Kamonseki 2020

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BJPT-305; No. of Pages 10 ARTICLE IN PRESS

Brazilian Journal of Physical Therapy 2020;xxx(xx):xxx---xxx
Brazilian Journal of
Physical Therapy
https://www.journals.elsevier.com/brazilian-journal-of-physical-therapy
CLINICAL TRIAL PROTOCOL
Scapular movement training versus standardized

exercises for individuals with chronic shoulder pain:
protocol for a randomized controlled trial
Danilo Harudy Kamonseki a , Melina Nevoeiro Haik b , Paula Rezende Camargo a,∗
a
Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade Federal de São
Carlos, São Carlos, SP, Brazil
b
Department of Physical Therapy, Center of Health and Sport Science, Universidade do Estado de Santa Catarina, Florianópolis,
SC, Brazil
Received 10 January 2020; received in revised form 31 July 2020; accepted 5 August 2020
KEYWORDS Abstract
Movement; Background: Scapular focused exercise interventions are frequently used to treat individuals
Physical therapy; with shoulder pain. However, evidence for changes in scapular motion after intervention is
Rehabilitation; limited.
Scapula Objective: To compare the effects of scapular movement training versus standardized exercises
for individuals with shoulder pain.
Methods: This will be a single-blinded randomized controlled trial. Sixty-four individuals with
shoulder pain for at least 3 months, scapular dyskinesis, and a positive scapular assistance test
will be randomly allocated to one of two groups: Scapular Movement Training (group 1) and
Standardized Exercises (group 2). Group 1 will receive education about scapular position and
movement, and be trained to modify the scapular movement pattern. Group 2 will perform
stretching and strengthening exercises. Both groups will be treated twice a week for eight
weeks. Three-dimensional scapular kinematics and muscle activity of the serratus anterior and
upper, middle, and lower trapezius during elevation and lowering of the arm will be assessed at
baseline and after 8 weeks of treatment. Pain intensity, function, fear avoidance beliefs, and
kinesiophobia will be assessed at baseline and after 4 and 8 weeks of treatment, and 4 weeks
after the end of treatment.
Conclusions: The results of this study may contribute to a better understanding of the efficacy
of scapular focused treatments for individuals with shoulder pain. Clinical trial registration:
NCT03528499
© 2020 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier
Editora Ltda. All rights reserved.
∗ Corresponding author at: Departamento de Fisioterapia, Universidade Federal de São Carlos, Rodovia Washington Luiz, km 235, CEP:
13565-905, São Carlos, SP, Brazil.

E-mail: prcamargo@ufscar.br (P.R. Camargo).
https://doi.org/10.1016/j.bjpt.2020.08.001
1413-3555/© 2020 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.
Please cite this article in press as: Kamonseki DH, et al. Scapular movement training versus standardized exer-
cises for individuals with chronic shoulder pain: protocol for a randomized controlled trial. Braz J Phys Ther. 2020,
+Model
2 D.H. Kamonseki et al.
Introduction The objective of this study will be to compare the effects

