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DOI: http://dx.doi.org/10.5007/1980-0037.2013v15n2p193

original articleRBCDH

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1 Universidade de Pernambuco.Curso graduao em Fisioterapia.Petrolina, PE. Brasil.

2 Universidade de Pernambuco.Programa Associado de Ps--graduao em Educao FsicaUPE/UFPB. Recife, PE. Brasil.

3 Universidade de Pernambuco.Departamento de Fisioterapia.Petrolina, PE, Brasil.

4 Universidade de Pernambuco.Programa de Mestrado em Hebia-tria. Recife, PE. Brasil.

Received: 13 April 2012Accepted: 09 August 2012

Electromyographic activity and scapulardyskenesia in athletes with and withoutshoulder impingement syndrome Atividade eletromiogrfca e discinesia escapular ematletas com e sem sndrome do impacto no ombroValria Mayaly Alves de Oliveira 1Lasla da Silva Paixo Batista1Andr Luiz orres Pirau 2Ana Carolina Rodarti Pitangui 3,4

Rodrigo Cappato de Arajo 2,3,4

Abstract Te objective o this study was to evaluate the presence o scapular dyskinesisand pain, satis action and unction levels, as well as analyze the activation o scapularstabilizing muscles during isometric tasks o shoulder abduction in athletes with andwithout SIS. Tirty men athletes were divided into two groups: SIS group and Controlgroup. Te volunteers answered the Penn Shoulder Score questionnaire translated intoPortuguese, which evaluates pain, dys unction, and satis action with the shoulder. Tey were also evaluated or the presence o scapular dyskinesis through the Slide ScapularLateral est. Te electromyographic activity o the upper trapezius (U ), middle trapezius(M ), lower trapezius (L ), and serratus anterior (SA) muscles was evaluated duringthe isometric shoulder abduction in the rontal and scapular planes at angles o 45, 90,and 120. Te SIS group had a higher indication o pain and scapular dyskinesis whencompared to control group. In the SIS group, higher values o electromyographic ratiosbetween U /L and U /SA were observed in the rontal plane in relation to the scapularplane. Te conclusion can be made that pain, scapular dyskinesis, and altered muscleactivation pattern was more requent in the SIS group compared to the Control group.Tere ore, exercises that emphasize the scapular muscles should be considered whenplanning rehabilitation programs or the SIS.Key words : Electromyography; Scapula; Impingement syndrome.

Resumo O objetivo do estudo oi avaliar a presena de discinesia escapular, nveis de dor,satis ao e uno, bem como analisar a ativao dos msculos estabilizadores da escpuladurante tare as isomtricas de abduo do ombro em atletas com e sem SIO. Trinta atletas dosexo masculino oram divididos em grupo SIO e grupo Controle. Os voluntrios responderamao questionrio Penn Shoulder Score para lngua portuguesa que avalia dor, dis uno esatis ao em relao ao ombro, e tambm oram avaliados quanto presena de discinesiaescapular pelo Slide Scapular Lateral Test. A atividade eletromiogrfca dos msculos trapziosuperior (TS), trapzio mdio (TM), trapzio in erior (TI) e serrtil anterior (SA) oi avaliadadurante a realizao da abduo isomtrica do ombro nos planos rontal e escapular nasangulaes de 45, 90 e 120. O grupo SIO apresentou maior indicativo de dor e discinesiaescapular quando comparado ao grupo controle. No grupo SIO, oram observados valoresmaiores da razo eletromiogrfca entre TS/TI e TI/SA no plano rontal em relao ao planoescapular. Pode-se concluir que a dor, discinesia escapular e alteraes na atividade muscular oram mais observadas no grupo SIO quando comparado ao grupo Controle. Sendo assim,exerccios que en atizam a musculatura escapular devem ser considerados no planejamentode programas de reabilitao para a SIO.Palavras-chave : Eletromiografa; Escpula; Sndrome de coliso do ombro.

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EMG activity and scapular dyskenesia in athletes Oliveira et al.

INTRODUCTION

Te combined movements o the scapula, humerus, and clavicle duringarm elevation meet a balanced and coordinated rhythm o muscle actions,called scapulothoracic rhythm. Trough the action o scapular muscles,the scapula acts as a stable base or the rotator cu muscles and allowsmaximum e ciency o the shoulder during movement 1. Any change inthis rhythm may predispose a condition known as scapular dyskinesis 2.

