Journal of Electromyography and Kinesiology xxx (2014) xxxxxx

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Journal of Electromyography and Kinesiology

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The effect of scapular posterior tilt exercise, pectoralis minor stretching,

and shoulder brace on scapular alignment and muscles activity in
subjects with round-shoulder posture
Ji-hyun Lee a,1, Heon-seock Cynn a,, Tae-lim Yoon a,b,1, Chang-hee Ko a,1, Woo-jeong Choi a,1, Sil-ah Choi a,1,
Bong-sam Choi b,2
a
Applied Kinesiology and Ergonomic Technology Laboratory, Department of Physical Therapy, The Graduate School, Yonsei University, Baekwoon-kwan, 1 Yonseidae-gil,
Wonju, Kangwon-do, Republic of Korea
b
Department of Physical Therapy, College of Health and Welfare, Woosong University, #17-2, Jayang-dong, Dong-gu, Daejeon, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Background: There are various methods for rehabilitating round-shoulder posture (RSP), including
Received 7 June 2014 strengthening exercises, stretching, and using a shoulder brace or taping to correct the altered posture.
Received in revised form 18 October 2014 However, no study has determined which intervention is the most effective of the three methods to
Accepted 20 October 2014
decrease RSP (intervention #1: scapular posterior tilting exercise alone [hereafter, SPT], intervention
Available online xxxx
#2: the scapular posterior tilting exercise after PM stretching [PM stretch + SPT], and intervention #3:
the scapular posterior tilting exercise with use of a shoulder brace [SPT + brace]). Objectives: The purpose
Keywords:
Pectoralis minor stretching
of this study was to compare the SPT, PM stretch + SPT, and SPT + brace on RSP, PM index (PMI), and
Scapular posterior tilting exercise lower trapezius (LT) and serratus anterior (SA) activity in subjects with RSP. Methods: In total, fteen
Shoulder brace young men with RSP, participated in the study (21.46 2.30 years old). RSP was conrmed using a caliper
Round-shoulder posture measure. Surface electromyography (SEMG) data for LT and SA activity were collected during the three
interventions, and the SEMG data are expressed as a percentage of the maximal voluntary isometric con-
traction (%MVIC). Results: RSP was signicantly less in the PM stretch + SPT and SPT + brace than in the
SPT (P < 0.05). PMI was signicantly greater in the PM stretch + SPT and SPT + brace than in the SPT
(P < 0.05). LT activity was signicantly greater in the PM stretch + SPT than in the SPT or SPT + brace in
subjects with RSP (P < 0.05). Conclusions: The PM stretching exercise and application of a shoulder brace
may help correct RSP and restore the length of the PM. The posterior tilting exercise after PM stretching
was the most effective method for eliciting greater LT muscle activation among the interventions tested.
2014 Elsevier Ltd. All rights reserved.

1. Introduction
Round-shoulder posture (RSP) is characterized by a protracted,
downwardly rotated, and anteriorly tipped scapula position with
increased cervical lordosis and upper thoracic kyphosis
(Chansirinukor et al., 2001; Magee, 2002; Wong et al., 2010). Sev-
eral factors may cause RSP, such as loss of lower trapezius (LT) and
serratus anterior (SA) activity, tightness in the pectoralis minor
(PM), greater thoracic kyphosis, and the scapular anatomical struc-
ture itself (Borstad and Ludewig, 2005; Ekstrom et al., 2003; Finley
Corresponding author. Tel.: +82 33 760 2427; fax: +82 33 760 2496.
E-mail addresses: jihyun.lee@yonsei.ac.kr (J.-h. Lee), cynn@yonsei.ac.kr
(H.-s. Cynn), free0829@gmail.com (T.-l. Yoon), gchpsh@hanmail.net (C.-h. Ko),
cwj7354@gmail.com (W.-j. Choi), silah88@naver.com (S.-a. Choi), bchoi@wsu.ac.kr
(B.-s. Choi).
1 loss associated with RSP (Ekstrom et al., 2003; Hall, 2005;
Tel.: +82 33 760 2497; fax: +82 33 760 2496.
2
Tel.: +82 42 630 4622.
and Lee, 2003; Hall, 2005; Kebaetse et al. 1999; Ludewig et al.,
2004; Lukasiewicz et al., 1999; Sahrmann, 2002; Smith et al.,
2002; Wang et al., 1999). Accordingly, altered scapular kinematics
and associated muscle imbalance in RSP place the anterior acro-
mion in close proximity to the supraspinatus and infraspinatus
tendons and increase the potential for subacromial impingement
(Holmgren et al., 2012; Ludewig and Cook, 2000; McClure et al.,
2004; Peterson et al., 1997; Thigpen et al., 2010).
Many previous studies have investigated various methods for
rehabilitating RSP, including LT and SA strengthening exercises,
PM stretching, and using a shoulder brace or taping to correct
the altered posture (Hrysomallis, 2010; Hrysomallis and
Goodman, 2001; Thigpen et al., 2010). Of theses methods,
strengthening of the LT and SA have routinely been included in
rehabilitation to actively counteract the strength and movement
Ludewig et al., 2004; Smith et al., 2002). Lynch et al. (2010) also

