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Introduction Currently, there is great concern in preventing a variety of diseases and injuries involving the shoulder joint due to postural changes that lead to the compensation system over the functionality [1]. The prevalence of shoulder pain accompanied by disability is present in about 20% of the population 2. The situations that overload in this joint complex is multifactorial [3]. It has been noted the importance of perception in health and quality of life for much of the population, which is impaired, often by acute and chronic musculoskeletal disorders [2,4]. The scapular motion, along with the movement of the humerus, allows a range of motion (ROM) in flexion or abduction of the arm 150 to 180 . The typical mobility in asymptomatic individuals, usually occurs with two degrees of movement to a degree of glenohumeral scapular motion, which determines a ratio of 2:1 in the rhythm scapulohumeral [5,6]. Several athletes and professionals who work with the upper limb (UL) have abducted a greater predisposition to develop alterations in the mobility-stability [7]. The professional activity of medical sonographer is characterized by high probability of change in mobilitystability relationship. With the advent of new technologies and the recognition of the diagnostic capabilities of ultrasound, has increased every year, the number and duration of the implementation of ultrasonographic exam [8,9]. Despite the technological advances have allowed high-resolution images, ergonomic conditions for the exams is not all favorable to the musculoskeletal system of ultrasonographer clinician [10]. The overload static and dynamic imposed on scapular girdle muscles and the upper end are due to the maintenance needs of the shoulder in abduction for a better function of the wrist and hand for fixing the transducer perpendicular to the skin of the individual over exam [2,8,10,11]. Impaired functionality of the individual and removal of their daily activities leads to an overload of health systems in different

countries. Ways to prevent and correct treatment of an injury must be developed in order to minimize the consequences arising from the functional impairment of the individual. Therefore, the objectives of this study were to analyze and measure the scapular positioning and correlating it to the inability of medical professionals UL sonographers.

2. Methodology 2.1. Study design and Sample Cross-sectional study. This study was approved by the Ethics and Research of Newton Paiva University Center under number 40/2005. The study included 18 volunteers, nine of the symptomatic group (SG) and nine asymptomatic group (AG), aged between 27 and 52 years old and sedentary. The working time ranged from 18 months to 20 years and the number of tests performed per day ranged from 10 to 30. The 18 participants were evaluated both shoulders (36 shoulders). Of the participants in the SG, five were women (55.6%) and four were men (44.4%), with a mean age of 33.67 8.89 years (27 to 52 years), body mass 69.66 13.10 kg (57.0 to 95.0 kg) and height of 1.73 0.07 m (1.63 to 1.83 m). The average body mass index of the sample was 22.97 3.5 kg / m (19.14 to 31.04 kg / m). Of the participants in the AG, four were women (44.4%) and five were men (55.6%), with an average age of 38.78 7.79 years (30 to 49 years), body mass 76.11 22.7 kg (49.0 to 115.0 kg) and height of 1.69 0.07 m (1.54 to 1.85 m). The average body mass index of the sample was 26.17 6.5 kg / m (18.9 to 38.46 kg / m).

2.2. Digital inclinometer It was used Inclinometer Digital Protractor Mitutoyo (Mitutoyo Evaluation Instruments, Aurora, Chicago, IL) for measurement of scapular positioning. The two arms that have been adapted in length (10.0 cm each), made of acrylic, for proper accommodation in the

scapula and reading of degrees of inclination. It was engaged at a level of water perpendicular to the equipment, to ensure correct alignment of the same for the evaluation plans. The validity and reliability of using the digital inclinometer, as a way of measuring scapular position was described by Johnson et al. [6]. 2.3. Questionnaire Disability of the Arm, Shoulder and Hand of Brazil We used the Disability Arm Shoulder Hand Questionnaire in Brazil (Brazil DASH), culturally adapted to Portuguese in Brazil by Orfale et al. [12]. This questionnaire, originally developed in English and called DASH Questionnaire was developed by Hudak et al. In 1996 with the aim of measuring the physical disability and symptoms of upper limbs in a heterogeneous population. Moreover, it was proposed to evaluate disability and symptoms in a single or multiple disorders of the UL. 2.4. Functional Postural Analysis To measure the angle of the MS functional, skin markers, made of acrylic, were placed on anatomical landmarks, using double-sided tape: the seventh cervical vertebra (C7), the seventh thoracic vertebra (T7), acromion and lateral epicondyle. The registration of functional image of the positioning was done using a digital camera Sony Mavica MVC-FD 200 (Sony Electronics, Inc., San Diego, CA).

