Brazilian Journal of Physical Therapy 26 (2022) 100420

Brazilian Journal of
Physical Therapy
https://www.journals.elsevier.com/brazilian-journal-of-physical-therapy

ORIGINAL RESEARCH

Scapulothoracic muscle activity during kinetic chain

variations of a prone elevation exercise
Dorien Bormsa,*, Annelies Maenhouta, Kelly Berckmansa, Valentien Spanhovea,
Fran Vanderstukkena, Ann Coolsa,b

a
Ghent University, Faculty of Medicine and Health Sciences, University Hospital Ghent, Department of Rehabilitation Sciences
(Physical Therapy), Gent, Belgium
b
University of Copenhagen, Department of Occupational and Physical Therapy and Institute of Sports Medicine, Bispebjerg Hospital,
Bispebjerg Bakke 23, Copenhagen, Denmark

Received 31 May 2021; received in revised form 29 March 2022; accepted 5 May 2022
Available online 18 May 2022

KEYWORDS Abstract
Electromyography; Background: Scapular rehabilitation exercises should target appropriate muscles. Recently, add-
Exercise therapy; ing external rotation resistance to scapular exercises has gained interest. Moreover, clinical
Periscapular muscles; experts advise kinetic chain integration into shoulder rehabilitation exercises.
Scapula; Objective: To investigate scapular muscle activity during kinetic chain variations of a prone ele-
Shoulder; vation exercise.
Trapezius Methods: Activity of the upper (UT), middle (MT), and lower (LT) trapezius and serratus ante-
rior (SA) muscles was determined with surface electromyography (EMG) in 31 asymptomatic
participants during six prone elevation exercise variations. Variation was created by adding
external rotation resistance, adding trunk extension, or changing exercise position (prone on
a Swiss ball with knees or feet supported, or prone on a physiotable). All data were normalized
as a percentage of maximal voluntary isometric contraction (% MVIC). For each muscle, a
Friedman’s ANOVA was conducted to analyse statistical differences in EMG signal intensity
between exercises.
Results: The LT was moderately (42 - 48% MVIC) and MT highly (63 - 66% MVIC) activated during
all exercise variations. No significant differences between exercises for these muscles could be
detected. Adding external rotation to a prone elevation exercise decreased UT activity while
adding trunk extension increased UT activity. Altering exercise position had no influence on scap-
ular muscle activity except increased UT activity when lying prone on a physiotable with trunk
extension.
Conclusion: Prone elevation exercises are appropriate for facilitating LT and MT activity. Adding
external rotation inhibits UT activity while UT facilitation could be achieved when adding trunk
extension.

* Corresponding author at: University Hospital Ghent, Department of Rehabilitation Sciences (Physical Therapy), Corneel Heymanslaan 10,
2B3, entrance 46, 9000 Gent, Belgium.
E-mail: Dorien.Borms@ugent.be (D. Borms).

https://doi.org/10.1016/j.bjpt.2022.100420
1413-3555/© 2022 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier España, S.L.U. All rights reserved.
 D. Borms, A. Maenhout, K. Berckmans et al.

© 2022 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier

España, S.L.U. All rights reserved.

