Patients referred to physical therapy with impaired upper extremity function, often exhibit postural alterations [
FSP and associated muscle imbalance is one of the factors contributing to episodes of head, neck, and shoulder pain [
Many shoulder rehabilitation programs emphasize scapular muscle control [
Taping is believed to affect the resting position of the scapula and assist in maintaining the proximal shoulder-girdle stability necessary to perform elevation of the arm [
Box Taping is one of the scapular taping techniques explained to correct the scapular position [
Normalised scapular abduction ratio (NSA ratio) is considered as one of the reliable measures for scapular position [
FSP on visual estimation is decided if any one of the following findings were present [ medial borders of scapula were not parallel to each other; anterior shoulder point was anterior to sternal notch/hollowing of the chest present.
The mean NSA ratio in this group was 1.60 which was in close approximation with the mean NSA ratio seen in population from the United States [
A randomised control trial (RCT) design was used in this study. A NSA ratio on measurement set at ≥1.60 was used as a criterion to define FSP. A convenient sample of 60 healthy participants was screened for FSP among graduate and postgraduate students from various departments of Manipal University. Thirty-eight healthy volunteers with FSP, aged between 18–35 years were included. Participants were excluded if they were symptomatic, had any neurological deficit in upper extremity, or any surgical intervention affecting the thorax and scapula.
All participants who fulfilled screening and eligibility criteria were informed about the study and written informed consent was taken before starting the procedure. The study was approved by institutional research committee of Manipal college of Allied Health Sciences.
Recording of static and dynamic scapular alignment measures was performed bilaterally by the primary investigator. All measurements were taken with measuring tape in centimetres.
For static scapular alignment, three tests were used [ Acromial distance [ T 3 distance [ Normalised scapular abduction ratio (NSA ratio) [
Acromial distance: distance between the posterior border of acromion and table surface.
T 3 distance: horizontal distance from the third thoracic spinous process to the corresponding point on medial border of the scapula.
NSA ratio: distance from posterolateral angle of acromion to thoracic spine process, (T 3): distance from posterolateral angle of acromion to root of spine of scapula.
For Dynamic scapular alignment: lateral scapular slide test (LSST) was done [
Lateral scapular slide test (LSST): distance from inferior angle of scapula to 7th thoracic spinous process.
The potential participants were contacted telephonically and were offered an appointment for a baseline assessment. After baseline measurements, participants were randomly assigned by the primary investigator to either of the box taping (
Comprehensive exercise treatment program (i) Stretching of tight anterior shoulder muscles (passive stretching) Pectoralis minor/major, upper trapezius 1st 5 sessions—5 stretches, each with 30 seconds of hold Next 10 sessions—10 stretches, each with 30 seconds of hold (ii) Strengthening exercises for posterior scapular muscles and glenohumeral external rotators with therabands Posterior scapular muscles—rhomboids, middle and lower trapezius Glenohumeral external rotators—infraspinatus and teres minor 1st 5 sessions—5 repetition, each with 10 seconds of hold Next 5 sessions—10 repetition, each with 10 seconds of hold Last 5 sessions—15 repetition, each with 10 seconds of hold (iii) Thoracic spine mobilization exercises Subject was made to lie down supine on a wedge placed at the level of maximum thoracic kyphosis for 5 minutes (iv) Strengthening of upper back musculature Subject was made to lie down on a pillow under the chest in prone lying and was instructed to straighten the upper back 1st 5 sessions—5 repetition, each with a hold 10 seconds Next 10 sessions—10 repetition, each with a hold of 10 seconds
The standard treatment program consisted of stretching-strengthening exercises and mobilization to counteract the muscle imbalances and joint restrictions that may be associated with FSP. The supervised stretching-strengthening exercise program (Box
At the first session of the exercise program, the participants were introduced to the different levels of theraband (Hygenic Corp). The participants began exercises using the yellow nonlatex band at mild tension. The subjects were progressed to the next colour resistive band when they were able to perform required repetitions (Box
Taping technique used was box taping [
Box taping technique.
