Chronic low back pain changes the latissmus dorsi and gluteus maximus muscles activation pattern and upward scapular rotation: A cross-sectional study

Abstract

BACKGROUND:

Patients with chronic low back pain (LBP) have an impaired dynamic spinal stability, which may lead to arm injuries.

OBJECTIVES:

To examine the latissimus dorsi and gluteus maximus muscles activation pattern and the upward scapular rotation in patients with chronic LBP.

METHODS:

Sixty-one right-handed males were divided into two groups: chronic LBP group ( $n=$ 31) and healthy controls ( $n=$ 30). The electromyography (EMG) activities of the right and left latissimus dorsi and gluteus maximus were recorded. The upward scapular rotation in different shoulder positions (neutral, 45 ${}^{\circ}$ , 90 ${}^{\circ}$ , 135 ${}^{\circ}$ abduction and end range) was measured in both groups.

RESULTS:

The LBP group has a bilateral significant increased EMG of latissimus dorsi ( $p<$ 0.05) and significantly decreased EMG of gluteus maximus ( $p<$ 0.05) compared to the control group, without significant differences between the right and left sides ( $p>$ 0.05). There was a significant increase in upward scapular rotation in the LBP group relative to the control group in all shoulder abduction positions on both sides. The left side upward scapular rotation was more significant than the right ( $p<$ 0.05).

CONCLUSION:

Chronic LBP increased the latissimus dorsi muscle activities and decreased the gluteus maximus activities. It furthermore increased the upward scapular rotation in different shoulder abduction positions.

Keywords

Lumbopelvic muscles low back pain electromyography scapula shoulder

1. Introduction

Nonspecific chronic low back pain (LBP) is one of the most prevalent musculoskeletal problems affecting most ages and genders. Most patients have chronic pain that lasts more than three months, limiting their activities and forcing them to miss work [1]. Chronic LBP is expressed as LBP not related to an exact disease such as inflammatory disorder, osteoporosis, fracture, structural deformity, radicular syndrome, cauda equina syndrome, or a tumor [2].

One of the common causes of chronic LBP is the trunk and hip muscles strength and length imbalance [3]. Various factors associated with chronic LBP, such as changes in motor control and muscular recruitment have been the primary concern of chronic LBP treatments within the past decade [4, 5]. Patients with chronic LBP experienced irregular adaptations that resulted in movement and control impairments, leading to either excessive or impaired dynamic spinal stabilization and loading, which causes pain [6]. The muscles and joints of the lumbopelvic region provide proximal stability to allow optimum force production and transmission for distal mobility of extremities through a kinetic chain. Thus, insufficient support of the trunk and lower extremities may affect arm injuries through breakage in the kinetic chain [7, 8].

The muscle chains are connected through myofascial slings, which maintain trunk stability and force transmission from the lower to the upper limbs during movement [9]. Muscle imbalance and pain produced due to sling muscle injury will irritate the trigger points. The posterior oblique myofascial sling, composed of the erector spinae latissimus dorsi, gluteus maximus, and hamstring muscles plays a critical role in trunk extension [9, 10, 11]. Moreover, the latissimus dorsi muscle acts as a synergist to the gluteus maximus muscle through the thoracolumbar fascia [12].

During the prone hip extension (PHE) test patients with chronic LBP had greater muscular activation of latissimus dorsi muscle [9]. When the control gluteus maximus to the lumbopelvic area is decreased, the contralateral latissimus dorsi muscle may be activated to compensate for gluteus maximus insufficiency and spinal instability [9, 12]. Furthermore, there is more significant pelvic motion and less lumbar motion during forward bending. Moreover, there is bilateral reduction in the gluteus maximus muscle and a significant association between ipsilateral erector spinae muscle function and lumbar activity in patients with chronic LBP [13].

Scapular dyskinesia is related to the increased latissimus dorsi stiffness. The latissimus dorsi stiffness increases the upward scapular rotation and posterior tilt; however, scapular internal scapular rotation decreased during humeral elevation [14]. Since the latissimus dorsi is attached to the inferior border of the scapula, its stiffness affects scapular motion [9]. Moreover, Taghizadeh et al. [15] found an increasing scapular rotation in a patient with chronic LBP at the neutral position and shoulder at 40–45 ${}^{\circ}$ abduction.

