Scapular positioning and motor control in children and adults a laboratory study using clinical measures
Manual Therapy 16 (2011) 155e160 Contents lists available at ScienceDirect Manual Therapy journal homepage: www.elsevier.com/mathOriginal articleScapular positioning and motor control in children and adults: A laboratory studyusing clinical measuresq,qqFilip Struyf a, b, Jo Nijs a, b, *, Stijn Horsten a, Sarah Mottram c, Steven Truijen a, Romain Meeusen ba Division of Musculoskeletal Physiotherapy, Department of Health Sciences, Artesis University College Antwerp, Antwerp, Belgiumb Department of Human Physiology, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgiumc Kinetic Control, UKa r t i c l e i n f o a b s t r a c tArticle history: Introduction: The scapular muscular system is the major determinant of scapular positioning. In addition,Received 14 May 2009 strength and muscular endurance develops from childhood through adolescence. It is not knownReceived in revised form whether differences in scapular positioning and motor control between adults and children may exist.9 August 2010 Methods: Ninety-two shoulders of 46 adults (mean ¼ 39.4; 18e86 years; SD ¼ 22.5), and 116 shoulders ofAccepted 14 September 2010 59 children (mean ¼ 11.6; 6e17 years; SD ¼ 3.5), were included in the study. Scapular positioning data were collected using a clinical assessment protocol including visual observation of titling and winging,Keywords: measurement of forward shoulder posture, measurement of scapular upward rotation, and the KineticScapulaShoulder Medial Rotation Test (KMRT).Assessment Results: The observation protocol for scapular winging and tilting did not show signiﬁcant differences between adults and children. After controlling for height, forward shoulder posture (relaxed (0.28 cm/cm (0.06) vs. 0.31 cm/cm (0.07) and retracted (0.15 cm/cm (0.05) vs. 0.20 cm/cm (0.06)) were signiﬁcantly smaller in children than in adults (P < 0.01). In addition, children showed greater scapular upward rotation (18.6 ; SD 9.6 ) than adults (14.5 ; SD 10.9 ) at 90 shoulder abduction. No signiﬁcant differences were seen between children (19% positive test) and adults (24% positive test) using the KMRT. Conclusion: Children and adults show signiﬁcant but small differences in scapular upward rotation and forward shoulder posture. These data provide useful reference values using a clinical protocol. Ó 2010 Elsevier Ltd. All rights reserved.1. Introduction indicators of known reliability and validity that allow clinicians to assess static and dynamic scapular positioning and motor control. Abnormalities of scapular positioning have been shown in These measurements are available, but should generate reliable andpatients with shoulder impingement syndrome, anterior shoulder valid data, and should have strong clinical utility (Sugamoto et al.,instability, and postoperative shoulder complaints (Paletta et al., 2002; Nijs et al., 2007).1997; Lukasiewicz et al., 1999; Ludewig and Cook, 2000; Hébert Decreased scapular upward rotation, reduced posterior tilting,et al., 2002; Wilgen van et al., 2003). The complex kinematic and excessive scapular internal rotation have been identiﬁed asbehaviour of the scapula and shoulder has typically been studied altered scapular positioning patterns in patients with shoulder(McKenna et al., 2004), using three-dimensional motion tracking disorders (Lukasiewicz et al., 1999; Ludewig and Cook, 2000; Hébertsystems. However, these are costly and not readily available for et al., 2002). It has been shown that people with short pectoralisclinical practice (Sugamoto et al., 2002). There is a need for clinical minor muscle length demonstrate similar scapular positioning as patients with shoulder impingement syndrome (Lukasiewicz et al., 1999; Ludewig and Cook, 2000; Borstad and Ludewig, 2005; Smith q We certify that no party having a direct interest in the results of the research et al., 2006). This observation supports the use of a pectoralissupporting this article has or will confer a beneﬁt on us or on any organization withwhich we are associated AND, if applicable, we certify that all ﬁnancial and material minor muscle length test for analyzing scapular positioning.support for this research (e.g., NIH or NHS grants) and work are clearly identiﬁed in In addition, a lack of scapulothoracic muscle control has beenthe title page of the manuscript. identiﬁed as a characteristic of people with shoulder disorders (Host, qq The study protocol was reviewed and approved by the medical ethics 1995; Schmitt and Snyder-Mackler, 1999; Hess, 2000; Ackermancommittee of the University Hospital Brussels (2006/138). et al., 2002; Cools et al., 2003; Nijs et al., 2007). When assessing * Corresponding author. Campus HIKE, Dept G, Artesis Hogeschool Antwerpen,Van Aertselaerstraat 31, 2170 Merksem, Belgium. Tel.: þ3236418265. scapular positioning or motor control, clinicians must be attentive E-mail address: firstname.lastname@example.org (J. Nijs). for patterns that are often seen in patients with shoulder disorders.1356-689X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.doi:10.1016/j.math.2010.09.002
