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1 TITLE PAGE

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


3 Shoulder Pain
4
5 Hillary A. Plummer, PhD, ATC
6 University of Southern California
7 Los Angeles, CA, USA
8
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9 Jonathan C. Sum, PT, DPT


10 University of Southern California
11 Los Angeles, CA, USA
12
13 Federico Pozzi, PhD, PT
14 University of Southern California
15 Los Angeles, CA, USA
16
17 Rini Varghese, MS, PT
18 University of Southern California
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19 Los Angeles, CA, USA


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21 Lori A. Michener, PhD, PT, ATC, SCS, FAPTA*
22 University of Southern California
23 Division of Biokinesiology and Physical Therapy
24 1540 E. Alcazar St., CHP 155
25 Los Angeles, CA 90089
26 [email protected]
27
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31 *Corresponding Author
32

33

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35 The Virginia Commonwealth University and University of Southern California

36 Institutional Review Boards approved this study.

37

38

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39 TITLE PAGE

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


41 Shoulder Pain
42
43 *The authors affirm that they have no financial affiliation (including research funding) or
44 involvement with any commercial organization that has a direct financial interest in any
45 matter included in this manuscript
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84 ACKNOWLEDGEMENTS
85

86 The authors would like to acknowledge Brian McNeill, PT, DPT, Jari Haile, PT, DPT,

87 Andrew Piraino, PT, DPT, and Keegan Kitzgerald, PT, DPT for their assistance with data

88 collection.
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126 Abstract
127 STUDY DESIGN: Cross-sectional.

128 BACKGROUND: The scapular dyskinesis test (SDT) has demonstrated reliability and

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

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


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131 and without shoulder pain, and to determine the influence of blinding to the presence of

132 shoulder pain on prevalence of scapular dyskinesis.

133 METHODS: Participants (n=135), 67 with shoulder pain and 68 healthy controls, were

134 included in this study. The SDT was performed by 2 examiners, from a total of 21

135 physical therapists. The second examiner was blinded to the participant’s presence of
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136 shoulder pain. The SDT involved participants performing 5-repetitions of shoulder

137 flexion and abduction, while the clinician observed for scapular dyskinesis characterized

138 by scapular winging or dysrhythmia. Dyskinesis was rated as normal, subtle, or obvious.

139 Ratings were collapsed into 2 groups, dyskinesis (subtle and obvious) and no dyskinesis

140 (normal) as recommended by expert consensus.


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141 RESULTS: There were no significant differences for scapula dyskinesis prevalence

142 between the shoulder pain and control groups during SDT in abduction [shoulder

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

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

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

146 examiners SDT rating in the shoulder pain group. The unblinded examiners reported a

147 higher prevalence when testing the involved shoulder for dyskinesis in flexion

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

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

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150 CONCLUSIONS: Scapular dyskinesis as assessed using the SDT is not more prevalent

151 in those with shoulder pain, but the rating is influenced by the examiners knowledge of

152 shoulder pain presence. Scapular dyskinesis may represent normal movement variability.

153 LEVEL OF EVIDENCE: Diagnosis, level 4.


154
155 KEY WORDS: Evaluation; Screening; Shoulder pain
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157 Word count: 261
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158 Scapular dyskinesis, defined as altered movement or position of the scapula, has been

159 proposed as cause of shoulder pain.4, 6, 8, 10 The scapular dyskinesis test (SDT)8 was

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

161 visual observation of scapular motion. The SDT classification described by McClure and

162 colleagues uses a 3-level classification (none, subtle and obvious dyskinesis), based on
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163 the presence of scapular winging or dysrhythmia during arm elevation. The SDT using 3-

164 level rating has demonstrated moderate reliability between clinician raters (ĸ =0.48 –

165 0.61;percentage agreement= 75–82%).8 Uhl and colleagues21 used a 2-level (yes/no)

166 classification of observational scapular dyskinesis without the use of weights also

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


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168 of the 3-level SDT17 was established by demonstrating that participants rated as having

169 obvious dyskinesis had larger alterations of scapular and clavicle three-dimensional (3D)

170 kinematics than those without dyskinesis.

