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Research Review By Dr. Keshena Malik©

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Date Posted:

April 2015

Study Title:

Impact of spinal alignment & back muscle strength on shoulder range of motion in middle-aged & elderly people in a prospective cohort study

Authors:

Imagama S, Hasegawa Y, Wakao N et al.

Author's Affiliations:

Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine; Department of Orthopaedic Surgery, Aichi Medical University; Department of Orthopaedic Surgery, Japanese Nagoya Red Cross Daiichi Hospital.

Publication Information:

European Spine Journal 2014; 23: 1414-1419.

Background Information:

Age-related changes in the spine and shoulder are generally thought to contribute to thoracic kyphosis, sagittal alignment imbalance and limited shoulder range of motion (ROM). These factors (alone or together) can adversely influence physical capacity and reduce adults’ ability to conduct routine activities of daily living (ADL). Encouraging independence of elderly people is integral for reducing nursing care and medical costs in our aging society. Previous studies have suggested that poor posture influences shoulder dysfunction (1, 2) and that the spine contributes to shoulder elevation, at least to some extent (3). EDITOR’S NOTE: To demonstrate this to yourself (or your patients), compare your ability to elevate your arm when sitting or standing straight versus when you are slouching forward! Several studies on rehabilitation have also suggested a relationship between spine and shoulder motion, since manipulation of the spine and ribs can improve symptoms of shoulder pain and shoulder impingement syndrome without shoulder rehabilitation (4-8).

Generally speaking, the details of the relationship between spinal angles, ROM, sagittal alignment and shoulder movement have not yet been revealed. The current study, therefore, was performed to clarify the influence of the spine on shoulder ROM through evaluation of spinal alignment, angles, spinal ROM and shoulder ROM.

Pertinent Results:

Study Participants & Measurements:
The study was prospectively performed on 317 participants with the following characteristics (average values with SD = standard deviation):
  • 114 males and 203 females, average age 67.0 (50-90) years
  • BMI 10.6 kg/m2 (SD = 7.6)
  • 29.7% had Osteoporosis (n = 94)
  • Average back muscle strength 66.9kg (SD = 28.9)
  • Grip strength 28.3kg (SD = 9.4)
  • 10m gait time average was 5.6 seconds (SD = 1.25)
Shoulder Measurements:
  • Shoulder pain was present in 9.1% (n = 29)
  • Average shoulder pain VAS value was 3.7 (SD = 13.9)
  • Average shoulder flexion was 177.0° (SD = 10.7°); abduction average was 175.3° (SD = 13.9)
  • ”Limited flexion group” contained 35 subjects (11.0% of sample)
  • ”Limited abduction group” contained 50 subjects (15.8% of sample)
Spinal Alignment Measurements:
  • Thoracic kyphosis average was 43.1° (SD = 9.7)
  • Lumbar lordosis average was 19.8° (SD = 11.2)
  • Thoracic ROM average was 16.9° (SD = 12.5)
  • Lumbar ROM average was 44.2° (SD = 17.1)
  • Spinal inclination average was 3.2° (SD = 4.0)
Comparison & Correlation Results:
A comparison of shoulder ROM and spinal parameters among age groups (50-59 years vs. 60-69 years vs. 70-79 years vs. 80-90 years) revealed that, as expected, shoulder ROM, spinal ROM and lumbar lordosis angle grew more limited with aging, while thoracic kyphosis angle and spinal inclination increased with age.

Correlations between measured variables revealed that:
  • Thoracic kyphosis angle and spinal inclination angle, as well as age, 10m gait and shoulder pain had significant negative correlations with shoulder ROM (for example: as thoracic kyphosis angle increased, shoulder ROM decreased).
  • Back muscle strength, lumbar lordosis angle and lumbar ROM had significant positive correlations with shoulder ROM (for example: as lumbar lordosis angle increased, shoulder ROM increased).
Multivariate logistic regression analysis to identify risk factors for limited shoulder ROM revealed that:
  • Increased thoracic kyphosis angle and the increased spinal inclination angle were significant risk factors for limited shoulder flexion (p < 0.05).
  • Increased thoracic kyphosis angle and weak back muscle strength were significant risk factors for limited shoulder abduction (p < 0.05).
  • Thoracic kyphosis angle was a significant risk factor for both shoulder flexion and abduction limitations.

