STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To determine the effect of the modified scapular assistance test (SAT) on 3-dimensional shoulder kinematics, strength, and linear measures of subacromial space in patients with subacromial impingement syndrome (SAIS). BACKGROUND: Abnormal scapular kinematics have been identified in patients with SAIS. Increased scapular upward rotation and posterior tilt, as induced with manual assistance using the SAT, has been theorized to increase subacromial space and may alter shoulder strength. METHODS: Forty-two subjects (21 with SAIS; 21 controls) participated in this study. The anterior outlet of the subacromial space, measured via the acromiohumeral distance (AHD) on ultrasound images, and 3D scapular kinematics, measured using motion analysis, were determined with the arm at rest, and at 45° and 90° of active elevation with and without SAT. A dynamometer was used to measure isometric shoulder strength. Full factorial mixed-model ANOVAs evaluated the effects of SAT on variables between groups. RESULTS: There was an increase in scapular posterior tilt at all angles, upward rotation at rest and 45° elevation, and AHD at 45° and at 90° with the SAT. The SAT did not alter normalized isometric strength. There were no differences in response to the SAT between the SAIS and control groups. CONCLUSIONS: Manual scapular assistance using the SAT influences factors associated with SAIS, such as subacromial space and potentially scapular orientation during static arm elevation, but not more so in individuals with SAIS than in healthy individuals. The SAT performed statically may be a way to identify potential subgroups of individuals with SAIS for whom subacromial space narrowing may be a contributing factor.

J Orthop Sports Phys Ther, Epub 27 January 2012. doi:10.2519/jospt.2012.3579

KEY WORDS: acromiohumeral distance, examination, rotator cuff disease, shoulder, ultrasound imaging

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To examine the effects of altering posture on the subacromial space (SAS) in subjects with rotator cuff disease and subjects without shoulder pain. BACKGROUND: Poor upper quadrant posture has been linked to altered scapular mechanics, which has been theorized to excessively reduce SAS. However, no study has examined the direct effects of altering upper quadrant posture on SAS. We hypothesized that upright posture would increase and slouched posture would decrease the SAS, as compared to a normal posture, when measured both with the shoulder at rest along the side of the trunk and when maintained in 45° of active shoulder abduction. METHODS: Participants included 2 groups: the subjects with shoulder pain and rotator cuff disease, as diagnosed via magnetic resonance imaging (n = 31), and control subjects without shoulder pain (n = 29). The SAS was imaged with ultrasound using a 7.5-MHz linear transducer placed in the coronal plane over the posterior to midportion of the acromion. The SAS was measured on ultrasound images using the acromiohumeral distance (AHD), defined as the shortest distance between the acromion and the humerus. The AHD was measured in 2 trials at 2 arm angles (at rest along the trunk and at 45° of active abduction) and across 3 postures (normal, slouched, and upright), and averaged for data analysis. RESULTS: Two mixed-model analyses of variance, 1 for each arm angle, were used to compare AHD across postures and between groups. There was no interaction between group and posture, and no significant main effect of group for either arm position. There was no significant main effect of posture for the arm at rest (P = .26); however, there was a significant main effect of posture on AHD at the 45° abduction arm angle (P = .0002), with a significantly greater AHD in upright posture (mean AHD, 9.8 mm), ascompared to normal posture (mean AHD, 8.6 mm). CONCLUSION: The effect of posture on SAS, as measured by the 2-dimensional AHD using ultrasound of the posterior to middle aspect of the SAS, is small. The AHD increased with upright posture by 1.2 mm compared to normal posture, when the arm was in 45° active abduction.

J Orthop Sports Phys Ther 2010;40(10):633-640, Epub 6 August 2010. doi:10.2519/jospt.2010.3155