Descriptive statistics (mean, SD) were computed for each study variable. Data was tested for normality and parametric tests were used for statistical analysis using SPSS version 18.0. The statistical significance was set at alpha < 0.05 at 95% confidence interval. Our study has investigated the effect of intervention on each variable on both sides at 3 different sessions. Each of these variables were analyzed using repeated measures of analysis of variance (ANOVA) with time as within-participant factor at 3 levels (baseline, 7th and 15th session) and group as between participant factor. Mauchly’s test of sphericity was used to test homogeneity of variance. In case of significant Mauchly test results for sphericity, Greenhouse-Geisser correction was applied to adjust the tests, as recommended by Portney and Watkins [
Nine participants dropped out from both the box taping and standard treatment group, leaving 20 patients for analysis. The groups were comparable before treatment (Table
Characteristics of participants (
Characteristic | Experiment group ( |
Control group ( |
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Age (years) |
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0.06 |
Weight (kg) |
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0.97 |
Height (cms) |
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0.30 |
Male ( |
5 | 3 | |
Females ( |
6 | 6 |
Mean difference [95% CI] between two groups at baseline (
Variable | Left | Right | ||
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Mean difference [95% CI] |
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Mean difference [95% CI] |
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Static scapular alignment | ||||
NSA ratio | −0.03 [−0.14, 0.08] | 0.59 | 0.01 [−0.07, 0.10] | 0.66 |
Acromial distance (cm) | 1.20 [−0.18, 2.60] | 0.08 | 0.62 [−0.57, 1.81] | 0.28 |
T 3 distance (cm) | 0.13 [−0.85, 1.12] | 0.78 | 0.47 [0.50, 1.45] | 0.32 |
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Dynamic scapular alignment (LSST) | ||||
0 degree | 0.02 [−1.18, 1.22] | 0.97 | −0.04 [−1.2, 1.12] | 0.94 |
45 degree | 0.44 [−1.85, 0.95] | 0.50 | 0.03 [−1.39, 1.45] | 0.96 |
90 degree | 0.15 [−2.00, 1.69] | 0.86 | 0.15 [−2.00,1.69] | 0.86 |
NSA ratio: normalised scapular abduction ratio.
T 3 distance: distance from medial scapular border to 3rd thoracic spine.
LSST: Lateral Scapular Slide Test.
CONSORT diagram describing participant recruitment and retention.
At 5% level of significance, ANOVA results revealed that there was a statistically significant improvement for two of the variables of static scapular alignment that is, NSA ratio (right side) and acromial distance (both sides), but no significant improvement in variables of dynamic scapular alignment in participants of box-taping group (Table
Scapular alignment measurements of the Experimental group (mean ± SD)
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Baseline | 7th session | 15th session | Baseline | 7th session | 15th session | |
Static scapular alignment | ||||||
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T 3 distance (cm) |
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Dynamic scapular alignment (LSST) | ||||||
0 degree |
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45 degree |
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90 degree |
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NSA ratio: normalised scapular abduction ratio.
T3 distance: distance from medial scapular border to 3rd thoracic spine.
LSST: Lateral Scapular Slide Test.
Scapular alignment measurements of the control group (mean ± SD)
Variable | Left | Right | ||||
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Baseline | 7th session | 15th session | Baseline | 7th session | 15th session | |
Static scapular alignment | ||||||
NSA ratio |
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Acromial distance |
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T 3 distance (cm) |
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Dynamic scapular alignment (LSST) | ||||||
0 degree |
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45 degree |
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90 degree |
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NSA ratio: normalised scapular abduction ratio.
T 3 distance: distance from medial scapular border to 3rd thoracic spine.
LSST: Lateral Scapular Slide Test.
Following commencement of treatment, both groups showed improvement (decrease) in NSA ratio, acromial distance, and T 3 distance bilaterally (Tables
Changes in acromial distance: left and righ at baseline (1), 7th session (2), and 15th (3) session.
