Title Page Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without Shoulder Pain

1 TITLE PAGE
2 Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without

3 Shoulder Pain
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5 Hillary A. Plummer, PhD, ATC
6 University of Southern California
7 Los Angeles, CA, USA
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Downloaded from www.jospt.org at University of Hong Kong Libraries on July 14, 2017. For personal use only. No other uses without permission.
9 Jonathan C. Sum, PT, DPT

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13 Federico Pozzi, PhD, PT
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17 Rini Varghese, MS, PT
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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21 Lori A. Michener, PhD, PT, ATC, SCS, FAPTA*
23 Division of Biokinesiology and Physical Therapy
24 1540 E. Alcazar St., CHP 155
25 Los Angeles, CA 90089
26 lmichene@usc.edu
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Journal of Orthopaedic & Sports Physical Therapy®
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31 *Corresponding Author
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35 The Virginia Commonwealth University and University of Southern California
36 Institutional Review Boards approved this study.
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39 TITLE PAGE
40 Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without

41 Shoulder Pain
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43 *The authors affirm that they have no financial affiliation (including research funding) or
44 involvement with any commercial organization that has a direct financial interest in any
45 matter included in this manuscript
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84 ACKNOWLEDGEMENTS
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86 The authors would like to acknowledge Brian McNeill, PT, DPT, Jari Haile, PT, DPT,
87 Andrew Piraino, PT, DPT, and Keegan Kitzgerald, PT, DPT for their assistance with data
88 collection.
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126 Abstract
127 STUDY DESIGN: Cross-sectional.
128 BACKGROUND: The scapular dyskinesis test (SDT) has demonstrated reliability and
129 validity, but the utility for clinical decision-making is unclear.
130 OBJECTIVES: Characterize the prevalence of scapular dyskinesis in participants with

131 and without shoulder pain, and to determine the influence of blinding to the presence of
132 shoulder pain on prevalence of scapular dyskinesis.
133 METHODS: Participants (n=135), 67 with shoulder pain and 68 healthy controls, were
134 included in this study. The SDT was performed by 2 examiners, from a total of 21
135 physical therapists. The second examiner was blinded to the participant’s presence of
136 shoulder pain. The SDT involved participants performing 5-repetitions of shoulder
137 flexion and abduction, while the clinician observed for scapular dyskinesis characterized
138 by scapular winging or dysrhythmia. Dyskinesis was rated as normal, subtle, or obvious.
139 Ratings were collapsed into 2 groups, dyskinesis (subtle and obvious) and no dyskinesis
140 (normal) as recommended by expert consensus.

141 RESULTS: There were no significant differences for scapula dyskinesis prevalence
142 between the shoulder pain and control groups during SDT in abduction [shoulder
143 pain=67.2% (95%CI:0.55,0.77); control group=52.9% (95%CI:0.41,0.64);p=0.09] or
144 flexion [shoulder pain=67.2% (95%CI:0.55,0.77); control group=61.8%
145 (95%CI:0.50,0.72);p=0.51]. There were significant differences (p<0.001) between the
146 examiners SDT rating in the shoulder pain group. The unblinded examiners reported a
147 higher prevalence when testing the involved shoulder for dyskinesis in flexion
148 [blinded=67.7% (95%CI:0.56,0.78; unblinded=80% (95%CI:0.69,0.88)], and during
149 abduction [blinded=66.2% (95%CI:0.54,0.76; unblinded=78.5% (95%CI:0.67,0.87)].
4
150 CONCLUSIONS: Scapular dyskinesis as assessed using the SDT is not more prevalent
151 in those with shoulder pain, but the rating is influenced by the examiners knowledge of
152 shoulder pain presence. Scapular dyskinesis may represent normal movement variability.
153 LEVEL OF EVIDENCE: Diagnosis, level 4.

