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The purpose of this study was to determine the intrarater and interrater
reliability of a clinical evaluation system for scapular dysfunction. No commonly
accepted terminology presently exists for describing the abnormal dynamic
scapular movement patterns that are commonly associated with shoulder
injury. A method of observation was devised for clinical evaluation of scapular
dysfunction. Blinded evaluators (2 physicians and 2 physical therapists) were
familiarized with the evaluation method of scapular movement patterns before
viewing a videotape of 26 subjects with and without scapular dysfunction. Each
evaluator was asked to categorize the predominant scapular movement pattern
observed during bilateral humeral scaption and abduction motions. Reliability
was assessed by a coefcient. Intertester reliability ( 0.4) was found to be
slightly lower than intratester reliability ( 0.5). These results indicate that, with
renement, this qualitative evaluation method may allow clinicians to
standardize the categorization of dynamic scapular dysfunction patterns. (J
Shoulder Elbow Surg 2002;11: 550-6.) Normal shoulder motion, force
development, force regulation, and ligamentous tension require coupling of
scapular motion and humeral motion.4,30 Alterations in resting scapular
position and dynamic scapular motion have been recognized frequently in
association with many types of shoulder disorders, such as impingement,
instability, and rotator cuf tears.12,14,19,29 These alterations have been
considered to be abnormal motions and positions compared with the opposite
side and a clinical indication of dysfunction of the scapula.1,9,12,14,29 They
have been collectively termed scapular dyskinesis.29 The term scapular
dyskinesis, though indicating that an alteration exists, is a qualitative collective
term that does not diferentiate between types of scapular positions or
motions. This hampers communication between examiners and increases the
difculty in characterizing a patients specic scapular involvement. Scapular
evaluation is challenging because the overlying muscle mass obscures surface
landmarks, scapular movement occurs under the skin, and there is no lever
arm to help quantify scapular movements. Several techniques have been
devised to quantify scapular dyskinesis objectively: visual
evaluation, measurement of scapular displacement from the trunk,8,9,21,26 3dimensional electromagnetic assessment,12,14,15,20 and Moire topography.29
Measurements of the scapula from the trunk only provide static assessment of
scapular position at one point in space. The more dynamic techniques require
equipment that is not readily available in the clinical environment. This leaves
the clinician with limited tools with which to characterize dynamic scapular
dyskinesis adequately. This study was designed to determine whether the
observable characteristics of altered scapular motion could be delineated in a
reliable manner among health care providers. The null hypothesis was that no
agreement would exist between the individual observed using the evaluation
system.
controlled by having the subject practice moving through the range of motion
several times while the investigator, using a stopwatch, counted each second
of aloud. Upon completion of collecting the video data, the video record of
each subject was randomly recorded onto a VHS tape for review by the blinded
evaluators. Each subjects video record was preceded by a code to identify the
subject during the evaluation process. Two licensed physical therapists and two
physicians were selected to evaluate the videotapes. These evaluators did not
work in the clinic from which the patient samples were drawn to minimize
bias. The clinicians were experienced in the eld of sports medicine and
orthopaedics but were not familiar with the new patterns devised to evaluate
scapular dyskinesis clinically. The 2 physicians and 2 therapists were
familiarized with the denitions and method by a 10-minute visual and
verbal presentation. A written description of the 4 scapular patterns was
provided to each evaluator to be referred to as needed during the observation
of the videotape (Table I). A video example of each abnormal pattern and a
symmetric pattern was shown to the evaluators before they viewed the actual
subjects. These examples were selected by the investigators to represent clear
examples of the 4 patterns and were not included among the 26 subjects
graded by the blinded evaluators. Each evaluator was instructed to determine
the predominant scapular movement pattern observed for each
subject presented on the videotape. The randomized videotape was presented
to all blinded physicians and therapists. Seventeen days after the initial
observation of the videotape, 1 physician and 1 therapist reviewed the same
videotape to determine intratester reliability. The videotape method of
presentation was used for several reasons. First, it allowed the use of
evaluators who were not associated with the senior author or with the
evaluation method. Second, it allowed us to present evaluations of all subjects
at one time; it would have been logistically difcult to connect the subjects with