position of the MS (anatomical position), 30, 60, 90 and 120 of shoulder elevation in the frontal, scapular and sagittal. To ensure correct positioning of the MS in these plans, a screen was used to normalize the position of the MS during the execution of the test. Then, after measuring the angle of scapular skin markers were placed on anatomical landmarks to register the functional angle of the positioning of the MS during the performance of ultrasound examination. The volunteer took the position of functional assessment during the simulation of ultrasound examination. The images were stored for later determination of the position angle of the MS to perform the examination. We used the program AutoCAD 2004 (AutoCAD, Autodesk, Inc., San Rafael, CA) for analysis of the positioning of the MS. Lines were drawn joining the points of the T7 C7 and the acromion to the lateral epicondyle. The functional angle of positioning of the UL for the examination was determined by the angle formed by these two lines. 3. Results

3.1. Variables Analyzed a) Positioning of the UP Functional The functional positioning of the UL showed no significant difference between the SG and AG (p = 0.765). The average angle of positioning of the MS GS during the simulation test was 51.78 15.11 degrees (38 to 78 degrees). The average angle of positioning of the UL during the simulation of AG test was 53.89 14.3 degrees (34 to 76 degrees). b) Analysis of the DASH Brazil Significant difference for the first 30 questions (p = 0.001) and the optional module of work (p = 0.012). The average of the first thirty issues of DASH Brazil for the SG, was 16.16 13.18 points (2.5 to 45.5 points) and fourth options, related to work, was 27.08 20 , 96 (0 to 56.25 points). The average of the first thirty issues of DASH Brazil, for the AG was 1.11 1.81 points (0-5 points) and four optional workrelated was 4.16 8.83 points (0 to 25 points).

2.5. Procedings Initially, all volunteers were briefed about the objectives and procedures, and signed a consent form. Then, there was an individual interview and a physical assessment with all participants. The examiners applied the questionnaire DASH Brazil and stored the data for later analysis. With the subject seated, the assessor, properly trained, the digital inclinometer placed on the spine of the scapula through the arms adapted to the equipment for proper placement and accommodation of the same anatomical reference, the spine of the scapula on the edge of the medial and inferior to the acromion. Another evaluator performed the reading and recording the values observed in the resting

c) Scapular Tilt There was significant difference of 6.65 (p = 0.016) and 5.87 (p = 0.033) of scapular inclination angle in the frontal plane at 90 and 120, respectively, compared to the SG of the right shoulder to right shoulder the AG. There was also a significant difference of 4.43 (p = 0.028) in AG, comparing the left shoulder over the right shoulder at rest (0) in the frontal plane. 4. Discussion In this study, the positioning angle of the MS during the simulation of ultrasound examination showed no significant differences between the SG and AG (p = 0.765). The SG had an average of 51.78 (38 to 78) and an average AG of 53.89 (34 to 76) of shoulder abduction. It was observed that most of the ultrasound clinics visited, the equipment used for the test followed a certain standardization in relation to ergonomic height of the chair of the physician, the patient's height and litter away from the monitor. Despite this standardization is not ideal, since each professional has a body type, this factor may have affected the angle of abduction between individuals. Jakes [13] Muir [14] and demonstrated that the attitude of the MS to perform the professional activity is an indicator of burden and risk of shoulder disorders. Jakes [13] reports that the main causes of musculoskeletal injury in medical ultrasound, are the maintenance needs of the shoulder in abduction for a better positioning of the transducer on the skin of the patient, the exam associated with the handling and display of images, the ergonomic conditions such as height and direction of the monitor, the chair of the sonographer and height of the stretcher to accommodate the patient during the examination. All of these factors, combined with the reduced time interval between one examination and the other, may contribute to functional changes and disability permanently [14,15.16]. It is considered acceptable for continuous duty and little overhead, an average of 20 abduction [13]. Once the averages found in this study exceeded the recommended 20, the risk of onset of muscle imbalances and postural