Scapular dyskinesis, in turn, has been associated with complaints o shoulder pain. Tis pain mainly a ects individuals who per orm physi-cal activities that involve overload and/or repetitive overhead activities 3,4.Moreover, changes in the scapular kinematics may result in another pain ulcondition, especially during activities that go beyond the 90 o elevationo the arm: the shoulder impingement syndrome (SIS). Te SIS is de nedas the compression o the so tissues contained in the subacromial spaceduring movements that reduce the space between the coracoacromial archand the greater tubercle o the humerus 5-8.

Several authors suggest that abnormalities in the shoulder and scapularmovement are most commonly caused by the imbalance o the scapularmuscles9-12. In asymptomatic individuals during the movement o shoulderabduction, the upward rotation and posterior tilt o the scapula progres-sively increase with arm elevation, since there is greater muscle activity o the serratus anterior and lower trapezius during the movement, althoughthe activation o the upper trapezius in the last degrees o amplitude is alsonecessary 2,13. However, in symptomatic individuals, the upper trapezius ismore active due to the compensatory strategy that these individuals per-

orm due to decreased activation o the serratus anterior muscle. Tis im-balance ound in individuals with SIS results in decreased upward rotationo the scapula, increased anterior tilt o the scapula, and consequently lessmaintenance o the subacromial space 11,14. Tus, the abnormal kinematicso the shoulder increases propensity to impact during arm elevation 8,11.

Considering the clinical importance that shoulder impingement syn-drome has, the objective o this study was to analyze the pain, satis ac-tion, and unction levels o the shoulder, as well as analyze the presence o scapular dyskinesis and the activation o scapular stabilizing muscles dur-ing isometric tasks o arm elevation in athletes with and without shoulderimpingement syndrome.

METHODOLOGICAL PROCEDURES

Study Design and SampleTis is an observational cross-sectional study on a convenience non-probability sampling, composed o 30 male volunteers that are amateurathletes o ve teams (handball, volleyball, swimming, judo, and jiu-jitsu)in the city o Petrolina - PEmen that practice sports that overload andrequire constant shoulder elevation. Teir data are shown in able 1. A er

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Rev Bras Cineantropom Desempenho Hum 2013, 15(2):193 203 195

presenting the project, 17 athletes reported that they elt pain in the shoul-der joint and expressed desire to participate in the study. However, only 15 athletes met the inclusion and exclusion criteria to orm the SIS group.From this, another 15 asymptomatic athletes were selected to compose thecontrol group, thus ensuring two equal groups.

Volunteers in the control group needed to present the dominant asymp-tomatic shoulder, whereas in the SIS group volunteers were included thathad signs, symptoms, and a con rmed diagnosis o SIS, reporting shoulderpain or at least six weeks and presenting pain on palpation and positiveresults in at least two o the tests (Neer, Hawkins, and Jobe)15. Te volunteerswho had a history o surgery, ractures, or degenerative joint diseases in theupper limb were not included in the study. All volunteers needed to practicephysical activity or at least six months with a minimum requency o ourtimes per week and weekly duration o more than six hours o training.Furthermore, the SIS group only included volunteers that had not donephysical or medication therapies (use o anti-infammatory drugs) or atleast six months. All signed a erm o Free and Clear Consent and thestudy was approved by the Research Ethics Committee o the University o Pernambuco under protocol 274/10.

Teir height was determined using a scienti c portable stadiometer(Seca, Hamburg, Germany), and the total body mass was measured on amechanical scale properly calibrated (Filizola, So Paulo, SP, Brazil) withall procedures in accordance with the standards o the International Society

or the Advancement o Kinanthropometry (ISAK).

Table 1.

Standard mean and deviation o anthropometric data, age, as well as absolute and relative requencyo the unctional dominance o groups evaluated

Characteristic SIS (n=15) Control (n=15)

Age (years) 22.003.87 20.271.79

Body Mass (kilograms) 73.378.57 75.7012.49

Height (meters) 1.760.08 1.750.06

Right-handedness 14 (93.3%) 14 (93.3%)

Left-handedness 1 (6.7%) 1 (6.7%)

Evaluation ProceduresEach volunteer underwent an initial assessment to determine to whichgroup he would belong. Ten, the volunteer was asked to ll out a ques-tionnaire that assesses the pain, satis action, and unction o the shoulderusing the Penn Shoulder Score in Portuguese (PSS-Brazil). Te score ranges

rom zero to 100 points, the maximum score being indicative o no pain,high satis action, and good unction16.