154
155 KEY WORDS: Evaluation; Screening; Shoulder pain
156
157 Word count: 261
5
158 Scapular dyskinesis, defined as altered movement or position of the scapula, has been
159 proposed as cause of shoulder pain.4, 6, 8, 10 The scapular dyskinesis test (SDT)8 was
160 developed as a clinical test to identify abnormalities in scapular movement or position by
161 visual observation of scapular motion. The SDT classification described by McClure and
162 colleagues uses a 3-level classification (none, subtle and obvious dyskinesis), based on
163 the presence of scapular winging or dysrhythmia during arm elevation. The SDT using 3-
164 level rating has demonstrated moderate reliability between clinician raters (ĸ =0.48 –
165 0.61;percentage agreement= 75–82%).8 Uhl and colleagues21 used a 2-level (yes/no)
166 classification of observational scapular dyskinesis without the use of weights also
167 reported moderate reliability (ĸ =0.40;percentage agreement= 79%). Construct validity

168 of the 3-level SDT17 was established by demonstrating that participants rated as having
169 obvious dyskinesis had larger alterations of scapular and clavicle three-dimensional (3D)
170 kinematics than those without dyskinesis.
171 Uhl and colleagues21 examined side-to-side scapular motion asymmetry using 3D
172 kinematics in participants with and without shoulder pain. Asymmetrical scapular motion
173 was almost equal for those with shoulder pain and healthy controls, with prevalence of
174 76% and 77% respectively during scaption, and 71% in both groups during flexion. It
175 does not appear that the asymmetry in scapular motion alone is related to presence of
176 shoulder pain. On the other hand if the presence of scapular dyskinesis that is
177 independent of asymmetry, is an impairment that is related to shoulder pain, or if it
178 represents just normal movement variability is not known.21
179 During a physical examination, the clinician rating the SDT is not blinded to
180 patient symptoms. In theory, rating of clinical tests may be influenced by knowledge of
6
181 participant symptoms, especially in qualitative observational tests. Therefore, it is
182 possible that examiner or confirmation bias may mask the true presence or absence of
183 scapular dyskinesis resulting in an inaccurate SDT rating. Biased scapular assessment
184 may lead to a treatment focus of correcting the dyskinesis, which may be unwarranted
185 because the observed dyskinesis may not be contributing to the participant’s symptoms.
186 The clinical relevance of a test is determined by its’ ability to guide clinical
187 decision-making.20 A systematic review concluded that visual scapular dyskinesis tests
188 are not useful in differentially diagnosing shoulder pathology.2 Moreover, they may have
189 limited clinical utility in isolation.22 Deciding what treatment to perform or
190 prognosticating the risk of re-injury are two potential clinical decisions that are enabled
191 by using the SDT. Further studies examining scapular dyskinesis are needed to determine
192 clinical utility of the SDT. A first step is to determine if the prevalence of observable
193 scapular dyskinesis is influenced by the presence of shoulder pain, or by clinician bias.
194 Aim 1 of this study was to characterize the prevalence of scapular dyskinesis in
195 participants with shoulder pain as compared to a matched control group without shoulder
196 pain. Aim 2 was to examine the prevalence of scapular dyskinesis as rated by examiners
197 blinded and unblinded to the presence of shoulder pain to assess potential bias that may
198 exist when rating the SDT. The research hypotheses were: (1) participants with shoulder
199 pain would not have a significantly different prevalence of scapular dyskinesis than those
200 without pain, and (2) the unblinded clinician would not report greater prevalence of
201 dyskinesis than the blinded examiner in participants with shoulder pain.
202 METHODS
203 Participants
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204 Potential participants with and without shoulder pain who presented for physical
205 therapy were screened during the treating physical therapist’s initial evaluation. If
206 potential participants met the inclusion criteria the study was explained to them and they
207 were asked to participate. Inclusion criteria included: 1) between 18-70 years of age,
208 comprehend English for instructions and completion of the data collection forms, and 2)
209 for the shoulder pain group only, participants were required to have shoulder pain with
210 activity ≥ 2/10 on the numeric pain rating scale. Participants for both groups were
211 excluded if any of the following conditions were present: 1) adhesive capsulitis, defined
212 as a loss of >50% in passive shoulder range of motion in shoulder external rotation and 1
213 other plane of motion, 2) previous shoulder surgery within the past year, 3) history of
214 shoulder fracture, 4) systemic musculoskeletal disease (rheumatoid arthritis and
215 fibromyalgia, etc.), and 5) shoulder pain that was reproduced with active/passive cervical
216 spine motion. Additionally, participants for the control group were excluded if they had a
217 history of shoulder pain within the past 1 year.

