THE PREDICTION OF DISABILITY TO SCAPULAR TRAINING IN PATIENTS WITH SHOULDER IMPINGEMENT SYNDROME

THE PREDICTION OF DISABILITY TO SCAPULAR
TRAINING IN PATIENTS WITH SHOULDER
IMPINGEMENT SYNDROME
Hager T.K. Mohamed *; Enas F. Youssef ** ; A.M.M. Gad ***
and Dina M.A. Al Hamaky ****
* Demonstrator of Physical Therapy for Musculoskeletal Disorder and its Surgery,
Faculty of Physical Therapy, Cairo University.
** Professor and chairman of Physical Therapy for Musculoskeletal Disorders and its
Surgery, Faculty of Physical Therapy, Cairo University.
*** Assistant Professor of Orthopedic Surgery and sports injuries, Faculty of Medicine,
Cairo University.
**** Lecturer of Physical Therapy for Musculoskeletal Disorders and its Surgery,
Faculty of Physical Therapy, Cairo University.
Key Words: scapular training, shoulder impingement syndrome, clinical
prediction rule, SPADI
ABSTRACT
Study design: prospective clinical trial study
Background: People with shoulder impingement syndrome (SIS)
present alterations in the scapular kinematics ‘scapular dyskinesis’ when
compared with asymptomatic individuals. Those patients consistently
report disability, especially during overhead activities, which might
hinder activities of daily living and for some sports movements.
Objectives: To investigate if the disability can predict patient’s response
to scapular training. Methods: Forty-five patients between 18-45 years
old, their mean age (32.56±2.85) years and their mean body mass index
(BMI) (29±6) kg/m², suffering from subacromial impingement syndrome
assessed by Shoulder Pain and Disability Index (SPADI) before and after
exercise program of scapular muscle training (Cools exercises), serratus
anterior strength (supine punch) and scapular stabilization exercises for
one month. Results: The Area under curve (AUC) showed excellent
results with disability percent 0.94(sensitivity 0.956, specificity 0.156).
Conclusion: disability is a predictor of treatment success in patients
suffering from subacromial impingement syndrome treated with scapular
training.
INTRODUCTION
Shoulder impingement syndrome (SIS) is a common complaint for
all aged patients with different activity levels (Moezy et al., 2014). It is
defined as compression and mechanical abrasion of the rotator cuff
structures as they pass under the coracoacromial arch during arm
elevation(Koester et al., 2005). People who are frequently doing
Egypt. J. of Appl. Sci., 36 (5-6) 2021 57-67
repetitive overhead motions related to their professions or athletic
activities are also at risk of SIS (Koester et al., 2005; Brumitt et al.,
2006). Thus, their physical independence and jobs are in danger of being
loosed, that have important socioeconomic implications (Moezy et al.,
2014).
Optimal scapular positioning and scapular control during shoulder
movements may be important for normal shoulder function (Ludewig
and Reynolds, 2009). Alteration in scapular position and movement are
important risk factors for subacromial impingement syndrome (Kibler et
al., 2013Clarsen et al., 2014). Stability of the scapula depends on the
surrounding musculature, so, altered muscle activity in the scapular
muscles and loss of scapular stabilization is commonly believed to be a
crucial factor contributing to shoulder impingement syndrome (Ludewig
and Cook, 2000; Cools et al., 2003).
Most of the exercise protocols emphasise the importance of
scapular training as an essential component of shoulder rehabilitation
(Başkurt et al., 2011; struyf et al., 2013; Moezy et al., 2014; Shah et
al., 2014; Aytar et al., 2015).
Clinical prediction rules (CPRs) are tools planned to improve
decision making in clinical practice, based on a subset of predictor
variables from the history and physical examination(Childs & Cleland,
2006). Up to authors knowledge no study has recognized specific clinical
examination variables that are predictive of which patients with the
condition will respond successfully to scapular training.
METHODS
This study designed as a single arm clinical trial study that was
conducted at outpatient clinic at faculty of physical therapy, Cairo
University, between September 2020 and April 2021 months.
