Effects of Scapular Upward Rotation

Exercises on Alignment of Scapula and

Clavicle and Strength of Scapular Upward

Rotators in Subjects With Scapular Down-

ward Rotation Syndrome

Sungmin Ha

The Graduate School

Yonsei University

Department of Physical Therapy

Effects of Scapular Upward Rotation

Exercises on Alignment of Scapula and

Clavicle and Strength of Scapular Upward

Rotators in Subjects With Scapular Down-

ward Rotation Syndrome

Sungmin Ha

The Graduate School

Yonsei University

Department of Physical Therapy

Effects of Scapular Upward Rotation

Exercises on Alignment of Scapula and

Clavicle and Strength of Scapular Upward

Rotators in Subjects With Scapular Down-

ward Rotation Syndrome

A Dissertation

Submitted to the Department of Physical Therapy

and the Graduate School of Yonsei University

in partial fulfillment of the

requirements for the degree of

Doctor of Philosophy

Sungmin Ha

June 2012

This certifies that the doctoral dissertation of Sungmin Ha is approved.

Thesis Supervisor: Ohyun Kwon

Chunghwi Yi: Thesis Committee Member #1

Heonseock Cynn: Thesis Committee Member #2

Jonghyuck Weon: Thesis Committee Member #3

Taeho Kim: Thesis Committee Member #4

The Graduate School Yonsei University

June 2012

Acknowledgements

Many people contributed to my progress in preparing this dissertation, and I am

grateful to all those who made it possible. First, I would like to express my deep

gratitude to professor Oh-yun Kwon for his help and support. As my primary mentor

and director, he perfectly guided me in the research topic, experiments, and writing of

my dissertation. Furthermore, he encouraged me not only in this work but also in my

growth as an independent thinker.

Additionally, I wish to express my deep gratitude to professor Chung-hwi Yi whose

advice, academic experience, and vast knowledge taught me a great deal. I would like

to express my gratitude to professor Heon-seock Cynn, who always demonstrated

gentle scholarly concern, giving encouragement and intelligent advice. I sincerely

appreciate professor Jong-hyuck Weon, who gave me copious advice and

encouragement, and professor Tae-ho Kim, whose prudent advice and sincere

encouragement helped to improve the quality of this dissertation. I also sincerely

thank professors Sang-hyun Cho, Hye-seon Jeon, and Seung-hyun Yoo, who helped

expand my knowledge and perspective.

I deeply appreciate all the members of KEMA, especially Jun-hyeok Jang, Do-

young Jung, Jae-sop Oh, Mun-whan Kim, and Won-whee Lee. I am grateful to my

colleagues, Su-jung Kim, Kyeu-nam Park, Sung-dae Choung, Si-hyun Kim, and In-

cheol Jeon, who have been like brothers or sisters to me, always giving me valuable

support and encouragement. Thanks to their support, I was able to earn a doctorate. I

would also like to express my deep gratitude to all members of the graduate school,

Department of Physical Therapy.

Finally, I am grateful to all my family, who always encouraged me, especially my

parents, who provided endless love and support. With their great care and affection, I

finished my graduate course and earned a doctoral degree in physical therapy. Never

satisfied with my own achievement, I will continue to work to make further progress.

Thank you.

Table of Contents

List of Figures ······································································ ii

List of Tables ······································································ iii

Abstract ············································································ iv

Introduction ········································································· 1

Method ·············································································· 6

1. Subjects ······································································ 6

2. Experimental Equipment ·················································· 8

2.1 Radiographic Analysis (X–ray) Using Simi Software ············ 8

2.2 Hand–Held Dynamometer ··········································· 11

3. Scapular Upward Rotation Exercise ···································· 14

4. Experimental Procedure ·················································· 17

5. Statistical Analysis ························································ 19

Results ·············································································· 20

1. Alignment of Scapula and CTA ········································· 20

2. Strength of Scapular Upward Rotators ································· 23

Discussion ········································································· 25

Conclusion ········································································· 30

References ········································································· 31

Abstract in Korean ································································ 38

-i-

List of Figures

Figure 1. Radiographic analysis using SIMI motion analysis program ···· 10

Figure 2. Measurement of scapular upward rotator strength ················· 13

Figure 3. Scapular upward rotation exercise ··································· 16

Figure 4. Scapular and clavicular alignment between pre–and post–program

············································································· 22

-ii-

List of Tables

Table 1. General characteristics of the subjects ··································· 7

