The Scapular Dyskinesis Test: is it reliable and valid? M J Smith1, R Goldsmith2, K Nicholas2, S Owen2 1 School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, UK 2 Cardiff and Vale University Health Board, Cardiff, UK Grateful thanks to Arthritis Research UK for funding this work under their Nurse and Allied Health Professional Training Fellowship scheme

Background Is scapular position, movement and control of relevance to shoulder pain/dysfunction? If so, what is the best way to asses scapular position, movement and control? Arguably this depends on the question you are looking to answer, the setting for the study and the resources available. There is a debate surrounding the importance of scapular dysfunction in managing shoulder pain. If you are interested in quantifying scapular movement…… McClure The Scapular Dyskinesis Test (SDT) The patient repeatedly performs active, weighted shoulder flexion and abduction The presence of scapula dyskineses is defined as an abnormal movement patterns, either dysrhythmia (the scapula demonstrates premature or excessive elevation or protraction, nonsmooth motion during arm elevation and/or lowering) or winging (medial border of the scapula and/or inferior angle of the scapula are posteriorly displaced away from the thorax). Based on the combined flexion and abduction test movements, the presence of scapular dyskinesis is classified as either not present (normal) or present (subtle dyskineses or obvious dyskinesis). The SDT classification system has shown moderate interrater reliability (weighted kappa 0.48-0.61, 75%-82% agreement), and concurrent validity was demonstrated by 3-dimensional motion tracking system among college athletes. Kibbler 2002 & 2003 classified into 4 groups (3 abnormal, 1 normal) Type 1: inferior angle visible/ ant tilt Type 2: Medial boarder visible Type 3: Upwards elevation / hitch Type 4: Normal One such approach is the Scapular Dyskinesis Test (SDT) (McClure et al. 2009).

Visual observation and subjectively classified. Background to the SDT Visual observation and subjectively classified. Advantages – uses no equipment, non-mutual exclusivity of movement components, dynamic. However – developed and tested on college-level overhead athletes; requires movement in 2 planes with hand-held weight. Can it be used in its current form with a routine UK public health (NHS) population?

A different population

Study design Part of a larger, £170k fellowship funded by Arthritis Research UK: ‘Prognostic Indicators of Successful Rehabilitation Outcome in Patients with Subacromial Impingement Syndrome / Rotator Cuff Tendinopathy’

Study design Part of a larger, £170k personal fellowship funded by Arthritis Research UK: ‘Prognostic Indicators of Successful Rehabilitation Outcome in Patients with Subacromial Impingement Syndrome / Rotator Cuff Tendinopathy’

Study design Study 1: n=76 patients with clinical diagnosis of SIS/RCT in an NHS secondary care setting. Videos of scapular movement recorded during scaption; where tolerated they used a hand-held weight. One of the variables in larger prognostic study. Study 2: Nested sample of 30 patients. Inter-rater reliability study between 2 experienced musculoskeletal physiotherapists. Agreement was calculated via linear weighted Kappa. Nested: randomly selected, but had to be blinded assessors (i.e. not involved in their treatment). Large number of other variables collected; however BMI and active humeral range of movement (ROM) used to compare with original McClure et al. (2009) study. Also pain (VAS) and shoulder function (OSS) measured.

Results Study 1: In patients with a clinical diagnosis of SIS/RCT in an NHS setting, 42% (n= 32/76) were unable to tolerate a loaded trial. McClure et al (2009) requires 2 x loaded trials for quantifying SDT. Study 2: Agreement between the 2 raters was only fair (Kappa of 0.33, p=0.002). McClure et al (2009) reported agreement of Kappa = 0.48 to 0.61 (left/right). MCClure had cut off of <30Kgm2 : approximately half of our cohort would not be eligible for McClure study. MCClure had cut off of >7/10 NRS (but did not report pain levels) McClure did not report ROM or disability: however were athletes so likely to be full ROM? Low disability? Mean (SD) BMI of 29.0kgm-2 (6.3kgm-2). Mean (SD) active humeral ROM of 138° (25°). Mean (SD) VAS pain score of 5.9 (2.2) out of 10 (worst pain). Mean (SD) OSS of 31.6 (7.7) out of 48 (least impaired function). McClure et al (2009) used overhead athletes; inclusion criteria of BMI <30kgm-2 & NRS <7/10

Conclusion Study 1: In patients with a clinical diagnosis of SIS/RCT in an NHS setting, 42% (n= 32/76) were unable to tolerate a loaded trial. McClure et al (2009) requires 2 x loaded trials for quantifying SDT. Study 2: Agreement between the 2 raters was only fair (Kappa of 0.33, p=0.002). McClure et al (2009) reported agreement of Kappa = 0.48 to 0.61 (left/right). Mean (SD) BMI of 29.0kgm-2 (6.3kgm-2). Mean (SD) active humeral ROM of 138° (25°). Mean (SD) VAS pain score of 5.9 (2.2) out of 10 (worst pain). Mean (SD) OSS of 31.6 (7.7) out of 48 (least impaired function). McClure et al (2009) used overhead athletes; inclusion criteria of BMI <30kgm-2 & NRS <7/10

Conclusion SDT in published form lacks ecological validity in patients with clinical diagnosis of SIS/RCT in a UK public health (NHS) secondary care setting Study 1: Of n=76 patients with clinical diagnosis of SIS/RCT in an NHS setting, 42% (n= 32) were unable to a loaded trial. McClure et al (2009) requires 2 x loaded trials for quantifying SDT. Study 2: Agreement between the 2 raters was only fair (Kappa of 0.33, p=0.002). McClure et al (2009) reported agreement of Kappa = 0.48 to 0.61 (left/right). Mean (SD) BMI of 29.0kgm-2 (6.3kgm-2). Mean (SD) active humeral ROM of 138° (25°). Mean (SD) VAS pain score of 5.9 (2.2) out of 10 (worst pain). Mean (SD) OSS of 31.6 (7.7) out of 48 (least impaired function). McClure et al (2009) used overhead athletes; inclusion criteria of BMI <30kgm-2 & NRS <7/10