Introduction rotation.34,35 Therefore, the second purpose of this study

was to assess scapular muscle activity during kinetic chain
Shoulder pain has been associated with abnormal scapular variations of a prone shoulder elevation exercise. This varia-
position or motion, also referred to as scapular dyskinesis.1-5 tion is achieved by (1) altering the exercise position of a
Although it is still unclear whether scapular dyskinesis is the prone shoulder elevation exercise or (2) adding trunk exten-
cause or consequence of shoulder pathology, alterations in sion to a prone shoulder elevation exercise.
scapular kinematics have been related to a variety of shoul-
der pathologies such as shoulder instability and rotator cuff
related shoulder pain.3-6 Different possible underlying mech- Methods
anisms could potentially contribute to abnormal scapular
kinematics such as a lack of soft tissue flexibility or a lack of Participants
muscle performance.7 Regarding the latter, decreased or
excessive scapular muscle activation might hinder adequate Individuals were recruited via advertisement on social
scapular function.8 Scapular dysfunction is often related to media. They were included in this cross-sectional study if
a lack of activity in serratus anterior (SA) and middle (MT) they were free from pain in the upper limbs, lower limbs,
and lower (LT) trapezius with no consensus on whether the and spine for at least 6 months prior to testing and never
upper trapezius (UT) is activated too much9,10 or too had fractures or orthopedic surgery. They were excluded if
little.11,12 Additionally, research has shown that exercise they performed overhead sports or upper limb strength
therapy, targeting the appropriate scapular muscles, could training for more than 6 hours per week. Informed consent
improve scapular dysfunction.13-15 Exercise selection should was obtained from all individual participants included in the
thus be focused on producing high activity in hypoactive study. This study was approved by the Ethical Committee of
muscles combined with low activity in hyperactive muscles.7 Ghent University Hospital and was conducted in accordance
Electromyography (EMG) is a frequently used method to with The Code of Ethics of the World Medical Association
investigate scapular muscle activity during therapeutic (Declaration of Helsinki) for experiments involving humans.
exercises and could aid in suggesting recommendations for An a priori sample size calculation was conducted in
appropriate exercise selection.16-21 Several studies have G*Power (version 3.1.9.2) with an effect size of 0.62, a sig-
examined scapular muscle activity during elevation exer- nificance level of .05, and a desired power of 0.80 (t tests;
cises while standing.8,22-24 But, performing shoulder eleva- Wilcoxon singed-rank test). The effect size was calculated
tion exercises from a prone position could be of interest for based on EMG signal intensity of the UT reported in a previ-
several reasons. First, exercises in prone could be chosen to ous study that investigated scapulothoracic muscle activity
match sport-specific characteristics. As such, swimmers during kinetic chain variations of a bilateral elevation exer-
have to exercise lying supine or prone mainly focusing on cise.32 The calculation revealed that a total sample size of
scapular concentric endurance.7,25 In this population, posi- at least 24 participants was required.
tions that require considerable amounts of core stability are
preferred, which could be enhanced by performing exercises Instrumentation
on an unstable surface. A prone elevation exercise is men-
tioned for this purpose where individuals are lying prone on Before surface electrode placement, the skin surface was
a Swiss ball performing bilateral arm elevation movements.7 shaved, scrubbed, and cleaned with alcohol to minimize skin
Second, exercises in prone have been proposed to better impedance. Bipolar surface electrodes (Ag/AgCl AmbuÒ
target trapezius muscle activity.26,27 Werin et al.27 found sig- BlueSensor P, REF P-00-S/50, 40.8 £ 34 mm, Ballerup, Den-
nificantly higher EMG signal intensity in the 3 trapezius mus- mark) were placed parallel to the muscle fibers of the three
cle parts in the prone compared with side and standing parts of the trapezius muscle and the SA on the dominant
positions. The elevated arm position in prone is probably shoulder with a reference electrode over the ipsilateral
more demanding for the trapezius muscles due to gravity clavicle. Arm dominance was determined as the arm used to
compared to the other positions. Enhancing MT and LT activ- throw a ball. The recommendations from the Surface EMG
ity could also be achieved by adding a humeral external for the Noninvasive Assessment of Muscles (SENIAM) were
rotation resistance to a scapular elevation exercise.22,28 followed for electrode placement and interelectrode dis-
Therefore, the first purpose of this study was to investigate tance.36 All surface electrodes were looped and taped on
the effect of adding humeral external rotation to variations the skin to prevent them from being accidentally detached
of a prone shoulder elevation exercise on scapular muscle during arm movements with consideration of a full elevation
activity (UT, MT, LT, and SA). range of motion. The electrodes were connected to a 16-
Furthermore, clinical experts advise integration of the channel Myosystem 2000 EMG receiver (Noraxon USA Inc,
kinetic chain into shoulder rehabilitation exercises to Scottsdale, AZ). The sampling rate was 1000 Hz, and all raw
address functional daily activities and sport-specific myoelectric signals were preamplified (overall gain, 1000;
demands.7,29-31 Previous studies have found altered scapular common rate rejection ratio, 115 dB; signal-to-noise ratio,
muscle activity by changing upper body position,32 lower <1mV root-mean-square baseline noise). Additionally, an
body position/exercise position,20,27,32,33 or by adding trunk OptiTrack Flex 3 highspeed camera (100 frames per second)