171 Uhl and colleagues21 examined side-to-side scapular motion asymmetry using 3D
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172 kinematics in participants with and without shoulder pain. Asymmetrical scapular motion

173 was almost equal for those with shoulder pain and healthy controls, with prevalence of

174 76% and 77% respectively during scaption, and 71% in both groups during flexion. It

175 does not appear that the asymmetry in scapular motion alone is related to presence of

176 shoulder pain. On the other hand if the presence of scapular dyskinesis that is

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

178 represents just normal movement variability is not known.21

179 During a physical examination, the clinician rating the SDT is not blinded to

180 patient symptoms. In theory, rating of clinical tests may be influenced by knowledge of

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181 participant symptoms, especially in qualitative observational tests. Therefore, it is

182 possible that examiner or confirmation bias may mask the true presence or absence of

183 scapular dyskinesis resulting in an inaccurate SDT rating. Biased scapular assessment

184 may lead to a treatment focus of correcting the dyskinesis, which may be unwarranted

185 because the observed dyskinesis may not be contributing to the participant’s symptoms.
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186 The clinical relevance of a test is determined by its’ ability to guide clinical

187 decision-making.20 A systematic review concluded that visual scapular dyskinesis tests

188 are not useful in differentially diagnosing shoulder pathology.2 Moreover, they may have

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

190 prognosticating the risk of re-injury are two potential clinical decisions that are enabled
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191 by using the SDT. Further studies examining scapular dyskinesis are needed to determine

192 clinical utility of the SDT. A first step is to determine if the prevalence of observable

193 scapular dyskinesis is influenced by the presence of shoulder pain, or by clinician bias.

194 Aim 1 of this study was to characterize the prevalence of scapular dyskinesis in
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195 participants with shoulder pain as compared to a matched control group without shoulder

196 pain. Aim 2 was to examine the prevalence of scapular dyskinesis as rated by examiners

197 blinded and unblinded to the presence of shoulder pain to assess potential bias that may

198 exist when rating the SDT. The research hypotheses were: (1) participants with shoulder

199 pain would not have a significantly different prevalence of scapular dyskinesis than those

200 without pain, and (2) the unblinded clinician would not report greater prevalence of

201 dyskinesis than the blinded examiner in participants with shoulder pain.

202 METHODS

203 Participants

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204 Potential participants with and without shoulder pain who presented for physical

205 therapy were screened during the treating physical therapist’s initial evaluation. If

206 potential participants met the inclusion criteria the study was explained to them and they

207 were asked to participate. Inclusion criteria included: 1) between 18-70 years of age,

208 comprehend English for instructions and completion of the data collection forms, and 2)
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209 for the shoulder pain group only, participants were required to have shoulder pain with

210 activity ≥ 2/10 on the numeric pain rating scale. Participants for both groups were

211 excluded if any of the following conditions were present: 1) adhesive capsulitis, defined

212 as a loss of >50% in passive shoulder range of motion in shoulder external rotation and 1

213 other plane of motion, 2) previous shoulder surgery within the past year, 3) history of
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214 shoulder fracture, 4) systemic musculoskeletal disease (rheumatoid arthritis and

215 fibromyalgia, etc.), and 5) shoulder pain that was reproduced with active/passive cervical

216 spine motion. Additionally, participants for the control group were excluded if they had a

217 history of shoulder pain within the past 1 year.


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218 Participants for both the shoulder pain and control groups were recruited at the

219 same clinics. Participants in the control group were being treated for conditions of the

220 lower extremities that did not affect the upper extremity. All participants completed the

221 informed consent, which was approved by the University of Southern California

222 Institutional Review Board. All potential participants who met the inclusion and

223 exclusion criteria agreed to participate. A tally was not recorded of those participants

224 who were screened, but were ineligible because of inclusion or exclusion criteria.