Te assessment o the scapular dyskinesis was obtained through theSlide Lateral Scapular est, which consists o measuring the distancebetween the in erior angle o the scapula to the corresponding spinousprocess. Te measurement was made with the individual standing uprightand the shoulder at 0, 45, and 90 o abduction. A positive test result

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occurs when the di erence between the measurements o le and rightexceeds 15 mm3.

From these data, the order o tasks was drawn, and then trichotomy,antisepsis with alcohol, and mild abrasion o the skin was carried out inplaces where the di erential electrodes and the re erence electrode wouldbe positioned. Sur ace electrodes o the trapezius muscle - upper bers(U ), middle bers (M ), and lower bers (L ) - were positioned with tape,longitudinally over the muscle belly, approximately in the direction o themuscle bers, according to the recommendations o SENIAM 17. However, toplace the electrode in the serratus anterior muscle (SA), recommendationsproposed by Hintermeister et al. 18 were ollowed. Te re erence electrodewas positioned on the ulnar styloid process o the contralateral limb o the one being evaluated.

Later, the volunteer was asked to per orm three maximum voluntary isometric contractions (MVIC) with the shoulder positioned at 90 o ab-duction in the scapular plane, holding a load o 2 kg in both hands or 6 s. Atwo-minute interval was allowed between each contraction to avoid atigue.

o normalize the data, instead o maximum voluntary isometric contrac-tion, the maximum amplitude recorded during three MVICs was used dueto ewer variations between the values or each person, less risk o musclestrain and atigue, and better control o di erences in muscle activation 19,20.

The activity proposed to the volunteer was to maintain, by means of isometric muscle contraction, the arm abduction in the scapular and fron-tal planes for eight seconds at different angles (45, 90. and 120). Thevolunteers performed the unilateral movement with the dominant limb inall activities and in MVICs. A universal goniometer was used for accuratedetermination of the various angles of arm abduction and for scapular

plane orientation. There was a 2-minute interval between each activity tominimize the effects of muscle fatigue.

ElectromyographyTo collect the trapezius (UT, MT, and LT) and SA muscles electromyo-graphic signal, four channels connected to the electromyograph MyosystemBr-1 ( Datahominis Tecnologia Ltda , Uberlndia - Brazil) were used, whichcaught the myoelectric activity through surface, differential, and simpleelectrodes with a gain of 20 times, consisting of two parallel rectangular

pure silver bars (10 x 2 x 1 mm with a distance of 10 mm between bars)( Datahominis Tecnologia Ltda , Uberlndia - Brazil).

The software Myosystem Br-1 version 3.5 (Datahominis TecnologiaLtda , Uberlndia - Brazil) was used for the EMG signal processing. Justsix seconds of contraction of the eight seconds collected were used for data analysis, excluding the rst and last second. Data was collected at asampling frequency of 4000 Hz, and digital band-pass lters of 15-500Hz were applied. The raw values of EMG amplitude are represented bythe root mean square (RMS) and were subsequently normalized with themaximum value of MVIC.

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Electromyographic ratioTe ratio o muscle activity between U /L and U /SA in each task couldbe assessed by calculating the EMG ratio. For this, the normalized valueo U was divided by the normalized value o L and SA, respectively.Te ratio would be considered low i it was less than 0.3, which means theactivation o L or SA is three times higher compared to U . I the valueo the ratio was close to or greater than 1, it is interpreted as a similarmuscle activation between the two muscles or greater predominance o U over SA and L 21.

Statistical analysisStatistics were analyzed using the SPSS version 16.0 so ware. Te normality o the data was veri ed through the Shapiro-Wilk test. Te chi-square testwas used to compare the dyskinesis and the t test o unpaired Student orthe scores o the PSS-Brazil. In the intragroup analysis, ANOVA repeatedmeasures and post hoc ukey was used or EMG activity and comparisonsbetween groups were analyzed by the t test o unpaired Student. All o themhad a signi cance level o 5%.

RESULTS

PSS Brazil and dyskinesisTe intergroup comparison revealed di erences between the total scoreso the PSS-Brazil as well as the values o the areas o pain, satis action, and

unction (p < 0.02). Greater scapular dyskinesis was observed in the SISgroup when compared to the control group (p = 0.01). ( able 2).