http://dx.doi.org/10.1016/j.jelekin.2014.10.010
1050-6411/ 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Lee J-h et al. The effect of scapular posterior tilt exercise, pectoralis minor stretching, and shoulder brace on scapular
alignment and muscles activity in subjects with round-shoulder posture. J Electromyogr Kinesiol (2014), http://dx.doi.org/10.1016/j.jelekin.2014.10.010
2 J.-h. Lee et al. / Journal of Electromyography and Kinesiology xxx (2014) xxxxxx
reported that muscle strengthening exercises successfully
decreased RSP in elite swimmers. In particular, a scapular posterior
tilting exercise in the prone position was the most effective
method for strengthening the LT and SA, and stabilizing the scap-
ula to the thoracic wall (Ekstrom et al., 2003; Ha et al., 2012).
PM stretching exercises have also been used (Kisner and Colby,
2002; Sahrmann, 2002), and have been reported to reduce RSP sig-
nicantly versus the pre-treatment baseline (Wong et al., 2010).
Previous studies have demonstrated that strengthening the poster-
ior scapular stabilizers, combined with stretching of the PM, can
result in improved muscle strength in the scapular adductors, ante-
rior inclination of the thoracic spine, and altered scapulohumeral
rhythm in healthy subjects (Wang et al., 1999). Another method
for restoring normal shoulder posture and scapular muscular activ-
ity involves bracing around the shoulder girdle. A shoulder brace is
believed to affect the resting position of the scapula and to help
maintain the proximal shoulder girdle stability necessary to per-
form elevation of the arm (Uhl et al., 2005, 2006). A previous study
found that application of a shoulder brace decreased the forward
shoulder angle (Cole et al., 2013). Another found that a functional
shoulder brace demonstrated the same improvements in shoulder
pain and function as traditional rehabilitation in subjects with sub-
acromial impingement syndrome (Walther et al., 2004). Based on
these previous researches, we included a scapular posterior tilting
exercise, PM stretching, and shoulder brace use in this study.
To determine which intervention is the most effective of the
three interventions to decrease RSP and increase LT and SA muscle
activity in subjects with RSP, the scapular posterior tilting exercise
alone (hereafter, SPT), the scapular posterior tilting exercise after
PM stretching (PM stretch + SPT), and the scapular posterior tilting
exercise with use of a shoulder brace (SPT + brace) were compared
in terms of effects on scapular alignment (degree of RSP and scap-
ular upward rotation angle), PM index (PMI), and LT and SA activity
in subjects with RSP. We hypothesized that scapular alignment,
PMI, and LT and SA activity would differ among the interventions.
2. Methods
2.1. Subjects
The G-power software was used for power analyses (G-power
software 3.1.2; Franz Faul, University of Kiel, Kiel, Germany). The
necessary sample size of seven subjects was calculated from data
obtained from a pilot study of eight subjects to achieve a power
of 0.80 and an effect size of 0.52 (calculated from the partial g2
of 0.21 from the pilot study), with an a level of 0.05. Thus, fteen
young men with RSP participated (age = 21.46 2.30 years,
height = 174.85 3.41 cm, weight = 66.00 4.24 kg, and
BMI = 21.59 1.27).
The dominant side (preferred arm when eating and writing)
was used in all tests (Yoshizaki et al., 2009). All of the subjects
reported the right arm as their dominant side.
RSP was conrmed via measurement using a caliper by the
principal investigator (JHL), who had 10 years of clinical experi-
ence. The distance between the posterior border of the acromion
and the table in the supine position was measured, as a simple
measurement for RSP (Magee, 2002; Sahrmann, 2002; Wong
et al., 2010). A supine position for measuring RSP could avoid mea-
surement variations due to humeral rotation and unwanted scap-
ular movement. The interclass correlation coefcient (ICC) of this
measurement was 0.880.94 (Nijs et al., 2005). A score P 2.5 cm
was dened as RSP (Sahrmann, 2002).
Exclusion criteria were a history or clinical exam revealing pain
or dysfunction that substantially limited shoulder motion or
resulted in gross instability of the shoulder during daily activities,
Please cite this article in press as: Lee J-h et al. The effect of scapular posterior tilt exercise, pectoralis minor stretching, and shoulder brace on scapular
alignment and muscles activity in subjects with round-shoulder posture. J Electromyogr Kinesiol (2014), http://dx.doi.org/10.1016/j.jelekin.2014.10.010
signs and symptoms of cervical pain, adhesive capsulitis, thoracic
outlet syndrome, or a current complaint of numbness or tingling
in the upper extremity. The examination included the impinge-
ment tests of Hawkins, Neer, and Jobe, the apprehension test for
anterior instability, the scapular winging test using a scapulometer
(>2 cm), and the short head tendon of the biceps brachii and cora-
cobrachialis muscle length test (Magee, 2002; Weon et al., 2011).
Prior to participation, the subjects provided written informed