2
 Brazilian Journal of Physical Therapy 26 (2022) 100420

was used to track direction of motion during all exercises for In the second part of the investigation, individuals ran-
the purpose of automatically and more precisely mark the domly performed six variations of a prone elevation exer-
start and end for each exercise repetition during analysis. cise, also called the “W-V” exercise because of the position
For this purpose, one reflective marker was applied in the of the arms at start and at end elevation (Fig. 1). In the
middle of the dorsal side of the dominant upper arm with starting position, elbows are pointing at the back pocket
double adhesive tape. The camera was installed perpendicu- (=both arms together form the letter “W”). In three sec-
lar to this reflective marker. onds, both arms are fully extended in 150° of abduction
with the thumbs upwards (=both arms together form the let-
Testing procedure ter “V”). In another three seconds, both arms were brought
back into the starting position. A metronome was used to
In the first part of the investigation, maximal voluntary iso- ensure correct exercise speed (60 beeps/min). In total, five
metric contractions (MVICs) were performed in a random- repetitions of each exercise variation was completed with a
ized order for normalization.37 Consistent with the resting period of four minutes in between each exercise vari-
protocol of Castelein et al.,37 a set of 4 different isometric ation. These six exercise variations consisted of a prone ele-
test positions were performed for normalizing the EMG vation on a Swiss Ball with the knees supported and without
data: (1) seated T, (2) seated U 135°, (3) prone T - thumbs (exercise 1) or with addition of an external rotation resis-
up, and (4) prone V thumbs up. The 4 different test posi- tance (exercise 2); on a Swiss Ball with the feet supported
tions are described in Table 1. Resistance was applied by and without (exercise 3) or with external rotation resistance
the same researcher just proximal to the elbow into fur- (exercise 4), on a physiotable without (exercise 5) or with
ther upward movement. The researcher held the resis- trunk extension (exercise 6). Standardized exercise instruc-
tance while the individual exerted a maximal force against tions are provided in Table 2. Quality of exercise perfor-
it. Three repetitions of five seconds were performed with mance was checked and corrected by the examiner. For
15 seconds of rest in between as controlled by a metro- exercises 2 and 4, the resistance to external rotation was
nome (60 beeps/min). Individuals were verbally encour- created by an elastic band. The amount of applied resis-
aged to reach their maximal effort in 2 seconds and sustain tance (i.e. color of the elastic band) was chosen so that par-
that effort for another 5 seconds. Between MVIC measure- ticipants rated the exercise effort between 12 and 18 on a
ments of two different muscles, 15 seconds of rest was 20-point Borg scale, which is considered as needed to train
provided.38 strength.39 This was determined in a pilot study with subdivi-
sion into sex and body weight (50-59kg, 60-69 kg, 70-79kg,
and 80-89kg).38,40 This resulted in the use of a yellow elastic
Table 1 Description of the 4 tests for maximum voluntary
band (Thera-BandÒ ) for women and red (Thera-BandÒ ) for
isometric contractions.
men for all weight categories.
Name Description
Seated T Participant is seated with the Signal processing and data analysis
shoulder abducted to 90°
(elbow fully extended) as resis- The Noraxon Myovideo module MR3.6 software program (Nor-
tance is applied above the axon USA, Inc) was used for signal processing. For all raw
elbow, in a downward direction EMG signals, cardiac artefact reduction was performed fol-
(to resist abduction) lowed by rectification and smoothing (Root Mean Square,
Seated U 135° Participant is seated with the window 100 ms). For all MVICs, the mean EMG signal inten-
shoulder flexed to 135° (elbow sity of the three intermediate seconds of every repetition
fully extended) as resistance is and for each muscle was used for further analysis. The nor-
applied above the elbow malization reference level for each of the scapular muscles
against further arm raise was taken as the maximal activity level generated across the
Prone T - thumbs up Participant in prone with the four MVIC tests.37 For all exercises, the analysis of marker
shoulder horizontally abducted motion identified the start and end of each repetition. Mean
to 90° and externally rotated EMG signal intensity for each muscle was calculated across
(elbow fully extended) as the the three intermediate repetitions for all exercises. Those
examiner applies manual pres- values were then normalized and subsequently expressed as
sure downward (above the a percentage of MVIC for further analysis.
elbow) to resist adduction of
the scapula and extension of Statistical analysis
the shoulder
Prone V thumbs up Participant in prone with the Statistical Package for the Social Sciences (SPSS) version 25
shoulder abducted 145° arm in (IBM Corporation, Armonk, NY) was used for statistical anal-