Electromyography Scapular planeTe results or the control group indicated that the EMG activity o allmuscles evaluated was greater at angles o 90 and 120 in relation to 45 (p< 0.03), and EMG activity o the SA was greater at 120 when compared to90 (p < 0.01). For the SIS group, the results showed that the EMG activity o all muscles evaluated, with the exception o L , was greater at angles o 90 and 120 in relation to 45 (p < 0.03). Moreover, it was observed thatat 120 o abduction, the M had lower EMG activity compared to othermuscles (p = 0.02) ( able 3). No statistical di erence was observed in theintergroup comparison (p > 0.09).

Table 2. Absolute and relative requency o scapular dyskinesis and mean scores o the PSS Brazil o the control and SIS group.

Dyskinesis PSS-Brazil

Present Absent Pain Satisfaction Function Total Score

SIS group 14 (93.3%) 1 (6.7%) 19.737.18 6.132.85 47.206.42 73.0712.75

Control group 6 (40%) 9 (60%) 26.734.57 8.132.07 56.135.44 91.0011.51

p 0.01 0.01 0.01 0.02 0.01 0.01

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Frontal planeFor both groups, increased scapular muscle activation was observed dur-ing elevation at 90 and 120 in relation to the angle o 45 (p < 0.02). Inthe control group, the M was more active in abduction at 45 and 90compared to the L and SA muscles (p < 0.03). However, when compar-ing the muscle activity in the angles o 90 and 120, it can be seen thatall the muscles are most active at 120 (p < 0.02), except or the M (p =0.06). In SIS group, the U indicated greater muscle activity than the Lat a 45 elevation (p = 0.001) and greater activation than SA during 90 o elevation (p = 0.01) ( able 3). No statistical di erence was observed in theintergroup comparison (p > 0.07).

Frontal plane vs. Scapular planeFor the control group, the results showed that the tasks in the rontalplane yielded increased activity o the U , L , and SA muscles at 120 (p< 0.03) and o the M muscle at 90 and 120 (p < 0.02). However, or theL muscle at 45, a decrease in electromyographic activity in the rontalplane (p = 0.01) was observed.

he results or the SIS group showed increased activity o U andM muscles at angles o 90 and 120 (p < 0.01), while per ormingtasks in the rontal plane in relation to the scapular plane. Further-more, lower activity was observed in the SA muscle when elevatingthe arm at 45 in the rontal plane (p = 0.03) when compared to thescapular plane.

UT/SA and UT/LT ratioTe results or the control group showed that the ratio U /SA had lower values at 90 and 120 compared to 45 in both planes o task execution(p < 0.05). No di erence was observed in the values o the ratio U /L incomparing the angles (p > 0.12). However, it was observed that the valueso the ratios U /SA and U /L were higher when carrying out the tasksin the rontal plane (p < 0.02).

In the SIS group, we observed a signi cant increase o the values o the ratio U /L when executing the tasks at 45 and 90 in the rontalplane in comparison to the scapular plane (p < 0.01). Moreover, the valueo the ratio U /SA showed an increase in the rontal plane only at 120(p = 0.02). In the rontal plane, the results showed that there is a decreasein the values o U /SA and U /L ratios at 120 in relation to the otherangles (p < 0.03). However, no signi cant di erences were observed in thescapular plane. No statistical di erence was observed (p > 0.16) in inter-group comparison. ( able 4).

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DISCUSSION

Several studies1,2,22 have evaluated the relationship between dyskinesis,pain, and muscle activation pattern during arm elevation in order toidenti y possible changes in symptomatic individuals and their rela-tionship with di erent degrees o abduction, whether on the rontal orscapular plane.

The dynamic stability of the scapula comes from the muscle action of the trapezius and SA bers 23, where any impairment in the activation of these muscles can trigger abnormalities in shoulder kinematics and conse-quently dysfunction of this joint 24,25 . The results of this study showed higher incidence of pain and dyskinesis in individuals with SIS, corroboratingwith other texts, since changes in scapular motility and positioning arefound in 68 to 100% of individuals that have an injury in their shoulder 26.Complaints of pain are reported in 80% of the cases 26.

