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Random allocation of subjects into a placebo-controlled, crossover study. To investigate the effect of changing thoracic and scapular posture on shoulder flexion and scapular plane abduction range of motion in asymptomatic subjects, and in subjects with subacromial impingement syndrome. Changes in upper body posture and concomitant imbalance of the muscle system have been proposed as one of the etiological mechanisms leading to subacromial impingement syndrome. Although clinicians commonly assess posture and devise rehabilitation programs to correct posture, there is little evidence to support this practice. Selected postural, range of movement, and pain measurements were investigated in 60 asymptomatic subjects and 60 subjects with subacromial impingement syndrome, prior to and following thoracic and scapular taping intended to change their posture. Changing posture had an effect on all components of posture measured (P<.001) and these changes were associated with a significant increase (P<.001) in the range of motion in shoulder flexion and abduction in the plane of the scapula. Changing posture was not found to have a significant effect on the intensity of pain experienced by the symptomatic subjects, although the point in the range of shoulder elevation at which they experienced their pain was significantly higher (P<.001). The findings of this investigation suggest that changing 1 or more of the components of posture may have a positive effect on shoulder range of movement and the point at which pain is experienced.
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Subacromial Impingement Syndrome: The
Effect of Changing Posture on Shoulder
Range of Movement
Jeremy S. Lewis, PT, PhD
1
Christine Wright, BSc (Hons)
2
Ann Green, MSc
3
Study Design: Random allocation of subjects into a placebo-controlled, crossover study.
Objectives: To investigate the effect of changing thoracic and scapular posture on shoulder flexion
and scapular plane abduction range of motion in asymptomatic subjects, and in subjects with
subacromial impingement syndrome.
Background: Changes in upper body posture and concomitant imbalance of the muscle system
have been proposed as one of the etiological mechanisms leading to subacromial impingement
syndrome. Although clinicians commonly assess posture and devise rehabilitation programs to
correct posture, there is little evidence to support this practice.
Methods and Materials: Selected postural, range of movement, and pain measurements were
investigated in 60 asymptomatic subjects and 60 subjects with subacromial impingement
syndrome, prior to and following thoracic and scapular taping intended to change their posture.
Results: Changing posture had an effect on all components of posture measured (P .001) and
these changes were associated with a significant increase (P .001) in the range of motion in
shoulder flexion and abduction in the plane of the scapula. Changing posture was not found to
have a significant effect on the intensity of pain experienced by the symptomatic subjects,
although the point in the range of shoulder elevation at which they experienced their pain was
significantly higher (P .001).
Conclusions: The findings of this investigation suggest that changing 1 or more of the components
of posture may have a positive effect on shoulder range of movement and the point at which pain
is experienced. J Orthop Sport Phys Ther 2005;35:72-87.
Key Words: pain, scapula, taping, thorax
S
houlder disorders are considered to be among the most
common of musculoskeletal disorders,
48
with 1.1% of patients
attending general medical practice each year in Holland for
such problems.
98
In a survey of 372 athletes who predomi-
nantly use their upper extremity, 43.8% reported shoulder
pain.
48
Shoulder pathology is associated with a high morbidity rate, with
1
Research Coordinator, Physiotherapy Department, Chelsea and Westminster Healthcare NHS Trust,
London, UK; Consultant Physiotherapist, Shoulder Unit, St George’s Hospital, London, UK.
2
Principal Lecturer Postgraduate Studies, School of Health and Social Studies, Coventry University,
Coventry, UK.
3
Associate Head of Physiotherapy and Dietetics, Coventry University, Coventry, UK.
Ethical approval to conduct this study was granted by the Riverside Research Ethics Committee, London,
UK, and by the Coventry University School of Health Sciences Ethics Committee, Coventry, UK. This
work was gratefully supported by the Hospital Saving Association Research Degree Award, the CSP
Charitable Trust Award, and the MACP Churchill Livingstone Award for research in Manipulative
Physiotherapy.
Address correspondence to Dr Jeremy Lewis, Physiotherapy Department, Chelsea & Westminster
Healthcare NHS Trust, 369 Fulham Road, London SW10 9NH, England. E-mail: jeremy.lewis@
chelwest.nhs.uk
up to 54% of sufferers reporting
ongoing symptoms after 3 years.
53
Subacromial impingement syn-
drome (SIS) has been considered
to be one of the most common
for ms of shoulder pathology.
35,40,98
The syndrome is associated with
pathology of 1 or more of the
contents of the subacromial space.
Pain and dysfunction occur when
the shoulder is placed in positions
of elevation, an activity that is
commonplace during many sport-
ing and vocational pursuits, and
activities involved in daily living.
SIS has been associated with shoul-
der pain in a number of sports,
including golf, volleyball, badmin-
ton, basketball, tennis, cricket, and
baseball.
3,4,37
It has also been re-
ported in competitive as well as
noncompetitive swim-
mers.
7,80,84,103,104
Richardson et
al
86
reported a 42% incidence of
SIS in 137 elite American swim-
mers. SIS has a detrimental effect
on quality of life, with shoulder
elevation, sleeping, throwing, and
working activities being most af-
fected.
17
Notwithstanding the high inci-
dence of SIS, the literature is beset
with controversy surrounding its
etiology. A number of alternative,
often contradictory, hypotheses
have been proposed to explain the
pathogenesis of the condition, the
cause of the pain, and the loss of
72 Journal of Orthopaedic & Sports Physical Therapy
Journal of Orthopaedic & Sports Physical Therapy
Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association
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function.
9,12,44,47,56,62,70,78,93,96,101
Although there were
earlier references to subacromial pathology,
1,5,20,61,64
Neer
70
was the first to use the term subacromial
impingement syndrome. He argued that 100% of SIS
and 95% of rotator cuff pathology were caused by
impingement of the subacromial contents, principally
the supraspinatus tendon, by the anterior one-third
of the acromion. Neer
70,71
described a continuum of
the pathology, a diagnostic test, conservative manage-
ment, and an operative procedure, the anterior
acromioplasty. This procedure remains the most com-
mon surgical technique performed on the shoulder.
22
Neer’s model involving acromial irritation of the
subacromial tissues has been embraced by physical
therapists,
3,6,28,89
who have suggested that an alter-
ation in upper body posture, colloquially known as a
forward head posture (FHP), is associated with the
impingement process due to changes in the position
of the scapula, an increase in the thoracic kyphosis
angle, and a concomitant imbalance of the surround-
ing muscles. These changes are thought to produce a
compressive impingement under the acromion, creat-
ing a mechanical block to elevation of the humerus
and irritation of the subacromial tissues.
3,6,28,89
As such, considerable importance is placed on the
assessment of posture in patients with SIS.
6,14,28,39,41
Identified deviations from an ideal posture then form
the basis for rehabilitation programs designed to
address imbalances of the musculoskeletal sys-
tem
15,32,39,67,89,94
and to restore normal postural rela-
tionships, with the aim of alleviating the symptoms
associated with SIS. Although this is common clinical
practice among physical therapists,
3,32,67,94
as well as
in other professions,
15,41,42
the evidence to support
this practice is largely anecdotal.
The aim of the current study was to investigate the
effect of changing posture on the range of movement
of shoulder flexion and abduction in the plane of the
scapula in asymptomatic subjects, and in subjects with
SIS. The influence of changing posture on the
intensity of pain was also investigated in the subjects
with symptoms. The null hypotheses for this investiga-
tion was that changing posture would have no effect
on shoulder range of movement in asymptomatic
subjects and on shoulder range of movement and
pain in subjects with SIS.
METHODS
Subject Information and Consent
Ethical approval for this study was granted by
Riverside Research Ethics Committee, London, UK
and by the Coventry University School of Health
Sciences Ethics Committee, Coventry, UK. Subjects
were provided with infor mation booklets explaining
the purpose of the study and signed informed con-
sent documents prior to participation. Subjects were
free to withdraw from the study at any time.
Power Analysis
The sample size required for a significance level of
0.05 and a power of 0.9 to detect a 10° increase in
shoulder flexion and scapular plane abduction, a
decrease in the thoracic kyphosis angle, a decrease
in the FHP angle, a 2-cm decrease in the sagittal
plane displacement of the acromion of the scapula,
and a 1-cm decrease in the lateral linear displace-
ment of the scapula, was calculated to be 60
asymptomatic subjects and 60 subjects with SIS.
The angular and linear measurements and the stan-
dard deviations used in the power analysis were
based on the findings of published clinical stud-
ies.
19,42,45,50,72,102
Experimental Design
A placebo-controlled crossover design was em-
ployed in this investigation,
91
with subjects random-
ized into either protocol A or B, using random-
number tables. For both protocols postural data were
collected during 2 data collection periods (periods 1
and 2), with an intervening 1-hour washout period.