line with lower trapezius mus- ysis. Trial-to-trial reliability for the three MVIC trials for
cle fibers (elbow fully each test position was calculated with intraclass correlation
extended) as the examiner coefficients (ICCs) (2-way random model, type consistency).
applies manual resistance To examine absolute reliability, the standard error of the
above the elbow against further measurement (SEM) was calculated, using the method of
arm raise Weir.41 Data showed nonnormal distribution based on the
outcome of the Shapiro-Wilk test and visual inspection

3
 D. Borms, A. Maenhout, K. Berckmans et al.

Fig. 1 Demonstrating the 6 exercises studied: prone elevation exercise: (1) with knee support without external rotation (above,
lateral view; below, superior view) (2) with knee support with external rotation, (3) with feet support without external rotation, (4)
with feet support with external rotation, (5) on physiotable without trunk extension, (6) on physiotable with trunk extension

(histogram). As a result, descriptive data are presented as To analyze statistical differences in muscle EMG signal
median and interquartile range (Table 3). Although less intensity between the 6 exercise variations, nonparametric
suited for nonnormal distributed data, means, standard statistics were used. For each muscle (UT, MT, LT, and SA), a
deviations (SD), and confidence intervals (CI) were also separate Friedman’s ANOVA (analysis of variance) with 6 var-
determined for the normalized EMG values (% MVIC) for each iables was conducted. Alpha level was set at 0.05. In case
muscle and for each exercise variation (Table 3) to compare the Friedman’s ANOVA revealed a significant result, post hoc
our results with others. To facilitate the interpretation, the tests were performed using a Wilcoxon signed rank test with
values of EMG were categorized as low activity (<20% MVIC), correction for the number of test (i.e. Bonferroni correction
moderate activity (20%-50% MVIC), or high activity (>50% for multiple comparisons).40 More specifically, when mutu-
MVIC).38 ally comparing the 6 exercise variations, a total of 15

4
 Brazilian Journal of Physical Therapy 26 (2022) 100420

Table 2 Standardised exercise instruction for the six W-V exercise variations.
No Exercise variation Exercise description
1 Knee support Without ER Individual is prone on a Swiss Ball with the knees, lower legs, and feet sup-
ported on the ground and shoulder width apart. Hips and knees are 90°
flexed and the trunk is horizontally aligned. Both upper arms and head are
aligned with the trunk. Elbows are flexed, in neutral rotation (=thumbs up)
and pointed towards the back pocket. In this position, both arms form the
letter “W”. Then, individuals extend both arms in 150° abduction. In this
position, both arms form the letter “V”.
2 Knee support With ER Same as previous exercise but a resistance is added to external rotation by an
elastic band. The ends of the elastic band are fixed to each other by a knot
and placed between the thumb and the other fingers of both hands. Individu-
als were asked to push with the hands against the elastic band while per-
forming the exercise until full range.
3 Feet support Without ER Individual is prone on a Swiss Ball with the knees and hips extended and with
feet supported on the ground, shoulder width apart. The trunk and head are
aligned with the legs. Both upper arms are aligned with the trunk. Elbows are
flexed, in neutral rotation (=thumbs up), and pointed towards the back
pocket. In this position, both arms form the letter “W”. Then, individuals
extend both arms in 150° abduction. In this position, both arms form the let-
ter “V”.
4 Feet support With ER Same as previous exercise but a resistance is added to external rotation by an
elastic band. The ends of the elastic band are fixed to each other by a knot
and placed between the thumb and the other fingers of both hands. Individu-
als were asked to push with the hands against the elastic band while per-
forming the exercise until full range.
5 Prone on physiotable Without TE Individual is prone on a physiotable with the knees and hips extended, shoul-
der width apart. The trunk and head are horizontally aligned with the legs.
Both upper arms are aligned with the trunk. Elbows are flexed, in neutral
rotation (=thumbs up), and pointed towards the back pocket. In this position,
both arms form the letter “W”. Then, individual extends both arms in 150°
abduction. In this position, both arms form the letter “V”.
6 Prone on physiotable With TE Individual is prone on a physiotable. Both legs are shoulder width apart. Legs
and trunk are maximally but still comfortably extended (feet and shoulders
are raised from the table). Head is aligned with the trunk. Both upper arms
are aligned with the trunk. Elbows are flexed, in neutral rotation (=thumbs
up), and pointed towards the back pocket. In this position, both arms form
the letter “W”. Then, individual extends both arms in 150° abduction. In this
position, both arms form the letter “V”.
Abbreviations: ER, external rotation; TE, trunk extension.

