2. 2 Amorim et al Journal of Manipulative and Physiological Therapeutics
Scapular Dyskinesis and Neck Pain Month 2014
balance and repercussion in several systems, often with
rheumatologic, neurological, and respiratory symptoms.12
Segmental exercises are static stretching exercises of
conventional physical therapy, which consists of stretching
a single muscle or small group of muscles up to a tolerable
point and sustaining the position for a certain period,
usually during 30 seconds. 13,14 Several randomized
clinical studies tested the effectiveness of GPR relative to
other interventions (eg, static stretching) in conditions such
as chronic neck pain, ankylosing spondylitis, and tempo-romandibular
joint disorders,15–17 but not in SD associated
with neck pain. For this reason, it is essential to study the
effectiveness of GPR relative to SE (stretching exercises)
in these patients.
Muscular changes (eg, on the superior trapezius and
pectoralis) and postural abnormalities (kyphosis or lordo-sis)
seem to be risk factors for SD and cervical pain. 1,2
There are studies that show the effectiveness of SE in
treatment of neck pain18 and SD,19,20 but few show the
effectiveness of GPR in these patients. Thus, a study is
needed to compare the effectiveness of GPR with SE of
conventional physical therapy in patients with SD
associated with cervical pain. Therefore, the aim of this
study was to assess the effectiveness of GPR, relative to
SE, in the treatment of SD with neck pain. This study
particularly focused on the function of neck and arms, on
pain, and on the quality of life.
METHODS
A preliminary randomized clinical study was performed.
Randomization was conducted by randomly picking
identical opaque envelopes with intervention assignment.
Two groups were defined: GPR group (n = 18) stretched the
anterior and posterior muscular chains, and SE group (n = 18)
conducted stretching exercises. The time frame of this study
was from July 2010 to February 2011.
Patients were referred to the study by a shoulder
specialist (medical orthopedist) in the Faculty of Medical
Sciences of Santa Casa of Misericordia of São Paulo,
São Paulo, Brazil. Inclusion criteria were as follows: SD as
per the scapular malposition, inferior medial border
prominence, coracoid pain and malposition, and dyskinesis
of scapular movement (SICK) Scapula Rating Scale,2 in
association to chronic neck pain (pain for at least 3 months).
Exclusion criteria included cervical stenosis, myelopathy,
prolapsed intervertebral disk (as confirmed by magnetic
resonance imaging), and/or winged scapula due to lesions
of the long thoracic nerve or spinal accessory nerve, as
documented by electromyography.
A total of 36 patients with SD and neck pain were
included, with age ranging from 18 to 65 years. Of them, 30
completed the study (6 patients withdrew consent for work-related
reasons). The flow of the study is described in
Figure 1. During the study, the patients did not receive other
treatment modalities.
This study was approved by the Ethics Committee of
Santa Casa de Misericórdia de São Paulo (Project no. 92/10).
All participants signed informed consent forms. The clinical
trial registration number is NCT01568840.
Outcome Measures
Function of the Upper Extremity. The upper extremity was
assessed using the validated Portuguese version of the
Disabilities of the Arm, Shoulder, and Hand questionnaire.
The Disabilities of the Arm, Shoulder, and Hand question-naire
is a self-administered, region-specific outcome
instrument developed as a measure of self-rated upper-extremity
disability and symptoms. Items ask about
difficulties while performing different physical activities
due to arm, shoulder, or hand problem (21 items); the
severity of spontaneous pain; activity-related pain; tingling;
weakness and stiffness (5 items); as well as impact on social
activities, work, sleep, and self-image (4 items). Each item
has 5 response options. The scores for all items are then
used to calculate a scale score ranging from 0 (no disability)
to 100 (most severe disability).21,22
Function of the Neck. Neck function was estimated using
the Neck Disability Index (NDI), translated and adapted
to Portuguese by Cook et al.23 The NDI consists of 10
questions, with 6 possible responses (from 0 to 5), reflecting
the burden of neck pain on pain, daily activities, work,
reading, concentration, driving a car, sleeping, and leisure.
