The Effects of Short-term Scapular Control Training in Overhead Athletes With Shoulder Impingement Syndrome

Study Overview
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Brief Summary
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Subacromial impingement syndrome (SIS) is a common disorder of shoulder joint. SIS has been accounted for 44-65 % of all shoulder pain. It is believed that one important contributing factor is scapular dyskinesis. Patients with SIS demonstrates scapular dyskinesis, including decrease in upward rotation, scapular posterior tilt, and external rotation. Altered muscle activity of scapular muscles may contribute to scapular dyskinesis, such as increase in activity of upper trapezius, and decrease in activity of lower trapezius and serratus anterior. In addition to these changes in neuromuscular control, central nervous system may be re-organized in patients with musculoskeletal disorders. Evidence has been reported that center of gravity of motor mapping changes, corticospinal excitability decreases and inhibition increases in patients with shoulder injuries such as instability, rotator cuff tendinopathy and SIS. These corticospinal changes are believed to be related to chronicity of symptoms and lack of treatment effects. Previous studies have applied many types of treatments to SIS, such as manipulation, taping, and exercises. However, most studies mainly focused on the outcomes of pain and function, few studies investigated changes in neuromuscular control following treatments. Yet, no study has addressed how corticospinal system changes following treatment in patient with shoulder injuries. Motor skill training, which has been widely used in training healthy subjects or patients with neurological disorders, has been shown to change corticospinal systems, including increasing excitability and decreasing inhibition. To our knowledge, no study has integrated the concepts of motor skill learning into a short-term treatment or investigated the effects of motor skill training on corticospinal systems in patients with SIS. The purposes of the study are to investigate the effects of short-term motor skill training on pain, neuromuscular control, corticospinal system in patients with SIS, and also to investigate whether changes in corticospinal parameters will be related to changes in pain, function and neuromuscular control.

Official Title
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The Effects of Short-term Scapular Control Training on Motor Control in Overhead Athletes With Shoulder Impingement Syndrome

Conditions
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Shoulder Impingement Syndrome, Scapular Dyskinesis

Intervention / Treatment
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* Procedure: Scapular control training
* Procedure: General exercise


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria (patients with shoulder impingement) : perform overhead exercise at least 4 hours a week present type I or II scapular dyskinesis at rest or moving pain at least two weeks 3 of 6 impingement test present positive Neer's impingement test: arm abduction overhead with shoulder internal rotation and thumb downward. If feel pain, then positive. Hawkins-Kennedy impingement Test: arm lift to horizontal plane, elbow flexion to 90 degree. Tester put force on forearm toward shoulder internal rotation. If feel pain, then positive. Empty can test: shoulder abduction with thumb down, then give a resistive force toward up. If feel pain, then positive. Resistive shoulder external rotation test: elbow flexion to 90 degrees and do resistive shoulder rotation. If feel pain, then positive. Rotator cuff tenderness test: tester put pressure on rotator cuff. If feel pain, then positive. Painful arc: perform arm elevation. If feel pain during movement, then positive. Inclusion Criteria (healthy people) : perform overhead exercise at least 4 hours a week no any symptoms or injuries on shoulder and neck Exclusion Criteria: Have a history of dislocation, fracture, or surgery of upper extremity A history of direct contact injury to the neck or upper extremities within the past 12 months A concussion within the past 12 months or a history of three or more concussions Brain injury and neurological impairment History of frequent headache or dizziness Contraindications to the use of transcranial magnetic stimulation (TMS), assessed with a safety screening questionnaire, including pregnancy, history of seizure, epilepsy and syncope, having cochlear implant, having medal implant and taking anti-depressant medication.

Ages Eligible for Study
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Minimum Age: 20 Years
Maximum Age: 40 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Scapular control training group<br>Participants in these group will be taught how to correctly movement arm overhead. And they will undergo series of movement tasks with mirror and also receive scapular-focused exercises. The difficulty of the movements protocol will increase weekly. | Procedure: Scapular control training<br>* Participants in this group will learn how to maintain normal scapular position at first. Then they will progress to moving arm with good scapular control with mirror. Afterward, participants will undergo movements protocol which give different directions of arm movements while keeping scapula in a good alignment. They will also receive scapular-focused exercises. The difficulty of the movement protocol will increase weekly. They will be trained three times per week for 6 weeks with an average duration of 30 min per session.<br>|
| Experimental: General exercise group<br>Participants in this group will receive a general strengthening exercise, focusing on the shoulder muscles. And the load will progressively increase weekly. | Procedure: General exercise<br>* Participants in this group will receive a general shoulder strengthening with theraband or dumbbell. Load will increase weekly. They will be trained three times per week for 6 weeks with an average duration of 30 min per session.<br>|
| No Intervention: Healthy subject group<br>No intervention. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in neurophysiological measures - Active motor threshold | Active motor threshold (AMT) will be described with the percentage (%) of maximum stimulator output (MSO). | Change from baseline AMT at 6 weeks | 
| Change in neurophysiological measures - Motor evoked potential | Motor evoked potential (MEP) will be described with millivolt (mV) at different points and with different stimulus intensity | Change from baseline MEP at 6 weeks | 
| Change in neurophysiological measures - Cortical silent period | Cortical silent period (CSP) will be measured with millisecond (ms). | Change from baseline CSP at 6 weeks | 
| Change in neurophysiological measures - Short interval cortical inhibition and short interval cortical facilitation | Short interval cortical inhibition (SICI) and short interval cortical facilitation (SICF) will be defined as percentage (%) of conditioning responses vs testing responses | Change from baseline SICI and SICF at 6 weeks | 
| Change in shoulder pain | Pain will be measured with a numerical rating scale (0-10). Zero indicates the absence of pain, while 10 represents the most intense pain possible. No unit. | Change from baseline pain at 6 weeks | 
| Change in shoulder function | Function will be measured questionnaire, Flexilevel Scale of Shoulder Function (FLEX-SF). There are 15 questions on each difficulty version. Zero indicates the most difficulty, while 3 means the least difficulty. | Change from baseline function at 6 weeks and 3 months | 
| Long-term change in shoulder pain | Pain will be measured with a numerical rating scale (0-10). Zero indicates the absence of pain, while 10 represents the most intense pain possible. No unit. | Change from baseline pain at 3 months | 
| Long-term change in shoulder function | Function will be measured questionnaire, FLEX-SF. There are 15 questions on each | Change from baseline pain at 3 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Scapular kinematics | Including anterior/posterior tilt, upward/downward rotation, and internal/external rotation in scapula plan elevation at 30°, 60°, 90°, and 120°, will be calculated and will be described with degree (°). | Change from baseline scapular kinematics at 6 weeks | 
| Scapular muscle activation | The root mean square of electromyography (EMG) data of the upper trapezius, lower trapezius, and serratus anterior will be normalized by the maximum voluntary contraction amplitude (percentage of maximal voluntary contraction, %) and calculated over three 30° increments of motion during arm elevation from 30° to 120°, including 30° - 60°, 60° - 90°, and 90° - 120° | Change from baseline muscle activation at 6 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Corticospinal excitability, Transcranial magnetic stimulation, Motor control training, Scapula-focused exercise