consent. The investigation was approved by Yonsei University
Wonju Institutional Review Board.
2.2. Electromyography (EMG) recording and data processing
Surface EMG data were collected using a Noraxon TeleMyo-DTS
with a wireless telemetry system (Noraxon, Inc., Scottsdale, AZ,
USA) and analyzed using the Noraxon MyoResearch 1.06 XP soft-
ware. EMG signals were amplied, band pass-ltered (10 and
450 Hz), and notch-ltered (60 Hz, 120 Hz) before being recorded
digitally at 1000 Hz and processed into root-mean-square data.
Data were collected from the LT and SA on the dominant side. After
shaving and rubbing the skin with alcohol, disposable Ag/AgCl sur-
face electrodes were placed on each muscle at standardized sites
(Criswell, 2010). To minimize cross-talk from proximal deep or
supercial muscles, this study selected the best electrode size
(1 cm in diameter). Two electrodes were placed approximately
2 cm apart, in the direction of the muscle bers. The LT electrodes
were placed at an oblique vertical angle, with one electrode supe-
rior and one inferior to a point 5 cm inferomedial from the root of
the spine of the scapula. The SA (lower part) electrodes were
attached just below the axillary area at the level of the inferior
tip of the scapula and medial to the latissimus dorsi. Correct elec-
trode placement was conrmed by visual inspection of the EMG
signals on a computer screen during specic muscle testing. Max-
imal voluntary isometric contractions (MVIC) were collected to
normalize the EMG data from the LT and SA using the manual mus-
cle testing positions recommended by previous studies (Ekstrom
et al., 2005; Kendall et al., 2005). To determine the MVIC value
for LT, each subject was tested in the prone position. The subjects
arm was placed diagonally overhead, in line with the lower bers
of the trapezius muscle during external rotation while resistance
was applied just above the elbow joints (Ekstrom et al., 2003;
Kendall et al., 2005). To obtain the MVIC value for SA, the subject
was seated on a treatment table with no back support. The sub-
jects shoulder was rotated internally and abducted to 125 in
the scapular plane, while resistance was applied above the elbow
by the investigator (Ekstrom et al., 2005). Each contraction was
held for 5 s, with maximal effort against manual resistance, and a
2-min rest was given between trials to minimize muscle fatigue
(Vera-Garcia et al., 2010). The rst and last second of the EMG data
from each MVIC trial were discarded, and the remaining 3 s of data
were used (De Oliveira et al., 2008; Vezina et al., 2000). We took
the mean value of 3 s in three trials. And then, the mean of the
three trials was calculated for data analysis. Intra-class correlation
coefcient (ICC) for MVICs of LT and SA were 0.96 (95% Condence
Interval [CI]: 0.870.99) and 0.94 (95% CI: 0.830.98), respectively.
The gathered EMG amplitudes for LT and SA during the exercises
were expressed as a percentage of the mean MVIC (%MVIC).
2.3. Procedures
Degree of RSP, scapular upward rotation angle, and PMI were
obtained after each intervention (SPT, PM stretch + SPT, and
SPT + brace). The results were not recorded by any investigator. A
student read the values of the results so that the investigator
remained blind. The EMG activities of the LT and SA muscles were
collected during 5 s in each intervention, and a 2-min rest was
 J.-h. Lee et al. / Journal of Electromyography and Kinesiology xxx (2014) xxxxxx
given between 2 trials. The mean value was used for data analysis
(De Luca, 1997). Subjects performed the three interventions in ran-
domized order; subjects drew lots to avoid learning effects or fati-
gue. Subjects had a wash-out period of 12 min among the
interventions to avoid the effects of stretching, based on previous
studies that demonstrated that a single session of static or PNF
hold-relax stretching results in increased exibility that lasts
approximately 3 min (4 repetitions stretching  3 min lasting =
12 min rest) (DePino et al., 2000; Spemoga et al., 2001). If measur-
ing RSP (with a caliper) was performed more than 12 min after the
stretching procedure, the stretching effect would be disappeared.
Thus, we measured RSP, scapular upward rotation angle, and PMI
immediately after each intervention. To ensure that each subject
performed the exercises at a standard speed, a metronome was
set at one beat per second (Nyland et al., 2004). Subjects were
familiarized with the SPT prior to testing. The familiarization
period was ended when the subject was able to maintain the exer-
cise positions for 5 s. All of the subjects were comfortable after the
familiarization period, and none reported fatigue. A 5-min rest
period was allowed after the familiarization period before data
collection began.
2.3.1. Scapular upward rotation angle measurement
The subject was in a standing position. Scapular upward rota-
tion was measured with two inclinometers; one was used to mea-
sure the 135 humeral abduction position, and the second was
used to measure the upward rotation of the scapula, manually
aligned along the scapular spine. Yano et al. (2010) demonstrated