Conclusion Study 1: In patients with a clinical diagnosis of SIS/RCT in an NHS setting, 42% (n= 32/76) were unable to tolerate a loaded trial. McClure et al (2009) requires 2 x loaded trials for quantifying SDT. SDT in published form cannot be applied reliably in patients with clinical diagnosis of SIS/RCT in a UK public health (NHS) secondary care setting Study 2: Agreement between the 2 raters was only fair (Kappa of 0.33, p=0.002). McClure et al (2009) reported agreement of Kappa = 0.48 to 0.61 (left/right). Mean (SD) BMI of 29.0kgm-2 (6.3kgm-2). Mean (SD) active humeral ROM of 138° (25°). Mean (SD) VAS pain score of 5.9 (2.2) out of 10 (worst pain). Mean (SD) OSS of 31.6 (7.7) out of 48 (least impaired function). McClure et al (2009) used overhead athletes; inclusion criteria of BMI <30kgm-2 & NRS <7/10

Conclusion SDT in published form lacks ecological validity in patients with clinical diagnosis of SIS/RCT in a UK public health (NHS) secondary care setting Study 1: Of n=76 patients with clinical diagnosis of SIS/RCT in an NHS setting, 42% (n= 32) were unable to a loaded trial. McClure et al (2009) requires 2 x loaded trials for quantifying SDT. Study 2: Agreement between the 2 raters was only fair (Kappa of 0.33, p=0.002). McClure et al (2009) reported agreement of Kappa = 0.48 to 0.61 (left/right). Mean (SD) BMI of 29.0kgm-2 (6.3kgm-2). Mean (SD) active humeral ROM of 138° (25°). Mean (SD) VAS pain score of 5.9 (2.2) out of 10 (worst pain). Mean (SD) OSS of 31.6 (7.7) out of 48 (least impaired function). McClure et al (2009) used overhead athletes; inclusion criteria of BMI <30kgm-2 & NRS <7/10

Potential explanation Conclusion SDT in published form lacks ecological validity in patients with clinical diagnosis of SIS/RCT in a UK public health (NHS) secondary care setting Study 1: Of n=76 patients with clinical diagnosis of SIS/RCT in an NHS setting, 42% (n= 32) were unable to a loaded trial. McClure et al (2009) requires 2 x loaded trials for quantifying SDT. Study 2: Agreement between the 2 raters was only fair (Kappa of 0.33, p=0.002). McClure et al (2009) reported agreement of Kappa = 0.48 to 0.61 (left/right). Ecological / external validity: Is it practical in the ‘real’ world? 42% were unable to tolerate a loaded trial Was the task too hard? Limited ROM? Potential explanation Mean (SD) BMI of 29.0kgm-2 (6.3kgm-2). Mean (SD) active humeral ROM of 138° (25°). Mean (SD) VAS pain score of 5.9 (2.2) out of 10 (worst pain). Mean (SD) OSS of 31.6 (7.7) out of 48 (least impaired function). McClure et al (2009) used overhead athletes; inclusion criteria of BMI <30kgm-2 & NRS <7/10

Conclusion Study 1: In patients with a clinical diagnosis of SIS/RCT in an NHS setting, 42% (n= 32/76) were unable to tolerate a loaded trial. McClure et al (2009) requires 2 x loaded trials for quantifying SDT. SDT in published form cannot be applied reliably in patients with clinical diagnosis of SIS/RCT in a UK public health (NHS) secondary care setting Study 2: Agreement between the 2 raters was only fair (Kappa of 0.33, p=0.002). McClure et al (2009) reported agreement of Kappa = 0.48 to 0.61 (left/right). Mean (SD) BMI of 29.0kgm-2 (6.3kgm-2). Mean (SD) active humeral ROM of 138° (25°). Mean (SD) VAS pain score of 5.9 (2.2) out of 10 (worst pain). Mean (SD) OSS of 31.6 (7.7) out of 48 (least impaired function). McClure et al (2009) used overhead athletes; inclusion criteria of BMI <30kgm-2 & NRS <7/10

Potential explanation Conclusion Study 1: In patients with a clinical diagnosis of SIS/RCT in an NHS setting, 42% (n= 32/76) were unable to tolerate a loaded trial McClure et al (2009) requires 2 x loaded trials for quantifying SDT. SDT in published form cannot be applied reliably in patients with clinical diagnosis of SIS/RCT in a UK public health (NHS) secondary care setting Study 2: Agreement between the 2 raters was only fair (Kappa of 0.33, p=0.002). McClure et al (2009) reported agreement of Kappa = 0.48 to 0.61 (left/right). Potential explanation Possible explanations: Increased variability of dysfunctions happening in a smaller movement? More to see, less movement to determine? BMI / hair obscuring scapula? Mean (SD) BMI of 29.0kgm-2 (6.3kgm-2). Mean (SD) active humeral ROM of 138° (25°). Mean (SD) VAS pain score of 5.9 (2.2) out of 10 (worst pain). Mean (SD) OSS of 31.6 (7.7) out of 48 (least impaired function). McClure et al (2009) used overhead athletes; inclusion criteria of BMI <30kgm-2 & NRS <7/10

Any questions?