the distant observers without videotape. Third, all observers reviewed the
exact same motions to minimize interday variability of fatigue, stress, and
patient position. Data analysis Categorical data were collected for each
therapist and physician. The data were analyzed with statistical software (SPSS
v10.0; SPSS Inc, Chicago, Ill). A () coefcient is the preferred statistic for
reporting the reliability of nominal or categorical data.2 It represents the
agreement among raters beyond that expected by chance. If agreement
among raters occurs simply by chance, the coefcient would return a value
near 0. Intertester reliability between the physicians and therapists was
calculated separately. Intratester reliability was assessed for 1 therapist and 1
physician. RESULTS The agreement between the 2 physicians categorizing
scapular dyskinesis into 1 of 4 categories was 0.31 (P .01), and between the
2 physical therapists, 0.42 (P .001). This indicates moderate agreement
between the individual observers and that the categorization of the 26
subjects scapular movements was signicantly greater than that expected by
chance alone.11 Intratester reliability was also found to be slightly higher as
activities, the two are linked. The scapula, shoulder, and arm are either
stabilized in or move to certain positions to generate, absorb, and transfer
forces that accomplish work or athletic tasks. Alterations of scapular position at
rest, or with coupled arm motion, are commonly associated with injuries that
create clinical dysfunction of the shoulder. These alterations, which may be
the result of injury or may exacerbate an existing injury (and thus may increase
symptoms), are called scapular dyskinesis,1 a general term describing the loss
of control of scapular motion and position seen clinically. The term does not
suggest etiology or dene patterns that correlate with specic
shoulder injuries. Classication of scapular dyskinesis patterns and
positions can help to determine treatment. A primary role of the scapula is that
it is integral to the glenohumeral articulation, which kinematically is a ball-andsocket conguration. To maintain this conguration, the scapula must move in
coordination with the moving humerus so that the instant center of rotation,
the mathematical point within the humeral head that is the axis of rotation of
the glenohumeral joint, is constrained within a physiologic pattern throughout
the full range of shoulder moD tion.2,3 Proper alignment of the glenoid allows
optimum function of both the bony constraints and the muscles of the rotator
cuf, allowing concentric glenohumeral motion.4,5 The second role of the
scapula is to provide motion along the thoracic wall. The scapula
retracts (externally rotates) to facilitate the position of cocking.6 This
cocking position is important in the baseball throw, the tennis serve, and
the swimming recovery. As acceleration proceeds, the scapula must protract
laterally (internally rotate) in a smooth fashion, then anteriorly around the
thoracic cage, to maintain a normal position in relation to the humerus and to
dissipate some of the deceleration forces that occur in follow-through as the
arm goes forward.4,6,7 In workers, scapular retraction creates a stable base
for the abducted or elevated arm to do tasks that require reaching, pushing, or
pulling. The rst two roles (glenohumeral articulation and motion along
the thoracic wall) confer a coupled interdependency between movements
of the arm and scapula that creates dynamic stability for the glenohumeral
joint in the positions and motions of athletic or work activities.3,7 This dynamic
relationship has been compared to a ball on a seals nose. (The seals nose
must move to keep the ball from falling of.) The third role that the
scapula plays in shoulder function is elevation of the acromion, which
occurs during the cocking and acceleration phases of throwing or arm
elevation, to clear the acromion from the moving rotator cuf to decrease
impingement and coracoacromial arch compression.8,9 Although rotator cuf
fatigue may cause superior humeral head migration to trigger subacromial
impingement in this position,10 lower trapezius and serratus anterior muscle
fatigue also may contribute to impingement by decreasing acromial
elevation.11 The nal role that the scapula plays in shoulder function is as a
link in proximal-to-distal sequencing of velocity, energy, and forces of shoulder
function.10,12,13 For most activities, sequencing begins at the ground, and
repet- Figure 1 Force couples for scapular rotation. In early coupled arm
elevation/scapular rotation (A and B), the upper and lower trapezius and
serratus anterior muscles have long moment arms and are efective rotators
and stabilizers. With higher arm elevation (C), the upper trapezius moment arm
is shorter, while the lower trapezius and serratus anterior moment arms remain
long and continue to rotate the scapula. With maximum arm elevation (D), the
lower trapezius is ideally placed to maintain scapular position and pull along its
long axis. As a result of these activities, the scapular instant center of rotation
() moves from the medial border of the spine to the acromioclavicular joint.