of scapular movement training to standardized exercises on
Shoulder pain is a common musculoskeletal complaint.1,2 scapular kinematics, scapulothoracic muscles activity, pain,
The annual incidence of the condition in primary medical disability, fear avoidance, and kinesiophobia in individuals
care is estimated to be 20.6 per 1000 individuals.3 The with shoulder pain. We hypothesized that scapular move-
prevalence is between 20 and 33% in the general popula- ment training will result in greater improvements compared
tion, and it may have an impact on work productivity and to standardized exercises on scapular kinematics, scapu-
healthcare expenses over time.4,5 lothoracic muscles activity, pain, disability, fear avoidance,
Appropriate scapular motion is essential for shoulder and kinesiophobia.
mobility and function.6,7 Although scapular dyskinesis has
already been associated with shoulder pain,8,9 it is not clear Methods
in the literature if scapular dyskinesis is the cause or con-
sequence of shoulder pain.8 Scapular dyskinesis has been Study setting
suggested to increase the risk for developing shoulder pain in
athletes,9 and this may also be the case for the general pop-
This will be a single-blind randomized clinical trial, with
ulation. Although more cohort studies are needed to provide
two-arm parallel groups and a blinded assessor. The trial
more evidence about the role of scapular motion in shoulder
has been designed according to the Standard Protocol Items:
pain, individuals with shoulder pain have shown decreased
Recommendations for Interventional Trials (SPIRIT)40 and
scapular posterior tilt, upward rotation, and external rota-
CONSORT41 guidelines. This trial was prospectively regis-
tion during arm elevation compared to individuals without
tered at clinicaltrials.gov (NCT03528499).
shoulder pain.6,10---12 However, other studies have identi-
fied different movements impairments, or no deviations.6,13
Increased activation of the upper trapezius (UT)14---17 and Study setting
decreased activation of the serratus anterior (SA),14,16---18 and
lower (LT) and middle trapezius (MT)19,20 have also been The study will be conducted at the Laboratory of Analysis
described and may contribute to shoulder pain and alter- and Intervention of the Shoulder Complex at Universidade
ations in scapular motion. Federal de São Carlos.
Evidence for strengthening and stretching exercises as
the most recommended management strategy to improve Sample size calculation
pain and disability in individuals with shoulder pain is The sample size was calculated based on estimated mean
currently increasing.21---23 However, the effectiveness on difference of 5.5◦ (standard deviation of 7.2◦ ) in the scapular
shoulder pain and disability has not been related to changes posterior tilt between groups, collected via an electromag-
in scapular motion.24---28 Although pain and function improve- netic system device,42 with two-tailed significance set at
ments are more meaningful to patients than scapular 0.05, power at 80%, and accounting for a 15% dropout.
motion, it is not clear yet whether scapular motion is a Thirty-two individuals are needed per group. Scapular poste-
modifiable contributing factor to shoulder pain.27,29 One rior tilt was considered for sample size calculation because
of the major issues in the past investigations is that it is commonly decreased in individuals with shoulder
scapular motion was not associated to shoulder symptoms pain.6,10,11,16
during the clinical evaluation process to guide exercise
prescription.24---26,28,30---33 Therefore, an approach that specif-
ically targets scapular motion deviation that is likely related Eligibility criteria
to the individual’s symptoms may be more effective to
restore normal scapular motion. A physical therapist with seven years of clinical experience
The movement-based classification system follows the will screen eligibility of potential participants, according to
kinesiopathologic model that creates a diagnostic classi- the following criteria: individuals of both sexes, between
fication related to the movement impairments that are 18---60 years old, with shoulder pain during arm eleva-
the cause of, or consequence of the patient’s pain or tion for at least 3 months and at least 3 points measured
dysfunction.34,35 This classification then leads directly to the using a 0 to 10-point Numerical Pain Rating Scale (NPRS),43
intervention approach (i.e. targeting to change the move- presence of scapular dyskinesis,44 positive Scapular Assis-
ment impairments). This model has been used to treat tance Test (SAT),45 and be able to elevate the arm at least
individuals with shoulder pain and showed positive effects 150◦ .
on pain,31,36 function,30---33 and scapular motion.33,37 How- Scapular dyskinesis will be assessed with the individu-
ever, the effects of movement-based approach on scapular als elevating both arms simultaneously to a 3-second count
kinematics and muscle activity have not been compared to using the ‘‘thumbs up’’, and then lowering to a 3-second
scapular strengthening and stretching exercises, which are count.44 At first, each individual will perform 5 repetitions of
frequently used in clinical practice for shoulder rehabilita- arm elevation in each plane (sagittal and frontal planes) with
tion and have effectively improved pain and function.21---23 In no weight in hands, followed by 5 more repetitions also in
addition, the assessment of fear avoidance and kinesiopho- each plane of arm elevation with weight in hands. The planes
bia is also important, as these aspects may play a role in the will be randomly chosen, and the weight will be deter-
symptoms, prognosis, and clinical conditions of individuals mined according to the body weight of the individual: 1.4 kg
with shoulder pain.38,39 for those weighing <68.1 kg, and 2.3 kg for those weigh-
ing 68.1 kg or more. Scapular dyskinesis will be considered
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Scapular Movement Training for Shoulder Pain 3
present when prominence of medial and/or superior scapu-