Analyzing the results of PSS-Brazil, it can be seen that signi cantdifferences were found in the total score and levels of pain, degree of

Table 3. Normalized electromyographic records o the Trapezius upper bers (UT), middle bers (TM), and lower bers (LT) and Serratus Anteriomuscles during Open Kinetic Chain (OKC) activities on rontal and scapular planes

Scapular plane

SIS group Control group

45 90 120 45 90 120

UT 0.380.13 0.510.11 f 0.630.11 a,g 0.390.13 0.540.14 f 0.620.12 g

MT 0.260.12 0.390.12 f 0.440.14 g 0.340.15 0.480.15 f 0.530.21 g

LT 0.470.56 0.520.14 0.630.20 b 0.370.13 0.570.21 f 0.670.24 g

SA 0.290.10 0.640.43 f 0.740.15 c,g 0.420.51 0.520.13 f 0.770.18 g,h

Frontal plane

UT 0.340.14 d 0.620.13 e,f 0.820.16 g 0.330.15 0.570.13 f 0.870.20 g,h

MT 0.320.21 0.650.27 f 0.800.21 g 0.440.20 b,c 0.860.39 b,c,f 1.050.42 g

LT 0.200.08 0.490.19 f 0.880.42 g,h 0.220.11 0.480.20 f 0.880.37 g,h

SA 0.230.06 0.450.10 f 0.760.18 g,h 0.220.10 0.460.11 f 0.850.19 g,h

P < 0.05; (a) indicates the statistical diference between UT and MT, (b) between LT and MT, (c) between SA and MT, (d) between UT and LT, (e) betweand SA, ( ) indicates the diference between 45 and 90, (g) between 45 and 120 and (h) between 90 and 120. ( ) Indicates the statistical diferencebetween the EMG activity in the scapular plane and rontal plane.

Table 4.Ratio between the activity o the Upper Trapezius and Serratus Anterior (UT/SA) and Upper Trapezius and Lower Trapezius (UT/LT) musclesOpen Kinetic Chain (OKC) activities on rontal and scapular planes

Scapular plane

SIS group Control group

45 90 120 45 90 120

UT/SA 1.350.51 1.411.80 0.880.20 1.360.53 1.050.26a 0.830.16b

UT/LT 1.210.60 1.020.22 1.130.62 1.190.56 0.990.18 1.050.50

Frontal plane

UT/SA 1.500.41 1.411.21 1.120.24b,c 1.871.12 1.320.52a 1.050.33b

UT/LT 1.881.10 1.440.53 1.05 0.23b,c 1.570.55 1.350.51 1.180.62

P < 0.05; (a) indicates the statistical diference between 45 and 90, (b) between 45 and 120, (c) between 90 and 120. ( ) Indicates the statisticaldiference between the ratios in the scapular plane and rontal plane.

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satisfaction, and shoulder function. However, aspects of pain and func-tion, as well as total score, gain prominence because besides the statisticaldifference, all these aspects differ between groups and are higher than thelevels reported in other texts and are considered clinically signi cant (6.51for pain, 8.16 for function and 12.1 for total score) 27. In the present study,

we found mean differences of 7.00, 8.93, and 17.3 points in the assessmentof pain, function, and total score, respectively.

These ndings are extremely important because they demonstratethat many individuals who practice different sports live with signi cantde cits in function and relevant levels of pain without any follow-up beit therapeutic or preventive. This reinforces the importance of greater at-tention by different health professionals in monitoring this public in order to act not only in the early detection and treatment, but also in preventingthis problem, thus ensuring improved health and functional performance.

In the present study, there was a progressive increase in the activity of all muscles according to the degree of elevation of the arm when analyzingthe tasks in the scapular plane of asymptomatic individuals. When Ludewiget al. 10 compared the kinematics and activity of the scapular muscles inasymptomatic individuals and with SIS, they also found that asymptomaticindividuals had increased electromyographic activity concurrent with theincrease of the angle, especially between the angles of 90 and 120. Fur-thermore, in this study it was observed that the SA became more active at120 of abduction in individuals without SIS, proving thus a greater need for stabilization, upward rotation, and posterior tilt of the scapula in this angle.