Table 2. Differences in scapular and clavicular alignment between pre– and

post–program ····························································· 21

Table 3. Strength of scapular upward rotators ·································· 24

-iii-

ABSTRACT

Effects of Scapular Upward Rotation Exercises on

Alignment of Scapula and Clavicle and Strength of

Scapular Upward Rotators in Subjects With

Scapular Downward Rotation Syndrome

Sungmin Ha Dept. of Physical Therapy

The Graduate School

Yonsei University

Scapular downward rotation syndrome (SDRS) is common scapular and clavicular

alignment impairment in individuals with shoulder pain. Changes in the alignment of

the scapula and clavicle can potentially influence the biomechanics of the shoulder

region. The purpose of this study was to investigate the effects of a 6–week scapular

upward rotation exercise (SURE) on scapular and clavicular alignment and scapular

upward rotators strength in subjects with SDRS. Twenty–one volunteer subjects with

SDRS (10 males and 11 females) were recruited from university populations. Thirteen

-iv-

subjects had bilateral SDRS, and eight subjects had one–sided SDRS (a total of 34

sides). The alignment of the scapula and clavicle was measured using radiographic

analysis (X–ray) and compared in subjects before and after a 6–week self–SURE

program. A hand–held dynamometer was used to measure the strength of the scapular

upward rotators (serratus anterior, and upper trapezius muscles). The subjects were

instructed how to perform the self–SURE program at home. The 6–week self–SURE

program was divided into two sections (the first section with non-resistive SURE

during weeks 1–3, and the second section with resistive SURE using thera–band

during weeks 4–6). The significance of the difference between pre– and post–program

was assessed using a paired t–test, with the level of statistical significance set at p <

0.05. Significant differences between pre– and post–program were found for scapular

and clavicular alignment (p < 0.05). Additionally, the comparison between pre– and

post–program measurements of the strength of the scapular upward rotators (serratus

anterior, and upper trapezius muscle) showed significant differences (p < 0.05). The

results of this study showed that a 6–week self–SURE program is effective for

improving scapular and clavicular alignment and increasing the strength of scapular

upward rotator muscles in subjects with SDRS.

Key Words: Scapular and clavicular alignment, Scapular downward rotation

syndrome, Scapular upward rotator exercise.

-v-

Introduction

Assessment of postural alignment is considered an important part of the physical

examination because impairment in alignment may contribute to excessive stress and

compression on joints, muscles, and ligaments, resulting in pain (Kendall et al. 2005;

Kibler 1998; Magee 1997; Sahrmann, 2002; Tuzun et al. 1999). Previous studies have

found a positive relationship between alignment and pathology (Swift, and Nichols

1984; Braun, 1991; Szeto, Straker, and Raine 2002). The position of the scapula is a

key contributor to normal shoulder motion and control (DiVeta, Walker, and Skibinski

1990).

Ideal scapular alignment is described as the vertebral border parallel to the spine and

positioned 3 inches from the midline of the thorax (Sobush et al. 1996). The scapula

should be positioned between the spinous process of the second and seventh thoracic

vertebrae and rotated 30° anterior to the frontal plane (Hoppenfeld 1976; Kendall et al.

2005; Magee 1997; Sahrmann 2002). Impairment in alignment of the scapula can be

classified as scapular downward rotation (SDR), depressed, elevated, adducted,

abducted, tilted, or winged (Kendall et al. 2005). When the inferior border of the

scapula is more medial than the superior border, the scapula is considered to be in

SDR; the shoulder is lower and slopes downward at the acromial end (VanDillen

2007). Scapular downward rotation syndrome (SDRS) is one of the most common

scapular and clavicular alignment impairments in individuals with shoulder pain

(Sahrmann 2002).

