Intraobserver Reliability of Angular and Linear Measurements of Scapular Position in Subjects With and Without Symptoms

doi:10.1016/j.apmr.2008.01.028

Archives of Physical Medicine and Rehabilitation

Volume 89, Issue 9, September 2008, Pages 1795-1802

https://doi.org/10.1016/j.apmr.2008.01.028 Get rights and content

Abstract

Lewis JS, Valentine RE. Intraobserver reliability of angular and linear measurements of scapular position in subjects with and without symptoms.

Objective

To assess intraobserver reliability of angular and linear clinical measurements of scapular position.

Design

Test-retest analyses.

Setting

Outpatient department in National Health Service teaching hospital in the United Kingdom.

Participants

Subjects (n=45) without symptoms (21 men, 24 women; age range, 23–56y) and 45 subjects (22 men, 23 women; age range, 19–84y) with shoulder symptoms (defined as pain in the C5-6 dermatome reproduced by shoulder movement and not reproduced with cervical movement).

Interventions

Not applicable.

Main Outcome Measures

Intraclass correlation coefficient (ICC) models 2,1 and 2,3, 95% confidence intervals (CIs), and SE of measurements for 68% confidence and 2 SEs of measurement (for the 95% CI) for the bilateral angular measurements of scapular rotation and tilt, and the bilateral linear measurements of lateral scapular displacement (protraction) and vertical displacement (elevation).

Results

For subjects without symptoms, ICC_2,3 results ranged from .75 to .98. The 2 SE results for the angular movements ranged from 1.8° to 2.4° and from 0.4 to 1.0cm for the direct linear measurements. Subjects with symptoms: ICC_2,3 results ranged from .61 to .98. The 2 SE results for the angular movements ranged from 1.4° to 2° and from 0.6 to 1cm for the direct linear measurements.

Conclusions

Repeated-measure (ICC_2,3) results were more reliable than single-measure (ICC_2,1) results. Very good to excellent intraobserver reliability was demonstrated for the angular and linear measurements of interest in both shoulders of subjects with and without symptoms. The 2 SE results provide guidance about the error associated with the individual measurements and will assist the clinician determining whether a change in the static position of the scapula has occurred as a result of intervention or over time. (National Research Register identifier N0060148286.)

Section snippets

Participants

Subjects with symptoms were recruited through the orthopedic and physical therapy outpatient department in the teaching hospital where the study was conducted. Symptoms included pain in the C5-6 dermatome at rest or reproduced on shoulder movement and not influenced by cervical movement. Because this study involved the reliability of measuring scapular position, subjects with acute and chronic conditions with varying durations and severities were included. Subjects with symptoms were assessed

Results

Forty-five subjects without symptoms (21 men [47%]; 24 women [53%]; combined mean age, 32y; range, 23–56y; mean height, 1.7m; range, 1.6–1.9m; mean weight, 70.4kg; range, 50–110kg) were recruited. Forty-five subjects with symptoms were recruited (22 men [49%]; 23 women [51%]; combined mean age, 43y; range, 19–84y; mean height, 1.7m; range, 1.5–1.9m; mean weight, 71.4kg; range, 49–90kg). Diagnostic categories for the subjects with symptoms included nonspecific shoulder pain (n=21), rotator cuff

Discussion

Although assessment of scapular position is considered to be an important component of the clinical examination of the shoulder, conflicting clinical and research findings1, 3, 16, 17, 18, 19, 29, 30, 31 suggest further investigations are necessary. To date, no study known to us has investigated the reliability of a series of static angular and linear clinical measurements of the scapula. In addition, we are unaware of any study that has measured scapular tilt using a simple clinical procedure.

