Clinical measurement of posterior shoulder flexibility

doi:10.1016/j.math.2006.07.014

Manual Therapy

Volume 12, Issue 4, November 2007, Pages 386-389

https://doi.org/10.1016/j.math.2006.07.014 Get rights and content

Abstract

The objectives of this study were to determine both the intra-rater reliability and the smallest real difference necessary to detect meaningful clinical changes over an 8–12 week period for three clinical measures of posterior shoulder flexibility. Posterior shoulder tightness has been associated with abnormal humeral head translations that narrow the subacromial space and contribute to impingement. Posterior shoulder stretching to normalize joint kinematics is often used when treating individuals with subacromial impingement. Currently there is no measurement of posterior shoulder flexibility that has been demonstrated to be reliable or responsive in patients over a treatment interval. Construction workers with overhead work exposure were recruited to an impingement group (n=37), and an asymptomatic group (n=22). Three flexibility measurements were taken on each subject at baseline and 8–12 weeks later by the same physical therapist. Intra-rater reliability was determined using intra-class correlation coefficients (ICCs) and standard errors of measurement (SEM). The smallest real difference value (SRD) determined the smallest detectable intervention-related measurement change over time. ICCs for the three measurements ranged from poor (0.40) to good (0.79). The SEM and SRD values reflected high test–retest variability in all three measurements. None of the three measures were proven to be highly stable indicators of posterior shoulder flexibility over this time period, nor were they able to detect small changes over this interval due to the high trial to trial variance in a non-intervention sample. Caution should be used when interpreting these clinical measurements over prolonged time periods.

Introduction

Posterior glenohumeral capsular tightness has been theorized to contribute to shoulder impingement syndrome (Bang and Deyle, 2000). In vitro tightening of the posterior capsule has resulted in increased anterior and superior humeral head translations on the glenoid (Harryman et al., 1990), which are believed to decrease the available subacromial space during upper extremity elevation (Deutsch et al., 1996; Ludewig and Cook, 2002). Tightness in the posterior shoulder has been associated with a loss of glenohumeral internal rotation range of motion (ROM) (Cohen and Williams, 1998; Tyler et al., 1999), and decreased glenohumeral internal rotation ROM has been identified in subjects with impingement syndrome (Warner et al., 1990). This ROM loss is believed indicative of posterior shoulder tightness because tension in the posterior capsule has limited glenohumeral internal rotation ROM in cadaver models (Terry et al., 1991).

Based on these findings, stretching and soft tissue mobilization of the posterior shoulder tissues are often included in rehabilitation of individuals with subacromial impingement. To determine the necessity and effectiveness of these interventions, a reliable and responsive clinical measure of posterior capsule flexibility is necessary. The purpose of this study was to compare three measurements used to quantify posterior shoulder flexibility.

Section snippets

Subjects

Subjects were recruited from construction trades that require daily overhead work. Volunteers were required to be at least 18 years of age and have at minimum a 1-year work history in their trade. Symptomatic individuals reporting at least 1 week of shoulder pain were considered. Asymptomatic individuals with similar overhead work exposure but no shoulder pain were recruited as a control group. All subjects signed an informed consent agreement upon entry into the study.

Symptomatic subjects were

Results

There were no significant differences (P>0.05) between groups on demographic variables (Table 1). Table 2 reports the ICC values for intra-rater reliability, and the stability of the measures indicated by the SEM and SRD. The sidelying adduction measure was least reliable for both groups and lowest in the symptomatic group, while the stability of the measures was comparable between groups for all three measures.

Discussion

None of the three measures were determined to be highly reliable or able to detect small clinical changes when used at least 8 weeks apart by the same rater. Lower intra-rater reliability values were demonstrated in symptomatic subjects, with relatively high variability within subjects for all measurements. The results indicate that these measurements may not be adequately stable for a single rater to detect within subject treatment effects beyond 5 days as has been previously reported (Tyler

Conclusion

Clinical measures demonstrated to be highly reliable on a healthy population over short periods may not be clinically useful on subjects with pathology tested over longer intervals. It may be necessary to use replicate measures, a cluster of tests, a modification of one of these techniques, or an entirely new validated test to reliably assess posterior shoulder flexibility in a clinical population over treatment intervals.

Acknowledgments

This research was supported in part by the Center to Protect Worker's Rights, the Public Health Service and the University of Iowa under Public Health Service Grant no. U60/CCU317202. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the Center to Protect Worker's Rights, the Public Health Service, or the University of Iowa.