- 1 -

Impairments in alignment are believed to be correlated with specific movement–

related diagnoses, and they provide clues about the resting length of muscles

(Caldwell, Sahrmann, and Van Dillen 2007). Changes in alignment of the scapula and

clavicle can potentially influence the biomechanics of the shoulder region by altering

tension at the cervicoscapular muscle (increased upper trapezius muscle length, and

levator scapula stiffness), which may lead to insufficient scapular upward rotation,

instability of the glenohumeral joint, thoracic outlet syndrome during arm elevation,

and prolonged compressive loading of the cervical spine (Caldwell, Sahrmann, and

Van Dillen 2007; Griegel-Morris et al. 1992; Sahrmann 2002; Szeto, Straker, and

Raine 2002; William et al. 2010). The clavicle is the sole bony structure connecting

the trunk to the shoulder girdle via the sternoclavicular joint medially and the

acromioclavicular joint laterally (Ljunggren 1979). The bone is strongly connected to

a number of muscles (deltoid, trapezius, and subclavius muscles) and to the fascicles

of the neck and pectoral region, which is functionally joined by the internal and

external jugular veins and the subclavian vein (Craig 1998). Because of its anatomical

position, the clavicle has many functions in the human body. The clavicle holds the

scapula in position allowing it to hang freely and obtain the maximum range of

movement (Inman, and Saunders 1945). The lateral part of the clavicle serves as an

attachment point for muscles and ligaments, and the medial part accepts axial loading

and transmits physical impact and force to other parts of the body to reduce trauma

and damage during upper–extremity movement (Lin, and Yang 2006). Furthermore,

the clavicle protects important neurovascular structures in the region (Craig 1998). An

- 2 -

alteration in clavicular tilt angle (CTA) (angle between horizontal line and the long

axis of the clavicle) may indicate a change in muscle length and joint alignment that

must be corrected to allow optimal motion (Sahrmann 2002). A change in CTA

associated with abnormal scapular alignment may affect the muscle length of the

deltoid, upper trapezius, and subclavius muscles, causing a biomechanical alteration

and possibly shoulder joint pain (Kendall et al. 2005; Novak, and Mackinnon 1997).

CTA can be used as an indicator to determine the presence of depressed scapula,

downward rotated scapula, and elevated scapula.

Sahrmann (2002) reported that patients with SDRS have relative muscle flexibility

impairment. Shortness of muscles (rhomboid, pectoralis minor, latissimus dorsi,

deltoid, and supraspinatus) by altered alignment can restrict shoulder motion.

Consistent with the length–tension relationship, lengthened serratus anterior, upper

trapezius, and lower trapezius muscles cannot generate sufficient tension to assist in

upward rotation of the scapula (Thibodeau, and Patton 2003). Furthermore, changes

in muscle–recruitment patterns in the neck–shoulder region lead to limitations in

functional range of movement and produce compensatory movement (Sahrmann

2002). During shoulder flexion and abduction in subjects with SDRS, the rhomboid,

levator scapula, and deltoid muscle are dominant over the activity of the serratus

anterior and upper trapezius muscles, which are the primary upward rotators of the

scapula. These muscles do not rotate the scapula the desired 60° and leads to

excessive glenohumeral motion during full shoulder flexion and/or abduction. A

change in the direction of the glenoid fossa in patients with SDRS can increase

- 3 -

downward–pulling tension as well as downward subluxation of the glenohumeral

joint (Basmajian, and Bazant 1959). Additionally, a prolonged SDR position may

increase downward–pulling tension by changing the stiffness of the scapulohumeral

muscles (subscapularis, infraspinatus, teres major, teres minor, and latissimus dorsi)

(Sahrmann 2002).

Previous studies have investigated the effects of modifying scapular alignment. Ha

et al. (2011) suggested that the passive correction of the scapular position could

decrease neck pain and improve neck range of motion (ROM) and proprioception

during active neck rotation in patients with bilateral SDR. Azevedo et al. (2008)

reported that passively elevating the scapula in subjects with scapular depression was

an effective strategy to decrease trapezius discomfort, neck pain, and cervicogenic

headache. Additionally, subjects with scapular position impairments had a

significantly lower pressure–pain threshold in the upper trapezius muscle region

compared with healthy young subjects with the scapula in a neutral position. Andrade

et al. (2008) suggested that supporting the upper limb leads to significant

improvement in cervical rotation ROM between subjects with neutral vertical

scapular alignment and those with depressed scapular alignment. Elevating and

adducting the patient’s scapula and supporting the weight of the limbs resulted in

increased cervical motion and a decrease in cervicogenic headache (McDonell,

Sahrmann, and Van Dillen 2005). Although these passive interventions have shown

immediate effects related to reducing neck–shoulder complaints and dysfunction,

there is a lack of long–term or carry–over effects. To gain the long–term or carry–over

- 4 -

effects, it is suggested that exercise intervention is necessary to restore optimal

muscle strength and length for normal functional upper–extremity motion (Ludewig,

and Borstad 2003). Stretching and strengthening exercise programs are often used in

the conservative treatment of shoulder pain in an attempt to reduce symptoms and

alter abnormal motion and muscle activities (Bang, and Deyle 2000; Wang et al.