Table 1 Position of the EMG electrodes.
lar border, inferior scapular angles, rapid scapular downward
rotation, or excessive clavicular elevation could be observed Muscle Position of the electrode
in 3 of 5 trials. The interrater reliability of this test showed Upper Trapezius ∼2 cm laterally to the midpoint of a
an agreement between 75% and 82%, and kw from 0.48 to line from the C7 spinous process to
0.61.44 lateral edge of the acromion.48,68
The SAT will be performed as previously described46,47 Middle Trapezius Laterally to the midpoint of a line
and considered positive when pain intensity reduces 2 or from the T3 spinous process toward
more points on the NPRS during assisted elevation as com- the root of the spine of the scapula.19
pared to elevation with no assistance. Lower Trapezius Midpoint of a line from the T7
The exclusion criteria will be body mass index higher spinous process to the inferior angle
than 28 kg/m2 ,17 history of fracture and/or surgery in the of the scapula.19,68
shoulder region,26 history of shoulder dislocation and/or Serratus Anterior Mid-axillary line at the seventh rib
instability (positive apprehension test and/or sulcus test) level with shoulder abducted at
and/or massive rotator tears (positive drop-arm test),26 90◦ .68,69
pregnancy,26 adhesive capsulitis, numbness or tingling of
the upper limb reproduced by the cervical compression
test or upper limb tension test,26 systemic or neurologic
illness,26 corticosteroid injection within 3 months prior to tation of each sensor will be tracked simultaneously at a
the intervention, physical therapy within 6 months prior to sampling rate of 100 Hz. The 3-dimensional scapular track-
the intervention,26 and self-reported tape allergy. All eli- ing methodology is described elsewhere.42 This procedure
gible individuals will receive information about the study has been shown to be reliable over time during elevation
from one of the researchers, and those who accept to and lowering of the arm in individuals with shoulder pain
participate will sign an informed consent form before par- with intraclass correlation coefficient (ICC) ranging between
ticipation. 0.54 and 0.85, standard error of measurement between 3.6◦
Individuals will be discontinued from the study if they and 7.4◦ , and minimal detectable change between 8.4◦ and
present fractures, surgeries, musculoskeletal injuries, neu- 17.2◦ .42 The 3-D scapular kinematics and EMG data will be
rological diseases, other injuries that prevent attendance at collected during three cycles of arm elevation and lowering,
sessions, or receive a corticosteroid injection at the shoul- with duration of approximately 3 s for each phase, in the
der complex during the treatment or follow-up periods. sagittal, scapular, and frontal planes, and with individuals
Individuals excluded, discontinued, or who complete study standing in front of the transmitter.42
follow-up with remaining shoulder symptoms will receive
written and verbal information about shoulder pain mana-
Muscle activity
gement and exercises.
Muscle activity of the UT, MT, LT, and SA will be mea-
sured during elevation and lowering of the arm using Trigno
Procedures TM Mobile System, DelSys® , Boston, USA. Electromyogra-
phy (EMG) electrodes will be attached to the individual’s
Individuals will be recruited through flyers placed at the skin using double-sided tape. Position of each electrode is
University buildings, local orthopedic clinics and commu- described on Table 1.
nity public places located in Universidade Federal de São For normalization of the data, a reference submaximal
Carlos. Advertisements in local newspapers and radio, and contraction will be collected at 90◦ of arm elevation in the
online resources (eg, university intranet and social media) scapular plane19 with the individual holding an 1 kg dumb-
will also be used to recruit patients. bell for 5 s.48 Two trials will be collected with 1 min of rest
Included participants will undergo a baseline assessment in between.19 The weight and duration for the submaximal
prior to randomization. Outcomes will be collected at each contractions was based on a previous study.48
time point according to Fig. 1. The most self-reported EMG signals acquisition will be synchronized with scapu-
painful shoulder will be considered for all outcome measures lar kinematics (MotionMonitor® ) at 2000 Hz and a voltage
in those with bilateral symptoms. gain of 1000. Data will be processed using Matlab (version
2015, The Mathworks Inc., Natick, MA, USA), filtered with
Outcome measures a 6th order zero-lag Butterworth filter in the 20−450 Hz
band, and a notch filter centered on 60 Hz and harmonics.
Signals will be converted into root-mean-square using 100
The primary outcome measures will be 3-D scapular kine-
millisecond moving windows with overlap of 99.5%, and nor-
matics. The secondary outcome measures will be scapular
malized as a percentage of the average of the reference
muscle activity, pain, disability, fear avoidance beliefs, and
contractions.48
kinesiophobia.
Three-dimensional scapular kinematics Pain scores

