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Long-term status following arthroscopic scapulothoracic debridement surgery : reliability of measures… Plotnikoff, Nadine Annalisa 2002

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LONG-TERM STATUS FOLLOWING ARTHROSCOPIC SCAPULOTHORACIC DEBRIDEMENT SURGERY: RELIABILITY OF MEASURES AND A COMPREHENSIVE ASSESSMENT PROFILE APPLIED TO OPERATED AND HEALTHY SUBJECTS by NADINE ANNALISA PLOTNTKOFF B. Sc. (PT) The University of British Columbia, 1991 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUHtEMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (School of Rehabilitation Sciences)  We accept thi&thesis as iconformin? to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA December 2001 © Nadine A. Plotnikoff, 2001  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives.  It is understood that copying or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department of  School  <C  r  The University of British Columbia Vancouver, Canada Date  DE-6 (2/88)  ZJas%- /£> ,  fie  h  o  b  !  I  C  -  C  S  .  ABSTRACT Long-term status following unilateral scapulothoracic arthroscopic debridement is not clearfromthe literature as no follow-up profiling specific to this intervention which includes the use of both subjective and objective outcome measures is available. A prospective study was first done with a group of healthy subjects to confirm test-retest reliability of two tests of static scapular position (n-30) and five positions for isometric strength testing of the scapular retractor and protractor muscle groups (n=20). High within-session reliability was calculated for both scapular position tests and four of the five scapular strength test positions. Between-session reliability data, however, was more varied. Subsequently, the Modified DeVita's static scapular position test, one scapular retraction and two scapular protraction strength test positions were chosen for the comparative study. A comprehensive assessment profile was then performed on 6 operated.subjects and 6 healthy subjects matched to them, comparing differences between arms in the operated group and between the surgical arms of the operated subjects and the dominant arms of the healthy subjects. The outcome measures utilized were the VAS and DDS pain scales, the DASH questionnaire, isometric scapular retraction and protraction strength testing, the Modified DeVita's Test and isokinetic strength testing of glenohumeral internal and external rotation. At a timeframeof at least one year postoperatively, the operated subjects reported significantly higher levels of pain and dysfunction than the healthy subjects did. Scapular retraction and protraction strength was significantly less in the affected arms of the operated group compared to their unaffected arms and to the dominant arms of the healthy group. Glenohumeral internal rotation strength was significantly less in the affected arms of the operated group, compared to their affected arms. Reliability data collected with the operated group confirmed high within-session reliability for the DASH questionnaire. It is hoped that the results of this study will lead to an enhanced understanding of the long-term status of individuals following arthroscopic scapulothoracic procedures and will initiate further development of scapular-based outcome measures, such that their use in clinical assessment and research expands.  ii  TABLE OF CONTENTS Abstract  ii  Table of Contents  iii  List of Tables  v  List of Figures  vii  Acknowledgements Introduction Chapter 1 (Literature Review) Scapular Anatomy - Normal & Abnormal Scapular Function - Normal & Abnormal Roles of the Scapula Scapular Motion Scapular Position Scapular Dysfunction & Shoulder Pathology Pathology in the Scapulothoracic Interval Outcomes Research in Orthopaedics Outcome Measures Utilized in the Studies of this Thesis Pain S elf-Perceived Function Scapular Protraction & Retraction Isometric Strength Testing Static Scapular Position Testing Isokinetic strength testing (glenohumeral internal & external rotators)  viii  1 4 5 8 9 10 12 14 15 17 18 18  Main Body Chapter 2 (Reliability Study) Abstract Introduction Purposes & Hypotheses Methods Statistical Analysis Results Discussion  21 23 25 25 32 33 39  Chapter 3 (Comparative Study) Abstract Introduction Purposes & Hypotheses Methods  50 52 54 55  iii  Statistical Analysis Results Discussion  62 63 69  Chapter 4 Conclusions and Future Works  80  Chapter 5 Reference List  83  Visual Analog Pain Scale Descriptor Differential Pain Scale DASH Questionnaire Scapular Isometric Retraction & Protraction Strength Testing Static Scapular Position Tests Glenohumeral Isokinetic Internal and External Rotation Strength Testing Raw data - Reliability Study Raw data - Comparative Study  92 93 95 99 102  Appendices A. B. C. D. E. F. G. H.  103 104 112  iv  LIST OF TABLES Chapter 1 (Literature Review) Table 1:  Scapular Motion and Contributing Muscles  6  Chapter 2 (Reliability Study) A.  B.  Static Scapular Position Testing  Table 2:  Demographic Data  33  Table 3:  Descriptive Statistics  33  Table 4:  Reliability Data  34  Hand-Held Dynamometry Testing for Isometric Scapular Retraction and Protraction Strength  Table 5:  Demographic Data  35  Table 6:  Descriptive Statistics for Scapular Retraction  35  Table 7:  Descriptive Statistics for Scapular Protraction  36  Table 8:  Within Session Reliability Data Using Intraclass Correlation Coefficients  37  Table 9: C.  DASH  Between-Session Reliability Data Using Pearson Product Moment Correlation Coefficients 38  Questionnaire  Table 10:  Demographic Data  38  Table 11:  Descriptive Statistics and Reliability Data  39  Chapter 3 (Comparative Study) Table 12: A.  Demographic Data  63  Data Concerning the Comparison of the Surgical and Non-Surgical Arms in the Group of Operated Subjects  Table 13:  Descriptive Data  64  v  Table 14:  Statistical Analysis  65  Data Concerning the Comparison of the Surgical Arm of the Group of Operated Subjects to the Dominant Arm of the Group of Healthy Subjects  Table 15:  Descriptive Data - Subjective Outcome Measures  66  Table 16:  Descriptive Data - Objective Outcome Measures  66  Table 17:  Statistical Analysis - Subjective Outcome Measures  68  Table 18:  Statistical Analysis - Objective Outcome Measures  68  vi  LIST OF FIGURES Chapter 1 (Literature Review) Figure 1:  Bones of the Upper Limb Showing Attachments of Muscles (Anterior View) .  Figure 2:  Bones of the Upper Limb Showing Attachments of Muscles (Posterior View)  Figure 3:  Force Couples of Muscles Acting to Produce Scapular Upward Rotation  vii  ACKNOWLEDGEMENTS I would like to sincerely thank my supervisor, Dr. Donna Maclntyre, for her encouragement, patience and flexibility throughout my graduate studies. Her constructive criticism and sharing of her knowledge has contributed to a very beneficial learning experience for me. As well, I would like to thank the other members of my committee, Dr. Bill Regan and Dr. Don Mckenzie, for their interest in my work and for their professional insights. Thanks are due to my fellow graduate students, the faculty of the School of Rehabilitation Sciences and the staff at the GF Strong Rehabilitation Research Laboratory. I have very much appreciated their eagerness to provide input and to offer me technical help whenever it was needed. Lastly, I would like to thank my family and friends for providing motivation and support over the past four years.  viii  CHAPTER  1  Introduction and Literature Review SCAPULAR ANATOMY - NORMAL AND ABNORMAL  The scapula is a thin, triangular bone, positioned between the second and seventh ribs when the arm is at rest (79). Reid (72) offered that the scapula could almost be thought of as a sesamoid bone in the parascapular musculature and that underneath these muscles and the scapula "is a shearing plane of loose areolar tissue that facilitates the gliding of this whole unit around the chest wall". The scapula is a site of origin or insertion (Figures 1 & 2) for several muscles connecting the upper limb to the axial skeleton and the humerus to the shoulder girdle. Moore (60) identified three groupings of muscles with scapular attachments. The superficial and deep extrinsic groups attach the upper limb to the trunk via the scapula and are composed of the trapezius and latissimus dorsi muscles superficially, with the levator scapulae, rhomboids (major and minor) and serratus anterior positioned deep to them. The intrinsic group, having attachments on the scapula and the upper limb (but not the trunk), includes the deltoid, supraspinatus, infraspinatus, teres major, teres minor and subscapularis muscles. Not included in Moore's groupings, but also having attachment points on the scapula, are the pectoralis minor and coracobrachialis muscles and the short head portion of the biceps, which all have an attachment point on the coracoid process of the scapula. In addition, the long head portion of the biceps originates from the supraglenoid tubercle of the scapula and the long head portion of the triceps originates from the infraglenoid tubercle of the scapula (2).  1  Fig. 2 Bones of the Upper Limb Showing Attachments of Muscles - Posterior View (2)  2  Ruland and his colleagues (78), in their cadaveric study identified two distinct triangular spaces, obliquely divided by the serratus anterior muscle, in the scapulothoracic interval. They identified the scapulothoracic interval as the space between the anterior surface of the scapula and the ribs. They defined the larger serratus anterior space as a region which contained a well-defined bursa and was bound by the chest wall anteriorly, the serratus anterior muscle posteriorly and the rhomboids medially. The boundaries of the smaller subscapular space were defined as the serratus anterior muscle anteriorly, the subscapularis muscle posteriorly and the axilla laterally. Similarly, in their cadaveric study, Williams and colleagues (100) divided the soft-tissue structures of the scapulothoracic articulation into superficial, intermediate and deep layers and uniquely reported on the consistency of the bursae found in the area. They reported that the superficial layer consisted of the trapezius and latissimus muscles with an inconsistent bursa between the inferior angle of the scapula and the latissimus dorsi. The intermediate layer consisted of the levator scapulae and rhomboid (major and minor) muscles, the spinal accessory nerve and the scapulotrapezial bursa, consistently located between the superomedial scapula and the trapezius muscle which overlies it. Lastly, they defined the deep layer as consisting of the serratus anterior and subscapularis muscles and two bursae, one consistently located between the serratus anterior and the thorax (scapulothoracic bursa) and the other, inconsistently found between the subscapularis and the serratus (the subscapularis bursa). Ruland's group (78) theorized that, although the scapulothoracic bursae do function to decrease friction in the scapulothoracic interval, the serratus anterior and subscapularis muscles provide better protection to the anterior surface of the scapula from the ribs while scapulothoracic motion is occurring than the bursae do. This leaves the superior, medial and inferior borders of the scapula, typically the sites protected more by bursae than by muscle, relatively more vulnerable to the development of scapular pain.  3  SCAPULAR FUNCTION - NORMAL AND ABNORMAL Roles of the Scapula  The scapulothoracic articulation is one of four components of the shoulder complex, which also includes the sternoclavicular, acromioclavicular and glenohumeral joints. These components must work in concert to produce biomechanically correct and efficient motion at the shoulder (20, 42, 62, 66, 74, 82, 98). The shoulder complex, primarily concerned with the ability to place and control the position of the hand in front of the body, requires a stable platform from which glenohumeral and upper limb motion can occur. The position of the scapula is crucial for providing this stable base (20, 42, 62, 66, 74, 82, 98). To quote Kelley (42), "trying to move the humerus without stabilizing scapular muscle function, particularly the trapezius or serratus anterior, is like trying to push against a solid wall while standing on ice". Current clinical thinking reinforces that understanding the dynamic function of the scapula is paramount in understanding movement-based pathology at the shoulder (20, 42, 62, 66, 74, 82, 98). As evidenced by numerous articles found in the recent literature, it would appear that current concepts for rehabilitation of a host of shoulder injuries have shifted towards an increased focus on specific evaluation and corrective treatment of the functional stability mechanisms of the scapulothoracic joint. As such, the roles of the scapula in shoulder function have been discussed in many articles (20, 42, 62, 66, 74, 82, 98). Kibler (43) provided a thorough synopsis of theories regarding scapular function commonly found in the literature and offered that the role of the scapula in overhead sport motion is five-fold. He defined the scapula's first role as being a stable part of the glenohumeral articulation. The scapula, through its glenoid fossa, provides the proximal articular surface of the glenohumeral joint. The maintenance of optimal articulation of the glenoid fossa and the  4  humeral head through upper extremity motion lends mechanical stability to the shoulder and prevents impingement associated with above-shoulder activity. The scapula's second role is retraction and protraction along the thoracic wall, allowing the set-up of the explosive acceleration motion of the throw or serve and the eccentric dissipation of the deceleration forces that occur through the subsequent follow-through phase. Thirdly, the elevation of the acromion, and upward rotation of the scapula, clears the acromion from the rotator cuff, thereby minimizing impingement and coracomacromial arch compression sequelae during above-shoulder arm activity. As detailed previously, the scapula also serves as a base for muscular attachment. In addition to scapulothoracic muscles, the prime movers of the glenohumeral joint (deltoid, biceps and triceps) and the rotator cuff all have attachments to the scapula. Kibler defined the scapula's final role as its link in the delivery of energy and force from the lower legs, hips and trunk to the arm and hand. Significant amounts of the force driving many upper extremity-based activities, such as the baseball pitch, are generated from the larger muscles of the lower quadrant, and he identified the scapula as the platform through which these forces are transferred to the upper extremity. For example, angular velocities of 7,000 degrees per second have been described by Fleisig and colleagues (29) to occur at the shoulder during the acceleration phase of throwing. It is not difficult to imagine that the resultant muscular demands required of the throwing shoulder are high (99).  Scapular  Motion  Specific categories of scapular motion are not consistently named in the literature. Ludewig and colleagues (47), for example, described three planes of scapular motion about three axis. They defined rotation about an axis perpendicular to the scapular plane as upward/downward rotation, rotation about an axis parallel to the scapular spine as  5  anterior/posterior tipping and rotation about a vertical axis as internal/external rotation ("winging"). McCluskey and Bigliani (53), however, described the potential motion of the scapula as being six-fold, with the specific movements and contributing muscle groups summarized in the tables below: Table 1. Scapular motion and contributing muscle groups Scapular movement Contributing muscles Elevation Upper fibres of trapezius, levator scapulae, rhomboids Latissimus dorsi, pectoralis minor, lower fibres of trapezius, Depression serratus anterior Protraction Serratus anterior, pectoralis minor and major Retraction Middle fibres of trapezius, rhomboids Upward Rotation Serratus anterior, trapezius (all components) Downward Rotation Rhomboids, pectoris minor and major, latissimus dorsi Inman and colleagues (39) theorized that the humeral and scapular contributions to full arm elevation were approximately 120 and 60 degrees, respectively. Another important contribution of their work was their theory that, after an initial setting phase, during arm elevation a constant relationship of two degrees of glenohumeral movement occurred for every degree of scapular rotation (39). As the ability to study the scapula in three-dimensional forms and in dynamic and functional, rather than strictly cardinal, planes of motion progresses, it seems that this early view of scapulohumeral rhythymn may have been too simplistic. For example, McQuade and Smidt's work (57), using electromagnetic tracking technology, has suggested that, depending on the phase of elevation and the external load on the arm, the scapulohumeral rhythymn changes to ratios as high as 1:7 and 1:9. A second study by McQuade and colleagues (56) has offered that scapulohumeral rhythym is altered when fatigue of the shoulder leads to increased scapular motion during arm elevation. The position of the scapula's instantaneous center of rotation (ICR) has been discussed in several studies. Poppen and Walker (70) proposed that the scapula rotates about its lower  6  midportion during the first 60 degrees of arm elevation, with its ICR progressively shifting towards the glenoid fossa as arm elevation progresses. Dvir and Berme (26) viewed that, during the first 100 degrees of arm abduction, the scapula's rotation occurs about an axis extending from the sternoclavicular joint to the root of the scapular spine. With further arm abduction, the acromioclavicular joint becomes the ICR for the remaining scapular rotation. As early as 1944, Inman (39) theorized that the scapular rotatory force couple is established by one muscular force, ocurring via the trapezius muscle, pulling medially in the area of the acromial process and another force, predominantly provided by the serratus anterior, pulling anterolateral^ from the inferior angle of the scapula, together achieving the scapular upward rotation necessary for arm elevation to occur. Inman's work remains the basis of comparison for many further electromyographic studies attempting to detail the muscular contributions of the scapulothoracic muscles more specifically (3, 47, 93). These studies have verified the activity of all portions of the trapezius, levator scapulae, rhomboids and serratus anterior during arm elevation, but there is no firm agreement yet as to each muscle group's relative contribution, with respect to timing and muscle force, to arm elevation. Although a tempting outcome measure, the use of electromyography at the scapular area, however, is to date still marred by unresolved investigative issues such as EMG crosstalk, the lack of standard electrode placement and systems and differences in instrumentation and methods (personal communication, Dr. J. Eng), contributing to the ongoing challenges posed in quantifying scapular motion.  From a clinical perspective, many currently regard the force couple occurring between the trapezius and serratus anterior muscles during arm elevation as similar to that illustrated by Schenkman and Rugo de Cartaya's (80) (Figure 3), where the upper trapezius is most active during the early stages of scapular rotation and the lower portion  7  of trapezius becoming the more important couple to serratus anterior during the later stages of scapular upward rotation.  Fig. 3 Force Couples of Muscles Acting to Produce Scapular Upward Rotation Scapular  Position  Static scapular position has been the subject of a number of studies (22, 31, 63, 69, 86, 91). Keeping in mind the challenges of accurately landmarking the scapula for palpation, clinicians (72, 79) have theorized the scapula to be positioned between the 2 and 7th nd  thoracic vertebrae, and at a distance of approximately two centimetres from the midline (79). Discussions of abnormal positioning in patient populations are often based on variances from this clinical norm. Several methods for measuring static scapular position, focussing on bilateral differences and deviations from the "norm", are offered in the literature (22, 31, 63, 69, 86, 91), but few studies have examined scapular positioning beyond the rest position, and, if so, have focussed on cardinal planes of motion (31, 91). Plafcan and his group (69) offered a method for testing medial winging and anterior tipping, but the study utilized equipment developed specifically for the purposes of that project and not currently available for use. When taking into account test-retest reliability information, it seems that the scapular position tests most often tested are still within the less complex two-dimensional format (superior/inferior position and degree of scapular abduction).  8  Scapular Dysfunction & Shoulder Pathology  Variances from clinical norms for scapular function (ie. position and strength) have been linked anecdotally with shoulder pathology. Clinically, decreased scapular upward rotation and increased anterior scapular tipping is theorized to decrease subacromial space and potentially contribute to impingement (20, 24, 42, 43, 48, 62, 74, 82, 96, 98). In addition, Kibler (43) proposed that increased antetilt (or internal rotation/winging) of the glenoid during the throwing motion leads to increased stress on the anterior glenohumeral structures, with potential sequelae such as glenoid labral tears and/or anterior capsular instability. The shoulder complex maintains a delicate balance between mobility and stability and, as such, is an area particularly prone to injuries manifesting from impingement and overuse stresses on dynamic tissues and failure of the static restraints at the joint. The active and passive contributors to glenohumeral joint stabilization function together to maintain optimal humeral head position in the glenoid fossa and, thereby, maintain healthy glenohumeral joint mechanics at all ranges of upper extremity movement. When high velocity, resistance and/or prolonged overhead positioning are combined with the known challenges of repetitive shoulder activity, these joint stabilization mechanisms are challenged even further to prevent the faulty mechanics that will lead to abnormal loads on soft-tissue structures (20, 24, 42, 43, 48, 62, 74, 82, 96, 98). In the research literature, several studies have attempted to prove the relationship between pathology and scapular dysfunction. Culham and Peat (20) determined changes in scapular orientation at rest with both increasing age and changing spinal posture in healthy females. Poppen & Walker (70) proposed the existence of abnormal scapulohumeral ratios to be associated with disease, but concluded that the presence of normal such ratios did not rule out the development of disease. Ozaki (65) demonstrated a significant decrease in scapular upward rotation values during humeral elevation in patients with involuntary inferior and multidirectional instability, as compared with healthy subjects.  