(Adapted with permission from Bagg SD, Forrest WJ: A biomechanical analysis
of scapular rotation during arm abduction in the scapular plane. repetitive
tensile use; or (4) are inhibited by painful conditions around the shoulder.
Muscle inhibition or weakness is quite common in glenohumeral pathology,
whether from instability, labral pathology, or arthrosis.10,11,19,21 The serratus
anterior and the lower trapezius muscles are the most susceptible to the
efect of the inhibition, and they are more frequently involved in early
phases of shoulder pathology.4,6,11 Muscle inhibition and resulting
scapular dyskinesis appear to be a nonspecic response to a painful condition
in the shoulder rather than a specic response to a certain
glenohumeral pathology. This fact is supported by the nding of scapular
dyskinesis in as many as 68% of patients with rotator cuf abnormalities, 94%
with labral tears, and 100% with glenohumeral instability
problems.1,22,23 Inhibition is seen as a decreased ability of the muscles to
exert torque and stabilize the scapula as well as disorganization of the normal
muscle ring patterns of the muscles around the shoulder.4,11,21 The exact
nature of this inhibition is not clear. The nonspecic response and the
disorganization of motor patterns suggest a proprioceptively based
mechanism. Pain, either from direct or indirect muscle injury, and fatigue
or uncontrolled muscle strain, have been shown to alter proprioceptive input
from Golgi tendon organs and muscle spindles. Contractures and
Other Flexibility Problems Inexibility or contracture of the muscles and
ligaments around the shoulder can afect the position and motion of the
scapula. Tightness in the pectoralis minor or in the short head of the biceps,
both of which attach to the coracoid process, can create an anterior tilt and
forward pull on the scapula. Lack of full internal rotation of the glenohumeral
joint, caused by capsular or muscular tightness, afects the normal motion of
the scapulothoracic articulation.6,23-25 This creates a wind up efect so that
the glenoid and scapula are pulled in a forward inferior direction by the moving
rotating arm.6 This can create an excessive amount of protraction of
the scapula on the thorax as the arm continues into an adducted position in
follow-through during throwing or into forward arm elevation in working.
Because of the ellipsoid geometry of the upper portion of the thorax, the
scapula moves disproportionately anteriorly and inferiorly around the thorax
with more scapular protraction.9,26 Classication of Scapular Dyskinesis
con una cmara Super-8 ( Sharp VL- E66U , Sharp Electronics Corp , Mahwah ,
NJ ) montada en un trpode 204 cm de distancia (Figura 4 ) . Los sujetos fueron
posicionados con su primera articulacin metatarsofalngica alineado con una
marca en el suelo para estandarizar la grabacin en vdeo . Un teln de fondo
ajustable ( Nimlock Co , Niles , Ill) se utiliza para proporcionar una gua para la
elevacin del brazo en el plano frontal y 45 anterior al plano frontal ( scaption
) . Se proporcion una iluminacin adecuada para que el movimiento escapular
podra ser delineado en la grabacin de vdeo. Todos los sujetos realizaron 3
repeticiones de elevaciones del brazo bilaterales en scaption y secuestro en un
orden alternado para evitar la fatiga . La elevacin del brazo y descenso se
realizaron a una velocidad de 45 / s . Este fue controlado por haber la prctica
objeto en movimiento a travs de la amplitud de movimiento varias veces
mientras el investigador , usando un cronmetro , cuenta cada segundo fuera
en voz alta . Al nalizar la recogida de los datos de vdeo , la grabacin de
vdeo de cada sujeto fue registrada al azar en una cinta VHS para su revisin
por los evaluadores cegados . Grabacin de video de cada sujeto fue precedida
por un cdigo para identicar el tema durante el proceso de evaluacin. Dos
sioterapeutas licenciados y dos mdicos fueron seleccionados para evaluar las
cintas de vdeo . Estos evaluadores no trabajan en la clnica de la que se
extrajeron las muestras de los pacientes para disminuir el sesgo . Los mdicos
tenan experiencia en el campo de la medicina deportiva y ortopedia , pero no
estaban familiarizados con los nuevos modelos ideados para evaluar discinesia
escapular clnicamente . Los 2 mdicos y 2 terapeutas se familiarizaron con las
deniciones y los mtodos de una presentacin visual y verbal de 10 minutos.