The TrakSTAR hardware (Ascension Technology Corporation, Shoulder pain at rest and during arm elevation and the
Burlington, VT) integrated with the MotionMonitor software worst and the least pain during the past week will be
(Innovative Sports Training, Inc, Chicago, IL) will be used to assessed with the NPRS, which is a valid and reliable scale
assess 3-D scapular kinematics. The 3-D position and orien- for individuals with shoulder pain. The minimal clinically
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Recruitment approaches
Enrollment Assessment for eligibility
Outcome Measures
Informed consent
• 3-D Scapular Kinematics
• Muscle activity
• Pain
Baseline data collection (n = 64) • Disability
• Fear Avoidance Beliefs
• Kinesiophobia
Randomization (n = 64)
Allocation
Scapular Movement Training Standardized Exercises Group

Group (n = 32) (n = 32)
• Pain 4
th
week • Pain
• Disability • Disability
• Fear Avoidance Beliefs • Fear Avoidance Beliefs
• Kinesiophobia • Kinesiophobia
• 3-D Scapular Kinematics • 3-D Scapular Kinematics

• Muscle activity th
• Muscle activity
• Pain 8 week • Pain
• Pain th • Pain
12 week
(follow-up)
Intention to treat analysis Intention to treat analysis
Figure 1 Study flow diagram.
important difference (MCID) is 2 points or a 30% change Fear-avoidance beliefs

score.49,50 Fear-Avoidance Beliefs will be assessed with the Brazil-
ian version of Fear-Avoidance Beliefs Questionnaire.53 This
questionnaire is divided in two subscales: physical activ-
Disability of the upper limb
ity and work. The score of the physical activity subscale
Disability of the upper limb will be assessed with the Brazil-
ranges from 0 to 24, and the work subscale ranges from 0
ian version of Disabilities of the Arm, Shoulder and Hand
to 42.53 Higher scores of this questionnaire indicate worse
(DASH), which is valid and reliable to assess individuals with
conditions. The Brazilian version was shown to be reliable
upper limb disorders.51 Final score ranges from 0 to 100,
for test-retest.53
where higher scores indicate higher disability. The MCID is
10.8 points.52
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Kinesiophobia Blinding
The Brazilian version of the Tampa Scale for Kinesiophobia
will be used to measure kinesiophobia.54 The score ranges The assessor and the statistician will be blinded to treat-
from 17 to 68 points, where higher scores indicate worse ment group assignment. Patients will be treated individually
conditions. This version of the scale was considered reliable and blinded to the study hypothesis.57 Circumstances that
for test-retest.54 unblinding is permissible have not been planned.
Global rating of change scale