9  PATHOLOGY IN THE SCAPULOTHORACIC INTERVAL Several authors (17, 27, 59, 68) reported that the development of the knowledge of pathology in the scapulothoracic interval began with Boinet, who, in 1867, defined "Snapping Scapula Syndrome" as a crepitation caused by movement of the scapula on the thorax posteriorly. Milch (59) later described the syndrome as a "tactile-acoustic phenomenon, occurring as a consequence of some anomolous condition existing between the thoracic wall and the undersurface of the scapula. Several examples of relevant osseous or osteocartilaginous lesions were noted in the literature (17, 27, 59, 68, 88). Osteochondromas, typically benign, isolated in their nature and protruding from the anterior aspect of the scapula or the posterior thorax, were described to often be "mushroom-shaped" in nature and, if large enough, could act to force the scapula and posterior thorax apart, resulting in a "pseudo-winging". Luschka's tubercle, located at the superomedial angle of the scapula when present, was an example of such an osteochondroma. Excessive length and forward curvature at the superior angle of the scapula, malunion of scapular or rib fractures and the presence of a Sprengel's deformity were also noted as potential causes of scapular snapping. After examining 700 scapular dry bone specimens, Edelson (27) reported that in 8.5% of the specimens, the supraspinatus portion of the scapula was bent inward at an angle of greater than 35° from the vertical border and in 6% of specimens, this "abnormality" was augmented by the presence of a tubercle of Luschka. He also identified that in 22% of the specimens examined, a "rhinocerus-horn" like projection, near the attachment area of the teres major muscle, was present at the inferior lateral border of the scapula, with this peak abnormally raised and angled sharply inward in 1% of cases. Carlson, Haig and Stewart's review (17), based on radiographic findings of eighty-nine reported cases, identified skeletal abnormalities among 43% and idiopathic causes among 30% of the patients reviewed (17).  10  In affected individuals, the abnormal mechanics encouraged by these boney lesions could result in a loss of the normal smooth gliding scapulothoracic mechanism and the development of subsequent pain and snapping in the periscapular area. Some theories, however, are found in the literature offering that an overuse-type of etiology, resulting from repetitive motion of the scapula on the thorax, could lead to an irritation of the scapulothoracic soft-tissues, over time resulting in their scarring and fibrosis. Specifically, Bateman (5) theorized that altered muscle function, and a resultant altered scapulohumeral rhythym, can, over time, cause minute periosteal tears at the medial scapular border and subsequent formation of an irritating traction epiphysis. Strizak (88) specifically implicated the levator scapula muscle in this scenario. Involvement of the bursae of the scapulothoracic interval is noted by several authors (17, 59, 61, 68, 78, 84, 100). The reason for the development of painful symptoms does not appear to be clear. Percy's group (68) found specific precipitating activities in 10 of their 14 patients, with the other 4 patients reporting symptoms of idiopathic origin. Patient demographics are varied. The duration and age of onset of symptoms is variable. Two studies (17, 68) have indicated some bias towards females developing the syndrome, with individuals in the 20-30 year old age range being most prevalent for both genders. From the literature, it would appear that diagnosis can be prolonged and management varies. Milch (59) advocated a partial scapulectomy, or removal of the superomedial angle of the scapula, when the crepitus and pain were local to this area. Carlson's group (17) reported that skeletal abnormalities were most successfully treated with a surgical approach but in disorders associated with a soft tissue cause, surgical or conservative treatment could be effective. Although Harper's group (33) reported that an indication for surgery with "snapping scapula" was a case that was resistant to all conservative therapies, in general, both conservative and surgical management are discussed in the literature with no clear guidelines as to when each option should be pursued.  11  Some literature was available regarding surgical intervention in cases of retroscapular soft-tissue involvement. Sisto and Jobe (84) wrote a case report of successful postoperative outcomes following excision of thickened subscapular bursae in four professional baseball pitchers with debilitating scapular pain. Conservative management had not been successful with these athletes. McCluskey & Bigliani (54) reported that 88% of patients reported satisfactory results after bursal excision alone. Much of the information presented in the literature on this condition is in case report format. Little information is provided on formal long-term evaluation and subsequent prognosis. Although his study reported immediate full symptomatic relief in those patients who had undergone surgery, Carlson's group (17) reported that, of the cases followed one year after surgery, 55% had relief of their symptoms. Follow-up profiling appears to have consisted of subjective outcome measures only. There is no literature available on testing of physical-based objective outcome measures following this surgical intervention. OUTCOMES RESEARCH IN ORTHOPAEDICS Concepts of outcomes research in orthopaedic medicine are described well in recent articles by Keller and his colleagues (41) and by Swiontkowski (90). The emergence of these concepts has been stimulated by factors such as the increasing costs of health care, identified variations in health care professional practice patterns and observed deficiencies in research methods available to clinicians (41). From the perspective of health care flinders, monetary gains can potentially be realized by knowing more about when procedures are likely or unlikely to benefit the health of the patient. An enhanced ability to establish accurate and comparable databases on outcomes of health care procedures should allow for more objective choices to be offered, on the part of health care professionals, to individual patients. Ultimately, better information on health care options should facilitate more-informed patient participation in their own care. (41)  12  Outcomes research can encompass several different modes of gathering information, with prospective clinical trials being one option (41). Traditionally, outcome data has looked at such measures as laboratory findings, radiographic information and measurement of joint range of motion but Swiontowski (90) offered that patient-derived information has been found to generally reveal more notable levels of functional disability than information derived solely from more traditional measures. Subsequently, he advocated that outcome assessment data was best generated from a combination of patient-derived functional measures, measures of patient satisfaction and relevant traditional outcome measures. According to Beaton and Richards (6), outcomes research should encourage the measurement of all possible effects of a disease or intervention. Studies employing assessment profiles relevant to the shoulder complex (19, 45, 75), are available in the literature, yet the specific process one should follow in choosing the most relevant outcome measures is not clear from these studies. In perusing these studies, it would appear that the developers of these assessment profiles have applied a clinical judgement of what outcome measures are most applicable, at times, in combination with choosing measures with established validity and reliability, to achieve their resulting assessment profile. Several studies have used scales and questionnaires developed specifically for the study in question and there is a mix of subjective outcome measures only and combined subjective/objective outcome measure profiles illustrated in the literature. The five outcome measures chosen for this study represented subjective pain and function, isometric scapular protraction and retraction strength, static scapular position and isokinetic rotator cuff strength. The combination of these subjective and objective outcome measures was felt by the study examiners to represent a comprehensive profile of shoulder girdle function and, uniquely, to include two outcome measures relevant to the scapula.  13  OUTCOME MEASURES UTILIZED IN THE STUDIES OF THIS THESIS A. Pain  Two scales were used to assess components of pain in this study. The Visual Analog Pain scale is a self-report scale measuring the intensity or magnitude of the subjects' pain along a continuous scale, the extreme limits of that scale representing no pain and the worst ever pain ever experienced (18). The scale consists of an unmarked vertical or horizontal line, usually 100 mm in length. Bearing in mind the extreme limits of the scale at either end of that 100 mm line, the subject completes the test by placing a mark, corresponding to their current intensity of pain, on the line. The VAS is scored by measuring the number of millimetres from the "no pain" end of the scale to the subjects' reported pain level. The VAS can be used as a comparative scale, measuring the intensity of pain over points in time, or can be used as an absolute scale, measuring the subjects' pain severity at a specific point in time. It was used as an absolute scale in this study. (18) Test-retest reliability has been reported at 0.99 (83). The VAS is a commonly used unidimensional instrument, measuring a single dimension (intensity) of pain only. Although the advantages of undimensional instruments include their relative clarity and simplicity, it is advised that additional scales relating to various other aspects of pain be used in combination with a unidimensional pain scale to offset it's limitations. (36) Accordingly, the Descriptor Differential Pain Scale was chosen. The DDS is a two-page scale, comprised of two parts examining subjective responses regarding the intensity of, and emotional responses to their current pain. There are twelve descriptors for each part, with each descriptor also being ranked along a linear scale that has 21 points scored from  14  0 to 20. Each descriptor is scored, all 12 descriptors are summed, and the average of the scores of the 12 descriptors is the final quantitative value. Prior published research demonstrated Pearson product-moment correlation scores ranging between 0.82-0.84 for the sensory intensity portion of the scale and between 0.78 -0.83 for the unpleasantness portion of the DDS when assessed for test-retest reliability (32). No reliability-related research was found specific to shoulder girdle pathology for the DDS. B. Self-Perceived  Function  The potential for impairment on an individual's ability to function, be that physically, socially or emotionally, exists with all acute and chronic conditions (41). As such, in the rehabilitation literature, several questionnaires allowing for individuals to self-assess their physical function have emerged, with a focus on distinguishing impairment, defined as a demonstrable anatomical loss or damage, from disability, defined as the functional limitation that may result from such an impairment (37, 49, 52). Several authors have addressed the relevant benefits of using generic health questionnaires, designed to be used across any patient group, versus the use of joint or disease-specific questionnaires in self-perceived functional assessment. Gartsman's group (30) demonstrated that subjects with a variety of shoulder conditions scored significantly below general population norms when using the SF-36 Health Survey, a commonly cited general health status evaluation designed to measure the impact of a disease on an individual's perception of his or her health. Matsen and his colleagues (52) studied 103 subjects with primary glenohumeral joint degenerative disease and demonstrated that this group scored significantly lower on both the SF-36 Survey and a shoulder-specific questionnaire than a population-based control group did. The results of Beaton and Richard's study (7) demonstrated that shoulder-specific questionnaires were more sensitive to change in subjects with shoulder pain than the SF-36 general health questionnaire was.  15  The DASH (Disabilities of the Arm, Shoulder and Hand) scale was chosen to assess the subjects' self-perceived current upper extremity functional status in this study. The DASH, developed recently through a collaborative effort between the Institute for Work & Health and the American Academy of Orthopaedic Surgeons, was designed to measure disability and symptoms in a heterogeneous population, including both genders and individuals with varying upper extremity demands and upper extremity disorders (37). Via a 3 page format, the DASH asks the subjects to rank a variety of tasks subjectively on a numerical scale representing a range of functional ability, from "no difficulty" to "inability" to perform. Specifically, the DASH asks the client to respond on their current ability to perform 30 tasks. A raw total score is transformed to yield a score out of 100, which is then placed on a linear scale of zero (indicating good function) to one hundred (indicating severe upper-limb disability). The index also asks subjects to respond to questions regarding any current symptom severity and any degree of social and activities of daily living limitations. In addition to the 30-item DASH questionnaire, there are two optional four-item modules designed to measure the impact of an upper extremity dysfunction on playing a musical instrument or sport, or on working. Michener and Leggin's recent study (58) reviewed 11 shoulder self-report scales, including the DASH, commonly used for practicability and methodological soundness, excluding 21 scales without established measurement properties prior to their review. They critiqued these 11 scales for the methodological properties of reliability, validity, responsiveness and the practical aspects of time for completion and scoring of the scale, ease of administration, usefulness and comprehensiveness of the scale. Their results demonstrated that all of the scales, including the DASH, met the minimal criteria they set for use, although not all equally. Their results did not offer an opinion on the "best" scale for use. Their study did not include disease-specific scales.  16  Some reliability work specific to the DASH is available in the literature. In two studies utilizing subjects with elbow pathology, intra-class correlation coefficients greater than 0.9 were calculated, indicating excellent test-retest reliability (49, 92). Although no reliability studies were found specific to the use of the DASH in subjects with scapular pathology, Beaton's group (8) demonstrated excellent test-retest reliability in a study including subjects with shoulder problems. Their study demonstrated that the DASH, designed for use with patients with any diagnosis involving the upper extremity, was both valid and responsive in proximal (shoulder) and distal (wrist) disorders of the upper extremity. Their results also showed higher responsiveness to the DASH than to a shoulder-specific scale in a group of patients with shoulder dysfunctions. From this, one can feel confident that the DASH is appropriate for use in individuals with scapularbased dysfunction. C. Scapular protraction and retraction isometric strength testing  The hand-held dynamometer offers a method for testing isometric strength at the scapula. Zmierski and colleagues (101), using a NICHOLAS hand-held dynamometer as was used in this study, measured scapular adduction strength in a position similar to our position #2 and showed high correlation coefficients (0.96-0.98) when three maximal test repetitions, using a "make" style of contraction, were calculated for each subject both prior to and after undertaking a six-week strengthening program. Among other findings, Marshall and Kramer's study (51) on the isometric strength of the scapular retractor and protractor muscles of healthy females examined test-retest reliability of the HHD for three test positions of scapular protraction and retraction, meant to mimic the entry, mid and exit portions of the freestyle swim stroke. Specific to scapular retraction, these positions are similar to those recommended by Daniels and Worthingham (21) for manual muscle testing of the middle and lower fibres of trapezius and rhomboid muscle groups. In Marshall & Kramer's study (51), the positions chosen for measurement of scapular protraction are unique to their work.  Reliability coefficient findings of three repetitions on two occasions ranged between 0.77 and 0.92 for scapular protraction and 0.80 to 0.92 for scapular retraction (25).  17  D. Scapular position testing  Several methods for measuring static scapular position, addressing components such as horizontal/vertical scapular position and degrees of scapular anterior tipping, are offered in the literature (22, 31, 63, 69, 86, 91). DeVita's test and Kibler's lateral slide tests, both simple and practical methods of quantifying scapular abduction, are most commonly quoted and, accordingly, the most reliability work is found regarding these two tests (22, 31,63,91). DeVita's test assesses scapular position by measuring the distancefromthe inferior angle of the acromion to the spinous process of the third thoracic vertebra. The subject stands in a relaxed position with their arms by their sides. The tester typically uses a piece of unmarked string to measure the scapular abduction distance (22). Kibler's lateral slide tests measure the distancefromthe inferior angle of the scapula to the nearest thoracic spinous process. This distance, using an unmarked piece of string for measurement, is taken with the subject's test arm in three different positions. These positions are: the arm relaxed at the side, the subject's hand on the hip with the web space between the thumb and second finger placed on the iliac crest, and with the arm abducted to 90 degrees (31, 91). In the literature, reliability work on DeVita's and Kibler's tests demonstrated varying results. For both tests, intratester reliability has been documented with intraclass correlation coefficient scores between 0.81 and 0.94. Intertester reliability has been demonstrated to have a much wider range of ICC scores, varyingfrom0.18 to 0.90. All studies quoted advocate the need for further reliability work, and for measurement in pathological situations (10, 13, 45).  E. Isokinetic strength testing of the glenohumeral internal and external rotators  The scapula, as described earlier, when maintaining a position of rotation corresponding optimally to the degree of humeral elevation, helps ensure optimal length-tension  18  relationships of the rotator cuff muscle group (9, 21, 30, 49). It was of interest to this study's examiners to note whether there would be a significant difference in rotator cuff strength in the post-surgical group with known prior scapular pathology compared to their unaffected side, and to the dominant side of the control subjects. Isokinetic dynamometry has, in more recent years, provided a tool for quantifying muscle performance. The large interest in knee evaluation and rehabilitation, however, and its relative suitability to isokinetic testing contributed to little isokinetic dynamometry testing of the shoulder complex prior to the 1980's (25). A number of research studies reporting shoulder strength norms and imbalances among various subject populations and recommending test protocols have since utilized isokinetic testing as part of their investigation (18, 34, 40, 47, 73, 76, 77, 81, 94, 95, 99). Little to no reference, however, was made in these articles to the reliability of the chosen test protocols and, in fact, there are few articles in the literature pertaining to reliability of isokinetic testing at the shoulder complex. One article pertaining to test-retest reliability of isokinetic shoulder flexion, extension and adduction strength testing (67) and two articles pertaining to test-retest reliability of shoulder external rotation strength testing, using isokinetic dynamometers, have been found. Kuhlman and colleagues (46) demonstrated high reliability for repeat testing of isokinetic shoulder external rotation while Kramer and Ng (44) demonstrated high reliability for repeat isometric testing of shoulder external rotation while using both handheld and isokinetic dynamometers. The differences in the test methodologies used in testing the shoulder are notable, mostly in areas of positioning, test velocities and modes of contraction. Lack of standardization makes interpretation of these results, development of normative data and any further comparative work difficult. Pilot reliability work in this area was performed by the study examiner in a previous directed study format. Utilizing a test position preset to the Kin-Corn isokinetic dynamometer, 15 subjects completed three test sessions each, measuring three repetitions  19  each of maximal concentric and eccentric internal and external rotation on each shoulder. These subjects were healthy, with no history of shoulder trauma and no recent history of overuse symptoms. These subjects represented individuals (n=10) with minimal regular upper-extremity exercise and individuals (n=5) who swam for a total of <3000m per week. The test position chosen placed the shoulder at approximately 50 degrees of abduction and 30 degrees of flexion (see Appendix F), avoiding positions that could potentially provoke symptoms of glenohumeral instability and/or impingement. During each test repetition, subjects were verbally encouraged by the study examiner to give maximal effort (ie. "push and/or pull as hard as you can"). High intra-class correlation coefficient scores, rangingfrom0.855 to 0.955, were demonstrated for all tests, indicating that this specific protocol was reliable.  