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1. Introduction

Currently, there is great concern in preventing avariety of diseases and injuries involving theshoulder joint due to postural changes that leadto the compensation system over thefunctionality [1].

The prevalence of shoulder pain accompanied by disability is present in about 20% of the population 2. The situations that overload in this joint complex is multifactorial [3].

It has been noted the importance of perceptionin health and quality of life for much of the

population, which is impaired, often by acuteand chronic musculoskeletal disorders [2,4].

The scapular motion, along with the movementof the humerus, allows a range of motion(ROM) in flexion or abduction of the arm 150 to 180 . The typical mobility in asymptomaticindividuals, usually occurs with two degrees of movement to a degree of glenohumeral scapular motion, which determines a ratio of 2:1 in therhythm scapulohumeral [5,6].

Several athletes and professionals who work with the upper limb (UL) have abducted a

greater predisposition to develop alterations inthe mobility-stability [7]. The professionalactivity of medical sonographer is characterized

by high probability of change in mobility-stability relationship. With the advent of newtechnologies and the recognition of thediagnostic capabilities of ultrasound, hasincreased every year, the number and durationof the implementation of ultrasonographic exam[8,9]. Despite the technological advances haveallowed high-resolution images, ergonomic

conditions for the exams is not all favorable tothe musculoskeletal system of ultrasonographer clinician [10].

The overload static and dynamic imposed onscapular girdle muscles and the upper end aredue to the maintenance needs of the shoulder inabduction for a better function of the wrist andhand for fixing the transducer perpendicular tothe skin of the individual over exam [2,8,10,11].

Impaired functionality of the individual and

removal of their daily activities leads to anoverload of health systems in different

countries. Ways to prevent and correct treatmentof an injury must be developed in order tominimize the consequences arising from thefunctional impairment of the individual.Therefore, the objectives of this study were toanalyze and measure the scapular positioningand correlating it to the inability of medical

professionals UL sonographers.

2. Methodology

2.1. Study design and Sample

Cross-sectional study. This study was approved by the Ethics and Research of Newton PaivaUniversity Center under number 40/2005.

The study included 18 volunteers, nine of thesymptomatic group (SG) and nine asymptomaticgroup (AG), aged between 27 and 52 years oldand sedentary. The working time ranged from18 months to 20 years and the number of tests

performed per day ranged from 10 to 30. The 18 participants were evaluated both shoulders (36shoulders). Of the participants in the SG, fivewere women (55.6%) and four were men(44.4%), with a mean age of 33.67 8.89 years

(27 to 52 years), body mass 69.66 13.10 kg(57.0 to 95.0 kg) and height of 1.73 0.07 m(1.63 to 1.83 m). The average body mass indexof the sample was 22.97 3.5 kg / m (19.14 to31.04 kg / m).

Of the participants in the AG, four were women(44.4%) and five were men (55.6%), with anaverage age of 38.78 7.79 years (30 to 49years), body mass 76.11 22.7 kg (49.0 to115.0 kg) and height of 1.69 0.07 m (1.54 to

1.85 m). The average body mass index of thesample was 26.17 6.5 kg / m (18.9 to 38.46 kg/ m).

2.2. Digital inclinometer

It was used Inclinometer Digital Protractor Mitutoyo (Mitutoyo Evaluation Instruments,Aurora, Chicago, IL) for measurement of scapular positioning. The two arms that have

been adapted in length (10.0 cm each), made of acrylic, for proper accommodation in the

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scapula and reading of degrees of inclination. Itwas engaged at a level of water perpendicular tothe equipment, to ensure correct alignment of the same for the evaluation plans. The validityand reliability of using the digital inclinometer,as a way of measuring scapular position wasdescribed by Johnson et al. [6].

2.3. Questionnaire Disability of the Arm,Shoulder and Hand of Brazil

We used the Disability Arm Shoulder HandQuestionnaire in Brazil (Brazil DASH),culturally adapted to Portuguese in Brazil byOrfale et al. [12]. This questionnaire, originallydeveloped in English and called DASHQuestionnaire was developed by Hudak et al. In

1996 with the aim of measuring the physicaldisability and symptoms of upper limbs in aheterogeneous population. Moreover, it was

proposed to evaluate disability and symptoms ina single or multiple disorders of the UL.

2.4. Functional Postural Analysis

To measure the angle of the MS functional, skinmarkers, made of acrylic, were placed onanatomical landmarks, using double-sided tape:the seventh cervical vertebra (C7), the seventh

thoracic vertebra (T7), acromion and lateralepicondyle. The registration of functional imageof the positioning was done using a digitalcamera Sony Mavica MVC-FD 200 (SonyElectronics, Inc., San Diego, CA).