225 An a priori power analysis indicated to that a total sample size of 108 participants

226 was required to determine a significant difference in prevalence rate, with a power of

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227 80%, alpha of 0.05, using estimates of prevalence from prior studies of 48% for patients

228 with shoulder pain and 25% in those without shoulder pain.8, 16

229 Examiners

230 Data for this study were collected at 4 physical therapy clinics in Virginia and

231 California. The examiners were physical therapists (n=21) with an average age of 31.8 ±
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232 7.4 years, 6.1 ± 7.8 year of practice, spent 90.3 ± 9.6% of their day treating patients, and

233 specifically 23.1 ± 14.1% of day treating patients with shoulder disorders. Prior to the

234 start of the study, all participating physical therapists completed an on-line training of the

235 clinical SDT. The developers of the SDT created this training.19 Live training occurred

236 following the on-line training to review data collection procedures. Prior to the start of
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237 the study, test-retest reliability was established on a subset of participating physical

238 therapists (n= 5) on 7 participants. Both shoulders were tested during weighted flexion

239 and abduction SDT. The clinicians rated scapular movement as normal, subtle or

240 obvious, and then these ratings were collapsed into the 2-level (yes/no) classification The
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241 kappa coefficient was 0.69 (95%CI: 0.36, 1), and the percent of agreement was 85%,

242 which is consistent with prior reports of reliability.8

243 Procedures

244 The Pennsylvania Shoulder Score (Penn), was used to assess shoulder pain,

245 satisfaction with shoulder use, and disability in the shoulder pain group (0-100; 100 = no

246 disability).5 The Penn has demonstrated validity and reliability when measuring patient-

247 rated symptoms and function 5, 11 Pain was assessed with a numeric pain rating scale (0-

248 10; 0 = no pain).

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249 The participants were asked to expose their scapula by either removing their shirt,

250 wearing only a halter-style shirt, or wearing a shirt with small straps such as a sports bra

251 or camisole. The SDT was performed as originally described by McClure et al.8 Each

252 participant performed 5 repetitions each of shoulder flexion and abduction, using a 2.2-kg

253 (5-lb) weight in their hands for those weighing 68-kg (150-lb) or greater, and 1.4-kg (3-
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254 lb) weight for those weighing less than 68-kg.8 If participants could not complete the

255 motion with weight, they performed the SDT without weight. The examiner observed for

256 the presence of scapula dyskinesia (winging and dysrhythmia) during elevation and

257 lowering of the participant’s arms. Winging was described as any excessive movement of

258 any part of the medial scapula moving off of the thorax. Dysrhythmia was described as
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259 any unsmooth movement of the scapula, relating to timing and speed of the scapular

260 movement. The presence of scapula dyskinesia was scored using a 3 category

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

262 evidence of abnormality that is not consistently present, 3- obvious = striking, clearly
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263 apparent abnormality that is evident on at least 3/5 trials.8 For data analysis, the 3-level

264 classification of the SDT was collapsed to a 2-level classification scheme based on

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

266 obvious dyskinesis ratings.

267 In participants with shoulder pain, the SDT was performed for both shoulders, and

268 by both the blinded and unblinded examiner. In participants without shoulder pain

269 (control group), the SDT was performed in both shoulders, but only by the blinded

270 examiner. Participants with shoulder pain were asked to perform the SDT twice and 2

271 independent examiners rated each test. There was approximately 5-30 minutes between

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272 examinations and the blinded examiner was selected based on availability during testing.

273 The SDT8, 17 was first rated by the physical therapist who recruited the patient for the

274 study, and this examiner was the unblinded examiner as they were not blinded to group

275 (shoulder pain or control group). A second physical therapist from the clinic was then

276 recruited by the treating physical therapist to assess scapular dyskinesis with the SDT.
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277 This second clinician was the blinded examiner, as they were blinded to the participants’

278 presence or absence of shoulder pain. This blinded examiner only communicated the

279 instructions for the flexion and abduction SDTs, so knowledge of shoulder pain or

280 symptoms would be eliminated during the testing. The participants in the control group

281 were assessed using the SDT only once by a blinded examiner in the same manner as
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282 described for the participants with shoulder pain. Both shoulders were rated during the

283 SDT for participants in the control group.

284

285 Statistical Analysis


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286 Group baseline characteristics were examined with independent t-tests for age,

287 height, mass, and Body Mass Index (BMI); and chi-square analysis for gender. Arm

288 dominance was controlled for between the groups, by matching the control group for arm

289 dominance. In the shoulder pain group 53/67 (79.1%) had pain in their dominant

290 shoulder. In the control group the dominant arm results of the SDT were selected

291 randomly using a random number generator in order to match the percentage of dominant

292 shoulders tested in the shoulder pain group. The dominant shoulder SDT results for the