comparisons were made. As a result, alpha level was reset at The descriptive analysis and results of the Friedman’s
0.0033 (0.05/15 comparisons).42 ANOVA are presented in Table 3. The Friedman’s ANOVA
yielded a statistically significant difference for UT (ꭕ2
(5) = 51.2, p<0.001), LT (ꭕ2 (5) = 11.3, p=0.045), and SA
activity (ꭕ2 (5) = 22.9, p<0.001). For MT, the result of the
Results Friedman’s ANOVA was not significant (ꭕ2 (5) = 5.3, p=381).
The results of the post-hoc tests with Bonferroni correction
Thirty-one healthy individuals (16 women, 15 men; mean revealed significant differences across exercises for UT and
age 22.5 § 1.3 years, weight 66.4 § 9.2 kg, and height 175.1 SA but not for LT (Table 3).
§ 7.1 cm) were included in this study. The ICCs for the 3
MVIC trials for each test position show high trial-to-trial reli-
ability with ICC values ranging from 0.965 to 0.987. The Discussion
SEMs for each MVIC test positions vary between 67.6 and
113.5 microvolts. An overview of ICC and SEM values for all 4 The most important finding of the present study was that
MVIC test positions can be found in Online supplementary only UT activity is influenced by variations of a prone eleva-
material. tion exercise. Adding external rotation decreases UT

5
 Table 3 Descriptive data and results of the Friedman’s ANOVA and post-hoc testsa,b
Muscle Descriptives Exercise number p value p value

1 2 3 4 5 6 Friedman’s Pairwise
ANOVA comparisons
(Bonferroni
correction)
UT Median [IQ range]a 33 [20] 22 [17] 35 [22] 23 [15] 34 [23] 40 [30] <0.001c 1-2: <0.001d
Mean § SD [95% CI]b 1-3: 0.8
1-4: <0.001d

D. Borms, A. Maenhout, K. Berckmans et al.

36 § 20 (29, 43) 28 § 20 (21, 35) 36 § 19 (29, 43) 27 § 17 (21, 33) 36 § 18 (29, 42) 42 § 23 (34, 51) 1-5: >0.9
1-6: 0.002d
2-3: 0.001d
2-4: 0.6
2-5: 0.0031d
2-6: <0.001d
3-4: <0.001d
3-5: >0.9
3-6: 0.001d
6

4-5: 0.002d
4-6: 0.001d
5-6: 0.001d
MT Median [IQ range]a 62 [54] 66 [43] 58 [49] 61 [47] 62 [42] 63 [42] 0.4 N.A.
Mean § SD [95% CI]b 63 § 29 (52, 73) 63 § 29 (53, 74) 64 § 31 (53, 76) 64 § 29 (53, 74) 66 § 28 (56, 77) 64 § 29 (53, 75)
LT 43 [19] 47 [20] 40 [20] 47 [16] 44 [20] 39 [28] 0.045c 1-2: 0.04
1-3: 0.3
1-4: 0.3
1-5: 0.8
1-6: 0.02
2-3: 0.1
2-4: 0.4
2-5: 0.08
2-6: 0.02
3-4: 0.1
3-5: 0.6
3-6: 0.3
4-5: 0.4
4-6: 0.07
Mean § SD [95% CI]b 46 § 21 (39, 54) 48 § 15 0 (42, 53) 45 § 21 (37, 52) 46 § 13 (41, 51) 46 § 22 (38, 54) 42 § 20 (35, 50) 5-6: 0.3
 Table 3 (Continued)
Muscle Descriptives Exercise number p value p value

1 2 3 4 5 6 Friedman’s Pairwise
ANOVA comparisons
(Bonferroni
correction)
SA Median [IQ range]a 19 [12] 18 [12] 18 [11] 17 [10] 18 [12] 21 [12] <0.001c 1-2: 0.8
21 § 10 (17, 24) 20 § 11 (16, 24) 21 § 9 (18, 24) 19 § 7 (16, 21) 20 § 9 (17, 23) 23 § 9 (20, 27) 1-3: 0.8
1-4: 0.2
1-5: 0.7
1-6: 0.01
2-3: 0.6
2-4: 0.2