20  CHAPTER  2  Test-Retest Reliability of Static Scapular Position Testing, Hand-Held Dynamometry for Scapular Protraction and Retraction Strength Testing and the DASH functional questionnaire ABSTRACT Study Design: Prospective test-retest reliability study. Objectives: To test reliability of the "Disabilities of the Arm, Shoulder and Hand" questionnaire (DASH), a modified DeVita's Test for static scapular position, one of three Kibler's static scapular position tests and isometric testing of scapular protraction and retraction using a hand-held dynamometer. Background: Although studies related to test-retest reliability for each of the above outcome measures are found in the literature, establishing further reliability was felt to be required by the study examiners prior to the use of these outcome measures in a future comparative study. Methods and Measures: Thirty healthy subjects attended for two sessions, where two measures each of the Modified DeVita's and Kibler's static scapular position tests were taken on their dominant arms. During these two test sessions, twenty of the healthy subjects participated in the scapular isometric strength testing portion of the study, where maximal isometric strength, using a hand-held dynamometer, was tested for three positions of scapular retraction and two positions of scapular protraction. Three test repetitions were taken for each position, using the subjects' dominant arms only. Seven subjects with previous known scapular pathology completed the DASH questionnaire at the beginning and end of a comprehensive assessment session. Results: High within-session test-retest reliability was confirmed for both tests of static scapular position, four of five positions of scapular isometric strength testing and for the DASH functional questionnaire. Good between-session test-retest reliability was confirmed for the Modified DeVita's test, while poor test-retest reliability was calculated  21  between sessions for the Kibler's test. Results varied between the five scapular strength test positions with respect to between-session test-retest reliability. Conclusions:  The results indicate that, when using either of the static scapular position  tests measured in this study, clinicians should measure one repetition of a position test as a representation of the individual's score. Based on our data, when choosing a test to use with individuals, our recommendation is to use the Modified DeVita's, rather than the Kibler's, Test. With respect to isometric scapular strength testing, our recommended test position for scapular retraction is Position #2, where the test arm is placed at 90° of glenohumeral abduction while, for protraction, we recommend that clinicians choose one of our two positions based on their own comfort and ease. One practice and one test repetition should be measured for each position. More work is recommended to establish higher between-session reliability for measures of scapular isometric strength. The results of this study also support that the DASH questionnaire can be used as a reliable outcome measure with individuals with shoulder dysfunction.  22  INTRODUCTION Domholdt (23) defined a reliable measure as one in which the "error component is small, thus allowing consistent estimation of the true quantity of interest." In establishing a group of outcome measures which would, in combination, represent a comprehensive assessment profile of subjective and objective measures relevant to the shoulder girdle, the specific purpose of this study was to establish further test-retest reliability for those measures where further reliability work would be considered relevant. Several methods for measuring static scapular position, addressing components such as horizontal/vertical scapular position and degrees of scapular anterior tipping, are offered in the literature (22, 31, 63, 69, 86, 91). DeVita's test (22, 31, 63, 91) and Kibler's lateral slide tests (31,91), both simple and practical methods of quantifying scapular abduction, are most commonly quoted with some reliability work regarding these two tests already available in the literature. For both tests, high intratester reliability has been documented with intraclass correlation coefficient scores ranging between 0.81 and 0.94 (22, 31, 63, 91), while intertester reliability has been less consistent, with ICC scores varying from 0.18 to 0.90 (31, 91). All studies quoted advocated the need for further reliability work, and for measurement in pathological situations. While Gibson's group (31) reported relative difficulty in using the inferior angle of the scapula as a landmark for position testing reported due to its arc-like shape, as is done in Kibler's series of tests, T'Jonck and Lysen 's results (91) demonstrated that the inferior angle could be used reliably as a reference point in measurement. By modifying the traditional DeVita's test to one in which the inferior angle of the scapula is used as the distal landmark, this study allowed the opportunity to assess and compare the reliability of two positions, both using this same point as their distal landmark.  Portability and ease of application have made hand-held dynamometers (HHD) attractive for measuring strength in clinical and research settings. Although only three studies (22, 51, 101) were found in the literature pertaining to the use of hand-held dynamometry around the scapula, the hand-held dynamometer has been shown to be a valid and reliable  23  indicator of muscle strength when used to test other muscle groups, both upper (1, 11, 12, 13, 15, 44, 46, 64, 89) and lower extremity (11, 12, 14, 15, 35) based in nature. Marshall and Kramer's study (51) on the isometric strength of the scapular retractor and protractor muscles of healthy females was the most comprehensive study of the three relevant scapular studies found in the literature. The authors examined test-retest reliability of the HHD for three test positions of scapular protraction and retraction, using positions which correlated with the entry, mid and exit portions of the freestyle swim stroke. In their study, the positions chosen for measurement of scapular protraction were unique to their work while the scapular retraction test positions resembled positions recommended in the literature for manual muscle testing of the trapezius and rhomboid muscle groups (21). While Marshall & Kramer (51) found that reliability coefficient findings of three repetitions oh two occasions ranged between 0.77 and 0.92 for scapular protraction and 0.80 to 0.92 for scapular retraction, demonstrating high test-retest reliability, they recommended that further work be pursued on the development of reliable test protocols and on the analysis of strength/function relationships. The DASH is a recently developed questionnaire scale, four pages in length, which can be used to assess an individual's self-perceived upper extremity functional status. The DASH was developed through a collaborative effort between the Institute for Work & Health and the American Academy of Orthopaedic Surgeons and was designed to measure disability and symptoms in a heterogeneous population, including both genders and individuals with varying upper extremity demands and upper extremity disorders (37). Some preliminary work is available in the literature, thus far showing the DASH to be a reliable, valid and responsive tool for measuring upper-limb disability (8, 49, 58, 92) however, the need for further reliability testing, particularly with individuals with pathology at the shoulder complex, was felt to be appropriate by this study's examiners prior to its use in a future comparative study. Once confidence in the test-retest reliability of these three outcome measures could be obtained, this assessment profile would be applied in a further study comparing healthy  24  individuals and individuals who had undergone a unilateral arthroscopic scapulothoracic debridement procedure. PURPOSE & HYPOTHESES  The purposes of this study were to: •  test reliability of a modified DeVita's Test and reliability of one of three Kibler's static scapular position tests  •  test reliability of hand-held dynamometry maximal isometric testing of scapular protraction and retraction  •  test reliability of the DASH functional scale  METHODS Setting:  Test sessions took place at the Rehabilitation Research Laboratory of the G.F. Strong Rehabilitation Centre, Vancouver, BC Subjects:  Thirty healthy volunteers participated in the static scapular position testing portion of this study. This group was made up of 19 female and 11 male subjects, with an average age of 30 years of age (range = 20-40 years of age). An average of 8.8 days occurred between test sessions with this group. Twenty of the thirty healthy volunteers participated in the scapular isometric strength testing portion of this reliability study. This group was made up of 12 female and 8 male subjects, also with an average age of 30 years of age (range =20-38 years of age). An average of 9.2 days occurred between test sessions with this group. Subjects who had a history of, on either shoulder, overuse-based shoulder pain in the past six months or who had had a prior glenohumeral dislocation, Grade 2+ acromioclavicular seperation, Grade 2+ rotator cuff strain or a long thoracic nerve palsy were excluded from  25  participation in the static scapular position and isometric scapular strength testing portions of this study. Seven subjects who had an arthroscopic scapulothoracic debridement procedure performed on one side at least one year prior to their test session participated in the portion of this study pertaining to the reliability of the DASH questionnaire. Subjects not proficient enough in the English language to be able to read and/or understand the DASH functional scale were also excluded from participation. This group was made up of 4 female and 3 male subjects, with an average age of 38 years of age (range =25-58 years of age). Healthy subjects were recruited through advertising in the campus newspaper and ads placed around campus. Operated subjects were recruited via direct contact, using contact information maintained at the orthopaedic surgeon's office. Prior to participation in this study, subjects signed an informed consent form. Ethics approval was granted by the University of British Columbia Ethics Committee prior to beginning this study.  Instruments:  A Nicholas Manual Muscle Tester Dynamometer (Lafayette Instruments) was used for this study. Calibration of this unit was performed in January 2000 by the manufacturer. Permission to use the DASH in this study was obtained from the Institute for Work and Health. Research Design:  Prospective test-retest reliability study.  Protocol:  Subjects participating in the reliability testing of the static scapular position testing and the hand-held dynamometry components attended for two test sessions. The test sessions  26  fulfilled the requirements for data collection for this reliability study and for the control group information of the further comparative study. Test sessions proceeded in the following sequence: 1.  Visual Analog Pain Scale and body diagram (performed on the first test session only as reliability had already been established)  2.  Descriptor Differential Pain Scale (performed on the first test session only as reliability had already been established)  3.  DASH functional scale (performed on the first test session only as test scores were seen to be near zero with most of the healthy subjects, making a test-retest reliability analysis difficult)  4.  Scapular position testing (completed on both test sessions)  5.  Scapular isometric strength testing (completed on both test sessions)  6.  KinCom isokinetic strength testing of glenohumeral internal and external rotation (completed on the first test session only as reliability had already been established)  Operated subjects participating in the reliability testing of the DASH functional scale attended for one test session, also done in the same sequence as detailed above. These subjects, however, also completed the Visual Analog and Descriptor Diffferential Pain Scales and the DASH functional scale at the end of their test session, allowing for comparison of pre and post-test session scores with these outcome measures. All assessment and measurement of outcomes was done by the study examiner, a physiotherapist with ten years of clinical experience. The examiner was not blinded to the results of the first session when doing the second sessions's assessment. A. Static scapular position testing DeVita's test assesses scapular position, or specific scapular abduction distance, by measuring the distance from the inferior angle of the acromion to the spinous process of the third thoracic vertebra. Kibler's three lateral slide tests measure the distance from the inferior angle of the scapula to the nearest thoracic spinous process with the subject's test  27  arm in three different positions (the arm relaxed at the side, the subject's hand on the hip with the web space between the thumb and second finger placed on the iliac crest, and the arm abducted to 90 degrees). In this study, a modified DeVita's test and one position of Kibler's lateral slide test, that with the subject's test arm positioned at 90 degrees of abduction, were assessed for intratester test-retest reliability. Two measures were taken on the dominant arm for each of the two tests. Subjects stood with their arms relaxed by their sides for 30 seconds before the Modified DeVita's test was performed. The subject's third thoracic spinous process was identified and marked with ink. Using an unmarked piece of string, the examiner measured the distance from this spinous process to the inferior angle of the subject's scapula, rather than to the inferior angle of the acromion as measured with the traditional DeVita's test. The examiner marked the string accordingly and immediately repeated the process. The subjects then stood with their test arms at 90 degrees of glenohumeral abduction, corresponding to Position Three of Kibler's test sequence. The spinous process nearest to the inferior angle of the scapula was marked with ink. Using an unmarked piece of string, the examiner measured the distance from the spinous process identified to the inferior angle of the subject's scapula. The string was marked accordingly and the process immediately repeated. B. Hand-held dynamometry (HHP) for isometric scapular retraction and protraction strength testing Reliability work for the scapular isometric strength testing was done for three positions of scapular retraction and two positions of scapular protraction. A "make" style of strength testing, where the examiner holds the dynamometer stationary while the subject exerts a maximal force against it, was used throughout the study.  28  1. Scapular retraction Subjects were positioned in prone lying on a standard treatment plinth. Glenohumeral positions were verified using a goniometer. After 10 subjects were tested with their nontest arm by their side, it was noted that their thoracic spines appeared better stabilized when their non-test arms were placed overhead instead. The next 20 subjects, accordingly, were then tested with their non-test arms placed overhead. In all cases, the subjects' heads were turned towards the test side during test repetitions. Two velcro straps were applied at the levels of T9 and S2, approximately, to limit compensatory movements of the pelvis and thorax. Maximal isometric scapular retraction was tested at three glenohumeral positions. The resistance pad of the HHD was positioned over the superior-lateral corner of the infraspinous fossa, inferior and medial to the acromion. This placement was similar to Daniels and Worthingham's (21) recommended hand placement position for manual muscle testing of scapular strength. Subjects were instructed to bring their shoulder blade towards their spine against the HHD held by the tester and were verbally encouraged (ie."pull back as hard as you can") to provide their maximal effort during each test repetition. The test protocol, modeled after Marshall and Kramer's study (51) with healthy female subjects, asked the subjects to practice two submaximal and one maximal practice contraction against the HHD. Three maximal test contractions, each three to five seconds in duration, then followed, with a 30 second rest interval between repetitions. The first position, taken from Marshall and Kramer's study (51), placed the test arm at 140 degrees of shoulder abduction, corresponding to the position commonly described and utilized by clinicians for manual muscle testing of the upper fibres of the trapezius muscle (21).  29  Position two placed the subject's shoulder at 90 degrees of abduction, corresponding to the position commonly described for manual muscle testing of the middle fibers of the trapezius muscle (21). The third position placed the shoulder at 40 degrees of abduction and 45 degrees of extension. This position demonstrated the highest degree of test-retest reliability in Marshall and Kramer's study (51) and, if modified slightly to rest the hand of the subject's test arm on their lumbar spine, would resemble the manual muscle test position commonly used by clinicians for testing the rhomboid muscle group (21). For all three positions, the subjects' shoulders were placed in line with the frontal plane of their body, ensuring that testing was done with the scapula in a position very close to full inner range retraction. Peak force (kg) was determined for each repetition. The average force of the three test contractions was also calculated for each position. 2. Scapular protraction For the first test position, subjects were positioned in prone lying. As in the third position described above for scapular retraction, the subject's shoulder was placed at 40 degrees of abduction and 45 degrees of extension. The subjects' shoulders were placed in line with the frontal plane of their body, as this posture allowed for relative ease in reproducing the start position with each test repetition. Their non-test arms were placed overhead, as with the positioning described above for scapular retraction, and the subjects' heads were turned towards their test arms. The resistance pad of the HHD was placed near the mid-point of the lateral border of the scapula to measure scapular protraction. The subjects were instructed to push their shoulder blade towards the floor. This position was chosen for further measurement in this study because it demonstrated the highest test-retest reliability of the scapular protraction positions used in Marshall and Kramer's study (51).  30  The second test position, developed specifically for this study by the examiner, approximated the position recommended by Daniels and Worthingham (21) for manual muscle testing of serratus anterior. Subjects were positioned in a supine lying position on the treatment plinth. Trunk stabilization was as described earlier for scapular retraction. Subjects' non-test arms were placed by their sides, inside the velcro trunk straps. Their test arms were positioned at 90 degrees of forward flexion and the resistance pad of the HHD was placed at the mid-point of the axillary border of the scapula. To determine the start posture for this test position, subjects were instructed to push their shoulder blade as far as possible towards the ceiling (inner range scapular protraction) and then drop back slightly from that position. Subjects were relied upon to achieve this start position as closely as possible for each repetition. For testing purposes, subjects were instructed to push their shoulder blade towards the ceiling against the HHD held by the tester. Although no studies using this position are available in the literature, this position resembles that commonly used by clinicians in assessing scapular protraction strength (21) and was, therefore, felt to be a relevant inclusion in this study. The protraction test protocol, also modeled after Marshall and Kramar's study (51) with healthy female subjects, asked the subjects to practice two submaximal and one maximal practice contraction against the HHD. Three maximal test contractions, of three to five seconds in duration each, then followed, with a 30 second rest interval between repetitions. Subjects were verbally encouraged by the tester to provide their maximal effort during each test repetition. Peak force (kg) was determined for each repetition. The average force of the three test contractions was also calculated for each position. C. DASH Functional Scale The DASH Functional Scale involves three component modules spanning a four page format. Component A, the mandatory portion of the scale, asks all subjects to subjectively rank their ability to perform each of 30 different tasks on a numerical scale representing a range of functional ability, from "1" (no difficulty) to "5" (inability) to  31  perform. The index also asks subjects to respond, using a similar numerical scale, to questions about current symptom severity and any degree of social and activities of daily living limitations. For scoring purposes, a raw total score is transformed to yield a score out of 100, which is then placed on a linear scale of zero (indicating good function) to one hundred (indicating severe upper-limb disability). Two optional four-item modules designed to measure the impact of an upper extremity dysfunction on playing a musical instrument or sport (Component B), or on working (Component C) follow Component A. The raw scores for Components B and C are also transformed to yield a score out of 100, with higher scores, again, indicating greater disability. Seven operated subjects completed the DASH functional scale at the beginning and end of their test session, done as part of a comparative study. STATISTICAL ANALYSIS  For the static scapular position testing portion of this study, means and standard deviations of the average distances measured over two repetitions were calculated for both test sessions for two position tests. Data were analyzed using a Pearson product moment correlation coefficient to determine the reliability across both test sessions and between sessions for both scapular position tests of the subjects' dominant shoulders. For the hand-held dynamometry testing, means and standard deviations of the average torque over three repetitions were calculated for both test sessions for all five test positions. Data were analyzed using an intraclass correlation coefficient (ICC) to determine the reliability within both test sessions for all test positions of scapular retraction and protraction of the subjects' dominant shoulders. To determine reliability between sessions, a Pearson product moment correlation coefficient was calculated. For the DASH portion of this study, data were analyzed using a Pearson product moment correlation coefficient to determine the reliability between test scores.  32  For the purpose of this study, all correlation coefficients were classified according to Blesh's scale (10), which is as follows: <0.69, poor correlation; 0.70 - 0.79, fair correlation; 0.80 - 0.89, good correlation; and 0.90 - 1.00, high correlation. RESULTS A. Static Scapular Position Testing - Healthy Group (n=30) Table 2. Demographic Data Gender Hand Dominance  19 female subjects 26 right-hand dominant  Age (years of age) Height (metres) Weight (kilograms) Body Mass Index (kg/m)  11 male subjects 4 left-hand dominant  Average  Range  29.96 1.73 70.17 23.17  20-40 1.56-1.88 51 - 108 17.99-31.22  Table 2 details the demographic data of the subjects (healthy group) who participated in the static scapular position testing reliability portion of this study. Table 3. Descriptive Statistics Test  Mean (cm)  Standard Deviation  Range (cm)  16.05 15.93 15.99 16.57 16.53 16.55  3.01 2.85 2.92. 