that the mean maximum arm elevation angles of healthy subjects
were 135.4 (range, 125.0150.0) for dominant arms. Thus, we
measured upward rotation in a 135 humeral abduction position.
The ICC was 0.88 (Watson et al., 2005).
2.3.2. PMI measurement
PMI was used to measure the length of the PM. The subjects
were standing erect with their test arm resting at their side. Fore-
arm position was neutral and hand was resting position. The rest-
ing muscle length was determined between the medial-inferior
angle of the coracoid process and just lateral to the sternocostal
junction of the inferior aspect of the fourth rib with a caliper mea-
sure. The PMI was calculated by dividing the resting muscle length
by the subjects height and multiplying by 100 (Borstad and
Ludewig, 2005). Increased PMI indicates increased PM length.
Borstad (2008) demonstrated the concurrent validity between
the caliper and the electromagnetic system with two anatomical
landmarks for measuring resting PM length; the ICCs for were
0.830.87 (Fig. 1). The testretest reliability for PMI measurement
was 0.94 in the current study (95% CI = 0.810.98, standard error of
measurement [SEM] = 0.32, minimal detectable changes 95% con-
dence interval [MDC95] = 0.89, and coefcient of variation
[CV] = 10.60%).
2.3.3. Scapular posterior tilting exercise
The subject began in quadruped and then shift the body back-
ward into a deep kneel position during 3 s. The subjects shoulder
was abducted to 145 by the investigator, and the subject was
instructed to lift the dominant arm, with extended elbow, neutral
forearm, extended hand. The radial border of the wrist slightly
touched but did not push a wooden target bar, and then to main-
tain this arm position (Fig. 2). This bar, positioned at the subjects
earlobe line in the backwards rocking exercise position, was used
to control the angle of shoulder exion in each exercise (Ha
et al., 2012).
Please cite this article in press as: Lee J-h et al. The effect of scapular posterior tilt exercise, pectoralis minor stretching, and shoulder brace on scapular
alignment and muscles activity in subjects with round-shoulder posture. J Electromyogr Kinesiol (2014), http://dx.doi.org/10.1016/j.jelekin.2014.10.010
3
Fig. 1. Measurement of pectoralis minor muscle length by a caliper. The resting
muscle length was determined between the medial-inferior angle of the coracoid
process (A) and just lateral to the sternocostal junction of the inferior aspect of the
fourth rib (B) with a caliper measure. The pectoralis minor index was calculated by
dividing the resting muscle length by the subjects height and multiplying by 100.
2.3.4. Scapular posterior tilting exercise after PM stretching (PM
stretch + SPT)
The subjects were positioned in a supine position, with their
hips and knees bent (90 exion) and their feet on the oor. The
test arm was abducted and rotated externally to 90, and the sub-
jects elbow was exed to 90. Subjects were instructed to contract
their abdominals by sucking their belly in towards their spine to
avoid rib cage elevation during PM stretching. The investigator sta-
bilized each subjects body by placing one hand on the contralat-
eral coracoid. Then the investigator passively horizontally
abducted the subjects shoulder. The stretching was performed
for four sequential repetitions, holding the stretches for 30 s, with
a 30 s break between each stretch. The investigator applied all of
the stretches at the end range of motion (Williams et al., 2013).
Williams et al. (2013) introduced the gross stretching technique
for PM stretching. However, they did not clearly describe how to
control rib cage elevation. A modied version of their stretching
technique was used in this study (Fig. 3). The PM stretching exer-
cise was overseen by a licensed physical therapist with 10 years of
clinical experiences. Following the PM stretching exercise, the sub-
jects performed the scapular posterior tilting exercise.
2.3.5. Scapular posterior tilting exercise with use of a shoulder brace
(SPT + brace)
The brace was applied by the principal investigator (JHL)
according to the manufacturers specications using a 1-strap
method for controlling strap tension (Fig. 4). The subject was in
the standing position as the shoulder brace was put on. Subjects
raised both arms. The investigator wrapped the strap at the sub-
jects coracoid process on the lower shoulder side rst. Then the
investigator pulled it towards the cranial and lateral side (the strap
ran from the midthorax, crossed at the coracoid process and axil-
lary area, and terminated at the midthorax again). This method
was repeated on the opposite side. Then the subject assumed a
quadruped position, as in the scapular posterior tilting exercise.
The principal investigator conrmed correct application of the
shoulder brace before the subject performed the tilting exercise.
And then, the subjects performed the scapular posterior tilting
exercise. The principal investigator also monitored electrode sites
during the tilting exercise to prevent a source of noise from the
brace.
4 J.-h. Lee et al. / Journal of Electromyography and Kinesiology xxx (2014) xxxxxx