Forty-five patients (male and female) between the age 18 and 45
years old, referred by orthopaedic surgeon as subacromial impingement
syndrome (stage I and II Neer’s classification). The first examiner
checked patient’s eligibility to the study according to the inclusion and
exclusion criteria:
Inclusion criteria: (NEER and Welsh RP., 1977; Lukasiewicz et al.,
1999; Michener et al., 2009; Cook et al., 2013; Consigliere et al.,
2018)
1. Age 18-45 years old patients diagnosed as subacromial
impingement syndrome.
Patients included in this study as if they have at least 3 of the
following 6 criteria:
 Positive "Neer sign": The examiner passively flexes the humerus
with medial rotation to end-range with over pressure. The
58 Egypt. J. of Appl. Sci., 36 (5-6) 2021
patient's facial expression and the reproduction of the pain
confirm the presence of impingement.
 Positive "Hawkins sign": The shoulder is passively placed in
approximately 90 degrees of flexion and is passively internally
rotated to end-range with overpressure, reproducing the patient's
pain.
 Pain with active shoulder elevation in the scapular plane.
 Pain with palpation of the rotator cuff tendons.
 Pain with resisted isometric abduction.
 A history of pain in the superior part of lateral arm.
2. Demonstration of a painful arc of the arm from 60 to 120 of
flexion.
Exclusion criteria: (Saito et al., 2018)
1. Diagnosis of internal shoulder impingement.
2. A history of traumatic onset of shoulder pain.
3. Recent trauma of shoulder.
4. Torn tendons.
5. Ligamentous laxity based on a positive Sulcus and apprehension
tests.
6. Numbness or tingling in the upper extremity.
7. Cervical discogenic problems.
8. Previous shoulder or cervical spine surgery.
9. Systemic illness.
10. Corticosteroid injection on the shoulder within 1 year of the
study.
11. Evidence of central nervous system involvement, or the inability
to comply with treatment.
All patients received explanation of the study objectives and procedures.
If the patients fit in the study criteria, they asked to sign the written
consent form to participate in the study. Also, they informed that the data
collected would be submitted for publication.
Instrumentations and procedures:
Shoulder Pain and Disability Index (SPADI):
It is a self-report questionnaire established to measure the pain and
disability associated with shoulder pathology in people with shoulder
pain of musculoskeletal, neurogenic, or undetermined origin(Roy et al.,
2009).
Test-retest reliability of the SPADI ranges from 0.84 to 0.91, and
the minimal clinically important difference ranges from 8 to 13.2 points
(Roy et al., 2009).
The translated version of SPADI in the Arabic language showed
excellent internal consistency and test–retest reliability and construct
Egypt. J. of Appl. Sci., 36 (5-6) 2021 59
validity based on substantial correlations of Arabic SPADI with other
methods of evaluation (Yahia et al., 2011). The SPADI is recommended
for the evaluation of patients with shoulder dysfunction (Alsanawi et al.,
2015).
Pretest evaluation
Shoulder function was assessed using the Arabic version of Shoulder
Pain and Disability Index (SPADI).
Disability domain of SPADI (physical function, 8 items): each
item scored on a visual analogue scale ranging from 0 to 10, where 0 no
difficulty and 10 so difficult require help (Roy et al., 2009).
Total disability score: ….. / 80 x 100 = %
Total percentage score ranging from 0 to 100, where 0 best and
100 worst (Roy et al., 2009)
a) Posttest evaluation
Final evaluation was assessed after twelve sessions of scapular
training by the second examiner.
Progression of:
 Shoulder disability by SPADI.
Interventions procedures
patients scheduled to join physical therapy three sessions per week
for one month (Saito et al., 2018). Three sets of 10 repetitions for each
exercise were given per session, with a 1-minute rest between sets (De
Mey et al., 2012). Resistance was established by 10 repetition maximum
(RM) testing, these interventions was achieved by the first examiner
(Cools et al., 2007).