218 Participants for both the shoulder pain and control groups were recruited at the
219 same clinics. Participants in the control group were being treated for conditions of the
220 lower extremities that did not affect the upper extremity. All participants completed the
221 informed consent, which was approved by the University of Southern California
222 Institutional Review Board. All potential participants who met the inclusion and
223 exclusion criteria agreed to participate. A tally was not recorded of those participants
224 who were screened, but were ineligible because of inclusion or exclusion criteria.
225 An a priori power analysis indicated to that a total sample size of 108 participants
226 was required to determine a significant difference in prevalence rate, with a power of
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227 80%, alpha of 0.05, using estimates of prevalence from prior studies of 48% for patients
228 with shoulder pain and 25% in those without shoulder pain.8, 16
229 Examiners
230 Data for this study were collected at 4 physical therapy clinics in Virginia and
231 California. The examiners were physical therapists (n=21) with an average age of 31.8 ±
232 7.4 years, 6.1 ± 7.8 year of practice, spent 90.3 ± 9.6% of their day treating patients, and
233 specifically 23.1 ± 14.1% of day treating patients with shoulder disorders. Prior to the
234 start of the study, all participating physical therapists completed an on-line training of the
235 clinical SDT. The developers of the SDT created this training.19 Live training occurred
236 following the on-line training to review data collection procedures. Prior to the start of
237 the study, test-retest reliability was established on a subset of participating physical
238 therapists (n= 5) on 7 participants. Both shoulders were tested during weighted flexion
239 and abduction SDT. The clinicians rated scapular movement as normal, subtle or
240 obvious, and then these ratings were collapsed into the 2-level (yes/no) classification The
241 kappa coefficient was 0.69 (95%CI: 0.36, 1), and the percent of agreement was 85%,
242 which is consistent with prior reports of reliability.8
243 Procedures
244 The Pennsylvania Shoulder Score (Penn), was used to assess shoulder pain,
245 satisfaction with shoulder use, and disability in the shoulder pain group (0-100; 100 = no
246 disability).5 The Penn has demonstrated validity and reliability when measuring patient-
247 rated symptoms and function 5, 11 Pain was assessed with a numeric pain rating scale (0-
248 10; 0 = no pain).
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249 The participants were asked to expose their scapula by either removing their shirt,
250 wearing only a halter-style shirt, or wearing a shirt with small straps such as a sports bra
251 or camisole. The SDT was performed as originally described by McClure et al.8 Each
252 participant performed 5 repetitions each of shoulder flexion and abduction, using a 2.2-kg
253 (5-lb) weight in their hands for those weighing 68-kg (150-lb) or greater, and 1.4-kg (3-
254 lb) weight for those weighing less than 68-kg.8 If participants could not complete the
255 motion with weight, they performed the SDT without weight. The examiner observed for
256 the presence of scapula dyskinesia (winging and dysrhythmia) during elevation and
257 lowering of the participant’s arms. Winging was described as any excessive movement of
258 any part of the medial scapula moving off of the thorax. Dysrhythmia was described as
259 any unsmooth movement of the scapula, relating to timing and speed of the scapular
260 movement. The presence of scapula dyskinesia was scored using a 3 category
261 classifications: 1- normal = no evidence of abnormality, 2- subtle = mild or questionable
262 evidence of abnormality that is not consistently present, 3- obvious = striking, clearly
263 apparent abnormality that is evident on at least 3/5 trials.8 For data analysis, the 3-level
264 classification of the SDT was collapsed to a 2-level classification scheme based on
265 consensus recommendations4 of no dyskinesis = normal rating, dyskinesis = subtle and
266 obvious dyskinesis ratings.
267 In participants with shoulder pain, the SDT was performed for both shoulders, and
268 by both the blinded and unblinded examiner. In participants without shoulder pain
269 (control group), the SDT was performed in both shoulders, but only by the blinded
270 examiner. Participants with shoulder pain were asked to perform the SDT twice and 2
271 independent examiners rated each test. There was approximately 5-30 minutes between
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272 examinations and the blinded examiner was selected based on availability during testing.
273 The SDT8, 17 was first rated by the physical therapist who recruited the patient for the
274 study, and this examiner was the unblinded examiner as they were not blinded to group
275 (shoulder pain or control group). A second physical therapist from the clinic was then
276 recruited by the treating physical therapist to assess scapular dyskinesis with the SDT.
277 This second clinician was the blinded examiner, as they were blinded to the participants’
278 presence or absence of shoulder pain. This blinded examiner only communicated the
279 instructions for the flexion and abduction SDTs, so knowledge of shoulder pain or
280 symptoms would be eliminated during the testing. The participants in the control group
281 were assessed using the SDT only once by a blinded examiner in the same manner as
282 described for the participants with shoulder pain. Both shoulders were rated during the
283 SDT for participants in the control group.
284
285 Statistical Analysis

