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spinous processes in patients with shoulder pain. One study21 examined the intrarater reliability of the horizontal distance from the medial border of the scapula to the third (not the fourth) thoracic spinous processes in healthy subjects (ICC=. 91). For positions 1, 2, and 3 of the LSST, the ICCs were greater than. 82,. 86, and. 70, respectively. These results are not in accordance with 2 previous studies, which found ICC values of. 79,. 45, and. 57 for subjects with shoulder impairments» and even lower ICC values (range,. 18-69) for asymptomatic subjects. 24 It is difficult to explain the differences in findings among various studies. Variation in training and clinical experience among examiners is unlikely to account for the observed discrepancies: the examiners of the Odom et al» study of shoulder patients had 4 to 7 years of experience in outpatient orthopedics, whereas the examiners in our study were senior PT students. These students received training before the study, but their skills may not be reflective of most experienced physical therapists and medical doctors who currently use these tests. One would therefore expect to find lower interobserver reliability between senior FT students than between experienced physical therapists (as was the case in the Odom» study). A study examining the intertester reliability of clinical tests of the sacroiliac joint concluded that the years of experience did not affect the reliability. 25
The internal consistency of these clinical tests was high for both assessors. This suggests that the 3 tests are assessing the same underlying construct and dimension. It is tempting to speculate that scapular positioning represents this construct.
Table 4
Correlations Between the Self-Reported Measures (VAS, SDQ) and the Outcome of the Tests for the Assessment of Scapular Positioning (N=29)
TestAssessor 1Assessor 2
r'SDQ (P) rVAS (P) r'SDQ (P) rVAS (P)
Table relaxed-, 18 (, 35) -, 02 (, 94) -, 20 (, 31) , 04 (, 85)
Table with active shoulder retraction-, 15 (, 45) , 14 (, 46) -, 08 (, 68) , 20 (, 29)
Distance medial scapular border
T4 relaxed-, 04 (, 85) , 13 (, 49) , 08 (, 67) , 20 (, 29)
T4 retraction-, 07 (, 72) , 25 (, 19) -, 05 (, 79) , 19 (, 33)
LSST
Position 1-, 01 (, 98) , 24 (, 22) , 02 (, 92) , 11 (, 59)
Position 2-, 24 (, 22) , 05 (, 79) -, 01 (, 95) , 11 (, 56)
Position 3-, 16 (, 40) , 02 (, 93) , 01 (, 97) , 08 (, 68)
Future studies (criterion validity studies) are required to confirm this assumption. Lewis et al26 showed that surface palpation of scapular position is a valid method for determining the actual location of the scapula, which in turn supports the use of scapular skin surface palpation as a component of the clinical tests of interest in our report. Further studying of the biometric properties of these clinical tests for the assessment of scapular positioning is still required.
We found a significant association between pain severity and shoulder disability, measured with the SDQ (r=. 61). This observation provides evidence supporting the convergent validity of the Dutch version of the SDQ. We found no significant correlations between the self-reported measures and the outcome of the 3 scapular positioning tests. Together with the inability of any of the 3 tests to differentiate between the symptomatic and asymptomatic side, these observations question the clinical importance of the data obtained with the 3 clinical tests for the assessment of scapular positioning. The data outlined by Hebert et al2 provide a hypothetical explanation for the lack of differences between the symptomatic and asymptomatic sides as observed in our report. Previous research has shown that in patients with shoulder impingement syndrome, the 3-dimensional scapular behavior does not differ between the symptomatic and asymptomatic sides. 2 However, when comparing the scapular behavior of the impingement syndrome patients with healthy subjects, Hebert concluded that both shoulders of the patients' group presented with abnormal scapular positioning as compared with the healthy subjects. 2 Thus, further studying of the outcome of the clinical assessment of scapular positioning and associated shoulder disability, especially in comparison with asymptomatic healthy subjects, is warranted. In addition, although the tests used in our study are linear, scapular movements are 3-dimensional. Thus, using 3-dimensional tests for assessing scapular positioning may increase the probability of finding evidence that supports a role of scapular positioning in patients with shoulder pain.
The results of our study should be interpreted in relation to the study limitations. The limited experience of the assessors has been discussed above, and one could argue that the sample size lacked strength to find significant associations between the self-reported measures and the scapular positioning tests' outcomes. Because the correlation coefficients were very small (the majority were <0. 2) and the corresponding P values did not come near to a trend toward statistical significance (P=. 05), we deemed a power analysis unnecessary. We conclude that the sample size did not affect the outcome of the correlation analysis. Furthermore, the patients included in the present study were recruited from different private practices for PT and hospital outpatient PT divisions and were referred by a physician for PT for their shoulder pain. Consequently, these subjects are likely to be representative of shoulder patients in general seen in outpatient PT settings. However, the study sample was not randomly allocated.
CONCLUSIONS
These data provide evidence favoring the interobserver reliability of 2 of 3 clinical tests for the assessment of scapular positioning in patients with shoulder pain. The internal consistency of the tests' outcomes was high for both assessors, suggesting that the 3 tests assess the same underlying construct and dimension. The clinical importance of the tests' outcomes, however, is questionable. Further work is required to provide clinicians with simple, reliable, and valid assessment techniques for scapular behavior in patients with shoulder pain.
Acknowledgments: We thank Steven Truyen, PhD, for his advice on the statistical analysis. We are grateful to Katrien Vanher-berghen for editing the manuscript. Special thanks to all the physical therapists for kindly cooperating.
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