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Thesis Title: Characteristics of Scapulothoracic Kinematics in A

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Thesis Title: Characteristics of Scapulothoracic Kinematics in A Refining scapulothoracic kinematic measurement and characterising scapulothoracic resting posture in those with and without chronic non-specific neck pain. Yaheli Bet-Or Master of Physiotherapy (Sport) Master of Physiotherapy (Musculoskeletal) Bachelor of Physiotherapy A thesis submitted for the degree of Doctor of Philosophy at The University of Queensland in 2017 School of Health and Rehabilitation Sciences i Abstract Neck pain is a common and recurrent condition affecting between 30 to 50% of adults in any given year. People experiencing neck pain commonly report difficulties in performing activities involving the upper extremity. Furthermore, clinical trials that have included exercises that target the shoulder girdle have shown beneficial effects in reducing neck pain. These observations are feasible based on the biomechanical dependence of the cervical spine and shoulder girdle, which includes common muscle attachments. However, to date there has been a paucity of studies investigating underlying movement disorders of the shoulder girdle in people with neck pain. This is in part due to the challenges of kinematic measurement in this region. The aim of this thesis is to contribute to the literature concerning the role of the shoulder girdle and thorax complex in neck pain from three perspectives. First, the thesis has further refined and informed measurement methods of shoulder girdle and thoracic kinematics (Studies 1-3). Secondly, the thesis further defined normative kinematics of the region with a focus on upright resting posture (Study 4). Thirdly, the thesis explored differences in shoulder girdle and thoracic resting posture in upright standing in those with and without neck pain (Study 5). Advancement in knowledge concerning normal and impaired function of the shoulder girdle has been hindered by challenges related to 3D motion capture of the shoulder girdle and thorax due to skin movement and the complexity of measuring multiple joints and axes of rotation. Therefore, Study1 focused on refining and validating an acromion marker cluster (AMC) method to track scapular movement with the intent of minimising skin movement error. Although the findings of Study 1 indicated that the refined AMC design did not appear to lessen skin movement error compared to previous designs, it was found to be of comparable accuracy (max RMSE 4.45°) and reliability to previous designs (within-session test-retest ICC 0.79-0.99) and appropriate for use in the subsequent thesis studies. In Study 2 the reliability and validity of the AMC method was further evaluated in its capacity to track the scapula at end range clavicular movements (protraction/retraction, elevation/depression). Establishing its measurement accuracy and reliability (max RMSE 6.6°) in these common directions of scapula motion was necessary as it had been previously unstudied. While Studies 1 and 2 focused on optimising the measurement of scapulothoracic kinematics by ensuring the scapula could be tracked accurately, Study 3 focused on refining the measurement of the relationship between the shoulder girdle and the underlying thorax. This study compared thoracic and shoulder girdle postural relationships expressed in the external reference frame to that expressed in the traditionally used ISB recommended thorax reference frame. Using these different frames of ii reference Study 3 also compared measures of thoracic inclination and thoracic curvature. The findings showed that measurements of thoracic inclination expressed in the external reference frame provided additional insight into scapulothoracic relationship compared to traditional measurements in the thorax reference frame. Study 4 then utilized the refined measurements of the scapula and thorax to more accurately describe normative shoulder girdle parameters, and to identify individual characteristics underpinning variations in these parameters, in a large cohort of asymptomatic individuals. This study demonstrated that scapular resting posture is strongly associated with thoracic inclination (scapular anterior/posterior tilt) and clavicular posture (scapular internal and upward rotation). Based on the results of Study 4, shoulder girdle resting posture and thoracic spine parameters were compared in individuals with (n=53) and without (n=100) chronic neck pain. The results presented in Study 5 show that mild differences in shoulder girdle and thoracic posture may exist between people with and without chronic non-specific neck pain. In summary, this thesis explores and improves upon the current methodology of investigating relationships between the thorax and shoulder girdle. It further defines normative characteristics