Total NDI score ranges from 0 to 50; and based on the scores,
the patients are categorized into the following: no disability
(0-5), mild disability (6-14), moderate disability (15-24),
severe disability (25-34), and totally disabled (35-50).23–25
Pain Severity. Pain severity was measured using a visual
analogical scale, where a 10-cm scale without numbers is
presented to patients. On the left extremity, the scale is labeled
no pain; on the right extremity, it is labeled maximum pain.
Patients marked on the line the severity of pain at the time
of assessment.26
Health-Related Quality of Life. Quality of life was assessed
using the Short Form (SF)–12, the abbreviated version of
the SF-36.27 The SF-12 consists of 12 questions measuring
physical and mental health. Time to complete the SF-12 is
around 2 minutes. Score ranges from 0 to 100, and higher
scores reflect better quality of life.28
Assessments were taken at baseline and at 10 weeks and
were identical at both time points. The therapist was trained
in obtaining all assessments.
Interventions
Interventions for both groups were performed by
the same physical therapist, who is a specialist in GPR
technique and trained specifically for the application of
3. Journal of Manipulative and Physiological Therapeutics Amorim et al 3
Volume xx, Number Scapular Dyskinesis and Neck Pain
Fig 1. Study flowchart. GPR, global postural reeducation; SE, segmental exercises.
GPR and SE. Sessions happened once a week for 10 weeks,
lasting 60 minutes each. The objectives of the treatment were
explained to the patients in the GPR and SE groups. At the
first 10 minutes of sessions, patients rested (supine position)
with all limbs relaxed. Manual therapy maneuvers were made
associated to breathing exercises to stretch the fasciae that
recover the scapulae, shoulders, and cervical spine muscles.
After that, stretching treatment (global or segmental) was
conducted for another 40 minutes. 29 Procedures are
described in Figure 2 and shown in Figure 3. 14–17,20,30–32
Statistical Analysis
Differences between sample characteristics across groups
were compared using the t test (parametric variables) or the
χ2 test (categorical data). Data were summarized using mean,
standard deviation, and percentiles.
Pre-post treatment analyses were compared using the
Wilcoxon signed rank test for quantitative nonparametric
variables. Between-group comparisons were conducted
using the Mann-Whitney test. The significance level
adopted was α b .05.
Global Postural Reeducation
- During the global stretching session, care was taken to avoid postural compensation (due to tension increase
in response to muscular tightness) on specific body segments; and patients maintained free breathing, with
no breath holding. At each session, patients maintained two different postures (20 minutes each).
- To stretching of the posterior muscular chain, patients were positioned in the supine position; and the goal
was to achieve the final stretching position with adducted upper limbs and lower limbs at 90° hip flexion
supported by a hanging strap. Gradual knee extensions were progressively performed (respecting patient's
limit) until tolerated, with ankle in dorsal flexion, keeping the occipital, lumbar region, and sacrum
stabilized, as rectified as possible (Fig 3A).
- To stretching of the anterior muscular chain, patients were positioned in the supine position and with upper
limbs abducted at 30° and supine forearms. Pelvis was kept in retroversion, whereas the lumbar spine
remained stabilized. Hips were flexed, abducted, and laterally rotated, with the soles of the feet touching
each other. Lower limbs were progressively extended to maximum knee extension, while maintaining the
tibiotarsal angle at 90°, with relaxed toes and lumbar region fully touching the table; and at the end of the
exercises, the arms reached 140° of abduction (Fig 3B).
.
Segmental exercises
- Patients performed segmental stretching exercises for the cervical spine, head and upper limbs, in passive
form. Each stretching position was held for 30 seconds, keeping a slow breathing and avoiding
compensations. Exercises were bilaterally repeated for 3 sets after a 10-second rest pause. Patient's limits
and possibilities were taken into account.
- Static segmental stretching targeting the shoulder (elevator muscle of scapulae, lateral, medial and anterior
muscles of arms).
- Static segmental stretching targeting the muscles of the neck (posterior, lateral, anterior, and rotators).
Fig 2. Description of global postural reeducation and segmental exercises.