Conclusions

Poor scapular posture and movement have been suggested as mechanisms in the pathogenesis of a number of shoulder pathologies. Although this is yet to be proven, many clinicians believe that the clinical assessment of scapular position is an essential part of the clinical examination of the shoulder. The findings of the current study provide clinicians with clinically accessible measurements to determine the static and angular position of the scapula (when the arm is by the side) in subjects

Acknowledgment

We thank the members of the physiotherapy outpatient department at Chelsea and Westminster Hospital for their support of this investigation.

References (43)

S.L. Mottram
Dynamic stability of the scapula
Man Ther
(1997)
W.B. Kibler et al.
Qualitative clinical evaluation of scapular dysfunction: a reliability study
J Shoulder Elbow Surg
(2002)
J. Smith et al.
Effect of scapular protraction and retraction on isometric shoulder elevation strength
Arch Phys Med Rehabil
(2002)
J. Gray et al.
Interrelationship of the spine, rib cage, and shoulder
J. Lewis et al.
Scapular position: the validity of skin surface palpation
Man Ther
(2002)
I. Michiels et al.
Kinematics of shoulder abduction in the scapular plane: on the influence of abduction velocity and external load
Clin Biomech
(1995)
S. Raine et al.
Head and shoulder posture variations in 160 asymptomatic women and men
Arch Phys Med Rehabil
(1997)
J.S. Lewis et al.
Subacromial impingement syndrome: the role of posture and muscle imbalance
J Shoulder Elbow Surg
(2005)
M. Kebaetse et al.
Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular kinematics
Arch Phys Med Rehabil
(1999)
E.G. Culham et al.
Shoulder complex position and glenohumeral subluxation in hemiplegia
Arch Phys Med Rehabil
(1995)

P.W. McClure et al.

Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo

J Shoulder Elbow Surg

(2001)

L. McKenna et al.

Inter-tester reliability of scapular position in junior elite swimmers

Phys Ther Sport

(2004)

O. Grimsby et al.

Interrelation of the spine to the shoulder girdle

W.B. Kibler

The role of the scapula in athletic shoulder function

Am J Sports Med

(1998)

S. Sahrmann

Diagnosis and treatment of movement impairment syndromes

(2002)

F. Kendall et al.

Muscle testing and function

(1993)

W. Kibler

Role of the scapula in the overhead throwing motion

Contemp Orthop

(1991)

S.D. Bagg et al.

A biomechanical analysis of scapular rotation during arm abduction in the scapular plane

Am J Phys Med Rehabil

(1988)

L. Freedman et al.

Abduction of the arm in the scapular plane: scapular and gleno-humeral movements: a roentgenographic study

J Bone Joint Surg Am

(1966)

N.K. Poppen et al.

Forces at the glenohumeral joint in abduction

Clin Orthop Relat Res

(1978)

S.G. Doody et al.

Shoulder movements during abduction in the scapular plane

Arch Phys Med Rehabil

(1970)