2.76 3.00 2.86  13-27 12-27 12-27 13-26 13-28 13-27  11.56 11.78 11.67 11.11 10.95 11.03  2.56 2.63 2.56 2.27 2.40 2.28  7-19 8-19 8-19 8-18 7-18 8-18  ModifiedDeVita's Test  Session 1 - Measure 1 Session 1 - Measure 2 Session 1 - Average Measure Session 2 - Measure 1 Session 2 - Measure 2 Session 2 - Average Measure Kibler's Test  Session 1 - Measure 1 Session 1 - Measure 2 Session 1 - Average Measure Session 2 - Measure 1 Session 2 - Measure 2 Session 2 - Average Measure  33  Table 3 illustrates the mean distance (cm), standard deviation and range of distances calculated for each of 2 measures and for the average measure for both the Modified DeVita's and Kibler's static scapular position tests during each of 2 test sessions. T-tests calculated indicated no significant differences existed between Measures 1 & 2 of each Test Session, between corresponding measures (ie. Measure 1 in Sessions 1 & 2) and between the Average Measure of Sessions 1 & 2 for both the Modified Devita's and Kibler's tests (p = 0.1 - 0.48). Table 4. Reliability Data Using Pearson Product Moment Correlation Coefficients (r) Test  Pearson Product Moment Correlation Coefficient (r)  Modified DeVita's Within-session test-retest reliability  Session 1 - Measure 1 vs. Session 1 - Measure 2 Session 2 - Measure 1 vs. Session 2 - Measure 2 Between-session  0.981 0.973  test-retest reliability  Session 1 - Measure 1 vs. Session 2 - Measure 1 Session 1 - Measure 2 vs. Session 2 - Measure 2 Session 1 - Average vs. Session 2 - Average  0.837 0.831 0.840  Kibler's Within-session test-retest reliability  Session 1 - Measure 1 vs. Session 1 - Measure 2 Session 2 - Measure 1 vs. Session 2 - Measure 2  0.958 0.907  Between-session test-retest reliability  Session 1 - Measure 1 vs. Session 2 - Measure 1 Session 1 - Measure 2 vs. Session 2 - Measure 2 Session 1 - Average vs. Session 2 - Average  0.611 0.699 0.675  Table 4 details the reliability data obtained with respect to the static scapular position testing portion of this study. Reliability was calculated between each of the 2 test measures of each test session, between the corresponding measures of Sessions 1 & 2 (ie. Measure #1 in both sessions) and between the average measures of the two sessions for both the Modified DeVita's and Kibler's tests. The data demonstrates that high withinsession and good between-session test-retest reliability has been obtained for the Modified DeVita's Test. For the Kibler's test, high test-retest reliability was obtained  34  within both test sessions, but poor reliability was demonstrated between sessions for each of the two measures and for their average scores. B. Hand-Held Dynamometry (HHD) for Isometric Scapular Retraction and Protraction Strength Testing - Healthy Group (n=20) Table 5. Demographic Data Gender Hand Dominance  12 female subjects 17 right-hand dominant  8 male subjects 3 left-hand dominant  Average Age (years of age) Height (metres) Weight (kilograms) Body Mass Index (kg/m)  Range  30.1 1.73 72.15 23.82  20-38 1.56-1.88 52-108 19.81 - 31.22  Table 5 details the demographic data of the subjects (healthy group) who participated in the scapular isometric strength testing reliability portion of this study. Table 6. Descriptive Statistics - Scapular Retraction Testing Test RETRACTION #1 Session 1 - Measure 1 Session 1 - Measure 2 Session 1 - Measure 3 Session 1 - Average Session Session Session Session  2222-  Measure 1 Measure 2 Measure 3 Average  RETRACTION #2 Session 1 - Measure 1 Session 1 - Measure 2 Session 1 - Measure 3 Session 1 - Average Session 2 - Measure 1 Session 2 - Measure 2  Mean (kg)  Standard Deviation  Range (kg)  4.85 5.12 5.14 5.03 5.20 5.18 5.14 5.17  0.95 1.04 1.09 1.00 1.13 1.08 1.08 1.05  4-7 4-7 4-8 4-7 3-8 3-8 3-8 4-8  4.79 4.89 5.03 4.90 4.91 4.98  1.18 1.14 1.18 1.15 1.24 1.12  4-8 3-8 4-8 4-8 3-8 3-7  35  Session  2 - Measure  Session  2-  3  Average  RETRACTION #3 Session 1 - Measure 1 Session 1 - Measure 2 Session 1 - Measure 3 Session 1 - Average Session  2 - Measure  Session  2 — Measure  2  Session 2 — Measure  3  1  Session 2 — Average  5.08 5.00  1.30 1.19  3-8 3-8  4.83 4.85 4.96 4.88 4.79 4.83 4.99 4.85  1.02 1.26 1.39 1.21 0.93 1.02 1.12 1.01  3-7 3-8 3-10 3-8 3-7 3-7 3-8 3-7  Table 6 illustrates the mean force for each of 3 measures and for the average force of the measures generated during each test session in the 3 scapular retraction strength test positions. For Retraction positions #1 and #2, the data indicates a trend towards an increased mean force with each measure, however, t-tests indicated no significant difference between sessions (p = 0.16 - 0.5). Table 7. Descriptive Statistics - Scapular Protraction Testing Test PROTRACTION #1 Session 1 - Measure 1 Session 1 - Measure 2 Session 1 - Measure 3 Session 1 - Average Session  2 - Measure  1  Session 2 - Measure  2  Session 2 — Measure  3  Session 2 -  Average  PROTRACTION #2 Session 1 - Measure 1 Session 1 - Measure 2 Session 1 - Measure 3 Session 1 - Average Session 2 - Measure  1  Session 2 — Measure  2  Session  3  2 - Measure  Session 2 -  Average  Mean (kg)  Standard Deviation  Range (kg)  5.87 5.61 5.64 5.71 6.02 6.01 6.07 6.03  1.21 1.06 1.15 1.09 0.91 0.97 1.18 0.93  4-9 4-9 4-8 4-9 4 -8 4-8 4-8 4-8  4.98 5.07 5.08 5.04 4.85 5.12 5.21 5.05  1.34 1.21 1.41 1.30 1.08 1.21 1.14 1.11  3-8 3-8 3-9 3-8 3-7 3-8 3-7 3-7  36  Table 7 illustrates the mean force for each of 3 measures and for the average force of the measures generated during each test session in the 2 scapular protraction strength test positions. With the exception of the first measure of Protraction position #2, the data indicates a trend towards an increased mean force with each measure, however, t-tests indicated no significant difference between sessions (p = 0.16 - 0.5).  Table 8. Within-Session Reliability Data Using Intraclass Correlation Coefficients Test Retraction #1 - Session 1 (Measures 1, 2, and 3) Retraction #1 - Session 2 (Measures 1, 2, and 3)  Intraclass Correlation Coefficient (ICC) 0.867 0.900  Retraction #2 - Session 1 (Measures 1, 2, and 3) Retraction #2 - Session 2 (Measures 1, 2, and 3)  0.952 0.905  Retraction #3 - Session 1 (Measures 1, 2, and 3) Retraction #3 - Session 2 (Measures 1, 2, and 3)  0.922 0.910  Protraction #1 - Session 1 (Measures 1, 2, and 3) Protraction #1 - Session 2 (Measures 1, 2, and 3)  0.911 0.852  Protraction #2 - Session 1 (Measures 1, 2, and 3) Protraction #2 - Session 2 (Measures 1, 2, and 3)  0.971 0.960  Using Intraclass Correlation Coefficients (ICC's), Table 8 details within-session reliability for the scapular isometric strength testing and demonstrates good to high testretest reliability within both test sessions for all five scapular strength tests. The high reliability demonstrated within Sessions 1 & 2 indicated the lack of a practice effect. The results did not change significantly as the subjects' experience with the test protocol increased, meaning that a one-time test, performed using the specific protocol (including a practice component to familiarize the client with the hand-held dynamometer), would provide an accurate representation of the subject's ability. The high reliability within the two test sessions also negated the possibility of a fatigue effect.  37  Table 9. Between-Session Reliability Data Using Pearson Product Moment Correlation Coefficients Test Position  Retraction #1 Retraction #2 Retraction #3 Protraction #1 Protraction #2  Correlation (r) between corresponding repetitions of test sessions 1 & 2 Rep. 1 - Rep. 1 Rep. 2 - Rep. 2 Rep. 3 - Rep. 3 Avge. - Avge. 0.72 0.69 0.74 0.75 0.86 0.66 0.76 0.79 0.72 0.75 0.78 0.79 0.46 0.64 0.58 0.66 0.57 0.75 0.64 0.68  Table 9 details the between-session reliability data obtained for scapular isometric strength testing using a NICHOLAS hand-held dynamometer. Reliability was calculated between the corresponding test repetitions in each session (eg. Repetition 1 in the first and second test sessions) and between the averages for each position. With respect to test-retest reliability between sessions, the results are varied between the five scapular strength test positions. For three of the five test positions (Retraction #1 and #3 and Protraction #2), the highest between-session reliability was demonstrated when comparing the average scores from each session. For Retraction position #2, comparing the first repetition between sessions yielded the best reliability while comparing the second repetition for Protraction #2 proved the most reliable. C. DASH Questionnaire - Operated Group (n=7) Table 10. Demographic Data Gender Hand Dominance  4 female subjects 6 right-hand dominant  3 male subjects 1 left-hand dominant  Average  Range  Age (years of age) Height (metres) Weight (kilograms) Body Mass Index (kg/m)  38.43 25-58 1.68 1.56-1.83 .70.71 . 55.5-90 25.01 •22.05-30.67 Table 10 details the demographic data of the subjects (operated group) who participated in the DASH functional scale reliability portion of this study.  38  Table 11. Descriptive Statistics and Reliability Data  Average Standard Deviation Range (Pre) Range (Post) Correlation  DASH A (n=7) Pre Post 32.54 33.24 16.2 16.3 10.3-61.7 5.2-60 0.97  DASH B (n=6) Pre Post 50.02 56.27 31.9 34.5 37.5-87.5 43.8-100 0.95  DASH C (n=7) Pre Post 36.61 40.19 25.6 29.1 12.5-75 12.5-87.5 0.99  Table 11 illustrates the average scores of each the three components of the DASH functional scale, taken at the start and end of the operated subjects' test sessions, the standard deviation and range of those scores and the correlation between the start and end-session scores for each component of the DASH scale. Components B & C of the DASH scale are optional modules and, as such, one subject chose not to complete Component B of the scale. For all 3 components of the scale, average scores were higher when taken after the test session compared to when calculated at the beginning of the session, indicating a higher degree of self-perceived dysfunction. Using t-test calculations, however, significant differences were not found between the average pre and post-session scores for each component of the DASH. Using a Pearson Product Moment Correlation, high test-retest reliability was demonstrated for all 3 components of the DASH functional scale. DISCUSSION According to the categories suggested by Blesh (10), high (above 0.9) within-session testretest reliability was confirmed for both tests of static scapular position, four of five positions of scapular isometric strength testing using a NICHOLAS hand-held dynamometer, and for the DASH functional scale. Good (0.8 - 0.9) between-session testretest reliability was confirmed for the Modified DeVita's static scapular position test, while poor (<0.7) test-retest reliability was calculated between sessions for the Kibler's Test. With respect to test-retest reliability between sessions for the hand-held dynamometry tests, the results varied between the five scapular strength test positions. Using Blesh's  39  classification scale (10) for the highest Pearson Product Moment correlation coefficient calculated for each of the five scapular strength test positions, good reliability was obtained for Retraction position #2, fair correlation was obtained for Retraction positions #1 and #3 and for Protraction position #2 and poor correlation was obtained for Protraction position #1. For three of the five test positions (Retraction #1 and #3 and Protraction #2), the highest between-session reliability was demonstrated when comparing the average scores from each session. For Retraction position #2, comparing the first repetition between sessions yielded the best reliability while comparing the second repetition for Protraction #2 proved the most reliable. Static  Scapular  Position  Testing:  Within-session and between-session reliability was examined in this study for the Modified DeVita's and one of Kibler's series of tests of static scapular position. Five Pearson Product Moment correlation coefficients were determined for each of the two static scapular position tests. These correlation coefficients detailed the correlations between the two test repetitions within each test session, between corresponding test repetitions of Sessions 1 and 2 and between the averages of the two sessions' test scores. The range of coefficients obtained for each position are detailed in Table 4 of the results section. The data demonstrated that high within-session and good between-session testretest reliability was obtained for the Modified DeVita's test. For the Kibler's test, high test-retest reliability was obtained within both test sessions, but considerably lower reliability was demonstrated between the two test sessions for each of the two measures and for their average scores. No other studies were found in the literature specifically commenting on between-session reliability work for these two static scapular position tests, however, several studies are available specific to within session test-retest reliability. High intrarater test-retest reliability has been documented for both the traditional DeVita's test (22, 31, 63, 91) and the full series of Kibler's tests (31 91), with DeVita's testing having slightly higher  40  reliability overall. The high within session test-retest reliability data obtained in this study supported the existing literature.  There is less literature pertaining to interrater reliability and with more varied results. In general intrarater test-retest reliability scores are consistently higher than interrater reliability for both tests, with interrater scores more varied (31, 91). It is unclear from the literature whether interrater reliability is higher with DeVita's or Kibler's testing, as only two studies existed commenting on this, with each study's findings in direct conflict to the other (31, 91).  This study was unique in its use o f the inferior angle o f the scapula as the distal landmark for both o f its scapular position tests (ie. the modification o f the DeVita's position, i n addition to the traditional Kibler landmarking). Gibson's group (31) commented on the relative difficulty o f using the inferior angle o f the scapula consistently as a landmark, due to its "arc-like" and less-definitive shape. The results o f this study demonstrated very high within session test-retest reliability for both tests, suggesting that the static scapular position can be measured reliably when the inferior angle o f the scapula is used as one o f the test landmarks.  The proximal landmarks i n this study were the T3 spinous process for the modified DeVita's test and the nearest spinous process to the inferior angle o f the scapula when the arm was positioned at 90° o f glenohumeral abduction for the Kibler's test. While this spinous process was marked and, therefore, remained consistent within each test session, it is possible that a different spinous process may have been chosen for the subsequent test session for the Kibler's test, depending on the position o f the scapula at the time o f the test. The potential for the Kibler's test proximal landmark to vary for each subject between sessions may explain the lower reliability obtained with between-session testing for the K i b l e r ' s test.  The authors o f two previous studies (31, 91) cautioned on the use o f string to measure scapular abduction distance, due to potential variances i n tension maintained in the string  41  and, therefore, in the length measured for a test. Because our Modified DeVita's test used a relatively more caudal spinous process as its proximal landmark, the scapular abduction distance measured for that test in each subject was always greater than the scapular abduction distance measured for that subject's Kibler's test, meaning that a greater length of string would have to be utilized in performing the Modified DeVita's Test. Interestingly, in our study, the Modifided DeVita's test yielded similarly high, if not higher, reliability data within session compared to the Kibler's test and certainly demonstrated significantly higher between session reliability. The tension of the string, therefore, was likely not a factor in this study. Based on the results of this study, the Modified DeVita's position was used in the comparative study outlined in Chapter 3. Although both positions used in this study demonstrated high within-session test-retest reliability, the examiner noted that identifying the inferior angle of the scapula was consistently easier when the subjects' arms were by their sides, rather than at 90° of glenohumeral abduction, as was required for the Kibler's test position. As the scapula upwardly rotated with arm elevation, its inferior angle appeared to approximate against the thorax and became relatively more difficult to landmark. The inferior angle of the scapula remained relatively prominent when the arm was at the subject's side, as it was during the DeVita's testing procedure. The high correlation coefficients obtained between two measures within each test session indicated that, for both the Modified DeVita's and Kibler's test positions used in this specific protocol, clinicians need only do one test repetition to represent the actual test score. The significantly lower between session reliability obtained, however, when using the Kibler's test in this study leads us to still caution clinicians when using that test. Our recommendation, based on the higher within and between session reliability, would be for clinicians to use the Modified DeVita's Test as described in this study. In the literature, Kibler's complete series of 3 tests is supported by several authors as being clinically relevant as these tests measure scapular distance in 3 varied arm positions, rather than just with the arm by the side (31,91). The discrepancy obtained in  42  our study between intra and inter-session test-retest reliability for this test would indicate that further study is warranted to determine whether higher between session reliability can be obtained for Kibler's test(s). In the meantime, according to our results, the most objective and standardized test of the two was the Modified DeVita's Test. Expanding knowledge and assessment methods of scapular mechanics and position to better reflect the scapula's three-dimensional status is a current focus in the literature and amongst clinicians (3, 4, 26, 47, 48, 56, 57, 93, 96). As research progresses, reliable and clinically applicable assessment methods offering different techniques of determining scapular position may become available. To date, however, techniques reflecting twodimensional analysis of static scapular positioning, such as the two tests used in this study, are the most researched methods available to clinicians. Hand-Held  Dynamometry  Within-session and between-session reliability were examined in this study for five positions of isometric scapular strength testing using a hand-held dynamometer. The Intraclass Correlation Coefficients calculated (detailed in Table 8) demonstrated that good to high test-retest reliability (0.852 - 0.971) was obtained within both test sessions for each of three test positions of scapular retraction and two test positions of scapular protraction. These high correlation coefficients would indicate that, within each test session, fatigue did not affect the subjects' performance over testing and that a practice effect was not evident. The high within-session test-retest reliability obtained for hand-held dynamometry in five scapular strength test positions in this study supported the results of two of the three studies pertaining to reliability of hand-held dynamometry about the scapula found in the literature (22, 101). These two studies reported ICC values ranging from 0.96 to 0.98. Zmierski's group (101), using a NICHOLAS hand-held dynamometer, as was used in this study, measured scapular adduction strength in a position similar to our Retraction position #2 and showed high correlation coefficients (0.96 - 0.98) when three maximal  43  test repetitions, using a "make" style of contraction, were calculated for each subject prior to and after undertaking a six-week strengthening program. Using a similar test position, DiVita's group (22) found an intraclass correlation coefficient of 0.96 when examining intrarater reliability for 2 maximal isometric "make" style contractions during one test session. Pearson Product Moment correlation coefficients, representing between session reliability, were determined for each of the five scapular strength tests. These correlation coefficients detailed the correlations between corresponding test repetitions of Sessions 1 and 2 and between the averages of the two sessions' test scores. The range of coefficients obtained for each position are detailed in Table 9 of the results section. With respect to test-retest reliability between sessions, the results varied between the five scapular strength test positions. For three of the five test positions (Retraction #1 and #3 and Protraction #1), the highest between-session reliability was demonstrated when comparing the average scoresfromeach session. For Retraction position #2, comparing the first repetition between sessions yielded the best reliability while comparing the second repetition for Protraction #2 proved the most reliable. Using Blesh's classification scale (10) for the highest Pearson Product Moment correlation coefficient calculated for each of the five scapular strength test positions, good reliability was obtained for Retraction position #2, fair correlation was obtained for Retraction positions #1 and #3 and for Protraction position #2 and poor correlation was obtained for Protraction position #1. Another study found in the literature, using a different make of hand-held dynamometer, was done by Marshall and Kramer (51). Four of the five test positions used in our study were identical to those used in their study, which examined within-session and betweensession test-retest reliability of isometric scapular protractor and retractor strength in healthy females and the relationship between scapular muscle strength and performance indicators of upper extremity activity levels. Using Blesh's scale of classification (10) for  44  correlation coefficients, Marshall and Kramer's (51) results indicated fair to high correlation coefficients, ranging between 0.77 to 0.92, for their six positions (three of each of scapular protraction and retraction) tested over two test sessions. Interestingly, their results indicated lower correlation coefficients overall, ranging between poor to good (0.62-0.86), for their six positions when measured within one test session compared to scores calculated over two test sessions. Scapular retraction and protraction reliability coefficients appeared similar within their study. The high reliability scores obtained in this study can be attributed to the examiner's adherence to a standardized protocol, in which the subjects were adequately stabilized to prevent substitution of other muscle groups. The placement of the hand-held dynamometer and the subjects' limbs were also standardized with each test repetition. Several factors have been offered in the literature as possibly affecting the reliability of hand-held dynamometry testing. The importance of choosing a consistent test position with adequate stabilization of the subject to avoid additional muscle contributions has been reported in several studies. As Nies and colleagues (64) reported, the stability of the examiner also plays a role in test reliability, as their results showed that both intra and interrater reliability scores were higher when testing was done with the examiner in a stabilized position. In our study, the subjects were placed in standardized test positions with optimal trunk stabilization and, although the examiner's position was not formally standardized, the examiner chose to either lock their arm into full elbow extension or to stabilize their elbow against their waist, as was done in Nies's study, when performing test repetitions. These measures served to provide maximum examiner stability. Examiner strength was likely not an issue in this study, as the magnitudes of the forces obtained did not exceed 9.2 Newtons. Theorizing that the strength of the examiner in a specific test position could affect the reliability of test scores, Wilkholm and Bohannon (97) demonstrated that both intra and intertester reliability decreased as the tested muscle  45  groups increased in force production, and that when test scores exceeded 120 Newtons in magnitude, tester strength affected the reliability of the forces obtained. Along this line, it is theorized that the choice of test population may also affect measurement reliability (97). When measuring the same muscle group, a group of healthy individuals could be more difficult to stabilize than a group of relatively weaker individuals, making reliability more difficult to achieve. This does not appear to have been a factor in this study because, while healthy individuals were used as subjects, the forces obtained in testing did not exceed the magnitude theorized by Wilkholm and Bohannon (97) to challenge tester strength to a level where test reliability would be affected. McMahon and colleagues (55) demonstrated that, in testing the same muscle group, proximal hand-held dynamometry readings yielded higher force readings than sites more distal due to the difference in lever arm distance. Depending on the muscle group tested, as a result, test scores may be more variable when an examiner is required to stabilize a hand-held dynamometer at more proximal sites due to the extra strength required by the examiner. These authors recommended that, when possible, distal placement sites for the hand-held dynamometer be chosen to minimize variance in force measurements. In our study, relatively proximal placement sites were chosen and high test-retest reliability was still obtained. Because applying resistance over the glenohumeral joint or along the humerus when attempting to assess scapular muscle strength may allow for other muscle groups attaching distal to the scapula to contribute to test results, it was decided that test positions in this study would follow the lead of two studies (51,101) where the hand-held placement sites were located directly over the scapula.  