4. 4 Amorim et al Journal of Manipulative and Physiological Therapeutics
Scapular Dyskinesis and Neck Pain Month 2014
Sample size was calculated to identify 20% in pain
improvement (SD = 2 points), with a power of 80%, at the
5% significance level. Required sample was 17 patients
per group.
RESULTS
Table 1 displays the characteristics of the sample.
No significant differences were seen for baseline anthropometric
and clinical variables (P N .05).
For pre-post treatment comparisons, patients in the GPR
group had significant improvements in the function of
upper extremities, function of neck, pain, and the physical
domain of quality of life (P b .05).
As for the SE group, significant improvements were seen
for function of upper extremities, function of neck, and
severity of pain (P b .05).
When contrasting groups, significantly superior im-provement
was seen in patients receiving GPR vs SE for
severity of pain and for quality of life (physical domain of
SF-12). No significant differences were seen for the other
variables (Table 2). No adverse events were reported for
this study.
DISCUSSION
Although both GPR and SE improved functionality of
upper extremity, function of neck, and pain in patients
with SD and neck pain, quality of life only improved in the
GPR group.
Scapular dyskinesis may result as a consequence of
various reasons but may exacerbate preexisting conditions
of the shoulder. 33 Its association with pain is well
known and may be due to shortening and stiffness of the
trapezius and pectoralis muscles, as well as accentuation of
the thoracic kyphosis and/or cervical lordosis.1,2 These
changes may in turn impact daily life activities, therefore
compromising the quality of life of a sizeable number
of patients. 15,34,35
The improvement in pain and function found in
this study after both interventions may be explained by
global stretching of muscular chains and by segmental
stretching of individual muscles or small muscular
groups. Global postural reeducation involves active
Fig 3. Global postural reeducation exercises (A, posterior muscle
chain; B, anterior muscle chain).
Table 1. Sample Characteristics
Variables
GPR (n = 15)
Mean (SD)
SE (n = 15)
Mean (SD) P Value
Age (y) 40.0 (11.2) 36.4(12.6) .34 a
Weight (kg) 67.0 (8.2) 64.9 (9.1) .51 a
Height (cm) 1.66 (0.1) 1.63 (0.1) .38 a
BMI (kg/cm2) 24.21 (1.6) 24.22 (2.4) .99 a
n (%) n (%)
Sex
Female 10 (66.7) 11(73.3) .50 b
Male 5 (33.3) 4 (26.7)
Scapula injured
Right 5 (33.3) 4 (26.7) .89 b
Left 6 (40.0) 6 (40.0)
Bilateral 4 (26.7) 5 (33.3)
Work posture
Sitting 12 (80.0) 12 (80.0) .99 b
Standing 1 (6.7) 1 (6.7)
Both 2 (13.3) 2 (13.3)
Physical activity
Active 3 (20.0) 1 (6.7) .29 b
Sedentary 12 (80.0) 14 (93.3)
Work
Active 12 (80.0) 15 (100.0) .11 b
Absent 3 (20.0) 0 (0.0)
Cervical alignment
Normal 3 (20.0) 4 (27.0) .58 b
Hyperlordosis 10 (64.0) 8 (53.0)
Rectification 2 (13.0) 3 (20.0)
BMI, body mass index; GPR, global postural reeducation; SE, segmental
exercises.
a P value for t test.
b P value for χ2 test.
5. Journal of Manipulative and Physiological Therapeutics Amorim et al 5
Volume xx, Number Scapular Dyskinesis and Neck Pain
Table 2. Inter- and Intragroup Comparisons for Clinical Variables: Functionality, Pain, and Quality of Life
and prolonged stretching for 20 minutes, which requires
good self-perception and attention to execute the
method; the second intervention involves short episodes
of stretching (30 seconds) that, although requiring
attention as well, are easier to learn and execute. 13,15,17.