Brazilian Journal of Physical Therapy 26 (2022) 100420

2-5: 0.7
2-6: 0.007
3-4: 0.03
3-5: 0.4
3-6: 0.03
4-5: 0.4
4-6: 0.001d
5-6: 0.005
a
Data reported as median [interquartile range].
b
Data reported as mean § SD (95% CI). Values are expressed in percentage of maximal voluntary isometric contractions (%MVIC): low <20 %MVIC, moderate 20-50 %MVIC, high >50 %MVIC.
c
p <0.05 indicates statistical significance for the results of the Friedman’s ANOVA
7

d
p <0.0033 indicates statistical significance for the results of the pairwise comparisons after Bonferroni correction.
(1) Prone elevation with knee support without external rotation (2) prone elevation with knee support with external rotation, (3) prone elevation with feet support without external rotation,
(4) prone elevation with feet support with external rotation, (5) prone elevation on physiotable without trunk extension, (6) prone elevation on physiotable with trunk extension
Abbreviations: ANOVA, analysis of variance; IQ, interquartile; LT, lower trapezius; MT, middle trapezius; N.A., not applicable; SA, serratus anterior; UT, upper trapezius.
 D. Borms, A. Maenhout, K. Berckmans et al.

activity. UT facilitation could be achieved by (1) adding support was changed i.e. mutually comparing exercises 1, 3,
trunk extension to the prone elevation exercise on a physiot- and 5 or comparing exercises 2 and 4. When two variables in
able or, (2) altering exercise position together with trunk body support changed, UT activity is significantly increased
extension. i.e. when performing the exercise lying prone on a physiot-
To investigate the effect of adding external rotation (ER) able with trunk extension (exercise 6) compared to when
on scapular muscle activity, exercises 1 versus 2, and 3 ver- the exercise is executed lying prone on a Swiss ball with
sus 4 were compared because the only difference between knees (exercise 1) or feet (exercise 3) supported. Mean dif-
them is the presence of an ER resistance. Exercise 2 and 4 ferences (95% CI) between exercise 1 and 6 was -6% MVIC
(with ER) showed significantly lower UT activity compared to (-10%, -2%) and between exercise 3 and 6 was -6% MVIC
exercise 1 and 3 (without ER). Mean differences (95% confi- (-10%, -3%).
dence interval (CI)) are 7% MVIC (4%, 10%) and 9% MVIC Based on our results, it is difficult to attribute the altered
(6%,13%), respectively. The significant decreased in UT activ- UT activity to one specific reason because two variables in
ity with addition of external rotation resistance in the prone chain position were changed (i.e. body position and trunk
elevation exercise is possibly due to the activation of the extension). A possible explanation could be found as
posterior shoulder muscles that are responsible for shoulder described above, the UT muscle is compensating by increas-
external rotation during the entire W-V exercise (i.e. infra- ing its activity with increased exercise difficulty to perform
spinatus and teres minor muscles). Activation of these the elevation as prime mover for upward scapular rotation.
muscles could possibly lead to decreased UT activity as the In contrast, when only one variable in body position was
UT muscle is not part of the posterior chain.43 Some authors changed, scapular muscle activity was not influenced. These
advise limiting UT activity during scapular rehabilitation findings are useful in scapular rehabilitation for exercise
exercises9,10 and adding an external rotation resistance to a progression by gradually loading the functional open chain.
W-V exercise is thus preferred based on our results. Previous During the W-V exercise, this loading is created by altering
studies advised the use of an external rotation resistance body position. More specifically for swimmers, the sport-spe-
during a standing elevation exercise for increasing MT and LT cific character of the W-V exercise could be made more chal-
activity.22,28 Our results do not support this recommendation lenging with changes in body position that require additional
because MT and LT activities were unchanged when adding core stability.25 This could be established by exercise perfor-
external rotation. This could be due to the difference in test mance on a table (exercise 5) followed by lying prone on a
position: a standing arm elevation compared to a prone posi- Swiss ball with the knees supported (exercise 1) and finally
tion, which could influence the stabilizing function of the MT with the feet supported (exercise 3). This functional exer-
and LT. Moreover, activation levels for both muscles were cise progression is possible without changing scapular mus-
already moderate (>40% MVIC for LT) to high (>60% MVIC for cle recruitment. Additionally, when decreased UT activity is
MT) in our study, which might limit a further increase. desired in rehabilitation, exercise 1 and 3 could be replaced
For the second objective, scapular muscle activity was by exercise 2 and 4 respectively. If higher UT activity is desir-
assessed during kinetic chain variations of a prone elevation able, exercise progression is also possible by performing the
exercise by means of adding trunk extension or altering W-V exercise when lying prone on a table with trunk exten-
exercise position. To investigate the influence of trunk sion.
extension, exercises 5 and 6 were compared. Our results When looking at the mean normalized EMG values in
showed higher UT activity with trunk extension with no sig- Table 3, all scapular muscles (except SA in exercise 4)
nificant differences for MT, LT, and SA. Mean difference in showed moderate (between 20% and 50% MVIC) to high
UT activity between exercise 5 and 6 was -7% MVIC (-11%, (>50% MVIC) activity meaning that activity levels in all
-3%). exercise variations might be suited for scapular muscle
Trunk extension is performed by elevating the trunk and control or strength training purposes.19,44 The SA showed
legs which makes the exercise considerably more challeng- the lowest activity of all muscles with overall values of
ing. Possibly, the UT muscle is compensating for this intensi- around 20% MVIC which is in line with previous research
fied effort by increasing its activity. Adding trunk extension on SA activity during standing elevation exercises with
might thus be useful for exercise progression in scapular and without external rotation22 or prone retraction exer-
rehabilitation to promote higher UT activity, which is sup- cises.35 It would be interesting to investigate whether
ported by some authors for patients with shoulder pain.11,12 addition of a load during a prone elevation exercise
Additionally, we assumed that MT and LT activity would also would affect scapular muscle activity because it has
be increased because trunk elevation might enhance scapu- been shown to increase SA activity during standing eleva-
lar retraction. Possibly, trunk extensor muscle activity is tion exercises.22,38
increased although activity in these muscles was not investi- Overall UT muscle activity is the second lowest with sig-
gated in this study. Previous research found similar results as nificant fluctuations in EMG activity between exercise varia-
ours with no significant differences in activity for these tions which is not the case for MT, LT, or SA activity. For this
muscles when a prone scapular retraction was performed reason, exercises could be ranked with progressive UT activ-
with and without trunk rotation.35 ity. First exercise 4 (27% MVIC) and 2 (28% MVIC) with the
To investigate the effect of changing exercise position, lowest UT activity, followed by significantly higher UT activ-
exercises 1, 3, 5, and 6 on the one hand and exercises 2 ver- ity in exercises 5 (36% MVIC), 3 (36% MVIC), and 1 (36% MVIC)
sus 4 (both with external rotation) on the other hand were and completed with the significantly highest UT activity in
compared because the difference between them is the exer- exercise 6 (42% MVIC). MT and LT activity was the highest
cise position. No statistically significant differences were during all exercise variations with activity levels between
found between exercises where only one variable in body 40% and 50% MVIC for LT and >60% for MT. This finding