293 first 54 subject numbers listed from the random number generator were selected. This

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

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295 Chi-square tests were performed to examine the differences in prevalence of

296 dyskinesis between groups for (Aim 1). The prevalence of dyskinesis in both involved

297 and uninvolved shoulder as rated by blinded and unblinded examiners (Aim 2) was

298 analyzed using McNemar Tests. These analyses were performed for both flexion SDT

299 and abduction SDT. The level of significance was set at p < 0.05.
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300 The 3 categories of SDT ratings were collapsed into 2 categories of dyskinesis=

301 subtle/ obvious, and no dyskinesis = normal rating. A sensitivity analysis was performed

302 to determine if the results would be different if the data was collapsed differently into 2

303 categories: no dyskinesis = normal/ subtle, and dyskinesis = obvious rating. Statistical

304 Package for Social Science (IBM Inc., Chicago, IL) was used for data analysis.
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305 RESULTS

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

307 participants with shoulder pain comprised the shoulder pain group and sixty-eight

308 participants without shoulder pain made up the control group. Demographic and
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309 diagnoses characteristics are presented in Table 1 and 2, respectively. There was a

310 significant difference in age between the groups; the shoulder pain group was 5.1 years

311 older. A sub-group analysis for age was performed to assess if prevalence of dyskinesis

312 differed between the 20 youngest and the 20 oldest participants. No significant

313 differences were observed between the youngest and oldest participants in each group for

314 abduction or flexion. There were missing data present for 2 participants rated by the

315 unblinded examiner.

316 Aim 1 – Shoulder Pain Group versus Control Group. There were no significant

317 differences between groups for the prevalence of scapular dyskinesis as rated by the SDT

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318 during flexion by the blinded examiner (p= 0.51); dyskinesis was reported in 45/67

319 (67.2%) in the shoulder pain group and 42/68 (61.8%) in the control group (Table 3).

320 There were no significant differences between groups for the prevalence of scapular

321 dyskinesis during abduction (p= 0.09) as rated by the blinded examiner; dyskinesis was

322 reported in 45/67 (67.2%) in the shoulder pain group and 36/68 (52.9%) of the control
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323 group (Table 3).

324 Aim 2 – Shoulder Pain Group- Involved Shoulder: Blinded vs. Unblinded

325 Examiner. There were significant differences in the rating of scapular dyskinesis

326 between the blinded and unblinded examiners for the involved shoulder in the shoulder

327 pain group during the flexion SDT (p< 0.001); dyskinesis was reported in 44/65 (67.7%)
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328 by the blinded examiner and 52/65 (80%) by the unblinded examiner (Table 4). Similar

329 results were also observed during abduction. For the abduction SDT, there were

330 significant differences in the rating of scapular dyskinesis between the blinded and

331 unblinded examiners for the involved shoulder in the shoulder pain group (p= 0.001);
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332 dyskinesis was reported in 43/65 (66.2%) by the blinded examiner and 51/65 (78.5%) by

333 the unblinded examiner (Table 4).

334 Aim 2- Shoulder Pain Group – Uninvolved shoulder: Blinded vs. Unblinded

335 Examiner. There were significant differences between examiners for abduction SDT

336 [unblinded examiner= 43/65 (66.2%) rated with dyskinesis; blinded examiner= 44/65

337 (67.7%) rated with dyskinesis; p= 0.008] described in Table 5. There was a higher overall

338 prevalence of dyskinesis during the abduction SDT. There were no significant differences

339 in prevalence of scapular dyskinesis between the blinded and unblinded examiners for the

340 uninvolved shoulder in the shoulder pain group during the flexion SDT [unblinded

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341 examiner= 39/65 (60%); blinded examiner= 37/65 (56.9%); p= 0.222]. The sensitivity

342 analysis revealed no significant differences between groups, or between the blinded

343 versus unblinded examiners ratings for the shoulder pain group for the alternative

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

345 DISCUSSION
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346 The overall goal of this study was to help understand the clinical utility of the

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

348 prevalence of observable scapular dyskinesis in those with shoulder pain using the SDT

349 and the potential bias that may exist when rating SDT. Our findings indicate that the

350 occurrence of scapular dyskinesis is not influenced by the presence of shoulder pain.
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351 However, the rating of scapular dyskinesis does appear to be impacted by the clinician’s