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Citation Excerpt :
Several studies have examined the reliability of posture measurements among healthy participants with radiographs [32], photographs [33], and electrogoniometer [34]. Different posture indices have been examined including the posture of the head [35], trunk [36], shoulders [37], and lower limbs [38]. No clear consensus concerning the reliability of posture measurement exists among studies.
Posture changes are a major consequence of idiopathic scoliosis (IS). Posture changes can lead to psychosocial and physical impairments in adolescents with IS. Therefore, it is important to assess posture, but the test-retest reliability of posture measurements still remains unknown in this population.
The primary objective of the present study was to determine the test-retest reliability of 25 head and trunk posture indices using the Clinical Photographic Postural Assessment Tool (CPPAT) in adolescents with IS. The secondary objective was to determine the standard error of measurement and the minimal detectable change.
This is a prospective test-retest reliability study carried out at two tertiary university hospital centers.
Forty-one adolescents with IS, aged 10–16 years old with curves 10°–45° and treated by medical intervention, were recruited.
Two posture assessments were done using the CPPAT 5–10 days apart following a standardized procedure. Photographs were analyzed with the CPPAT software by digitizing reference landmarks placed on the participant by a physiotherapist evaluator. Generalizability theory was used to obtain a coefficient of dependability, standard error of measurement, and the minimal detectable change at 90% confidence interval.
Fourteen of 25 posture indices had a good reliability (ϕ≥0.78), 10 had moderate reliability (ϕ=0.55–0.74), and 1 had poor reliability (ϕ=0.45). The most reliable posture indices were waist angle asymmetry (ϕ=0.93), right waist angle (ϕ=0.91), and frontal trunk list (ϕ=0.92). Right sagittal trunk list was the least reliable posture index (ϕ=0.45). The MDC₉₀ values ranged from 2.6 to 10.3° for angular measurements and from 8.4 to 35.1 mm for linear measurements.
The present study demonstrates that most posture indices, especially the trunk posture indices, are reproducible in time among adolescents with IS and provides reference values. Clinicians and researchers can use these reference values to assess change in posture over time attributable to treatment effectiveness.
The effects of a conservative rehabilitation program for multidirectional instability of the shoulder
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Conservative management is commonly recommended as the first-line treatment for multidirectional instability (MDI) of the shoulder. Despite this, the evidence for efficacy of treatment is limited, and until recently, guidance for clinicians on conservative rehabilitation programs has been inadequate. This study evaluated the effectiveness of a physiotherapy-led exercise program for participants with MDI.
In a single-group study design, 43 participants (16 male, 27 female; mean age, 19.8 years, standard deviation, 4.9 years) diagnosed with MDI undertook a 12-week exercise program. Primary outcome measures were the Melbourne Instability Shoulder Score, Western Ontario Shoulder Instability Index, and Oxford Shoulder Instability Score. Secondary outcomes were strength and scapular position. All measures were taken at baseline and repeated at the conclusion of the program. Test differences before and after rehabilitation were evaluated with dependent t tests and single-group effect size calculations (standardized mean difference [SMD]) to provide a measure of the magnitude of the difference.
Large effects were found between pre- and postrehabilitation scores on all functional instability questionnaires, with the Western Ontario Shoulder Instability Index demonstrating the largest effect (SMD, –3.04). Scapular upward rotation improved significantly in the early ranges of abduction (0°-60°), with moderate to large effects (SMDs, 0.54-0.95). All strength measures significantly improved, with large differences identified (SMDs, 0.69-2.08).
The identified improvement in functional status, shoulder muscle strength, and scapular positioning after rehabilitation allows greater confidence in the value of conservative management of MDI and informs further research by way of clinical trials in the area.
Comparing non-invasive scapular tracking methods across elevation angles, planes of elevation and humeral axial rotations