A "make" style of strength testing was used in this study. Both "make" and "break" tests can be used when testing muscle strength with several instruments, including the handheld dynamometer. A make test occurs when the examiner holds the dynamometer stationary while the subject exerts a maximal force against it (13). During a break test, however, the examiner overcomes the subject's maximal force, pushing the dynamameter  46  against the subject's limb until the joint gives way (13). It is unclear from the literature whether "make" or "break" styles of testing yield higher reliability. Examining both healthy and patient subjects in two different studies, Bohannon (13) demonstrated that "break" testing yielded significantly higher strength values than "make" testing in the same muscle group, but reliability remained high in all tests. Stratford and Balsor's study (87) confirmed that higher forces were obtained when "break" testing was used as opposed to "make" testing, but showed that, while similar reliability coefficients were obtained when assessing "make" and "break" testing with a Kin-Corn isokinetic dynamometer, higher reliability was obtained with "make" testing than with "break" testing when using the hand-held dynamometer. In this study, a "make" style of testing was used and, for four of the five test positions, measurement was done with the muscle group in almost a fully shortened inner-range position, ensuring that an isometric contraction was achieved, with as little joint motion as possible. These factors also likely contributed to the high reliability scores achieved. Based on the data obtained in this study, Retraction position #2 and both Protraction positions were chosen for further use in a later comparative study. Within-session and between-session reliability coefficients were the highest of the three retraction positions for Retraction position #2. Upon completion of this study, the examiner also noted that, in general, test subjects expressed more ease in understanding how to achieve scapular retraction with Retraction position #2, as compared to the other two retraction positions. As well, during Retraction position #2, the subjects' test arms were placed at 90° of abduction, a start position that was relatively the easiest to reproduce of the three retraction positions. While similarly high within-session test-retest reliability was obtained for both protraction positions, Protraction position #2 demonstrated higher reliability overall. It was noted, however, that subjects were generally evenly divided when asked to choose which protraction position they felt most easily able to understand and achieve. Based on this, and on the fact that reliability testing of Protraction position #2 has not been  47  documented elsewhere in the literature, both protraction positions were chosen for further use in the further comparative study. Hand-held dynamometry provides an easy and reliable method of measuring muscle strength for clinicians. While all 5 test positions in this study demonstrated high withinsession test-retest reliability, Retraction position #2, where the test arm is placed at 90° of glenohumeral abduction, is recommended by this examiner. Clinicians should choose one of the two protraction test positions assessed in this study based on their own comfort levels with the positions after having opportunity to thoroughly practice both. Based on the results of this study, it is recommended to clinicians that they use a practice repetition and one test repetition of one position each of scapular retraction and scapular protraction to provide an objective, and comparable, measure of clients' isometric scapular strength. Several studies in the literature (1, 11, 12-15, 35, 44, 46, 64, 88) have confirmed high intrarater test-retest reliability scores of hand-held dynamometry when assessing strength of several muscle groups of both the upper and lower extremities. The range of reliability coefficient scores when examining interrater reliability is more varied and, in general, indicates a lower level of reliability than does intrarater testing. As good to high withinsession test-retest reliability for scapular retraction has now been calculated in four studies for scapular retraction and three studies for scapular protraction, future work should focus on examining between-session and/or interrater reliability for these muscle actions.  D.A.S.H. Functional Scale  Excellent test-retest reliability was demonstrated in this study for all 3 components of the DASH functional scale. Seven subjects completed the scale at the beginning and end of their test sessions, with Pearson Product Moment correlation scores rangingfrom0.95 0.99. These results confirm the results of three other studies available in the literature, both of which demonstrated similarly high correlation coefficients. The recently published study  48  by Beaton's group (8) examined test-retest reliability in a mixed group of 85 subjects with upper extremity disorders, including some with shoulder injuries, while Turchin's group (92) examined patients with elbow disorders. Similarly, MacDermid's (49) recently published study, using 50 subjects with a variety of elbow pathologies, found an ICC of 0.93 for the main body of the DASH and an ICC of 0.94 for the supplemental portions (n=24). Beaton and colleagues (8) demonstrated excellent test-retest reliability in a study which included subjects with shoulder problems and confirmed that the DASH, which was designed for use with patients with any diagnosis involving the upper extremity, was both valid and responsive in proximal (shoulder) and distal (wrist) disorders of the upper extremity. Their (8) results also showed higher responsiveness to the DASH than to a shoulder-specific scale in a group of patients with shoulder dysfunctions. The available literature supports the use of the DASH as a reliable outcome measure with individuals with shoulder dysfunction. CONCLUSION  The results of this study have provided reliability information supporting the use of three outcome measures, increasing the confidence in the ability of those outcome measures to be considered meaningful and interpretable in clinical and research settings. While the scapula is clinically recognized as an important component in the function of the upper extremity, the ability to scientifically study components of its function remains limited. Although this study examined healthy people, as opposed to those with shoulder injuries, it is hoped that this study contributes to the body of literature regarding scapular function, encourages increased use of and motivates further development of scapular outcome measures in clinical work and research.  49  CHAPTER  3  Long-term Status Following Unilateral Scapulothoracic Arthroscopic Debridement - A Comprehensive Assessment Profile Applied to Operated and Healthy Subjects ABSTRACT  Study Design: Non-experimental analysis of differences between sides and between groups. Objectives: The objectives of this study were three-fold: l.To compare shoulder and scapular strength and scapular position in the affected and unaffected shoulders in a group of subjects who have had a unilateral scapulothoracic arthroscopic debridement (one to five years prior to their test date). 2. To compare shoulder and scapular strength and scapular position of the affected shoulders in the operated group to the dominant shoulder in a group of healthy individuals. 3. To compare self-perceived pain and function in the operated and healthy groups of subjects. Background: Very little information in the literature is available on long-term status after this surgical procedure, with no documentation of the use of objective outcome measures. No outcome research was found where standardized measures specific to the scapula were applied to individuals with previously known scapular pathology. Methods & Measures: Six operated subjects, all at least one-year post-operative, attended for one test session. Their results were matched with the results of six healthy subjects who had undergone the identical test protocol during a previous reliability study. Six outcome measures were utilized in this study. These measures were: Visual Analog and Descriptor Differential Pain Scales, the DASH functional scale, Isometric Scapular Retraction and Protraction strength testing using a hand-held dynamometer, a Modified DeVita's Test of static scapular position and Kin-Corn isokinetic testing of glenohumeral concentric and eccentric internal and external rotation. Results: Significantly increased levels of pain and dysfunction were reported by the operated group. Isometric scapular retraction and protraction were significantly weaker in the affected arms of the operated group compared to their unaffected arms and also  50  significantly weaker when compared to the dominant arms of the healthy group. Isokinetic glenohumeral internal rotation, both concentric and eccentric, was significantly weaker in the affected arms of the operated group, compared to their affected arms. Conclusion:  Individuals having undergone this procedure did not regain the status of  healthy controls at a time frame of at least one year post-operatively.  51  INTRODUCTION This study compared a number of outcome measures relevant to the function of the glenohumeral joint and the scapulothoracic complex in a group of individuals with prior scapulothoracic bursitis and arthroscopic scapulothoracic debridement, to a group of healthy individuals. This study provided an opportunity to examine long-term outcomes, at least one year post-operatively, in a group of post-operative subjects after undergoing a unilateral arthroscopic debridement of offending scapular bursae and soft-tissue. Several authors (17, 27, 59, 68) reported that the development of the knowledge of pathology in the scapulothoracic interval began with Boinet, who, in 1867, defined "Snapping Scapula Syndrome" as a crepitation caused by movement of the scapula on the thorax posteriorly. Milch (59) later differentiated between scapular snapping and scapular crepitus based on the quality and the etiology of sounds caused by osseous and/or softtissue lesions of the scapulothoracic joint. He defined scapular snapping as the sound occuring when an osseous or osteocartilaginous lesion, from either the anterior surface of the scapula or the posterior surface of the thorax, moved against the opposite surface while scapular crepitus differed in its etiology, with inflammation of periscapular bursae and soft-tissue felt to be the cause of the audible and palpable scapular crepitus. Similar in the two syndromes (scapular snapping and scapular crepitus), patients often presented with pain in the periscapular area associated with audible and palpable snapping and/or crepitus as the scapula moved on the thorax. The reason for the development of painful symptoms does not appear to be clear. Percy & colleagues (68) found specific precipitating activities in 10 of his 14 patients, with the other 4 patients reporting symptoms of idiopathic origin. Milch (59) offered that a direct blow to the scapula or indirect trauma, such as a fall on an extended arm could injure soft-tissues in the scapulothoracic interval. Several authors (17, 84) offered that an overuse-type of etiology, resulting from repetitive motion of the scapula on the thorax, could lead to an irritation of these same soft-tissues, over time resulting in their scarring and fibrosis. Bateman (5) theorized that altered muscle function, and a resultant altered scapulohumeral rhythymn, can cause, over time, minute periosteal tears at the medial  52  scapular border and subsequent formation of an irritating traction epiphysis. Strizak & Owen (88) specifically implicates the levator scapula muscle in this scenario. Patient demographics are varied. The duration and age of onset of symptoms is variable. Two studies have indicated some bias towards females developing the syndrome, with individuals in the 20-30 year old age range being most prevalent for both genders (6, 35). From the literature, it would appear that diagnosis can be prolonged and management varies. Milch (59) advocated a partial scapulectomy, or removal of the superomedial angle of the scapula when the crepitus and pain were local to this area (59). Carlson's group (17) reported that skeletal abnormalities are most successfully treated with a surgical approach but in disorders associated with a soft tissue cause, surgical or conservative treatment may be effective. Although Harper and colleagues (33) reported that indication for surgery with "snapping" scapula was a case that was resistant to all conservative therapies, in general, both conservative and surgical management are discussed with no clear guidelines as to when each option should be pursued. Some literature was available regarding surgical intervention in cases of retroscapular soft-tissue ivolvement. Sisto and Jobe (84) wrote a case report of successful postoperative outcomes following excision of thickened subscapular bursae in four professional baseball pitchers with debilitating scapular pain. Conservative management had not been successful with these athletes. McCluskey and Bigliani (54) reported that 88% of patients achieved satisfactory results after bursal excision alone. Much of the information presented in the literature on this condition is in case report format. Little information is provided on formal long-term evaluation and subsequent prognosis. Although his study reported immediate full symptomatic relief in those patients who had undergone surgery, Carlson's group (17) reported that, of the cases followed one year after surgery, 55% had relief of their symptoms. Follow-up profiling appears to have consisted of subjective outcome measures only. There is no literature  53  available on testing of physical-based objective outcome measures following surgical intervention. PURPOSE & HYPOTHESES The purposes of this study were to: •  compare shoulder and scapular strength and scapular position in the affected and unaffected shoulders in a group of subjects who have had a unilateral scapulothoracic arthroscopic debridement (one to five years prior to their test date).  •  compare shoulder and scapular strength and scapular position of the affected shoulders in a group of subjects who have had a unilateral scapulothoracic arthroscopic debridement (one to five years prior to their test date) to the dominant shoulder in a group of healthy individuals.  •  compare pain and function in a group of subjects who have had a unilateral scapulothoracic arthroscopic debridement one to five years prior to their test date to a group of healthy individuals.  Null hypotheses were taken. These hypotheses were: •  There will be no significant differences in current pain levels, as measured by the Visual Analog and Descriptor Differential Pain Scales, between the healthy and operated groups.  •  There will be no significant difference in upper extremity function, as measured by the "DASH" functional scale, between the healthy and operated groups.  •  There will be no significant differences in glenohumeral external and internal rotation isokinetic strength between the operated subjects' unaffected and affected shoulders or between healthy and operated groups.  •  There will be no significant differences in scapular protraction and retraction isometric strength between the operated subjects' unaffected and affected sides or between healthy and operated groups.  •  There will be no significant differences in static scapular position between the healthy subjects' unaffected and affected sides or between the healthy and operated groups.  54  METHODS Setting: S u b j e c t t e s t s e s s i o n s t o o k p l a c e at t h e R e h a b i l i t a t i o n R e s e a r c h L a b o r a t o r y o f t h e G . F . Strong Rehabilitation Centre, Vancouver, B C .  Subjects: A:  Healthy group  A healthy g r o u p , c o m p r i s e d o f 6 subjects, were i n c l u d e d i n this study. F r o m a potential g r o u p o f 3 2 h e a l t h y subjects, these s i x subjects w e r e c h o s e n as the best " m a t c h e s " f o r t h e six operated subjects, a c c o r d i n g to the m a t c h i n g criteria ( i n order o f importance) o f age, gender, a r m d o m i n a n c e a n d b o d y mass i n d e x to the operated subjects.  T h e mean age o f  the g r o u p o f s i x subjects w a s 41 years o f age ( S . D . = 13.6) w i t h a range o f 2 7 to 5 9 years o f age. T h e m e a n B o d y M a s s I n d e x o f the g r o u p w a s 2 5 . 9 ( S . D . = 3 . 4 1 ) w i t h a r a n g e o f scores o f 21.97 -  31.22.  Volunteers were recruited through advertising i n the campus newspaper a n d ads p l a c e d a r o u n d c a m p u s . E a c h h e a l t h y subject p a r t i c i p a t e d i n t w o test s e s s i o n s , d e t a i l e d p r i o r i n the R e l i a b i l i t y S t u d y s e c t i o n a n d t h e r e s u l t s f r o m t h e i r first test s e s s i o n w e r e u s e d i n t h i s comparative study.  H e a l t h y subjects presented w i t h healthy shoulders bilaterally. P o t e n t i a l healthy  subjects  w h o h a d h a d a h i s t o r y o f overuse based shoulder p a i n i n the past s i x m o n t h s and/or h a d had a prior glenohumeral dislocation, G r . 2+ acromioclavicular seperation, Grade 2 + rotator c u f f strain o r l o n g thoracic nerve palsy o n either shoulder were excluded.  B:  Operated group  S i x subjects w h o h a d h a d a unilateral scapulothoracic d e b r i d e m e n t arthroscopic p r o c e d u r e , p e r f o r m e d o n e t o f i v e y e a r s p r i o r t o t h e i r test date, w e r e r e c r u i t e d f o r t h e operated g r o u p o f this study. T h e m e a n age o f the g r o u p o f s i x subjects w a s 39.8 years o f age ( S . D . = 12.9) w i t h a r a n g e o f 2 5 to 58 years o f age. T h e m e a n B o d y M a s s I n d e x o f the g r o u p w a s 2 5 . 2 ( S . D . = 4.0) w i t h a range o f scores o f 2 2 . 0 5 - 3 0 . 6 7 .  