1999). Scapular upward rotation exercise (SURE), which improves the strength of the

scapular upward rotators (serratus anterior, and upper trapezius muscles) and stretches

the scapular downward rotator (levator scapulae), is necessary to restore optimal

muscle length and strength in patients with SDRS (Sahrmann 2002). Studies

examining persons with abnormal scapular alignment have suggested that impairment

in scapular alignment results in functional limitations and painful symptoms. Several

studies have employed a self–reported questionnaire (pain, and disability) and

measurement of cervical ROM and muscle strength before and after therapeutic

intervention; however, the effects of intervention on scapular and clavicular alignment

have not been examined (Andrade et al. 2008; Azevedo et al. 2008; Ha et al. 2011;

McDonell, Sahrmann, and Van Dillen 2005). Therefore, this study was conducted to

investigate the effects of a 6–week self–SURE program on scapular and clavicular

alignment and scapular upward rotator strength in subjects with SDRS. It was

hypothesized that pre– and post–program measures would reveal differences in the

alignment of the scapula and clavicle and the strength of the scapular upward rotators.

- 5 -

Method

1. Subjects

Twenty–one volunteer subjects with SDRS (10 males and 11 females) were recruited

from university populations. Thirteen subjects had bilateral SDRS, and eight subjects

had one–sided SDRS (a total of 34 sides). The inclusion criteria for subject selection

in this study based on the literature (Caldwell, Sahrmann, and Van Dillen 2007; Ha et

al. 2011; Sahrmann 2002) included (1) the scapula was downwardly rotated by visual

appraisal; (2) the clavicle appeared to be horizontal or the acromioclavicular joint was

lower than the sternoclavicular joint by visual appraisal; and (3) the vertebral borders

of the scapula were less than 3 inches from the spine by tape measure. Subjects with

cervical spinal fractures, neck-rotation ROM of <20º, radiating pain to an upper

extremity, or a history of unresolved cancer were excluded. Prior to the study, the

principal investigator explained all procedures to the subjects, and all subjects signed

an informed consent form, which was approved by the Yonsei University Wonju

Campus Human Studies Committee. The subject’s general characteristics are

presented in Table 1.

- 6 -

Table 1. General characteristics of the subjects (N=21)

.

Mean ± SD Range

Age (yr) 24.3 ± 2.6 21–32

Height (㎝) 166.8 ± 7.0 153–180

Weight (㎏) 60.4 ± 10.5 45–82

- 7 -

2. Experimental Equipment

2.1 Radiographic Analysis (X–ray) Using SIMI Software

All radiographs were taken by the same X–ray technician using a radiography

apparatus in postero-anterior projection (Diagnostic X–ray, Dong-A Co., Ltd., Japan).

The subject was asked to stand in front of the grid, and the X–ray technician placed

the grid on the subject`s chest. A 5–㎝–long horizontal steel rod attached to the

cervicothorasic junction was used as a reference point to calibrate using the SIMI

Motion Analysis System (SIMI Motion 5.0 Reality Motion Systems,

Unterschleissheim, Germany) in the frontal plane (Figure 1A). The scapular

alignment and clavicular tilt angle were measured from radiographic findings of chest

X–ray (Akel et al. 2008; Sobush et al. 1996). All acquired images were converted to

digital images using a conversion program and analyzed using SIMI software. The

scapular alignment was measured by drawing a vertical axis line connecting two

points in the centerline of the body of the sternum. The perpendicular distance from

the vertical axis line was calculated at the superior border, the midpoint of the

vertebral border, and the inferior border of the scapula (Figure 1A) (distance between

inferior border and corresponding spine: DIS, distance between medial border and

corresponding spine: DMS, distance between superior border and corresponding

spine: DSS) (Caldwell, Sahrmann, and Van Dillen 2007; Sobush et al. 1996). Using

an image of radiographic finding, the CTA was measured at the axis of lines drawn

through the centerline of the body of the sternum and centerline of the long axis of the

- 8 -

- 9 -

clavicles at both end (Figure 1B). The clavicular tilt angle was calculated as follows:

clavicular tilt angle = (angle between vertical axis line and the long axis of the

clavicle) – 90° (Akel et al. 2008).

