Reliability and validity of shoulder tightness measurement in patients with stiff shoulders

doi:10.1016/j.math.2005.05.002

Manual Therapy

Volume 11, Issue 2, May 2006, Pages 146-152

https://doi.org/10.1016/j.math.2005.05.002 Get rights and content

Abstract

The purposes of this study were (1) to examine intratester and intertester reliability of measurement of anterior and posterior shoulder tightness in patients with stiff shoulders (SS), and (2) to assess construct validity by determining the relations between shoulder tightness, shoulder range of motion (ROM), and self-report measures of functional limitation. Anterior and posterior shoulder tightness were measured by two testers in below-chest abduction and cross-chest adduction tests with an inclinometer, respectively, in 16 patients with SS. Both the intratester and intertester reliability for shoulder tightness measurements were good (intratester ICC=0.84 and 0.91; intertester ICC=0.82 and 0.89). The limit of intra-tester and inter-tester agreement (mean, −0.3±4.4°) was acceptable as compared to the standard deviations of the measurements (range, 6.2–7.4°). Significant relationships between internal rotation and posterior shoulder tightness ( $R^{2} = 0.448$ , $P = 0.002$ ), external rotation and anterior shoulder tightness ( $R^{2} = 0.499$ , $P = 0.003$ ), and functional disabilities and posterior shoulder tightness ( $R^{2} = 0.432$ , $P = 0.006$ ) were found. Significant correlations between shoulder internal rotation and cross-chest adduction, shoulder external rotation and below-chest abduction were observed, indicating that internal and external rotations might be related to posterior and anterior shoulder stiffness. The study also revealed significant relationship between functional disabilities and cross-chest adduction. Below-chest abduction and cross-chest adduction were found to provide reliable data. The construct validity of the abduction and adduction tests is supported by the relationship among these measurements, shoulder ROM, and functional disabilities in patients with SS.

Introduction

Stiff shoulder (SS), which is characterized by a loss of shoulder motion, is one of the most common musculoskeletal disorders encountered in daily orthopaedic practice and remains challenging to treat (Codman, 1934; Neviaser and Neviaser, 1987; Vermeulen et al., 2000). Clinical syndromes include pain, a limited range of motion (ROM), and muscle weakness from disuse (Codman, 1934; Reeves, 1975). The manifestation of shoulder capsule tightness and muscle contractures in patients could be related to their syndromes (Warner et al., 1990; Vermeulen et al., 2000). Thus, much attention has been given to how capsule stretching exercises and mobilization might decrease shoulder capsule tightness and result in shoulder motion improvement (Vermeulen et al., 2000; Griggs et al., 2000). Clinically, however, a quantification of shoulder tightness in patients with SS has been inadequately researched.

Cyriax proposed that tightness in a joint capsule would restrict motion in a predictable pattern, a capsular pattern (Cyriax, 1978). For the shoulder, a capsular pattern is one in which external rotation is more limited than abduction, which in turn is more limited than internal rotation. Researchers have documented, however, that no single capsular pattern emerges in patients with SS (Rundquist et al., 2003). Subsequently, tightness in the posterior capsule and anterior capsule has been hypothesized to restrict internal rotation and external rotation of the shoulder joint, respectively (Harryman et al., 1992; Johansen et al., 1995; Tyler et al., 1999, Tyler et al., 2000). An investigation of the relationships between shoulder tightness and ROM loss, as well as those between shoulder tightness and functional disabilities, may help clinicians target only those aspects of shoulder tightness that are related to ROM loss and functional disabilities.

An objective side-lying method for assessing posterior shoulder tightness has been developed and has demonstrated good reliability (intratester and intertester ICC>0.80) and construct validity ( $r = - 0.61$ , between posterior shoulder tightness and internal rotation) in unimpaired subjects and baseball pitchers (Tyler et al., 1999). This assessment method, however, has some shortcomings. Posterior shoulder tightness comparisons between bilateral shoulders in patients with SS are not possible due to pain and discomfort that occur in the side-lying position. In addition, no method is specified for evaluating anterior shoulder tightness.

The purpose of our study is to develop a clinically reliable method to evaluate anterior and posterior shoulder tightness in patients with SS. First, both the intratester and intertester reliability of the two methods were evaluated. Second, the methods’ construct validities were assessed by determining the relations between shoulder tightness and shoulder ROM as well as those between shoulder tightness and self-report measures of functional limitation and disability.

Section snippets

Participants

Patients suffering from SS were recruited from National Taiwan University Hospital, Taiwan. All subjects were at least 18 years old. The inclusion criteria of patients with SS were: (1) a limited ROM of a shoulder joint (ROM losses of 25% or greater compared with the non-involved shoulder in at least two of the following shoulder motions: glenohumeral flexion, abduction, or internal/external rotation), (2) pain and stiffness in the shoulder region for at least 3 months, and (3) pain when

Results

Sixteen patients with unilateral SS (six of them male) between the ages of 41 and 80 (mean=54.5, SD=9.2) years were recruited from an outpatient clinic at our hospital. The affected shoulders (11 dominant shoulders and 5 non-dominant shoulders) of the 16 patients were tested. Two patients did not return for the second examination within 5 days. One patient complained of pain and discomfort during the below-chest abduction test. Descriptive data of the subjects’ characteristics are summarized in

Discussion

The reliability and validity of the measurement tools are important for pathology documentation and outcome assessments in the clinic as well as in research. In patients with SS, soft tissue tightness has been postulated as a possible cause of ROM loss and functional disability (Harryman et al., 1992; Tyler et al., 1999). ROM can be measured objectively with a goniometer; however, valid and reliable measurements of posterior and anterior shoulder tightness in patients with SS had yet to be

Conclusion

Below-chest abduction and cross-chest adduction tests are reliable for use in measurement of anterior and posterior shoulder tightness in patients with SS, respectively. Correlations between shoulder tightness and decreased rotation ROM as well as functional disabilities may guide clinicians in their implementation of proper stretching/mobilization and exercise programs.

Acknowledgement

The authors would like to thank physical therapist Wei-chun Yen for his help with recruiting subjects and all the subjects who participated in this study.

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Original articleReliability and validity of shoulder tightness measurement in patients with stiff shoulders

Abstract

Introduction

Section snippets

Participants

Results

Discussion

Conclusion

Acknowledgement

Journal of Hand Therapy

Archives of Physical Medicine and Rehabilitation

Statistical method for assessment of agreement between two methods of clinical measurement

Lancet

Measuring agreement in method comparison studies

Statistical Methods in Medical Research

The shoulder. Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa

Development and psychometric evaluation of the flexilevel scale of shoulder function

Medical Care

Glenohumeral joint internal and external rotation range of motion in elite junior tennis players

Journal of Orthopaedic and Sports Physical Therapy

Idiopathic adhesive capsulitis: a prospective functional outcome study of nonoperative treatment

Journal of Bone and Joint Surgery

The role of the rotator interval capsule in passive motion and stability of the shoulder

Journal of Bone and Joint Surgery: American

Original article
Reliability and validity of shoulder tightness measurement in patients with stiff shoulders