286 Group baseline characteristics were examined with independent t-tests for age,
287 height, mass, and Body Mass Index (BMI); and chi-square analysis for gender. Arm
288 dominance was controlled for between the groups, by matching the control group for arm
289 dominance. In the shoulder pain group 53/67 (79.1%) had pain in their dominant
290 shoulder. In the control group the dominant arm results of the SDT were selected
291 randomly using a random number generator in order to match the percentage of dominant
292 shoulders tested in the shoulder pain group. The dominant shoulder SDT results for the
293 first 54 subject numbers listed from the random number generator were selected. This
294 resulted in 54/68 (79.4%) of dominant shoulder in the control group.
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295 Chi-square tests were performed to examine the differences in prevalence of
296 dyskinesis between groups for (Aim 1). The prevalence of dyskinesis in both involved
297 and uninvolved shoulder as rated by blinded and unblinded examiners (Aim 2) was
298 analyzed using McNemar Tests. These analyses were performed for both flexion SDT
299 and abduction SDT. The level of significance was set at p < 0.05.
300 The 3 categories of SDT ratings were collapsed into 2 categories of dyskinesis=
301 subtle/ obvious, and no dyskinesis = normal rating. A sensitivity analysis was performed
302 to determine if the results would be different if the data was collapsed differently into 2
303 categories: no dyskinesis = normal/ subtle, and dyskinesis = obvious rating. Statistical
304 Package for Social Science (IBM Inc., Chicago, IL) was used for data analysis.
305 RESULTS
306 One-hundred thirty-five participants volunteered for this study. Sixty-seven
307 participants with shoulder pain comprised the shoulder pain group and sixty-eight
308 participants without shoulder pain made up the control group. Demographic and
309 diagnoses characteristics are presented in Table 1 and 2, respectively. There was a
310 significant difference in age between the groups; the shoulder pain group was 5.1 years
311 older. A sub-group analysis for age was performed to assess if prevalence of dyskinesis
312 differed between the 20 youngest and the 20 oldest participants. No significant
313 differences were observed between the youngest and oldest participants in each group for
314 abduction or flexion. There were missing data present for 2 participants rated by the
315 unblinded examiner.
316 Aim 1 – Shoulder Pain Group versus Control Group. There were no significant
317 differences between groups for the prevalence of scapular dyskinesis as rated by the SDT
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318 during flexion by the blinded examiner (p= 0.51); dyskinesis was reported in 45/67
319 (67.2%) in the shoulder pain group and 42/68 (61.8%) in the control group (Table 3).
320 There were no significant differences between groups for the prevalence of scapular
321 dyskinesis during abduction (p= 0.09) as rated by the blinded examiner; dyskinesis was
322 reported in 45/67 (67.2%) in the shoulder pain group and 36/68 (52.9%) of the control
323 group (Table 3).
324 Aim 2 – Shoulder Pain Group- Involved Shoulder: Blinded vs. Unblinded
325 Examiner. There were significant differences in the rating of scapular dyskinesis
326 between the blinded and unblinded examiners for the involved shoulder in the shoulder
327 pain group during the flexion SDT (p< 0.001); dyskinesis was reported in 44/65 (67.7%)
328 by the blinded examiner and 52/65 (80%) by the unblinded examiner (Table 4). Similar
329 results were also observed during abduction. For the abduction SDT, there were
330 significant differences in the rating of scapular dyskinesis between the blinded and
331 unblinded examiners for the involved shoulder in the shoulder pain group (p= 0.001);
332 dyskinesis was reported in 43/65 (66.2%) by the blinded examiner and 51/65 (78.5%) by
333 the unblinded examiner (Table 4).
334 Aim 2- Shoulder Pain Group – Uninvolved shoulder: Blinded vs. Unblinded
335 Examiner. There were significant differences between examiners for abduction SDT
336 [unblinded examiner= 43/65 (66.2%) rated with dyskinesis; blinded examiner= 44/65
337 (67.7%) rated with dyskinesis; p= 0.008] described in Table 5. There was a higher overall
338 prevalence of dyskinesis during the abduction SDT. There were no significant differences
339 in prevalence of scapular dyskinesis between the blinded and unblinded examiners for the
340 uninvolved shoulder in the shoulder pain group during the flexion SDT [unblinded
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341 examiner= 39/65 (60%); blinded examiner= 37/65 (56.9%); p= 0.222]. The sensitivity
342 analysis revealed no significant differences between groups, or between the blinded