In the SIS group, a progressive increase in the activation of all mus-cles was also seen with the increase in angle on the scapular plane, withthe exception of LT. The LT muscle is antagonistic to the UT. Thus, theimbalance in the activation of these muscles may contribute to alterationsin scapular kinematics and consequently reduce the subacromial space 10.The MT, in turn, plays an important role in stabilizing and controllingthe scapular position. Cools et al. 20 state that this muscle is active duringshoulder abduction because it acts as a stabilizer while contracting eccentri-cally to control the change of position of the scapula produced by UT andSA. However, it was seen in their study that changes in MT activation can

be found in individuals with SIS, agreeing with the results of this studyin which the MT showed less activation in the last degrees of abductionin relation to other muscles.

Tucker et al. 23 observed that the MT has different muscle activation between individuals with and without SIS. The MT tends to x the scapular shaft to allow the controlled upward rotation of the scapula, but changesin the activity of this muscle can compromise the function of scapular

positioning and possibly trigger scapular dyskinesis.In relation to the frontal plane, both the control group and the SIS group

had ascending muscle activations with the angles proposed. But increasedactivity of MT in relation to UT and SA was identi ed in the control group,where at 120 of abduction this increase was no longer viewed. Cools et

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al. 20 reported that different trapezius bers react differently. As the SAcontracts, the scapula tends to lateralization, but this displacement tends to

be resisted by the LT, which is continuously changing in length to stabilizethe rotation axis. The UT in turn exerts higher rotational movement aroundthe axis, complementing the action of the SA. Therefore, although the MT

is very strong, it is located near the scapulas axis of rotation, and therefore,its ability to generate torque is decreased, especially in the last degrees of scapular abduction, which explains the behavior of the MT in this study.

As to individuals in the SIS group, the elevation in the frontal planeshowed an increase in activity of the UT in relation to the LT at 45. Coolset al. 20 found delay in the UT activation in individuals with SIS duringthe rst degrees of elevation when comparing the relative latency of thethree bers of the trapezius in people with and without SIS. Thus, thedelay in the activation of the LT can lead to a relative increase of the UT.However, the results of this study found that at 90 of abduction, the UTshowed higher muscle activity when compared to SA. This behavior canalso be seen in the studies of Lin et al. 28 that reported an increase in theactivity of the UT and a decrease of the SA by analyzing the pattern of muscle activation in individuals with SIS. The increased UT activationresults in the elevation of the clavicle and anterior tilt of the scapula andcan be seen as a compensatory strategy used by individuals with SIS inan attempt to raise the arm.

When comparing the muscle behavior between frontal and scapular plains, individuals with SIS showed increase in EMG activity of the UTand MT and lower activation of the SA when compared to the scapular

plane. Additionally, analysis of EMG ratios could show the scapular muscleimbalance in individuals with SIS. The proportion of activation betweenthe UT and LT during the 45 and 90 and between UT and SA at 120was signi cantly higher in the frontal plane when compared to the scapular

plane. The exercises of arm elevation are widely used during rehabilitation by promoting a strengthening of glenohumeral muscles 29. However, it isimportant to consider rebalancing the scapular stabilizing muscles prior toglenohumeral strengthening. The exercises in the scapular plane are moreindicated to ensure the rebalancing of scapular muscles before a greater activation of the SA and LT.

Limitations - The analysis of the EMG signal and dyskinesis were performed during the execution of isometric tasks, not allowing thus thegeneralization of the results for dynamic activities. However, isometriccontractions provide more reliable results regarding the EMG analysis.Furthermore, this study emphasized the presence of imbalances even while

performing tasks considered simple and easy, indicating that additionaloverload may worsen this condition. However, this hypothesis remains to

be tested. Through these results, future studies can investigate speci c ex -ercises for the scapular stabilizing muscles in order to better predict whichactivity contributes to the proper conduct of the scapula and consequentlycorrection of scapular dyskinesis.

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CONCLUSION

Individuals with SIS showed di erences in pain, dyskinesis, and muscleactivation levels when compared to asymptomatic individuals. Moreover,it was observed that muscle imbalance is present in tasks considered sim-ple or trained athletes and that this is most evident in the rontal plane.Tere ore, strengthening scapular muscles must be stressed initially in theSIS treatment and per ormed pre erably in the scapular plane.

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Corresponding author

Rodrigo Cappato de ArajoUniversidade de Pernambuco,Campus Petrolina.Departamento de Fisioterapia.BR 203 Km 2 S/N, Vila EduardoCEP 56300 000 Petrolina, PE. Brasile mail: [email protected]

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