Following commencement of treatment, there is no regular trend towards improvement in distances for LSST at 0 deg, 45 deg, and 90 deg (both sides) in both the groups which could be the reason for no statistical significant difference between as well as within the two groups (Tables
Optimal posture provides both mechanical and functional benefits [
In our study, although we were underpowered to detect significant differences between the two groups at
Changes observed in static scapular alignment in our study are similar to results found in a cross-over study done by Lewis et al. [
The improvement in static scapular alignment was observed in all 20 subjects irrespective of the group in our study which is contradictory to previous studies where 6 weeks (3 times/week) of scapular muscle stretching-strengthening exercises did not find any improvement in static scapular alignment in FSP population [
The literature has shown that a minimum of six weeks of exercise is needed to show statistically significant strength gains [
The assumption is that taping provides biofeedback and mechanical support for optimal shoulder position. Both the type and duration of biofeedback for optimal posture from taping are different than that provided by advice and exercise. Greater duration of feedback from application of taping should have potential beneficial effect allowing adaptation of neural pathways by consistent correct proprioceptive feedback [
Furthermore, no statistically significant change is observed even when taping was used as an adjunct over a duration of three weeks in overall subject population. This is in support with the literature which has proved that at least 12 weeks of taping may be necessary to affect muscle tension properties in comparison to three weeks of treatment used in the present study [
We conducted measurements of both shoulders in our study. The process revealed interesting data showing more improvement on right side which could be related to hand dominance as all 20 subjects included in the study were right handed or could be due to the fact that subjects included in the study were fourteen right sided, two left sided, and four bilateral FSP subjects. This is a different approach from previous research involving shoulder measurements to evaluate posture, which typically evaluated only one shoulder on each subject, usually the right shoulder [
Although this study suggests that the exercise and postural advice program was beneficial in improving posture in the healthy populations who were perceived to be at risk for musculoskeletal problems due to FSP. However, there are a number of limitations that should be considered as limiting our confidence in these findings or their readiness for implementation. There were substantial designs flaws since the trial did not have concealment of treatment allocation, or blinded outcome evaluation. Since blinding of patients was not possible, it would have been preferable if a blinded evaluator had been used to measure the outcomes. However, the measures were at different time points and the treating therapist was unaware of the previous scores. Further, it is unlikely that the treating therapist would have influenced measures like dynamic posture. This potentially reduces the impact of observer bias. There is a need for more research establishing reliable and valid outcome measures for scapular assessment in FSP population.
From an implementation perspective, there were additional concerns which were reflected in a high drop-out rate. Reasons for discontinuing the treatment included allergic reactions with use of leukotape and lack of interest in continuing. The motivation to adhere to treatments that are preventative may be more challenging than those provided to reduce symptoms as the motivation may be low. Finally, since this study recruited a small healthy sample of convenience derived from a single university campus, this precludes generalization of the results beyond the sample population
Implications of the present study are as follows. Supervised stretching-strengthening exercise program alone or in combination with box-taping were well tolerated in healthy forward shoulder posture subjects for correction of scapular alignment; but adherence may be challenging in asymptomatic young individuals. Supervised stretching-strengthening exercise program was effective (
Supervised stretching-strengthening exercise program with or without box-taping resulted in improvement in posture in healthy forward shoulder posture population. There were no significant additive effects of box taping.
The research study is approved by institutional review committee of Manipal College of Allied Health Sciences (MCOAHS) towards postgraduation in orthopaedic physical therapy dissertation.
The authors declare that there are no financial gains from the content of this research paper. (i) The research paper is presented as a paper at 9th Triennial Congress of International Federation of Societies for Hand Therapists (IFSHT) and 12th International federation of Societies for Hand Surgeons (IFSSH), New Delhi, India (2013, March 5). (ii) The research paper is presented as a poster at CPA Congress, Montreal (2013, May 25).
The authors declare that they have no conflict of interests.
Neha Dewan is supported in part by the Joint Motion Program: “A CIHR Training Program in Musculoskeletal Health Research and Leadership.” Dr. Joy C. MacDermid is supported by a CIHR Chair: Gender in Measurement and Rehabilitation of Musculoskeletal Work Disability. The authors would like to thank Dr. Shreemathi Mayya, Mr