The Study of Asymmetrical of the Serratus Anterior and Lower Trapezius Muscles in Chronic Stroke Patients

만성 뇌졸중 환자의 앞 톱니근과 하부 등세모근의 비대칭성 연구

  • Received : 2015.09.24
  • Accepted : 2015.10.15
  • Published : 2015.11.30


PURPOSE: The purpose of this study was to compare the muscle architecture of serratus anterior and lower trapezius using rehabilitative ultrasound imaging (RUSI) in affected and unaffected side of chronic stroke patients. METHODS: The participants were thirty five patients with stroke hemiplegia in this study. RUSI was used to measure the muscle thickness of the serratus anterior and lower trapezius muscles. We compared the muscle thickness according to affected side and sex, determined the reliability of the measurement image. Independent t-test, intra-class correlation coefficient (ICC) and standard error of measurement (SEM) were used for statistical analysis. RESULTS: Significant difference in muscle thickness of serratus anterior was observed between affected and unaffected side (p<.001). Muscle thickness according to gender showed a significant difference in unaffected side of serratus anterior (p<.05). Compare asymmetry ratio of serratus anterior and lower trapezius muscle thickness showed a significant difference (p<.001). ICC for intra-reliability was .944~.962 in serratus anterior and .873~.925 in lower trapezius muscle thickness, respectively. SEM was .001~.004 in serratus anterior and .002~.008 in lower trapezius muscle. CONCLUSION: This study, using RUSI, showed significant difference in muscle thickness of serratus anterior in affected and unaffected side of stroke patients. RUSI is a practical tool for measuring soft-tissue thickness in the scapular region muscle of stroke.