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In addition, all studies examining both the supine and side-lying HA methods scored a negative measurement property.7,28 Reliability examination for internal rotation,4,20 low-flexion,3,7 and myotonometer7,17 methods was performed within 2 studies for each method, all of which received a positive measurement property score. A single study examining reliability for both the extension–with–internal rotation method and the scapular-plane abduction method received a positive measurement property score for both.7
Posterior shoulder tightness (PST) has been linked to numerous shoulder pathologies in both the general and athletic populations. Several methods for documenting PST have been described in the literature, which may lend to variability in clinical practice and research. The purpose of this study was to perform a systematic review with meta-analysis to investigate the reliability, validity, and methodologic quality of methods used to quantify PST.
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The search resulted in 1006 studies identified, with 18 ultimately retained. Intrarater reliability was reported in 12 studies with a summary intraclass correlation coefficient of 0.93 (95% confidence interval, 0.90-0.95), whereas inter-rater reliability was reported in 6 studies with a summary intraclass correlation coefficient of 0.89 (95% confidence interval, 0.80-0.94). Validity was reported in 10 studies, all using internal rotation as the convergent standard, and was found to be significant in all but 1 study.
Current methods used to quantify PST have good reliability but are primarily limited to measures of horizontal adduction of the glenohumeral joint with scapular stabilization. Limitations in using a single measurement technique exist particularly as there may be multiple contributing factors to PST. A more comprehensive approach for quantifying PST is necessary, and suggested components include a cluster of techniques composed of horizontal adduction, internal rotation, and total glenohumeral joint range of motion.
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To date, the significance of factors purported to be associated with subacromial shoulder impingement (SSI) and what differences, if any, are present in those with SSI compared to a matched asymptomatic population has not been identified. Gaining information about differences between people with SSI and asymptomatic people may direct clinicians towards treatments that impact upon these differences.
Compare the assessment findings of factors suggested to be associated with SSI; passive posterior shoulder range, passive internal rotation range, resting cervical and thoracic postures, active thoracic range in standing and scapula positioning between cases experiencing SSI and a matched asymptomatic group (controls).
Case Control Study.
Fifty one SSI cases and 51 asymptomatic controls were matched for age, gender, hand dominance and physical activity level. The suggested associated factors were measured bilaterally. Independent t-tests were used to compare each of these measurements between the groups. Any variables for which a significant difference was identified, were then included in a conditional logistic regression analysis to identify independent predictors of SSI.
The SSI group had significantly increased resting thoracic flexion and forward head posture, as well as significantly reduced upper thoracic active motion, passive internal rotation range and posterior shoulder range than the matched asymptomatic group. No independent predictors of SSI were identified in conditional logistic regression analysis.
Thoracic posture, passive internal rotation range and posterior shoulder range were significantly different between cases experiencing SSI and a matched asymptomatic group.
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GIRD, TRROM, and humeral torsion-based classification of shoulder risk in throwing athletes are not in agreement and should not be used interchangeably
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Athletes were classified as “at risk” using the previously documented cut-points—GIRD: ≥20°, TRROM ≥ 5°, GIRD-torsion: 10°. The 10° figure was derived after considering: the smallest detectable differences of the torsion measure,13 shoulder rotational ROM,20–22 clinical reasoning, and clinical experience. The prevalence of each of these classifications as well as the agreement between each of the approaches was calculated individually by simple arithmetic and estimations of agreement for each of the pair-wise comparisons23.
Clinicians commonly interpret the findings of shoulder rotational ranges of motion using various approaches: an apparent reduction in dominant arm internal rotation (“GIRD”), a difference in total rotational range of motion—i.e. differences in the sum of internal and external rotational range (TRROM), and a combination of rotational ROM and torsional difference (“GIRD-torsion”). We have noticed that these approaches are being considered to provide equivalent estimates of shoulder rotational range. This investigation sought to document the extent of agreement of these three different approaches when classifying athletes’ “at-risk” status.
Observational cohort study.
162 professional male athletes participating in overhead sports (baseball, handball, and volleyball) had their GIRD, TRROM, and GIRD-torsion calculated, and classified as “at risk” using standard cut-points of 20°, 5°, and 10°, respectively.
25 (15.4%) athletes were classified as “at-risk” using GIRD, 55 (34%) with TRROM, and 30 (18.5%) using GIRD-torsion. Only 3/162 (1.9%) athletes were classified as “at-risk” by all 3 approaches, 4 athletes were concurrently classified as “at-risk” by GIRD and TRROM (Kappa = −0.142, poor agreement), 11 by GIRD and GIRD-torsion (Kappa = 0.279, fair agreement), and 11 by TRROM and GIRD-torsion (Kappa = 0.025, slight agreement).
25 (15.4%) athletes were classified as at risk using GIRD, 55 (34%) with TRROM, and 30 (18.5%) using GIRD-torsion. Only 3/162 (1.9%) athletes were classified as at risk by all 3 approaches, 4 athletes were concurrently classified as at risk by GIRD and TRROM (Kappa = −0.142, poor agreement), 11 by GIRD and GIRD-torsion (Kappa = 0.279, fair agreement), and 11 by TRROM and GIRD-torsion (Kappa = 0.025, slight agreement).
The three described approaches yield demonstrably different findings, and these approaches cannot be used interchangeably. Examples of clinical reasoning are provided to assist with the interpretation of these different measures.
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These results are similar to those of a previous study where intrarater reliability of the pectoralis minor index showed ICCs ranging from 0.91 (symptomatic side) to 0.93 (asymptomatic side) in patients with shoulder impingement syndrome (Struyf et al., 2014). In contrast, Borstad et al. (2007) reported that intrarater reliability of posterior shoulder flexibility was generally lower in subjects with subacromial impingement (ICC: 0.40–0.79) compared with asymptomatic subjects (ICC: 0.63–0.79) because the inability to relax, guarding against pain onset, or pain elicited by the measurement may have influenced measurement error. Although previous results are controversial, the results of this study allow us to conclude that the LSI can be used with confidence across different condition levels because it did not elicit pain in subjects with SDRS.
The objective of this study was to introduce levator scapulae (LS) measurement using a caliper and the levator scapulae index (LSI) and to investigate intra- and interrater reliability of the LSI in subjects with and without scapular downward rotation syndrome (SDRS).
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Despite this, the group receiving MWM with exercise exhibited greater improvement than that receiving exercise/hot pack, reaching 34.55°, which approximates the mean normal range of 39.7° when measured in side lying,29 indicating clinically significant improvement. Borstad et al55 reported that a change of 19° in shoulder internal rotation ROM can be considered as a true change in shoulder posterior capsule flexibility. The improvement seen in both groups was greater than this ROM.
The aim of this study was to investigate the effects of hand-behind-back (HBB) Mulligan mobilization with movement (MWM) techniques on acute shoulder pain, impairment, and disability.
This double-blind, randomized, controlled trial recruited 44 patients with acute shoulder pain and movement impairment presenting to an Indian general hospital. Participants were allocated to receive either MWM and exercise/hot pack (n = 22) or exercise/hot pack alone (n = 22). The average duration of symptoms was 4.1and 4.7 weeks in the exercise and MWM groups, respectively. The primary outcome was HBB range of motion (ROM). Secondary variables were shoulder internal rotation ROM, pain intensity score, and shoulder disability identified by the shoulder pain and disability index. All variables were evaluated by a blinded assessor before and immediately after 9 treatment sessions over 3 weeks.
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Electromagnetic devices allow the non invasive and accurate measurement of 3D scapula kinematics. The acromial method allows continuous dynamic measurement using a skin surface sensor fixed to the acromion. Inter-session intra and inter-observer repeatability of 3D scapular kinematics have only been partially assessed for analytical movements and never for functional tasks. Inter-session intra and inter-observer repeatability of 3D scapular kinematics were assessed for arm elevation in the sagittal and frontal planes and for two activities of daily living (ADL), hair combing and back washing, in both shoulders of 15 healthy subjects, using the intraclass correlation coefficient (ICC), the standard error of measurement (SEM), the small real difference (SRD) and the Bland and Altman's graphical method. Intra-observer repeatability was good to excellent for every scapular rotation for both arm elevation in isolated planes and ADL (ICC ranged from 0.64 to 0.95). Inter-observer repeatability of scapular rotations was fair to excellent for arm elevation in isolated planes (ICC ranged from 0.49 to 0.92) and poor to excellent for ADL (ICC ranged from 0.35 to 0.89). Inter-observer repeatability of scapular protraction/retraction had the lowest ICC. For both inter-session intra and inter-observer reliability, the SEM and SRD remained low and Bland and Altman's graphical method showed a good repeatability of the measurement method. Longitudinal monitoring of a subject's scapular kinematics by a trained observer is reliable. The inter-observer repeatability of scapular protraction/retraction must be improved.