Fig. 2. Scapular posterior tilting exercise. The subject began in quadruped and then shift the body backward into a deep kneel position. The subject was instructed to lift the
dominant arm, with the elbow extended until the radial border of the wrist slightly touched but did not push a wooden target bar, and then to maintain this arm position.

p
[MDC95 = SEM 1.96 2] was calculated (Ries et al., 2009). Effect
size (ES) is generally considered more appropriate to determine if
meaningful change has occurred, because it does take group vari-
ability into account. The ES is calculated to determine meaningful
changes between interventions [differences of mean between
interventions/standard deviation of SPT or differences of mean
between PM stretch + SPT and SPT + brace/standard deviation of
SPT + brace] (Portney and Watkins, 2009). A one-way, repeated-
measures ANOVA was used to assess the statistical signicance
of degree of RSP, scapular upward rotation angle, PMI, and LT
and SA activity among the three interventions. The level of signif-
icance was set at 0.05.

3. Results

3.1. Degree of RSP, scapular upward rotation angle, and PMI

Fig. 3. Pectoralis minor stretching exercise.
2.4. Statistical analysis
PASW Statistics 18 software (SPSS, Chicago, IL, USA) was used to
perform all statistical analyses. Testretest reliability of EMG mea-
surements in three interventions (SPT, PM stretch + SPT, and
SPT + brace) was assessed by ICC, 95% CI, the SEM, and MDC95.
The SEM was calculated for each measurement to assess absolute
p
consistency [SEM = SD (1-ICC)]. Additionally, the CV is another
measure of variability which is a measure of relative variation
[CV = SD/mean 100] (Portney and Watkins, 2009). MDC95
There were signicant differences in degree of RSP among the
interventions (F2, 13 = 36.59, P < 0.05), with the values being signif-
icantly less in the PM stretch + SPT (P < 0.05, ES = 2.21) and
SPT + brace (P < 0.05, ES = 2.26) than in the SPT.
There were also signicant differences in PMI (F2, 13 = 6.971,
P = 0.011) among the three interventions. PMI was signicantly
greater in the PM stretch + SPT (P = 0.017, ES = 0.43) and
SPT + brace (P = 0.004, ES = 0.70) than in the SPT. However, there
were no signicant differences in scapular upward rotation angle
among the three interventions (F2, 13 = 1.498, P = 0.266; ES
between the SPT and the PM stretch + SPT was 0.68 and ES
between the SPT and the SPT + brace was 0.52, Fig. 5, Table 1).

Fig. 4. Shoulder braces application. (A) The subjects raised both arms in the standing position. (B) The investigator wrapped the strap at the subjects coracoid process on the
lower shoulder side rst. Then the investigator pulled it towards the cranial and lateral side (the strap ran from the midthorax, crossed at the coracoid process and axillary
area, and terminated at the midthorax again). (C) This method was repeated on the opposite side. (D) The subjects lowered their arms to the side from elevated position.

Please cite this article in press as: Lee J-h et al. The effect of scapular posterior tilt exercise, pectoralis minor stretching, and shoulder brace on scapular
alignment and muscles activity in subjects with round-shoulder posture. J Electromyogr Kinesiol (2014), http://dx.doi.org/10.1016/j.jelekin.2014.10.010
 J.-h. Lee et al. / Journal of Electromyography and Kinesiology xxx (2014) xxxxxx 5