The following postural data were collected from
subjects randomized to protocol A: period 1, baseline
postural data followed by postural data after real
postural change; period 2, baseline postural data
followed by placebo postural change. Subjects ran-
domized to protocol B followed the same procedure,
with the exception that the order of allocation for
the placebo and real postural data was reversed. The
results of a pilot study had revealed that a 1-hour
passive washout period was sufficient time to allow
the subjects to return to their natural posture,
following the techniques used to change posture.
Inclusion Criteria
The relationship between rotator cuff pathology,
identified by diagnostic imaging and symptoms, ap-
pears to be equivocal
65,66,92
and, as such, subjects in
the SIS group were included on the basis of clinical
findings. In an attempt to recruit a homogeneous
group of subjects with SIS, a standard set of clinical
tests was performed after the subjects gave consent to
participate. Table 1 provides the full details of the
inclusion criteria for this study.
Neer Impingement Sign This test is performed with
the patient in sitting. The examiner stabilizes the
clavicle and scapula with one hand and passively
flexes the patient’s inter nally rotated arm with the
other hand. The purpose of the test is to compress
the subacromial contents under the acromion. Repro-
duction of pain indicates a positive test.
71
This test
J Orthop Sports Phys Ther Volume 35 Number 2 February 2005 73
RESEARCH REPORT
TABLE 1. Inclusion and exclusion criteria.
Subjects Without Symptoms
Inclusion criteria
1. Male and female between the ages of 18 to 75 years
Exclusion criteria
1. Health professionals
2. Staff members of the institutions where data were collected
3. Neuromusculoskeletal disorders of the spine and upper limb
4. Spinal pain or upper limb pain in the past year
5. Treatment for any spinal or upper limb pathology in the past year
6. Systemic illnesses and connective tissue disorders
7. Pregnancy
8. Allergy to taping products
Subjects With Symptoms
Inclusion criteria
1. Male and female between the ages of 18 to 75 years
2. Unilateral shoulder pain of more than 1 week localized (anterior and/or anterolateral) to the acromion
3. Pain produced or increased during flexion and/or abduction of the symptomatic shoulder
And at least 4 of the following:
1. Positive Neer impingement sign
2. Positive Hawkins sign
3. Pain reproduced during supraspinatus empty can test
4. Painful arc of movement between 60° to 120°
5. Pain with palpation on the greater tuberosity of the humerus
Exclusion criteria
1. Health professionals
2. Staff members of the institutions where data were collected
3. Systemic illnesses
4. Pregnancy
5. Cervical pain at rest, or cervical pain during active cervical movements
6. Reproduction of shoulder symptoms during active cervical movements
7. Reproduction of shoulder symptoms with the addition of overpressure at the end of range of left and right cervical rotation, and,
left rotation combined with left side flexion, and right rotation combined with right side flexion
8. History of cervical pain or treatment to this region over the past 12 months
9. History of spinal or upper limb surgery
10. History of spinal or upper limb fractures
11. Post traumatic onset of symptoms
12. Radiographic evidence of shoulder laxity (if available)
13. Presence of a positive sulcus sign
14. Presence of a positive load and shift test
15. Presence of a positive active compression labral test
16. Presence of clinical signs of acromioclavicular pathology
17. Known allergies to taping
18. Subjects involved in elite levels of sport
has been used widely in both clinical practice and
shoulder research.
3,10,13,17,50,54,81,97
Hawkins and Kennedy Impingement Test This test is
performed with the patient either sitting or standing.
The examiner flexes the arm to 90° and then
internally rotates the shoulder. This procedure may
be done at varying degrees of horizontal adduction.
Reproduction of pain indicates a positive test. This
test has also been used widely in both clinical
practice and research into SIS.
3,10,13,54,81,97
Empty Can Test
36
This test is performed in 2 stages
and is used to deter mine the presence of
supraspinatus pathology. The patient’s shoulder is
abducted to 90° in the plane of the scapula. The
humerus is in neutral rotation. Resistance to abduc-
tion is applied by the examiner. The humerus is then
inter nally rotated so that the thumb points to the
floor and the same resistance is applied. Pain or
painful weakness in the second part of the test is a
positive finding and indicates supraspinatus pathol-
ogy
36
and was used in this investigation to support
the clinical diagnosis of SIS. The use of this test has
been recommended by a number of clinical authori-
ties.
3,10,51,54,81
Painful Arc of Shoulder Movement Test
40
The patient
actively abducts the arm. The presence of a painful
arc of movement between 60° and 120° suggests
subacromial pathology. This test is recommended by
clinical authorities and has been used in research
studies.
10,13,17,24,54
Palpation of the Supraspinatus Tendon Tenderness
when palpating the greater tuberosity of the humerus
74 J Or thop Sports Phys Ther Volume 35 Number 2 February 2005
has been described as being indicative of
supraspinatus tendon pathology,
10,81
and has been
used in clinical research on SIS.
49,50
Mattingly and
Mackarey
57
examined 24 shoulders in 12 cadavers
and recommended that palpation of the
supraspinatus tendon is possible when the hand is
placed behind the back with the arm adducted
against the chest. In this position, the tendon is
palpable from under the acromion to a point ante-
rior to the acromioclavicular joint. Exposure is in-
creased if the arm is then hyperextended. The
addition of hyperextension was not considered appro-
priate in the current investigation due to the poten-
tial aggravation of shoulder symptoms it might cause.
Although the supraspinatus tendon has been de-
scribed as being palpable with the forearm on the
abdomen,
29
Mattingly and Mackarey
57
described it as
being inaccessible in this position.
Exclusion Criteria
The tests used to exclude subjects were performed
to identify subjects who clinically presented with
shoulder symptoms referred from the cervical spine,
shoulder instability, labral lesions, and acromio-
clavicular joint pathology.
Cervical Spine Tests
55
In sitting, the patient actively
(1) flexes the head and neck, (2) extends the head
and neck, (3) rotates the head and neck to the left,
(4) rotates the head and neck to the right, (5) side
flexes the head and neck to the left, and (6) side
flexes the head and neck to the right. Reproduction
of local and/or shoulder pain during these tests is
suggestive of a cervical component to the symptoms.
If the active movements did not reproduce local or
referred pain, then overpressure, when appropriate,
was performed by the examiner at the end of range
of the active movements to further stress the cervical
structures. In this investigation the overpressures used
were left and right rotation, and left rotation com-
bined with left side flexion and right rotation com-
bined with right side flexion. A subject was
considered to have a positive response if local shoul-
der pain was reproduced during any of the cervical
testing procedures. A positive finding excluded par-
ticipation in the study.
Sulcus Sign Test
25
The presence of an excessive
sulcus under the acromion following traction to the
humerus applied in an inferior direction, with the
ar m along the trunk, has been suggested to indicate
inferior laxity and potentially multidirectional insta-
bility of the glenohumeral joint.
25
The traction is
applied by the clinician grasping the forearm below
the elbow. The patient can stand or sit and should
relax the shoulder muscles. The use of this test has
been widely reported.
3,50,51,100
In the current investi-
gation potential subjects with a positive finding (pres-
ence of a sulcus) were excluded from the study.
Load and Shift Test
31
This procedure is designed to
test for the presence of anterior and posterior laxity
of the humeral head on the glenoid fossa. The
patient sits and the clinician stabilizes the clavicle and
scapula with one hand and grasps the head of the
humerus with the thumb and fingers of the other
hand. The humeral head is gently pushed into the
glenoid fossa in order to ‘seat’ it against the fossa.
Following this, the clinician moves the humeral head
anteriorly and posteriorly, noting the amount of
translation.
31
The amount of translation is compared
with the asymptomatic side. The use of this test has
been widely recommended.
3,10,31,54,51,60
In the cur-
rent investigation a subject with a positive anterior or
posterior load and shift test was excluded.
Active Compression Labral Test/Acromioclavicular Joint
Test
75
This test is designed to test the integrity of the
glenoid labrum and the acromioclavicular joint. The
examiner stands behind the patient. The patient is
asked to forward flex the affected arm to 90° with the
elbow in full extension. The patient then horizontally
adducts the arm 10° to 15°. The arm is then
inter nally rotated so that the thumb points downward
towards the floor. The examiner then applies a
downward force on the forearm. Maintaining the 90°
shoulder flexion and 10° to 15° horizontal adduction
past midline, the shoulder is externally rotated so
that the palm faces upwards towards the ceiling. The
same pressure in the same direction is applied. The
test is considered to be positive if pain is elicited in
the first manoeuvre and reduced or eliminated in the
second. Pain or painful clicking described inside the
glenohumeral joint is indicative of labral pathology.
Pain located to the area of the acromioclavicular joint
or to the top of the shoulder is diagnostic of an
acromioclavicular pathology. Individuals with a posi-
tive test were excluded from the study.
Table 1 details the exclusion criteria for the sub-
jects participating in this study.