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The scapula is a broad, irregular bone with no fixed mechanical center of rotation and substantial amounts of overlying soft tissue (Hebert et al., 2000; Klopcar and Lenarcic, 2006; van Andel et al., 2009). Skin motion that occurs over the scapula makes it challenging to collect accurate measurement of 3D scapular motion (Karduna et al., 2001), and some research continues to focus on quantifying levels of intra- and interrater reliability of physical examination methods measuring scapular position (Baertschi et al., 2013; Lewis and Valentine, 2008; McClure et al., 2009; Nijs et al., 2005). Invasive methods, including subcutaneous bone pins and implanted radiopaque media have been described as the “gold standard” method of scapular tracking as the instrumentation directly contacts the shoulder bones (Bourne et al., 2009; Högfors et al., 1991; Karduna et al., 2001; Ludewig et al., 2009; McClure et al., 2001).
Altered scapular motions premeditate shoulder impingement and other musculoskeletal disorders. Divergent experimental conditions in previous research precludes rigorous comparisons of non-invasive scapular tracking techniques. This study evaluated scapular orientation measurement methods across an expanded range of humeral postures. Scapular medial/lateral rotation, anterior/posterior tilt and protraction/retraction was measured using an acromion marker cluster (AMC), a scapular locator, and a reference stylus. Motion was captured using reflective markers on the upper body, as well as on the AMC, locator and stylus. A combination of 5 arm elevation angles, 3 arm elevation planes and 3 arm axial rotations was examined. Measurement method interacted with elevation angle and plane of elevation for all three scapular orientation directions (p < 0.01). Method of measurement interacted with axial rotation in anterior/posterior tilt and protraction/retraction (p < 0.01). The AMC had strong agreement with the reference stylus than the locator for the majority of humeral elevations, planes and axial rotations. The AMC underestimated lateral rotation, with the largest difference of ∼2° at 0° elevation. Both the locator and AMC overestimated posterior tilt at high arm elevation by up to 7.4°. Misestimations from using the locator could be enough to potentially obscure meaningful differences in scapular rotations.
The reliability of physical examination tests for the clinical assessment of scapular dyskinesis in subjects with shoulder complaints: A systematic review
2017, Physical Therapy in Sport
Citation Excerpt :
Characteristics of included studies are summarized in Table A1. All included studies were prospective and intrarater reliability in four (Juul-Kristensen et al., 2011; J. S.; Lewis & Valentine, 2007, 2008; Watson et al., 2005), interrater reliability was assessed in seven (Baertschi et al., 2013; Curtis & Roush, 2006; P.; McClure et al., 2009; Nijs et al., 2005; Rabin et al., 2006; Terwee et al., 2005; Uhl et al., 2009), and both types of reliability in four studies (Kibler et al., 2002; Odom et al., 2001; Shadmehr et al., 2010; Struyf, Meeus et al., 2014). In twelve out of fifteen publications studies were conducted in primary (Baertschi et al., 2013; Curtis & Roush, 2006; J. S.; Lewis & Valentine, 2008; P.; McClure et al., 2009; Nijs et al., 2005; Odom et al., 2001; Rabin et al., 2006; Shadmehr et al., 2010; Struyf, Meeus, et al., 2014; Terwee et al., 2005; Uhl et al., 2009; Watson et al., 2005), one in secondary (J. S. Lewis & Valentine, 2007) and two in undefined care settings (Juul-Kristensen et al., 2011; Kibler et al., 2002).
Systematic review.
The aim of this systematic review was to summarize and evaluate intra- and interrater reliability research of physical examination tests used for the assessment of scapular dyskinesis.
Scapular dyskinesis, defined as alteration of normal scapular kinematics, is described as a non-specific response to different shoulder pathologies.
A systematic literature search was conducted in MEDLINE, EMBASE, AMED and PEDro until March 20th, 2015. Methodological quality was assessed with the Quality Appraisal of Reliability Studies (QAREL) by two independent reviewers.
The search strategy revealed 3259 articles, of which 15 met the inclusion criteria. These studies evaluated the reliability of 41 test and test variations used for the assessment of scapular dyskinesis.
This review identified a lack of high-quality studies evaluating intra- as well as interrater reliability of tests used for the assessment of scapular dyskinesis. In addition, reliability measures differed between included studies hindering proper cross-study comparisons. The effect of manual correction of the scapula on shoulder symptoms was evaluated in only one study, which is striking, since symptom alteration tests are used in routine care to guide further treatment. Thus, there is a strong need for further research in this area.
Diagnosis, level 3a.
Scapular balance angle reference values in a healthy population
2014, Revista Espanola de Cirugia Ortopedica y Traumatologia
Calcular los valores de referencia del ángulo de balance escapular (ABE) en la población sana entre 18 y 85 años de edad, y definir los criterios muestrales de anormalidad para esta muestra.
