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Closed Kinetic Chain Upper Extremity Stability Test (CKCUES Test): a

reliability study in persons with and without shoulder impingement
syndrome.

Article  in  BMC Musculoskeletal Disorders · January 2014

DOI: 10.1186/1471-2474-15-1 · Source: PubMed

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Tucci et al. BMC Musculoskeletal Disorders 2014, 15:1
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RESEARCH ARTICLE Open Access

Closed Kinetic Chain Upper Extremity Stability

test (CKCUES test): a reliability study in persons
with and without shoulder impingement
syndrome
Helga Tatiana Tucci1,2*, Jaqueline Martins2, Guilherme de Carvalho Sposito3, Paula Maria Ferreira Camarini4
and Anamaria Siriani de Oliveira2

Abstract
Background: The Close Kinetic Chain Upper Extremity Stability Test (CKCUES test) is a low cost shoulder functional
test that could be considered as a complementary and objective clinical outcome for shoulder performance
evaluation. However, its reliability was tested only in recreational athletes’ males and there are no studies
comparing scores between sedentary and active samples. The purpose was to examine inter and intrasession
reliability of CKCUES Test for samples of sedentary male and female with (SIS), for samples of sedentary healthy
male and female, and for male and female samples of healthy upper extremity sport specific recreational athletes.
Other purpose was to compare scores within sedentary and within recreational athletes samples of same gender.
Methods: A sample of 108 subjects with and without SIS was recruited. Subjects were tested twice, seven days
apart. Each subject performed four test repetitions, with 45 seconds of rest between them. The last three
repetitions were averaged and used to statistical analysis. Intraclass Correlation Coefficient ICC2,1 was used to assess
intrasession reliability of number of touches score and ICC2,3 was used to assess intersession reliability of number of
touches, normalized score, and power score. Test scores within groups of same gender also were compared.
Measurement error was determined by calculating the Standard Error of the Measurement (SEM) and Minimum
detectable change (MDC) for all scores.
Results: The CKCUES Test showed excellent intersession reliability for scores in all samples. Results also showed
excellent intrasession reliability of number of touches for all samples. Scores were greater in active compared to
sedentary, with exception of power score. All scores were greater in active compared to sedentary and SIS males
and females. SEM ranged from 1.45 to 2.76 touches (based on a 95% CI) and MDC ranged from 2.05 to 3.91
(based on a 95% CI) in subjects with and without SIS. At least three touches are needed to be considered a real
improvement on CKCUES Test scores.
Conclusion: Results suggest CKCUES Test is a reliable tool to evaluate upper extremity functional performance for
sedentary, for upper extremity sport specific recreational, and for sedentary males and females with SIS.
Keywords: Upper extremity, Functional test, Reliability

* Correspondence: [email protected]
1
Department of Human Movement Science, Federal University of São Paulo,
Santos, Brazil
2
Department of Biomechanics, Medicine and Rehabilitation of Locomotor
Apparatus, School of Medicine, University of São Paulo, Ribeirão Preto, Brazil
Full list of author information is available at the end of the article

© 2014 Tucci et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Tucci et al. BMC Musculoskeletal Disorders 2014, 15:1 Page 2 of 9
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Background know the minimal change without error that could be