The individual’s perception of improvement/deterioration Interventions
over time will be measured with the Global Rating of Change
Scale. They will be asked to rate the overall change in Individuals of both groups will attend 16 individualized treat-
their shoulder condition from baseline evaluation. This scale ment sessions, at a frequency of twice a week for 8 weeks,
ranges from −7 to 7, where positive and higher scores indi- with at least one-day interval between sessions. If the par-
cate higher perception of health improvement, negative and ticipants miss a treatment session, it will be rescheduled.
lower scores indicate worsening of health perception, and The estimated duration of each treatment session will be
zero means no change.55 45−60 min. The therapist will manage symptoms by applying
ice or reducing active trigger points through deep fric-
tion in the deltoid and upper trapezius as necessary.58,59
Random allocation Two physical therapists will be responsible for delivering
the interventions. The therapist who will be in charge of
Patients will be randomly assigned to one of the two groups: the scapular movement training has 10 years of clinical
Scapular Movement Training Group or Standardized Exer- experience, and specializations in sports rehabilitation and
cises Group. Randomization will be computer-based and manual therapy. The therapist who will be in charge of the
conducted at a 1:1 ratio according to a random sequence standardized exercises group has five years of clinical expe-
generated by the website http://www.randomization.com, rience, and residency in orthopedics rehabilitation. Both
stratified by age (< or ≥50 years)56 and sex (female or therapists will receive 6 h training about shoulder rehabil-
male). An independent researcher, not involved in the treat- itation and scapula movement impairments by the principal
ment or assessment, will perform the randomization process investigator. To improve adherence to the protocol, parti-
and prepare the consecutively numbered sealed opaque cipants retention and complete follow-up, the participants
envelopes with group allocation. The envelopes will be will receive face-to-face adherence reminders in every ses-
securely stored and will be opened in sequence to reveal sion, and/or cellphone reminders or text messages. We
group allocation prior to the first treatment session by the have not planned any change on the intervention proto-
researcher responsible for the treatments. cols.
Figure 2 Planned intervention for Scapular Movement Training Group.
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Scapular movement training group to perform the exercises and if it would be possible to
The scapular movement training will be divided in two increase the level of resistance. Three sets of 10 repeti-
phases: educational phase in the first week of treatment tions for each exercise will be completed, with 1 min of
and scapular movement training phase during the remaining rest between sets. The following exercises will be per-
weeks (Supplemental material online and Fig. 2). formed: prone extension,63 prone horizontal abduction with
In the educational phase, instructions about proper external rotation,63 serratus punch,64 and side-lying exter-
scapular position in the rest position and during arm ele- nal rotation.63
vation, as well as muscle activation during elevation of the
arm will be delivered to each individual (Fig. 2). The instruc-
tions will be reinforced with verbal, tactile, and visual Data management
feedback with the aid of a mirror, anatomical models, and
EMG. During the pilot of this study, the ability to learn Data about recruitment, characteristics of the individuals
and control scapular motion and muscle contractions var- who will complete or dropout of the study, as well as the
ied between individuals. Therefore, it would not be possible outcome measures will be stored in a secure place at Uni-
to standardize the number of repetitions and movements versidade Federal de São Carlos. All data will be entered into
for all participants during the educational phase. Detailed a computer software (ExcelTM Microsoft, 2016) and weekly
information of the treatment protocol is described in Sup- double-checked by an assistant, using standard coding to
plemental online material.30---33,37,60 Fig. 2 displays a diagram ensure the confidentiality of the participants. Also, only the
of the approaches based on the scapular movement impair- researchers involved in this study will have access to the
ments. database.
Scapular movement training phase: This phase will aim
to improve scapular movement pattern during arm eleva-
tion and during a functional activity relevant and chosen Statistical methods
by the patient. The exercises will be performed with slow,
conscious, and paced movements in 3 sets of 10---15 rep- Analysis of the effects of treatment
etitions, or until the individual report muscle fatigue.31,33 The statistical analysis will be performed using Statisti-
The exercises will progress in the following order accord- cal Package for the Social Sciences version 24.0 (SPSS Inc,
ing to the individual ability to control scapular movements Chicago, IL). Mean ± standard deviation (SD) values and 95%
and to reach full range of arm elevation: wall slide, arm confidence interval (CI) will be calculated for continuous
elevation with elbow flexion, arm elevation with elbow data. Data normality will be tested by visual inspection of
extension, and arm elevation against resistance. The ther- histograms and using the Shapiro-Wilkś test. The significance
apist will supervise all exercises to guarantee proper level will be 0.05 for all statistical analyses.
execution. The statistical analysis will follow the principles of
EMG biofeedback will be used in the education and train- intention-to-treat analysis. Three-D scapular kinematics,
ing phases. EMG sensors (Trigno TM Mobile System, DelSys® , scapular muscle activity, pain, disability, fear avoidance
Boston, USA) will be placed at the same muscles and posi- beliefs, and kinesiophobia will be the dependent variables.
tions as previously described to allow individuals to observe Data analysis for scapular orientation and muscle activity
their muscles activations. The EMG signals will be displayed will be performed for selected angles of humerothoracic
at real-time on a screen, showing amplitude (Y-axis) and elevation (30◦ , 60◦ , 90◦ , and 120◦ ) and lowering (120◦ , 90◦ ,
time (X-axis). The therapist will give verbal instructions and 60◦ , and 30◦ ). The between-group differences (treatment
tactile feedback to assist the individuals to increase SA, LT, effects) and their respective 95% CIs will be calculated by
and MT activation and decrease UT activation. As soon as multilevel linear mixed models.65 For kinematics and EMG
the individuals are able to control their scapular muscles by outcomes, longitudinal models will be constructed using
themselves the EMG biofeedback will no longer be used.32 fixed effects for group, angle, and group versus angle inter-
The individuals allocated in this group will not receive any action terms, with baseline values used as covariate to the
additional strengthening exercises or intervention targeting adjustment of the model. For clinical outcomes, models will
other impairments. be constructed using group, time, and interaction term of
group versus time as fixed effects. For all models, individuals
will be modeled as random effects. If the residual distribu-
Standardized exercises group tion violates the assumptions for the mixed linear models,
This group will perform stretching and strengthening exer- data will be analyzed using repeated measures Analysis
cises commonly used to treat individuals with shoulder pain of Variance (ANOVA). If data are not normally distributed,
(Appendix A, Supplementary data).26,61 The self-stretching statistical analysis will be performed using non-parametric
exercises will address the UT,26 pectoralis minor,25 and pos- correspondent tests.
terior shoulder.62 Each stretch will consist of 3 repetitions
of 30 s, with an interval of 30 s between repetitions.
The strengthening exercises will be performed using Data monitoring
elastic resistance bands (Theraband ® ) with 4 progressive
levels of resistance: red, green, blue, and gray. The resis- An independent researcher will monitor data collection
tance will be progressed through the colors when the sets progress and safety. No interim analyses have been planned.
are performed easily (with no muscle fatigue reported by Data will be analyzed when all recruitment and data collec-
the individual).26 The therapist will ask the level of effort tion are done.
+Model
Harms focused approaches. Moreover, we believe that this study

