Physical Therapists Rethink Effect of Scapula on Neck Motion

Physical therapists routinely examine patients with neck pain for posture and alignment. There is an assumption that these three things are linked together. In other words, if everything isn't lined up in a neutral or correct position, then neck pain may develop. Or neck pain gets worse in someone who already has neck pain. In this study, therapists take the first steps toward possibly proving that theory wrong.

The focus of this research was the position of the scapula (shoulder blade) in relation to cervical (neck) motion. In particular, the therapists looked at the effect of a depressed scapula on neck range of motion. A depressed scapula was defined as a shoulder blade that was located below the expected, normal anatomic position (between the second and seventh thoracic vertebra).

Normal, healthy adults were examined. The idea was that studying a young, healthy group of adults would show the effect of scapula position on neck motion in someone who didn't have neck pain. Two groups of subjects were included. One group had neutral vertical scapular alignment. The second group had depressed scapular alignment. There were equal numbers of people in both groups matched by age and sex. No one in either group had a recent history (last 12 months) of neck, shoulder, or arm problems.

A special device called the Cervical Range of Motion (CROM) was used to measure neck motion. The CROM is placed over the head like a cap. A dial in the middle of the forehead with a needle registers the degrees of motion. The device is known to be a valid and reliable tool for measuring neck motion.

The experiment was set up so that a digital camera could read the CROM and report the results to a computer. That way, no one knew which group the subjects were in when recording motion. This type of study is called a blind study.

The therapists went into this study knowing that neck motion is increased when the normal, neutrally aligned scapulae are elevated or lifted up. They also knew (from other studies) that a loss of cervical (neck) rotation affects function more than a loss of any other neck motion (bending, extending, tilting sideways).

What they didn't know was whether people with depressed scapulae have the same neck motion as people with neutral scapular alignment. And they didn't know what would happen to the cervical range of motion in otherwise healthy subjects who have depressed scapulae when the arms are supported to raise the scapulae to a more normal, vertical position.

With that information in mind, they built a special chair for the subjects to sit in during the motion testing. The arms of the chair were adjustable so that the scapulae could be placed in various positions of elevation or depression. Testing was done in two positions for each person.

The first position was with the scapula in the neutral position (between second and seventh thoracic vertebrae). This required the subjects to use the armrests on the chair. Cervical rotation to the left and right were measured and combined together as one figure. The second position placed the subject in his or her normal scapular resting position. In order to accomplish this, the armrests were not used. Each subject sat on the chair with the arms hanging down at the sides. Cervical rotation was measured in this new position.

They found that cervical rotation was definitely increased when the arms were supported. This was true for both groups (neutral vertical scapula and depressed scapula). They also reported that cervical motion was equal between the two groups in either test position.

Without the influence of pain as a factor, this study helped showed that scapular position isn't necessarily related to neck and shoulder dysfunction. Contrary to previous held beliefs, scapular depression does not appear to negatively influence neck motion.

It is clear that there is a link between scapula position and cervical spine motion in healthy adults. Since only healthy adults were included in this study, specific conclusions cannot be made about the influence of a depressed scapular position on neck pain.

What's the take home message from this study for physical therapists? First, it should not be automatically assumed that a depressed scapular position is the cause of decreased neck rotation in someone with neck pain. Second, neck motion should be measured with and without upper arm support. This would show the effect of the upper limbs on the patient's neck motion. And third, neck exercises with the arms supported can be prescribed to help increase neck motion and potentially improve function.

Future studies are needed to verify these findings in patients with neck pain. The benefits of arm support on neck motion are clear, but the effect of this factor on neck pain is still unknown. The influence of other scapular positions on neck motion (and on neck pain) should also be tested.

Guilherme Trivellato Andrade, PT, et al. Influence of Scapular Position on Cervical Rotation Range of Motion. In Journal of Orthopaedic & Sports Physical Therapy. November 2008. Vol. 38. No. 11. Pp. 668-673.

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