Serratus anterior;Lower trapezius;RUSI;Stroke


  1. Wallwork TL, Hides JA, Stanton WR. Intrarater and interrater reliability of assessment of lumbar multifidus muscle thickness using rehabilitative ultrasound imaging. J Orthop Sports Phys Ther. 2007;37(10):608-12.
  2. Wolf SL, Blanton S, Baer H, et al. Repetitive task practice: a critical review of constraint-induced movement therapy in stroke. Neurologis. 2002;8(6):325-38.
  3. Yang CS, Chen HC, Liang CC, et al. Sonographic measurements of the thickness of the soft tissues of the interscapular region in a population of normal young adults. J Clin Ultrasound. 2011;39(2):78-82.
  4. Yang YB, Zhang J, Leng ZP, et al. Evaluation of spasticity after stroke by using ultrasound to measure the muscle architecture parameters: a clinical study. Int J Clin Exp Med. 2014;7(9):2712-17.
  5. Yoo J, Jeong J, Lee W. The effect of trunk stabilization exercise using an unstable surface on the abdominal muscle structure and balance of stroke patients. J Phys Ther Sci. 2014;26(6):857-59.
  6. De Baets L, Jaspers E, Janssens L, et al. Characteristics of neuromuscular control of the scapula after stroke : a first exploration. Front Hum Neurosci. 2014;17(8):933.
  7. Dupont AC, Sauerbrei EE, Fenton PV, et al. Real-time sonography to estimate muscle thickness: comparison with MRI and CT. J Clin Ultrasound. 2001;29(4):230-36.
  8. English CH, McLennan K, Thoirs A, et al. Loss of skeletal muscle mass after stroke: a systematic review. Int J Stroke. 2010;5(5):395-402.
  9. Feys HM, De Weerdt WJ, Selz BE, et al. Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke. Stroke. 1998;29:785-92.
  10. Fujiwara KH, Toyama H, Asai K, et al. Regular heel-raise training focused on the soleus for the elderly: evaluation of muscle thickness by ultrasound. J Physiol Anthropol. 2010;29(1):23-8.
  11. Janssen I, Heymsfield SB, Wang ZM, et al. Skeletal muscle mass and distribution in 468 men and women aged 18-88 yr. J Appl Physiol. 2000;89(1):81-8.
  12. Jaraczewska E, Long C. Kinesio taping in stroke: improving functional use of the upper extremity in hemiplegia. Top Stroke Rehabil. 2006;13(3):31-42.
  13. Kim HD, You JM, Han N, et al. Ultrasonographic measurement of transverse abdominis in stroke patients. Ann Rehabil Med. 2014;38(3):317-26.
  14. An SH, Lee DG, Lee YB, et al. Inter-rater, absolute reliability and concurrent validity of tinetti-gait scale (Korean version) in stroke patients J Korean Soc Phys Med. 2014;9(2):201-11.
  15. Cho KH, Lee HJ, Lee WH. Reliability of rehabilitative ultrasound imaging for the medial gastrocnemius muscle in poststroke patients. Clin Physiol Funct Imaging. 2014;34(1):26-31.
  16. Lear LJ, Gross MT. An electromyographical analysis of the scapular stabilizing synergists during a push-up progression. J Orthop Sports Phys Ther. 1998;28(3): 146-57.
  17. Lieber RL, Friden J. Functional and clinical significance of skeletal muscle architecture. Muscle Nerve. 2000;23: 1647-66.<1647::AID-MUS1>3.0.CO;2-M
  18. Liesbet DB, Ellen J, Luc J, et al. Characteristics of neuromuscular control of the scapula after stroke: A first exploration. Front Hum Neurosci. 2014;8:933.
  19. Lu WS, Wang CH, Lin JH, et al. The minimal detectable change of the simplified stroke rehabilitation assessment of movement measure. J Rehabil Med. 2008;40(8):615-9.
  20. Ludewig PM, Cook TM, Nawoczenski DA. Three-dimensional scapular orientation and muscle activity at selected positions of humeral elevation. J Orthop Sports Phys Ther. 1996;24(2):57-65.
  21. Lynne TS. Diana J. Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway. Clin Rehab. 2002;16(3):276-98.
  22. Mottram SL. Dynamic stability of the scapula. Man Ther. 1997;2(3):123-31.
  23. Neumann DA. Kinesiology of the musculoskeletal system. Mosby. 2002.
  24. Norkin CC, Levangie PK. Joint structure and function. F.A. Davis Company. Philadelphia. 1992.
  25. Nozoe M, Kanai M, Kubo H, et al. Changes in quadriceps muscle thickness in acute non-ambulatory stroke survi vors. Top Stroke Rehabil. 2015[Epub ahead of print].
  26. O'Sullivan C, Bentman S, Bennett K, et al. Rehabilitative ultrasound imaging of the lower trapezius muscle: technical description and reliability. J Orthop Sports Phys Ther. 2007;37(10);620-26.
  27. O'Sullivan SB, Schmitz TJ. Physical rehabilitation(5th ed). F.A. Davis Company. 2006.
  28. Paine RM, Voight M. The role of the scapula. Journal of orthopaedic and sports physical therapy. 1993;18(1): 386-91.
  29. Park HJ, Oh DW, Shin WS. The study of asymmetrical contraction of the lateral abdominal muscles in stroke patients using ultrasound imaging. J Korean Soc Phys Med. 2012;7(3):319-27.
  30. Patten CJ, Lexell, Brown HE. Weakness and strength training in persons with poststroke hemiplegia: rationale, method, and efficacy. J Rehabil Res Dev. 2004;41(3): 293-312.
  31. Phadke V, Camargo PR, Ludewig PM. Scapular and rotator cuff muscle activity during arm elevation: A review of normal function and alterations with shoulder impingement. Rev Bras Fisioter. 2009;13(1):1-9.
  32. Ploutz-Snyder LL, Clark BC, Logan L, et al. Evaluation of spastic muscle in stroke survivors using magnetic resonance imaging and resistance to passive motion. Arch Phys Med Rehabil. 2006;87(12):1636-42.
  33. Portney L. Watkins MP. Statistical measures of reliability In:Foundations of clinical research: Applications to practice(2nd ed). Upper Saddle River. NJ Prentice Hall Health. 2000.
  34. Price CI, Ridgers G, Franklin P, et al. Glenohumeral subluxation, scapula resting position, and scapula rotation after stroke: a noninvasive evaluation. Arch Phys Med Rehabil. 2001;82(7):955-60.
  35. Schuck P, Zwingmann C. The 'smallest real difference' as a measure of sensitivity to change: a critical analysis. Int J Rehabil Res. 2003;26(2):85-91.
  36. Seitz AL, Baxter CJ, Benya K. Muscle thickness measurements of the lower trapezius with rehabilitative ultrasound imaging are confounded by scapular dyskinesis. Man Ther. 2015;20(4):558-63.
  37. Talbott NR. Ultrasound examination of the serratus anterior during scapular protraction in asymptomatic individuals: reliability and changes with contraction. PM R. 2014;6(3):227-34.
  38. Talbott NR, Witt DW. Ultrasound imaging of the serratus anterior muscle at rest and during contraction. Clin Physiol Funct Imaging. 2013;33(3):192-200.
  39. Tighe J, McManus IC, Dewhurst NG, et al. The standard error of measurement is a more appropriate measure of quality for postgraduate medical assessments than is reliability: an analysis of MRCP(UK) examinations. BMC Med Educ. 2010;10:40.
  40. Trombly Latham CA, Radomski MV. Occupational therapy for physical dysfunction(5th ed). Philadelphia : Lippincott Williams & Wilkins. 2002.