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Effect of Posture On Acromiohumeral Print
Effect of Posture On Acromiohumeral Print
research report
Nitin Kalra, PT, MS1 Amee L. Seitz, PT, PhD, OCS2 N. Douglas Boardman III, MD3 Lori A. Michener, PT, PhD, ATC, SCS4
posture on the subacromial space (SAS) in subjects with rotator cuff disease and subjects without
shoulder pain.
extremity
impairments 8,20,22
and
16,18,21,25,27
RCD.
A forward head posture has been linked to pain related to
shoulder overuse.16 Adopting a slouched
posture has been shown to decrease glenohumeral abduction strength,20 while
adopting an upright posture resulted
in increased glenohumeral elevation.8,22
Slouched posture may limit shoulder
motion due to impingement beneath the
acromion, creating a mechanical block
to shoulder elevation coupled with tissue
impingement.11,27,28 Taping applied to the
posterior trunk parallel to the thoracic
spine and over the scapula of patients
with shoulder pain increased thoracic
extension, reduced pain with shoulder
elevation, and improved resting scapular
position.22 Slouched posture is linked to
shoulder pain, changes in scapular position, shoulder strength, and range of motion, which may contribute to disability.
Mechanistically, upper quadrant posture can affect scapular motion or kinematics,9,12,20,21 which may reduce the
subacromial space (SAS) and contribute
to shoulder pain and the development of
RCD.6,16,21,23,24,27 Increased thoracic spine
kyphosis or slouched thoracic posture has
been shown to decrease scapular upward
rotation,20 posterior tilting,9,12,20 and external rotation.9,20,21 Patients with RCD,
1
Orthopaedic Physical Therapist, Select Physical Therapy, Fairfax, VA; Masters student [at time of study], Department of Anatomy and Physical Therapy, Virginia Commonwealth
University, Richmond, VA. 2Research Associate, Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA. 3Associate Professor, Department
of Orthopedic Surgery, Virginia Commonwealth University Health Systems, Richmond, VA. 4Associate Professor, Department of Physical Therapy, Virginia Commonwealth
University, Richmond, VA. This study was completed as partial fulfillment for a Masters Degree in Anatomical Sciences from Virginia Commonwealth University. The study was
approved by The Institutional Review Board at Virginia Commonwealth University. Funding for this study was provided partially by the A. D. Williams Fund for Research at Virginia
Commonwealth University, the Department of Physical Therapy at Virginia Commonwealth University, and by the Foundation for Physical Therapy. Address correspondence to
Dr Lori A. Michener, Department of Physical Therapy, 1200 E Broad St, Richmond, VA, 23298. E-mail: lamichen@vcu.edu
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[
specifically, impingement syndrome,
have demonstrated these same altered
scapular kinematic patterns.23 These altered scapular kinematics may decrease
the SAS and clearance of the humeral
head beneath the acromion during arm
elevation.6,7,13,34,35 Studies provide some
support for this relationship. Artificially
induced scapular protraction, compared
to a position of scapular retraction, decreased the 2-dimensional (2-D) linear
distance between the acromion and humerusthe acromiohumeral distance
(AHD)as measured on magnetic resonance images (MRIs).35 Another study
found a reduced AHD measured on ultrasound images in tennis players without
shoulder pain but with scapular dyskinesis as compared to those without scapular
dyskinesis.34
Direct effects of posture on SAS for
individuals with RCD are unknown.
Subjects with acquired or idiopathic
thoracic hyperkyphosis have a smaller
AHD as measured on radiographic
images compared to nonkyphotic subjects.17 However, this study used subjects
without shoulder pain and measured
AHD with the arm at rest only. Moreover, slouched posture is not analogous
to hyperkyphosis, thereby limiting the
generalizability of these results. Studies
examining the direct effects of posture
on SAS in patients with RCD are needed to elucidate the relationship between
posture and RCD.
Generally, the AHD is smaller in patients with RCD as compared to healthy
shoulders.1,3,14,15,19 Studies using MRI reported a smaller AHD in patients with
impingement syndrome as compared
to healthy shoulders.1,15,19 Studies using
ultrasound imaging corroborate these
findings with a smaller AHD in patients
with RCD3,14 and a smaller AHD with increased severity of the RCD.3 Although
these studies consistently indicated a
smaller AHD with RCD, they varied on
the location of the measurement of the
SAS. MRI studies1,15,19 depicted the location as the anterior to middle aspect of
the SAS, or at the location of the small-
research report
TABLE 1
Descriptive Statistics*
Subjects With RCD (n = 31) Control Subjects (n = 29)
Age (y)
Height (cm)
Pain (mo)
METHODS
Subjects
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Procedures
After signing the informed consent form,
subjects completed an intake form and
the American Shoulder and Elbow Surgeons patient self-report shoulder score
to assess shoulder functional loss and disability (TABLE 2). Next, ultrasound images
of the SAS were collected for AHD measurement. The examiner was not blinded
to group assignment to conduct the ultrasound imaging, but was blinded for AHD
measurements.