Procedure
Postural measurements were made on the painful
side of the subjects with symptoms and the dominant
ar m of the asymptomatic subjects. Male subjects were
asked to remove their shirts and female subjects were
asked to wear an open-back bathing costume. Sub-
jects stood 30 cm in front of a plumb line hanging
from the ceiling, with their nondominant shoulder
(asymptomatic subjects), or pain-free shoulder (sub-
jects with symptoms) 20 cm from a plain white wall.
Adhesive tape on the floor was used to identify these
distances. Following palpation, nonallergenic adhesive
markers 6 mm in diameter were attached to the
following anatomical points that were designated with
an alphabetical reference (Figure 1):
1. The posterior aspect of the acromion (point C)
2. The inferior angle of the scapula (point E)
J Orthop Sports Phys Ther Volume 35 Number 2 February 2005 75
RESEARCH REPORT
3. The thoracic spinous process (SP) correspond-
ing with the root of the spine (point A)
4. The thoracic SP corresponding with the inferior
angle (point D)
5. The 12th thoracic SP (point F)
6. The lateral midpoint of the humeral head
7. The tragus of the ear
8. A 3-cm straw marker was attached through a
hole, the same diameter as the straw, in adhesive
felt padding of 3.2-mm width to the seventh
cervical (C7) SP. The straw marker was held in
place on the C7 SP by sliding the adhesive felt
down the straw to secure it in place onto the
skin
Subjects were then asked to adopt a comfortable
and natural standing position. To facilitate this, each
subject was informed that during the investigation it
was important that a natural posture be adopted and
to pretend that nobody was observing them. The
specific postural instructions that were given to each
subject, were developed during pilot testing and were
standardized for all subjects.
To measure FHP and forward shoulder posture
(FSP) angles, a lateral photograph was then taken of
the cervicothoracic region, using an Olympus OM2
SLR camera (Olympus Optical Company, London,
UK) set at 100ASA, with a 28- to 50-mm adjustable
lens. The lens aperture was set at F-stop 8. The
camera was placed2mfromthesubject and
mounted on a tripod, leveled with a bubble spirit
level to control frontal and sagittal angles. One
hundred ASA color photographic film (Eastman
Kodak Company, Rochester, NY) was used. This
procedure has been used in previous published
studies.
84,85
The method chosen to measure the FHP
and FSP angles for the current investigation was
direct measurement from lateral view photographs of
head and shoulder posture. To measure the angles,
an A4-sized sheet of graph paper was photocopied
onto transparency film for photocopiers. The graph
paper had vertical and horizontal lines spaced at
1-mm intervals. The transparency film was then
placed over the photograph and aligned so that one
of the vertical lines was placed over the plumb line
and the intersection of 1 vertical and 1 horizontal
line coincided with the point the C7 marker came in
contact with the skin (Figure 2). To calculate the
position of the head in relation to C7 (C7-tragus
angle), shown as angle A in Figure 2, the vertical
distance and the horizontal distance from the C7
marker to the tragus were measured. The angle was
deter mined by calculating the length of the vertical
distance divided by the length of the horizontal
distance. The angle was determined by using the tan
-1
function key on a pocket calculator. The method
used to calculate the angular position of the
shoulder in relation to C7 (FSP), involved dividing
the vertical distance from the C7 marker to the
FIGURE 1. Bony landmarks identified by palpation used to investi-
gate resting position of the scapula. The diagram on the left depicts
the landmarks and the diagram on the right details the method of
measuring the lateral linear displacement of the scapula (distance
AC), and the method for calculating the elevation of the scapula
above the T12 spinous process (distance DF), after the distances DE
and FE were measured.
FIGURE 2. Forward head posture determined by calculating the
angle (A) made between the horizontal and the tragus of the ear
from the C7 spinous process. Forward shoulder posture determined
by calculating the angle (B) made between the horizontal and the
midpoint of the shoulder
76 J Or thop Sports Phys Ther Volume 35 Number 2 February 2005
lateral midpoint of the shoulder by the horizontal
distance between these points. The angle was deter-
mined using the same method as described above.
Figure 2 depicts how the FHP and FSP angles were
deter mined from the lateral photograph.
Following the photograph, the following measure-
ments were each made 3 times with the same
standard nonstretch measuring tape and recorded to
the nearest millimeter on the data collection form.
The measurements were the lengths between the
landmarks identified in Figure 1, and were AC, DE,
and FE. The measurement AC was used to determine
the distance between the posterior angle of the
acromion and the SP corresponding with the root of
the spine of the scapula. The measurements FE and
DE were used in Pythagoras’ theorem to calculate the
vertical displacement of the inferior angle of the
scapula above the T12 SP. Although the distance FD
could have been measured, during the pilot stages of
this investigation it was found that the curvature of
the spine made this direct measurement difficult in a
number of patients.
Inclinometers (Isomed, Inc, Portland, OR) were
then placed with their feet over the T1 and T2 SP,
and the T12 and L1 SP, and the angles were
recorded. Each measurement was made 3 times. This
method of generating a clinical measurement for the
thoracic kyphosis has been described previously.
19,77
Figure 3 details how the kyphosis angle was mea-
sured.
Two lines marked with tape on the floor served as
guides for the direction of shoulder flexion and
scapular plane abduction. Flexion was performed in
the sagittal plane and abduction was performed in a
plane defined as being 30° anterior of the frontal
plane (abduction in the plane of the scapula). To
standardize the internal/external rotation position of
the glenohumeral joint, subjects were requested to
perform the movement with their thumbs pointing
towards the ceiling. Each movement was performed 3
times. The range of shoulder flexion and scapular
plane abduction for the subjects with symptoms was
at the first point of pain, or the first increase in their
resting pain. The end of available range of movement
for this group was not measured to avoid aggravating
symptoms. Measurements for the asymptomatic sub-
jects were made at the end of their available range.
Shoulder flexion and abduction in the plane of the
scapula range of movement was recorded with the
inclinometer facing towards the ceiling and with its
proximal foot at the insertion of the deltoid. Subjects
were asked to record their maximal pain during the
movements on a 10-cm horizontal visual analogue
scale (VAS) for pain, where the left side (0) was
marked as no pain and the right side (10) as the
worse pain imaginable.
FIGURE 3. Thoracic kyphosis angle calculated by the summation of
the inclinometer placed over the spinous process of T1 and T2
(angle
) and the inclinometer placed over the spinous process of
T12 and L1 (angle
)
To determine if the taping technique had an
influence on the sagittal plane position of the
scapula, a nonstretch fiberglass tape measure was
attached to a tripod located behind the patient and
adjusted to the height of the individual subject’s
acromion. To measure the linear distance from the
tripod to the posterior aspect of the acromion,
subjects were asked to sit to the back of an armless
office chair with only their lumbar spines supported
on a pressure biofeedback device (Stabilizer, Chatta-
nooga, Australia). The tripod was secured to the floor
at a fixed distance (60 cm) behind the chair. To
facilitate the same sitting position during the 4 data
collection phases (no tape, tape, no tape, placebo
tape), the subject’s lumbar spines were supported on
a pressure biofeedback device (Stabilizer, Chatta-
nooga, Australia). The pressure in the device was
recorded and, on each occasion that the linear
measurement from the tripod to the posterior aspect
of the acromion was made, the subjects were required
to sit and reproduce the same pressure in the
pressure device. The linear distance from the tripod
to the posterior aspect of the acromion was the only
measurement made in sitting. It was done so, as the
results of pilot studies had suggested that because
method of measurement produced minimal
J Orthop Sports Phys Ther Volume 35 Number 2 February 2005 77
RESEARCH REPORT
anteroposterior postural sway of the trunk. Once
seated, subjects were asked to let their arms hang to
their sides and adopt a comfortable posture. While
the subjects remained sitting, the linear measurement
from the tripod to the posterior aspect of the
acromion was made 3 times on each data collection
phase.
To reduce investigator bias, the measurements
made by the investigator were reported to an assistant
who recorded the measurements on data collection
sheets. Four data collection sheets were used for each
subject and the investigator was not able to observe
the imputed data during data collection. Postural
data were collected from other subjects during the
1-hour washout period that separated the 2 data
collection phases for each subject, which further
reduced investigator bias.
Changing Posture
Taping products were used to change posture and
as a placebo procedure. Real postural change was
achieved by requesting the subjects to extend their
thoracic spines. The investigator demonstrated the
movement to each subject and the subjects were
allowed to practice this once before the application
of 3.8-cm-wide Leukotape (Beiersdorf UK Ltd, Bir-
mingham, UK) which was applied bilaterally from T1
to T12. Subjects were then asked to fully retract and
depress their scapula, and tape was applied from the
center of the spine of the scapula to the T12 SP in a
diagonal fashion. The leukotape was pretensioned
prior to application on the subject and the subjects
maintained the required postural changes while the
tape was applied. Subjects were not required to
actively maintain the postural change, as the aim of
the tape was to hold each subject in the new posture.
