attitudes of symptomatic and asymptomatic shoulders of SIS subjects. We analyzed the scapula behavior of subjects with SIS and classified them into subgroups based on scapular anterior tilting asymmetry. RESULTS: In flexion, almost half of the scapular total ROM was provided by anterior tilting (48.2%-51.3%), whereas in abduction, external rotation (40.3%-42.4%) was the main contributor. Scapular total ROM was higher in abduction than in flexion in all arm positions for both shoulder groups (P <.01). Also, 3D scapular attitude patterns of both shoulders of SIS subjects were different from those of healthy subjects. At 90 degrees, scapular asymmetry in anterior tilting allowed us to classify SIS subjects with respect to more (lead) or less (lag) scapular tilting in the affected side (P <.0001) or no difference (P =.11) between the sides (symmetrical). No significant differences (P >.05), except for a small 2 degrees difference in transverse rotation during arm flexion at 110 degrees (P =.002), were observed in 3D scapular attitudes and scapular total ROM between both shoulders of SIS subjects. Patterns of 3D scapular attitudes and scapular total ROM were significantly different between flexion and abduction arm positions (P <.05). CONCLUSIONS: The contribution of rotations and scapular total ROM differed according to the plane of arm elevation in SIS subjects. Group analyses revealed no differences in 3D scapular attitudes between symptomatic and asymptomatic shoulders of subjects with unilateral SIS. This could be caused by the use, in SIS subjects, of inappropriate neuromuscular strategies affecting both shoulders. However, individual analyses revealed scapular asymmetry in the sagittal plane, which suggests that SIS subjects with less anterior tilting in the symptomatic shoulder, as compared with the asymptomatic contralateral one, may be at high risk of developing chronic SIS. This last finding provides scientific evidence to focus rehabilitation protocols toward a restoration of anterior tilting.     

MEASURING FITNESS IN FEMALE GYMNASTS: THE GYMNASTICS FUNCTIONAL MEASUREMENT TOOL

Purpose/Background:

A reliable and valid method of measuring and monitoring a gymnast''s total physical fitness level is needed to assist female gymnasts in achieving healthy, injury-free participation in the sport. The Gymnastics Functional Measurement Tool (GFMT) was previously designed as a field-test to assess physical fitness in female competitive gymnasts. The purpose of this study was to further develop the GFMT by establishing a scoring system for individual test items and to initiate the process of establishing the test-retest reliability and construct validity of the GFMT.

Methods:

A total of 105 competitive female gymnasts ages 6-18 underwent testing using the GFMT. Fifty of these subjects underwent re-testing one week later in order to assess test-retest reliability. Construct validity was assessed using a simple regression analysis between total GFMT scores and the gymnasts'' competition level to calculate the coefficient of determination (r²). Test-retest reliability was analyzed using Model 1 Intraclass correlation coefficients (ICC). Statistical significance was set at the p<0.05 level.

Results:

The relationship between total GFMT scores and subjects'' current USAG competitive level was found to be good (r² = 0.60). Reliability testing of the GFMT total score showed good test-retest reliability over a one week period (ICC=0.97). Test-retest reliability of the individual component items was good (ICC = 0.80-0.92).

Conclusions:

The results of this study provide initial support for the construct validity and test-retest reliability of the GFMT.     

THE RELIABILITY,MINIMAL DETECTABLE CHANGE AND CONSTRUCT VALIDITY OF A CLINICAL MEASUREMENT FOR IDENTIFYING POSTERIOR SHOULDER TIGHTNESS

Purpose/Background:

Posterior shoulder tightness (PST) has been implicated in the etiology of numerous shoulder disorders. Therefore, clinicians and researchers must have a reliable and valid method for quantifying PST. The purpose of this study was to investigate the interrater reliability, minimal detectable change at the 90% confidence interval (MDC₉₀) and construct validity of an inclinometric measurement designed to quantify PST.

Methods:

Two investigators each performed sidelying PST measurements on the non-dominant shoulder of 45 asymptomatic participants in a blinded repeated measures design. Upon completion of the PST measurements, one rater assessed active internal and external rotation for the validity component of the investigation.

Results:

Interrater reliability using an intraclass correlation coefficient (ICC) model 2,k was good (ICC 5 0.90). The MDC₉₀ indicated that a change of greater than or equal to 9 degrees would be required to be 90% certain that a change in the measurement would not be the result of inter-trial variability or measurement error. Construct validity was evaluated using active internal rotation for convergence and external rotation for discrimination. Construct validity was supported by a good to excellent relationship between PST and internal rotation (r 5 0.88) and by an inverse relationship between PST and external rotation (r 5 20.07).

Conclusion:

The sidelying procedure described in this investigation appears to be a reliable and valid means for quantifying PST when strict measurement protocols are adhered to. An advantage of this procedure lies in the ability to control scapular position to ensure motion is limited to the glenohumeral joint. Moreover, the use of inclinometry provides an absolute angle of tightness that may be used for intersubject comparison, documenting change, and to determine reference values. Clinicians and researchers should consider the MDC values presented when interpreting change values during subsequent measurement sessions.     

EVALUATING CHANGE IN CLINICAL STATUS: RELIABILITY AND MEASURES OF AGREEMENT FOR THE ASSESSMENT OF GLENOHUMERAL RANGE OF MOTION

Objectives:

To evaluate intra-rater and inter-rater reliability and measurement error in glenohumeral range of motion (ROM) measurements using a standard goniometer.

Study design:

17 adult subjects with and without shoulder pathology were evaluated for active and passive range of motion. Fifteen shoulder motions were assessed by two raters to determine reliability. The intra-class correlation coefficients (ICC) were calculated and examined to determine if reliability of ICC ≥ 0.70 existed. The standard error of measurement (SEM) and the minimal clinical difference (MCD) were also calculated.

Results:

Thxe criterion reliability was achieved in both groups for intra-rater reliability of standing AROM abduction; supine AROM and PROM abduction, flexion, external rotation at 0° abduction; and for inter-rater reliability of supine AROM and PROM abduction, external rotation at 0° abduction. The SEM ranged from 4°-7° for intra-rater and 6°-9° for inter-rater agreement on movements that achieved the criterion reliability. The MCD ranged from 11°-16° for a single evaluator and 14°-24° for two evaluators.

Conclusions:

Assessment of AROM and PROM in supine achieves superior reliability. The use of either a single or multiple raters affects the number of movements that achieved clinically meaningful reliability. Some movements consistently did not achieve the criterion and may not be the best movements to monitor treatment outcome.