Una descripcin por escrito de los patrones 4 escapulares se proporcion a
cada evaluador que se hace referencia , segn sea necesario durante la
observacin de la cinta de vdeo ( Tabla I ) . Un ejemplo de vdeo de cada
patrn anormal y un patrn simtrico se demostr que los evaluadores antes
de ver los temas reales. Estos ejemplos fueron seleccionados por los
investigadores para representar un claro ejemplo de los 4 patrones y no fueron
incluidos entre los 26 temas clasicados por los evaluadores cegados . Cada
evaluador se encarg de determinar el patrn de movimiento escapular
predominante observada para cada tema presentado en el video . La cinta de
vdeo al azar fue presentado a todos los mdicos y terapeutas ciegos .
Diecisiete das despus de la observacin inicial de la cinta de vdeo , 1 mdico
y 1 terapeuta crtica la misma cinta de vdeo para determinar intratester
abilidad. El mtodo de cinta de vdeo de la presentacin se utiliz por varias
razones . En primer lugar, permite el uso de evaluadores que no estaban
asociados con el autor o con el mtodo de evaluacin . En segundo lugar, nos
ha permitido presentar las evaluaciones de todos los temas a la vez , sino que
habra sido logsticamente difcil conectar los sujetos con los observadores
distantes sin video. En tercer lugar, todos los observadores crtica exactamente
los mismos movimientos para minimizar la variabilidad entre das de la fatiga ,
el estrs y la posicin del paciente . Los datos categricos anlisis de los datos
fueron recogidos para cada terapeuta y mdico. Los datos se analizaron con el
software estadstico ( SPSS v10.0 , SPSS Inc. , Chicago, Ill ) . A ( ) coeciente es
el estadstico preferido para informar de la abilidad de la nominal o categrica
datos.2 Representa el acuerdo entre los evaluadores ms all de lo esperado
por azar . Si el acuerdo entre los evaluadores se produce simplemente por
casualidad, el coeciente sera devolver un valor cercano a 0 . Intertester
abilidad entre los mdicos y terapeutas se calcul por separado. Intratester
abilidad se evalu para 1 terapeuta y 1 mdico . RESULTADOS El acuerdo
entre el 2 mdicos categorizar discinesia escapular en 1 de las 4 categoras fue
0,31 ( P 0,01 ) , y entre los 2 sioterapeutas, 0.42 ( P 0.001 ) . Esto indica
moderada acuerdo entre los observadores individuales y que la categorizacin
de los movimientos escapulares los 26 sujetos fue signicativamente mayor
que el esperado por casualidad alone.11 Intratester abilidad tambin fue
encontrado para ser ligeramente ms altos como sera de esperar para 1
mdico ( 0,59 , P 0.001 ) y 1 terapeuta fsico ( 0,49 , P 0,001 ) . La hiptesis
nula fue rechazada , lo que indica un acuerdo entre los evaluadores estaba
presente. Un nivel moderado de acuerdo y abilidad estuvo presente con este
sistema.11 DISCUSIN Existe una creciente evidencia clnica de que las
alteraciones en la posicin de reposo escapular y movimientos dinmicos se
ven en pacientes con una variedad de hombro injuries.12 , 14,19,29 Estas
alteraciones pueden afecta el rendimiento de hombro y la inuencia de la
cinemtica del hombro normal como resultado de la interferencia con el
acoplamiento de cadena cerrada obligatoria de movimiento escapular con
humeral motion.4 , 27 Prdida de este acoplamiento tiene varios efectos sobre
la funcin del hombro dinmico . El aumento de los lugares protraccin
aument la tensin en los ligamentos glenohumeral anteroinferior y altera
glenohumeral ptima kinematics.18 , 30 Alteracin del movimiento escapular
aumenta la demanda de la musculatura del manguito rotador y el coste
metablico de llegar hacia adelante y disminuye mxima del manguito rotador
strength.4 , 7 Prdida de la normal posterior inclinacin parece estar asociada
con la incidencia de pacientes12 , 14 Aunque no est claro si estas alteraciones
son la causa o el resultado de la lesin en el hombro , la mayora de los autores
creen que deben ser abordados en la evaluacin y tratamiento program.6
general , 9,16,28,31 Warner et al29 utiliza la discinesia escapular trmino