3.2. LT and SA muscle activity
The testretest reliabilities for EMG measurement of LT and SA
muscle were substantial in three interventions (SPT: ICC = 0.86,
95% CI = 0.610.96, SEM = 7.22, MDC95 = 20.00, and CV = 45.00%
for LT (49.02 22.06%MVIC), and ICC = 0.95, 95% CI = 0.840.98,
SEM = 2.81, MDC95 = 7.79, and CV = 46.86% for SA (25.82
12.10%MVIC); PM stretch + SPT: ICC = 0.87, 95% CI = 0.630.96,
SEM = 10.22, MDC95 = 28.33, and CV = 46.29% for LT (61.01
28.24%MVIC), and ICC = 0.99, 95% CI = 0.980.99, SEM = 2.09,
MDC95 = 5.79, and CV = 74.75% for SA (32.31 24.15%MVIC);
SPT + brace: ICC = 0.95, 95% CI = 0.840.98, SEM = 4.05, MDC95 =
11.23, and CV = 35.55% for LT (48.98 17.41%MVIC), and
ICC = 0.89, 95% CI = 0.650.97, SEM = 6.31, MDC95 = 17.49, and
CV = 57.41% for SA (33.60 19.29%MVIC).
There were signicant differences in LT muscle activity (F2,
13 = 7.405, P = 0.009) among three interventions, with the PM
stretch + SPT showing signicantly greater LT muscle activity than
the SPT or SPT + brace (P = 0.002, ES between the SPT and the PM
stretch + SPT was 0.55; P = 0.002, ES between the PM stretch + SPT
and the SPT + brace was 0.69, Fig. 6). There were no statistically
signicant differences in SA muscle activity among the three inter-
ventions (F2, 13 = 2.331, P = 0.143; ES between the SPT and the PM
stretch + SPT was 0.54, ES between the SPT and the SPT + brace was
0.64, and ES between the PM stretch + SPT and the SPT + brace was
0.07, Fig. 6).
4. Discussion
We compared the effects of three different interventions,
namely, SPT, PM stretch + SPT, and SPT + brace, on scapular align-
ment, PMI, and LT and SA activity in subjects with RSP. To the best
of our knowledge, this is the rst study to make this comparison.
Degree of RSP was signicantly less in the PM stretch + SPT than
in the SPT, decreasing by 2.94 cm (30.72%). Decreased RSP indi-
cates less anterior tilting in the sagittal plane and internal rotation
in the transverse plane of the scapula conrming stretching effect
of the tight PM in subjects with RSP. These ndings support the
research hypothesis and are consistent with previous studies
(Lynch et al., 2010; Kluemper et al., 2006; Roddey et al., 2002).
Roddey et al. (2002) found that a 2-week self PM stretching pro-
gram decreased RSP in asymptomatic forward-head-posture with
RSP subjects. Two previous studies also reported that stretching
of the anterior shoulder muscles (the levator scapulae, sternoclei-
domastoid, and PM) and strengthening of the posterior shoulder
muscles (middle trapezius, LT, and SA) decreased RSP following
6- or 8-week treatments in swimmers (Kluemper et al., 2006;
Lynch et al., 2010). The mechanism behind this change is believed
to be a viscoelastic response of the muscletendon unit due to sta-
tic stretching (Klinge et al., 1997). A viscoelastic response results in
passive tension reduction for any given length of the tissue, allow-
ing increased exibility to be achieved (Klinge et al., 1997; Taylor
et al., 1997). Thus, our results indicate that the PM stretching
method with SPT may be more effective for improving RSP versus
SPT alone.
We also found that degree of RSP was signicantly less in the
SPT + brace compared to the SPT, decreasing by 3.01 cm (31.45%).
Especially, decreased RSP indicates less internal rotation of the
scapula in the transverse plane suggesting benecial effect of
applying brace in subjects with RSP. These results are consistent
with previous reports, although the application methods and
materials of the shoulder braces differed slightly among studies
(Cole et al., 2013; Dewan et al., 2014). Cole et al. (2013) reported
that application of a shoulder brace decreased RSP (or the forward
shoulder angle) in a compression shirt with fully tightened straps.
Other researchers have also demonstrated that scapular taping
decreases RSP (Dewan et al., 2014; Lewis et al., 2005). However,
the application of adhesive tape might cause skin irritation in some
patients and might not be a feasible treatment for daily or pro-
longed use. Thus, we chose the shoulder brace instead of straps
or tape. The mechanisms of shoulder brace action may include a
mechanical change in shoulder girdle alignment and propriocep-
tion input augmentation (Cole et al., 2013). Use of the shoulder

Fig. 5. Comparison of degree of round-shoulder posture, pectoralis minor index, and scapular upward rotation angle among the scapular posterior tilting exercise alone, the
scapular posterior tilting exercise after PM stretching, and the scapular posterior tilting exercise with use of a shoulder brace. indicates a signicant difference (p < 0.05). The
pectoralis minor index was calculated by dividing the resting muscle length by the subjects height and multiplying by 100. An increased pectoralis minor index indicated
increased pectoralis minor muscle length.