2.5. Procedings

Initially, all volunteers were briefed about theobjectives and procedures, and signed a consent

form. Then, there was an individual interviewand a physical assessment with all participants.The examiners applied the questionnaire DASHBrazil and stored the data for later analysis.

With the subject seated, the assessor, properlytrained, the digital inclinometer placed on thespine of the scapula through the arms adapted tothe equipment for proper placement andaccommodation of the same anatomicalreference, the spine of the scapula on the edge

of the medial and inferior to the acromion.Another evaluator performed the reading andrecording the values observed in the resting

position of the MS (anatomical position), 30,60, 90 and 120 of shoulder elevation in thefrontal, scapular and sagittal. To ensure correct

positioning of the MS in these plans, a screenwas used to normalize the position of the MSduring the execution of the test.

Then, after measuring the angle of scapular skinmarkers were placed on anatomical landmarksto register the functional angle of the

positioning of the MS during the performance of ultrasound examination. The volunteer took the

position of functional assessment during thesimulation of ultrasound examination. Theimages were stored for later determination of the position angle of the MS to perform theexamination. We used the program AutoCAD

2004 (AutoCAD, Autodesk, Inc., SanRafael, CA) for analysis of the positioning of the MS. Lines were drawn joining the points of the T7 C7 and the acromion to the lateralepicondyle. The functional angle of positioningof the UL for the examination was determined

by the angle formed by these two lines.

3. Results

3.1. Variables Analyzed

a) Positioning of the UP Functional

The functional positioning of the UL showed nosignificant difference between the SG and AG(p = 0.765). The average angle of positioning of the MS GS during the simulation test was 51.78

15.11 degrees (38 to 78 degrees). The averageangle of positioning of the UL during thesimulation of AG test was 53.89 14.3 degrees(34 to 76 degrees).

b) Analysis of the DASH Brazil

Significant difference for the first 30 questions(p = 0.001) and the optional module of work (p= 0.012). The average of the first thirty issues of DASH Brazil for the SG, was 16.16 13.18

points (2.5 to 45.5 points) and fourth options,related to work, was 27.08 20 , 96 (0 to 56.25

points). The average of the first thirty issues of DASH Brazil, for the AG was 1.11 1.81

points (0-5 points) and four optional work-related was 4.16 8.83 points (0 to 25 points).

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c) Scapular Tilt

There was significant difference of 6.65 (p =0.016) and 5.87 (p = 0.033) of scapular inclination angle in the frontal plane at 90 and120, respectively, compared to the SG of theright shoulder to right shoulder the AG. Therewas also a significant difference of 4.43 (p =0.028) in AG, comparing the left shoulder over the right shoulder at rest (0) in the frontal plane.

4. Discussion

In this study, the positioning angle of the MSduring the simulation of ultrasound examinationshowed no significant differences between theSG and AG (p = 0.765). The SG had an averageof 51.78 (38 to 78) and an average AG of 53.89(34 to 76) of shoulder abduction.

It was observed that most of the ultrasoundclinics visited, the equipment used for the testfollowed a certain standardization in relation toergonomic height of the chair of the physician,the patient's height and litter away from themonitor. Despite this standardization is notideal, since each professional has a body type,this factor may have affected the angle of abduction between individuals.

Jakes [13] Muir [14] and demonstrated that theattitude of the MS to perform the professionalactivity is an indicator of burden and risk of shoulder disorders. Jakes [13] reports that themain causes of musculoskeletal injury inmedical ultrasound, are the maintenance needsof the shoulder in abduction for a better

positioning of the transducer on the skin of the patient, the exam associated with the handlingand display of images, the ergonomic conditions

such as height and direction of the monitor, thechair of the sonographer and height of thestretcher to accommodate the patient during theexamination. All of these factors, combinedwith the reduced time interval between oneexamination and the other, may contribute tofunctional changes and disability permanently[14,15.16].

It is considered acceptable for continuous dutyand little overhead, an average of 20 abduction[13]. Once the averages found in this study

exceeded the recommended 20, the risk of onset of muscle imbalances and postural

changes and dynamic overload, are apparentlyhigher for individuals evaluated in this study.

To evaluate the DASH questionnaire Brazil, thefirst 30 questions showed significant differences

between the SG and AG (p = 0.001). The SGhad an average of 16.16 and an average of 1.11AG. The four issues of the optional module,work-related, also showed significantdifferences between the SG and AG (p = 0.012).The SG had an average of 27.08 and an averageof 4.16 AG.