changes and dynamic overload, are apparently higher for individuals evaluated in this study. To evaluate the DASH questionnaire Brazil, the first 30 questions showed significant differences between the SG and AG (p = 0.001). The SG had an average of 16.16 and an average of 1.11 AG. The four issues of the optional module, work-related, also showed significant differences between the SG and AG (p = 0.012). The SG had an average of 27.08 and an average of 4.16 AG. In this study, the results obtained from the questionnaire indicated pain and / or discomfort in the shoulder of the SG. It can be inferred that these symptoms result from sustained postures of the shoulder abduction of adopted medical sonographer for examination, corroborated by measuring the angle of placement of MS during the test. The need to hold the transducer in abduction and without support, especially for the visualization of organs found in the patient's left hemibody, and prolonged time of endoscopic ultrasound show a direct relationship to the symptoms reported by volunteers in this study. Barbosa et al. [10] reported that during the exam, the physician sonographer needs to keep the shoulder in abduction without support, which causes an isometric contraction of the muscles of UP, especially the scapular girdle, in an attempt to promote stabilization can to allow a precise movement of the wrist and hand and increase the effectiveness of the performance of motor task presented. In this study, no significant differences between the time of occupation (p = 0.092) and number of tests per day (p = 0.186), compared to SG and AG. The average length of employment was in AG and SG 10 years was four years and nine months. The mean number of tests per day in AG was 17.8 and the average was 22.7 in SG. Thus there was a direct relationship between working time and symptoms. It can be inferred that this may be due to a physiological adaptation of muscle as a result of occupational activity needs. According to the results of the DASH questionnaire Brazil was still possible to draw a

parallel with the domains of the International Classification of Functioning, Disability and Health (ICF). It was observed that the activity and participation in the SG has been demonstrated impaired due to the very changes to the structures and functions of UL, which led to a certain degree of disability in the performance of both the ADL and occupational activity. However, failure should always be viewed within a biopsychosocial context, since all these factors affect directly the components of ICF [17,18]. In relation to the inclinometer measures, significant differences were found between the SG and AG in the frontal plane, 90 and 120. The difference of 90 was 6.65 (F= 4.021, p = 0.016) on the right shoulder of the symptomatic to the asymptomatic right shoulder, in 120 was found a difference of 5.87 (F = 2.638, p = 0.033) symptomatic of the right shoulder to right shoulder of asymptomatic. There was also a significant difference in AG, in the frontal plane, where at rest (position 0) there was a difference of 4.43 (F = 2.772, p = 0.028) over the left shoulder to the right. While staying with the shoulder abducted at approximately 90, the muscles may have fatigue, with consequent inability to maintain this position for long periods, related to occupational activity (ultrasound). This factor can lead to muscle adaptation, in order to ensure the functionality, in addition, it can trigger muscle imbalances in arcs of motion in which there is difficulty in maintaining proper muscle groups stabilizing or positioning of body segments during the course of a specific activity, such as gestures sports and occupational activities. In this study the difference appears when comparing the groups of the shoulders used to perform the ultrasound may be due to muscle fatigue due to the stance taken in support of UL abduction to the test. Associated with the time of the examination and compensation that emerge to keep the system functional, this imbalance can affect the continuity of movement in the upper ranges of motion. There has been a scapular dyskinesia in 120 of abduction seems to have a direct association with the difficulties reported by participants, as

observed in some items of the DASH questionnaire Brazil related to ADL, for example, "washing away", "change a light bulb above his head. " For the difference found in AG in the frontal plane in the rest position (0), we can infer that symptomatic individuals would be presenting an antalgic position during the measure scapular, which may have interfered with the angles found between the right shoulder and left. Borstad [19] in his study of variations in the resting position of the shoulder, said that the relationship between postural deviations and shoulder pain is based on the theory that prolonged postural changes lead to an adaptation of soft tissue on one side leading to an increase in tension and the opposite side leading to a shortening. These changes alter the passive and active forces acting on the shoulder during the move. Therefore, postural changes can lead to an impairment in the ability of the biomechanical system to perform precise movements over time and the frequency of repetition of the task, the pain arises as a result of inaccurate movements.

CONCLUSION According to the results obtained in this study, we observed that there is a relationship between the change of the measurement of scapular inclination angle and the degree of disability of the upper limbs of medical sonographers during the examination. The change in slope makes it difficult to maintain and scapular stabilization of the upper limbs, reducing the functionality of them during the work-related activities and ADL. The ideal is to prioritize the examination of ultrasound in the scapular plane, where the scapular muscles are acting on mechanical advantage, which can prevent muscle imbalance occurred between these muscles and the glenohumeral. You should also make ergonomic changes and emphasize the strengthening of the muscles stabilizing the scapula in order to prevent these changes and provide better functional performance to the doctor in their occupational activity and ADL.