Clinical Application & Conclusions:

In true ‘chicken and egg’ fashion, it is unclear whether the spine affects shoulder ROM or whether limited shoulder ROM affects spinal alignment. There exists, however, an important relationship between thoracic kyphosis and the shoulder joint (i.e. increased thoracic kyphosis and spinal inclination angles are independent risk factors for limited shoulder ROM) in middle-aged and elderly patients. In terms of evidence-based manual therapy, several reports on treatment and rehabilitation have suggested that thoracic manipulation itself improves shoulder pain and movement in patients with limited shoulder ROM (4-8).

In addition, this study demonstrates that weak back muscle strength is another independent risk factor for limited shoulder ROM. Back muscle strength is thought to be an important element in spine sagittal alignment (10-11) and daily exercise targeting the spine and its musculature improves quality of life in middle-aged and elderly people. Taken together, these results suggest that these patients could benefit from a combination of appropriate manual therapy and exercise regimens to maintain overall spinal function (including alignment and strength) and shoulder function. This statement, of course, could apply to numerous clinical conditions and body regions!

Study Methods:

Healthy volunteers between the ages of 50-90 years old, who attended a basic health checkup (a program supported by the Hokkaido Japan local government), were recruited to participate in this study.

Exclusion Criteria:
  • Fresh vertebral compression fracture
  • History of spine or shoulder surgery
  • Cervical neurological symptoms
Shoulder ROM, shoulder pain, spinal angle, sagittal spinal alignment balance, spinal mobility, body mass index (BMI), bone mineral density (presence of osteoporosis), grip strength, back muscle strength and 10m gait time were evaluated in this study.

Spinal Alignment & Shoulder ROM Measurement:
  • Participants received lateral lumbar radiographs in a standing position to evaluate lumbar lordosis and sacral inclination (to verify reproducibility of SpinalMouse® measurements).
  • The SpinalMouse® is an electronic computer-aided surface technique device measuring:
    • Sagittal spinal ROM
    • Intersegmental angles
    • Thoracic kyphosis angle (positive value)
    • Lumbar lordosis angle (positive value)
    • Thoracic ROM
    • Lumbar ROM
    • Each angle was measured three times in a neutral standing position, maximum bending position, maximum extension position and average data were used
  • Shoulder pain was defined as pain accompanying shoulder motion, excluding resting pain and was measured using the Visual Analogue Scale – VAS (0-10cm).
  • Shoulder ROM during flexion and abduction was measured with the participant seated with his/her scapulae stabilized by an orthopedic surgeon using an angle meter. (Note: Participants were divided into groups based on limited or full shoulder flexion and abduction).
  • Diagnosis of osteoporosis was defined as a percent of the young adult mean (YAM) < 70% in the calcaneus (as per Japanese Society for Bone Mineral Research) (9).
Back Muscle Strength & 10m Gait Time Measurement:
  • Back muscle strength was determined from the maximal isometric strength of the truck muscles in a standing position with 30 degrees of lumbar flexion using a digital back muscle strength meter. The average force of two trials was recorded.
  • 10m gait time was evaluated as an index of physical ability and was measured by a physical therapist (blinded to the evaluation results) who evaluated the maximum speed of the participants walking 10m (without running).
Statistical Analysis:
  • Data shown as mean ± standard deviation
  • Correlations between variables were analyzed using Pearson correlation coefficient analysis.
  • Multivariate logistic regression analysis was adjusted for age, shoulder pain and other variables to determine risk factors for limited shoulder ROM
  • Probability values of < 0.05 were considered statistically significant.

Study Strengths / Weaknesses:

Strengths:
  • The study provides the first evidence that increased thoracic kyphosis, increased spinal inclination angles and weak back muscle strength are independent risk factors for limited shoulder ROM in middle-aged and elderly participants. The data from this study can be used as a basis for future research.
Weaknesses:
  • The findings may not be generalizable to populations with severe shoulder pain and dysfunction (the participants were healthy volunteers attending a public health checkup and the sample did not include those with severe difficulty in shoulder ROM, or those with severe difficulty in their activities of daily living).
  • The relationship with the surrounding musculature of the shoulder girdle was not evaluated, hence further studies are needed to investigate these relationships.