Commonly, the musculoskeletal physical exam is focused considered as meaningful to report clinically significant or
on measures of range of motion (ROM) and muscular real gain in the scores obtained between sessions [13,14].
strength of the affected segment that could not provide Thus, the objectives of this study were (i) to determine the
enough information about overall segment functional level intrasession and intersession reliability of CKCUES Test
of activity [1]. Thus, shoulder evaluation could be improved scores for samples of sedentary healthy males and females,
by including techniques those assess functional movements healthy recreational upper extremity sport specific athletes,
and biomechanical impairment present in professional or and for sedentary males and females with SIS; (ii) to com-
daily life activities [1]. Functional tests could be considered pare the scores of CKCUES Test among healthy sedentary,
a valuable complementary low-cost clinical tool to provide recreational upper extremity sport specific, and SIS samples
quantitative data about the functional ability and perform- and (iii) to determine the standard error of measurement
ance of a body segment [2,3]. Some tests also can be (SEM) and minimum detectable change (MDC) of number
used to record the progress of a rehabilitation protocol of touches among groups to assist the clinical interpretation
by measuring, for example, performance and ability of a of shoulder performance improvement.
patient during physical task [4-7].
The Closed Kinetic Chain Upper Extremity Stability Methods
Test (CKCUES Test) is a performance test that provides Subjects
quantitative data (score) for a upper extremity task in The population of interest in this study was males and
closed kinetic chain (CKC) with no needs of high technol- females with and without subacromial impingement
ogy to be realized in sportive or clinical settings. The test syndrome. Subjects with no shoulder impairments were
consists in counting how much times, during 15 seconds, recruited from a local university area. Patients with SIS
the subject assuming a push-up position is able to touch were recruited from a university’s orthopedic service. All
his/her supporting hand with the swinging hand. The test participants read and signed consent form before starting
is considered easy for clinicians to apply and also easy for in the study procedures. The study protocol was approved
clients to understand [8]. by the University Ethics Committee.
CKCUES Test was applied to subjects with different A total of 108 volunteers, aged between 20 and 65 years,
shoulder dysfunctions [8] and to evaluate shoulder per- were included in this study and their anthropometric data
formance before and after a muscle strengthening proto- are described in Table 1. Volunteers were divided into six
col [1,7]. However, the diversity of patients with shoulder groups: a) healthy sedentary males (n = 20), b) healthy
dysfunction ranges from ordinary people who would like sedentary females (n = 20), c) healthy males’ upper extrem-
to return to their free-pain daily life activity to elite ath- ity sport-specific recreational athletes (n = 20), d) healthy
letes that want to return to their professional routine [9]. females’ upper extremity sport-specific recreational athletes
As CKCUES Test is a performance test, subjects with low (n = 20), e) sedentary males with SIS (n = 13) and f) seden-
physical activity levels and patients with painful shoulder tary females with SIS (n = 15).
dysfunctions or injuries might find it difficult to properly Subjects were considered sedentary when they per-
perform or to complete the test, thus affecting score results formed less than 30 minutes of daily physical activity
and test reliability. [15]. Additionally, the activities should be non-specific
Number of touches reliability of CKCUES Test, in push- for upper extremity and without aim of physical training
up position, was published only for a sample of recreational or competitions. Otherwise, subjects were considered
male athletes without shoulder dysfunction [2]. However, physically active when they were performing one or
CKCUES Test can be performed by females in a modified more physical activity at least three times per week in
(or kneeling) push-up position as suggested by original pro-
Table 1 Demographic characteristic [mean and
posers and also can be used to assess males and females
(standard deviation)] of volunteer groups
with shoulder conditions. Thus, to be considered as a tool
Groups Age (y) Weight (Kg) Height (m)
to assess and follow upper extremity performance it is ne-
Sedentary male (n=20) 24.95 (2.45) 81.99 (12.58) 1.75 (0.05)
cessary to determine the test reliability considering genders,
level of physical activity, and presence of shoulder impair- Sedentary female (n=20) 22.65 (3.00) 56.25 (5.58) 1.62 (0.08)
ment. Although, there was a variety of shoulder conditions Active¥ Male (n=20) 23.15 (2.48) 75.70 (10.49) 1.73 (0.05)
those could be considered to be included in this study, a Active¥ Female (n=20) 21.75 (1.37) 57.45 (8.91) 1.61 (0.06)
sample with subacromial impingement syndrome (SIS) was Male SIS£ (n=13) 45.15 (12.59) 83.73 (12.73) 1.70 (0.06)
chosen for being the most common shoulder dysfunction
Female SIS£ (n=15) 49.87 (5.87) 68.85 (15.87) 1.55 (0.06)
causing pain and impairment of function [10-12]. ¥
Active = young healthy male or female recreationally active for upper
Additionally, to apply CKCUES Test as a measure of extremity sport-specific.
shoulder performance improvement, it is important to £
SIS = subacromial impingement syndrome.
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the last 3 months or more, including at least one spe- number of touches. The second examiner was respon-