The placebo procedure involved the application of
5-cm-wide Fixomull Tape (Beiersdorf UK Ltd, Bir-
mingham, UK), which was applied over the same
locations as the real postural tape. During the appli-
cation of placebo taping subjects stood in their
natural postures with no attempt made to change
posture in any way. The placebo taping was not
pretensioned and was included in the protocol to
deter mine if any observed changes in the dependent
variables had occurred as a result of the postural
change and not as a result of another effect of the
tape. The use of placebo taping in this fashion has
been reported previously.
95
The findings of a pilot
study on 5 asymptomatic subjects suggested that the
real postural change procedure was able to produce a
decrease in the thoracic kyphosis and a more de-
pressed scapula, as well as reductions in the sagittal
plane position of the scapula and lateral linear
displacement of the scapula. The pilot study also
revealed that subjects returned to their baseline
posture within 1 hour of removing the taping materi-
als. The taping techniques are depicted in Figure 4,
and Figure 5 details a lateral photograph of a subject
in the 4 postural measurement phases.
Measurement Reliability
The intrainvestigator reliability, using the measur-
ing devices to produce the measurements of interest,
was investigated in a separate study involving 15
asymptomatic and 15 subjects with symptoms who
completed informed consent documentation. A
1-hour interval separated each set of measurements,
where the subjects were asked to move around, but
not adopt, extremes of posture or participate in
heavy lifting or any sporting activity. Photographic
FIGURE 4. Diagram A depicts the application of real postural
change thoracic taping followed by the postural change scapular
taping (B). Figure C represents a lateral view of a subject with the
taping in place.
FIGURE 5. The 4 data collection phases for a subject randomized
to protocol B. The order of the techniques performed was A B
C D: A, first no tape measurements; B, placebo tape measure-
ments; C, second no tape measurements; D, postural correction
taping measurements.
78 J Or thop Sports Phys Ther Volume 35 Number 2 February 2005
TABLE 2. Pilot reliability study.
Measurement ICC
3,1
95% CI for ICC
3,1
SEM
Subjects Without Symptoms
AC 0.98 0.96 to 0.99 0.3 cm
DE 0.96 0.90 to 0.98 0.3 cm
FE 0.91 0.77 to 0.97 0.7 cm
Scapular elevation (DF) 0.82 0.55 to 0.93 0.9 cm
Kyphosis (T1/2 + T12/L1) 0.96 0.90 to 0.98 1.5°
Sagittal plane position of scapula 0.94 0.84 to 0.98 1.9 cm
Shoulder flexion 0.98 0.95 to 0.99 1.1°
Shoulder abduction 0.98 0.96 to 0.99 1.1°
Subjects With Symptoms
AC 0.92 0.80 to 0.97 0.5 cm
DE 0.91 0.77 to 0.97 0.4 cm
FE 0.90 0.74 to 0.96 0.5 cm
Scapular elevation (DF) 0.81 0.52 to 0.93 0.7 cm
Kyphosis (T1/2 + T12/L1) 0.94 0.83 to 0.98 2.5°
Sagittal plane position of scapula 0.97 0.94 to 0.99 1.9 cm
Shoulder flexion 0.99 0.97 to 0.99 2.9°
Shoulder abduction 0.98 0.96 to 0.99 3.3°
Abbreviations: AC, distance between spinous process corresponding with the root of the spine of the scapula, and, the posterior aspect of the
acromion; CI, confidence interval; DE, distance between spinous process corresponding with the inferior angle of the scapula, and, the inferior
angle of the scapula; DF, distance between spinous process corresponding with the root of the spine of the scapula, and, the spinous process of
the twelfth thoracic vertebra; FE, distance between spinous process corresponding with the twelfth thoracic spinous process and the inferior angle
of the scapula; ICC, intraclass correlation coefficient; SEM, standard error of measurement; T1/2, measurements made at the first and second
thoracic vertebrae; T12/L1, measurements made at the 12th thoracic and first lumbar vertebrae.
reliability was tested by (1) measuring the same
photograph (intraphotograph reliability) on 2 occa-
sions (C7-tragus angle [ICC
3,1
, 0.98; 95% CI, 0.89-
0.99; SEM, 0.5°] and C7-shoulder angle [ICC
3,1
, 0.99;
95% CI, 0.99-1.0; SEM, 0.5°]), (2) taking measure-
ments from 2 photographs (interphotograph reliabil-
ity) of the same posture with an hour interval
between each photograph (C7-tragus angle [ICC
3,1
,
0.93; 95% CI, 0.76-0.98; SEM, 1.1°] and C7-shoulder
angle [ICC
3,1
, 0.93; 95% CI, 0.78-0.99; SEM, 1.4°]),
and (3) the accuracy of the technique was measured
by comparing the method used to measure the angles
on the photographs from known angles (ICC
3,1
, 0.99;
95% CI, 0.97-0.99). The other measurements are
detailed in Table 2.
The results of the intratester reliability study sug-
gested that the measurement reliability for the out-
come measurements of interest would be acceptable
for the main investigation.
16,82
Data Analysis
The measurements available for analysis were: FHP,
FSP, thoracic kyphosis angle, lateral linear displace-
ment of the scapula, scapular elevation (above T12),
the sagittal plane position of the acromion, the
pain-free ranges of sagittal plane shoulder flexion,
and abduction in the plane of the scapula, and the
VAS pain score during these movements. Data were
analyzed using the SPSS, Version 11.5.0. Descriptive
statistics (mean, SD, range) were computed for each
study variable.
The crossover design allowed postural corrections
on each subject to be computed for the real postural
change tape (defined as postural measurements after
application of the real postural correction taping,
minus baseline postural measurements before the
application of the real tape), the placebo tape (de-
fined as, postural measurements after the application
of placebo postural correction taping, minus baseline
postural measurements before the application of
placebo tape), and a control (baseline postural mea-
surements for period 2, minus baseline postural
measurements for period 1). The postural taping
effect on measurements was defined as the compari-
son of postural corrections for the real tape and the
placebo tape, and the placebo taping ef fect as the
comparison of postural corrections for the placebo
tape and the control.
Postural and placebo taping effects were tested for
statistical significance using a 1-factor repeated-
measures analysis of variance. Comparisons of main
effects, with a Bonferonni adjustment, were used to
produce 99% CIs for the mean postural and taping
effects. The levels of the within-subject factor were
taken as the postural corrections for real tape,
placebo tape, and the control. Homogeneity of vari-
ances was tested using Mauchly’s test of sphericity.
83
When the sphericity test was significant, the
Greenhouse-Geisser correction was applied to adjust
the tests, as recommended by Portney and Watkins.
83
All adjusted tests produced the same P values as
unadjusted tests. There were 10 variables of interest
in this study, so the hypothesis tests were conducted
at a 0.01 level of significance.
J Orthop Sports Phys Ther Volume 35 Number 2 February 2005 79
RESEARCH REPORT
Multiple regression analyses were conducted for
improvement in range of movement (shoulder flex-
ion, sagittal plane abduction) following real taping
on changes in postural measures (FHP, FSP, thoracic
kyphosis angle, lateral linear displacement of the
scapula, scapular elevation [above T12], the sagittal
plane position of the acromion). Standardized regres-
sion coefficients and partial correlation coefficients
83
were computed to consider the relative importance of
changes in individual postural measures to the im-
provement in range of movement.
RESULTS
All 120 subjects completed the study. There were
56 females and 64 males, with ages ranging from 19
to 75 years, heights between 149 to 189 cm, and
masses between 43 and 108 kg. Characteristics for the
asymptomatic and symptomatic subjects are given in
Table 3.
Postural taping effects were statistically significant
(P.001) for all postural measures for both symptom-
atic and asymptomatic subjects (Table 4). For symp-
tomatic subjects, postural taping produced
significantly less FHP (mean, 4.1°), less FSP (mean,
3.9°), smaller kyphosis (mean, 5.8°), less lateral
scapular displacement (mean, 1.8 cm), less elevated
scapula position (mean, 1.7 cm), less forward sagittal
position (mean, 2.5 cm), increased pain-free range of
shoulder flexion (mean 16.2°), and increased pain-
free range of scapular plane abduction (mean 14.7°),
as compared to when measured with placebo taping.
Similar improvements were found on asymptomatic
subjects (Table 4). No significant effects were found
on VAS pain score for shoulder flexion (P = .136), or
VAS pain scores for shoulder scapular plane abduc-
tion (P = .111), for symptomatic subjects. Ninety-nine
percent confidence intervals for effects are given in
Table 4.