Figure 1. Radiographic analysis using SIMI motion analysis program. (A) Scapular alignment, (B) Clavicular alignment. DSS: Distance between superior border and corresponding spine. DMS: Distance between medial border and corresponding spine. DIS: Distance between inferior border and corresponding spine.

- 10 -

2.2. Hand–Held Dynamometer

A hand-held dynamometer (HHD) (Lafayette Manual Muscle Test System Model

01163, Lafayette Instrument Co., NL, USA) was used to measure the strength of the

serratus anterior and upper trapezius muscle (Figure 2A). The HHD was calibrated

before testing by calculating the difference between a known load applied to a digital

weight scale and the known load applied to the HHD. The absolute difference

between the digital weight scale and the HHD for the known load of 1, 2, 3, and 5 ㎏

were calculated. The resultant error was less than 0.1 ㎏.

The serratus anterior muscle strength test was performed as described by Kendall et

al. (2005) in supine position. The original test described the resistance applied against

the subject’s closed fist. In the present study, the elbow was placed at 90º of flexion,

and resistance was applied to the ulna at the olecranon process along the long axis of

the humerus. This application of resistance was modified for the serratus anterior

muscle test because the HHD could not be applied in a stable or consistent manner

over the subject’s hand (Michener et al. 2005), as depicted in the original description

of the test by Kendall et al. (2005). Moreover, this modification decreased the number

of joints that had to be crossed as force was applied to the scapulothoracic joint. The

triceps muscle was monitored visually and by palpation to ensure that it did not

contribute to the force produced during the serratus anterior muscle test. The scapular

motion for this test was scapular protraction (Figure 2B).

The upper trapezius muscle strength test was performed as described by Hislop, and

Montgomery (1995). The HHD was placed over the superior scapula, and force was

- 11 -

applied directly downward (inferior) through the HHD in the direction of scapular

depression. Scapular elevation was the scapular motion for the upper trapezius muscle

test (Figure 2C).

All subjects performed the muscle strength tests in the same order, i.e., serratus

anterior followed by and upper trapezius muscle test. The examiner viewed the digital

readout on the HHD during each performance of the muscle strength test and recorded

muscle strength in kilogram on a data–recording sheet. Each muscle strength test was

performed three times consecutively, and the average was used for data analysis.

- 12 -

Figure 2. Measurement of scapular upward rotator strength. (A) Hand–held dynamometer, (B)Serratus anterior muscle strength test, (C) Upper trapezius strength test

- 13 -

3. Scapular Upward Rotation Exercise

SURE instruction was provided to the subjects by asking them to stand with their

back against the wall, with wall contact from head to buttock, and feet shoulder–width

apart. In the starting position, the radial border of the forearms and lateral side of the

humerus were in contact with the wall, and the shoulder was abducted 90º with the

elbow flexed 90º. The subjects were instructed to slide their arms up the wall. The

sliding movement ended when the shoulder reached 180º of abduction. The subject

was then instructed to maintain the arm position for 10 seconds (Figure 3). The

subjects were instructed that the exercises may induce muscle fatigue but should not

cause increased shoulder pain. Subjects were instructed to perform SURE 3 days per

week.

The 6–week self–SURE program was divided into two sections (the first section with

non–resistive SURE during weeks 1–3 and the second section with resistive SURE

using a thera–band during weeks 4–6 (Figure 3). During the 6–week self–SURE

program, subjects were asked to perform three sets of 10 repetitions during the first

week, progress to three sets of 15 repetitions during each session in the second week,

and complete three sets of 20 repetitions during the third week. After completing three

sets of 20 repetitions for three consecutive sessions, subjects were evaluated whether

they were pain–free and had achieved full active range of motion. All subjects who

were pain–free in full active range of motion were prescribed self–SURE.

After the first section of the 6–week self–SURE program, subjects were allowed to

- 14 -

progress to the second section of the 6–week self–SURE program at the fourth week.

The low level of tension of the thera–band was controlled by a concentric exercise

phase that did not cause excessive loading for activated muscles and joint pain. The

level of thera–band tension was increased by shortening the thera–band as tolerated

without discomfort or pain while maintaining the exercise performance instructed by

the physical therapist. If subjects felt or complained of pain during the resistive SURE

using thera–band, they were asked to lengthen the thera–band. The subjects were

asked to perform resistive SURE using thera–band for three sets of 10 repetitions

during each session in the fourth week, progress to three sets of 15 repetitions in the

fifth week, and complete three sets of 20 repetitions in the sixth week.