In this study, the results obtained from thequestionnaire indicated pain and / or discomfortin the shoulder of the SG. It can be inferred thatthese symptoms result from sustained postures

of the shoulder abduction of adopted medicalsonographer for examination, corroborated bymeasuring the angle of placement of MS duringthe test.

The need to hold the transducer in abductionand without support, especially for thevisualization of organs found in the patient's lefthemibody, and prolonged time of endoscopicultrasound show a direct relationship to thesymptoms reported by volunteers in this study.

Barbosa et al. [10] reported that during theexam, the physician sonographer needs to keepthe shoulder in abduction without support,which causes an isometric contraction of themuscles of UP, especially the scapular girdle, inan attempt to promote stabilization can to allowa precise movement of the wrist and hand andincrease the effectiveness of the performance of motor task presented.

In this study, no significant differences between

the time of occupation (p = 0.092) and number of tests per day (p = 0.186), compared to SGand AG. The average length of employment wasin AG and SG 10 years was four years and ninemonths. The mean number of tests per day inAG was 17.8 and the average was 22.7 in SG.Thus there was a direct relationship betweenworking time and symptoms. It can be inferredthat this may be due to a physiologicaladaptation of muscle as a result of occupationalactivity needs.

According to the results of the DASHquestionnaire Brazil was still possible to draw a

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parallel with the domains of the InternationalClassification of Functioning, Disability andHealth (ICF). It was observed that the activityand participation in the SG has beendemonstrated impaired due to the very changesto the structures and functions of UL, which ledto a certain degree of disability in the

performance of both the ADL and occupationalactivity. However, failure should always beviewed within a biopsychosocial context, sinceall these factors affect directly the componentsof ICF [17,18].

In relation to the inclinometer measures,significant differences were found between theSG and AG in the frontal plane, 90 and 120.The difference of 90 was 6.65 (F= 4.021, p =

0.016) on the right shoulder of the symptomaticto the asymptomatic right shoulder, in 120 wasfound a difference of 5.87 (F = 2.638, p =0.033) symptomatic of the right shoulder toright shoulder of asymptomatic. There was alsoa significant difference in AG, in the frontal

plane, where at rest (position 0) there was adifference of 4.43 (F = 2.772, p = 0.028) over the left shoulder to the right.

While staying with the shoulder abducted atapproximately 90, the muscles may havefatigue, with consequent inability to maintainthis position for long periods, related tooccupational activity (ultrasound). This factor can lead to muscle adaptation, in order to ensurethe functionality, in addition, it can trigger muscle imbalances in arcs of motion in whichthere is difficulty in maintaining proper musclegroups stabilizing or positioning of bodysegments during the course of a specificactivity, such as gestures sports andoccupational activities.

In this study the difference appears whencomparing the groups of the shoulders used to

perform the ultrasound may be due to musclefatigue due to the stance taken in support of ULabduction to the test. Associated with the timeof the examination and compensation thatemerge to keep the system functional, thisimbalance can affect the continuity of movement in the upper ranges of motion.

There has been a scapular dyskinesia in 120 of abduction seems to have a direct associationwith the difficulties reported by participants, as

observed in some items of the DASHquestionnaire Brazil related to ADL, for example, "washing away", "change a light bulbabove his head. " For the difference found inAG in the frontal plane in the rest position (0),we can infer that symptomatic individualswould be presenting an antalgic position duringthe measure scapular, which may haveinterfered with the angles found between theright shoulder and left.

Borstad [19] in his study of variations in theresting position of the shoulder, said that therelationship between postural deviations andshoulder pain is based on the theory that

prolonged postural changes lead to anadaptation of soft tissue on one side leading to

an increase in tension and the opposite sideleading to a shortening.

These changes alter the passive and activeforces acting on the shoulder during the move.Therefore, postural changes can lead to animpairment in the ability of the biomechanicalsystem to perform precise movements over timeand the frequency of repetition of the task, the

pain arises as a result of inaccurate movements.

CONCLUSION

According to the results obtained in this study,we observed that there is a relationship betweenthe change of the measurement of scapular inclination angle and the degree of disability of the upper limbs of medical sonographers duringthe examination. The change in slope makes itdifficult to maintain and scapular stabilizationof the upper limbs, reducing the functionality of

them during the work-related activities andADL. The ideal is to prioritize the examinationof ultrasound in the scapular plane, where thescapular muscles are acting on mechanicaladvantage, which can prevent muscle imbalanceoccurred between these muscles and theglenohumeral. You should also make ergonomicchanges and emphasize the strengthening of themuscles stabilizing the scapula in order to

prevent these changes and provide better functional performance to the doctor in their occupational activity and ADL.