55  Patients of the orthopaedic surgeon involved in this study were contacted and were invited to participate, in conjunction with a possible follow-up appointment with the orthopaedic surgeon. As all subjects were patients of the same surgeon, this group represented a sample of convenience. This uncommon surgical procedure, however, is only performed locally by that one surgeon, meaning that this study's sample group, in fact, represented the accessible population. Inclusion criteria were that the surgical procedure was unilateral and performed at least one year prior to the subject's test date. Because the subjects' unaffected shoulders also served as one component of the control in this study, exclusion criteria precluded any subjects who had had a history of overuse based shoulder pain in the past six months and/or had had a prior glenohumeral dislocation, Gr. 2+ acromioclavicular seperation, Grade 2+ rotator cuff strain or long thoracic nerve palsy on their unaffected side. As the test session included completing functional and pain scale forms, subjects in healthy or operated groups who were not proficient in the English language well enough to be able to read and/or understand the forms were excluded from participation. Instruments  Permission to use the DASH in this study was obtainedfromthe Institute for Work and Health. A Nicholas Manual Muscle Tester Dynamometer (Lafayette Instruments) was used for the study. Calibration of this unit was performed in January 2000 by the manufacturer. The Kin-Com Isokinetic Dynamometer (Chattanooga Group) was used as a measuring device in this study. The reliability and validity of the operating systems of the KinCom isokinetic dynamometer has been established in earlier work by Farrell and Richards. For  56  the functions of lever arm position, lever arm velocity and force measurement, high intraclass correlation coefficients of 0.999, 0.99 and 0.948, respectively, were demonstrated (28). Calibration of the new unit was done in 1998 by the manufacturer. Research Design  This study utilized a non-experimental analysis of differences between sides and between groups method of research design. Protocol  This study employed a non-experimental analysis of differences design, comparing outcome measures between sides in the operated group of subjects and between operated and healthy groups. Healthy subjects attended for two test sessions to fulfill the requirements for data collection for both this comparative study and for the previous reliability study. Test sessions proceeded in the following sequence: 1. Visual Analog Pain Scale and body diagram (performed on the first test session only as reliability had already been established) 2. Descriptor Differential Pain Scale (performed on the first test session only as reliability had already been established) 3. DASH functional scale (completed on both test sessions) 4. Scapular isometric strength testing (completed on both test sessions) 5. Scapular position testing (completed on both test sessions) 6. KinCom isokinetic strength testing of glenohumeral internal and external rotation (completed on the first test session only as reliability had already been established) Operated subjects met with the study investigator individually for a one-time test session, requiring approximately two hours of their time. The test session proceeded in the identical sequence to the healthy group. In addition, the operated subjects completed the VAS, DDS and DASH scores at the end of their session to determine if any of the  57  physical testing had led to increased pain symptoms at their involved side and to provide a measure of reliability for the DASH scale. The specifics of the protocol were as follows: 1. Pain Scales  a. Visual Analog Pain Scale (VAS) (Appendix A) Subjects were asked to record their perception of the current intensity of their pain at the affected shoulder by making a mark on a 10 cm. line, anchored with the words "no pain" and "worst pain". Following testing, the point on the line was measured with a ruler to determine the score out of 10. Subjects who reported pain were asked to then mark the body diagram to illustrate where their reported pain was located (50). This step allowed examiners to ensure that the pain scales were being answered with respect to symptoms specifically related to the subjects' previous scapulothoracic disorders. b. Descriptor Differential Scale (DDS) (Appendix B) Subjects were shown the two scales of the DDS, one scoring the sensation and the other scoring the unpleasantness of their shoulder pain. The subjects were shown that the scoring scale increased from the left side of the page to the right side, with the extreme left side being a score of "0" and the extreme right side a score of "20". They were shown the 12 descriptors on each scale that they would be scoring and were instructed to place a window over the first descriptor and put a tick on the line where they would rate their score relative to that descriptor. The same protocol was followed for each of the 12 descriptors of the 2 components of the DDS scale. Following testing, each scale was scored by calculating the score of each descriptor (from 0 to 20) and finding the average score of the 12 descriptors for the two components of sensation and unpleasantness of their shoulder girdle pain. 2. Self-Perceived Functional Scale  Disabilities of the Arm, Shoulder and Hand Index (DASH) (Appendix C)  58  The DASH, via a 3 page format, asked the subjects to subjectively rank their ability to perform 30 tasks on a numerical scale representing a range of functional ability, from "1" (no difficulty) to "5" (inability) to perform. A raw total score was transformed to yield a score out of 100, which was then placed on a linear scale of zero (indicating good function) to one hundred (indicating severe upper-limb disability). The index also asked the subjects to respond regarding any current symptom severity and any degree of social and activities of daily living limitations. In addition to the 30-item questionnaire, the DASH included two optional four-item modules designed to measure the impact of an upper extremity dysfunction on playing a musical instrument or sport, or on working. 3. Isokinetic Strength Testing of the Glenohumeral Internal and External Rotator Muscle Groups (Appendix F)  An established reliable protocol, preset on the Kin-Corn Isokinetic Dynamometer, (Chattanooga Group) was used. Subjects were tested in a seated position, with their trunk stabilized and their test arm supported and stabilized in a position of 50 degrees abduction and 30 degrees of glenohumeral flexion (see Appendix F). The elbow joint on the test side was maintained at 90 degrees of flexion and the wrist was supported in a neutral position, with respect to flexion and extension. Testing was performed first on the subjects' unaffected side, followed by testing on their affected shoulder. With the healthy subjects, testing was done on their dominant arm only. A test velocity of 30 degrees per second was used. Three maximal repetitions of maximal concentric and eccentric internal rotation were tested first, followed by three repetitions of maximal concentric and eccentric external rotation. During each maximal test repetition, subjects were verbally encouraged by the tester to provide maximal effort (ie. "push and/or pull as hard as you can"). A submaximal warm-up set of three repetitions was completed prior to testing internal rotation and one submaximal warm-up repeitition of external rotation was performed.  59  The test range of motion encompassed 70 degrees of rotational range of motion, surrounding a point determined as neutral rotation of the glenohumeral joint. Data generated represented the average peak torque (Newton-metres) of the three test repetitions for each of the directions, in both their concentric and eccentric modes. 4. Hand Held Dynamometry (HHD) for Strength Testing of the Scapular Protractor  and  Retractor Muscle Groups (Appendix D)  Based on the results of prior reliability work, one position for scapular retraction and two positions for scapular protraction were chosen for use in the comparative study. A. Scapular retraction Subjects were positioned in prone lying on a standard treatment plinth. Glenohumeral positions were verified using a goniometer. The non-test arm was placed overhead (to stabilize the thoracic spine) and the subject's head was turned towards the test side. Two velcro straps were applied at the levels of T9 and S2 to limit compensatory movements of the pelvis and thorax. The resistance pad of the HHD was positioned over the superior-lateral corner of the infraspinous fossa, inferior and medial to the acromion. This placement was similar to Daniels and Worthingham's (21) recommended hand position for manual muscle testing of scapular strength. Subjects were instructed to bring their shoulder blade towards their spine against the HHD held by the tester and were verbally encouraged to provide maximal effort (ie. "pull back as hard as you can") during each test repetition. The test protocol, modeled after Marshall and Kramer's study (51) with healthy female subjects, asked the subjects to practice two submaximal and one maximal practice contraction against the HHD. Three maximal test contractions, each three to five seconds in duration, then followed, with a 30 second rest interval between repetitions.  60  The specific scapular retraction position chosen (position two of the reliability study) placed the subject's shoulder at 90 degrees of abduction, with the scapula near parallel to the coronal plane. This position corresponds to that described for manual muscle testing of the middle fibers of the trapezius muscle (21). Peak force (kg) was determined for each repetition and the average force of the three test contractions was calculated for each position. B. Scapular protraction For the first test position, subjects were positioned in prone. The subject's shoulder was placed at 40 degrees of abduction and 45 degrees of extension. The resistance pad of the HHD was placed near the mid-point of the axillary border of the scapula to measure scapular protraction. The subjects were instructed to push their shoulder blade towards the floor. This position was initially chosen because it demonstrated the highest test-retest reliability in Marshall and Kramer's study (51). The second test position, developed specifically for this study by the examiner, approximated the position recommended by Daniels and Worthingham (21) for manual muscle testing of serratus anterior. Subjects were positioned in a supine position on the treatment plinth. Trunk stabilization was as described for scapular retraction. Their non-test arms were placed by their sides. Their test arms were positioned at 90 degrees of forward flexion and the resistance pad of the HHD was placed at the mid-point of the axillary border of the scapula. Subjects were instructed to push their shoulder blade towards the ceiling against the HHD held by the tester. Although no studies using this position are available in the literature, this position resembles that commonly used by clinicians in assessing scapular protraction strength and was, therefore, felt to be a relevant inclusion in this study. The protraction test protocol, also modeled after Marshall and Kramar's study (51) with healthy female subjects, also asked the subjects to practice two submaximal and  61  one maximal practice contraction against the HHD. Three maximal test contractions, of three to five seconds in duration each, then followed, with a 30 second rest interval between repetitions. For both test positions, subjects were verbally encouraged by the tester to give their maximal effort during the test repetitions. Peak force (kg) was determined for each repetition and the average force of the three test contractions was calculated for each position. 5. Static Scapular Position Testing (Appendix E)  Based on the results of the prior reliability work, a modified DeVita's test, which assesses scapular position by measuring the distance from the inferior angle of the scapula to the spinous process of the third thoracic vertebra, was chosen for use in this study. Subjects stood with their arms relaxed by their sides for 30 seconds before the modified DeVita's test was performed. The subject's third thoracic spinous process was identified and marked with ink. Using an unmarked piece of string, the examiner measured the distance from this spinous process to the inferior angle of the subject's scapula. The examiner marked the string accordingly and immediately repeated the process. Testing was performed first on the subjects' unaffected side, followed by testing on their affected shoulder. With the healthy subjects, testing was done on their dominant arm only. In order to calculate the Body Mass Index Score for each subject, height and weight were recorded during the test session (the first session for the healthy group) and a Body Mass Index Score (kg/m ) calculated for each subject. STATISTICAL ANALYSIS  Pain and functional scale scores between groups were analyzed using an independent ttest. Paired t-tests were used for within-subject analysis to assess differences in glenohumeral internal and external rotation strength, scapular protraction and retraction strength and  62  )  scapular static position. These same outcome measures were analyzed for between-group differences using an independent t-test. Significance levels were set at p<0.1 due to the small sample size. RESULTS A.  Table 12. Demographic Data Age  Gender  Body Mass Index  Operated Arm  F F  Hand Dominance Right Right  Healthy Subject #1 Operated Subject #1  27 25  21.97 22.68  N/A  Healthy Subject #2 Operated Subject #2  57 53  F F  Right Right  28.35 22.84  N/A  Right  Healthy Subject #3 Operated Subject #3  36 37  M M  Right Left  31.22 22.69  Right  Healthy Subject #4 Operated Subject #4  59 58  M M  Right Right  25.57 30.07  Healthy Subject #5 Operated Subject #5  35 34  F F  Right Right  23.12 30.67  Healthy Subject #6 Operated Subject #6  32 32  F F  Right Right  25.16 22.05  Left  N/A  N/A  Right N/A  Right N/A  Left  Table 12 details the demographic data of the operated subjects and the healthy subjects matched to them, according to the criteria (in order of decreasing importance) of age, gender, hand dominance and Body Mass Index.  63  B.  Data Concerning the Comparison of the Surgical and Non-surgical Arms in the Group of Operated Subjects  Table 13. Descriptive Data Outcome Measure (n=6 for all except Protraction #2) Modified DeVita's Test Surgical Arm Non-Surgical Arm Isometric Scapular Retraction (kg/BMI score) Surgical Arm Non-Surgical Arm Isometric Scapular Protraction #1 (kg/BMI score) Surgical Arm Non-Surgical Arm Isometric Scapular Protraction #2 (kg/BMI score) (n=4) Surgical Arm Non-Surgical Arm Isokinetic Rotator Cuff Strength Testing (newton-metres/BMI score) IR concentric - Surgical Arm Non-Surgical Arm IR ecccentric - Surgical Arm Non-Surgical Arm ER concentric - Surgical Arm Non-Surgical Arm ER ecccentric - Surgical Arm Non-Surgical Arm  Mean  Standard Range Deviation  14.70 14.75  2.98 2.79  11.1- 17.1 11.3 -18.1  0.11 0.15  0.03 0.03  0.08 -0.13 0.11-0.19  0.13 0.20  0.04 0.11  0.07-0.17 0.11 -0.38  0.16 0.18  0.02 0.07  0.12-0.19 0.11 -0.27  0.67 0.80 0.95 1.18 0.60 0.59 0.77 0.78  0.22 0.22 0.39 0.60 0.21 0.25 0.28 0.28  0.44 - 0.97 0.57- 1.19 0.53- 1.63 0.79-2.34 0.35-0.86 0.35 -1.01 0.54-1.2 0.54-1.23  Table 13 details the descriptive data obtained for the static scapular position testing, isometric scapular strength testing and isokinetic rotator cuff strength testing for the surgical and non-surgical arms in the group of operated subjects. For the Modified DeVita's test of static scapular position, a higher mean value was demonstrated for the non-surgical arms than for the subjects' surgical arms. For all the strength-related outcomes measured in this study, the non-surgical arm demonstrated a higher mean value within the group than did the data collected from the subjects' surgical arms. Each subject's strength measures (scapular and rotator cuff) were normalized for Body Mass  64  Index prior to statistical calculation. Isometric strength data for the position of Scapular Protraction #2 was collected from four subjects only due to this outcome measure being included in the study after the first two operated subjects had already completed their test sessions. Table 14. Statistical Analysis Outcome Measure Modified DeVita'sTest of Static Scapular Position Isometric Scapular Retraction Strength Isometric Scapular Protraction #1 Strength Isometric Scapular Protraction #2 Strength Isokinetic Glenohumeral Internal Rotation (Concentric) Strength Isokinetic Glenohumeral Internal Rotation (Eccentric) Strength Isokinetic Glenohumeral External Rotation (Concentric) Strength Isokinetic Glenohumeral External Rotation (Eccentric) Strength • statistical significance has been found where p<0.1  p (value) 0.94 0.005* 0.077* 0.48 0.045* 0.071* 0.85 0.78  Table 14 details the statistical analysis of the objective outcome measures of static scapular position, isometric scapular protraction and retraction strength and isokinetic glenohumeral rotation strength collected from the surgical and non-surgical arms of the operated group of subjects. Where p<0.1, statistical significance was found in the measures of isometric scapular retraction strength, isometric scapular protraction strength (Position #1 only) and isokinetic glenohumeral internal rotation strength, measured both concentrically and eccentrically, demonstrating statistically significant higher strength in the non-surgical arms of the operated group, as compared to their surgical arms.  65  C.  Data Concerning the Comparison of the Surgical Arm of the Group of Operated Subjects to the Dominant Arm of the Group of Healthy Subjects  Table 15. Descriptive Data - Subjective Outcome Measures Outcome Measure (n=6 unless otherwise indicated) Visual Analog Pain Scale (cm) Operated Group Healthy Group Descriptor Differential Pain Scale - Part A Operated Group Healthy Group Descriptor Differential Pain Scale - Part B Operated Group Healthy Group D.A.S.H. Functional Scale - Part A Operated Group Healthy Group D.A.S.H. Functional Scale - Part B Operated Group (n = 5) Healthy Group (n = 4) D.A.S.H. Functional Scale - Part C Operated Group Healthy Group  Mean  Standard Deviation  Range  3.68 0.00  2.43 0.00  1-8 0  10.98 0.00  3.54 0.00  8-17 0  9.67 0.00  5.75 0.00  2-19 0  33.80 1.40  17.33 2.27  10-62 0-6  42.52 4.70  29.13 9.40  0-81 0-19  30.22 0.00  21.08 0.00  0-50 0.00  Table 15 details the descriptive data obtained for the subjective outcome measures in the operated and healthy groups of subjects. For all the subjective pain and function outcomes measured in this study, the data collected from the operated group demonstrated higher mean values, indicating increased pain and decreased function, than the data collected from the healthy group of subjects as reported on the 3 self-report pain and functional scales. Table 16. Descriptive Data - Objective Outcome Measures Outcome Measure (n=6 unless otherwise indicated) Modified DeVita's Test (cm) Operated Group Healthy Group Isometric Scapular Retraction Strength (kg)  Mean  Standard Deviation  Range  14.70 16.67  2.98 2.07  11.1- 17.1 15.1 - 19.9  66  Operated Group Healthy Group Isometric Scapular Protraction #1 Strength (kg/BMI score) Operated Group Healthy Group Isometric Scapular Protraction #2 Strength (kg/BMI score) Operated Group (n = 4) Healthy Group Isokinetic Glenohumeral Strength Testing (newton-metres/BMI score) IR Concentric - Operated Group Healthy Group IR Eccentric - Operated Group Healthy Group ER Concentric - Operated Group Healthy Group ER Eccentric - Operated Group Healthy Group  0.11 0.20  0.03 0.04  0.08-0.13 0.15-0.25  0.13 0.22  0.04 0.04  0.07-0.17 0.18-0.27  0.16 0.21  0.02 0.05  0.12-0.19 0.14-0.26  0.67 0.89 0.95 1.24 0.60 0.73 0.77 0.95  0.22 0.42 0.39 0.60 0.21 0.35 0.28 0.41  0.44 - 0.97 0.5-1.63 0.53- 1.63 0.77-2.31 0.35-0.86 0.5-1.41 0.54-1.2 0.63-1.73  Table 16 details the descriptive data obtained for the static scapular position testing, isometric scapular strength testing and isokinetic rotator cuff strength testing of the groups of operated and healthy subjects. For the Modified DeVita's test of static scapular position, a higher mean value was demonstrated for the healthy group of subjects than for the operated group of subjects. For all the strength-related outcomes measured in this study, the healthy group of subjects demonstrated higher mean values than did the group of operated subjects. Each subject's strength measures (scapular and rotator cuff) were normalized for Body Mass Index prior to statistical calculation. Isometric strength data for the position of Scapular Protraction #2 was collected from only four operated subjects due to this outcome measure being included in the study after the first two operated subjects had already completed their test sessions.  67  Table 17. Statistical Analysis - Subjective Outcome Measures Outcome Measure Visual Analog Pain Scale Descriptor Differential Pain Scale - Part A Descriptor Differential Pain Scale - Part B D.A.S.H. Functional Scale -Part A D.A.S.H. Functional Scale -Part B D.A.S.H. Functional Scale -Part C • statistical significance has been found where p<0.1  p (value) 0.04* 0.000* 0.002* 0.001* 0.043* 0.006*  Table 17 details the statistical analysis for the subjective outcome measures collected from the operated and healthy groups of subjects using 3 self-report scales of pain and function. Where p<0.1, statistical significance was found in all subjective outcome measures between groups, demonstrating statistically significant higher levels of pain and dysfunction reported in the group of operated subjects, as compared to the group of healthy subjects. Table 18. Statistical Analysis - Objective Outcome Measures Outcome Measure Modified DeVita'sTest of Static Scapular Position Isometric Scapular Retraction Strength Isometric Scapular Protraction #1 Strength Isometric Scapular Protraction #2 Strength Isokinetic Glenohumeral Internal Rotation (Concentric) Strength Isokinetic Glenohumeral Internal Rotation (Eccentric) Strength Isokinetic Glenohumeral External Rotation (Concentric) Strength Isokinetic Glenohumeral External Rotation (Eccentric) Strength * statistical significance has been found where p<0.1  p (Value) 0.214 0.001* 0.004* 0.122 0.278 0.329 0.454 0.406  Table 18 details the statistical analysis of the objective outcome measures of static scapular position, isometric scapular protraction and retraction strength and isokinetic glenohumeral rotation strength collected from the operated and healthy groups of subjects. Where p<0.1, statistical significance was found in isometric scapular retraction strength and isometric scapular protraction strength (Position #1 only) between groups, demonstrating statistically significant higher strength in the group of healthy subjects, as compared to the group of operated subjects.  