The relationship between scapular position and electromyography (EMG) of lumbopelvic muscles, especially the latissimus dorsi and gluteus maximus, must be identified. Therefore, this study was set to examine the latissimus dorsi and gluteus maximus muscles activation pattern and upward scapular rotation in male patients with chronic LBP. It has been hypothesized that there was no effect of chronic LBP on scapular positions and EMG of latissimus dorsi and gluteus maximus muscles of the right and left side.

2. Materials and methods

2.1 Participants

A total of 61 right-handed male participants (mean age 22.47 $\pm$ 1.75 years; range, 21 to 26 years) participated in this cross-sectional study. The study was conducted between June and September 2018. The inclusion criteria were: age ranged from 20–40 years old, chronic LBP which sustained form more than $>$ 3 months [16], and body mass index (BMI) less than 30 [9]. The subjects were excluded if they had persistent pain more than 8 based on a visual analogue scale (VAS) [17], a history of any shoulder pathology or surgery, leg limb discrepancy, thoracic or shoulder girdle pain, congenital pathology affecting spine or shoulder, any neurological disorder, non-mechanical LBP (e.g., fracture, malignancy, infection, spinal dislocation) and BMI 30 or higher, as fat tissue may decrease the ability to measure surface EMG activity [9, 15, 18], or if they participated in a rehabilitation program. The sample size was calculated using G Power 3.1 software (University of Dusseldorf, Dusseldorf, Germany), with a one-tailed comparison of the difference between two dependent means. The sample size was determined as 31 participants according to $\alpha=$ 0.05, power $=$ 0.85 and effect size $=$ 0.50, which was larger than the related similar studies [13, 15, 16, 18, 19, 20, 21]. The demographic characteristics of the participants are shown in Table 1.

The participants were divided into two groups: those with chronic LBP (LBP group, $n=$ 31) and healthy controls (control group, $n=$ 30). The control group included healthy males who were matched to the LBP group. The control group participants had no musculoskeletal, or neurological problems, no previous history of trauma or pain or surgery to the back. Besides, they had a VAS score of 0 for the back on the testing day and at least a week before. The recruitment, assignment, and progression of the participants through the study are shown in Fig. 1.

Figure 1.

The participants’ flowchart.

The study followed the principles of the Declaration of Helsinki and each participant signed an informed consent form. The ethical committee of the Faculty of Physical Therapy, Cairo University approved the current research work (No. P.T. REC/012/002035).

2.2 Procedures

Before baseline measurements, the subjects were given a full explanation of the study protocol, scapular movement, and contraction of latissimus dorsi and gluteus maximus muscles. Then, the subjects were asked to perform each movement.

2.2.1 Electromyography recording

The EMG surface device (MyoTrac Infiniti, model SA9800, Canada) was a modular EMG data collection system. The system offers dual channels to assess the ipsilateral gluteus maximus and contralateral latissimus dorsi muscles EMG during the PHE test for both sides [19].

The PHE test is a widely used and recognized method of determining lumbopelvic stability and the muscle recruitment pattern of the posterior oblique sling muscles in chronic LBP patients. Muscle activity pattern during PHE test has been theorized to be similar to those muscles activated during gait and changes in this pattern may decrease lumbopelvic stability during walking [6, 9, 16, 22].

Before placement of the electrodes, the skin was cleaned with isopropyl alcohol 70% to remove excess oils and debris, and shaved (if required). The active and reference electrodes were stuck in the muscle belly parallel to muscle fibers and away from the tendon and muscle edges. The ground electrode was placed on any bony prominence distal to the other electrodes [19].

For the latissimus dorsi muscle, the active electrode was stuck 4 cm below the inferior angle of the scapula, mid the distance between the vertebral column and the lateral edge of the torso. The reference electrode was mounted next to the active electrode, parallel to the muscle fibers, and at a distance equal to the electrode scale. The ground electrode was placed distally on the acromion process (Fig. 2A) [9].

Figure 2.

A. Electrodes placement for EMG of latissimus dorsi muscle. B. Electrodes placement for EMG of gluteus maximus muscle.

For the gluteus maximus muscle, the active electrode was stuck in mid-distance between the greater trochanter and 2 ${}^{\text{nd}}$ sacral vertebra slightly above the level of the greater trochanter. The reference electrode was mounted next to the active one, parallel to the muscle fibers, and at a distance equal to the electrode’s size. The ground electrode was placed distally on the greater trochanter (Fig. 2B) [19].