1. Scapular muscle training (Cools exercises):
These exercises are successful in restoration of upper trapezius,
middle trapezius and lower trapezius muscle imbalances (Cools et al.,
2007).
a. Forward flexion in side-lying, patient was in side-lying,
shoulder in neutral position; patient performed forward sidelying
position flexion in a horizontal plane to 135°.
b. Side-lying external rotation, patient was in side-lying with the
shoulder in neutral position and the elbow flexed 90°; patient
performed external rotation of the shoulder (with towel between
trunk and elbow to avoid compensatory movements).
c. Horizontal abduction with external rotation, patient was in
prone with the shoulders resting in 90° forward flexion; patient
performed horizontal abduction to horizontal position, with an
60 Egypt. J. of Appl. Sci., 36 (5-6) 2021
additional external rotation of the shoulder at the end of the
movement.
d. Prone extension, patient was in prone with the shoulders resting
in 90° forward flexion; patient performed extension to neutral
position with the shoulder in neutral rotational position.
b. Serratus anterior strength (supine punch):
Supine (serratus anterior) punch done by lying supine on a bench,
while keeping the shoulder at 90° of flexion with the elbow extended
maximally, then protracting the scapula to its ending rang (Escalante et
al., 2020).
1. Scapular stabilization exercises:
Scapular-clock exercise enhanced the scapular motions of elevation,
depression, protraction, and retraction also, enhance joint kinaesthesia and
range of motion. The participant stood at the side of a plinth while putting
his hand on a ball and move it to show 3, 6, 9 or 12 o'clock based on an
imaginary clock he had on his mind. This exercise can performed by
pressing a ball and replacing it on a wall (Moezy et al., 2014).
Data Analysis:
forty-five patients between the age 18 and 45 years old (41 female and4
male), referred by orthopaedic surgeon as subacromial impingement
syndrome (stage I and II Neer’s classification).
First the patients were interviewed, and if they matched with the
inclusion criteria, they were asked to join the study. Then the detailed
history was recorded from the patient included (name, age, sex,
occupation, duration of symptoms, and affected side).
RESULTS:
The results of the demographic data showed that their mean age
was (32.56±2.85) years and their mean body mass index was (BMI)
(29±6) kg/m².
Table (1): Distribution of disability in percent among the
participants and correlation between results of
participants before and after using of the test, as
regarding to.
Variables Mean ±SD Range (Min-Max) P value
Disability in percent ¶0.001
Ƒ0.0001
‡0.001
 Pre 17±10 43(1-44)
 Post 52±20 74(17-92)
¶ Test of Correlation (Pearson’s correlation)
Ƒ T – test
‡ One way anova test
There was highly statistically significant difference between
results of participants pre and post as regarding to disability in percent.
Egypt. J. of Appl. Sci., 36 (5-6) 2021 61
Figure 1: mean of pre and post disability in percent
Table (2): Description of the ROC curve, demonstrating AUC,
Reliability, validity of interfering with this procedure,
and Cut off points.
Cut Off Points
AUC Result Positive if Greater
Than or Equal Toa Sensitivity 1 -
Specificity
Disability
in
percent
0.94 Excellent 30.850 0.956 0.156
AUC = Area under the curve
This table shows that disability Percent:
 Its sensitivity is 0.956
 Its 1-specificity is 0.156
 Positive if greater than or equal Toa is 30.85
 Area under carve is 0.94 ad result is excellent
Figure 2: ROC curve, demonstrating AUC, Reliability, validity of
interfering with this procedure, and Cut off points
62 Egypt. J. of Appl. Sci., 36 (5-6) 2021
DISCUSSION
This study was conducted to investigate if disability can predict
patient’s response to scapular training in patients with subacromial
impingement syndrome.
The results of the present study showed a significant difference
regarding disability in percent pre and post the scapular training test 17±10;
52±20 respectively) (P value < 0.05).
This study indicated that, scapular training is effective in improving
function in patients suffering from subacromial impingement syndrome.
These findings were similar to findings of (Bury et al., 2016; Reijneveld et
al., 2017; Saito et al., 2018), who found that scapular training were
effective in controlling pain, improving disability status and improving the
scapular kinematics in patient with subacromial impingement syndrome.
Other study evaluated the effects of scapular stabilisation exercises
immediately after surgery in patients with subacromial impingement
syndrome, they found reduced pain and improved function after
treatment(Park et al., 2013).
