The scapula: its place in clinical reasoning in paents

Thescapula:itsplaceinclinicalreasoninginpa2entswithshoulderpain

FilipStruyf,PhD,PT

Scapularassessmentanditsplaceinclinicalreasoninginpa2entswithshoulderpain

Whyshouldweadressthescapular?Howcanweassessscapularmovement?Whenshouldweassessscapularmovement?Howdoesthisfitwithinclinicalreasoning?

Whydidhomininsevolvetheabilitytothrowathighspeed?+/2millionyearsagoinHomoerectus:adapta2onsinfeaturesthatenableenergystorageandreleaseattheshoulder?Hun2ngac2vi2esintensifiedaroundthis2meEvolu2onofthehumanshoulderisthereasonwhyhumankindsurvivedOrisitthebrain?

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Abriefintroduc2on...

Proper2esofanoutcomemeasure  Consensusonterminology

Proper2esofaoutcomemeasures

Reliable,valid&responsiveSomesay…

(Ludewig et al., 2009)

Whatisscapulardyskinesis?

  “Thescapulademonstratesprematureorexcessiveeleva2onorprotrac2on,nonsmoothorstuPeringmo2onduringarmeleva2onorlowering,orrapiddownwardrota2onduringarmlowering”(Dysrhythmia)

  “Themedialborderand/orinferiorangleofthescapulaareposteriorlydisplacedawayfromtheposteriorthorax.”(Winging)

(McClure et al. 2009)

Scapularassessmentanditsplaceinclinicalreasoninginpa2entswithshoulderpain

Whyshouldweadressthescapula?Howcanweassessscapularmovement?Whenshouldweassessscapularmovement?Howdoesthisfitwithinclinicalreasoning?

Isscapulardyskinesisthecauseoreffectofshoulderdisorders?

CAUSE?

Does scapular positioning predict shoulder pain? (Struyf et al. IJSM 2013)

Obvious scapular dyskinesis => higher probability of shoulder porblems in elite handball players (Clarsen et al. BJSM 2014)

Isscapulardyskinesisthecauseoreffectofshoulderdisorders?

EFFECT?

Hodges et al. 2013; Hodges and Tucker 2011a; Nijs et al. 2012b; Farina et al. 2001; La Pera 2001; Valeriani et al. 1999

pain-dependentinhibitoryinput(bothipsilateralandcontralateral)

Isscapulardyskinesisthecauseoreffectofshoulderdisorders?

CAUSE? EFFECT?

Assessment&Therapy

Riskoftransi2ontochronic?

Assessment&Therapy

YES

NO

  “scapularmusclerehabilita2onimprovespainandfunc2on(SPADI)inpa2entswithmildimpingementsymptoms”(6weekstraining)”DeMeyetal.AmJSportsMed2012

  “Alargeclinicallyimportanttreatmenteffectinfavorofscapularmotorcontroltrainingwasfoundinself-reporteddisability”Struyfetal.ClinRheum2013

Studiesthatdifferen2atehavelargersuccesrates!

  6studiesincluded(>6/10PEDROscore)scapular-focusedexercisetherapyscapularmobiliza2onscapulartaping

Clinicaloutcomesofascapular-focusedtreatmentinpar2cipantswithshoulderinjury:asystema2creview(BJSMinreview)EljaAEReijneveld1,SuzieNoten2,LoriAMichener3,AnnCools4,FilipStruyf2

  Moderateevidence=scapular-focusedtreatmentcomparedtootherphysiotherapeu2ctreatmentiseffec2vetoimprovescapularmusclestrengthinpar2cipantswithsubacromialimpingementsyndrome.

  Conflic2ngevidencewasfoundforimprovementsinpain,func2onandclinicalmeasuresofscapularposi2oning.

  Noevidencewasfoundforimprovementsinshoulderrangeofmo2on,rotatorcuffmusclestrengthandqualityoflife.

RESULTS?

Scapularassessmentanditsplaceinclinicalreasoninginpa2entswithshoulderpain

Whyshouldweassessscapularmovement?Howcanweassessscapularmovement?Whenshouldweassessscapularmovement?Howdoesthisfitwithinclinicalreasoning?

Howcanweassessscapularmovement?