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

353 Our first hypothesis was confirmed; there were no statistically significant

354 differences in prevalence of scapular dyskinesis in those with shoulder pain as compared
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355 to those without shoulder pain. The prevalence rate of dyskinesis was 5% higher in the

356 shoulder pain group, which was not statistically different, and is likely not meaningfully

357 different than the control group. Uhl and colleagues21 reported similar findings with

358 almost identical prevalence rates of scapular asymmetry in participants with shoulder

359 pain and healthy controls. However, it is important to note that Uhl and colleagues

360 examined only asymmetries by comparing scapular motion bilaterally within individuals.

361 The results of Uhl and colleagues are not directly comparable to the results of the current

362 study because we did not rely on scapular asymmetry to determine the presence of

363 scapular dyskinesis. Results from the current study indicate that the presence of scapular

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364 dyskinesis may not be a relevant impairment for those with shoulder pain, and may

365 represent normal movement variability.9 The participants in the current study had low

366 levels of pain and disability. Furthermore, approximately 70% of the participants were

367 diagnosed with subacromial pain / rotator cuff disease or posterior impingement. It is

368 possible that a more symptomatic or functionally limited group would present with
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369 different findings than what was observed.

370 The results for aim 2 of the study revealed that blinded and unblinded examiners

371 rated the presence of scapular dyskinesis significantly different for both motions in the

372 involved shoulder and for abduction in the uninvolved shoulder. The unblinded examiner

373 reported a higher rate of positive SDT than the blinded examiner. The prevalence rate of
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374 dyskinesis was 12.3% higher in the involved shoulder when rated by the unblinded

375 examiner during flexion and abduction SDT. The differences in prevalence rates between

376 examiners may be clinically meaningful and indicate a potential confirmation bias since a

377 higher presence of scapular dyskinesis was reported when examiners knew they were
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378 rating an individual’s painful shoulder. However, this was not the case for the uninvolved

379 shoulder, where the prevalence rates were similar for the flexion SDT between

380 examiners. The difference in prevalence of dyskinesis between the two examiners was

381 1.5% for abduction and 3.1% difference in flexion in the uninvolved shoulder.

382 The results of this study indicate that clinical tests that rely on observational

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

384 for observational dyskinesis could lead to a treatment plan that does not address the

385 underlying cause of shoulder pain. Addressing normal variability in scapula movement

386 may not be warranted based on the results of the SDT because this variability may not be

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387 contributing to the patient’s shoulder pain. Further research is warranted to determine if a

388 reduction in pain or increase in shoulder strength is observed during the scapular

389 reposition test18 or scapular assistance test.13 These clinical tests may differentiate the

390 role of the scapula in the contribution to shoulder pain. The scapular reposition test or

391 scapular assistance test may better identify how normal movement variability may be
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392 present but not contribute to and allow clinicians to devise improved plans of care.

393 A priori, the planned data reduction was to collapse the data from 3 categories

394 (normal, subtle, obvious) into 2 categories (normal vs. subtle/ obvious). This was based

395 on the assumption that when any level of dyskinesis is observed, clinicians would rate

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


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397 examining the prevalence in dyskinesis when collapsed into dyskinesis = normal/ subtle

398 versus no dyskinesis = obvious. There were no significant differences between groups or

399 blinded versus unblinded examiners, thus we draw the same conclusions as when the data

400 was collapsed in the original method.


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401 Clinical decision-making using the SDT has been investigated.23 Prior studies

402 have examined the ability of observational scapular dyskinesis using the SDT to predict

403 the risk of injury.1, 3, 12, 14, 15 These studies have reported varying results in varying

404 participant populations and observational methods. The findings are equivocal as to the

405 predictive ability of scapular dyskinesis tests, with two previous studies reporting that

406 observable scapular dyskinesis tests can predict injury risk,1, 3 and three others indicating

407 no predictive ability.12, 14, 15 Observational scapular dyskinesis tests have questionable

408 ability to predict injury risk. Clinical shoulder evaluations often compare scapular motion

409 between the pathological shoulder and the contralateral shoulder without accounting for

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410 the potential confounding effects of arm dominance.7 It has been suggested that the

411 increased frequency of dominant shoulder use can contribute to scapular motion deficits.7

412 Studies classifying the presence of dyskinesis between the dominant and non-dominant

413 shoulders, with the SDT, are lacking. However, scapular kinematic data between

414 shoulders during dynamic arm elevation have been reported.7, 21, 24, 25 The results are
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415 equivocal, with no difference in kinematics between shoulders reported in 2 studies,24, 25

416 while 2 other studies reported differences.7, 21 These conflicting results may be due to the

417 different methods used to measure scapular kinematics. We controlled for dominance by

418 matching the groups for arm tested by dominance, thus eliminating this potential

419 confounding factor.