156 F. Struyf et al. / Manual Therapy 16 (2011) 155e160 Movement skills in children may be inﬂuenced by strength andmuscular endurance. Hence, movement patterns develop fromchildhood through adolescence (Branta et al., 1984). Since thescapular muscular system is the major contributor to scapularpositioning, differences in scapular positioning and motor controlbetween adults and children may exist (Nijs et al., 2005; Dayanidhiet al., 2005). In fact, signiﬁcant differences in scapular kinematicpatterns between children (4e9 years) and adults (25e37 years)have previously been reported (Dayanidhi et al., 2005). The authorsreported that children have a greater contribution of the scap-ulothoracic joint to upper limb movements (Karduna et al., 2001). Aprevious study using radiographic evaluation identiﬁed a decreasein the range of the posterior tilt and upward rotation as an ageingeffect (Endo et al., 2004). Numerous studies have investigated theapplicability of clinical tests for assessing scapular positioning inadults. Given the fact that differences in scapular positioningbetween children and adults are present, the use of these clinicaltests to assess children requires additional study. Fig. 1. Winging of the right scapula. The primary aim of the study was to provide clinicians with datafor interpreting clinical tests when assessing scapular positioningand motor control in adults and children. The secondary aim of this Prior to the study, the assessor (holder of a bachelor degree instudy was to examine whether clinical measures revealed differ- physiotherapy) underwent a 4-h training session. The trainingences in scapular positioning (i.e. scapular upward rotation, tilting, session was used to instruct the assessor in performing an accuratewinging, forward shoulder posture, and scapular motor control) measurement of scapular positioning and scapular dynamic controlbetween adults and children. including pilot testing on healthy subjects. The assessor was trained by two instructors, one manual therapist, with 10 years of clinical experience, and one sports physical therapist with 5 years of clin-2. Methods ical experience. Both assessor and instructors performed test evaluations without knowledge of each other’s outcome. When all2.1. Subjects three (both assessor and instructors) ﬁnished the evaluation, results were compared and discussed. Both shoulders of 105 subjects were measured yielding data fora total of 210 shoulders for further analysis. Children (n ¼ 59; meanage 11.6; 6e17 years; 30 ; 83% right handed) were recruited from 2.3. Outcome measureslocal schools. The adult group (n ¼ 46; mean age 39.4; 18e86 years;17 ; 93% right handed) comprised of a sample of convenience. To 2.3.1. Visual observation for tilting and wingingbe included in the trial, subjects had to be at least 6 years of age. The The observation was performed with the subject instructed toexclusion criteria for all subjects were shoulder pain, neck pain and stand relaxed (barefoot). The subject was observed from dorsala history of injury or surgery to the shoulder complex, upper (frontal plane) and lateral (sagittal plane). Ideally, the inferior anglethorax, upper back or humerus during the previous year. The should be ﬂat against the chest wall (Mottram, 1997) and theexclusion criteria for all subjects were shoulder pain, neck pain and scapula should be 30 internally rotated with respect to the frontala history of injury (in the previous year) or surgery (life-time) to the plane (De Groot, 1999). Scapular positioning was deemed impairedshoulder complex, upper thorax, upper back or humerus. when: (1) the inferior angle of the scapula became prominent Prior to clinical assessment, all participants received an infor- dorsally (rotating about the horizontal axis e tilting); (2) the entiremation leaﬂet and provided written informed consent. Minors medial border of the scapula became prominent dorsally (rotationprovided their verbal agreement and a written informed consent about the vertical axis e winging: Fig. 1). If one (or more) of thefrom their parents or responsible adult. The study protocol was criteria listed above were fulﬁlled, then we judged scapular