cific activity for upper extremity with no other reason sible to check the digital stopwatch and verbally in-
than recreational fitness. formed the first examiner the beginning and ending of
Inclusion criteria for SIS groups were history of shoulder the test.
pain for at least 3 months, at least two positive shoulder Two testing procedures were realized over 2 sessions,
impingement tests (Neer, Hawkins/Kennedy, Jobe), shoul- seven days apart. At the first session, the first examiner
der abduction or flexion painful arc of motion (60°-120°); was responsible to explain how CKCUES test should be
shoulder flexion and abduction of at least 90°, to be youn- performed and, in the sequence, the examiner herself
ger than 65 years-old; to be sedentary; and should not be in demonstrated the properly way to perform the test.
a physical therapy rehabilitation program. For healthy The CKCUES test is performed from a push-up pos-
subjects, inclusion criteria were to be sedentary or upper ition. Males perform CKCUES test by assuming a
extremity sport-specific recreational athletes, absence of push-up position and females by assuming a modified
shoulder pain; absence of previous surgery in the spine and (kneeling) push-up position; both with back flat paral-
upper extremity, and absence of complaints in the shoulder, lel to the floor, hands at 36-inches apart and weight-
elbow, wrist, hand and trunk musculoskeletal system. bearing upper extremities positioned perpendicular to
Exclusion criteria for all volunteers were history of the floor and over the hands (Figure 2). Two parallel
total tear in any muscle of shoulder complex; history of and aligned lines are marked on the floor to determine
surgery or traumatic injury to the trunk, elbow or hand; the initial placement of the hands. Thus, to beginning
history of luxation or orteoarthrosis in the glenohumeral the test, subject assumes a push-up position with one
or acromioclavicular joints; rheumatoid, neurological hand of each line marked at the floor. Then, during
or degenerative disease; and positivity to Adison and/ 15 seconds, the subject leans over one hand and picks
or Allen tests. Inclusion and exclusion criteria were up the opposite hand reaches over to touch hands and
checked through the interview and clinical examination then returns the hand to the starting position.
performed by a physical therapist previously to the ex- After the instructions and demonstration, every sub-
perimental procedure. ject performed a familiarization task, performing few
A total of 152 medical records from orthopedic sector repetitions of hand touches. Verbal cues were given during
of a local hospital were analyzed and 106 patients with familiarization when necessary.
SIS diagnosed by a senior orthopedic physician were eli- Then, for data collections, each volunteer performed
gible for the study in a period of 11 months. From those three trials of 15 seconds. The time counting started
106 patients, 56 patients were recruited to perform the when the second examiner said “GO” and stopped
test, but 11 were unable to performing the test and 6 did when the same examiner said “STOP”. A time rest of
not attend the retest day. Thus, 15 women and 13 men 45 seconds was established between repetitions, be-
with subacromial impingement syndrome completed the cause a work/rest ratio of 1:3 was suggested as appro-
study protocol (Figure 1). Clinical findings of the SIS group priate for avoiding fatigue effects in the performance
participants are briefly described. All subjects were positive during a short duration and relative high intensity
for Neer and Hawkins’ tests and for painful arc of motion test, such as CKCUES Test [2]. If the subject was un-
between 60° and 120°. Traumatic (unidirectional) joint able to perform properly the test, he/she was stopped
instability tests were negative. SIS samples showed reduced and after 45 seconds of rest another repetition was
values of active glenohumeral joint range of motion (ROM). tried. Acceptable male test repetition was defined as
However, they were able to rise their upper extremity at fully test complete with back flat, did not touch down
least 130º of shoulder flexion and 140º of shoulder abduc- the floor with knee(s), kept his weight-bearing upper
tion. Their grades for manual muscle testing (MMT) range extremity perpendicular to the floor and over his
from 5/normal (subject completes ROM against gravity with hands, and keep his/her feet as in the initial position.
maximal resistance) to +3/fair plus (completes ROM against Females had an acceptable repetition when keeping
gravity with only minimal resistance). All MMT grades were back flat, weight-bearing upper extremity perpendicu-
reduced in the affected side of males and females when lar to the floor and over his hands.
compared to the non-affected side, with exception of MMT Rating Numeric Rating Scale (RNRS) [16] was applied
grades for the shoulder extension muscle group which were to assess pain before and after experimental procedure
reduced only in the female group. of data collecting. Pain was analyzed to observe if test
could cause pain, in which level and, also to report if a
Testing procedure specific level of pain could prevent the test accomplish-
As measuring the reliability of the CKCUES was one ment. In the second session, experimental procedures were
purpose of this study, test procedures were conducted repeated to obtain data to estimate test–retest reliability,
by two examiners. The first examiner counted the with exception of physical examination.
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Figure 1 Subacromial shoulder syndrome (SIS) volunteer recruitment process flowchart.