A systematic review of the effectiveness of different
types of exercises for prevention and cure of neck pain
has shown that stretching exercises increase the
flexibility of joint structures, neck muscles, and range
of joint motion, and encourages circulation and
oxygenation in joints, muscles, and muscle tendon
units.18 In addition, randomized clinical studies found
that stretching exercise reduced discomfort in neck pain
workers compared with those who received deep
breathing,31 and found that stretching exercise once or
twice a day under the supervision of a physiotherapist
increased improvement index compared with only
receiving education.32 Bronfort et al36 have shown
positive results in associating exercises with manual
therapy for relieving pain. Some studies indicate the
effectiveness of GPR and static stretching exercises in
reducing pain and in improving range of motion and
quality of life in conditions such as chronic neck
pain, ankylosing spondylitis, and temporomandibular
joint disorders.15–17
Some similarities exist between the 2 treatment
methods and may explain why patients in both groups
had improved pain and function. Time of intervention
was similar (60 minutes), and therapist was the
same; therefore, patient/therapist dynamics were likely
similar. Additionally, all patients received the same
instructions and supervision, including on how to
avoid muscular compensation, respiratory techniques,
and others 11,15,17
Our findings are supported by previous studies, which
also reported improvement of quality of life after GPR due
to changes in the corporal representation and increased self-perception,
which are associated with well-being and better
postural conscience.11,15–17
We emphasize that both groups were oriented to
perform exercises while in a slow breathing rhythm. In the
GPR, they were asked to conduct slow, gentle, and
prolonged expirations, which not only improve subse-quent
inspirations but also seem to increase well-being
and quality of life per se. 15 Finally, the differential
improvements in GPR relative to SE may be due to the
fact that the first also addresses risk factors for SD with
neck pain by decreasing muscular tension at the level of
the superior trapezius and pectoralis as well as by
realigning the cervical and dorsal spine.1,2,19,20,34 None-theless,
we found that GPR and SE are effective in
treating specific musculoskeletal disorders.
Limitations of the Study
The study limitations were as follows. There were
few patients included in this study. Some patients
withdrew consent for work-related reasons and left the
study. There was an absence of a control group. The
assessment was unblinded. Future studies should be
larger; include a control group, blinding, and a long
term of follow-up assessment; and test combination of
interventions, such as stretching exercises and specific
stabilization exercise for the scapula muscles in patients
with SD.
CONCLUSION
For this group of patients with SD associated with
neck pain, GPR and SE had similar effects on
functionality of the neck and upper extremity. Global
postural reeducation was superior to SE in improving
pain and quality of life.
Variables
GPR (n = 15) SE (n = 15)
P b
Pretreat Posttreat
P
Pretreat Posttreat
Mean (SD) Mean (SD) Mean (SD) Mean (SD) P
Function
Neck (0-50) 22.5(10.31) 11.07(8.70) .001 a 21.27(9.78) 17.23(11.82) .023 a .134
Arm, shoulder, and hand
(0-100)
21.16(11.80) 12.88(11.59) .001 a 25.66(18.06) 21.94(18.76) .023 a .281
Pain (0-10) 5.73(1.83) 2.6(0.99) .001 a 6.07(2.25) 5.0(2.59) .004 a .003 b
Quality of life (0-100)
Domains Physical 43.33(9.78) 48.98(7.43) .010 a 40.37(8.16) 42.28(9.49) .279 .049 b
Mental 54.21(7.53) 55.48(5.70) .061 50.65(6.89) 51.63(7.57) .795 .025 b
GPR, global postural reeducation; Pretreat, before treatment; Posttreat, immediately after treatment; SE, segmental exercises.
a Statistically significant difference (Wilcoxon signed rank test).
b Statistically significant difference (Mann-Whitney test): intergroups.
6. 6 Amorim et al Journal of Manipulative and Physiological Therapeutics
Scapular Dyskinesis and Neck Pain Month 2014
FUNDING SOURCES AND POTENTIALCONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
C.S.M.A., M.E.C.G., A.P.M., V.L.S.A.
Design (planned the methods to generate the results):
C.S.M.A., M.E.C.G., A.P.M., V.L.S.A.
Supervision (provided oversight, responsible for orga-nization
and implementation, writing of the manuscript):
C.S.M.A., M.E.C.G., A.P.M., V.L.S.A.