posi-reviewed and approved by the medical ethics committee of the tioning as impaired (score ¼ 1). If none of the criteria were met,University Hospital Brussels (2006/138). The male subjects and all then scapular positioning was judged normal. Next, in standing thechildren (12 years) were tested with their trunk bare. Female subject performed active maximal range of abduction. No differ-subjects wore a sports bra or a halter-top so that the scapula entiation in the amount of abduction was speciﬁed. The sameremained visible and shoulder movements were not hampered by criteria as above were used to check for winging and tilting.clothing. All reference points that were used during the inclinom- Systematically, both upward and downward upper limb move-etry and acromion-table distance were palpated (Lewis et al., 2002; ments had to last 5 s each. Scapular positioning was only deemedMorrissey et al., 2008). abnormal if there was a clear observation of the positioning fault. Each position was observed and evaluated once.2.2. Study design 2.3.2. Forward shoulder posture (acromial distance) After measuring the subjects body mass and height, clinical The Acromial Distance was deﬁned as the measurement of theassessment was performed in the following order: observation of posterior border of the acromion to the table in supine (measuredforward tilt and winging, measurement of forward shoulder vertically with a sliding calliper e ManutanÔ, accuracy 0.03 mm)1,posture (the acromial distance), scapular upward rotation (inclin- intended to represent forward shoulder posture. The assessorometry) and scapular dynamic control Kinetic Medial Rotation Test repeated this procedure while the subject actively retracted both(KMRT)). After the assessment protocol, height and body mass weremeasured using a measurement tape and a digital scale (Exacta, 1Germany). Manutan nv, 19 Doverstraat, Brussels, 1070, Belgium.
F. Struyf et al. / Manual Therapy 16 (2011) 155e160 157shoulders. The subject was instructed to keep the thorax still inrelation to the examination table. The data collected with thismeasurement were adjusted by dividing the measured distance bythe body length (BL), which resulted in a score entered as cm/cm.Each position was measured once.2.3.3. Scapular upward rotation (inclinometry) A gravity referenced inclinometer (Plurimeter-V, Dr. Rippstein,Switzerland; accuracy to 1 )2 (Green et al., 1999) was used tomeasure shoulder elevation, and a second inclinometer was used tomeasure upward rotation of the scapula. Again, all subjects wereassessed in a relaxed, standing (barefoot) position. Subjects wereasked to perform full extension at the elbow, neutral wrist position,and with the thumb leading in the coronal plane. The inclinometerwas attached perpendicular to the humerus, just under the deltoidinsertion, with use of a Velcro tape. Subjects were then asked toactively move both arms into abduction and to hold at 45 , 90 and135 of humeral abduction (measured with an inclinometer)(Fig. 2). The resting position of shoulder abduction was taken aszero. The degree of upward rotation of the scapula was measured Fig. 2. Measurement of scapular upward rotation at 90 humeral abduction by meansusing the second inclinometer. This was achieved by manually of 2 inclinometers.aligning the base of the inclinometer along the spine of the scapula. Acromial Distance was found to generate reliable data (ICC 0.88)Each subject underwent one test-rehearsal before the test was (Nijs et al., 2005) and is suggested to be indicative for pectoralisperformed. The scapulohumeral rhythm was calculated by dividing minor muscle length (Host, 1995). Likewise, the plurimeter-V canthe shoulder elevation (humerothoracic) by the scapular upward be used in an effective and reliable manner for the measurement ofrotation (scapulothoracic). scapular upward rotation during shoulder elevation in the coronal plane (ICC ¼ 0.88) (Green et al., 1999; Watson et al., 2005). In2.3.4. Kinetic medial rotation test addition, excellent intrarater reliability was found for the assess- The KMRT was used to indicate movement faults at the scapula ment of scapular upward rotation in four static positions ofand glenohumeral joint associated with glenohumeral medial humeral elevation (Johnson et al., 2001). Validity has been shownrotation (Comerford and Mottram, 2001, 2003; Morrissey et al., when comparing an inclinometer to a three-dimensional motion-2008). The test has been developed based on the combination of tracking device (Johnson et al., 2001). Finally, the KMRT has beenclinical experience and research results addressing shoulder girdle validated against dynamic ultrasound (Morrissey, 