Data analysis corresponds to the weight of the arms, head and trunk)
The CKCUES test was proposed [8] to provide three scores: divided by 15 (elapsed test time in seconds).
1) Number of touches score: representing the number Intrasession and intersession reliability of CKCUES test
of touches that subjects can perform in 15 seconds. were calculate using values scores obtained from the last
2) Normalized score: obtained dividing the number of three of four repetitions in both sessions. The intersession
touches by subject height and; 3) Power score: obtained reliability of CKCUES Test was determined for number of
by multiplying the average number of touches by 68% touches, normalized score and power score using mean
of subject’s body weight in kilograms (percentage that values of the last three repetitions between test and retest

A B

Figure 2 CKCUES Test initial position. A. Push-up initial position for male test, and B. Modified push-up initial position for female. Hands were
36-inches apart.
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session. The intrasession reliability of CKCUES Test was A one-factor Analysis of Variance was chosen to com-
determined for number of touches score of test and retest. pare scores of CKCUES Test between SIS, sedentary and
Number of touches, normalized score and power score recreationally athletes for upper extremity sport specific
mean values were compared among groups within the groups within same gender. The Shapiro-Wilk test was
same gender in both sessions. used for post hoc analysis when differences were found.
Standard Measurement Error (SEM) was calculated for The level of significance was set at 5%.
comparisons of scores of CKCUES Test between groups of
the same gender. This analysis was determined aiming to Results
estimate how reliably the scores of CKCUES Test estimate Descriptive data of number of touches and normalized
an “true score” that could be obtained for a subject if the score showed that values for healthy groups were consid-
scores measures rightly, without error [13]. The Minimal ered inside the CKCUES Test reference scores (Table 2).
Detectable Change (MDC) also was calculated for com- Scores of SIS samples were lower than reference scores
parisons between groups of the same gender. MDC is the values (Table 2). All scores obtained of healthy female and
minimal amount of change required for the CKCUES Test healthy male upper extremity sport-specific athletes were
score exceeds the measurement error; that is to determine greater than its correspondent gender of SIS group. With
the smallest amount of change that could be considered exception of power score compared among females
relevant to detect a difference between 2 measurements of groups of sedentary and healthy upper extremity sport
same score. specific athletes, all scores were greater where compared
Pain measurement was obtained by Visual Numeric between active and healthy groups. When sedentary males
Rating Scale (VNRS). Rating 0 represents no pain, rating and active males were compared, there were not found
1–3 represents mild pain; rating 4–6 represents moderate differences between scores (Table 3).
pain, and rating 7–10 represents severe pain [15]. VNRS The intrassesion reliability of CKCUES Test for all
ratings of pain were compared pre and post test performing samples showed excellent intraclass correlation coeffi-
for each session. Pain scores will be showed in percentile, cient (ICC > 0.75) for number of touches, power score
for each session and for each sample. and normalized score. Intersession reliability of CKCUES
test for all scores also showed excellent values of ICC
(ICC >0.75) for all samples (Table 4).
Statistical analysis Number of touches SEM for groups ranged from 1.45
