Blackburn Exercises in Type-1 Scapular Dyskinesia
Condition: Scapular Dyskinesis
MeSH terms: Dyskinesias
Study type: Interventional

Summary: 
      The purpose of this study is to evaluate the effects of Blackburn exercises on
      Scapulothoracic stability in patients with Type-1 Scapular Dyskinesia, in comparison with
      conventional physical therapy. A randomized control trial is being conducted at National
      Institute of Rehabilitation Medicine (NIRM), Islamabad and Railway Hospital, Rawalpindi. The
      sample size was calculated through open epi tool, is 38. The participants are divided into
      two equal groups, 19 participants in experimental group and 19 participants in control group.
      The study duration is six months. Sampling technique applied is non-probability convenient
      sampling and groups have been randomized using sealed envelope method. Participants aged
      25-55 years, having Type-1 Scapular Dyskinesia due to shoulder related causes, positive
      scapular assistance test, bilateral distance>1.5 cm in Lateral scapular slide test are being
      included in the study. Tools that are being used in this study are Lateral Scapular Slide
      Test, handheld dynamometer, Static measurements with scapula goniometry, and Shoulder pain
      and disability index (SPADI). Data will be analyzed through Statistical Package for Social
      Sciences (SPSS).
    

Detailed description: 
      The shoulder joint plays an important role in the function of the upper limb and in the
      activities of daily living. Shoulder pathologies are very common with the lifetime risk being
      between 40% and 60%. Prevalence rates of shoulder disorders are approximately 70% as compared
      to other musculoskeletal conditions. Ideal motion of scapula plays a major role in the
      shoulder functioning, any variation in the kinematics of scapula leads to various pathologies
      in shoulder and alteration in the scapular positioning can affect pain in the shoulder. Loss
      in the rhythmic functionality of the scapula due to muscular imbalance results in the
      scapular dyskinesia.

      Scapular Dyskinesia is an observable alteration in the position of the scapula and the
      pattern of scapular motion in relation to the thoracic cage during static or dynamic movement
      of scapula. According to Borloz et al., a defective scapular posture caused by muscular
      imbalances, also generates imbalances of muscular strength. Scapular dyskinesia is followed
      by combination of symptoms such as malposition of scapula, prominent inferior border, pain in
      coracoids process and scapular motion dyskinesia. Patients report scapular medial border pain
      mainly. Kibler et al classified scapular dyskinesia in three dysfunctional patterns. Type I
      is characterized by posterior displacement or winging of the inferior medial scapular border.
      It is associated with inflexibility of pectoralis major and minor, and weakness of lower
      trapezius and serratus anterior. Type II is characterized by the projection of the entire
      medial border of the scapula. Type III is characterized by excessive superior translation,
      with elevation and some anterior displacement of the superior border of the scapula on the
      thorax. According to data reported in the literature, Scapular Dyskinesia (SD) incidence is
      frequent in patients with shoulder diseases, including rotator cuff diseases, glenohumeral
      instability, impingement syndrome, and labral tears. Type 1 pattern is however most commonly
      found in patients with rotator cuff dysfunction , shoulder impingement and instability, with
      the development of dyskinesis being associated with trapezius and serratus anterior, both of
      which are weakened in Type 1 Scapular Dyskinesia.

      Generally the muscles that stabilize the scapula are directly related to direct-trauma,
      microtrauma, leading to muscle weakness and inhibition of movement by painful conditions
      around the shoulder. The serratus anterior and trapezius are the most susceptible to the
      effects of this inhibition, and are most often involved in the early stages of shoulder
      pathology. Stability at the scapulothoracic joint depends on the surrounding musculature.
      When the arm is raised overhead, the scapulothoracic motion involves upward rotation and
      posterior tilt of the scapula. Of the numerous muscles inserted on the scapula, those playing
      the most important role in the scapulothoracic kinematics are the upper and lower trapezius,
      and the serratus anterior. The serratus anterior (SA) works in concert with the upper and
      lower trapezius to upwardly rotate the scapula. Most overhead lifts and push-ups effectively
      recruit the serratus anterior. Activity of the serratus anterior tends to increase linearly
      with the amount of elevation at the glenohumeral joint. So when the scapulothoracic rhythm is
      altered, there are associated changes in glenohumeral angulation and loss of normal arm
      position, motion and stability.

      In rehabilitation of scapular dyskinesia, therapeutic exercises should give attention to
      restoring the alignment of the scapulothoracic area and control of scapular muscles. The
      physiotherapy management is aimed to decrease the imbalances in the scapular stabilizing
      muscles so that control of scapular motion can be acquired. Interventions for scapular
      dyskinesia comprise of various stabilization exercises for scapula, but evidence scarcity is
      there in relation to Blackburn exercises in scapular dyskinesia. Blackburn exercises are one
      of the ways to treat shoulder pain and to regain proper mobility and decrease painful
      movements. These scapular stabilization exercises, based on stretching and strengthening, aim
      to improve muscle strength and joint position sense. The goal of increasing muscle strength
      is obtained with the aid of facilitation, and focus on restoring the alignment of the
      scapulothoracic area and control of scapular muscles. The Blackburn exercises are optimal for
      the stimulation of lower trapezius, being the "Y" the optimal exercise for this purpose.
      However, there is no clear evidence regarding their effect on serratus anterior. Although
      serratus anterior muscle works in concert with lower trapezius, and it is the only
      scapulothoracic muscle that produces upward rotation of the scapula with acromioclavicular
      (AC) joint external rotation and posterior tilting.