will contribute to the evidence-based practice of scapu-
All self-reported adverse effects will be registered by the lar focused-approach in individuals with shoulder pain and
therapists and/or assessor and reported to the Human scapular dyskinesis.
Research Ethics Committee from Universidade Federal de Unfortunately, due to the nature of the interventions, we
São Carlos, São Carlos, São Paulo, Brazil. Use of pain med- will not be able to blind therapists and patients for treat-
ication, ice, and hot pack during of the study will also be ment allocation. Furthermore, effective dosages of exercise
recorded. interventions and movement training are unknown, and the
criteria of assessments for specific movement pattern devia-
Auditing tions are not well established in the literature. Deep friction
will be used when myofascial trigger point is found on the
An independent researcher will monitor the progress of the upper trapezius and deltoid. However, it may systemati-
study every 6 months, and audit the quality and complete- cally influence the pain and muscle stiffness of both groups.
ness of the data, and verify if all steps of the protocol is Finally, this study will treat individuals with chronic shoulder
being followed as planned. pain, scapular dyskinesis, and positive scapular assistance
test, and the findings of this study might not be applicable
Ethics for individuals with different characteristics.
This protocol was approved by the Human research Ethics

Committee of the Universidade Federal de São Carlos (CAAE:
Conflict of interest
86974318.7.0000.5504). Any protocol modifications will be
reported to the Human research Ethics Committee and to The authors have no conflicts to disclose.
the trial registry.
Acknowledgements
Dissemination policy
The trial was supported by the São Paulo Research
The study will be disseminated through publication in jour- Foundation (Grant 18/07571-7, Fellowship 2018/04911-1),
nals, as well as presentations in conferences. The data of Coordenação de Aperfeiçoamento de Pessoal de Nível
this study will be shared under reasonable request. The Superior - Brasil (CAPES), and Conselho Nacional de Desen-
researchers that substantively contribute to the design, con- volvimento Científico e Tecnológico - CNPq (142373/2018-4).
duct, interpretation, and reporting of a clinical trial will be
considered an author on the final study. Appendix A. Supplementary data
Discussion Supplementary material related to this article can be found,

in the online version, at doi:https://doi.org/10.1016/
Although physical therapy is the first recommended treat- j.bjpt.2020.08.001.
ment to patients with shoulder pain, the rate of full recovery
of these patients is still far from ideal.1,66,67 If the scapu- References
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BJPT-305; No. of Pages 10 ARTICLE IN PRESS

CLINICAL TRIAL PROTOCOL

Scapular movement training versus standardized

13565-905, São Carlos, SP, Brazil.

Introduction The objective of this study will be to compare the effects

present when prominence of medial and/or superior scapu-

Three-dimensional scapular kinematics Pain scores

Enrollment Assessment for eligibility

Scapular Movement Training Standardized Exercises Group

• 3-D Scapular Kinematics • 3-D Scapular Kinematics

Intention to treat analysis Intention to treat analysis

Figure 1 Study ﬂow diagram.

important difference (MCID) is 2 points or a 30% change Fear-avoidance beliefs

Global rating of change scale

Figure 2 Planned intervention for Scapular Movement Training Group.

Harms focused approaches. Moreover, we believe that this study

This protocol was approved by the Human research Ethics

Discussion Supplementary material related to this article can be found,

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