Subacromial Space MeasurementThe
outlet of the SAS was measured on ultrasound-generated 2-D images via the
AHD. The AHD is a 2-D linear measure
defined as the shortest distance between
the acromion and the humerus (FIGURE 1).
An ultrasound unit (The Pyramid 764;
Pyramid Management LLC, Los Alamitos, CA) with a 7.5-MHz linear ultrasound
transducer was utilized. Placement of the
ultrasound transducer was standardized,
with its location on the posterior to middle portion of the acromion in the coronal
plane, with the transducer placed parallel
to the flat superior aspect of the acromion
so that both the acromion and humerus
were visualized (FIGURE 2). All ultrasound
images were saved on a computer for
AHD measurements performed later.
Two ultrasound images were taken for
TABLE 2
Subject Demographics
Subjects With RCD (n = 31) Control Subjects (n = 29)
Gender (n)
Male
11
14
Female
20
15
22
27
Left
Ambidextrous
15
Partial-thickness tear
9
Full-thickness tear
7
ASES pain score*
Abbreviations: ASES, American Shoulder and Elbow Surgeons Self-Report Form; RCD, rotator cuff
disease.
* Mean SD (range), 0-50 points, with 50 as no pain.
Mean SD (range), 0-100 points, with 100 as no pain and functional loss.
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research report
Data Analysis
To examine the effect of posture on
AHD, 2 separate mixed-model analyses of variance (ANOVAs), 1 for each
arm position (rest and 45 abduction),
were performed. These included effects
for group (RCD and control), posture
(normal, upright, slouched), and groupposture interaction, with posture as the
repeated factor. Post hoc testing was performed using contrasts. All analyses used
a significance set at = .05. Test-retest
intrarater reliability was calculated using
an intraclass correlation coefficient (ICC)
2-way random analysis for each arm position. Error was calculated using SEM
(SD 1ICC) and minimal detectable
change (MDC) (SEM 2) values. The
90% confidence bounds were calculated
by multiplying error values by the z score
of 1.64.
RESULTS
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TABLE 3
Acromiohumeral Distance*
Posture and Arm Elevation Angle
Normal Posture
Slouched Posture
Upright Posture
Rest
45 Abd Rest
45 Abd Rest
All subjects
8.6 1.9
9.2 1.9
12.1 2.6
12.5 3.1
12.6 2.5
45 Abd
9.8 2.0
Groups
Control
11.8 2.5
8.7 1.9
12.2 2.5
9.4 2.0
12.5 2.3
9.6 1.9
RCD
12.5 2.6
8.5 2.0
12.8 3.6
9.0 2.0
12.7 2.6
9.9 2.1
Subgroups of RCD
Impingement
12.8 2.5
8.6 2.4
12.9 4.0
8.3 1.7
12.8 2.4
9.8 1.7
Partial-thickness tear
12.0 2.1
8.6 1.8
13.6 2.6
9.4 1.8
12.8 2.2
11.1 2.5
Full-thickness tear
12.3 3.8
8.4 1.8
11.6 4.2
9.8 2.4
11.8 3.6
8.9 1.7
14
13
12
11
10
7
Normal
Slouch
At rest (0)
Upright
45 abduction
FIGURE 5. Acromiohumeral distance in millimeters for 3 postures and for 2 arm positions (at rest and 45
abduction). Data represent combined results for the control and patients with rotator cuff disease. Vertical bars
represent 95% confidence intervals.
DISCUSSION
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[
2-D measure in the coronal plane of the
posterior to middle portion of the SAS.
Upright posture increased the AHD,
as compared to normal posture, when
the arm was actively held at 45 abduction but not when the arm was at rest.
Slouched posture did not change AHD
as compared to normal posture.