      There is dearth in literature regarding the effect of Blackburn exercises on scapulothoracic
      stability in Dyskinesia, in relation to serratus anterior and lower trapezius muscles. There
      is poor available evidence regarding the effects of Blackburn exercises specifically on
      serratus anterior muscle strength, contributing to scapulothoracic stability. Also, the
      studies conducted previously were lacking a control group for comparison, and majority of the
      intervention protocols evaluated the immediate effects of Blackburn exercises with no focus
      on scapular stabilizers.

      Literature Review:

      A case report presented by Navreet Kaur et al. in 2019 evaluated the effects of Blackburn
      exercises in scapular dyskinesia. By the end of one week of treatment, the patient felt no
      pain in resisted movements and range of motion was complete. After one month of treatment,
      observations included both shoulders on the same level, no droop observed from
      antero-posterior view and no prominency of scapular border from postero-anterior view.

      In 2018, Rasika Panse et al evaluated the effects of Blackburn exercises in shoulder
      impingement in rock climbers on pain and disability using Shoulder pain and disability index
      (SPADI) scale. Subjects were given Blackburn exercises thrice a week with each session
      lasting for 30 minutes. They reported positive results of Blackburn exercises in shoulder
      impingement, with decreased pain in certain shoulder movements after treatment. However, long
      term effects and the effects of Blackburn exercises on shoulder muscles were not considered.

      Another study was conducted by Patel Neelam Jayesh et al. regarding the effectiveness of open
      kinematic chain exercises in overhead atheletes with SICK scapula. Participants were given 4
      sessions per week for 3 weeks and the intervention protocol included Blackburn exercises
      along with Dynamic hug, W exercise, Lunges with dumbells and Pectoralis minor stretching.
      Results of this study showed significant improvement after 3 weeks of intervention.

      Pradeep Shankar et al conducted a study to find the effect of scapular stabilization
      exercises for Type 2 Scapular Dyskinesia in subjects with shoulder impingement. 3 sessions of
      scapular stabilization exercises were given per week for 2 weeks and outcomes were measured
      using Lateral Scapular Slide Test and Shoulder pain and disability index (SPADI). Study
      findings reported the protocol to be effective. However this study lacked a control group
      receiving only conventional exercises. Also, the study was done for a period of two weeks,
      therefore long term effects were not known.

      In 2018, Hugo Machado Sanchez reviewed the Scapular Dyskinesia from the point of view of
      pathology, evaluation and treatment. He concluded that emphasis on strengthening of scapular
      depressor muscles and scapular stabilizers acting primarily on the shoulder should be of
      paramount importance for the restoration of normal scapular function in rehabilitation of
      Scapular Dyskinesia.

      Kevin G. Laudner et al. assessed the relationship between lower trapezius and serratus
      anterior strength and the quantity of scapular upward rotation by using a hand-held
      dynamometer. The results of their study demonstrated a moderate-good relationship between
      scapular upward rotation and lower trapezius strength. However, a poor relationship was seen
      between scapular upward rotation and serratus anterior strength that was thought to be due to
      strength measurement occurring at a higher amount of humeral elevation (120°-130°) than was
      tested during scapular upward rotation (0° , 60° , 90° , 120°).
    

Intervention name(s): Blackburn exercises; Conventional Physical therapy
Intervention type(s): Other; Other
Intervention description(s): Experimental group will include Blackburn exercises and hot pack for 10 minutes prior to the application of exercises; 3 sessions/week for a total of 4 weeks. Measurement will be taken at base level and after the last session, i.e. bilateral difference in lateral scapular slide test, serratus anterior and lower trapezius muscle strength, static measurements of scapula ROM, and pain and disability.
These exercises will include prone horizontal abduction neutral and with full external rotation, prone horizontal scaption neutral and with full external rotation, prone horizontal external rotation, prone horizontal extension. All these exercises will be performed 3x15 repetitions with 30 seconds rest interval between each set.; Control group will include conventional physical therapy and hot pack for 10 minutes prior to the application of exercises; 3 sessions/week for a total of 4 weeks. Measurement will be taken at base level and after the last session, i.e. bilateral difference in lateral scapular slide test, serratus anterior and lower trapezius muscle strength, static measurements of scapula ROM, and pain and disability.
These exercises will include push-ups on a stable surface, upward rotation shrugs and resisted scapular retraction. All these exercises will be performed 3x15 repetitions with 30 seconds rest interval between each set.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Scapulothoracic stability; Blackburn exercises; Lateral scapular slide test; Type-1 Scapular Dyskinesia