- 15 -

Figure 3. Scapular upward rotation exercise.

- 16 -

4. Experimental Procedure

All subjects were evaluated for study inclusion/exclusion at the initial visit. The

position of each subject’s shoulder girdle was assessed by radiography and analyzed

by SIMI software. The strength of the scapular upward rotators (serratus anterior, and

upper trapezius muscles) was measured three times using a hand–held dynamometer.

All measurements were performed both at the time of entry into the study (pre–

program) and at follow–up (post–program).

Following the initial measurement, the subjects received instruction in a 6–week

self–SURE program by a licensed physical therapist with 9 years of clinical

experience in evaluation and treatment of musculoskeletal disorders. Each subjects

received written/pictorial instructions and a video file for home reference during the

SURE program and a daily exercise log to monitor compliance with the exercise

program. All subjects received a 1–hour training session at the initial visit. The

subjects were asked to perform a 6–week self–SURE program. The subjects returned

1 week after the initial session for review of the home self–SURE program, and

questions regarding the exercise regime were answered by the physical therapist. At 4

weeks, the therapist checked whether subjects clearly understood the self–SURE

program or were having any difficulty performing the exercise regime. Every week,

the subjects were contacted by telephone to monitor compliance, discuss any

problems, and ensure proper progression of self–SURE program at home. At the post–

- 17 -

program visit, subjects rated their exercise compliance during the 6–week self–SURE

program using a numerical rating scale ranging from 0 to 100%.

- 18 -

5. Statistical Analysis

The data are expressed as the means ± standard deviations. The paired t–test was

used to test for significant differences between pre– and post–program measurements.

The effect size, cohen`s “d,” was calculated to determine the standardized mean

difference between pre– and post–program values. The level of statistical significance

was set at p < 0.05. The statistical package for the Social Sciences for Windows

version 18.0 (SPSS, Inc., Chicago, IL, USA) was used for statistical analysis.

- 19 -

Results

1. Alignment of Scapula and CTA

The comparison of pre– and post–program values showed significant differences for

DSS, DMS, DIS, and CTA (p < 0.05) (Table 2) (Figure 4). The calculated effect sizes

for DSS, DMS, DIS, and CTA between pre– and post–program are shown Table 2.

- 20 -

Table 2. Differences in scapular and clavicular alignment between pre– and post–

program (N=34 sides)

aDSS: Distance between superior border and corresponding spine.

Pre–program Post–program t p Effect size

DSSa (㎝) 7.27 ± 0.91e 6.57 ± 0.88 7.50 0.000 0.36

DMSb (㎝) 6.35 ± 1.04 6.53 ± 1.05 -5.68 0.000 0.09

DISc (㎝) 6.30 ± 1.01 6.65 ± 0.92 -3.34 0.002 0.17

CTAd (°) 1.99 ± 3.09 9.50 ± 4.08 -9.77 0.000 0.72

bDMS: Distance between medial border and corresponding spine. cDIS: Distance between inferior border and corresponding spine. dCTA: Clavicular tilt angle. eMean ± standard deviation.

- 21 -

Figure 4. Scapular and clavicular alignment between pre– and post–program.

- 22 -

2. Strength of Scapular Upward Rotators

A paired t–test revealed significant differences between the pre– and post–program

measures, indicating that the 6–week self–SURE program increased the muscle

strength of the serratus anterior and upper trapezius muscles (p < 0.05) (Table 3). The

calculated effect size between pre– and post–program of the serratus anterior and that

of the upper trapezius muscles is shown Table 3.

- 23 -

Table 3. Strength of scapular upward rotators (N=34 sides)

aSA: Serratus anterior.

Pre-program Post-program t p Effect

size

SAa (㎏) 22.68 ± 4.49 36.00 ± 10.32 - 8.46 0.000 0.64

UTb(㎏) 25.29 ± 6.95 41.07 ± 9.45 - 10.16 0.000 0.75

bUT: Upper trapezius.

- 24 -

Discussion

The purpose of the present study was to examine the effect of a 6–week self–SURE

program on scapular and clavicular alignment and scapular upward rotator strength in

subjects with SDRS. To our knowledge, this is the first study to investigate the effect

of a 6–week self–SURE program on the changes in alignment of the scapula and

clavicle and strength of the scapular upward rotators (serratus anterior, and upper

trapezius muscles) in subject with SDRS. The results of the present study support the

hypothesis that a 6–week self–SURE program can improve the alignment of the

scapula and clavicle (DSS, DMS, DIS, and CTA) and the strength of the scapular

upward rotators (serratus anterior, and upper trapezius muscle).