68  D I S C U S S I O N  This study undertook to examine long-term status in a group of individuals following arthroscopic scapulothoracic debridement procedure by comparing their performance on six outcome measures to a group of individuals with no known history of shoulder pathology. Results were notable in several areas. Statistically significant differences in current pain levels, as measured by the VAS (p<0.04) and DDS Part A (p=0.00) and DDS Part B (p<0.002) pain scales, existed between the healthy and operated groups. Part A of the DDS questions the subject regarding the intensity of their pain, while Part B asks the subject to reflect on the emotional unpleasantness of their pain. As detailed in Tables 15 & 17, at a time frame of at least one-year post-operatively, the group of operated subjects continued to report significantly more pain than a group of matched healthy subjects did. When comparing specific means between the groups, the group of operated subjects reported an average VAS score of 3.7 compared to an average score of zero as reported by the group of healthy subjects. Likewise for the DDS, the means of the scores reported by the group of operated subjects were 10.98 and 9.67 for Parts A & B of the scale, respectively, compared to means of zero reported by the healthy subjects. When the range of scores on both scales was examined specifically, none of the operated subjects had reported a score of zero, in contrast to the group of healthy subjects, who only reported scores of zero on both scales. The results of this study also showed that, at the same time frame of at least one-year post-operatively, the group of operated subjects reported significantly more selfperceived upper-extremity dysfunction than the group of healthy subjects did. Statistically significant differences in upper extremity function were found for all three components of the DASH scale (pO.OOl (Part A), p<0.043 (Part B) and p<0.006) (Part C)) between the healthy and operated groups of subjects in this study. Specific means calculated were 32.4% (Part A) and 37.8% (Part B) higher for the group of operated subjects, as compared to the healthy group. For Part C, a mean score of 30.22 was reported by the operated group compared to a mean score of zero by the healthy group. In  69  contrast to the ranges of pain scales scores described above, where no scores of zero were reported by the operated subjects, it is interesting that in Components B & C of the DASH (which asked the subjects to comment on the effect of their injury on their occupation and on recreational activities) the range of scores reflected that scores of zero had been chosen by some subjects in the operated group. Exclusion criteria in this study necessitated operated subjects being at least one year postoperative. The study was designed in this manner to capture subjects whose signs and symptoms would likely have already progressed to stable, minimally varying levels. The results of this study have shown that, at a perceived stable level, the operated subjects had, in fact, not recovered post-operatively to a subjective status of pain and function equivalent to individuals with no history of shoulder injury. Most of the information presented in the literature on this condition is in case report format, with little information provided on formal long-term evaluation and subsequent prognosis (17, 61, 68, 84, 88). Any post-operative profiles available in the literature consisted of reporting of subjective symptom changes only, and primarily without the use of formal outcome measurures. Most studies reported improvements in the patients' pain levels post-operatively, both in the short and long-term, compared to their pre-operative pain levels (17, 61, 84, 88). Harper's study specifically used the VAS pre and postoperatively in four of seven patients (33). Decreased pain levels were reported by those four patients post-operatively, although the specific post-operative time frame was not defined and the data was not analyzed for significance. No studies were found where a formal outcome measure pertaining to self-perceived upper extremity function, such as the DASH, was used with this specific population. Skutek and colleagues (85) recently applied the DASH, among other scales, preoperatively and approximately one year post-operatively to a group of individuals who had undergone an open rotator cuff repair. Their DASH scores reflected improvement at a statistically significant level post-operatively. Similar to our study, however, the group of subjects did not achieve a mean post-operative score of zero (zero being a return to a  70  level of "no disability"). Because of the design of our study, information about the operated subjects' self-perceived pain and functional levels prior to surgery and in the short-term post-operatively was not available, therefore not allowing for direct comparisons to their previous status. All the operated subjects tested in this study expressed a considerable level of improvement in these two areas since having had the surgery done. Based on this, it would have been interesting to be able to compare results of these pain and function scales at both pre-operative and short-term post-operative stages to allow for additional discussion on changes in these areas and for more comparison to results of other shoulder-related operative procedures. This study also included the use of several objective outcome measures, in addition to the subjective self-perceived pain and functional scales detailed above. Several statistically significant differences were found in the two control settings (between the healthy and affected arms in the operated group and between the affected arm of the operated group and the dominant arm of the healthy group). With respect to objective outcome measures, there is no literature available on formal testing in this population, negating the possibility of comparing this study's results to earlier information specific to scapulothoracic bursitis. Also unique to this study, outcome measures specifically relevant to the scapula were employed with a group of individuals with known prior scapular pathology. These two outcome measures were the use of hand-held dynamometry to determine isometric scapular retraction and protraction strength and the use of a test to measure static scapular position. Statistical analysis demonstrated that significant differences existed in both scapular retraction and protraction strength, as measured isometrically, between the operated subjects' unaffected and affected sides and between healthy and operated groups. As detailed in Tables 14 & 18, scapular retraction and Position #1 of scapular protraction proved statistically significant in both settings. When examining the differences between means in the operated group, the mean scores obtained when testing retraction and  71  protraction (in Position #1) were 27% and 35% lower in the affected arms of the operated subjects than in their unaffected arms. When examining the differences between subject groups, the mean scores obtained were 45% and 41% lower for scapular retraction and protraction (Position #1), respectively, in the operated group. Several factors may have influenced these findings. Harper and colleagues (33) described portals of entry when performing arthroscopic partial resection of the scapula to be located medial to the vertebral border of the scapula and approximately at the junction of the upper and middle thirds of the border. Relevant muscles passed through in gaining entry to the scapulothoracic space would include the trapezius and rhomboid groups. This approach would suggest some interruption of these scapular muscles, perhaps, with subsequent scarring and weakness, although it is difficult to quantify to what degree. In addition, several operated subjects in this study described ongoing pain in the area medial to the affected scapula. The concept of pain-inhibited muscle weakness around the shoulder was studied by Ben-Yishay and colleagues (9), who examined several outcome measures in a group of individuals with impingement syndrome before and after receiving an injection of lidocaine. Among other findings, their study demonstrated significant post-injection increases in shoulder isokinetic strength in those indiviuals, theorized to be linked to the decrease in pain obtained with the injection. Clinically, one might theorize that the ongoing presence of painful symptoms in the periscapular area of the operated subjects might have contributed to a pain-related inhibition or weakness in related muscle groups. While test-retest reliability of isometric hand-held dynamometry around the scapular retractor and protractor muscle groups has been established in the literature (22, 51, 101), no information is available regarding comparisons of formal measurement of the strength of scapular-based muscles in healthy and affected subject groups. This is the first study to do so.  72  The second objective scapular outcome measure utilized in this study was a Modified DeVita's test for static scapular position. No significant differences were demonstrated between the healthy subjects' unaffected and affected scapulae or between the healthy and operated groups. The concept of assessing scapular position, both static and dynamic, is a current area of interest for clinicians as variances from perceived norms for scapular biomechanics are linked anecdotally with dysfunction and pathology of the shoulder complex (20, 24, 42, 43, 48, 62, 66, 74, 82, 93, 96, 98). Test-retest reliability of several static scapular positional tests (22, 31, 63, 91), including the DeVita's test, has been established in the literature, however, the ability to link findings of these tests to pathology is, so far, inconclusive. Although the examiner of this study noted visible scapular winging through arm elevation with several of the operated subjects, the outcome measure chosen in this study did not reflect any significant differences between arms of the operated subjects or between subject groups. A significant challenge remains in continuing to develop further reliable outcome measures which are clinically relevant and capture the intricacies of scapular biomechanics. While strides are being taken to increase the sophistication level of scapular assessment tools, reliable tests of scapular position are currently limited to static tests and those of two-dimension, as was done in this study. As the battery of available tests progresses in time, perhaps to include three-dimensional and dynamic tests, other options for quantifying altered scapular mechanics may become available. The last outcome measure utilized in this study was the determination of rotator cuff strength via isokinetic testing of glenohumeral internal and external rotation strength. Statistical analysis demonstrated a significant difference in internal rotation strength, both concentric (p<0.045) and eccentric (p<0.071) between the operated subjects' unaffected and affected shoulders, but no significant differences in internal and external rotation strength between healthy and operated groups. This data indicates that the internal rotation strength of the subjects' operated shoulders, tested both concentrically and eccentrically, was not at a comparable level of strength  73  post-operatively, using their unaffected shoulders as the controls. It is interesting that this difference was present, even when the operated side was the subject's dominant arm, as was the case in three of six operated subjects. Several factors may have contributed to this. Theoretically, if the subscapularis muscle was affected by the specifics of the surgical approach, perhaps some of this resultant internal rotation weakness could be explained. Most of the operated subjects reported that diagnosis and, thereby, surgical management of their scapulothoracic dysfunction did not occur for them until a considerable length of time had passed from the onset of their scapular dysfunction. Several of them reported having learnt to rely on their unaffected arm to perform work and activities of daily living pre-operatively and reported continuing on in this regard, to some degree, postoperatively. This compensatory reliance on their unaffected arms could explain some of the ongoing discrepancy in strength between arms, even after an operation which all operated subjects agreed had been very helpful to them. Perhaps the group of glenohumeral internal rotator muscles did not receive adequate focus during the operated subjects' rehabilitation, resulting in this long-term weakness. As well, depending on the position of the shoulder, theoretically, anterior shoulder pain can be generated during internal rotation strengthening exercises, particularly when important glenohumeral dynamic stabilizers (scapular and glenohumeral external rotator muscles) are not functioning optimally. If subjects found this to be the case and did not optimize internal rotation strengthening protocols, this internal rotation strength deficit might also be explained. External rotation strength, however, when tested both concentrically and eccentrically, was not significantly different between the operated subjects' affected and unaffected shoulders. Without knowing the specifics of the operated subjects' rehabilitation programs, it is impossible to know the proportional focus of strengthening for the  74  glenohumeral internal or external rotators. It is common for clinicians to include strengthening exercises for the shoulder external rotators - perhaps this group was adequately strengthened such that comparable strength levels were obtained postoperatively between the operated subjects' affected and unaffected shoulders. Interestingly, no statistically significant differences in glenohumeral internal and external rotation strength were found when the affected arms of the operated subjects were compared to the dominant arms of the healthy subjects. The previously noted long-term compensatory reliance on their unaffected arms could perhaps explain this unusual result. If the subjects were relying primarily on their unaffected arms long-term to perform most of their arm-based activities, perhaps their unaffected arms would have reached a level of strength greater than that of the healthy subjects' dominant arms. The strength of the operated subjects' affected shoulders, therefore, might be significantly less than the strength of their own unaffected shoulders but not significantly less than the strength of the healthy subjects' shoulders. Alternately, the matching procedure in this study did not account for activity levels, work or sport-related, in the groups. If the operated subjects participated, in general, in more arm-based activities than the healthy group, perhaps the operated group was stronger overall in their healthy shoulders than the healthy group was. Concepts of muscle balance are addressed to a large degree in rehabilitation literature, as shifts in muscle balance ratios are often associated clinically with the development of pathology or with the signs and symptoms of an injury (20, 42, 98). Specific to the shoulder, for healthy subjects, studies exist where norms for isokinetic internal and external rotation strength ratios have been offered, with an external rotatoninternal rotator ratio of 2:3 generally cited (40, 73). When shoulder pathology is involved, however, the literature is not clear with respect to how this rotator ratio may be altered. As a result, it is not possible to determine whether the changes in the operated subjects' glenohumeral rotation muscle strength fit expected patterns of change.  75  Several studies are available in the literature pertaining to the measurement of components of shoulder strength following various operative procedures at the shoulder girdle (34, 38, 76, 77, 81). Two studies done by Rokito and colleagues (76, 77), for example, indicated that strength of the affected shoulder did not match that of the unaffected shoulders until at least one year post-operatively. Although the operated subjects in this study were not able to provide the specific lengths of their rehabilitation programs, none mentioned a length of program near one year. In addition to the limitations specific to the outcome measures chosen for this study and detailed above in this discussion, several other limitations should be discussed relevant to the results of this study. Most notably, this study was limited by the inability to recruit more than six operated subjects, falling short of the originally predicted number of ten subjects. Although attempts were made to contact all 13 of the potential operated subjects, current contact information was not available for two individuals and four individuals did not follow up with their initial expressed interest to participate. One individual was excluded from the study due to an ongoing limiting injury to his unaffected shoulder, thereby negating that arm as a control comparison. Because of the resultant small group size, p-values were reset to 0.1 on the advice of a statistician, as a more rigorous standard of p<0.5 was felt to be too restrictive to the results. As detailed in Table 12, efforts were made to match the operated subjects with the most compatible subjects from the healthy group, based on the criteria of age, gender, hand dominance and Body Mass Index. When the groups are compared, the mean age of the healthy group was 41 years of age, while the mean age of the operated group of subjects was 39.8 years of age. The mean Body Mass Index scores were also very similar, with the healthy group having an average BMI score of 25.9 and the operated group having an average score of 25.2. These numbers would support that the two comparison groups were closely matched. Several of the operated subjects reported a concurrent and, in some cases, ongoing history of other upper quadrant dysfunction. These included reports of cervical disc  76  herniation, thoracic spine compression fracture and humeral fracture, making it difficult to know how much these pathologies, rather than any sequelae of the scapulothoracic bursitis, contributed to these subjects' results on all the outcome measures of this study. Information about the operated subjects prior to surgery and in the short-term postoperatively was not available, therefore not allowing for direct comparisons to their previous status. All the operated subjects tested in this study expressed a significant level of improvement in pain and function since having had the surgery done. Based on this, it would have been interesting to be able to compare results of outcome measures at both of the pre-operative and short-term post-operative stages to allow for an additional level of comparison. Patient satisfaction data was not formally measured in this study. Keller's group (41) advocates that such data is an important component of outcome measurement, but acknowledges that there is, to date, no agreement on the best way to measure this. Informally, all operated subjects of this study offered that they were satisfied with the procedure and, in fact, their satisfaction motivated them to contribute to the body of literature surrounding it. Outcome measures should be easily usable by clinicians. Because the Kin-Corn may not be typically available in the majority of clinical settings, clinicians may hesitate to use this study's shoulder profile, thereby limiting the scope of its future use. The concept of substituting a hand-held dynamometer for an isokinetic dynamometer to obtain measures of strength is addressed to some degree in the literature. For example, in his study of stroke patients, Bohannon (14) demonstrated parallel reliability between the two instruments, meaning that isometric knee extension torque measures obtained with the two different dynamometers were comparable in magnitude. Although the literature specific to the upper extremity is not extensive, two studies were found demonstrating high parallel reliability between isokinetic and hand-held dynamometers when used to test shoulder rotation strength (44, 46). Some of the benefits  77  associated with the use of hand-held dynamometry include relative portability and cost. Reliability of hand-held dynamometry, however, can be influenced by factors such as tester and subject stabilization (64), tester strength (97) and the distance the dynamometer is placed from the axis of rotation of the joint in question (55). These factors, as well the tester's comfort and experience with the available instruments, must all be considered when choosing an instrument for measuring strength. Accepting the loss of ability to examine strength in an isokinetic capacity and to have information on both concentric and eccentric components of strength, it would appear that there may be some basis in the literature to consider using a hand-held dynamometer instead of an isokinetic dynamometer for measuring glenohumeral rotation strength when the situation best suits it. Based on the literature, this study is the first known in which a formal profile of reliable subjective and objective outcome measures relevant to the shoulder complex has been administered to a group of individuals with a prior unilateral arthroscopic scapulothoracic debridement procedure. Our results have demonstrated that, although all operated subjects reported significant improvements in their injuries since having had the surgery done, significant differences in pain, function and isometric scapular retraction and protraction strength persist long-term post-operatively for these individuals, as compared to a group with no known history of shoulder dysfunction. Similar significant strength deficits were found in the isometric strength of the scapular protractor and retractor muscle groups as well as in isokinetic concentric and eccentric glenohumeral internal rotation strength of the operated subjects' affected arms, versus their unaffected arms. Several recommendations can be put forward from these results. Specific information on the type and length of rehabilitation protocol pursued by each operated subject was not available to the study examiners but, based on the ongoing strength deficits still demonstrated by the operated subjects at one year post-operatively, further thought should be given to extending the rehabilitation programs normally pursued after this operative procedure. Bearing in mind the concept of pain-inhibited muscle weakness, physiotherapy clinicians might consider treatment modalities providing pain relief and  78  education regarding ongoing pain management in attempts to minimize the long-term strength deficits potentially experienced by individuals after undergoing this surgical procedure. Likewise, clinicians might be wise to consider providing ongoing rehabilitation and/or monitored strengthening until the post-operative clients appear to have plateaued, considering the ongoing significant strength deficits still demonstrated by the operated subjects at a timeframeof at least one year post-operatively. Further studies of individuals following arthroscopic scapular debridement would be relevant to build on this study and should allow for assessment in the pre-operative and short-term post-operative stages. This present study may be extended in attempts to obtain an operated group with a size of at least 10 subjects. Lastly, although other literature is available regarding the development and use of shoulder complex profiles (45, 71, 75), no studies were found which incorporated the use of valid and reliable objective outcome measures designed to provide information specific to the status of the scapula. Considering the current clinical focus on the role that scapular mechanics play in the health of the shoulder girdle, it seems appropriate that an ability to account for the "health" of the scapulothoracic complex would be a relevant inclusion. It is hoped that this study will initiate further development of scapular-based outcome measures such that their use in clinical assessment and research expands.  79  CHAPTER  4  Conclusions and Future Works The reliability study portion of this thesis examined test-retest reliability of three outcome measures. New information that this portion's results will provide to the literature are further confirmation that the DASH questionnaire can be used reliably with individuals with shoulder girdle pathology and the preliminary knowledge that the inferior angle of the scapula can be used reliably as a landmark when performing static scapular position testing. Although the literature has already supported that both DeVita's and Kibler's tests were highly reliable with respect to intratester measures, the literature has not shown that the Kibler's series of tests has consistent high intertester reliability. Although this study did not examine intertester reliability, our results did not demonstrate high between-session test-retest reliability for the Kibler's test used in this study. Future reliability work performed with this test should focus on intertester and between-session components. Interestingly, although the comparative study portion of this thesis yielded several significant differences between the operated and healthy groups, there were no significant differences noted in the area of static scapular position. From this, one would have to question the validity of such tests in identifying scapular positional dysfunction. Indeed, the current literature focus on scapular biomechanics has evolved to a level of questioning beyond the measurement of elevation and abduction components of scapular position in controlled, static shoulder positions that the two tests used in our study measured. Unfortunately, however, the assessment tools available do not currently reflect that clinical level of theorizing. With time, I believe that the clinical interest in scapular function will continue to drive the "unravelling" of the mysteries of scapular function through scientific avenues.  