Literature ReviewThe reliability of physical examination tests for the clinical assessment of scapular dyskinesis in subjects with shoulder complaints: A systematic review
Introduction
An alteration of normal scapular kinematics is defined as scapular dyskinesis (Kibler and Sciascia, 2010, Kibler et al., 2009, Kibler et al., 2013), and has been identified in patients with shoulder impingement syndrome (Cools et al., 2003, Ludewig and Cook, 2000; P. W.; McClure et al., 2006, Struyf et al., 2014a, Timmons et al., 2012), rotator cuff pathology (Ludewig and Reynolds, 2009, Mell et al., 2005), shoulder instability (Ludewig and Reynolds, 2009, Ogston and Ludewig, 2007, Struyf et al., 2014a) labral injuries (Myers et al., 2006, Roche et al., 2015) and adhesive capsulitis (Fayad et al., 2008, Ludewig and Reynolds, 2009). Scapular dyskinesis is assumed to be an unspecific response to specific shoulder pathology (Kibler and Sciascia, 2010, Kibler et al., 2013). In a cohort of Norwegian elite handball players, Clarsen, Bahr, Andersson, Munk, and Myklebust (2014) identified obvious scapular dyskinesis as a risk factor for shoulder injury. Also in rugby players scapular dyskinesis was associated with shoulder discomfort (ie, pain, apprehension, or fatigue; if any, persisting more than 2 weeks) (Kawasaki, Yamakawa, Kaketa, Kobayashi, & Kaneko, 2012). In contrast, in a prospective study of recreational overhead athletes, Struyf, Nijs, Meeus, et al. (2014) did not identify scapular characteristics predicting shoulder pain. In addition, two other studies did not find an association between scapular dyskinesis and shoulder complaints in baseball players (Myers et al., 2013, Shitara et al., 2015). Because of conflicting evidence regarding the causal relationship of scapular dyskinesis and shoulder pathologies, it seems comprehensible that this issue is still under debate (Cools et al., 2014). It is suggested that during active elevation of the upper limb the scapula needs to upwardly rotate, posteriorly tilt and externally rotate to avoid pathology (Bourne et al., 2007, Braman et al., 2009, Braman et al., 2014, Kibler et al., 2013, Kibler and Sciascia, 2010, Lawrence et al., 2014, Ludewig and Cook, 2000, Ludewig et al., 2009, Matsuki et al., 2011; P. W.; McClure et al., 2001, Yano et al., 2010). Consistent patterns of alterations of scapular movement have not yet been identified for specific pathologies (Kibler et al., 2013, Lawrence et al., 2014, Ludewig and Reynolds, 2009, Ratcliffe et al., 2014), and altered positions or motions of the scapula might be part of normal variations or adaptations to sporting demands (Cools et al., 2010, Myers et al., 2005, Oyama et al., 2008, Ribeiro and Pascoal, 2013, Wright et al., 2013).
Physical examination tests for the assessment of scapular dyskinesis are being used to identify existing impairments of patients with shoulder pain and based on identified impairments during the examination, adequate rehabilitation programs addressing possible cause for scapular dyskinesis can be developed (Cools et al., 2014, Klintberg et al., 2015, Wright et al., 2013). There is evidence that rehabilitation, including exercises targeting the scapulothoracic muscles, is effective in patients with shoulder impingement syndrome (Baskurt et al., 2011, De Mey et al., 2012, Struyf et al., 2013) and chronic type III acromioclavicular dislocation (Carbone, Postacchini, & Gumina, 2015). Scapular dyskinesis has been primarily evaluated by clinical observation (Kibler & Sciascia, 2013). Therefore, it is essential to use reliable and valid clinical testing procedures to assess the position of the scapula during rest as well as active movement and to evaluate if scapular position or dynamics contribute to shoulder pain. Wright et al. (2013) conducted a systematic review to assess the validity of scapular physical examination tests and questioned the use of specific tests to diagnose shoulder pain or pathology.