All participants were informed about the PHE test procedure before testing. The EMG measurements were conducted while the participants lay prone on a plinth with a firm mattress. The participants lay prone with their arms beside their trunk, and maintained their pelvis and hip joint in neutral positions. A universal goniometer was used to set the degree of hip extension at 10 ${}^{\circ}$ ; an adjustable bar was fixed at the level of 10 ${}^{\circ}$ hip extension to avoid undesirable movement. Verbal instructions were also given to the participants as a feedback about the 10 ${}^{\circ}$ of hip extension.

Figure 3.

Prone hip extension test.

The participants were instructed to keep the knee extended and extend their hip from the neutral to 10 ${}^{\circ}$ extension position (Fig. 3). The participants were then told to hold this position for five seconds. The trial was excluded if the examiner observed changes in the neutral pelvis position, hip extension, knee extension position, and hip or pelvic rotation. The system automatically measured three trials, each lasting five seconds with a five-second rest in between. Then, the average value was calculated. The root mean square (RMS) was calculated after signals amplification. The average RMS was calculated as a percentage of the normalized value chosen for EMG data analysis during each trial [9].

The maximum voluntary isometric contraction (MVIC) method was used to normalize the RMS value of the latissimus dorsi muscle. The participants lay in a prone position with the upper extremity suspended on the plinth side and were asked to flex their elbow to 90 ${}^{\circ}$ and extend their shoulder until their arm was parallel to the trunk. The examiner then instructed the participants to perform shoulder abduction and extension to apply maximum resistance to the distal humerus. At the same time, another examiner stabilized the ipsilateral scapula and contralateral pelvic (Fig. 4A) [23].

Figure 4.

A. Normalization of the RMS values of latissimus dorsi muscle. B. Normalization of the RMS values of gluteus maximus muscle.

The submaximal isometric contraction method was used to normalize the RMS value of the gluteus maximus muscle. The participants were asked to lift both knees 5 cm above the plinth and keep this position for five seconds while lying down with their knees flexed at 90 ${}^{\circ}$ . It was recommended to avoid the gluteus maximus muscle’s maximal contractions because pain during testing would invalidate the RMS values to be used for normalization (Fig. 4B) [24].

2.2.2 Scapular upward rotation

The Plurimeter-V gravity Inclinometer (Baseline 12-1056 bubble inclinometer, USA) was used as an effective and reliable tool for measuring the upward scapular rotation in all shoulder abduction ranges in the frontal plane [25].

The degree of upward scapular rotation was measured by using two inclinometers. The first inclinometer was taped vertically to the arm, just above the humerus’s lateral epicondyle. The participants were asked to abduct their shoulder with complete elbow extension and neutral wrist position while the examiner registered the humeral resting position. The participants were instructed to stop the movement at 45 ${}^{\circ}$ , 90 ${}^{\circ}$ , 135 ${}^{\circ}$ abduction, and at the maximum abduction position. The thumb was used as a reference landmark to ensure that the inclinometer was vertically balanced. For each of these positions, the upward scapular rotation was measured by the second inclinometer, which was manually aligned along the scapular spine (Fig. 5) [26].

Figure 5.

Measurement of upward rotation of the scapula.

2.3 Statistical analysis

Statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSS; IBM Corp., Armonk, NY, USA) version 24 for Windows. The data were normally distributed as indicated by non-significant values of the Shapiro-Wilk normality test ( $p>$ 0.05). So, the parametric analysis of the measured outcomes was conducted. An independent $t$ -test was used to identify any significant difference in the demographic characteristics between both groups. A two-way analysis of variance (ANOVA) was performed to compare the normalized RMS values (%) of the latissimus dorsi, gluteus maximus muscle, and the upward scapular rotation bilaterally of both groups. The alpha level ( $p$ -value) of significance was set at less than 0.05.

3. Results

As shown in Table 1, the difference in mean age, weight, height, or BMI between the two groups was non-significant ( $p=$ 0.077, 0.902, 0.413, 0.444, respectively).

The RMS values of the latissimus dorsi muscle of the LBP group were significantly higher than those of the control group on both sides ( $p=$ 0.001). However, the RMS values of the gluteus maximus muscle of the LBP group were significantly lower than those of the control group on both sides ( $p=$ 0.001). There were no significant differences between the right and left latissimus dorsi muscles ( $p=$ 0.256, 0.464) and gluteus maximus muscles of both groups ( $p=$ 0.543, 0.923 respectively), as shown in Table 2.