343 versus unblinded examiners ratings for the shoulder pain group for the alternative
344 categories of no dyskinesis = normal/ subtle, dyskinesis = obvious rating.
345 DISCUSSION
346 The overall goal of this study was to help understand the clinical utility of the
347 SDT in management of patients with shoulder pain. Specifically, we examined
348 prevalence of observable scapular dyskinesis in those with shoulder pain using the SDT
349 and the potential bias that may exist when rating SDT. Our findings indicate that the
350 occurrence of scapular dyskinesis is not influenced by the presence of shoulder pain.
351 However, the rating of scapular dyskinesis does appear to be impacted by the clinician’s
352 knowledge of the presence of shoulder pain in the involved shoulder.
353 Our first hypothesis was confirmed; there were no statistically significant
354 differences in prevalence of scapular dyskinesis in those with shoulder pain as compared
355 to those without shoulder pain. The prevalence rate of dyskinesis was 5% higher in the
356 shoulder pain group, which was not statistically different, and is likely not meaningfully
357 different than the control group. Uhl and colleagues21 reported similar findings with
358 almost identical prevalence rates of scapular asymmetry in participants with shoulder
359 pain and healthy controls. However, it is important to note that Uhl and colleagues
360 examined only asymmetries by comparing scapular motion bilaterally within individuals.
361 The results of Uhl and colleagues are not directly comparable to the results of the current
362 study because we did not rely on scapular asymmetry to determine the presence of
363 scapular dyskinesis. Results from the current study indicate that the presence of scapular
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364 dyskinesis may not be a relevant impairment for those with shoulder pain, and may
365 represent normal movement variability.9 The participants in the current study had low
366 levels of pain and disability. Furthermore, approximately 70% of the participants were
367 diagnosed with subacromial pain / rotator cuff disease or posterior impingement. It is
368 possible that a more symptomatic or functionally limited group would present with
369 different findings than what was observed.
370 The results for aim 2 of the study revealed that blinded and unblinded examiners
371 rated the presence of scapular dyskinesis significantly different for both motions in the
372 involved shoulder and for abduction in the uninvolved shoulder. The unblinded examiner
373 reported a higher rate of positive SDT than the blinded examiner. The prevalence rate of
374 dyskinesis was 12.3% higher in the involved shoulder when rated by the unblinded
375 examiner during flexion and abduction SDT. The differences in prevalence rates between
376 examiners may be clinically meaningful and indicate a potential confirmation bias since a
377 higher presence of scapular dyskinesis was reported when examiners knew they were
378 rating an individual’s painful shoulder. However, this was not the case for the uninvolved
379 shoulder, where the prevalence rates were similar for the flexion SDT between
380 examiners. The difference in prevalence of dyskinesis between the two examiners was
381 1.5% for abduction and 3.1% difference in flexion in the uninvolved shoulder.
382 The results of this study indicate that clinical tests that rely on observational
383 assessment may be influenced by knowledge of patients’ symptoms. Confirmation bias
384 for observational dyskinesis could lead to a treatment plan that does not address the
385 underlying cause of shoulder pain. Addressing normal variability in scapula movement
386 may not be warranted based on the results of the SDT because this variability may not be
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387 contributing to the patient’s shoulder pain. Further research is warranted to determine if a
388 reduction in pain or increase in shoulder strength is observed during the scapular
389 reposition test18 or scapular assistance test.13 These clinical tests may differentiate the
390 role of the scapula in the contribution to shoulder pain. The scapular reposition test or
391 scapular assistance test may better identify how normal movement variability may be
392 present but not contribute to and allow clinicians to devise improved plans of care.
393 A priori, the planned data reduction was to collapse the data from 3 categories
394 (normal, subtle, obvious) into 2 categories (normal vs. subtle/ obvious). This was based
395 on the assumption that when any level of dyskinesis is observed, clinicians would rate
396 that as having scapular dyskinesis. We subsequently performed a sensitivity analysis by