8
 Brazilian Journal of Physical Therapy 26 (2022) 100420

supports the use of scapular retraction movements to References

enhance posterior shoulder muscle performance.19,40,45,46
The results of this study must be viewed with regard to 1. Hickey D, Solvig V, Cavalheri V, Harrold M, McKenna L. Scapular
its limitations. First, the influence of adding external rota- dyskinesis increases the risk of future shoulder pain by 43% in
tion to a W-V exercise was only studied when lying prone asymptomatic athletes: a systematic review and meta-analysis.
Br J Sports Med. 2018;52(2):102 110. https://doi.org/
on a Swiss ball with knees or feet supported. Due to practi-
10.1136/bjsports-2017-097559.
cal reasons, it was not possible to add an external rotation 2. Kibler WB, Sciascia A. Current concepts: scapular dyskinesis. Br
resistance when lying prone on a physiotable. Second, J Sports Med. 2010;44(5):300 305. https://doi.org/10.1136/
extrapolation of these results to other age categories or bjsm.2009.058834.
patients with shoulder conditions should be done with cau- 3. Kibler WB, Sciascia A. The role of the scapula in preventing and
tion because this study was performed on healthy, young treating shoulder instability. Knee Surg Sports Traumatol
participants. However, similar populations have been Arthrosc. 2016;24(2):390 397. https://doi.org/10.1007/
tested in previous EMG research, suggesting appropriate s00167-015-3736-z.
shoulder rehabilitation exercises.16,20,22,35,38,40 Third, this 4. Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its rela-
study evaluated four scapular muscles important for scapu- tion to shoulder injury. J Am Acad Orthop Surg. 2012;20
(6):364 372. https://doi.org/10.5435/JAAOS-20-06-364.
lar control, which are often the scapular muscles of inter-
5. Ludewig PM, Reynolds JF. The association of scapular kinematics
est to examine with surface EMG. Other muscles such as and glenohumeral joint pathologies. J Orthop Sports Phys Ther.
the pectoralis minor, rhomboids, or levator scapulae might 2009;39(2):90 104. https://doi.org/10.2519/jospt.2009.2808.
also have significant value in scapular control during reha- 6. Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Scias-
bilitation exercises. But, these deeper lying muscles are cia AD. Clinical implications of scapular dyskinesis in shoulder
not accessible through surface EMG. Fourth, this study did injury: the 2013 consensus statement from the 'Scapular Sum-
not include the timing of muscle activity which is also an mit'. Br J Sports Med. 2013;47(14):877 885. https://doi.org/
important contributor to scapular dyskinesis. Fifth, the 10.1136/bjsports-2013-092425.
activity levels of shoulder external rotation muscles were 7. Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie
not investigated in this study and could be the focus of fur- B. Rehabilitation of scapular dyskinesis: from the office worker
to the elite overhead athlete. Br J Sports Med. 2014;48
ther research. Additionally, investigating the effect of
(8):692 697. https://doi.org/10.1136/bjsports-2013-092148.
kinetic chain variations on core muscle activity (back and 8. Castelein B, Cagnie B, Parlevliet T, Cools A. Scapulothoracic
abdominal muscles) or shoulder external rotation muscles muscle activity during elevation exercises measured with sur-
could be of interest. face and fine wire EMG: A comparative study between patients
with subacromial impingement syndrome and healthy controls.
Man Ther. 2016;23:33 39. https://doi.org/10.1016/j.
Conclusion math.2016.03.007.
9. Chester R, Smith TO, Hooper L, Dixon J. The impact of subacro-
The results of this research provide clinical information mial impingement syndrome on muscle activity patterns of the
about which exercise variation to choose when targeting shoulder complex: a systematic review of electromyographic
studies. BMC Musculoskelet Disord. 2010;11:45. 10.1186/1471-
activity in specific scapular muscles, depending on which
2474-11-45.
muscle is desired to be activated. Our research supports the 10. Cools AM, Declercq GA, Cambier DC, Mahieu NN, Witvrouw EE.
use of a prone elevation exercise for enhancing LT and MT Trapezius activity and intramuscular balance during isokinetic
activity. Regarding UT activity, adding an external rotation exercise in overhead athletes with impingement symptoms.
resistance is preferred for decreasing UT activity while UT Scand J Med Sci Sports. 2007;17(1):25 33. https://doi.org/
activity is facilitated when performing the prone elevation 10.1111/j.1600-0838.2006.00570.x.
exercise lying prone on a table with trunk extension. 11. Mottram SL, Woledge RC, Morrissey D. Motion analysis study of a
scapular orientation exercise and subjects' ability to learn the
exercise. Man Ther. 2009;14(1):13 18. https://doi.org/
10.1016/j.math.2007.07.008.
Conflicts of interest 12. Pizzari T, Wickham J, Balster S, Ganderton C, Watson L. Modify-
ing a shrug exercise can facilitate the upward rotator muscles
This research did not receive any specific grant from funding of the scapula. Clin Biomech. 2014;29(2):201 205. https://
agencies in the public, commercial, or not-for-profit sectors. doi.org/10.1016/j.clinbiomech.2013.11.011.
13. Baskurt Z, Baskurt F, Gelecek N, Ozkan MH. The effectiveness of
scapular stabilization exercise in the patients with subacromial
Acknowledgements impingement syndrome. J Back Musculoskelet Rehabil. 2011;24
(3):173 179. https://doi.org/10.3233/BMR-2011-0291.
The authors would like to thank all participants for their vol- 14. Kromer TO, Tautenhahn UG, de Bie RA, Staal JB, Bastiaenen CH.
untary participation and Adriaan Borms for the assistance Effects of physiotherapy in patients with shoulder impingement
with collecting the photo material. syndrome: a systematic review of the literature. J Rehabil Med.
2009;41(11):870 880. https://doi.org/10.2340/16501977-
0453.
15. Struyf F, Nijs J, Mollekens S, et al. Scapular-focused treatment
Supplementary materials in patients with shoulder impingement syndrome: a randomized
clinical trial. Clin Rheumatol. 2013;32(1):73 85. https://doi.
Supplementary material associated with this article can be org/10.1007/s10067-012-2093-2.
found in the online version at doi:10.1016/j. 16. Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of scap-
bjpt.2022.100420. ular muscle balance: which exercises to prescribe? Am J Sports