Se realizó un estudio de tipo descriptivo-transversal en un total de 300 individuos (edad promedio: 44,83; rango: 18-83; proporción mujer/varón: 1,59), calculándose el ABE mediante la medición manual con goniómetro. Se obtuvo un valor de coeficiente de correlación intraclase (CCI) intraobservador de 0,87 y un valor de CCI interobservador de 0,84.
Los valores para población sana del ABE fueron de 2,505 ± 2,340°. Se define el criterio de anormalidad muestral con un ángulo mayor a 7,185°.
La medición manual del ABE es una técnica sencilla y reproducible en la práctica clínica diaria para la evaluación general de la posición y la rotación de la escápula. El principal hallazgo de este estudio son los valores de referencia para el ABE y el punto de corte estadístico para definir anormalidad.
To calculate the Scapular Balance Angle (SBA) reference values in a healthy population between 18 and 85 years old, and to define abnormality criteria for this sample.
A descriptive study was conducted on a total of 300 individuals (mean age: 44.83, range: 18-83; proportion male/female: 1.59), calculating the SBA through manual measurement with a goniometer. An intraobserver Intraclass Correlation Coefficient (ICC) of 0.87 and a interobserver ICC of 0.84 was observed.
The values for the SBA in healthy population were 2.505±2.340°. We define the abnormality criteria for this sample with an angle greater than 7.185°.
SBA manual measurement is a simple and reproducible assessment of the position and rotation of the scapula in clinical practice. The main findings of this study are the reference values for the SBA and a statistical cut-off to define abnormality.
Reliability of physical examination tests used in the assessment of patients with shoulder problems: A systematic review
2010, Physiotherapy
Citation Excerpt :
A large number of studies were initially identified through the search strategy, many of which were not deemed to be relevant after review of abstracts or full articles. Finally, 36 studies [37–72] that met the inclusion criteria and had been identified by the search strategy were included. Fig. 1 provides a flow diagram of the selection process.
Shoulder pain is a common clinical problem, and numerous tests are used to diagnose structural pathology.
To systematically review the reliability of physical examination procedures used in the clinical examination of patients with shoulder pain.
MEDLINE, PEDro, AMED, PsychInfo, Cochrane Library (2009) and CINAHL were searched from the earliest record on the database to June 2009.
Reliability studies that included any patients with shoulder pain were analysed for their quality and reliability results.
Pre-established criteria were used to judge the quality of the studies (high quality >60% methods score) and satisfactory levels of reliability (kappa or intraclass correlation coefficient ≥0.85, sensitivity analysis 0.70). A qualitative synthesis was performed based on levels of evidence.
Thirty-six studies were included with a mean methods score of 57%. Seventeen studies were deemed to be of high quality; high-quality studies were less likely to meet the pre-agreed level of reliability. The majority of studies indicated poor reliability for all procedures investigated.
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: Supported by the Westminster Medical School Research Trust and the Chelsea and Westminster Healthcare National Health Service Trust Charity.

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

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Original articleIntraobserver Reliability of Angular and Linear Measurements of Scapular Position in Subjects With and Without Symptoms

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Results

Discussion

Conclusions

Acknowledgment

Man Ther

J Shoulder Elbow Surg

Arch Phys Med Rehabil

Man Ther

Clin Biomech

Arch Phys Med Rehabil

J Shoulder Elbow Surg

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Shoulder Elbow Surg

Phys Ther Sport

Interrelation of the spine to the shoulder girdle

The role of the scapula in athletic shoulder function

Am J Sports Med

Diagnosis and treatment of movement impairment syndromes

Muscle testing and function

Role of the scapula in the overhead throwing motion

Contemp Orthop

A biomechanical analysis of scapular rotation during arm abduction in the scapular plane

Am J Phys Med Rehabil

Abduction of the arm in the scapular plane: scapular and gleno-humeral movements: a roentgenographic study

J Bone Joint Surg Am

Forces at the glenohumeral joint in abduction

Clin Orthop Relat Res

Shoulder movements during abduction in the scapular plane

Arch Phys Med Rehabil

Original article
Intraobserver Reliability of Angular and Linear Measurements of Scapular Position in Subjects With and Without Symptoms