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^☆: This research was supported in part by the Center to Protect Worker's Rights, the Public Health Service and the University of Iowa under Public Health Service Grant no. U60/CCU317202. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the Center to Protect Worker's Rights, the Public Health Service, or the University of Iowa.

¹: At the time of the study, these authors were graduate students, University of Minnesota Program in Physical Therapy or Rehabilitation Science, Department of Physical Medicine and Rehabilitation, Minneapolis, MN, USA.

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Technical & measurement reportClinical measurement of posterior shoulder flexibility☆

Abstract

Introduction

Section snippets

Subjects

Results

Discussion

Conclusion

Acknowledgments

Journal of Shoulder and Elbow Surgery

Comparison of supervised exercises with and without manual therapy for patients with shoulder impingement syndrome

Journal of Orthopaedic and Sports Physical Therapy

Smallest real difference, a link between reproducibility and responsiveness

Quality of Life Research

Impingement syndrome and rotator cuff disease as repetitive motion disorders

Clinical Orthopaedics and Related Research

Reliability of measurement

Translation of the humeral head on the glenoid with passive glenohumeral motion

Journal of Bone and Joint Surgery

Translations of the humerus in persons with impingement syndrome

Journal of Orthopaedic and Sports Physical Therapy

Technical & measurement report
Clinical measurement of posterior shoulder flexibility☆