2005).movement (Mottram, 1997, 2003; Comerford and Mottram, 2001;Morrissey et al., 2008). The subject was positioned supine with 184.108.40.206. Data analysis. Means, standard deviations, and ranges werethe humerus abducted to 90 in the scapular plane (hand to the calculated for all measured and corrected (AT-distance) data. A 1-ceiling with the humerus in the plane of the scapula). The subject sample KolmogoroveSmirnov goodness-of-ﬁt test was used towas taught to perform medial rotation at the glenohumeral joint at identify normal distribution. Since the descriptive data revealed90 abduction whilst keeping the scapula still in its neutral posi- some high ranges, box plots were used to detect possible outliers.tion. The assessor then palpated the humeral head and coracoid For within subgroup comparisons, a Bonferroni adjustment for theprocesses for translation (Fig. 3). The KMRT was performed up to correction of Type 1 errors was performed. No signiﬁcant differ-60 of medial rotation. Normative research data suggested that ences were found between the left and the right shoulder, thereforeduring medial rotation to 60 e in non-painful shoulders e the both left and right shoulder were analysed together. An indepen-glenoid did not translate anteriorly more than 4 mm, and the dent-samples T-test was used when analysing the differencescapula did not translate more than 6 mm (Morrissey et al., 2008). between adults and children using the inclinometry and acromialFor this experiment test scoring was twofold: ﬁrst, this test wasscored positive (score ¼ 1) when the assessor felt that the scapulatilted forward or when elevation occurred. Second, the test wasscored positive when the subject showed difﬁculties in performingthe test (alteration of breathing pattern, feedback needed, supportneeded, effort needed) (Comerford and Mottram, 2001). Eachsubject underwent one test-rehearsal before the test wasperformed.2.3.5. Reliability and validity Previous study on the inter-tester reliability of scapular obser-vation concluded that observation of the scapula is a reliable toolfor screening prominence of the medial scapular border (winging)and prominence of the inferior scapular angle (tilting) duringunloaded movement in healthy musicians (Kappa of 0.48 and 0.42at rest, and 0.52 and 0.78 during unloaded movement respectivelyfor tilting and winging) (Struyf et al., 2009). In addition, the 2 Plurimeter-V, Dr. Rippstein, 1093 La Conversion, Switzerland. Fig. 3. Kinetic Medial Rotation Test.
158 F. Struyf et al. / Manual Therapy 16 (2011) 155e160Table 1Differences between adults and children in different scapular parameters. Test Observed position or movement fault Children (n ¼ 116) Adults (n ¼ 92) P-value Power (SD) (SD) Observation Tilting present 17 (15%) 18 (20%) 0.51 Winging present 14 (12%) 16 (17%) 0.41 AT-distance Relaxed position (cm/cm) 0.28 (0.06) 0.31 (0.07) 0.00 0.86 Retracted position (cm/cm) 0.15 (0.05) 0.20 (0.06) 0.00 0.99 Inclinometry Scapular upward rotation at rest ( ) À12.4 (6.2) À11.8 (6.2) 0.12 0.21 Scapular upward rotation at 45 humeral elevation ( ) À4.8 (8.4) À5.7 (10.3) 0.47 0.57 Scapular upward rotation at 90 humeral elevation ( ) 18.6 (9.6) 14.5 (10.9) 0.01 0.60 Scapular upward rotation at 135 humeral elevation ( ) 49.9 (14.3) 47.3 (19.8) 0.32 0.54 Ratio from 0 to 45 of humeral abduction 7.1 (12.6) 6.6 (13.9) 0.81 0.53 SH ratio from 45 to 90 of humeral abduction 2.4 (1.5) 3.2 (3.2) 0.04 0.82 SH ratio from 90 to 135 humeral abduction 1.6 (0.7) 1.6 (2.2) 0.86 0.63 KMRT Negative KMRT 107 78 0.14 Positive KMRT 11 14 0.14Abbreviations: SD: standard deviation; SH: scapulohumeral. Bold values: P 0.05.distance. The ManneWhitney U test was used to identify potential study identiﬁed a number of statistically signiﬁcant differences indifferences for the KMRT. A post-hoc power analysis was performed scapular positioning between children and adults.for identiﬁcation of possible type-II errors. A power of 80% was set First, the observation protocol for scapular winging and tiltingas standard for adequacy. The power analysis was performed using did not show signiﬁcant differences between adults and children.SigmaStat 3.1 (Systat Software, Inc., San Jose, CA). Except for the We suggest to further explore the observation of downward scap-power analysis, data were analysed using SPSS version 12.0, for ular rotation as this was previously identiﬁed as variable withWindows (SPSS, Chicago, Illinois, US)3. increasing age (Endo et al., 2004). These results should be taken into account when assessing scapular positioning in subjects without shoulder disorders: not all cases of scapular winging or3. Results scapular