Table 1
Demographic characteristics of the participants

	LBP group, $n=$ 31	Control group, $n=$ 30	$p$ value
Age, years	22.87 $\pm$ 1.48	22.07 $\pm$ 1.93	0.077
Height, cm	169.73 $\pm$ 5.84	171.00 $\pm$ 6.05	0.413
Weight, kg	70.94 $\pm$ 7.39	70.66 $\pm$ 9.95	0.902
BMI (kg/m ${}^{2}$ )	24.62 $\pm$ 2.19	24.12 $\pm$ 2.77	0.444

Data are presented as mean $\pm$ standard deviation, ${}^{*}$ significantly ( $p<$ 0.05).

Table 2

RMS of latissimus dorsi and gluteus maximus muscles

Variables	LBP group, $n=$ 31	Control group, $n=$ 30	$p$ value
Latissimus dorsi
Right side	88.09 $\pm$ 13.96	46.96 $\pm$ 20.36	0.001 ${}^{*}$
Left side	85.25 $\pm$ 16.59	45.14 $\pm$ 18.40	0.001 ${}^{*}$
$p$ value	0.256	0.464
Gluteus maximus
Right side	48.24 $\pm$ 15.92	95.48 $\pm$ 4.48	0.001 ${}^{*}$
Left side	46.57 $\pm$ 18.94	95.22 $\pm$ 4.24	0.001 ${}^{*}$
$p$ value	0.543	0.923

Data are presented as mean $\pm$ standard deviation, ${}^{*}$ significantly ( $p<$ 0.05).

Table 3

Scapular upward rotation values from different shoulder abduction positions

Variables	LBP group, $n=$ 31	Control group, $n=$ 30	$p$ value
Neutral position
Right side	7.33 $\pm$ 2.04	9.07 $\pm$ 1.05	0.001 ${}^{*}$
Left side	8.60 $\pm$ 2.09	9.93 $\pm$ 0.37	0.001 ${}^{*}$
$p$ value	0.001 ${}^{*}$	0.021 ${}^{*}$
45 ${}^{\circ}$ abduction
Right side	11.70 $\pm$ 2.38	15.00 $\pm$ 0.00	0.001 ${}^{*}$
Left side	13.70 $\pm$ 3.35	18.67 $\pm$ 2.25	0.001 ${}^{*}$
$p$ value	0.042 ${}^{*}$	0.001 ${}^{*}$
90 ${}^{\circ}$ abduction
Right side	18.83 $\pm$ 4.49	27.83 $\pm$ 3.87	0.001 ${}^{*}$
Left side	21.67 $\pm$ 4.42	30.33 $\pm$ 3.20	0.001 ${}^{*}$
$p$ value	0.001 ${}^{*}$	0.003 ${}^{*}$
135 ${}^{\circ}$ abduction
Right side	25.83 $\pm$ 4.93	37.17 $\pm$ 4.49	0.001 ${}^{*}$
Left side	31.33 $\pm$ 4.90	39.17 $\pm$ 2.31	0.001 ${}^{*}$
$p$ value	0.001 ${}^{*}$	0.032 ${}^{*}$
Full abduction
Right side	36.00 $\pm$ 5.78	45.93 $\pm$ 3.57	0.001 ${}^{*}$
Left side	40.67 $\pm$ 4.69	49.13 $\pm$ 1.87	0.001 ${}^{*}$
$p$ value	0.001 ${}^{*}$	0.001 ${}^{*}$

Data are presented as mean $\pm$ standard deviation, ${}^{*}$ significantly ( $p<$ 0.05).

The upward scapular rotation of the right and left sides of the chronic LBP group were significantly lower than those of the control group in different shoulder abduction positions: neutral position, 45 ${}^{\circ}$ , 90 ${}^{\circ}$ , 135 ${}^{\circ}$ , and full abduction ( $p=$ 0.001). The left side scapular upward rotation was significantly greater than the right side in different shoulder abduction positions of the LBP group ( $p=$ 0.001, 0.042, 0.001, 0.001, 0.001, respectively) and control group ( $p=$ 0.021, 0.001, 0.003, 0.032, 0.001), as shown in Table 3.