Additional References:

  1. Greenfield B, Catlin PA, Coats PW, et al. Posture in patients with shoulder overuse injuries and healthy individuals. J Orthop Sports Phys Ther 1995; 21(5): 287–295.
  2. Nicholson GG. Rehabilitation of common shoulder injuries. Clin Sports Med 1989; 8(4): 633–655.
  3. Culham E & Peat M. Functional anatomy of the shoulder complex. J Orthop Sports Phys Ther 1993; 18(1): 342–350.
  4. Bang MD & Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome 2003; J Orthop Sports Phys Ther 30(3): 126–137.
  5. Bergman GJ, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med 2004; 141(6): 432–439.
  6. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther 2009; 14(4): 375–380.
  7. Strunce JB, Walker MJ, Boyles RE, et al. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther 2009; 17(4): 230–236.
  8. Winters JC, Sobel JS, Groenier KH, et al. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: Randomised, single blind study. BMJ 1997; 314(7090): 1320–1325.
  9. Orimo H, Hayashi Y, Fukunaga M, et al. Diagnostic criteria for primary osteoporosis: Year 2000 revision. J Bone Miner Metab 2001; 19(6): 331–337.
  10. Imagama S, Matsuyama Y, Hasegawa Y, et al. Back muscle strength and spinal mobility are predictors of quality of life in middle-aged and elderly males. Eur Spine J 2011; 20(6): 954-61.
  11. Imagama S, Hasegawa Y, Matsuyama Y, et al. Influence of sagittal balance and physical ability associated with exercise on quality of life in middle-aged and elderly people. Arch Osteoporos 2011; 6(1-2): 13–20.
Impact of Spinal Alignment & Back Strength on Shoulder ROM in Middle-Aged & Elderly +MP3

Research Review By Dr. Keshena Malik©

Audio:

{audio}spinal_alignment_shoulder_rom_elderly.mp3{/audio}

Date Posted:

April 2015

Study Title:

Impact of spinal alignment & back muscle strength on shoulder range of motion in middle-aged & elderly people in a prospective cohort study

Authors:

Imagama S, Hasegawa Y, Wakao N et al.

Author's Affiliations:

Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine; Department of Orthopaedic Surgery, Aichi Medical University; Department of Orthopaedic Surgery, Japanese Nagoya Red Cross Daiichi Hospital.

Publication Information:

European Spine Journal 2014; 23: 1414-1419.

Background Information:

Age-related changes in the spine and shoulder are generally thought to contribute to thoracic kyphosis, sagittal alignment imbalance and limited shoulder range of motion (ROM). These factors (alone or together) can adversely influence physical capacity and reduce adults’ ability to conduct routine activities of daily living (ADL). Encouraging independence of elderly people is integral for reducing nursing care and medical costs in our aging society. Previous studies have suggested that poor posture influences shoulder dysfunction (1, 2) and that the spine contributes to shoulder elevation, at least to some extent (3). EDITOR’S NOTE: To demonstrate this to yourself (or your patients), compare your ability to elevate your arm when sitting or standing straight versus when you are slouching forward! Several studies on rehabilitation have also suggested a relationship between spine and shoulder motion, since manipulation of the spine and ribs can improve symptoms of shoulder pain and shoulder impingement syndrome without shoulder rehabilitation (4-8).

Generally speaking, the details of the relationship between spinal angles, ROM, sagittal alignment and shoulder movement have not yet been revealed. The current study, therefore, was performed to clarify the influence of the spine on shoulder ROM through evaluation of spinal alignment, angles, spinal ROM and shoulder ROM.