There were no statistically significant effects of
placebo taping for the symptomatic subjects on FHP
(mean difference, –1.32°; SE, 0.54°; P = .05), FSP
(mean difference, 1.65°; SE, 0.97°; P = .28), kyphosis
(mean difference, 0.43°; SE, 0.40°; P = .86), lateral
linear displacement of the scapula (mean difference,
–0.04 cm; SE, 0.10 cm; P = 1.00), scapular elevation
(mean difference, 0.09 cm; SE, 0.09 cm; P = 1.00),
scapular sagittal plane (mean difference, –0.10 cm;
SE, 0.19 cm; P = 1.00), shoulder flexion (mean
difference, –1.52°; SE, 2.18°; P = 1.00), and shoulder
abduction in the plane of the scapula (mean differ-
ence, –3.15°; SE, 2.23°; P = .49). In addition, no
significant effects of placebo taping were found on
VAS pain scores for shoulder flexion (mean differ-
ence, 0.28; SE, 0.17; P = .32) and scapular plane
abduction (mean difference, 0.07; SE, 0.16; P = 1.00).
There were no statistically significant effects of
placebo taping for the asymptomatic subjects on FHP
(mean difference, –0.23°; SE, 0.47°; P = 1.00), FSP
(mean difference, 2.10°; SE, 0.86°; P = .05), kyphosis
(mean difference, –0.78°; SE, 0.55°; P = .48), scapular
elevation (mean difference, 0.02 cm; SE, 0.14 cm; P =
1.00), scapular sagittal plane (mean difference, –0.41
cm; SE, 0.24 cm; P = .26), shoulder flexion (mean
difference, –0.87°; SE, 0.56°; P = .39), and shoulder
abduction in the plane of the scapula (mean differ-
ence, –1.12°; SE, 0.55°; P = .14). Mean postural
correction of lateral linear displacement of the
scapula was significantly smaller for placebo tape than
the control (mean difference, –0.33 cm; SE, 0.08 cm;
P = .001).
TABLE 3. Descriptive statistics.
Subjects Without Symptoms Subjects With Symptoms
Protocol A Protocol B Protocol A Protocol B
Sex (n)
Female 17 14 13 12
Male 13 16 17 18
Age (y)* 32.8 ± 9.9
(19.0-59.0)
35.3 ± 10.0
(23.0-65.0)
47.9 ± 15.3
(22.0-72.0)
49.9 ± 15.1
(19.0-75.0)
Height (cm)* 168.5 ± 10.2
(150.0-184.0)
173.3 ± 10.6
(150.0-188.0)
170.9 ± 11.4
(149.0-189.0)
171.4 ± 7.9
(155.0-185.0)
Mass(kg)* 65.9 ± 13.4
(45.0-94.0)
69.7 ± 13.5
(43.0-100.0)
76.3 ± 15.0
(52.0-108.0)
72.6 ± 10.4
(54.0-95.0)
DOS (y)* - - 1.5 ± 4.0
(0.1-22.0)
0.8 ± 1.0
(0.4-5.0)
Arm dominance (n)
Left 1 1 5 3
Right 29 29 25 27
Painful side
Left - - 14 11
Right - - 16 19
Abbreviations: DOS, duration of symptoms.
* Data are presented in (means ± SD [range]).
80 J Or thop Sports Phys Ther Volume 35 Number 2 February 2005
TABLE 4. Effect of taping techniques (compared to placebo taping condition) on postural measurements of interest. With the exception
of pain, taping produced a significant change (P .001) for all variables measured.
Subjects Without Symptoms Subjects With Symptoms
Outcome Measures Mean (SE)* 99% CI* DF
P Value
Mean (SE)* 99% CI* DF
P Value
‡§
FHP (°) 2.5 (0.45) 1.1-3.9 2,118 .001 4.1 (0.66) 2.0-6.1 2,118 .001
FSP (°) 5.0 (1.12) 1.6-8.4 2,118 .001 3.9 (1.12) 0.4-7.3 2,118 .001
Kyphosis (°) –6.4 (.72) –8.6- –4.2 2,118 .001 –5.8 (0.66) –7.8- –3.7 2,92 .001
Lateral scapular
displacement (cm)
–1.4 (.14) –1.8- –1.0 2,90 .001 –1.8 (0.15) –2.2- –1.3 2,100 .001
Elevation (cm) –1.7 (.18) –2.2- –1.1 2,95 .001 –1.7 (0.18) –2.3- –1.2 2,84 .001
Sagittal position (cm) –1.8 (.32) –2.7- –0.8 2,94 .001 –2.5 (0.25) –3.3- –1.7 2,118 .001
Shoulder flexion (°) 8.2 (.69) 6.1-10.3 2,118 .001 16.2 (2.70) 7.9-24.4 2,118 .001
Scapular plane
abduction (°)
7.0 (.65) 5.0-9.0 2,118 .001 14.7 (2.92) 5.7-23.6 2,118 .001
Shoulder flexion VAS
(pain)
- - - - –0.4 (0.23) –1.1-0.3 2,118 .136
Shoulder abduction
VAS (pain)
- - - - –0.4 (0.20) –1.0-0.2 2,118 .111
Abbreviations: FHP, forward head posture; FSP, forward shoulder posture; VAS, visual analogue scale.
* SE (standard error) and CI (confidence intervals) from Bonferonni adjusted comparisons of main effects in a repeated measures analysis of
variance.
DF (degrees of freedom) from repeated measures analysis of variance, Greenhouse-Geisser adjusted where appropriate.
P value from repeated measures analysis of variance.
§
Significant at the .001 level.
TABLE 5. Standardized regression coefficients and partial correlation coefficients for the prediction of improvement in range of move-
ment from improvements in postural measurements after the application of postural taping.
Subjects Without Symptoms Subjects With Symptoms
Improvements on Postural
Measure Beta*
Partial
Correlation
Coefficient
P Value Beta*
Partial
Correlation
Coefficient
P Value
Shoulder flexion
FHP (°) .140 .14 .31 .222 .20 .14
FSP (°) .041 .04 .79 –.029 –.03 .84
Kyphosis (°) –.199 –.19 .16 –.120 –.13 .39
Lateral scapular
displacement (cm)
–.231 –.21 .13 –.042 –.04 .77
Elevation (cm) .057 .06 .67 –.137 –.14 .33
Sagittal position (cm) –.008 –.01 .96 –.043 –.04 .78
Scapular plane abduction (°)
FHP (°) .315 .32 .02 .200 .18 .18
FSP (°) .116 .11 .41 –.081 –.08 .57
Kyphosis (°) –.298 –.30 .03 .031 .03 .82
Lateral scapular
displacement (cm)
–.017 –.02 .90 .095 .09 .51
Elevation (cm) .118 .13 .35 –.102 –.10 .47
Sagittal position (cm) .019 .02 .90 –.119 –.11 .44
Abbreviations: FHP, forward head posture; FSP, forward shoulder posture.
* Standardized regression coefficient.
Correlation between measure for the range of movement and improvement in postural measure, adjusting for the influence of improvements on
other postural measures.
At a 5% level of significance, changes in postural
measures did not individually contribute significantly
to improvement in range of movement for subjects
with symptoms (Table 5), or to improvement in
shoulder flexion for asymptomatic subjects. Improve-
ments on FHP (
= .315, partial correlation = .32, P =
.02) and kyphosis (
= –0.298, partial correlation =
–.30, P = .03) were related to improvements on range
of scapular plane abduction for asymptomatic sub-
jects (Table 5).
DISCUSSION
Clinical authorities have suggested that poor upper
body posture and muscle imbalance may cause or
perpetuate SIS. The aim of many conservative reha-
J Orthop Sports Phys Ther Volume 35 Number 2 February 2005 81
RESEARCH REPORT
bilitation programs is to correct posture and muscle
imbalance using muscle strengthening, muscle
stretching, and joint mobilization techniques.
39,68,94,99
The evidence to support the efficacy of these clinical
practices is limited. The aim of this study was to
contribute to knowledge regarding the influence on
changing posture on shoulder range of movement in
asymptomatic and symptomatic subjects, as well as
pain in subjects with SIS. It was considered important
to choose a model of changing posture that could be
considered realistic to an extent that it might be
achievable as a result of a clinical rehabilitation
program. Models that required subjects to be assessed
in extremes of inflexible postures
38
were rejected,
and the model chosen was the use of taping
materials. The application of taping has been
recommended for many therapeutic rea-
sons
23,32,52,58,59,68,87,90
and it was necessary to demon-
strate that one of the effects of taping, as used in this
investigation, was to elicit a change in the static
posture of the subjects. Placebo taping, applied over
the same area as the postural correction taping, but
without requesting the subjects to alter their posture,
was also investigated in an attempt to determine if it
was the influence of changing posture, or another
effect of applying tape, that brought about any
observed changes in the outcome measurements of
interest. If the postural correction tape influenced
the postural and functional measurements of interest
and the placebo postural taping did not, it was
considered that a change in the postural measure-
ments may be attributable to a change in the static
posture of the subject, produced by the subject and
maintained by the tape.