4. Discussion

The present study revealed that the subjects with chronic LBP have bilateral increased EMG activities of latissimus dorsi muscle and decreased EMG activities of gluteus maximus muscle compared to healthy subjects without difference between the right and left sides. Moreover, there is an increased scapular upward rotation ROM of subjects with chronic LBP compared to healthy subjects with the left side scapular upward rotation ROM of both groups was more significant than the right side.

Changes in motor control due to chronic LBP may cause abnormality in muscle activation pattern, timing and rate of force development [6]. The muscles and joints of the lumbopelvic region provide proximal stability to allow optimum force production and transmission for extremity distal mobility through a kinetic chain. Insufficient support of the trunk may affect arm injuries through breaks in the kinetic chain [7].

In patients with chronic LBP, Taghizadeh et al. [15] observed an increased upward rotation of the scapula at neutral position and shoulder abduction of 40 ${}^{\circ}$ –45 ${}^{\circ}$ relative to healthy subjects. This could be explained by the thoracolumbar fascia’s connection to the internal and external oblique, transverse abdominis, latissimus dorsi, and gluteus maximus muscles. This connection distributes the loads between upper and lower limbs [10]. Moreover, the attachment of latissimus dorsi muscle to the inferior angle of the scapula helps this action [14]. So, the latissimus dorsi muscle’s increased activity leads to a difference in the scapular position in patients with chronic LBP. However, they did not record a change in the scapular position in 90 ${}^{\circ}$ shoulder abduction, which disagreed with the current results, which may be due to using different tests in assessing the scapular position (Lateral scapular slide test and Lennie test) [15, 27].

These findings are in line with those of the previous study that demonstrated a significant increase in latissimus dorsi muscle activation in women with chronic LBP, compared to healthy women during the PHE task [9]. This can be attributed to the ability of healthy women to stabilize the lumbopelvic region more efficiently than women with chronic LBP. Increased latissimus dorsi muscle activation is required to complete the task. As the gluteus maximus muscle on one side fails to control the pelvis during PHE, the thoracolumbar spine rotates to the opposite side. As a compensatory mechanism for that faulty movement, the contralateral latissimus dorsi muscle’s over-activation may execute during the PHE task [28, 29].

Furthermore, the increased EMG activity of the latissimus dorsi muscle is coincident with the findings of Masaki et al. [30], who reported that the activity of latissimus dorsi muscle increased in patients with LBP, enhancing the compressive and shear stress on the intervertebral disks and leading to a recurrence of LBP symptoms. Moreover, the increased latissimus dorsi muscle activation attached to the lower tip of the scapula affects the scapula’s upward rotation position. It pulls the inferior tip of the scapula superiorly and laterally during arm elevation (increased upward rotation), which inserts into the humerus [15].

However, the findings of the current study do not support the previous research, which demonstrated no major differences in latissimus dorsi muscle EMG activity while lifting bags in several different conditions in female students with chronic LBP [27]. This may be due to the use of a different task to measure the latissimus dorsi muscle’s activity level. On the other hand, the present findings are in keeping with this previous study, which shown no differences in latissmus dorsi muscles EMG activity during lifting bags in many different conditions in female students with chronic LBP [27]. This may be attributed to use another task to assess the activity level of the latissimus dorsi muscle. This finding is contrary to previous studies, showing significantly lower endurance in back extensors in collegiate male athletes with LBP than healthy male athletes [31].

The decreased EMG activity of the gluteus maximus muscle may follow the pain adaptation model, predicting a reduction in the activity of the motor neuron output of agonist’s muscle due to pain (shorter muscle) and increased activity antagonist muscles (elongated muscle). This can, in turn, lead to a reduction in the MVC and range and velocity of movement. All these adaptations aim to protect the injured part against more injury [32, 33]. Furthermore, this finding supports a study that revealed a substantial reduction in concentric torque of hip extensor muscles in females with LBP compared to healthy subjects [20].

The results of Leinonen et al. [21], who observed the same result during forward bending in patients with chronic LBP, may explain the substantial reduction in gluteus maximus muscle function. They clarified that the pain caused the patients to stop using their back muscles during everyday activities, leading the back muscles, particularly the multifidus muscle, to atrophy. As a result, the gluteus maximus muscle, which functions in conjunction with the lumbar paraspinal muscles, is affected by this deconditioning state. Moreover, some research works found a significantly delayed onset of gluteus maximus muscle activity while performing PHE tests in patients with LBP compared to healthy individuals [18, 34, 35, 36].