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420 There are some limitations to this study. We did not control for shoulder diagnosis

421 or examine the effect of diagnosis on the presence of scapular dyskinesis, so it is unclear

422 if the prevalence of dyskinesis may have been affected by the presence of a specific

423 diagnosis. The participants in the shoulder pain group had low reported levels of pain and
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424 disability. Results of this study can only be generalized to patients with similar diagnoses

425 and pain/ function levels. We did not to take into account that classification of scapular

426 dyskinesis was obtained by 21 different physical therapists, assuming this variation was

427 random. Future research should examine the prevalence of dyskinesis in diagnostic

428 subgroups of patients with shoulder disorders. There were only 8 participants who did

429 not use weights during the SDT due to an inability to perform the test due to pain or

430 weakness. The potential exists that the blinded examiner could have assumed that these

431 participants had shoulder pain, however the examiner would not have known which side

432 was painful, as the use of weights (or no weights) were the same for both arms. To reduce

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433 the likelihood that bias was introduced we reanalyzed the data with the 8 participants

434 removed and our results did not change. Additionally, examining the clinical utility of

435 the scapular reposition test18 and scapular assistance test may help to elucidate the

436 differential prevalence of dyskinesis in patients whose pain is reduced with these tests.

437 CONCLUSIONS
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438 Scapular dyskinesis does not appear to be related to the presence of shoulder pain.

439 Scapular dyskinesis was observed in participants with shoulder pain as well as healthy

440 controls, but the prevalence was not statistically different between these 2 groups.

441 Focusing solely on the prevalence of dyskinesis in patients with shoulder pain may not be

442 beneficial during a clinical evaluation, as scapular dyskinesis may represent normal
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443 movement variability. Potential bias may exist when unblinded examiners assess the

444 presence of scapular dyskinesis in patients with shoulder pain because higher rates of

445 prevalence were reported by unblinded versus blinded examiners. Assessment of scapular

446 symptom alteration tests and other associated impairments may help to delineate the
Journal of Orthopaedic & Sports Physical Therapy®

447 effect of scapular dysfunction on shoulder pain in these patients and enable clinical

448 decision-making.

449

18
450 KEY POINTS

451 FINDINGS: The prevalence of scapular dyskinesis is very similar in participants with

452 and without shoulder pain. Unblinded examiners consistently rated the presence of

453 scapular dyskinesis higher than blinded examiner. This may indicate a potential bias of

454 reporting for the SDT when a clinician is aware of the presence of shoulder pain.
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455 IMPLICATIONS: Scapular dyskinesis is an impairment that may represent normal

456 movement variability. Clinical evaluation and treatment focused on scapular dyskinesis

457 may not be warranted based solely on the presence of observable scapular dyskinesis.

458 CAUTION: Shoulder diagnoses may have influenced the prevalence of scapular

459 dyskinesis.
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460
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19
461 References
462
463 1. Clarsen B, Bahr R, Andersson SH, Munk R, Myklebust G. Reduced glenohumeral
464 rotation, external rotation weakness and scapular dyskinesis are risk factors for
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466 Br J Sports Med. 2014;48(17):1327-1333.
467 2. Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests
468 provide clinicians with the most value when examining the shoulder? Update of a
469 systematic review with meta-analysis of individual tests. Br J Sports Med.
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470 2012:1-16.
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474 4. Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD.
475 Clinical implications of scapular dyskinesis in shoulder injury: The 2013
476 consensus statement from the ‘scapular summit’. Br J Sports Med. 2013;47:877-
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478 5. Leggin BG, Michener LA, Shaffer MA, Brenneman SK, Iannotti JP, Williams Jr.
479 GR. The Penn Shoulder Score: Reliability and validity. J Orthop Sports Phys
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480 Ther. 2006;36:138-151.