of shoulder girdle kinematics and thus enabled comparison to a neck pain population. Understanding these relationships and the association between shoulder girdle function and neck pain will facilitate future development of patient-centred management approaches for those suffering with neck pain. iii Declaration by author This thesis is composed of my original work, and contains no material previously published or written by another person except where due reference has been made in the text. I have clearly stated the contribution by others to jointly-authored works that I have included in my thesis. I have clearly stated the contribution of others to my thesis as a whole, including statistical assistance, survey design, data analysis, significant technical procedures, professional editorial advice, and any other original research work used or reported in my thesis. The content of my thesis is the result of work I have carried out since the commencement of my research higher degree candidature and does not include a substantial part of work that has been submitted to qualify for the award of any other degree or diploma in any university or other tertiary institution. I have clearly stated which parts of my thesis, if any, have been submitted to qualify for another award. I acknowledge that an electronic copy of my thesis must be lodged with the University Library and, subject to the policy and procedures of The University of Queensland, the thesis be made available for research and study in accordance with the Copyright Act 1968 unless a period of embargo has been approved by the Dean of the Graduate School. I acknowledge that copyright of all material contained in my thesis resides with the copyright holder(s) of that material. Where appropriate I have obtained copyright permission from the copyright holder to reproduce material in this thesis. iv Publications during candidature Peer-reviewed papers Bet-Or, Y., van den Hoorn, W., Johnston, V., O'Leary, S.P., 2017. Reliability and Validity of an Acromion Marker Cluster for Recording Scapula Posture at End Range Clavicle Protraction, Retraction, Elevation and Depression. Journal of Applied Biomechanics 1-19 Conference abstracts Bet-Or, Y., Johnston, V., van den Hoorn, W., O’Leary, S., 2016. Is there a difference in scapula kinematics between people with and without chronic neck pain? In Proceedings of the School of Health and Rehabilitation Science Postgraduate Research Conference 2016. University of Queensland, Queensland. Bet-Or, Y., O’Leary, S., van den Hoorn, W., Johnston, V., 2017. The influence of thoracic inclination, gender, BMI, hand dominance, and age, on the resting posture of the clavicle and scapula in healthy individuals. In Proceedings of The XXVI Congress of the International Society of Biomechanics (ISB) Conference, Brisbane, 2017. Bet-Or, Y., van den Hoorn, W., Johnston, V., O’Leary, S., 2017. Factors influencing resting posture of the shoulder girdle in asymptomatic individuals. In Proceedings of the Australian Physiotherapy Association (APA) Conference, Sydney 2017. v Publications included in this thesis Incorporated as Chapter 4 Bet-Or, Y., van den Hoorn, W., Johnston, V., O'Leary, S.P., 2017. Reliability and Validity of an Acromion Marker Cluster for Recording Scapula Posture at End Range Clavicle Protraction, Retraction, Elevation and Depression. Journal of Applied Biomechanics 1-19. Contributor Statement of contribution Yaheli Bet-Or Study design (70%) Participant recruitment (100%) Data collection (100%) Data processing (80%) Statistical analysis (80%) Manuscript preparation and revision (60%) Dr Shaun O’Leary Study design (15%) Manuscript revision (20%) Statistical analysis (10%) Associate Professor Venerina Johnston Study design (15%) Manuscript revision (15%) Statistical analysis (10%) Wolbert van den Hoorn Data processing (20%) Manuscript preparation and revision (5%) vi Contributions by others to the thesis No contributions by others. Statement of parts of the thesis submitted to qualify for the award of another degree None. vii Acknowledgements First and foremost, I would like to express my sincere gratitude to my supervisory team: Associate Professor Venerina Johnston and Dr Shaun O’Leary, for guiding me through my candidature with patience, motivation, and advice. Venerina, your knowledge and experience, combined with kindness and encouragement were invaluable. You knew exactly when to cut to the chase and keep me on track. Shaun, your constant support, expert advice, and skilful guidance helped maintain the clinical relevance of my projects and were greatly appreciated (and many thanks for allowing me the use of your office!!!). I thank you both for your unflagging support throughout this very long process. I would also like to take the opportunity to thank Emeritus Professor Gwendolen Jull, who was another member
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