Factorsthatinfluencescapularposi2oning

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VisualobservaFonofscapularposiFoning

McClure et al., 2009; Tate et al. 2009; Struyf, et al., 2009; Huang et al. 2015

a)NormalmoFon:noevidenceofabnormalityb)Subtleabnormality:mildorques2onableevidenceofabnormality,notconsistentlypresent

c)Obviousabnormality:striking,clearlyapparentabnormality,evidentonatleast3/5trials

Ra2ngscaleofMclureetal.JAT2009

Loadingdependsonbodyweight:<68kg=>1.4kgload>68kg=>2.3kg

Tate et al. 2009

  Shoulderprotrac2on(Baylorsquare/acromion-tabledistance)

  Pectoralisminormusclelength  Scapularupwardrota2on  Scapularasymmetry

Clinicalmeasurements

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Acromion–tabledistance

(Acromion-table distance (cm)/ BL (cm))*100 Reliable ! (ICC’s > 0.88)

(Nijs et al., 2005; Struyf et al. 2009)

  Baylorsquaremethod  Proc.spinosaC7=>Anteriorcorneracromion  Reliable&valid(Petersonetal.,1997)

AlternaFvemethodinstanding?

Pectoralisminormusclelength

Inferomedialaspectofproc.corracoidèinferolateralaspectofcostosternaljunc2onofthe4thrib

Struyf et al., 2014

Pectoralisminorindex

PMI=

PectoralisMinorlength(cm)/BL(cm))x100

Reliable(intrarater)Valid?(Yestocadavericstudies)Caliper!!

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ScapularupwardrotaFon

Gravity or digital inclinometers At rest, 45°, 90°, 135° & endrange Reliable (intra) Valid (digital)

(Watson et al., 2005; Johnson et al. 2001)

Scapularasymmetry

Distance medial border scapula => proc. Spin. Th4 or Th3 Reliable & Valid

(Peterson et al. 1997, Nijs et al. 2005)

  “scapulardistance”  DistanceangulusacromialistoTh3  Dividedbythelengthofthespinascapulae  Reliable

Scapularasymmetry

Scapularasymmetry

Lateral scapular slide test

(Koslow et al. 2003; Nijs et al. 2005)

Observa2onalevalua2onsystemsandassessmentofscapularupwardrota2onseemsuitablyevidence-basedforclinicaluse.Donotuseitasaphysicalexamina2ontestfordiagnosingpathologiesoftheshoulder.Asymmetryisok!

Insummary

Larsen et al. 2015; Wright et al. 2013; Morais et al. 2013

Whenshouldweassessscapularmovement?

IsthescapularelatedtothepaFents’shoulderpain?

IsthescapularelatedtothepaFents’shoulderpain?

ScapularAssistanceTest(SAT)ModifiedScapularAssistanceTest(mSAT)

ScapularRetrac2onTest(SRT)ScapularReposi2oningTest(SRT)

ScapularAssistanceTest

ScapularAssistanceTest(m)SAT

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reliable

(Seitz et al. 2012; Rabin et al., 2006)

ScapularreposiFoningtest

  reposi2oningtest(SRT)

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reliable Reduces pain and increase strength

(Tate et al., 2008)

Howdoesthisfitwithinclinicalreasoning?

Atthispoint…

  Clinicianscanusereliable(andvalid)clinicaltestsfortheassessmentofbothsta2canddynamicscapularposi2oninginpa2entswithshoulderpain.

  Nocausalassocia2onwithshoulderpainproven

  Benefitofsymptomaltera2ontests

Scapulardyskinesis≠diagnosis

  isaclearexampleofanassessmentstrategythatemphasizesthesearchfordysfunc2ons

Scapulardyskinesis

  prognosesofshoulderpainisnega2velyalteredbymorethenmovementimpairmentorpainseverityalone.

Clinicalreasoning:factoranalysisof…PsychosocialNeurophysiological

  LifestyleMovementrelatedimpairments

DONOTPATHOLOGIZEYOURPATIENTPROFILEYOURPATIENT

WhatabouttheSICKscapulasyndrome?

Scapularmalposi2onInferiormedialborderprominenceCoracoidpainKinesisabnormaili2esofthescapula

Shouldweuseanalgorithm?

  easytofollow  andhavetheinten2ontoeliminateunconsciousmistakes

  excellentwaytostructureandvisualizeclinicalreasoningprocesses

Shouldweuseanalgorithm?

  “easytofollow”=rela2velysimple  Ashoulderpainpa2ents≠simple  itwouldbeeasiertousereasontosolvetheproblem.

Shouldweuseanalgorithm?

Whatifthepa2ent’sshoulderproblemfallsoutsideofthereasoningofthealgorithm?

=>itwillnotbefixed

Shouldweuseanalgorithm?

Insummary

  useapa2ent-centeredapproach,profilingthepa2ents’psychosocial-,neurophysiological-,andlifestylefactorsandmovementimpairmentsthatinformourclinicaldecision-making.

Stoppathologizing,startprofiling!

THANKS ! Filip.struyf@uantwerp.be

@FilipStruyf