Data collection/processing (responsible for experi-ments,
patient management, organization, or reporting
data): C.S.M.A., M.E.C.G., A.P.M., V.L.S.A.
Analysis/interpretation (responsible for statistical
analysis, evaluation, and presentation of the results):
C.S.M.A., M.E.C.G., A.P.M., V.L.S.A.
Literature search (performed the literature search):
C.S.M.A., M.E.C.G., A.P.M., V.L.S.A.
Writing (responsible for writing a substantive part of the
manuscript): C.S.M.A., M.E.C.G., A.P.M., V.L.S.A.
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): C.S.M.A., M.E.C.G., A.P.M., V.L.S.A.
REFERENCES
1. Kibler WB, McMullen J. Scapular dyskinesis and its relation
to shoulder pain. J Am Acad Orthop Surg 2003;11:142-51.
2. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing
shoulder: spectrum of pathology part III: the SICK scapula,
scapular dyskinesis, the kinetic chain, and rehabilitation.
Arthroscopy 2003;19:641-61.
3. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R.
Scapulothoracic motion in normal shoulders and shoulders
with glenohumeral instability and impingement syndrome.
A study using Moire topographic analysis. Clin Orthop Relat
Res 1992;285:191-9.
4. Madsen PH, Bak K, Jensen S, Welter U. Training induces
scapular dyskinesis in pain-free competitive swimmers: a
reliability and observational study. Clin J Sport Med 2011;21:
109-13.
5. Bring G, Bring J. Neck pain in the general population. Spine
(Phila Pa 1976) 1995;20:624-7.
6. Vernon H, Humphreys K, Hagino C. Chronic mechanical
neck pain in adults treated by manual therapy: a systematic review
of change scores in randomized clinical trials. J Manipulative
Physiol Ther 2007;30:215-27.
7. Zakharova-Luneva E, Jull G, Johnston V, O'Leary S. Altered
trapezius muscle behavior in individuals with neck pain and
clinical signs of scapular dysfunction. J Manipulative Physiol
Ther 2012;35:346-53.
8. Nijs J, Roussel N, Struyf F, Mottram S, Meeusen R. Clinical
assessment of scapular positioning in patients with shoulder
pain: state of the art. J Manipulative Physiol Ther 2007;30:
69-75.
9. Sheard B, Elliott J, Cagnie B, O'Leary S. Evaluating serratus
anterior muscle function in neck pain using muscle functional
magnetic resonance imaging. J Manipulative Physiol Ther
2012;35:629-35.
10. Marques AP. Cadeias musculares: um programa para ensinar
avaliação fisioterapêutica global. São Paulo: Manole; 2005.
11. Teodori RM, Negri JR, Cruz MC, Marques AP. Global
postural re-education: a literature review. Rev Bras Fisioter
2011;15:185-9.
12. Souchard PE. Principes et originalité de la rééducation
posturale globale. France: Le Pousoë; 2003.
13. Shrier I, Gossal K. Myths and truths of stretching:
individualized recommendations for healthy muscles. Phys
Sportsmed 2000;28:57-63.
14. Marques AP, Vasconcelos AA, Cabral CM, Sacco IC. Effect
of frequency of static stretching on flexibility, hamstring
tightness and electromyographic activity. Braz J Med Biol Res
2009;42:949-53.
15. Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of
global posture reeducation and of static stretching on pain,
range of motion, and quality of life in women with chronic
neck pain: a randomized clinical trial. Clinics (Sao Paulo)
2008;63:763-70.
16. Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-
Cabezas M, Miangolarra-Page JC. Two exercise interventions
for the management of patients with ankylosing spondylitis: a
randomized controlled trial. Am J Phys Med Rehabil 2005;84:
407-19.
17. Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G,
Marques AP. Global postural reeducation and static stretching
exercises in the treatment of myogenic temporomandibular
disorders: a randomized study. J Manipulative Physiol Ther
2010;33:500-7.
18. Sihawong R, Janwantanakul P, Sitthipornvorakul E, Pensri P.
Exercise therapy for office workers with nonspecific neck
pain: a systematic review. J Manipulative Physiol Ther 2011;
34:62-71.