481 6. Ludewig PM, Reynolds JF. The association of scapular kinematics and
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483 7. Matsuki K, Matsuki KO, Mu S, et al. In vivo 3-dimensional analysis of scapular
484 kinematics: comparison of dominant and nondominant shoulders. J Shoulder
485 Elbow Surg. 2011;20(4):659-665.
486 8. McClure P, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method for
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489 9. McQuade KJ, Borstad J, deOliveira AS. A critical and theoretical perspective on
490 scapular stabilization: What does it really mean, and are we on the right track?
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492 10. Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical
493 mechanisms of subacromial impingement syndrome. Clin Biomech.
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496 scale in patients with shoulder pain and the effect of surgical status. J Sport
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498 12. Myers JB, Oyama S, Hibberd EE. Scapular dysfunction in high school baseball
499 players sustaining throwing-related upper extremity injury: a prospective study. J
500 Shoulder Elbow Surg. 2013;22(9):1154-1159.
501 13. Seitz AL, McClure PW, Finucane S, et al. The scapular assistance test results in
502 changes in scapular position and subacromial space but not rotator cuff strength in
503 subacromial impingement. J Orthop Sports Phys Ther. 2012;42(5):400-412.
504 14. Shitara H, Kobayashi T, Yamamoto A, et al. Prospective multifactorial analysis of
505 preseason risk factors for shoulder and elbow injuries in high school baseball
506 pitchers. Knee Surg Sports Traumatol Arthrosc. 2015:1-8.

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507 15. Struyf F, Nijs J, Meeus M, et al. Does scapular positioning predict shoulder pain
508 in recreational overhead athletes? Int J Sports Med. 2014;35(1):75-82.
509 16. Tate A, Turner GN, Knab SE, Jorgensen C, Strittmatter A, Michener LA. Risk
510 factors associated with shoulder pain and disability across the lifespan of
511 competitive swimmers. J Athl Train. 2012;47(2):149-158.
512 17. Tate AR, McClure P, Kareha S, Irwin D, Barbe MF. A clinical method for
513 identifying scapular dyskinesis, Part 2: Validity. J Athl Train. 2009;44(2):165-
514 175.
515 18. Tate AR, McClure PW, Kareha S, Irwin D. Effect of the Scapula Reposition Test
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516 on shoulder impingement symptoms and elevation strength in overhead athletes. J


517 Orthop Sports Phys Ther. 2008;38(1):4-11.
518 19. Tate AR, McClure PW, Young IA, Salvatori R, Michener LA. Comprehensive
519 impairment-based exercise and manual therapy intervention for patients with
520 subacromial impingement syndrome: A case series. J Orthop Sports Phys Ther.
521 2010;40(8):474-493.
522 20. Tunis SR, Strayer DB, Clancey CM. Practical clinicl trials increasing the value of
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525 21. Uhl TL, Kibler WB, Gecewich B, Tripp BL. Evaluation of clinical assessment
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526 methods for scapular dyskinesis. Arthroscopy. 2009;25(11):1240-1248.


527 22. Wassinger CA, Williams DA, Milosavljevic S, Hegedus EJ. Clinical reliability
528 and diagnostic accuracy of visual scapulohumeral movement evaluation in
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530 2015;10(4):456-463.
531 23. Wright AA, Wassinger CA, Frank M, Michener LA, Hegedus EJ. Diagnostic
532 accuracy of scapular physical examination tests for shoulder disorders: a
533 systematic review. Br J Sports Med. 2013;47(14):886-892.
534 24. Yano Y, Hamada J, Tamai K, et al. Different scapular kinematics in healthy
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535 subjects during arm elevation and lowering: Glenohumeral and scapulothoracic
536 patterns. J Shoulder Elbow Surg. 2010;19(2):209-215.
537 25. Yoshizaki K, Hamada J, Tamai K, Sahara R, Fujiwara T, Fujimoto T. Analysis of
538 the scapulohumeral rhythm and electromyography of the shoulder muscles during
539 elevation and lowering: Comparison of dominant and nondominant shoulders. J
540 Shoulder Elbow Surg. 2009;18(5):756-763.
541