Reliability was assessed by using intraclass correlation to 2.76 touches, and MDC95% ranged from 2.05 to 3.91
coefficient (ICC) with 95% confidence interval. The touches. For power scores, SEM ranged from 6.02 to
intersession reliability of number of touches, normalized 20.03, and MDC from 8.52 to 28.32. Normalized score
score, and power score was assessed using ICC2,3 model SEM ranged from 0.02 to 0.04, and MDC from 0.03 to
(two-way random effect model analysis of variance). 0.06 (Table 5).
To determine the intrasession reliability of number of Healthy subjects reported no shoulder pain before
touches ICC2,1 model (two-way random effect model performing the test in both sessions. After test, mild
analysis of variance) was chosen for analysis [17]. ICC pain was reported by males sport specific recreational
values of 0.75 and above represent good reliability, athletes (25% of subjects in test and 15% in retest), by
values between 0.40 and 0.74 represent moderate reli- females sport specific recreational athletes (35% of subjects
ability and those below 0.40 indicate poor reliability in test and 25% in retest), and by sedentary females
0.75 [18]. Statistical analyses were conducted using (10% in test and 20% in retest). Sedentary males reported
SPSS Version 16.0. mild (20% in test and 25% in retest) and moderate pain
Standard Error Measurement (SEM) and Minimum (10% in test and 5% in retest) after test.
Detectable Change at 95% of Confidence Interval (CI) For samples with SIS, 96.4% of subjects reported severe
were determined for each test score by the formulas:
pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi and moderate pain before test in both sessions. After
SEM 95 ¼ SD  ð1−ICC test−retest Þ, where SD is the stand- test, 86.7% of females in the test session and 80% in the
ard deviation of mean at baseline; and ICC (2,3) value retest session remained with pain in moderate and severe
was derived from test-retest reliability [13]. The SEM levels and 16.7% reported pain relief after test session
was multiplied by the z value associated with the 95% (13.3% in test and 20% in retest), changing their pain level
CI (z = 1.96) to achieve 95% confidence level. to a lower category.
pffiffiffi
MDC 95 ¼ 1:96  SEM 95  2 , where SEM is the stand-
ard error of measurement [19]. The 95% CI was calculated Discussion
for the MDC, which is the statistically minimal amount of The purpose of this study was to evaluate the test-retest
change required in CKCUES Test score to be 90% confident reliability of Closed Kinetic Chain Upper Extremity Stability
that true change has occurred. Test- CKCUES test scores. Results showed excellent values
Tucci et al. BMC Musculoskeletal Disorders 2014, 15:1 Page 6 of 9
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Table 2 Test and retest mean (and standard deviation) of CKCUES Test scores and reference values
CKCUES test scores
Number of touches Power Normalized score
Groups Test Retest Test Retest Test Retest
Sedentary male (n=20) 22.67 (3.75) 25.30 (3.68) 83.43 (14.66) 93.37 (16.10) 0.33 (0.06) 0.37 (0.06)
Sedentary female (n=20) 24.58 (4.48) 28.47 (4.96) 62.93 (14.60) 72.87 (17.05) 0.39 (0.07) 0.45 (0.08)
¥
Active Male (n=20) 24.78 (3.19) 27.13 (3.15) 84.47 (11.59) 92.78 (13.92) 0.40 (0.05) 0.39 (0.05)
Active¥ Female (n=20) 27.97 (3.84) 31.97 (4.47) 72.55 (12.90) 83.06 (16.23) 0.44 (0.06) 0.51 (0.08)
£
Male SIS (n=13) 10.10 (3.31) 11.82 (2.68) 38.59 (14.46) 45.02 (12.22) 0.15 (0.05) 0.18 (0.04)
Female SIS£(n=15) 12.20 (3.64) 13.73 (3.41) 37.63 (12.54) 42.33 (12.49) 0.20 (0.06) 0.23 (0.06)
Male reference values 18.5 150 0.26
Female reference values 20.5 135 0.31
¥
Active = young healthy male or female recreationally active for upper extremity sport-specific.
£
SIS = subacromial impingement syndrome.