19. Hrysomallis C. Effectiveness of strengthening and stretching
exercises for the postural correction of abducted scapulae: a
review. J Strength Cond Res 2010;24:567-74.
Practical Applications
• This study found that GPR and SE had
similar effects on functionality of the neck
and upper extremity in patients with SD and
neck pain.
• In this preliminary study, GPR was superior
to SE in improving pain and quality of life.
• Because GPR was superior to SE in some
parameters, using GPR as an initial strategy
to treat patients with SD and neck pain is
reasonable.
• Because both methods were similar in most
parameters, patient’s preference and providers’
experience should possibly drive initial approach.
7. Journal of Manipulative and Physiological Therapeutics Amorim et al 7
Volume xx, Number Scapular Dyskinesis and Neck Pain
20. Wang CH, McClure P, Pratt NE, Nobilini R. Stretching and
strengthening exercises: their effect on three-dimensional
scapular kinematics. Arch Phys Med Rehabil 1999;80:923-9.
21. Orfale AG, Araujo PM, Ferraz MB, Natour J. Translation into
Brazilian Portuguese, cultural adaptation and evaluation of the
reliability of the Disabilities of the Arm, Shoulder and Hand
Questionnaire. Braz J Med Biol Res 2005;38:293-302.
22. ChengHM, Sampaio RF,ManciniMC, Fonseca ST, CottaRM.
Disabilities of the arm, shoulder and hand (DASH): factor
analysis of the version adapted to Portuguese/Brazil. Disabil
Rehabil 2008;30:1901-9.
23. Cook C, Richardson JK, Braga L, et al. Cross-cultural
adaptation and validation of the Brazilian Portuguese version
of the Neck Disability Index and Neck Pain and Disability
Scale. Spine (Phila Pa 1976) 2006;31:1621-7.
24. Sterling M, Rebbeck T. The Neck Disability Index (NDI).
Aust J Physiother 2005;51:271.
25. Vernon H, Mior S. The Neck Disability Index: a study of
reliability and validity. J Manipulative Physiol Ther 1991;14:
409-15.
26. Johnson EW. Visual analog scale (VAS). Am J Phys Med
Rehabil 2001;80:717.
27. Campolina AG, Ciconelli RM. SF-36 and the development of
new assessment tools for quality of life. Acta Reumatol Port
2008;33:127-33.
28. Luo X, Lynn George M, Kakouras I, et al. Reliability, validity,
and responsiveness of the short form 12-item survey (SF-12)
in patients with back pain. Spine (Phila Pa 1976) 2003;28:
1739-45.
29. Bienfait M. La fascia et son traitement: les pompages. Paris:
Speak; 1995.
30. Camargo PR, Haik MN, Ludewig PM, Filho RB,Mattiello-Rosa
SM, Salvini TF. Effects of strengthening and stretching exercises
applied during working hours on pain and physical impairment in
workers with subacromial impingement syndrome. Physiother
Theory Pract 2009;25:463-75.
31. Kietrys DM, Galper JS, Verno V. Effects of at-work exercises
on computer operators. Work 2007;28:67-75.
32. Tsauo JY, Lee HY, Hsu JH, Chen CY, Chen CJ. Physical
exercise and health education for neck and shoulder
complaints among sedentary workers. J Rehabil Med 2004;
36:253-7.
33. Voight ML, Thomson BC. The role of the scapula in the
rehabilitation of shoulder injuries. J Athl Train 2000;35:
364-72.
34. Kibler WB, Sciascia A. Current concepts: scapular dyskinesis.
Br J Sports Med 2010;44:300-5.
35. GeisserME, RobinsonME, Miller QL, Bade SM. Psychosocial
factors and functional capacity evaluation among persons with
chronic pain. J Occup Rehabil 2003;13:259-76.
36. Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH,
Vernon H. A randomized clinical trial of exercise and
spinal manipulation for patients with chronic neck pain.
Spine (Phila Pa 1976) 2001;26:788-97.