80  Good to high within-session reliability was obtained in this study for testing of isometric scapular retraction and protraction strength. Our results for between-session reliability of these tests positions, however, do not preclude the necessity of further such work prior to their use. Currently, clinicians are typically limited to the use of manual muscle testing around the scapula. Our results will, hopefully, offer hand-held dynamometry as a potential tool for the measurement of scapular strength that merits further interest and involvement in research and clinical settings. From the results of the reliability study, an assessment profile relevant to shoulder girdle outcomes was developed that encompassed the use of both subjective and objective outcome measures. This profile included the use of patient-derived information, in the form of pain and self-perceived functional questionnaires, and the use of physical outcome measures specific to scapular function. This study's incorporation of patientderived information and inclusion of outcome measures (ie. scapular measures) specific to all potential aspects of a disability or limitation adheres to current concepts surrounding the development of outcome measures discussed in the orthopaedic literature. It is interesting to note that, while the literature is full of examples of both clinical and research interest in scapular function as a component of shoulder girdle pathology, there were no examples available of assessment profiles, with healthy or patient subjects, where specific scapular function was addressed as part of the examination. It is hoped that the presentation of our assessment profile in this thesis will interest others in considering incorporating scapular-relevant measures in the refining of future shoulder girdle profiles. The comparative study portion of this thesis yielded that, in general, the operated subjects in this study did not return to a level comparable to a group of healthy subjects at a time frame of at least one-year post-operatively following their arthroscopic scapulothoracic debridement procedures. 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Very Intolerable +  Very Distressing +  Slightly Distressing + Slightly Annoying +  Very Annoying + Intolerable +  Annoying +  Slightly Intolerable +  Slightly Unpleasant +  Unpleasant +  Distressing + Very Unpleasant +  94  Appendix D.A.S.H. Questionnaire •*».*f». • • .  THE  I N S T R U C T I O N S This questionnaire asks about your symptoms as well as your ability to perform certain activities. Rlease answer every question, based on your condition in the last week, 1  by circling the appropriate number. If you did not have the opportunity to perform an activity in the past "Weekjiiplease make your best estimate on which response would be the most accurate. It doesn't matter which hand or arm you use to perform the activity; please answer based: on your ability regardless of how you perform the task.  DISABILITIES O F THE A R M , S H O U L D E R A N D H A N D  Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.  NO DIFFICULTY  MILD DIFFICULTY  MODERATE DIFFICULTY  SEVERE DIFFICULTY  UNABLE  17. Recreational activities which require little effort (e.g., cardplaying, knitting, etc.).  V •* 19. Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.).  96  DISABILITIES O F T H E A R M , S H O U L D E R A N D H A N D  NOT AT ALL  22. During the past week, to what extent has your arm. shoulder or hand problem :interferedlwithyour;norrnal social activities with.family, friends,'neighbours or-groups? (circle number)  SLIGHTLY  1  MODERATELY  ..  3  2  EXTREMELY  5  4  NOT LIMITED AT ALL  SLIGHTLY LIMITED  MODERATELY LIMITED  1  2  3  NONE  MILD  MODERATE  SEVERE  EXTREME  1  2  3  4  .5.  1  2  3  4  5  26. Tingling:(pins.;and needles) in your arm, shoulder or hand.  1  2  3  4  5*  27. Weakness in your arm, shoulder or hand.  1  2  3  4  5  28.•'•Stiffness in ypufarrn, shoulder or hand.  1  2  3  4  ,5  NO DIFFICULTY  MILD DIFFICULTY  MODERATE DIFFICULTY  SEVERE DIFFICULTY  .SO M U C H DIFFICULTY THAT I CAN'T SLEEP  , « DISAGREE  NEITHER AGREE NOR DISAGREE  23.  During the pastweek, were you limited in your work or other regular daily activities as a result of your arm, shoulderorf'handiproblemViifarc/e.numiiec)  VERY LIMITED  ••««!?• U  N  R  B  F J  4'  Please rate, the severity of the followingisymptoms.in the last week, (circle number)  24. Arm, shoulder or hand pain.  .  25. Arm, shoulder or hand pain when you performed any:specific activity.  29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number)  .  1  STRONGLY DISAGREE  N  K  R  C  .  R D (  .,  STRONGLY AGREE  30. I feel less capable,-less confident:or less useful: because of my arm. shoulder or hand problem. (circle number)"  97  SPORTS/PERFORMING ARTS M O D U L E (OPTIONAL) The following questions relate to the impact of your arm. shoulder or hand problem, on playing your musical instrument or sport, or both. If youiplay more than one sport or.instrument (or play both), please answer with respect to.that.actiyityiwhich ismost'important to you..  :  :  Please indicate the sport or instrument which is most important to you: •  •. . :.  Ido not play a sport or an instrument. (You may skip this section.)  .  _  -  :  Please circle the number that, best describes your physical ability in the past week. Did you have any difficulty NO DIFFICULTY  1.  using your usual technique for playing your instrument or sport?  2  playing your musical instrument or sport because of arm, shoulder or hand pain?  3.  playing your musical instrument or sport .as well as you would like?  A. f  '  MILD DIFFICULTY  MODERATE DIFFICULTY  SEVERE DIFFICULTY  spending your usual amount of time practising or playing your instrument or sport?  W O R K M O D U L E (OPTIONAL) The following questions ask about the impact of your arnvshoulderonhand problem on your ability to work (including.homemaking if that is your main work role). • • •': Please indicate what your job/work is: •  :• • • • • • _  I do not Work. (You may skip, this section.)  '  :  "  •  • Please circle the number that best describes your physical ability: in the past week. Did you have any difficulty: NO DIFFICULTY  1.  MILD DIFFICULTY  MODERATE DIFFICULTY  SEVERE DIFFICULTY  UNABLE  using your usual technique for your work?  •2i-doing.your usual work because of arm. shoulder or hand pain?  . .. .  3.: •; doing yourwofk as well as you would:like? 4;:  spending your usual amount of time doing yourwork?  98  Appendix D  99  Appendix E  102  Appendix F Glenohumeral Isokinetic Internal and External Rotation Strength Testing  Start position for concentric internal rotation and eccentric external rotation strength testing  Start position for concentric external rotation and eccentric internal rotation strength testing  103  Appendix G Raw Data Tables (Reliability Study)  Scapular Retraction Position #1 Session 1 Isometric Rep.  Session 2  1  2  3  Average  1  2  3  Average  Subjects CS11 CS12 CS13 CS14 CS15 CS16 CS17 CS18 CS19 CS20 CS21 CS22 CS23 CS24 CS25 CS26 CS27 CS28 CS29 CS30  7.1 6.3 5.2 4.5 4.7 5.6 3.6 4.8 3.8 4.1 5.6 5.2 4.7 4 4.4 5.9 5.6 4.1 3.9 3.8  6.9 7.2 5.2 4.4 5.1 5.7 5 4.6 3.5 5.2 5.6 6.5 4.8 3.9 4.8 6.2 5.7 4.5 3.8 3.7  7.2 7.7 5.3 4.8 4.3 5.8 5.6 4.8 3.5 5.1 5.2 5.9 4.9 4.1 4.9 6 5.8 4.4 3.8 3.6  7.1 7.1 5.2 4.6 4.7 5.7 4.7 4.7 3.6 4.8 5.5 5.9 4.8 4 4.7 6 5.7 4.3 3.8 3.7  7.8 8 5 4.5 4.9 6.1 5.2 5.4 3.4 4.1 4.6 5.1 5 3.9 4.5 5.4 5.4 4.4 6 5.2  7.6 7.2 4.8 4.8 4.7 5.9 5.1 5.1 3.6 4.4 5 6 5.7 4.1 3.4 5.4 5.4 4.4 6.4 4.5  7.5 6.7 5.2 4.6 4.7 5.8 6.5 5 3.4 4.2 5 5.7 5.5 4.1 3.4 5.5 5.4 4.4 6.1 4.1  7.6 7.3 5 4.6 4.8 5.9 5.6 5.2 3.5 4.2 4.9 5.6 5.4 4 3.8 5.4 5.4 4.4 6.2 4.6  Mean St Dev  4.85 0.95  5.12 1.045  5.14 1.09  5.03 1.00  5.2 1.13  5.18 1.08  5.14 1.08  5.17 1.05  Isometric hand-held dynamometer strength (kg) data for Scapular Retraction Position #1  104  Scapular Retraction *osition #2 Session 1 Isometric Rep.  1  2  3  CS11 CS12 CS13 CS14 CS15 CS16 CS17 CS18 CS19 CS20 CS21 CS22 CS23 CS24 CS25 CS26 CS27 CS28 CS29 CS30  7.8 7.4 4.2 5.2 4.7 6 4.3 4 3.6 3.7 3.9 4.8 4.1 4.2 5.1 5.2 5.8 4 3.9 3.8  7.6 7.5 4.5 5 4.4 5.3 4.5 4.2 3.8 4.2 4.1 5.8 4.6 4.3 5.8 5 5.8 4.1 3.9 3.3  8 7.7 4.6 5.2 4.4 6 4.7 4.5 3.9 4.3 4.3 6 4.3 4.3 5.5 5.2 5.7 4.4 3.9 3.7  Mean St Dev  4.79 1.18  4.89 1.14  5.03 1.18  Session 2  1  2  3  Average  7.8 . 7.5 4.4 5.1 4.5 5.8 4.5 4.2 3.8 4.1 4.1 5.5 4.3 4.3 5.5 5.1 5.8 4.2 3.9 3.6  7.9 7.4 4.3 5.4 4.5 5.8 4.7 5 3 4.1 4.3 4.8 4.5 3.7 3.5 5.9 5.9 4.2 5.5 3.7  7.2 6.1 5 4.5 5.1 5.6 4.8 4.7 3.4 4.2 4 5.7 4.5 4.2 3.6 6.7 6.7 4 6 3.7  7.6 7.1 4.6 5 4.8 5.5 4.9 5.9 3.4 4 3.7 5.6 4.3 4 7.1 7.1 4.1 5.3 3.7  7.6 6.9 4.6 5 4.8 5.6 4.8 5.2 3.3 4.1 4 5.4 4.4 4 3.7 6.6 6.6 4.1 5.6 3.7  4.9 1.15  4.91 1.24  4.99 1.12  5.08 1.30  5 1.19  Average  Subjects  .3.9  Isometric hand-held dynamometer strength (kg) data for Scapular Retraction Position #2  105  Scapular Retraction Position #3 Session 1 Isometric Rep.  Session 2  1  2  3  Average  1  2  3  Average  7.1 7.3 4.4 4.8 4.2 4.7 4.3 5.2 3 3.8 4.9 5.4 4.8 5 5.5 4.4 5.5 4.2 3.8 4.3  7.1 8.3 4.8 4.6 3.9 3.9 4.1 5 2.6 4.2 4.2 5.7 5.1 5.5 5.6 5.1 5.5 4.1 3.7 4  6.8 9.6 4.1 5 3.8 4.3 4.2 5.4 2.9 4 4.3 5.6 4.9 5.1 5.6 5 5.7 4.6 3.9 4.3  7 8.4 4.4 4.8 4 4.3 4.2 5.2 2.8 4 4.5 5.6 4.9 5.2 5.6 4.8 5.6 4.3 3.8 4.2  6.7 6.9 5.4 4.9 4.3 4.3 4.6 5.3 3.3 4 3.7 5.4 4.3 4 4.4 5 5 4.2 5.8 4.3  7.1 7 4.7 4.9 4.2 4.6 4.6 5.3 3 3.8 4.1 5.4 4.5 4.6 4.2 5 5 4.1 6.3 4.1  7.3 7.6 4.9 5 5.1 4 4.4 5.9 3.1 3.6 4.6 5.8 4.4 5.5 4.6 4.8 4.8 4.4 6.1 4  7 7.2 5 4.9 4.5 4.3 4.5 5.5 3.1 3.8 4.1 5.5 4.4 4.7 4.4 4.9 4.9 4.2 6.1 4.1  Subjects  CS11 CS12 CS13 CS14 CS15 CS16 CS17 CS18 CS19 CS20 CS21 CS22 CS23 CS24 CS25 CS26 CS27 CS28 CS29 CS30 Mean St Dev  4.83 1.02  4.85 1.26  4.955 1.39  4.88 1.21  4.79 0.93  4.825 1.02  4.995 1.12  4.855 1.01  Isometric hand-held dynamometer strength (kg) data for Scapular Retraction Position #3  106  Scapular Protraction Position #1 Session 1 Isometric Rep.  Session 2  1  2  3  Average  1  2  3  Average  CS11 CS12 CS13 CS14 CS15 CS16 CS17 CS18 CS19 CS20 CS21 CS22 CS23 CS24 CS25 CS26 CS27 CS28 CS29 CS30  9 5.2 4 4.4 4.6 6 4.9 6.2 5 5.7 7.3 6.3 5.8 6.4 6.9 6.8 7.4 5.3 5.3 4.9  8.6 5.1 4.6 4.2 4.6 6.7 4.8 5.7 4.7 5.4 6 6.5 5.6 6.5 6.8 6.2 5.6 4.5 5 5  8.4 5 4 4.4 4.6 7.3 5.1 6.1 4.1 5.2 6.2 6.2 5.8 6.2 6.6 6.2 5.6 6.6 4 5.2  8.7 5.1 4.2 4.3 4.6 6.7 4.9 6 4.6 5.4 6.5 6.3 5.7 6.4 6.8 6.4 6.2 5.5 4.8 5  6.4 5.2 4.5 4.3 4.6 7.4 6.3 5.8 5.1 6.2 6.1 6.2 6.2 6 5.7 6.8 6.8 6.6 7.7 6.5  7.8 5.8 4.8 4.1 4.7 7.2 6.6 5.4 5.3 5.5 6.9 6.3 5.1 6.3 5.9 6.6 6.6 6.2 7.5 5.5  9.2 5.3 4.6 4.4 5.4 6.5 6.3 7.7 4.8 5.6 6.2 6.5 4.4 5.7 5.6 6.6 6.6 6.1 7.5 6.4  7.8 5.4 4.6 4.3 4.9 7 6.4 6.3 5.1 5.8 6.4 6.3 5.2 6 5.7 6.7 6.7 6.3 7.6 6.1  Mean St Dev  5.87 1.21  5.605 1.06  5.64 1.15  5.705 1.09  6.02 0.91  6.005 0.97  6.07 1.18  6.03 0.93  Subjects  Isometric hand-held dynamometer strength (kg) data for Scapular Protraction Position #1  107  Scapular Protraction Position #2 Session 1 Isometric Rep.  Session 2  1  2  3  Average  1  2  3  Average  Subjects CS11 CS12 CS13 CS14 CS15 CS16 CS17 CS18 CS19 CS20 CS21 CS22 CS23 CS24 CS25 CS26 CS27 CS28 CS29 CS30  7.2 6.7 4.3 3.9 3.1 6.9 3.6 4.5 4.1 3.6 4 5 4.6 5.1 5.4 5 6 5.4 3.5 7.8  7.1 6.3 4.4 3.7 3.5 6.2 3.4 4.8 4.2 4.2 4.5 5.3 4.4 5.8 4.6 5.5 6 6.1 3.8 7.6  6.7 7.3 4.3 3.4 3.4 5.8 3.2 4.5 4.5 4.3 4.3 5.1 4.8 5.4 4.7 5.8 6.4 5.9 3.4 8.5  7 6.8 4.3 3.7 3.3 6.3 3.4 4.6 4.3 4 4.3 5.1 4.6 5.4 4.9 5.4 6.1 5.8 3.6 8  6.8 5 3.5 3.5 4.4 5.6 3.1 5.3 4.3 3.7 4.5 5.4 4.3 4.6 3.7 5.4 5.4 5.2 6.8 6.4  6.8 4.8 3.8 3.8 4.7 6.5 3.4 5.3 4.4 3.4 5.3 5.6 4.6 4.8 3.8 5.8 5.8 5.7 6.3 7.9  7.2 4.8 4.5 3.8 4.6 6.8 3.4 5.4 4.6 4.3 4.9 5.1 4.9 4.5 3.7 6.3 6.3 5.6 6.4 7.1  6.9 4.9 3.9 3.7 4.6 6.3 3.3 5.3 4.4 3.8 4.9 5.4 4.6 4.6 3.7 5.8 5.8 5.5 6.5 7.1  Mean St Dev  4.99 1.34  5.07 1.21  5.09 1.41  5.05 1.3  4.85 1.08  5.13 1.21  5.21 1.14  5.05 1.11  Isometric hand-held dynamometer strength (kg) data for Scapular Protraction Position #2  108  Modified DeVita's Test of Static Scapular Position Session 1 Session2 1 2 1 2 Average Repetition Average Subject CS1 CS2 CS3 CS4 CS5 CS6 CS7 CS8 CS9 CS10 CS11 CS12 CS13 CS14 CS15 CS16 CS17 CS18 CS19 CS20 CS21 CS22 CS23 CS24 CS25 CS26 CS27 CS28 CS29 CS30 Mean St Dev  14.3 27.3 13.9 14.8 15 12.5 13.5 19.6 15.5 15.8 16.1 19.9 14.3 13.6 15.3 18.5 14.7 17.4 19.4 16.5 16.4 13.9 14.1 15 17.1 12.7 15.1 16 13.2 20.1  14.8 26.6 14.1 14.6 14.4 12.1 13.1 19 15.9 15.8 15.2 19.3 13.8 13.5 15.4 18.9 15.8 16.5 18.8 16.7 14.8 14.5 14.2 15.3 16.5 12.8 16 15.8 13.5 20.2  14.55 26.95 14 14.7 14.7 12.3 13.3 19.3 15.7 15.8 15.65 19.6 14.05 13.55 15.35 18.7 15.25 16.95 19.1 16.6 15.6 14.2 14.15 15.15 16.8 12.75 15.55 15.9 13.35 20.15  13.8 26.3 15.2 16.5 14.4 12.7 15 19 14.4 17.9 16.3 21.8 18.4 13.9 13.4 17.6 18.2 15.5 16.7 18.5 17.4 16.4 15.2 14 16.8 13.8 16 16.2 16.3 19.5  14 28.4 15 16.1 14.1 12.5 15 18.4 15 17.9 15.8 21.4 18.1 14.5 12.8 17.4 18.2 16 14.7 18.5 16.4 16.9 15.5 14.8 16.5 14.6 15.5 15.8 15.9 20.2  13.9 27.35 15.1 16.3 14.25 12.6 15 18.7 14.7 17.9 16.05 21.6 18.25 14.2 13.1 17.5 18.2 15.75 15.7 18.5 16.9 16.65 15.35 14.4 16.56 14.2 15.75 16 16.1 19.85  16.05 3.01  15.93 2.85  15.99 2.92  16.57 2.76  16.53 3.00  16.55 2.86  Data from Modified DeVita's Static Scapular Position Testing (cm.)  Repetition  Kibler's Test of Static Scapular Position Session2 Session 1 2 1 2 Average 1 Average  Subject CS1 CS2 CS3 CS4 CS5 CS6 CS7 CS8 CS9 CS10 CS11 CS12 CS13 CS14 CS15 CS16 CS17 CS18 CS19 CS20 CS21 CS22 CS23 CS24 CS25 CS26 CS27 CS28 CS29 CS30  13.3 14.8 8.8 7.4 11.4 10.7 9.2 13.3 10 9.8 14.5 14.2 13.7 10.4 8.2 11.5 13.3 12.5 12.7 12.6 18.5 10.9 11.3 8.3 12.4 8 10.8 12.1 7.7 14.5  14.2 15.8 10 8.4 11.4 11.6 9.8 12.1 9.7 8.8 15.2 14.1 14.5 10.8 8.3 11.2 13.5 12.6 13.1 11.6 19.1 11.9 11 8.7 12.4 8.1 9.2 11.7 9.3 15.3  13.75 15.3 9.4 7.9 11.4 11.15 9.5 12.7 9.85 9.3 14.85 14.15 14.1 10.6 8.25 11.35 13.4 12.55 12.9 12.1 18.8 11.4 11.15 8.5 12.4 8.05 10 11.9 8.5 14.9  12.5 13 10.1 10 12.6 8 7.8 13.7 9.7 7.7 13.6 13.7 18.1 8.5 10.2 11.5 12 10.5 11.8 10.2 11.7 10.2 12.4 9.4 9.1 9.2 11 10.3 10.3 14.5  12.9 15.6 10.7 8.9 11.2 8.8 7.2 12.5 10.2 7.3 12 13.7 17.9 7.7 9.2 11.1 12.6 11.1 11.2 9 11.8 11.5 11.1 8.8 11.1 8.6 11.7 10 9.2 13.9  12.7 14.3 10.4 9.45 11.9 8.4 7.5 13.1 9.95 7.5 12.8 13.7 18 8.1 9.7 11.3 12.3 10.8 11.5 9.6 11.75 10.85 11.75 9.1 10.1 8.9 11.35 10.15 9.75 14.2  Mean St Dev  11.56 2.56  11.78 2.63  11.67 2.56  11.11 2.27  10.95  11.03 2.28  2.4  Data from Kibler's Static Scapular Position Testing (cm.)  Dash A pre post  Dash B pre post  Dash C pre post  Subject 1 2 3 4 5 6 7  61.67 40 32.5 10.3 35.8 22.5 25  60 38.3 35 5.2 37.5 30 26.7  50 81.3 0 37.5 43.8 87.5  50 81.3 0 62.5 43.8 100  25 50 50 0 12.5 43.8 75  31.25 50 56.3 0 12.5 43.8 87.5  Mean SD  32.54 16.16  33.24 16.34  50.02 31.88  56.27 34.46  36.6 25.63  40.19 29.07  Reliability of DASH questionnaire scores taken at the beginning and end of the test session with the operated group (n=7, except for Part B of the DASH questionnaire, where n=6)  Appendix H Raw Data Tables (Comparative Study)  DeVita (cm)  Outcome Measures Retracl Protracl Protrac2 IR-conc IR-ecc ER-conc ER-ecc (kg/BMI (kg/BMI (kg/BMI (n/m/BM (n/m/BM (n/m/BM (n/m/BM score) I score) I score) I score) I score) score) score) n=4  Surgical Arm 10.4 PS1 PS2 11.5 17 PS3 PS4 16.7 15.5 PS5 PS6 17.1 Mean 14.7 SD 2.98  0.08 0.15 0.13 0.09 0.1 0.09 0.11 0.03  0.07 0.15 0.18 0.14 0.1 0.15 0.13 0.04  Non-Surg ical Arm 12.1 PS1 PS2 11.5 PS3 14.6 PS4 17.8 PS5 14.3 18.2 PS6 Mean 14.75 SD 2.79  0.11 0.16 0.19 0.15 0.14 0.12 0.15 0.03  0.11 0.24 0.39 0.18 0.1 0.18 0.2 0.11  0.17 0.12 0.17 0.16 0.16 0.02  0.53 0.44 0.97 0.9 0.62 0.54 0.67 0.22  0.79 0.53 1.63 1.13 • 0.82 0.77 0.95 0.39  0.62 0.35 0.79 0.86 0.62 0.36 0.6 0.21  0.75 0.57 1.01 1.2 0.55 0.54 0.77 0.28  0.27 0.12 0.14 0.18 0.18 0.07  0.57 0.61 1.19 0.86 0.72 0.82 0.8 0.22  0.79 0.83 2.34 1.3 0.88 0.95 1.18 0.6  0.57 0.35 1.01 0.73 0.52 0.36 0.59 0.25  0.75 0.57 1.23 1.03 0.59 0.54 0.79 0.28  Comparison of objective outcome measure data obtained from the surgical and nonsurgical arms of the operated group  112  DeVita (cm)  Subject 1 2 3 4 5 6 Mean SD  10.4 11.5 17 16.7 15.5 17.1 14.7 2.98  Surgical Arm of Operated Group Outcome Measures Retracl Protracl Protrac2 IR-conc IR-ecc ER-conc ER-ecc (kg/BMI (kg/BMI (kg/BMI (n/m/BM (n/m/BM (n/m/BM (n/m/BM score) score) score) I score) I score) I score) I score) n=4 0.08 0.15 0.13 0.09 0.1 0.09 0.11 0.03  0.07 0.15 0.18 0.14 0.1 0.15 0.13 0.04  0.17 0.12 0.17 0.16 0.16 0.02  0.53 0.44 0.97 0.9 0.62 0.54 0.67 0.22  0.79 0.53 1.63 1.13 0.82 0.77 0.95 0.39  0.62 0.35 0.79 0.86 0.62 0.36 0.6 0.21  0.75 0.57 1.01 1.2 0.55 0.54 0.77 0.28  Dominant Arm of Healthy Group Outcome Measures DeVita Retracl Protracl Protrac2 IR-conc IR-ecc ER-conc ER-ecc (cm) (kg/BMI (kg/BMI (kg/BMI (n/m/BM (n/m/BM (n/m/BM (n/m/BM score) score) score) I score) I score) I score) I score) Subject 1 2 3 4 5 6 Mean SD  15.3 15.1 19.9 18.6 15.1 16 16.67 2.07  0.21 0.15 0.23 0.18 0.25 0.16 0.2 0.04  0.21 0.19 0.16 0.27 0.27 0.22 0.22 0.04  0.15 0.13 0.22 0.23 0.27 0.23 0.21 0.05  0.5 0.74 1.63 1.13 0.61 0.72 0.89 0.42  0.77 0.92 2.31 1.6 0.95 0.91 1.24 0.6  0.5 0.53 1.41 0.78 0.52 0.64 0.73 0.35  0.68 0.63 1.73 1.02 0.74 0.87 0.95 0.41  Comparison of objective outcome measure data obtained from the surgical arms of the operated group and the dominant arms of the healthy group  113  Operated Group Outcome Measures DDSA DDSB DASH A DASH B DASH C  VAS Subject  1 2 3 4 5 6  7.7 1.5 5.1 3.6 3 1.2  17 7.6 12.2 8.4 12.1 8.6  . 18.8 2.3 13 8.8 9.4 5.7  . 61.67 40 32.5 10.3 35.8 22.5  50 81.3 0 37.5 43.8  25 50 50 0 12.5 43.8  Mean SD  3.68 2.43  10.98 3.54  9.67 5.75  33.8 17.33  42.52 29.13  30.22 21.08  Healthy Group Outcome Measures DDSA DDSB DASH A DASH B DASH C  VAS Subject  1 2 3 4 5 6  0 0 0 0 0 0  0 0 0 0 0 0  0 0 0 0 0 0  0.83 1.75 0 0 5.8 0  0 0 18.75 0  0 0 0 0 0 0  Mean SD  0 0  0 0  0 0  1.4 2.27  4.69 9.38  0 0  Comparison of subjective outcome measure data obtained from the operated and the healthy groups Within-Group (Operated) Repeated Measures Analysis of Variance  Tests involving "outcomes" within-subject effect Tests involving "surgical" within-subject effect Tests involving "outcomes by surgical" within-subject effect  F  p-value  161.27 1.16 0.10  O.00 0.33 0.99  Comparison of non-surgical and surgical arms on 7 outcome variables (DeVita's Test, Retraction #1 and Protraction #1 Scapular Strength Testing and all Kin-Com Test Positions (Internal Rotation Concentric/Eccentric and External Rotation Concentric/Eccentric)  114  Tests involving "outcomes" within-subject effect Tests involving "surgical" within-subject effect Tests involving "outcomes by surgical" within-subject effect  F  p-value  166.18 0.06 0.00  <0.00 0.81 0.99  Comparison of non-surgical and surgical arms on 3 outcome variables (DeVita's Test, Retraction #1 and Protraction #1 Scapular Strength Test Positions)  Tests involving "outcomes" within-subject effect Tests involving "surgical" within-subject effect Tests involving "outcomes by surgical" within-subject effect  F  p-value  8.54 2.69 6.97  0.02 0.16 0.004  Comparison of non-surgical and surgical arms on 4 outcome variables (Internal Rotation Concentric, Internal Rotation Eccentric, External Rotation Concentric, External Rotation Eccentric)  Tests involving "outcomes" within-subject effect Tests involving "surgical" within-subject effect Tests involving "outcomes by surgical" within-subject effect  F  p-value  8.00 7.37 1.44  0.04 0.04 0.28  Comparison of non-surgical and surgical arms on 2 outcome variables (Internal Rotation Concentric and Internal Rotation Eccentric)  Tests involving "outcomes" within-subject effect Tests involving "surgical" within-subject effect Tests involving "outcomes by surgical" within-subject effect  F  p-value  17.91 0.00 0.94  0.008 0.96 0.38  Comparison of non-surgical and surgical arms on 2 outcome variables (External Rotation Concentric and External Rotation Eccentric)  115  Between-Group Repeated Measures Analysis of Variance  Tests of Between-Subjects Effects Tests involving "Outcomes" Within-Subject Effect - Outcomes Tests involving "Outcomes" Within-Subject Effect - Group by Outcomes  F 0.15 942.68 0.01  p-value 0.706 0.00 1.00  Comparison of surgical arms of operated group and dominant arms of healthy group on 8 outcome variables (DeVita's Test, Retraction #1 Strength Test, Protraction #1 Strength Test, Protraction #2 Strength Test, Internal Rotation Concentric, Internal Rotation Eccentric, External Rotation Concentric and External Rotation Eccentric)  Tests of Between-Subjects Effects Tests involving "Outcomes" Within-Subject Effect - Outcomes Tests involving "Outcomes" Within-Subject Effect - Group by Outcomes  F 0.08 905.85 0.00  p-value 0.78 0.00 1.00  Comparison of surgical arms of operated group and dominant arms of healthy group on 4 outcome variables (DeVita's Test, Retraction #1 Strength Test, Protraction #1 Strength Test and Protraction #2 Strength Test)  Tests of Between-Subjects Effects Tests involving "Outcomes" Within-Subject Effect - Outcomes Tests involving "Outcomes" Within-Subject Effect - Group by Outcomes  F 2.08 440.61 1.61  p-value 0.18 0.00 0.22  Comparison of surgical arms of operated group and dominant arms of healthy group on 3 outcome variables (DeVita's Test, Retraction #1 Strength Test and Protraction #1 Strength Test)  116  Tests of Between-Subjects Effects Tests involving "Outcomes" Within-Subject Effect - Outcomes Tests involving "Outcomes" Within-Subject Effect - Group by Outcomes  F 0.99 22.19 0.87  p-value 0.33 0.00 0.47  Comparison of surgical arms of operated group and dominant arms of healthy group on 4 outcome variables (Internal Rotation Concentric, Internal Rotation Eccentric, External Rotation Concentric and External Rotation Eccentric)  Tests of Between-Subjects Effects Tests involving "Outcomes" Within-Subject Effect - Outcomes Tests involving "Outcomes" Within-Subject Effect - Group by Outcomes  F 14.11 5.74 3.97  p-value 0.007 0.001 0.006  Comparison of operated and healthy groups on 6 outcome variables (VAS, DDS "A", DDS "B", DASH "A", DASH "B" AND DASH "C")  117  

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