397 examining the prevalence in dyskinesis when collapsed into dyskinesis = normal/ subtle
398 versus no dyskinesis = obvious. There were no significant differences between groups or
399 blinded versus unblinded examiners, thus we draw the same conclusions as when the data
400 was collapsed in the original method.

401 Clinical decision-making using the SDT has been investigated.23 Prior studies
402 have examined the ability of observational scapular dyskinesis using the SDT to predict
403 the risk of injury.1, 3, 12, 14, 15 These studies have reported varying results in varying
404 participant populations and observational methods. The findings are equivocal as to the
405 predictive ability of scapular dyskinesis tests, with two previous studies reporting that
406 observable scapular dyskinesis tests can predict injury risk,1, 3 and three others indicating
407 no predictive ability.12, 14, 15 Observational scapular dyskinesis tests have questionable
408 ability to predict injury risk. Clinical shoulder evaluations often compare scapular motion
409 between the pathological shoulder and the contralateral shoulder without accounting for
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410 the potential confounding effects of arm dominance.7 It has been suggested that the
411 increased frequency of dominant shoulder use can contribute to scapular motion deficits.7
412 Studies classifying the presence of dyskinesis between the dominant and non-dominant
413 shoulders, with the SDT, are lacking. However, scapular kinematic data between
414 shoulders during dynamic arm elevation have been reported.7, 21, 24, 25 The results are
415 equivocal, with no difference in kinematics between shoulders reported in 2 studies,24, 25
416 while 2 other studies reported differences.7, 21 These conflicting results may be due to the
417 different methods used to measure scapular kinematics. We controlled for dominance by
418 matching the groups for arm tested by dominance, thus eliminating this potential
419 confounding factor.

420 There are some limitations to this study. We did not control for shoulder diagnosis
421 or examine the effect of diagnosis on the presence of scapular dyskinesis, so it is unclear
422 if the prevalence of dyskinesis may have been affected by the presence of a specific
423 diagnosis. The participants in the shoulder pain group had low reported levels of pain and
424 disability. Results of this study can only be generalized to patients with similar diagnoses
425 and pain/ function levels. We did not to take into account that classification of scapular
426 dyskinesis was obtained by 21 different physical therapists, assuming this variation was
427 random. Future research should examine the prevalence of dyskinesis in diagnostic
428 subgroups of patients with shoulder disorders. There were only 8 participants who did
429 not use weights during the SDT due to an inability to perform the test due to pain or
430 weakness. The potential exists that the blinded examiner could have assumed that these
431 participants had shoulder pain, however the examiner would not have known which side
432 was painful, as the use of weights (or no weights) were the same for both arms. To reduce
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433 the likelihood that bias was introduced we reanalyzed the data with the 8 participants
434 removed and our results did not change. Additionally, examining the clinical utility of
435 the scapular reposition test18 and scapular assistance test may help to elucidate the
436 differential prevalence of dyskinesis in patients whose pain is reduced with these tests.
437 CONCLUSIONS
438 Scapular dyskinesis does not appear to be related to the presence of shoulder pain.
439 Scapular dyskinesis was observed in participants with shoulder pain as well as healthy
440 controls, but the prevalence was not statistically different between these 2 groups.
441 Focusing solely on the prevalence of dyskinesis in patients with shoulder pain may not be
442 beneficial during a clinical evaluation, as scapular dyskinesis may represent normal
443 movement variability. Potential bias may exist when unblinded examiners assess the
444 presence of scapular dyskinesis in patients with shoulder pain because higher rates of
445 prevalence were reported by unblinded versus blinded examiners. Assessment of scapular
446 symptom alteration tests and other associated impairments may help to delineate the
447 effect of scapular dysfunction on shoulder pain in these patients and enable clinical
448 decision-making.
449
18
450 KEY POINTS
451 FINDINGS: The prevalence of scapular dyskinesis is very similar in participants with
452 and without shoulder pain. Unblinded examiners consistently rated the presence of
453 scapular dyskinesis higher than blinded examiner. This may indicate a potential bias of
454 reporting for the SDT when a clinician is aware of the presence of shoulder pain.
455 IMPLICATIONS: Scapular dyskinesis is an impairment that may represent normal
456 movement variability. Clinical evaluation and treatment focused on scapular dyskinesis
457 may not be warranted based solely on the presence of observable scapular dyskinesis.
458 CAUTION: Shoulder diagnoses may have influenced the prevalence of scapular
459 dyskinesis.
460
19
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20
507 15. Struyf F, Nijs J, Meeus M, et al. Does scapular positioning predict shoulder pain
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514 175.
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517 Orthop Sports Phys Ther. 2008;38(1):4-11.
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526 methods for scapular dyskinesis. Arthroscopy. 2009;25(11):1240-1248.