For scapular alignment, DIS was increased significantly after the 6–week self–

SURE program (p < 0.05). Shoulder girdle alignments are an indicator of possible

muscle length changes and joint alignments that need to be corrected to allow for

optimal shoulder girdle motion (Sahrmann 2002). Bunch and Siegel (1993) described

a standard position for scapular alignment, which specifies that the vertebral border of

the scapula be parallel to the spine and positioned approximately 3 inches

(approximately 7–8 ㎝) from the midline of the thorax. Before the program, DIS was

less than DSS, which reflects the SDR position. Furthermore, DMS was less than 3

inches. After the 6–week self–SURE program, and significant decreased in DSS was

observed at post-program compared with pre–program (p < 0.05). DMS and DIS

increased significantly in the post–program compared with pre–program (p < 0.05).

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After the 6–week self–SURE program, DIS was closer to DSS, indicating a scapular

position more parallel to the spine compared with pre–program. DMS was closer to

the target value of approximately 3 inches. Based on these findings, the scapular

alignment was close to a normal position, as described Kendall (2005). Thus, the 6–

week self–SURE program can assist in restoring normal alignment of the scapula and

possibly in restoring the normal length of scapular upward rotators.

Previous studies using plain-film radiography incorporated CTA measurements to

investigate shoulder muscle imbalance in individuals with scoliosis (Akel et al. 2008;

Kuklo et al. 2002; Uzümcügil et al. 2011). Ludewig et al. (2009) reported that the

clavicular tilt angle was 5.9° in neutral standing by electromagnetic motion analysis.

McClure et al. (2004) reported that the clavicular tilt angle was about 4°, which was

derived from the electromagnetic sensor at the sternal notch and acromioclavicular

joint. Although CTA has been measured using an electromagnetic motion analysis

system in previous reports (Ludewig et al. 2009; McClure et al. 2004), few studies

have reported normative data for CTA measurement, which is available and accessible

for musculoskeletal evaluation and diagnosis (Sahrmann 2002). Additionally,

increased CTA can reduce prolonged compressive loading of the posterior cervical

structures as a result of the transfer of the weight of the extremities to the cervical

region through the attachments of the cervicoscapular muscle (upper trapezius and

levator scapulae) (Van Dillen et al. 2007). For these reasons, CTA assessment is

important for upper-extremity evaluation. In the present study, CTA was significantly

increased after compared with before program (p < 0.05). These results suggest that

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the 6–week self–SURE program was useful for restoring optimal alignment of the

clavicle in subjects with SDRS.

Significant differences in scapular upward rotator strength (serratus anterior, and

upper trapezius muscle) between pre– and post–program were also found (p < 0.05).

The serratus anterior and upper trapezius muscles are critical for maintaining optimal

scapular position, and they control the scapular upward rotation, which was targeted

in this study (Neumann 2002) In a previous study, a 6–week strengthening exercise

for the correction of SDR demonstrated that the serratus anterior and upper trapezius

increased in strength grade, as defined by Kendall, in patients with SDRS (McDonell,

Sahrmann, and Van Dillen 2005). Through the 6–week self–SURE program, we

hypothesized that increased muscle strength of the serratus anterior and upper

trapezius muscle could change the resting muscle length. It has been suggested that a

6–week self–SURE program might have decreased muscle length by reducing the

sarcomere number (Herring, Grimm, and Grimm 1984). The change in resting muscle

length associated with body posture may influence body alignment (Goldspink, and

Williams, 1990; Hrysomallis, and Goodman 2001). In the present study, increased

strength of the scapular upward rotators led to alignment changes in the scapula and

clavicle (DSS, DMS, DIS, and CAT). Although we did not directly measure the

change in muscle length, the 6–week self–SURE program was designed to stretch the

scapular downward rotator (levator scapulae) as well as strengthen the scapular

upward rotators (serratus anterior, and upper trapezius muscles). An effective exercise

for correcting anatomic length adaptation is to contract the lengthened muscle into a

- 27 -

shortened position and simultaneously stretch the shortened muscle (Sahrmann 2002).