Please cite this article in press as: Lee J-h et al. The effect of scapular posterior tilt exercise, pectoralis minor stretching, and shoulder brace on scapular
alignment and muscles activity in subjects with round-shoulder posture. J Electromyogr Kinesiol (2014), http://dx.doi.org/10.1016/j.jelekin.2014.10.010
6 J.-h. Lee et al. / Journal of Electromyography and Kinesiology xxx (2014) xxxxxx
Table 1
Data of amounts of round shoulder posture, pectoralis minor index, and scapular upward rotation angle after scapular posterior tilting exercises alone, scapular posterior tilting
exercises after pectoralis minor stretching, and scapular posterior tilting exercises with applying shoulder brace.
Variables Interventions
After SPT
Amounts of round shoulder posture (cm) 9.57 1.33a
Pectoralis minor index (%) 16.51 1.75
Scapular upward rotation angle () 35.62 6.40
SPT: Scapular posterior tilting exercise alone.
PM stretch + SPT: scapular posterior tilting exercises after pectoralis minor stretching.
SPT + Brace: posterior tilting exercises with applying shoulder brace.
a
Mean standard deviation.
Fig. 6. Comparison of muscle activity in the lower trapezius and serratus anterior
among the scapular posterior tilting exercise alone, the scapular posterior tilting
exercise after PM stretching, and scapular posterior tilting exercise with use of a
shoulder brace. indicates a signicant difference (p < 0.05).
brace involves having the subject retract and depress the scapula,
then applying the brace over the coracoid process, thorax, and
scapular spine. Thus, use of the shoulder brace is more effective
for restoring shoulder position than the SPT in subjects with RSP.
Because there was no signicant difference in the degree of RSP
between the PM stretch + SPT and SPT + brace groups, our results
suggest that both methods may be incorporated into the treatment
protocol to improve RSP.
Our results revealed greater PMI in the PM stretch + SPT and
SPT + brace than in the SPT group, increasing by 0.75 (4.54%) and
0.96 (5.82%) in the former intervention, respectively. Increased
PMI indicated the lengthening of the PM. These ndings support
the research hypothesis. However, no previous study has examined
PMI in relation to the three interventions used in the present study.
Therefore, it is not possible to compare these results directly with
those of any other previous study. When the PM is shortened,
excessive anterior tilt, protraction, and scapular downward rota-
tion would limit normal scapulothoracic motions and cause even
impingement syndrome. Thus, lengthen PMI might be expected
to correct the RSP by posterior tilt, retraction, and scapular upward
rotation. In addition to this lengthening effect of the PM, our
results suggest that the PM stretch + SPT and SPT + brace are effec-
tive for lengthening the PM muscle compared to SPT alone in sub-
jects with RSP.
However, there were no signicant differences in scapular
upward rotation angle among the three interventions, although it
did increase by 4.37 (12.27%) and 3.33 (9.35%) in the PM
stretch + SPT and SPT + brace compared to the SPT. The hypothesis
was based on the theory that 30 or greater shoulder elevation
angles would require the scapular upward rotation and further
posterior tilt through lengthening of the shortened muscle
(Muraki et al., 2009). However, these ndings did not support
Please cite this article in press as: Lee J-h et al. The effect of scapular posterior tilt exercise, pectoralis minor stretching, and shoulder brace on scapular
alignment and muscles activity in subjects with round-shoulder posture. J Electromyogr Kinesiol (2014), http://dx.doi.org/10.1016/j.jelekin.2014.10.010
After PM stretch + SPT After SPT + Brace
6.63 1.33 6.56 1.34
17.26 2.18 17.47 2.55
39.99 11.55 38.95 7.28
the research hypothesis. These ndings are similar to those
reported by McClure et al. (2004) and Williams et al. (2013), both
of which reported that there was no difference in scapular upward
rotation angle after PM stretching exercises. According to McClure
et al. (2004), this may have been due to the protocol they used not
being challenging enough. No previous study has examined
changes in scapular upward rotation angle while using a shoulder
brace; thus, it is not possible to compare our results with previous
work. Considering our results, none of the interventions applied in
the present study may be sufcient to alter the scapular upward
rotation angle immediately.
We also found that LT activity increased signicantly in the PM
stretch + SPT group compared to the SPT (by 24.02%) and
SPT + brace (by 24.56%). The result supports the research hypothe-
sis. However, again, no previous study has considered these
aspects and thus we cannot directly compare our results to any
other studies. There are several possible explanations for the
increased activity of the LT following PM stretch + SPT. First, after
PM stretching, the scapular posterior tilting increased due to the
lengthened PM. This was conrmed by the RSP and PMI measure-
ments. Due to this increased range, the LT was able to continue to
contract during the SPT exercise. Second, after PM stretching, the
viscoelastic properties of the PM may have changed. Reduced pas-
sive tension allowed increased activation of LT as a main scapular
posterior tilting muscle. Third, PM stretching might reduce the
muscle imbalance between PM and LT; thus, the inhibited LT could
be activated more after PM stretching. These results also suggest
that simply providing afferent feedback from cutaneous receptors
under the shoulder brace is not enough to increase LT activity
immediately. Additionally, the subscapularis, pectoralis major, cor-
acobrachialis, biceps long head, teres major and latissimus dorsi to
an extent, were well stretched during the PM stretching. Thus, all
of these muscles may have had an effect on the ability to perform
the LT exercise. These mechanisms may explain why LT activity
increased after PM stretching whereas no change occurred after
SPT + brace.
However, there were no signicant differences in SA activity
among the three interventions, although it did increase by
16.59% and 12.11% in the PM stretch + SPT and SPT + brace com-
pared to the SPT. The results for the SPT + brace are consistent with
Cole et al. (2013), who reported no signicant difference in SA
activity with and without a shoulder brace. A lack of tactile feed-
back on the SA muscle may partially explain these results because
the brace is applied to the midthorax, coracoid process, and axil-
lary area. Thus, the brace may be insufcient to elicit SA activity.
Consequently, the usage of a brace should not be encouraged to
increase LT and SA activity in subjects with RSP.
This study has several limitations. First, its generalizability is
limited because healthy, young male subjects with no symptoms
of subacromial impingement participated. The results may have
been different if we had used female subjects or subjects with such
symptoms. Second, this study used a wash-out period based on
 J.-h. Lee et al. / Journal of Electromyography and Kinesiology xxx (2014) xxxxxx
previous studies (Depino et al., 2000; Spemoga et al., 2001)
although the applying muscles and stretching technique differed
from our study. Thus, future research should examine the wash-
out period after stretching techniques. Third, it was a cross-sec-
tional study. Therefore, long-term effects of PM stretching and
brace use cannot be determined. Further studies should compare
the long-term effects of these different treatments on scapular
upward rotation angle, PMI, and LT and SA activity in subjects with
RSP.
5. Conclusions
Degree of RSP decreased and PMI increased after the PM
stretch + SPT and SPT + brace treatments compared to SPT alone.
Thus, PM stretching exercises and use of a shoulder brace may
reduce RSP and restore the length of the PM. LT activity increased
after PM stretch + SPT compared to the SPT and SPT + brace. The
PM stretch + SPT elicited the greatest LT muscle activation among
the interventions compared.
Conict of interest
We certify that no party having a direct interest in the results of
the research supporting this article has or will confer a benet on
us or on any organization with which we are associated.
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a reliable clinical procedure. Br J Sports Med 2005;39(9):599603. a physical therapist in Seoul National University
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Bundang Hospital.
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an experimental study. J Physiother 2011;57(2):1017.
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on rounded-shoulder posture, and associated muscle strength. J Bodyw Mov
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Yano Y, Hamada J, Tamai K, Yoshizaki K, Sahara R, Fujiwara T, et al. Different of Physical Therapy at the Graduate School of Yonsei
scapular kinematics in healthy subjects during arm elevation and lowering: University. She received B.S. degree in Physical
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2010;19(2):20915. applied kinesiology and ergonomic technology labo-
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ratory. Her research interests are musculoskeletal
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Shoulder Elbow Surg 2009;18(5):75663.