KEY WORDS: impingement, posture, rotator cuff, shoulder, subacromial space

STUDY DESIGN: Case series. BACKGROUND: Few studies have defined the dosage and specific techniques of manual therapy and exercise for rehabilitation for patients with subacromial impingement syndrome. This case series describes a standardized treatment program for subacromial impingement syndrome and the time course and outcomes over a 12-week period. CASE DESCRIPTION: Ten patients (age range, 19-70 years) with subacromial impingement syndrome defined by inclusion and exclusion criteria were treated with a standardized protocol for 10 visits over 6 to 8 weeks. The protocol included a 3-phase progressive strengthening program, manual stretching, thrust and nonthrust manipulation to the shoulder and spine, patient education, activity modification, and a daily home exercise program of stretching and strengthening. Patients completed a history and measures of impairments and functional disability at 2, 4, 6, and 12 weeks. OUTCOMES: Treatment success was defined as both a 50% improvement on the Disabilities of the Arm, Shoulder, and Hand (DASH) score and a global rating of change of at least “moderately better.” At 6 weeks, 6 of 10 patients had a successful (mean ± SD) DASH outcome score (initial, 33.9 ± 16.2; 6 weeks, 8.1 ± 9.2). At 12 weeks, 8 of 10 patients had a successful DASH outcome score (initial, 33.1 ± 14; 12 weeks, 8.3 ± 6.4). As a group, the largest improvement was in the first 2 weeks. The most common impairments for all 10 patients were rotator cuff and trapezius muscle weakness (10 of 10 patients), limited shoulder internal rotation motion (8 of 10 patients), and reduced kyphosis of the midthoracic area (7 of 10 patients). DISCUSSION: A program aimed at strengthening rotator cuff and scapular muscles, with stretching and manual therapy aimed at thoracic spine and the posterior and inferior soft-tissue structures of the glenohumeral joint appeared to be successful in the majority of patients. This case series describes a comprehensive impairment-based treatment which resulted in symptomatic and functional improvement in 8 of 10 patients in 6 to 12 weeks. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(8):474-493. doi:10.2519/jospt.2010.3223

KEY WORDS: manipulation, pain, rotator cuff, shoulder, supraspinatus

SYNOPSIS: This manuscript describes the consensus rehabilitation guideline developed by the American Society of Shoulder and Elbow Therapists. The purpose of this guideline is to facilitate clinical decision making during the rehabilitation of patients following arthroscopic anterior capsulolabral repair of the shoulder. This guideline is centered on the principle of the gradual application of stress to the healing capsulolabral repair through appropriate integration of range of motion, strengthening, and shoulder girdle stabilization exercises during rehabilitation and daily activities. Components of this guideline include a 0- to 4-week period of absolute immobilization, a staged recovery of full range of motion over a 3-month period, a strengthening progression beginning at postoperative week 6, and a functional progression for return to athletic or demanding work activities between postoperative months 4 and 6. This document represents the first consensus rehabilitation guideline developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients following arthroscopic anterior capsulolabral repair of the shoulder.

J Orthop Sports Phys Ther 2010;40(3):155-168, Epub 5 February 2010. doi:10.2519/jospt.2010.3186

KEY WORDS: Bankart repair, capsular plication, postoperative rehabilitation, shoulder instability, therapeutic exercise

Study Design: Psychometric evaluation of a cross-sectional survey. Objectives: To determine the validity of measures obtained from the MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care (MRPS) to differentiate between patient satisfaction with internal and external factors. Background: Self-report measures that sample a variety of items provide clinicians with an array of information that may assist in assessing patient satisfaction. An important measurement characteristic of these instruments is the ability to discriminate between different factors that may influence patient reports of satisfaction with care, ie, discriminant validity. In previous work, exploratory factor analysis suggested that the MRPS questionnaire has a 2-factor structure: ‘‘internal,’’ relating to the patient-therapist interaction, and ‘‘external,’’ describing nontherapist issues such as admissions and clinic environment. Methods and Measures: One thousand four hundred forty-nine adult patients completed the MRPS questionnaire upon finishing their course of outpatient physical therapy treatment. Discriminant validity of the 2-factor model was assessed using confirmatory factor analysis. The measures from the 2 factors were then evaluated for reliability by calculating the standard error of measurement (SEM), and for concurrent validity by correlating the mean score of the factors and individual items to global measures of satisfaction. Results: Confirmatory factor analysis supported a good to excellent model fit for the internal factor (7 items) and external factor (3 items). The SEM for the 2 factors was 0.19 and 0.24, indicating a low degree of measurement error. Both factors had high significant correlation with global measures of satisfaction (internal, r = 0.83 and 0.80; external, r = 0.71 and 0.71). All individual items within the 2 factors had significant correlations with global measures ranging from r =0.33 to 0.80. Conclusions: Our findings provide evidence of discriminant and concurrent validity of the 2-factor solution for the MRPS questionnaire for the sample that was tested. This 2-factor solution yields measures that are relatively free of error and may discriminate between internal and external factors influencing patient satisfaction. Patients who complete their course of physical therapy report that the professional interaction between the therapist and patient, especially the meaningful exchange of relevant information, is critical for patient satisfaction with care. The generalizability of our data to patients who do not complete their physical therapy care or who are receiving care in other health care environments is unknown.