These findings are also consistent with those Tateuchi et al. [37], who discovered a significant decrease in gluteus maximus muscle activation with the semitendinosus muscle during PHE caused by increased hip flexor activation, resulting in increased anterior pelvic tilting in healthy subjects. Their findings indicated an agonist and antagonist imbalance of the hip muscles. Moreover, there is an increased lumbopelvic motion due to the delayed trunk muscle onset [37]. Wattananon et al. [13] observed a similar result to the current study despite their limited sample size (8 subjects). They reported that chronic LBP leads to less bilaterally activation of the gluteus maximus muscle, associated with greater pelvic and less lumbar spine contribution to the forward bending task.

However, Himmelreich et al. [38] showed that the LBP is associated with changes in the amount and duration of gluteus maximus activation under different gait conditions (level ambulation, incline walking, and stair ascent). The alterations may be compensated to increase the lumbopelvic stabilization. There is an average increase in the gluteus maximus muscle activity of about 35% in incline walking and stair climbing in men with chronic LBP. Furthermore, Kim et al. [29] found that females with chronic LBP had significantly higher EMG activity of the gluteus maximus than healthy subjects during PHE, contradicting the current findings. The increased activity of the gluteus maximus muscle is needed to support the pelvic and thoracolumbar regions during the PHE task. There is a laxity in the ligaments supporting the pelvic in women with chronic LBP, explaining their results [29, 30, 39]. Their sample consisted of females, causing this contradiction, whereas in the current study only males were enrolled.

It was found that the left side (non-dominant) upward scapular rotation in different shoulder abduction positions, i.e. neutral position, 45 ${}^{\circ}$ , 90 ${}^{\circ}$ , 135 ${}^{\circ}$ and full abduction, were greater than the right side (dominant) for both groups. These results match previous studies that compared the range of motion of dominant and non-dominant sides of the upper and lower extremities [40]. They reported that the dominant side has 10 motions greater than the non-dominant side and the non-dominant side has other 24 motions greater than the dominant side. The passive glenohumeral internal rotation of the non-dominant side was 7.5 ${}^{\circ}$ greater than the dominant side. Moreover, it has been found that the dominant shoulder extension, internal rotation, and horizontal abduction were significantly better than the dominant shoulder in baseball pitchers [41].

This study is not without limitations. First, the assessment included only the latissimus dorsi and gluteus maximus muscles of the posterior oblique sling. Second, the position of the scapula could be altered by the erector spinae or hamstring muscles. Third, only adult male subjects with chronic LBP were recruited for the current study. Accordingly, the interpretation of the findings is limited to this specific population and cannot be generalized to other types of LBP, females, or elderly subjects. Future research is required to investigate the effect of lumbopelvic muscle activation patterns on lumbar and pelvic kinematics and the relationship between EMG activity pattern and the trunk extensors and trunk muscles strength endurance in patients with chronic LBP.

5. Conclusion

Chronic LBP leads to a bilateral increased EMG activity pattern of latissimus dorsi muscle and decreased EMG activities of gluteus maximus muscle than healthy males, without difference between the right and left sides. Moreover, males with chronic LBP had a bilateral increased scapular upward rotation compared to healthy subjects in different shoulder abduction positions. The left side rotation was more significant than the right side of both groups. These results should be taken into account in patients with chronic LBP and scapular dyskinesia when assessing and treating the lumbopelvic region. Moreover, clinicians should focus not only on the proximal cause of the lesion but also on the distal vital points that may affect the LBP prognosis.

Footnotes

Acknowledgments

The authors would like to acknowledge the participants of the study.

Conflict of interest

There are no conflicts of interest.

Funding

The authors received no financial support for this research.

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Chronic low back pain changes the latissmus dorsi and gluteus maximus muscles activation pattern and upward scapular rotation: A cross-sectional study

Abstract

BACKGROUND:

OBJECTIVES:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Participants

2.2.1 Electromyography recording

3. Results

Table 1 Demographic characteristics of the participants

5. Conclusion

Footnotes

Acknowledgments

Conflict of interest

Funding

References

Table 1
Demographic characteristics of the participants