We examined the direct effect of
posture on the AHD linear measure in
patients with RCD and control subjects
at 2 arm angles. At 45 active abduction, AHD increased by a mean of 1.2
mm with a change from normal to the
upright posture. This supports the hypothesis that upright posture increases
AHD. This increase in AHD may have
the effect of relieving the symptoms of
compression of the SAS structures. The
meaningful change in AHD, the amount
needed to change patient symptoms and
shoulder function is unknown. Subjects
without shoulder pain but with thoracic
hyperkyphosis had 1.4 to 1.7 mm smaller
mean AHD than those without hyperkyphosis.17 A study of 4 healthy subjects
using MRI images of the midcoronal
plane, which approximated the middle
SAS, noted a mean AHD increase of 0.5
mm (range, 0.3-1.5 mm) with scapular
retraction as compared to protraction.35
In our study, the mean change of 1.2 mm
in AHD with upright posture was greater than that of the scapular protractionretraction study, but smaller than the
study of thoracic hyperkyphosis. The
MDC, the distribution-based error
for our AHD measure, was 2.2 mm. A
change in AHD of 2.2 mm from normal
to upright posture was experienced by
17 of 60 subjects (28%) in this study.
Although the AHD change with upright posture is statistically significant,
it was less than the MDC in 72% of the
subjects. The relationship of a 1.2-mm
change in AHD to patient symptoms is
unknown. Research is needed to determine the meaningful amount of change
in AHD.
Slouched posture was expected to decrease AHD when compared to normal
posture in both subjects with RCD and
research report
control. However, our results did not
confirm this hypothesis. What may partially explain this lack of difference is the
subject report of difficulty and pain while
maintaining their arm at 45 of abduction when in the slouched posture. Subjects might have elevated their scapula to
relieve pain, and this substitution movement might have prevented a reduction
in the AHD. Also, scapular muscle activity might have been altered with the
postures, and this might have an effect
on AHD. We did not monitor scapular
motion or muscle activity.
Upper quadrant posture is a combination of thoracic and cervical spine
posture, and shoulder posture of
the humerus and scapula. The components of upper quadrant posture
were not measured in the 3 postures.
Changes in shoulder and spine posture were inferred with the postures.
However, changes in components of
the upper quadrant posture could have
been inconsistent across subjects and,
therefore, would explain the lack of differences across postures.
The posterior to middle aspect of
the SAS was the best position to obtain
the landmarks for AHD measures with
ultrasound images. Prior studies using
ultrasound to measure the AHD in individuals with RCD imaged the SAS over
the middle2,3 or anterior10 aspect of the
SAS space, or did not describe location14
of the ultrasound probe. Findings from
these ultrasound studies were generally
consistent with those using MRI to image the SAS,1,15,19 which depicted the AHD
measure of the anterior to middle aspect
of the SAS or described it as the smallest
distance between the acromion and humerus regardless of location in the SAS.
There is evidence of greater humeral
contact on the anterior aspect of the acromion13 and a decrease of the anterior
aspect of the SAS with clinical impingement maneuvers30; however, the purpose
of this study was not to look at contact
or absolute values but to examine the effects of change in AHD with change in
posture. Additionally, no evidence indi-
]
cates that the anterior aspect differs from
the posterior aspect with respect to AHD
change during arm movement or altered
postures. A recent study33 comparing
changes in AHD with arm elevation between the anterior and posterior aspect of
SAS indicated that changes in AHD with
arm elevation were not significantly different when AHD was measured at the
anterior versus the posterior aspect of
the SAS. AHD was significantly smaller
in the anterior aspect of SAS compared to
posterior aspect, but the change in AHD
with arm elevation was not significantly
different. However, this does not exclude
the possibility that different effects of
posture on AHD might have occurred if
the anterior SAS was imaged. Measurement of the anterior SAS is indicated in
future studies.
The AHD measure does not represent
the entire SAS, rather, only a 2-D linear distance of a portion of the outlet of
the SAS. AHD measured on ultrasound
images are reliable2,3,10,38 and have demonstrated concurrent validity with radiographs (r = 0.77-0.85),2,3 and a high
correlation has been demonstrated between AHD measures taken with radiographs and those with MRI (r = 0.81).32
With 2-D imaging, significant projection
variations31 can be avoided with standardization of subject and transducer
position. The reliability of our AHD
measures were excellent, with all ICC
values greater than 0.75. Our results are
comparable to a recent reliability study
of AHD measured on ultrasound images
of patients with RCD, with reported reliability of 0.92 and 0.90 at rest and 60
abduction, respectively.29
There was no effect of the presence
or absence of RCD on AHD across postures and arm angles. Subjects in the RCD
group represented the broad spectrum of
the disease as identified by their MRI,
ranging from impingement syndrome to
partial-thickness and full-thickness rotator cuff tear. This supports external validity. However, this heterogeneity might have
limited the internal validity and, therefore,
the ability to detect differences between
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CONCLUSION
KEY POINTS
FINDINGS: Upright posture resulted in a
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more information
www.jospt.org
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