542

543

544

545

546

21
547 TABLES
548 TABLE 1. Participant Descriptive Data.
549
Shoulder Pain Control p-value
Group Group
(n=67) (n=68)
Age, years (SD) 32.5 (12.4) 27.4 (8.8) 0.01
Sex – Female, n (%) 33 (49.3%) 41 (60.3%) 0.20
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Height, cm (SD) 171.1 (10.0) 171.1 (9.3) 0.98


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


553

Diagnosis Number
Subacromial Pain / Rotator Cuff Disease 35
Posterior Impingement 17
Labral Tear 14
Journal of Orthopaedic & Sports Physical Therapy®

Instability 5
Acromioclavicular Joint Sprain 10
Muscle Strain 5
Thoracic Outlet Syndrome 2

554
555
556
557
558
559
560
561
562
563
564
565
566

22
567 TABLE 3. Prevalence of scapular dyskinesis in the shoulder pain group (n=67) and the
568 control group (n=68) during the flexion and abduction SDT, as examined by the blinded
569 examiner in the involved shoulder.
570
Blinded Examiner, No Dyskinesis % Dyskinesis Χ2
Involved Shoulder Dyskinesis [95%CI] p-value
Flexion SDT
Shoulder Pain Group 22 45 67.2% 0.51
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[0.55, 0.77]
Control Group 26 42 61.8%
[0.50, 0.72]
Abduction SDT
Shoulder Pain Group 22 45 67.2% 0.09
[0.55, 0.77]
Control Group 32 36 52.9%
[0.41, 0.64]
571
572 TABLE 4. Presence of scapular dyskinesis in the involved shoulder of the shoulder pain
573 group (n=65), as rated by the unblinded and blinded examiners during the flexion and
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574 abduction SDT.


575
576 A. Flexion SDT

Blinded Examiner

No Dyskinesis
Dyskinesis Dyskinesis Total prevalence:
Journal of Orthopaedic & Sports Physical Therapy®

No Unblinded
Unblinded Dyskinesis 5 8 13 Clinician

Examiner 52 /65
Dyskinesis 16 36 52 (80%)
[95%CI:0.69,0.88]

Total 21 44 65
McNemar Dyskinesis
test prevalence: 44 /65
p< 0.001 Blinded (67.7%)
577 Clinician [95%CI:0.56,0.78]
578
579
580
581
582
583

23
584 B. Abduction SDT

Blinded Examiner

No Dyskinesis
Dyskinesis Dyskinesis Total prevalence:
No Unblinded
Unblinded Dyskinesis 7 7 14 Clinician
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Examiner 51 /65
Dyskinesis 9 35 51 (78.5%)
[95%CI:0.67,0.87]

Total 22 43 65
McNemar Dyskinesis
test prevalence: 43 /65
p= 0.001 Blinded (66.2%)
585 Clinician [95%CI:0.54,0.76]
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586
587
588 TABLE 5. Presence of scapular dyskinesis in the Uninvolved shoulder of the shoulder
589 pain group (n=65), as rated by the unblinded and blinded examiners during the flexion
590 and abduction SDT.
591
592
593 A. Flexion SDT
Journal of Orthopaedic & Sports Physical Therapy®

Blinded Examiner

No Dyskinesis
Dyskinesis Dyskinesis Total prevalence:
No Unblinded
Unblinded Dyskinesis 16 10 26 Clinician

Examiner 39 /65
Dyskinesis 12 27 39 (60%)
[95%CI:0.48,
0.71]

Total 28 37 65
McNemar Dyskinesis
test prevalence: 37 /65
p= 0.222 Blinded (56.9%)
Clinician [95%CI: 0.45,
0.68]

24
594 B. Abduction SDT

Blinded Examiner

No Dyskinesis
Dyskinesis Dyskinesis Total prevalence:
No Unblinded
Unblinded Dyskinesis 12 10 22 Clinician
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Examiner 43/65
Dyskinesis 9 34 43 (66.2%)
[95%CI:0.54,
0.76]

Total 21 44 65
McNemar Dyskinesis
test prevalence: 44 /65
p= 0.008 Blinded (67.7%)
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Clinician [95%CI:0.56,
0.78]
595
596
597
598

599
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600

25

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