The placebo postural correction procedure did not
produce a significant change in the static position of
the scapula, or on the range of pain-free shoulder
flexion and abduction in the plane of the scapula in
the symptomatic subjects. With the exception of a
significantly smaller lateral linear displacement of the
scapula from the thoracic spine (–0.3 cm, P = .001),
the placebo procedure did not produce a significant
effect on any of the measurements of interest in the
asymptomatic group. However, the clinical impor-
tance of the reduced lateral linear displacement of 3
mm is questionable. In contrast, the findings suggest
that the taping technique used to change posture did
have a significant effect on all the postural variables
measured. There was a significant (P.001) decrease
in the FHP angle, FSP angle, thoracic kyphosis angle,
amount of lateral linear displacement of the scapula,
and elevation and sagittal plane position of the
acromion. There was also a significant increase
(P.001) in the range of shoulder flexion and
scapular plane abduction for both groups of subjects.
Although the point at which pain was first experi-
enced or first felt to increase occurred later in the
shoulder flexion and scapular plane abduction range
in the symptomatic subjects, the intensity of pain was
not found to be significantly reduced. The results of
multiple regression analysis suggested that there was
no predominant postural variable that influenced
shoulder flexion and abduction in the plane of the
scapula range, and that the subjects responded indi-
vidually to the effects of postural change. Therefore,
it is not possible to determine if a single change, or a
combination of changes, in the static posture led to
the recorded increased range in shoulder flexion and
abduction in the plane of the scapula. It is also not
possible to determine if isolated changes had a
positive or negative effect on the results. The purpose
of the postural change taping was to extend the
thoracic spine, and, to retract, depress, and posteri-
orly tilt the scapula. It is unknown if the addition of
either upward or downward rotation would have had
a beneficial or detrimental effect on the results. The
results from other studies
27,46,84,85
have suggested that
upper body posture does not follow the set patterns
described in the literature and have challenged the
belief that clinicians may assume the presence of a
specific changes in posture based on the presence of
a FHP. Although the findings from the current study
suggest that changing components of posture may
lead to an increase in shoulder flexion and scapular
plane abduction range of movement, it is important
to acknowledge that the findings do not suggest that
posture follows set patterns, or that the postural
change reported here has functional relevance. This
is important to emphasize, as the postural change
described in the current investigation, despite an
overall mean improvement, had a detrimental effect
on shoulder range in a number of subjects in both
groups. The findings of this and other stud-
ies
27,46,84,85
suggest that it may be more useful clini-
cally to assess the individual components of posture
and their effect on range of movement and pain than
to examine sagittal plane posture.
Although the clinical and functional implications
of an increase mean 8.2° shoulder flexion and 7.0°
abduction in the plane of the scapula, as observed in
the asymptomatic subjects in this investigation, is
unknown, it is comparable to the mean 6.6° increase
in shoulder abduction reported by Wang et al,
99
who
assessed the effect of a 6-week exercise program
aimed at correcting posture on 20 asymptomatic
subjects. Subjects exercised 3 times a week, perform-
ing pectoral muscle stretches and strengthening exer-
cises for the scapular retractors, glenohumeral
exter nal rotators, and abductors. Wang et al
99
also
reported that, following the program, the scapula was
more downwardly rotated, a finding that contradicts
postural theory, due to the belief that a downwardly
rotated scapula increases subacromial compression.
Wang et al
99
also reported that, following the pro-
gram, there was a significant reduction in the upper
thoracic kyphosis. Roddey et al
88
investigated the
82 J Or thop Sports Phys Ther Volume 35 Number 2 February 2005
short-term effect of a daily pectoralis major stretching
program in a control (nonstretching) group, a group
with mild FHP, and a group with moderate FHP, on
the short-term resting static scapular protraction dis-
tance from the spine. No significant change was
reported in either the control or the mild FHP
groups. A significant decrease in the scapular protrac-
tion distance was reported in the moderate FHP
group. Although the results presented by Roddey et
al
88
suggested that in asymptomatic subjects with
moderate FHP a pectoralis major stretching program
would lead to a significant decrease in the amount of
static scapular protraction, it is not known what effect
this had on shoulder range of movement, as it was
not investigated, nor was the effect of stretching in
subjects with symptoms.
Scapular Elevation
Wang et al
99
reported that the scapula was less
elevated following their exercise program. This find-
ing is relevant, as other studies have reported that the
scapula is more elevated in slouched postures
38
and
in subjects with SIS.
18,50
Warner et al
101
also reported
increased scapular elevation in 4 subjects out of a
group of 7 with shoulder pathology. It is not known if
the scapular elevation reported in these studies was
involved in the pathogenesis of the condition or was
a secondary compensatory response to the pathology.
The results from the current investigation suggest
that the mean decrease of resting scapular elevation
following the postural correction technique used in
the current investigation was 1.7 cm for both the
asymptomatic and symptomatic subjects.
Lateral Linear Displacement of the Scapula
As the scapula protracts and retracts around the
thorax, its lateral linear distance from the thoracic
spine increases and decreases. The mean within-
subject decrease in lateral linear displacement of the
scapula was found to be 1.4 cm for the asymptomatic
subjects and 1.7 cm for those with SIS. This suggests
that the scapula was more retracted following the
procedure. Although previous research
21
suggests that
there is no statistical difference between function and
the amount of medial/lateral displacement of the
scapula from the thoracic spine, in this study, reduc-
ing the amount of resting lateral linear displacement
of the scapula as part of a combination of postural
changes led to an increase in shoulder flexion and
scapular plane abduction range. By itself there was no
significant relationship between a change in lateral
scapular displacement and shoulder motion (Table
5).
Sagittal Plane Position of the Acromion
Other studies have reported that the scapula is
more anteriorly tilted in slouched postures
38
and in
subjects with SIS.
49,50
Postural theorists
6,28
and clin-
ical observations
32
have suggested that this may be
due to an associated shortening of the pectoralis
minor muscle. The taping technique in the current
study significantly reduced the sagittal plane position
of the acromion by 1.7 cm and 2.5 cm in the
asymptomatic and symptomatic subjects, respectively.
This reduction potentially reduced the anterior tilt of
the scapula and may have contributed to the ob-
served increase in shoulder flexion and scapular
plane abduction observed in the cur rent investiga-
tion.
Thoracic Kyphosis
The review of the literature failed to identify any
studies that had investigated the effect of changing
the resting angle of the thoracic kyphosis experimen-
tally in subjects with SIS to determine the effect on
shoulder range of movement and pain. The mean
decrease in the kyphosis angle of 6.4° and 5.8° in the
asymptomatic and symptomatic subjects (in conjunc-
tion with other postural changes), respectively, ob-
served in this study, following the postural correction
taping, offers some suppor t to the belief that reduc-
ing the thoracic kyphosis can contribute to improving
ar m elevation.
11,28,41
Shoulder Flexion and Scapular Plane Abduction
The results suggest that the combined effect of
changing several components of posture in the symp-
tomatic subjects led to a mean increase of 16.2°
shoulder flexion and 14.7° abduction in the plane of
the scapula from their respective baseline values (end
point of movement defined by the onset or increase
in pain). The mean baseline values were 120.1° (SD,
30.8°) and 111.2° (SD, 30.8°), respectively, for these
measurements, and the mean values following pos-
tural correction were 136.3° (SD, 28.4°) and 125.9°
(SD, 31.3°), respectively. Although the large standard
deviations reflect considerable variation among the
subjects, the increases in shoulder flexion and
scapular plane abduction range observed following
the taping technique may allow subjects with SIS to
perform activities with the upper limb in a greater
degree of elevation before experiencing pain, or an
increase in pain. A limitation of this study, inherent
to investigations involving nonconstrained subjects, is
that the method used to measure shoulder flexion
and scapular plane abduction could not isolate the
movement occurring at the glenohumeral joint, and
also involved scapular and trunk movement. This
limitation is acknowledged and future research involv-
ing nonconstrained subjects should attempt to isolate
the humeral, scapular, thoracic, lumbar, and lower
limb contribution to the movement of arm elevation.
J Orthop Sports Phys Ther Volume 35 Number 2 February 2005 83
RESEARCH REPORT
The Therapeutic Use of Taping
The use of taping has been widely reported in the
literature. The therapeutic effects of taping have
been hypothesized to include joint stabilization,
52
changing and controlling posture at a joint,
32,58
inhibiting muscle activity,
59
reducing pain,
52
increas-
ing motoneurone excitability,
74
and increasing joint
torque.
23
Taping has also been reported to enhance
proprioception.
87
Although the taping technique
used in this study appears to alter static postural
measurements, there is no evidence that it had an
effect on posture during movement. There are other
potential reasons for the beneficial effect of the
taping technique used. Potential benefits include
improved muscular effort,
23
enhanced sensory motor
control,
8,33,43,87
cutaneous stimulation,
26,74,79
pain
modulation via altered sensory input,
63
and facilita-
tion or inhibition of muscle activity.
2,73
Further research is necessary to determine if these
or other mechanisms are involved in the observed
changes. Future research is also required to deter-
mine the long-term effectiveness of the taping proce-
dure and its relevance in a rehabilitation program.