9
 D. Borms, A. Maenhout, K. Berckmans et al.

Med. 2007;35(10):1744 1751. https://doi.org/10.1177/ systematic review with best evidence synthesis. Br J Sports
0363546507303560. Med. 2017;52(4):231 237. https://doi.org/10.1136/bjsports-
17. De Mey K, Danneels LA, Cagnie B, Huyghe L, Seyns E, Cools AM. 2016-096915.
Conscious correction of scapular orientation in overhead ath- 32. Borms D MA, Cools AM. Incorporation of the kinetic chain into
letes performing selected shoulder rehabilitation exercises: the shoulder-elevation exercises: does it affect scapular muscle
effect on trapezius muscle activation measured by surface elec- activity? J Athl Train. 2020;55(4):343 349. https://doi.org/
tromyography. J Orthop Sports Phys Ther. 2013;43(1):3 10. 10.4085/1062-6050-136-19.
https://doi.org/10.2519/jospt.2013.4283. 33. De Mey K, Danneels L, Cagnie B, Van den Bosch L, Flier J. Cools
18. Ekstrom RA, Donatelli RA, Soderberg GL. Surface electromyo- AM. Kinetic chain influences on upper and lower trapezius mus-
graphic analysis of exercises for the trapezius and serratus ante- cle activation during eight variations of a scapular retraction
rior muscles. J Orthop Sports Phys Ther. 2003;33(5):247 258. exercise in overhead athletes. J Sci Med Sport. 2013;16
https://doi.org/10.2519/jospt.2003.33.5.247. (1):65 70. https://doi.org/10.1016/j.jsams.2012.04.008.
19. Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T. 34. Nagai K, Tateuchi H, Takashima S, et al. Effects of trunk rota-
Electromyographic analysis of specific exercises for scapular tion on scapular kinematics and muscle activity during humeral
control in early phases of shoulder rehabilitation. Am J Sports elevation. J Electromyogr Kinesiol. 2013;23(3):679 687.
Med. 2008;36(9):1789 1798. https://doi.org/10.1177/ https://doi.org/10.1016/j.jelekin.2013.01.012.
0363546508316281. 35. Yamauchi T, Hasegawa S, Matsumura A, Nakamura M, Ibuki S,
20. Maenhout A, Van Praet K, Pizzi L, Van Herzeele M, Cools A. Ichihashi N. The effect of trunk rotation during shoulder exer-
Electromyographic analysis of knee push up plus variations: cises on the activity of the scapular muscle and scapular kine-
what is the influence of the kinetic chain on scapular muscle matics. J Shoulder Elbow Surg. 2015;24(6):955 964. https://
activity? Br J Sports Med. 2010;44(14):1010 1015. https://doi. doi.org/10.1016/j.jse.2014.10.010.
org/10.1136/bjsm.2009.062810. 36. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development
21. Escamilla RF, Yamashiro K, Paulos L, Andrews JR. Shoulder mus- of recommendations for SEMG sensors and sensor placement
cle activity and function in common shoulder rehabilitation procedures. J Electromyogr Kinesiol. 2000;10(5):361 374.
exercises. Sports Med. 2009;39(8):663 685. https://doi.org/ https://doi.org/10.1016/S1050-6411(00)00027-4.
10.2165/00007256-200939080-00004. 37. Castelein B, Cagnie B, Parlevliet T, Danneels L, Cools A. Optimal
22. Castelein B, Cagnie B, Parlevliet T, Cools A. Superficial and deep normalization tests for muscle activation of the levator scapu-
scapulothoracic muscle electromyographic activity during ele- lae, pectoralis minor, and rhomboid major: an electromyogra-
vation exercises in the scapular plane. J Orthop Sports Phys phy study using maximum voluntary isometric contractions.
Ther. 2016;46(3):184 193. https://doi.org/10.2519/ Arch Phys Med Rehab. 2015;96(10):1820 1827. https://doi.
jospt.2016.5927. org/10.1016/j.apmr.2015.06.004.
23. Lin JJ, Hsieh SC, Cheng WC, Chen WC, Lai Y. Adaptive patterns 38. Borms D, Ackerman I, Smets P, Van den Berge G, Cools AM.
of movement during arm elevation test in patients with shoul- Biceps disorder rehabilitation for the athlete: a continuum of
der impingement syndrome. J Orthop Res. 2011;29 moderate- to high-load exercises. Am J Sports Med. 2017;45
(5):653 657. https://doi.org/10.1002/jor.21300. (3):642 650. https://doi.org/10.1177/0363546516674190.
24. Roy JS, Moffet H, McFadyen BJ. Upper limb motor strategies in 39. Andersen LL, Andersen CH, Mortensen OS, Poulsen OM, Bjorn-
persons with and without shoulder impingement syndrome lund IB, Zebis MK. Muscle activation and perceived loading dur-
across different speeds of movement. Clin Biomech (Bristol, ing rehabilitation exercises: comparison of dumbbells and
Avon). 2008;23(10):1227 1236. https://doi.org/10.1016/j. elastic resistance. Phys Ther. 2010;90(4):538 549. https://doi.
clinbiomech.2008.07.009. org/10.2522/ptj.20090167.
25. Cools AM, Borms D, Castelein B, Vanderstukken F, Johansson FR. 40. Cools AM, Borms D, Cottens S, Himpe M, Meersdom S, Cagnie B.
Evidence-based rehabilitation of athletes with glenohumeral Rehabilitation exercises for athletes with biceps disorders and
instability. Knee Surg Sports Traumatol Arthrosc. 2016;24 SLAP lesions: a continuum of exercises with increasing loads on
(2):382 389. https://doi.org/10.1007/s00167-015-3940-x. the biceps. Am J Sports Med. 2014;42(6):1315 1322. https://
26. Camargo PR, Neumann DA. Kinesiologic considerations for tar- doi.org/10.1177/0363546514526692.
geting activation of scapulothoracic muscles - part 2: trapezius. 41. Weir JP. Quantifying test-retest reliability using the intraclass
Braz J Phys Ther. 2019;23(6):467 475. https://doi.org/ correlation coefficient and the SEM. J Strength Cond Res.
10.1016/j.bjpt.2019.01.011. 2005;19(1):231 240. https://doi.org/10.1519/15184.1.
27. Werin MB, Maenhout AG, Icket J, Jacxsens N, Kempkes E, Cools 42. F A. Discovering Staistics Using SPSS. 3rd ed. London: SAGE Pub-
AM. Does the activity in scapular muscles during plyometric lications; 2009.
exercises change when the kinetic chain is challenged? - An 43. TW M. Anatomy Trains. Myofascial Meridians for Manual and
EMG Study. J Strength Cond Res. 2020. https://doi.org/ Movement Therapists. Edinburgh: Scotland Churchill Living-
10.1519/JSC.0000000000003747. stone; 2001.
28. Holmgren T, Hallgren HB, Oberg B, Adolfsson L, Johansson K. 44. Maenhout A, Benzoor M, Werin M, Cools A. Scapular muscle
Effect of specific exercise strategy on need for surgery in activity in a variety of plyometric exercises. J Electromyogr
patients with subacromial impingement syndrome: randomised Kinesiol. 2016;27:39 45. https://doi.org/10.1016/j.jele-
controlled study. Br J Sports Med. 2014;48(19):1456 1457. kin.2016.01.003.
https://doi.org/10.1136/bjsports-2014-e787rep. 45. Ellenbecker TS, Cools A. Rehabilitation of shoulder impinge-
29. McMullen J, Uhl TL. A kinetic chain approach for shoulder reha- ment syndrome and rotator cuff injuries: an evidence-based
bilitation. J Athl Train. 2000;35(3):329 337. review. Br J Sports Med. 2010;44(5):319 327. https://doi.org/
30. Sciascia A, Cromwell R. Kinetic chain rehabilitation: a theoreti- 10.1136/bjsm.2009.058875.
cal framework. Rehabil Res Pract. 2012;2012: 853037. https:// 46. Oliver GD, Plummer HA, Gascon SS. Electromyographic analysis
doi.org/10.1155/2012/853037. of traditional and kinetic chain exercises for dynamic shoulder
31. Wright AA, Hegedus EJ, Tarara DT, Ray SC, Dischiavi SL. Exercise movements. J Strength Cond Res. 2016;30(11):3146 3154.
prescription for overhead athletes with shoulder pathology: a https://doi.org/10.1519/JSC.0000000000001389.

10