tilting are related to shoulder impairments. Second, forward shoulder posture was signiﬁcantly smaller in Table 1 shows all differences between adults and children (Table children than in adults. After controlling for the BL, the mean AT-1). Overall, 15% of the study population demonstrated tilting, while distance of children in relaxed and with bilateral shoulder retrac-11% showed winging. The observation protocol for scapular wing- tion was smaller than in adults. Since the AT-distance is closelying and tilting did not show signiﬁcant differences between adults related to the pectoralis minor muscle length and posterior tilting,and children. The BL correlated with the distance of the posterior this ﬁnding is consistent with an earlier report of increasedborder of the acromion and the table (r 0.46 relaxed; P 0.01 and posterior tilt in children compared to adults (Dayanidhi et al.,r 0.40; P 0.01 retracted). The distance between the acromion 2005). Additional comparison to other study results is notand the table with both shoulders relaxed was signiﬁcantly smaller possible: this is the ﬁrst study to report body length-corrected datain children than in adults (P 0.01). Fig. 4 shows the scapular of the Acromial Distance. These indicative data may assist manualupward rotation in the different age categories. First, an decreased therapists identifying abnormal forward shoulder posture.scapular upward rotation is seen up to the 25e55-year-old group.After that, the scapular upward rotation increased. Combining thedata of all subjects studied here, mean scapulohumeral ratio up to135 of shoulder abduction was 2.76:1. Children showed greater 50humeral elevation angles (158.9 ; SD 7.8 ) than adults (151.4 ; SD9.8 ) (P 0.001). In addition, children demonstrated with signiﬁ-cantly smaller scapulohumeral ratios in comparison to adults 40(P 0.05). A total of 11.9% (n ¼ 25) of all shoulders showed Scapular upward rotationa positive KMRT. No signiﬁcant difference was noted betweenchildren’s and adult’s shoulders. A total of 11 children (¼19%) 30demonstrated with a positive KMRT, whereas 14 adults showedpositive results (¼24%). With the sample of 116 children and 92adults, power is greater than 0.8 for the AT-distance. Using the 20Inclinometry, only the SH ratio from 45 to 90 of humeralabduction attained sufﬁcient power. 104. Discussion 0 Shoulder abduction involves a complex variety of movementsthat has been the subject of numerous studies and discussions. Thepresent study has attempted to provide clinicians with indicative -10data for interpreting clinical tests when assessing scapular posi-tioning and motor control in adults and children. Secondly, this 6-11 years 12-17 years 18-23 years 24-56 years 56-86 years category 3 SPSS Inc., 233 S Wacker Dr, 11th Fl, Chicago, IL 60606, US. Fig. 4. Scapular upward rotation between the ﬁve age categories.
F. Struyf et al. / Manual Therapy 16 (2011) 155e160 159 Third, when comparing scapular upward rotation between static measurements during various positions of arm elevation werechildren and adults by means of two inclinometers, signiﬁcant used to describe the scapulohumeral rhythm, which may not sufﬁ-differences were found between the two age groups. Dayanidhi et al. ciently represent functional movement patterns. Third, the number(2005), previously showed that children display more scapular of study participants who had experienced a shoulder injury moreupward rotation (43.9 ; SD 6.4) than adults (29.1 ; SD 10.1). than 1 year prior to study participation, was not registered. Fourth,However, they studied scapular upward rotation from 25 to 125 of although concurrent validity of the digital inclinometers is known tohumeral elevation, while the present study examined up to 135 of be excellent (Johnson et al., 2001), this has not yet been reported forhumeral abduction This explains their lower degrees of upward the analogue inclinometers. Finally, although previous studies onrotation in contrast to the present study. Watson et al. (2005) used the inter-tester reliability of clinical assessment tools (Green et al.,the same measurements to study 26 adult shoulder patients. Overall, 1999; Johnson et al., 2001; Nijs et al., 2005; Watson et al., 2005;their patients demonstrated larger degrees of scapular upward Struyf et al., 2009) concluded that they are reliable for screeningrotation at rest (3.75 ), 45 (13 ) and 90 (28.3 ) of humeral scapular positioning, no inter-tester reliability analysis was per-abduction than our adult study subjects (rest: À11.8 ; 45 :À5.7 and formed to test the assessor’s accuracy. In addition, all our methods of90 :14.5 ). However, above 90 of humeral elevation, the