Although the data were entered by an assistant, the
investigator was not blinded to the postural measure-
ments as they were being taken. This is a limitation of
this investigation and future studies should endeavor
to employ procedures that blind the investigator from
the linear and angular measurements. It is important
to emphasize that, although the majority of subjects
responded positively to the procedure, a number did
not demonstrate an increase in range of shoulder
motion and in some there was a decrease in range
and an increase in pain. Future studies could aim at
deter mining the characteristics of subjects who ben-
efit from postural change and those in which the
technique has a detrimental effect. The technique
used to change posture described in this investiga-
tion, and modifications to this technique, may possi-
bly be considered as part of the clinical assessment of
a patient, in an attempt to determine the relevance
of posture and the potential benefit of changing
posture for that individual patient. Furthermore, as
the findings from the multiple regression analysis did
not suggest that changes in posture individually
contributed significantly to increases in shoulder
range, and, as some subjects responded negatively to
the postural changes used in this investigation, it may
be beneficial to assess the individual effect of elevat-
ing, protracting, and increasing the anterior sagittal
plane position of the scapula on individual subjects to
deter mine the influence of each factor on range of
movement and pain. These individual postural varia-
tions could also be investigated in future investiga-
tions.
The basis for correcting muscle imbalances and
posture is based upon models suggesting that the
postural fault is associated with acromial impinge-
ment of the subacromial tissues.
3,6,28,89
The acromial
mechanism of impingement has been challenged
with studies suggesting that the acromion may not be
involved in the pathogenesis of the condition,
34
the
joint and not the acromial side of the supraspinatus
tendon is more vulnerable,
69
and the pathology in
SIS may involve an intrinsic degenerative tendinosis
and not an inflammatory tendinitis caused by
acromial irritation.
12,76,78,96
As the exact cause and
nature of SIS remains unknown, future research is
necessary to establish the mechanism that postural
change may have on the pathology.
CONCLUSION
The forward head or ‘slouched’’ posture has been
associated with an increased thoracic kyphosis, for-
ward shoulder posture, and a scapula that is pro-
tracted, elevated, anteriorly tilted, and downwardly
rotated. This combination of postures has been
associated with a reduction in glenohumeral move-
ment and a number of clinical conditions including
SIS. There is little evidence that posture does follow
the set patterns described in the literature, and the
evidence to support the belief that correcting posture
and muscle imbalance will produce an improvement
in function and reduction in pain is also limited. The
results of the current study, combining active correc-
tion of posture and taping, suggest that there may be
a short-term improvement in the range of shoulder
flexion and scapular plane abduction in
asymptomatic subjects and those with SIS. There may
be a place for the techniques described in this study
in the assessment of patients to determine the
possible benefit of postural changes and taping on
SIS. Future research needs to determine the long-
term benefits of treating muscle imbalances and
changes in posture in the conditions where it is
thought to be involved as an etiological factor.
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RESEARCH REPORT
... The inclusion criteria included male and female athletes with overhead movements aged 18 to 45 years, unilateral pain for more than one week to the acromion, pain during flexion and abduction against resistance [19], a positive Neer's test [20], positive Hawkins [20], and a positive supraspinatus Empty Can Test (ECT), and pain when touching humeral tuberosity, [21] which was confirmed with a physical examination by a specialist physiotherapist. ...
... The inclusion criteria included male and female athletes with overhead movements aged 18 to 45 years, unilateral pain for more than one week to the acromion, pain during flexion and abduction against resistance [19], a positive Neer's test [20], positive Hawkins [20], and a positive supraspinatus Empty Can Test (ECT), and pain when touching humeral tuberosity, [21] which was confirmed with a physical examination by a specialist physiotherapist. ...
... The sling exercises were performed for 8 weeks, 3 sessions per week, each lasting one hour. These exercises were also prepared based on previous studies [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29]. Each exercise session included a 10-minute warm-up, a 45-minute main exercise, and a 5-minute cool-down. ...
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Purpose: Sub-acromial impingement syndrome (SAIS) is one of the most common causes of shoulder pain and affects shoulder joint proprioception. The closed kinetic chain (CKC) exercises with sling are more effective and safer than open kinetic chain (OKC) exercises. This study aimed to compare the effectiveness of OKC and total-body resistance exercises (TRX) sling training on shoulder joint position sense (JPS) in overhead athletes with shoulder impingement syndrome (SIS). Methods: This article was a randomized control trial (RCT) study conducted in Kerman City, Iran, in 2019. The research sample included 33 overhead athletes with SIS who were randomly classified into three groups: OKC, sling, and control groups. Joint position sense (JPS) was evaluated in external rotation (ER), internal rotation (IR), and abduction of the dominant arm in the target angle concerning the shoulder range of motion with the Leighton flexometer. The obtained data were analyzed using the analysis of covariance (ANCOVA). Results: The post-intervention results showed that a significant difference was observed between groups (ER, P<0.001; IR, P<0.001; abduction P<0.001). The change in the sling exercises group was significantly higher in ER, and IR, except abduction JPS than in OKC (P=0.001, P=0.001, P=0.235, respectively) and control groups (P<0.001, P<0.001, P<0.001, respectively). Change in the OKC group was significantly higher in ER, IR, and abduction JPS (P=0.001, P=0.019, P<0.001, respectively) than in the control group. The OKC and sling exercise improved the shoulder JPS of overhead athletes with SIS. Conclusion: The study results showed that the sling exercises were more effective than the OKC exercise for the shoulder JPS because these exercises were CKC and performed on an unstable level.
... The SFT technique was applied to the scapula of the participants' dominant arm using two pieces of standard 2-inch tape (MSSM Kino Soft Inc., Seoul, South Korea) according to the method suggested by Lewis et al [29] First, the participants were seated on a stool while keeping their backs straight and asked to fully retract and depress their scapula. One I-shaped tape was parallel to vertebrae from the 1st to the 12th thoracic with light tension (15-25%) and the other I-shaped tape was applied diagonally from the middle of the scapular spine to the 12th thoracic vertebra with the same tension ( Fig. 1). ...
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This study aimed to investigate the short-term effectiveness of scapular focused taping (SFT) on scapular position and kinematics during the tennis serve among professional players with and without shoulder pain. The cohort included 7 players who had no history of non-shoulder pain (NSP) and 6 players with shoulder pain (SP). All participants performed tennis flat serves while the Qualisys motion capture system recorded three-dimensional scapular kinematic data according to the International Society of Biomechanics recommendations. SFT was applied to the participants’ torso aligned with the lower trapezius, and the same movements were repeated. In the SP group, the scapula was tilted more posteriorly after the application of SFT as compared to before at ball release and maximally externally rotated humerothoracic joint during tennis serve (t = −5.081, P = .004 and t = −2.623, P = .047, respectively). In the NSP group, the scapula was tilted more posteriorly with SFT as compared to without at first 75% timing of the cocking phase and maximally externally rotated humerothoracic joint (t = −3.733, P = .010 and t = −2.510, P = .046, respectively). And the SP group exhibited a more rotated scapula externally after the application of SFT as compared to before at Ball impact (t = 5.283, P = .003). SFT had a positive immediate effect on the scapular posterior tilting and external rotation during certain phases of the tennis serve among tennis athletes with and without shoulder pain. These findings may help clinicians and sports practitioners to prevent and rehabilitate shoulder injuries for overhead athletes. Level of evidence: Level III; Case-Control Design; Comparative Study.
... This also increases the risk of neck pain, shoulder pain, and non-specific arm pain. 21 The research by Day10 also reported that the lateral epicondylitis patients showed scapular dyskinesis due to weakening of scapular muscles. ...
... These tests only ruled out glenohumeral instability, cervical referral pain and frozen shoulder and failed to identify the exact tissues involved and differentiate between rotator cuff tendinopathy and tear (12), which might have affected the results. Failing to investigate postural alignment, especially spinal thoracic curvature and rounded shoulder, and pectoralis muscle length in any of the studies might have also changed scapular motions and orientation in the healthy individuals (37). Moreover, selection bias associated with the sampling method might have influenced the results. ...
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Context: With a key role in normal shoulder function, scapular kinematics have been investigated in shoulder impingement syndrome (SIS). Objectives: This systematic review aimed at determining scapular kinematic patterns in patients with SIS compared to in asymptomatic individuals. Data Sources: Databases such as PubMed, Scopus, Web of Science, Ovid, Embase and PEDRO were searched from January 1995 to June 2021. Study Selection: Articles in English published in peer-reviewed journals and using motion analysis systems to compare scapular kinematics between patients with SIS and asymptomatic subjects during arm elevation were included. Data Extraction: A modified Downs and Black checklist was used to assess the risk of bias of the included studies. A random-effects model was employed to perform a meta-analysis. Results: Nine out of 1650 screened abstracts were included for data extraction. Scapular upward rotation significantly decreased during arm elevation in SIS (SMD = -0.13, 95% CI = -0.23 to -0.02) with a low effect size (I2 = 46%). No differences were observed in scapular posterior tilt (SMD = -0.07, 95% CI = -0.18 to 0.03) and external rotation (SMD = 0.02, 95% CI = -0.06 to 0.09) between patients with SIS and asymptomatic subjects. Conclusions: This review revealed that except for scapular upward rotation, scapular movement was generally insignificantly different between the subjects with and without SIS during arm elevation. Between-group differences might have been overlooked as a result of the high risk of bias in the included studies. The high-quality studies addressing confounders are required to provide a definitive conclusion on the relationship between SIS and scapular kinematics.