J Orthop Sports Phys Ther. 2005;35(1):24-32. doi: 10.2519/jospt.2005.1471

Key Words: instrument validation, questionnaire, self-report, survey

Study Design: Nonrandomized 2-group post-test only. Objective: To compare scapular position and orientation between subjects with and without impingement syndrome. Background: Abnormal scapular motion is commonly believed to be a contributing factor to shoulder impingement syndrome. Methods and Measures: Twenty nonimpaired subjects with a mean age of 34.3 (± 7.5 years) and 17 patients with impingement syndrome with a mean age of 45.8 (± 11.0) participated. A 3-dimemionaI electromechanical digitizer was used to measure scapular position and orientation in 3 planes. Measurements were taken with the arm at the side, elevated in the scapular plane to horizontal, and at maximum elevation. One-way analysis of variance was used to compare nonimpaired subjects to the impingement group and the symptomatic and asymptomatic sides within the impingement group. Five scapular kinematic variables were assessed at each arm position. Orientation was described by posterior tilting angle, upward rotation angle, and internal rotation angle. Position was described by medial-lateral position and superior-inferior position and determined by the distance from the scapula centroid to the seventh cervical vertebra (C7). Results: During scapular plane elevation of the arm, the scapula showed a general pattern of increasing posterior-tilt angle, increasing upward-rotation angle, and decreasing internal-rotation angle in both impingement and nonimpaired groups. Also, the scapula moved to a more superior position and a slightly more medial position with increasing arm elevation. Compared to nonimpaired subjects (34.6° ± 9.7), those with impingement demonstrated a significantly lower posterior tilting angle of the scapula in the sagittal plane (25.1° ± 9.1). Subjects with impingement also demonstrated higher superior-inferior scapular position with maximal arm elevation (5.2 cm ± 1.6 below the first thoracic vertebrae) compared to nonimpaired subjects (7.5 cm ± 1.5). Conclusions: These results suggest that altered scapular kinematics may be an important aspect of the impingement syndrome.

J Orthop Sports Phys Ther. 1999;29(10):574-586.

Key Words: impingement, kinematics, rotator cuff, scapula, shoulder

Study Design: Psychometric evaluation of a cross-sectional survey. Objectives: The purpose of this study was to examine the psychometric properties of reliability and validity of the Penn Shoulder Score (PSS). Background: Shoulder outcome measures are used to assess patient self-report levels of pain, satisfaction, and function. The PSS is a 100-point shoulder-specific self-report questionnaire consisting of 3 subscales of pain, satisfaction, and function. This scale has been utilized in the literature. However, the measurement properties of reliability and validity, including responsiveness, of the PSS subscales and overall scale need to be established. Methods and Measures: Patients (n = 40) with shoulder disorders undergoing a course of outpatient physical therapy completed the PSS at initial visit and again within 72 hours to assess test-retest reliability. The Constant Shoulder Score (CSS) and the American Shoulder and Elbow Surgeons Shoulder Score (ASES) were also completed at the initial visit and compared to the PSS to assess convergent construct validity. A separate cohort of patients (n = 109) completed the PSS at initial visit and 4 weeks later. These scores were used to assess internal consistency and responsiveness. Results: Reliability analysis revealed a test-retest ICC _2,1 of 0.94 (95% CI, 0.89-0.97). Internal consistency analysis revealed a Cronbach alpha of 0.93. The standard error of measurement (SEM) was ± 8.5 scale points (based on a 90% CI) and the minimal detectable change (MDC) was ± 12.1 scale points (based on a 90% CI). The minimal clinically important difference (MCID) for improvement was 11.4 points. Pearson product moment correlation coefficients between the PSS and the CSS and ASES were 0.85 and 0.87, respectively. Responsiveness analysis revealed an effect size of 1.01 and a standardized response mean of 1.27. Conclusions: This study has demonstrated that the PSS is a reliable and valid measure for reporting outcome of patients with various shoulder disorders.

J Orthop Sports Phys Ther. 2006;36(3):138-151. doi:10.2519/jospt.2006.2090

Key Words: outcome assessment, psychometrics, reliability, validity