adults in measuring and scoring of scapular motion should be validatedthe present study demonstrate more scapular upward rotation against accurate motion analysis. It is clear from the methodological(135 :47.3 ) than the patients in Watsons’ study (135 :43.2 ). The problems encountered here that, because of the complexity ofscapulohumeral rhythm is described as the relative movement assessing three-dimensional motions, it is necessary to train manualbetween the scapula and the humerus during arm movements. The therapists in the difﬁculties and pitfalls in interpreting scapularscapulohumeral rhythm is therefore deﬁned as the ratio of the gle- kinematics (Baeyens et al., 2005).nohumeral movement to the scapulothoracic movement during arm The post-hoc power analysis demonstrated sufﬁcient power forelevation. In addition, several studies demonstrated similar scap- the measurement of AT-distance, and the SH ratio from 45 to 90 ofulohumeral ratios ranging from 1.7:1 (McQuade and Smidt, 1998), humeral abduction. The lack of power in the other measurements2.1:1 (Graichen et al., 2001), 2.4:1 (Sugamoto et al., 2002), up to 2.6:1 can be due to the magnitude of the study sample. However, we(De Groot,1999). The wide range of reported ratios appears to be due believe a more precise measurement protocol would result into differences in measurement techniques and methodologies for smaller standard deviations and subsequently increase the power.describing and deﬁning scapulohumeral rhythm (McQuade and In conclusion, our ﬁndings suggest that the clinical assessmentSmidt, 1998). As a disrupted balance between scapular upward protocol, and more speciﬁc the measurement of scapular upwardrotation and humeral elevation might increase the risk of developing rotation and forward shoulder posture, has identiﬁed a signiﬁcantshoulder disorders, assessment of scapular upward rotation and the difference between children and adults: therapists can use thesescapulohumeral rhythm are essential for physical therapists clinical tools in both children and adults. In addition, manual(Sugamoto et al., 2002). therapists can use the data presented here to identify abnormal When searching scientiﬁc literature for differences between scapular positioning: scapular upward/downward rotation orchildren and adults, the study by Dayanidhi et al. (2005) reported forward/backward shoulder posture (measured with analoguethe following glenohumeral to scapulothoracic ratios between 25 inclinometers or the AT-distance) that exceed the presented valuesand 125 of humeral elevation: 2.4:1 for adults and 1.3:1 for chil- (taking the SD into account), should alert therapists for a possibledren. This is inline with our ﬁndings. However, they did not include scapular position that increases the risk for shoulder pathologies.subjects older than 46 years of age. In addition, between 45 and However, future work should aim at searching for a cut-off value for90 of shoulder abduction, children demonstrated signiﬁcantly identifying abnormal scapular postures associated with increasedsmaller scapulohumeral ratios than adults. During this phase of risk for shoulder pathology.humeral abduction, a mechanical compression of the rotator cuff ispossible, creating a condition that is related with the subacromial Acknowledgmentsimpingement syndrome (McClure et al., 2006). Thus, adultsdemonstrate lesser scapular upward rotation during this phase, This study was ﬁnancially supported by a research grant (G826)which might explain the greater incidence numbers of shoulder supplied by the Department of Health Sciences, Artesis Universityimpingement syndrome in adults. However, direct measurement of College Antwerp, Antwerp, Belgium.the subacromial space distance is required to conﬁrm this. Finally,our study found no signiﬁcant differences between children and Referencesadults for scapular dynamic control during performance of theKMRT. Research has provided us with an increased understanding Ackerman B, Adams R, Marshall E. The effect of scapula taping on electromyo-of motor control and its interactions with pain. The current study graphic activity and musical performance in professional violinists. Australian Journal of Physiotherapy 2002;48:197e204.did not show differences in motor control. However, we only Baeyens JP, Cattrysse E, Van Roy P, Clarys JP. Measurement of three-dimensionalincluded healthy, (shoulder-) pain-free subject, whereas motor intra-articular kinematics: methodological and interpretation problems. Ergo-control is probably mainly affected by the experience of pain. nomics 2005;48:1638e44. Borstad JD, Ludewig PM. 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