527 22. Wassinger CA, Williams DA, Milosavljevic S, Hegedus EJ. Clinical reliability
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529 detecting patients with shoulder impairment. Int J Sports Phys Ther.
530 2015;10(4):456-463.
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532 accuracy of scapular physical examination tests for shoulder disorders: a
533 systematic review. Br J Sports Med. 2013;47(14):886-892.
534 24. Yano Y, Hamada J, Tamai K, et al. Different scapular kinematics in healthy
535 subjects during arm elevation and lowering: Glenohumeral and scapulothoracic
536 patterns. J Shoulder Elbow Surg. 2010;19(2):209-215.
537 25. Yoshizaki K, Hamada J, Tamai K, Sahara R, Fujiwara T, Fujimoto T. Analysis of
538 the scapulohumeral rhythm and electromyography of the shoulder muscles during
539 elevation and lowering: Comparison of dominant and nondominant shoulders. J
540 Shoulder Elbow Surg. 2009;18(5):756-763.
541
542
543
544
545
546
21
547 TABLES
548 TABLE 1. Participant Descriptive Data.
549
Shoulder Pain Control p-value
Group Group
(n=67) (n=68)
Age, years (SD) 32.5 (12.4) 27.4 (8.8) 0.01
Sex – Female, n (%) 33 (49.3%) 41 (60.3%) 0.20
Height, cm (SD) 171.1 (10.0) 171.1 (9.3) 0.98

Weight, kg (SD) 70.2 (13.2) 68.9 (13.1) 0.57
Body Mass Index 24.3 (4.5) 24.1 (4.1) 0.01
Dominant shoulder tested, n (%) 53 (79.1%) 54 (79.4%)
Pain, 0 -10 points, 0=no pain (SD) 2.2 (1.1) N/A
Penn Shoulder Score, 0 -100 points, 100=no disability (SD) 78.8 (11.0) N/A
Work with arms overhead, n (%) 3 (4.5%) 4 (5.9%)
Sports participation > 2 days/ week, 2 hrs/ day, n (%) 22 (32.8%) 17 (25.0%)
Exercise with shoulders > 2 days/ week, 2 hrs/ day, n (%) 43 (64.2%) 41 (60.3%)
550
551 TABLE 2. Diagnosis of Participants in the Shoulder Pain Group (n=67); 37% of
552 participants had more than 1 diagnosis.

553
Diagnosis Number
Subacromial Pain / Rotator Cuff Disease 35
Posterior Impingement 17
Labral Tear 14
Instability 5
Acromioclavicular Joint Sprain 10
Muscle Strain 5
Thoracic Outlet Syndrome 2
554
555
556
557
558
559
560
561
562
563
564
565
566
22
567 TABLE 3. Prevalence of scapular dyskinesis in the shoulder pain group (n=67) and the
568 control group (n=68) during the flexion and abduction SDT, as examined by the blinded
569 examiner in the involved shoulder.
570
Blinded Examiner, No Dyskinesis % Dyskinesis Χ2
Involved Shoulder Dyskinesis [95%CI] p-value
Flexion SDT
Shoulder Pain Group 22 45 67.2% 0.51
[0.55, 0.77]
Control Group 26 42 61.8%
[0.50, 0.72]
Abduction SDT
Shoulder Pain Group 22 45 67.2% 0.09
[0.55, 0.77]
Control Group 32 36 52.9%
[0.41, 0.64]
571
572 TABLE 4. Presence of scapular dyskinesis in the involved shoulder of the shoulder pain
573 group (n=65), as rated by the unblinded and blinded examiners during the flexion and
574 abduction SDT.