Furthermore, in multiple case series studies, positive effects on
function and clinical measures of scapular positioning were found after a
scapular exercise programme(De Mey et al., 2012; Worsley et al., 2013).
Our results showed that disability percent has an excellent sensitivity
and is a positive predictor of the use of scapular training in patients with
subacromial impingement syndrome if its value is greater than or equal Toa
is 30.85.
Such findings come to an agreement with (Hotta et al., 2018) study
analyzing the effect of scapular training protocol in impingement syndrome
indicated that exercises focused on scapula are beneficial in decreasing
impingement syndrome, there have been significant improvement in
shoulder pain and disability index (P<0.01).
CONCLUSION:
Disability was a predictor of treatment success in patients suffering
from subacromial impingement syndrome treated with scapular training.
RECOMMENDATION:
Future studies are recommended to investigate the effect of other
factors on patient’s outcome following scapular training.
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التنبؤ بالإعاقة لمتدريب الکتفي في المرضى الذين يعانون
من متلازمة اصطدام الکتف
هاجر طارق خاطر محمد * ، إيناس فوزي يوسف ** ، أحمد محمود محمد جاد *** ،
دينا محمد عمي الحماقي****
*معيد العلاج الطبيعي لاضط ا ربات الجهاز العضمي الحرکي وج ا رحتها ، کمية العلاج الطبيعي ، جامعة القاهرة.
**أستاذ ورئيس قسم العلاج الطبيعي لاضط ا ربات الجهاز العضمي الحرکي وج ا رحتها ، کمية العلاج الطبيعي ،
جامعة القاهرة.
***أستاذ مساعد ج ا رحة العظام والإصابات الرياضية ، کمية الطب ، جامعة القاهرة.
****مدرس العلاج الطبيعي لاضط ا ربات الجهاز العضمي الحرکي وج ا رحتها ، کمية العلاج الطبيعي ، جامعة
القاهرة.
نبذة مختصرة
تصميم الد ا رسة: د ا رسة التجارب السريرية المستقبمية
يظهرون تغي ا رت في الحرکة (SIS) الخمفية: الأشخاص المصابون بمتلازمة اصطدام الکتف
الکتفية "خمل الحرکة الکتفي" عند مقارنتها مع الأف ا رد الذين لا يعانون من أع ا رض. يبمغ هؤلاء
66 Egypt. J. of Appl. Sci., 36 (5-6) 2021
المرضى باستم ا رر عن إعاقتهم ، خاصة أثناء الأنشطة العموية ، والتي قد تعيق أنشطة الحياة
اليومية وبعض الحرکات الرياضية. الهدف: لمعرفة ما إذا کانت الإعاقة يمکن أن تتنبأ باستجابة
45 عامًا ، - المريض لمتدريب الکتفي. الطريقة: خمسة وأربعون مريضًا تت ا روح أعمارهم بين 11
(BMI) (29 ± 2.15 ( عامًا ومؤشر کتمة الجسم المتوسط ( 6 ± ومتوسط أعمارهم ) 32.56
کجم / م 2 ، يعانون من متلازمة الاصطدام تحت الأخرم التي تم تقييمها بواسطة آلام الکتف و
، ) Cools قبل وبعد ممارسة برنامج تدريب عضلات الکتف )تمارين (SPADI) مؤشر الإعاقة
وتمارين القوة الأمامية المسننة )لکمة الاستمقاء( وتمارين التثبيت الکتفي لمدة شهر واحد.
0 )حساسية .. نتائج ممتازة مع نسبة إعاقة 4 (AUC) النتائج: أظهرت المنطقة تحت المنحنى
0 ، خصوصية 0.156 (. الخلاصة: کانت الإعاقة مؤش ا ر عمى نجاح العلاج في ..56
المرضى الذين يعانون من متلازمة الاصطدام تحت الأخرمي الذين عولجوا بتدريب کتفي.
SPADI ، الکممات الدالة: تدريب کتفي ، متلازمة انحشار الکتف ، قاعدة التنبؤ السريري
Egypt. J. of Appl. Sci., 36 (5-6) 2021 67