Article
Variability is inevitable in human movement and posture, including piano performance, although little research has been conducted in this area. The purpose of this study was to determine if, when comparing individuals to themselves, pianists demonstrate consistent postural angles within a task across multiple measurements and to ascertain if, between various tasks, there are discernible task-related postural patterns. Fifteen pianists participated in this study. Each pianist returned for a total of three measurement sessions. The tasks they were required to perform at each session were quiet sitting, raising their hands on and off the keyboard, playing an ascending and descending scale, sight reading, and playing a piece in three expressive conditions (i.e., deadpan, projected, exaggerated). The following postural angles were calculated based on motion capture data collected during the performance of these tasks: craniovertebral angle, head tilt, head-neck-trunk angle, trunk angle, thoracic angle, thoracolumbar angle, and lumbar angle. The within-person variability ratio across the three measurements was calculated for each angle and across all tasks. Task-related patterns in angles were examined by comparing the same postural angle across different tasks. Results showed that there is a considerable amount of within-person variability, but not enough to be inconsistent over time. Task-related patterns indicate that reading a musical score or playing at the extreme ends of the keyboard tend to involve leaning closer to the instrument. Implications for future studies, intervention studies in particular, include taking more than a single baseline measurement to provide a more accurate picture of an individual pianist's typical posture.
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BACKGROUND Rounded shoulder (RS) posture causes neck and shoulder pathologies. Mechanical correction taping (MCT) is often incorporated into postural corrective therapies; however, its effects on muscle stiffness are unclear. OBJECTIVE We investigated the effect of MCT with different tape fabrics, along with exercise, on upper trapezius and pectoralis minor muscle stiffness and the posture of sedentary workers. DESIGN AND SETTING A randomized controlled study was performed at Aydın Adnan Menderes University, Aydın, Turkey. METHODS The study included 39 workers with RS posture. Two intervention groups (performance tape: PT and classic tape: CT) were taped twice a week and administered a home exercise program for 4 weeks. The control (C) group performed only home exercises. RS was measured using an acromion-testing table (AT), stiffness using shear wave elastography ultrasound, and shoulder angle (SA) using a smartphone application at baseline and 4 weeks. Time and group interactions were determined using 3 × 2 mixed analysis of variance. RESULTS Intragroup analyses revealed a significant main effect of time on AT distance (η² = 0.445) and SA (η² = 0.325) in the PT and C groups (P < 0.05) and left upper trapezius stiffness (η² = 0.287) in the CT and C groups (P < 0.05). In the post hoc analyses, no difference was noted between the groups from baseline to 4 weeks (P > 0.05). CONCLUSION Scapular MCT added to postural exercises did not show any difference between the intervention groups and controls in terms of muscle stiffness and posture in sedentary workers. KEYWORDS (MeSH terms): Posture; Shoulder; Exercise; Photogrammetry AUTHORS’ KEYWORDS: Taping; Scapular correction; Stiffness; Elastography
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Background Physical risk factors for osteochondritis dissecans (OCD) of the humeral capitellum in young baseball players have not been fully elucidated. We aimed to identify the risk factors for capitellar OCD in baseball players aged 8–14 years. Methods Between December 2018 and December 2019, young baseball players were recruited from eight regional baseball leagues. Ultrasonography and physical assessments were performed preseason and at the end of the study period. Bilateral passive ranges of motion (ROM) of horizontal adduction (HA) of the shoulders, internal rotation (IR) of the hips, and the thoracic kyphosis angle were measured. One-year follow-ups were scheduled to determine the occurrence of OCD. Players with OCD were categorized into an OCD group; those without OCD and without any elbow pain for one year were categorized into a non-injured group. The players’ baseline data (age, sex, position in baseball, and Rohrer's Index) were analyzed using univariate analyses. Their physical parameters were analyzed using two-way analysis of variance with repeated measures to investigate OCD-related risk factors. Results In total, 3651 baseball players attended the one-year follow-up. Of these, 71 (1.9%) players had OCD of the humeral capitellum. In the OCD group, a significant association was found at baseline and at the end of the study period between a higher Rohrer index at baseline and a smaller hip IR ROM on the nondominant side. Conclusions Loss of hip IR ROM on the nondominant side is a newly discovered risk factor related to physical function in the development of OCD.
Article
Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supra and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic versus vascular disorders, and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical exam, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative work-up, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.
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Background: Diagnoses and treatments based on movement system impairment syndromes were developed to guide physical therapy treatment. Objectives: This masterclass aims to describe the concepts on that are the basis of the syndromes and treatment and to provide the current research on movement system impairment syndromes. Results: The conceptual basis of the movement system impairment syndromes is that sustained alignment in a non-ideal position and repeated movements in a specific direction are thought to be associated with several musculoskeletal conditions. Classification into movement system impairment syndromes and treatment has been described for all body regions. The classification involves interpreting data from standardized tests of alignments and movements. Treatment is based on correcting the impaired alignment and movement patterns as well as correcting the tissue adaptations associated with the impaired alignment and movement patterns. The reliability and validity of movement system impairment syndromes have been partially tested. Although several case reports involving treatment using the movement system impairment syndromes concept have been published, efficacy of treatment based on movement system impairment syndromes has not been tested in randomized controlled trials, except in people with chronic low back pain.
Article
Subacromial impingement syndrome is one uf the most frequently seen causes of shoulder pain. The symptoms are often vague and may be difficult to differentiate from other shoulder problems. The purpose of this paper is to provide the clinician with a more thorough understanding of this entity by reviewing the pertinent anatomy and underlying etiology. Suggestions are made to aid in establishing the diagnosis, and treatment recommendations are proposed.
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Assessment of posture is an integral component of the evaluation of patients with neck and shoulder dysfunctions. Protraction of the scapulae has been postulated to produce weakness of the shoulder musculature. Therefore, an accurate method is needed to assess scapular position in order to determine the effect of therapeutic intervention and classify dysfunction. The purpose of this study was to determine if an experienced clinician would accurately determine scapular position. Fifty subjects (age = 26±5.7 years, weight = 69.2±14.09kg; height = 173.9±13.91cm) participated in this study. The results revealed the following reliability coefficients: scapular distance (SD) intraclass correlation coefficient (ICC) =.80, scapular size (SS) ICC =.96, and normalized scapular abduction (NSA) (SD/SS) ICC =.34. These data demonstrate that NSA was not reproducible in this study. The authors hypothesize that NSA contains more measurement error because NSA is a ratio value in which both the numerator and denominator contain measurement error. Further study is needed before NSA values are used to determine scapular position or correlated NSA is used to force development of shoulder musculature.
Chapter
An ExampleA Simple Analysis Ignoring the Effect of PeriodStudent's ApproachAssumptions in the Matched-pairs t ApproachAdjusting for a Period Effect: Two-sample t ApproachAdjusting for a Period Effect: The Hills–Armitage ApproachExamining Period EffectsTesting for Carry-over and/or Treatment by Period InteractionA Model for the AB/BA Cross-overCarry-over or Treatment by Period Interaction?Confidence Intervals for Carry-overAre Unbiased Estimators of the Treatment Effect Available?Can We Adjust for Carry-over?The Two-stage AnalysisCorrecting the Two-stage ProcedureUse of Baseline MeasurementsA Bayesian ApproachComputer AnalysisFurther ReadingRecommendationsAppendix 3.1 Analysis With GenStat®Appendix 3.2 Analysis With S-Plus®
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Impingement on the tendinous portion of the rotator cuff by the coracoacromial ligament and the anterior third of the acromion is responsible for a characteristic syndrome of disability of the shoulder. A characteristic proliferative spur and ridge has been noted on the anterior lip and undersurface of the anterior process of the acromion and this area may also show erosion and eburnation. The treatment of the impingement is to remove the anterior edge and undersurface of the anterior part of the acromion with the attached coracoacromial ligament. The impingement may also involve the tendon of the long head of the biceps and if it does, it is best to decompress the tendon and remove any osteophytes which may be in its groove, but to avoid transplanting the biceps tendon if possible. Hypertrophic lipping at the acromio-clavicular joint may impinge on the supraspinatus tendon when the arm is in abduction and, if the lip is prominent, this joint should be resected. These are the principles of anterior acromioplasty.