575
576 A. Flexion SDT
Blinded Examiner
No Dyskinesis
Dyskinesis Dyskinesis Total prevalence:
No Unblinded
Unblinded Dyskinesis 5 8 13 Clinician
Examiner 52 /65
Dyskinesis 16 36 52 (80%)
[95%CI:0.69,0.88]
Total 21 44 65
McNemar Dyskinesis
test prevalence: 44 /65
p< 0.001 Blinded (67.7%)
577 Clinician [95%CI:0.56,0.78]
578
579
580
581
582
583
23
584 B. Abduction SDT
Blinded Examiner
No Dyskinesis
No Unblinded
Examiner 51 /65
Dyskinesis 9 35 51 (78.5%)
[95%CI:0.67,0.87]
Total 22 43 65
McNemar Dyskinesis
p= 0.001 Blinded (66.2%)
585 Clinician [95%CI:0.54,0.76]
586
587
588 TABLE 5. Presence of scapular dyskinesis in the Uninvolved shoulder of the shoulder
589 pain group (n=65), as rated by the unblinded and blinded examiners during the flexion
590 and abduction SDT.
591
592
593 A. Flexion SDT
Blinded Examiner
No Dyskinesis
No Unblinded
Examiner 39 /65
Dyskinesis 12 27 39 (60%)
[95%CI:0.48,
0.71]
Total 28 37 65
McNemar Dyskinesis
p= 0.222 Blinded (56.9%)
Clinician [95%CI: 0.45,
0.68]
24
594 B. Abduction SDT
Blinded Examiner
No Dyskinesis
No Unblinded
Examiner 43/65
Dyskinesis 9 34 43 (66.2%)
[95%CI:0.54,
0.76]
Total 21 44 65
McNemar Dyskinesis
p= 0.008 Blinded (67.7%)
Clinician [95%CI:0.56,
0.78]
595
596
597
598
599
600
25

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1 TITLE PAGE

2 Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without

9 Jonathan C. Sum, PT, DPT

19 Los Angeles, CA, USA

35 The Virginia Commonwealth University and University of Southern California

36 Institutional Review Boards approved this study.

40 Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without

129 validity, but the utility for clinical decision-making is unclear.

130 OBJECTIVES: Characterize the prevalence of scapular dyskinesis in participants with

132 shoulder pain on prevalence of scapular dyskinesis.

140 (normal) as recommended by expert consensus.

143 pain=67.2% (95%CI:0.55,0.77); control group=52.9% (95%CI:0.41,0.64);p=0.09] or

144 flexion [shoulder pain=67.2% (95%CI:0.55,0.77); control group=61.8%

145 (95%CI:0.50,0.72);p=0.51]. There were significant differences (p<0.001) between the

148 [blinded=67.7% (95%CI:0.56,0.78; unblinded=80% (95%CI:0.69,0.88)], and during

149 abduction [blinded=66.2% (95%CI:0.54,0.76; unblinded=78.5% (95%CI:0.67,0.87)].

153 LEVEL OF EVIDENCE: Diagnosis, level 4.

160 developed as a clinical test to identify abnormalities in scapular movement or position by

167 reported moderate reliability (ĸ =0.40;percentage agreement= 79%). Construct validity

170 kinematics than those without dyskinesis.

177 independent of asymmetry, is an impairment that is related to shoulder pain, or if it

178 represents just normal movement variability is not known.21

189 limited clinical utility in isolation.22 Deciding what treatment to perform or

214 shoulder fracture, 4) systemic musculoskeletal disease (rheumatoid arthritis and

217 history of shoulder pain within the past 1 year.

242 which is consistent with prior reports of reliability.8

248 10; 0 = no pain).

261 classifications: 1- normal = no evidence of abnormality, 2- subtle = mild or questionable

265 consensus recommendations4 of no dyskinesis = normal rating, dyskinesis = subtle and

266 obvious dyskinesis ratings.

283 SDT for participants in the control group.

285 Statistical Analysis

294 resulted in 54/68 (79.4%) of dominant shoulder in the control group.

306 One-hundred thirty-five participants volunteered for this study. Sixty-seven

315 unblinded examiner.

323 group (Table 3).

333 the unblinded examiner (Table 4).

344 categories of no dyskinesis = normal/ subtle, dyskinesis = obvious rating.

347 SDT in management of patients with shoulder pain. Specifically, we examined

352 knowledge of the presence of shoulder pain in the involved shoulder.

369 different findings than what was observed.

383 assessment may be influenced by knowledge of patients’ symptoms. Confirmation bias

396 that as having scapular dyskinesis. We subsequently performed a sensitivity analysis by

400 was collapsed in the original method.

415 equivocal, with no difference in kinematics between shoulders reported in 2 studies,24, 25

419 confounding factor.

455 IMPLICATIONS: Scapular dyskinesis is an impairment that may represent normal

480 Ther. 2006;36:138-151.

516 on shoulder impingement symptoms and elevation strength in overhead athletes. J

526 methods for scapular dyskinesis. Arthroscopy. 2009;25(11):1240-1248.

Height, cm (SD) 171.1 (10.0) 171.1 (9.3) 0.98

552 participants had more than 1 diagnosis.

574 abduction SDT.

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