Ji-Hyun Lee is a Ph.D. Student in the Department of

Physical Therapy at the Graduate School of Yonsei
University. She received B.S. degree in Physical
Therapy from Hanseo University, M.S. degree in
Physical Therapy from Yonsei University. She is a
member of applied kinesiology and ergonomic tech-
nology laboratory, and she is a part time lecturer of
Yonsei University. Her main research interests are
shoulder and hip assessment and treatment strategy.
Her papers have been published in several interna-
tional journals in these elds.
Sil-Ah Choi received her B.S. degree in Physical
Therapy from Yonsei University, and M.S. degree in
Physical Therapy from Yonsei University. She is a
member of applied kinesiology and ergonomic tech-
nology laboratory. Her research interests are the
clinical biomechanics associated with musculoskel-
etal problems.

Heon-Seock Cynn is a professor in the Department

of Physical Therapy at the College of Health Science
of Yonsei University. He received B.S. degree in
Physical Therapy from Yonsei University, M.A. degree
in Physical Therapy from New York University, and
Ph.D. degree in Physical Therapy from Yonsei Uni- Bong-sam Choi is an associate professor and chair in
versity. He was a full time lecturer of Seoul Health the Department of Physical Therapy at the College of
College and an associate professor of Hanseo Uni- Health and Welfare, Woosong University. He earned
versity. He is a director of applied kinesiology and a B.S. degree in Department of Health Science from
ergonomic technology laboratory, and his research Yonsei University, a Masters degree in Public Health
interests are identication of etiologic factors, clas- in the Graduate School, Yonsei University, and a Ph.D
sication, and intervention approaches for move- degree in the Department of Rehabilitation Science,
ment disorders and musculoskeletal diseases. University of Florida, Gainesville, Florida. He has an
extensive clinical experience in the care of patients
with Parkinsons, musculoskeletal, and geriatric-
related diseases at acute care hospitals, sub-acute
Tae-Lim Yoon is a professor in the Department rehabilitation/long-term care, and out-patient set-
of Physical Therapy at the College of Health and tings for 20 years in the United States. His research
Welfare of Woosong University and Ph.D. Candidate interests involve the development of patient-repor-
in the Department of Physical Therapy at the ted instruments as well as rehabilitation outcome
Graduate School of Yonsei University. He received measures.
B.S. degree in Physical Therapy from Yonsei
University, M.A. degree in Physical Therapy from
New York University. He is a member of applied
kinesiology and ergonomic technology laboratory,
and his research interests are movement analysis,
human factors and ergonomics, and prevention
and management of musculoskeletal problems.

Please cite this article in press as: Lee J-h et al. The effect of scapular posterior tilt exercise, pectoralis minor stretching, and shoulder brace on scapular
alignment and muscles activity in subjects with round-shoulder posture. J Electromyogr Kinesiol (2014), http://dx.doi.org/10.1016/j.jelekin.2014.10.010