Pertinent Results:

Study Participants & Measurements:
The study was prospectively performed on 317 participants with the following characteristics (average values with SD = standard deviation):
  • 114 males and 203 females, average age 67.0 (50-90) years
  • BMI 10.6 kg/m2 (SD = 7.6)
  • 29.7% had Osteoporosis (n = 94)
  • Average back muscle strength 66.9kg (SD = 28.9)
  • Grip strength 28.3kg (SD = 9.4)
  • 10m gait time average was 5.6 seconds (SD = 1.25)
Shoulder Measurements:
  • Shoulder pain was present in 9.1% (n = 29)
  • Average shoulder pain VAS value was 3.7 (SD = 13.9)
  • Average shoulder flexion was 177.0° (SD = 10.7°); abduction average was 175.3° (SD = 13.9)
  • ”Limited flexion group” contained 35 subjects (11.0% of sample)
  • ”Limited abduction group” contained 50 subjects (15.8% of sample)
Spinal Alignment Measurements:
  • Thoracic kyphosis average was 43.1° (SD = 9.7)
  • Lumbar lordosis average was 19.8° (SD = 11.2)
  • Thoracic ROM average was 16.9° (SD = 12.5)
  • Lumbar ROM average was 44.2° (SD = 17.1)
  • Spinal inclination average was 3.2° (SD = 4.0)
Comparison & Correlation Results:
A comparison of shoulder ROM and spinal parameters among age groups (50-59 years vs. 60-69 years vs. 70-79 years vs. 80-90 years) revealed that, as expected, shoulder ROM, spinal ROM and lumbar lordosis angle grew more limited with aging, while thoracic kyphosis angle and spinal inclination increased with age.

Correlations between measured variables revealed that:
  • Thoracic kyphosis angle and spinal inclination angle, as well as age, 10m gait and shoulder pain had significant negative correlations with shoulder ROM (for example: as thoracic kyphosis angle increased, shoulder ROM decreased).
  • Back muscle strength, lumbar lordosis angle and lumbar ROM had significant positive correlations with shoulder ROM (for example: as lumbar lordosis angle increased, shoulder ROM increased).
Multivariate logistic regression analysis to identify risk factors for limited shoulder ROM revealed that:
  • Increased thoracic kyphosis angle and the increased spinal inclination angle were significant risk factors for limited shoulder flexion (p < 0.05).
  • Increased thoracic kyphosis angle and weak back muscle strength were significant risk factors for limited shoulder abduction (p < 0.05).
  • Thoracic kyphosis angle was a significant risk factor for both shoulder flexion and abduction limitations.

Clinical Application & Conclusions:

In true ‘chicken and egg’ fashion, it is unclear whether the spine affects shoulder ROM or whether limited shoulder ROM affects spinal alignment. There exists, however, an important relationship between thoracic kyphosis and the shoulder joint (i.e. increased thoracic kyphosis and spinal inclination angles are independent risk factors for limited shoulder ROM) in middle-aged and elderly patients. In terms of evidence-based manual therapy, several reports on treatment and rehabilitation have suggested that thoracic manipulation itself improves shoulder pain and movement in patients with limited shoulder ROM (4-8).

In addition, this study demonstrates that weak back muscle strength is another independent risk factor for limited shoulder ROM. Back muscle strength is thought to be an important element in spine sagittal alignment (10-11) and daily exercise targeting the spine and its musculature improves quality of life in middle-aged and elderly people. Taken together, these results suggest that these patients could benefit from a combination of appropriate manual therapy and exercise regimens to maintain overall spinal function (including alignment and strength) and shoulder function. This statement, of course, could apply to numerous clinical conditions and body regions!

Study Methods:

Healthy volunteers between the ages of 50-90 years old, who attended a basic health checkup (a program supported by the Hokkaido Japan local government), were recruited to participate in this study.

Exclusion Criteria:
  • Fresh vertebral compression fracture
  • History of spine or shoulder surgery
  • Cervical neurological symptoms
Shoulder ROM, shoulder pain, spinal angle, sagittal spinal alignment balance, spinal mobility, body mass index (BMI), bone mineral density (presence of osteoporosis), grip strength, back muscle strength and 10m gait time were evaluated in this study.