general para describir colectivamente el hecho cualitativo que , en el anlisis
topogrco Moire , la escpula en el lado afectado exhibi una posicin
diferente y caractersticas de movimiento que en el lado no afectado . Otros
trminos , como el deslizamiento lateral escapular , la inclinacin escapular y
aleteo escapular , se han utilizado para describir el movimiento anormal
patterns.6 , 8 Estos trminos no pretenden delinear posibles patrones de
movimiento escapulario alterada. La falta de nomenclatura comn diculta la
comunicacin entre los profesionales mdicos y no proporciona orientacin
para la comprensin de las alteraciones mecnicas escapulares posiblemente
contribuyen a la condicin de un paciente . Este estudio demuestra que las
las manos en las caderas , los dedos y el pulgar anterior posterior con
aproximadamente 10 de extensin del hombro . La nueva posicin de la
frontera inferomedial de la escpula est marcado , y se mantiene el punto de
referencia en la columna vertebral . Las distancias se calculan una vez ms en
ambos lados . El mismo protocolo se realiza por tercera posicin , con los
brazos en o por debajo de 90 del brazo de elevacin con rotacin interna
mxima a la articulacin glenohumeral ( g. 6 , B ) . Esta posicin nal
presenta un desafo a los msculos en la posicin de la funcin ms comn en
90 de elevacin del hombro . A - 1.5 cm asimetra es el umbral para
anormalidad y se ve con mayor frecuencia en la posicin 3 . El ensayo de
deslizamiento escapular lateral es ms sensible para los patrones discinticos
que se producen con protraccin excesiva u otro movimiento escapular lejos de
la columna ( tipos I y II ) . El examen de otras estructuras pertinentes para la
evaluacin escapular incluye la evaluacin de la artrosis o la inestabilidad de la
articulacin acromioclavicular , el acortamiento de la clavcula ( fractura de la
clavcula o reseccin distal ) , y la rotacin glenohumeral y la fuerza muscular .
El tratamiento de la discinesia escapular La mayora de las anormalidades en el
movimiento o la posicin escapular puede ser tratado por terapia fsica para
aliviar los sntomas asociados con la falta de exibilidad o puntos gatillo y para
restablecer la fuerza muscular y la activacin patterns.20 , 28,32 El
tratamiento quirrgico se utiliza para reparar el fuente de las anormalidades
subyacentes y a menudo es una parte integral del programa de tratamiento .
Anormalidades seas tales como la mala consolidacin de una fractura de la
clavcula o una separacin de la articulacin acromioclavicular pueden ser la
causa de la discinesia . Con mayor frecuencia , la fuente de la inhibicin
muscular o el desequilibrio es glenohumeral trastornos internos , tales como la
inestabilidad, desgarros del labrum , lesiones del manguito rotador o tendinitis.
Cuando los problemas estructurales o el trastorno interno se ha corregido , la
rehabilitacin muscular escapular puede iniciarse . Rehabilitacin Una vez
establecido el diagnstico completo y preciso de todos los factores que causan
o contribuyen a los problemas de la escpula y el hombro , la rehabilitacin
escapular puede ser initiated.19 , 26,33 rehabilitacin Escapulario es un
componente integral de rehabilitacin del hombro . La rehabilitacin debe
comenzar en la base de la cadena cintica , de 33 aos , que por lo general
signica que la correccin de cualquier fuerza o dcits de exibilidad en la
espalda baja y los niveles torcicos antes de comenzar en el componente
escapular. Esta fase incluye ejercicios de exibilidad , fortalecimiento del
tronco, y la correccin de las alteraciones posturales. El rango de movimiento
de la articulacin glenohumeral se puede mejorar por el estiramiento
apropiado haciendo hincapi en la cpsula posterior en lugar de estirar toda la
extremidad superior . Retraccin escapular y el masaje puede aumentar la
rigidez de los msculos coracoides basados . Rehabilitacin Protocolo de
Rehabilitacin de discinesia escapular ( Tabla 1 ) se basa en un extremo
proximal a distal protocol26 , 33 ( Figs. 7-10 ) . Se hace hincapi en el logro de