Not only validity, but also reliability are of concern regarding the application of clinical tests (Drummond, 2008, Karanicolas et al., 2009, Scholtes et al., 2011), since a test will not be valid if not reliable (Atkinson and Nevill, 1998, de Vet et al., 2011). Reliability is generally defined as “the degree to which a measurement is free from measurement error” (Mokkink et al., 2010b). Measurements by the same persons on different occasions are referred to as intrarater reliability, whereas measurements by different persons on the same occasion as interrater reliability (Mokkink et al., 2010b). Intra- as well as interrater reliability both provide valuable information for clinicians. Intrarater reliability is relevant for repeated measurements by the same rater (H. C. de Vet, Mokkink, Terwee, Hoekstra, & Knol, 2013) and therefore a prerequisite for documentation of changes in the patient's status (e.g. position of the scapula or pain before and after treatment) over time. In contrast, if clinicians are interested in knowing if their diagnosis made is in agreement with the diagnosis made by colleagues, this would be reflected by interrater reliability (H. C. de Vet et al., 2013). Variability among raters influences diagnostic accuracy, as empirical research has shown (P. Whiting et al., 2004; P. F. Whiting, Rutjes, Westwood, Mallett, & Group, 2013).
Scapular physical examination tests are likely to be performed in routine care very frequently to identify patients in need of specific rehabilitation programs, to evaluate the effectiveness of the therapy and to monitor the patient's status. Thus not only the validity, but also the reliability of physical examination tests for scapular dyskinesis should be summarized systematically and assessed critically.
Therefore, the objective of this systematic review was to summarize and evaluate intra- and interrater reliability research on physical examination tests used for the assessment of scapular dyskinesis in symptomatic subjects.
Section snippets
Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used during the whole process of this review (Liberati et al., 2009). The PRISMA statement aims to improve the reporting of systematic reviews and meta-analyses. This systematic review was registered a priori within the International prospective register of systematic reviews (PROSPERO; CRD42014009018).
Study selection
Results of the literature search and study selection are shown in the PRISMA flow chart (Fig. 1). In total, 3259 records were screened after duplicates were removed, of which 15 publications met the predefined inclusion/exclusion criteria (Baertschi et al., 2013, Curtis and Roush, 2006, Juul-Kristensen et al., 2011, Kibler et al., 2002; J. S.; Lewis and Valentine, 2007, Lewis and Valentine, 2008; P.; McClure et al., 2009, Nijs et al., 2005, Odom et al., 2001, Rabin et al., 2006, Shadmehr
Main findings
This systematic review identified fifteen articles, which examined the reliability of forty-one physical examination tests for the clinical assessment of scapular dyskinesis with varying intrarater as well as interrater reliability. The included studies were partly of low methodological quality according to the methodological assessment using the QAREL tool (N. P. Lucas et al., 2010). In addition, it is notable that for only five out of forty-one (12.20%) physical examination tests evaluated in
Conclusion
Numerous physical examinations tests for the assessment of scapular dyskinesis are described in the literature. Overall, there is a lack of high-quality studies evaluating intra- as well as interrater reliability. In addition, reliability measures differed between included studies which hinder proper comparison of results. The effect of manual correction of the scapula on shoulder symptoms was evaluated in only one study, which is striking, since symptom alteration tests are used in routine
Competing interests
TL, JS, JL and CK: None known. FS: Author/Coauthor of studies included in this review. However, FS was not involved in screening of titles and abstracts or full texts, data extraction or methodological assessment of included studies.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Contributors
TL made a substantial contribution to the design of the study; performed the literature search; reviewed the literature; methodologically appraised the articles; extracted, analyzed and interpreted the data; produced the figures and graphs; critically revised and wrote the manuscript.
FS assisted with analysis and interpretation of data; critically revised the article and wrote the manuscript.
JS critically commented on the design of the study; critically revised the article.
JL critically
Highlights
Findings: This systematic review identified a lack of high-quality studies evaluating intra- as well as interrater reliability of physical examination tests for the clinical assessment of scapular dyskinesis.
Implications: There is a strong need for sound research of high methodological quality to establish the reliability especially of symptom alteration tests for scapula dyskinesis, which are used to develop rehabilitation program, to evaluate the effectiveness of the therapy, and to monitor
Acknowledgments
All person who participated in the workflow are stated as author.
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