Therefore, restoring the muscle length of the scapular upward rotators and downward

rotators through SURE is important for changing scapular and clavicular alignment in

subjects with SDRS. The findings of the present study suggest that the 6–week self–

SURE program in subjects with SDRS may be an effective exercise program,

supporting the findings of Sahrmann (2002) and Caldwell, Sahrmann, and Van Dillen

(2007) who investigated the effectiveness of SURE on scapular alignment.

We designed the 6–week self–SURE program to be simple and to require relatively

few visits. The 6–week self–SURE program was essentially a home–based program

with weekly coaching and minor modifications rather than one requiring extensive

manual techniques from a physical therapist. Subjects reported 73% exercise

compliance in the 6–week self–SURE program. The data in the present study agree

with those of other reports using a home–based program in showing improved

function and reduced impairments in patients with SDRS (McDonell, Sahrmann, and

Van Dillen 2005). Therefore, the 6–week self–SURE program can be recommended

for correcting SDRS.

The present study has several limitations. First, generalization of the study is limited

because our subjects were young and had no pain. Additionally, no control program

was incorporated in the study. Thus, further research is needed to examine the effect

of SURE program in subjects in different age groups and individuals with neck–

shoulder pain. Second, the measurement of scapular and clavicular alignment was

conducted only in the static standing position. Further study is needed to investigate

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scapular and clavicular motion during dynamic upper–extremity motions after

performing the 6–week self–SURE program.

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Conclusion

The effects of the 6–week self–SURE program on scapular and clavicular alignment

and scapular upward rotator strength were investigated in subjects with SDRS. The

findings of the present study showed significant differences in alignment of the

scapula and clavicle and the strength of scapular upward rotators between pre– and

post–program. The findings of the present study provide evidence for the

effectiveness of SURE in subjects with SDRS.

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국문 요약

어깨뼈 아래돌림 증후군을 가진 대상자에게 어깨뼈

위돌림 운동이 어깨뼈와 빗장뼈의 정렬 및 어깨뼈

위돌림근의 근력에 미치는 영향

연세대학교 대학원

물리치료학과

하 성 민

어깨뼈 아래돌림 증후군은 어깨 통증을 가진 사람들에게 가장 흔하게

나타나는 어깨뼈와 빗장뼈 정렬 손상이다. 어깨뼈와 빗장뼈의 정렬 변화는

잠재적으로 어깨부위의 생체역학적 변화를 일으킬 수 있다. 본 연구의

목적은 어깨뼈 아래돌림 증후군을 가진 대상자에게 6 주간의 어깨뼈

위돌림 운동이 어깨뼈 및 빗장뼈의 정렬 그리고 어깨뼈 위돌림근의 근력에

미치는 영향을 알아보고자 하였다.

- 38 -

21 명의 (남자 10 명과 여자 11 명) 어깨뼈 아래돌림 증후군을 가진

대상자들이 연구에 참여했으며, 13 명은 양측에 어깨뼈 아래돌림 증후군을

가지고 있으며 8 명은 한 쪽 어깨에만 어깨뼈 아래돌림 증후군을 가지고

있었다. 어깨뼈와 빗장뼈의 정렬은 6 주간의 자가 어깨뼈 위돌림 운동

전후에 방사선 촬영기기를 이용하여 측정하였다. 어깨뼈 위돌림근의

(앞톱니근 및 위 등세모근) 근력을 측정하기 위해서 도수용 근력 측정기를

이용하였다. 실험대상자들은 6 주간의 자가 어깨뼈 위돌림 운동을

시행하였다. 운동 전후간에 어깨뼈와 빗장뼈의 정렬, 그리고 어깨뼈

위돌림근들의 근력에 어떠한 차이가 있는지 알아보기 위해 짝비교 t-

검정을 실시하였으며, 유의수준은 0.05 로 하였다.

어깨뼈와 빗장뼈의 정렬이 유의하게 호전되었다. 위돌림근들 (앞톱니근

및 위 등세모근)의 근력이 유의하게 증가하였다. 본 연구의 결과로 볼 때,

6 주간의 자가 어깨뼈 위돌림 운동이 어깨뼈 및 빗장뼈의 정렬과 어깨뼈

위돌림근의 근력 개선에 효과적인 운동방법이라고 사료된다.

핵심되는 말: 어깨뼈와 빗장뼈의 정렬, 어깨뼈 아래돌림 증후군, 어깨뼈

위돌림 운동.

- 39 -