Spinal Alignment & Shoulder ROM Measurement:
  • Participants received lateral lumbar radiographs in a standing position to evaluate lumbar lordosis and sacral inclination (to verify reproducibility of SpinalMouse® measurements).
  • The SpinalMouse® is an electronic computer-aided surface technique device measuring:
    • Sagittal spinal ROM
    • Intersegmental angles
    • Thoracic kyphosis angle (positive value)
    • Lumbar lordosis angle (positive value)
    • Thoracic ROM
    • Lumbar ROM
    • Each angle was measured three times in a neutral standing position, maximum bending position, maximum extension position and average data were used
  • Shoulder pain was defined as pain accompanying shoulder motion, excluding resting pain and was measured using the Visual Analogue Scale – VAS (0-10cm).
  • Shoulder ROM during flexion and abduction was measured with the participant seated with his/her scapulae stabilized by an orthopedic surgeon using an angle meter. (Note: Participants were divided into groups based on limited or full shoulder flexion and abduction).
  • Diagnosis of osteoporosis was defined as a percent of the young adult mean (YAM) < 70% in the calcaneus (as per Japanese Society for Bone Mineral Research) (9).
Back Muscle Strength & 10m Gait Time Measurement:
  • Back muscle strength was determined from the maximal isometric strength of the truck muscles in a standing position with 30 degrees of lumbar flexion using a digital back muscle strength meter. The average force of two trials was recorded.
  • 10m gait time was evaluated as an index of physical ability and was measured by a physical therapist (blinded to the evaluation results) who evaluated the maximum speed of the participants walking 10m (without running).
Statistical Analysis:
  • Data shown as mean ± standard deviation
  • Correlations between variables were analyzed using Pearson correlation coefficient analysis.
  • Multivariate logistic regression analysis was adjusted for age, shoulder pain and other variables to determine risk factors for limited shoulder ROM
  • Probability values of < 0.05 were considered statistically significant.

Study Strengths / Weaknesses:

Strengths:
  • The study provides the first evidence that increased thoracic kyphosis, increased spinal inclination angles and weak back muscle strength are independent risk factors for limited shoulder ROM in middle-aged and elderly participants. The data from this study can be used as a basis for future research.
Weaknesses:
  • The findings may not be generalizable to populations with severe shoulder pain and dysfunction (the participants were healthy volunteers attending a public health checkup and the sample did not include those with severe difficulty in shoulder ROM, or those with severe difficulty in their activities of daily living).
  • The relationship with the surrounding musculature of the shoulder girdle was not evaluated, hence further studies are needed to investigate these relationships.

Additional References:

  1. Greenfield B, Catlin PA, Coats PW, et al. Posture in patients with shoulder overuse injuries and healthy individuals. J Orthop Sports Phys Ther 1995; 21(5): 287–295.
  2. Nicholson GG. Rehabilitation of common shoulder injuries. Clin Sports Med 1989; 8(4): 633–655.
  3. Culham E & Peat M. Functional anatomy of the shoulder complex. J Orthop Sports Phys Ther 1993; 18(1): 342–350.
  4. Bang MD & Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome 2003; J Orthop Sports Phys Ther 30(3): 126–137.
  5. Bergman GJ, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med 2004; 141(6): 432–439.
  6. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther 2009; 14(4): 375–380.
  7. Strunce JB, Walker MJ, Boyles RE, et al. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther 2009; 17(4): 230–236.
  8. Winters JC, Sobel JS, Groenier KH, et al. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: Randomised, single blind study. BMJ 1997; 314(7090): 1320–1325.
  9. Orimo H, Hayashi Y, Fukunaga M, et al. Diagnostic criteria for primary osteoporosis: Year 2000 revision. J Bone Miner Metab 2001; 19(6): 331–337.
  10. Imagama S, Matsuyama Y, Hasegawa Y, et al. Back muscle strength and spinal mobility are predictors of quality of life in middle-aged and elderly males. Eur Spine J 2011; 20(6): 954-61.
  11. Imagama S, Hasegawa Y, Matsuyama Y, et al. Influence of sagittal balance and physical ability associated with exercise on quality of life in middle-aged and elderly people. Arch Osteoporos 2011; 6(1-2): 13–20.

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