of ICC for intersession reliability of number of touches or injuries. Moreover, that test includes an equipment
score. Intrasession reliability of test also showed excellent to sample quantitative data. Thus, we believe our results
(ICC ≥ 0.75) values scores for all samples. The results sup- could be important for sportive and clinical assessment for
port the reliability of CKCUES Test as a complementary two reasons. First because CKCUES Test is a low cost test
outcome measure for evaluating shoulder functional condi- with no need of an equipment to measure the scores, and
tion in healthy sedentary, healthy active and SIS subjects. second because the reliability of the test was determined
Results of intrasession reliability of this research are in for samples with different levels of physical conditioning
accordance to Goldbeck & Davies, the only study found and also in sample with SIS. Thus, we believe clinicians
in the literature about CKCUES Test reliability. However, and athletic trainers can choice this test to first evaluations
Goldbeck & Davies assessed just reliability of number of and to follow-ups of upper extremity performance.
touches score in a sample of male recreational athletes. Number of touches and normalized score values obtained
Moreover, there were not found studies about CKCUES in this research were greater than the reference values for
Test reliability in females, sedentary subjects and in a sam- CKCUES Test [8]. However, it is important to consider that
ple with shoulder injury. Thus, some results of this study from the original reference there is not a range of values,
were not possible to be compared with other researches. but only a unique value for each score that could be
There was found in the literature other research that considered as reference. Thus if a person has his/her
has determined reliability of other closed kinetic chain score lower than reference values, scores of test can be
performance tests for upper extremity, with excellent values improved. Otherwise, if scores are greater than references
of test-retest reliability [1]. However, that research also values, a comparison of those score could be done before
has not evaluated subjects with shoulder dysfunctions and after a specific training as parameter of evaluation.

Table 3 CKCUES Test scores [mean (standard deviation)] for comparisons within gender groups
CKCUES test
Number of touches Power Normalized score
Groups Test Retest Test Retest Test Retest
Sedentary male (n=20) 22.67 (3.75)* 25.30 (3.68)* 83.43 (14.66)* 93.37 (16.10)* 0.33 (0.06)* 0.37 (0.06)*
Active¥ Male (n=20) 24.58 (4.48) ○ 28.47 (4.96) ○
62.93 (14.60) ○ 72.87 (17.05) ○ 0.39 (0.07) ○ 0.45 (0.08) ○
¥ §■ §■ ■ ■ §■
Active Female (n=20) 27.97 (3.84) 31.97 (4.47) 72.55 (12.90) 83.06 (16.23) 0.44 (0.06) 0.51 (0.08) §■
Sedentary female (n=20) 24.78 (3.19) §& 27.13 (3.15) §& 84.47 (11.59) & 92.78 (13.92) & 0.40 (0.05) §& 0.39 (0.05) §&
○ ○ ○ ○ ○
£
Male SIS (n=13) 10.10 (3.31)* 11.82 (2.68)* 38.59 (14.46)* 45.02 (12.22)* 0.15 (0.05)* 0.18 (0.04)* ○
Female SIS£ (n=15) 12.20 (3.64) &■ 13.73 (3.41) &■ 37.63 (12.54) &■ 42.33 (12.49) &■ 0.20 (0.06) &■ 0.23 (0.06) &■
¥ ■
Active = young healthy male or female recreationally active for upper extremity sport-specific .
£
SIS = subacromial impingement syndrome.
§
significant difference between sedentary and young recreationally healthy female.
& significant difference between sedentary and SIS female.
*significant difference between sedentary and SIS male.
■
significant difference between SIS female and young recreationally healthy female.
○
significant difference between SIS male and young recreationally healthy male.
Tucci et al. BMC Musculoskeletal Disorders 2014, 15:1 Page 7 of 9
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Table 4 Intraclass correlation coefficients (confidence intervals of 95%) for CKCUES Test score intrasession and
intersession reliabilities
Intersession reliability Intrasession reliability
Groups Number of touches Power Normalized score Number of touches Number of touches
Test-retest Test-retest Test-retest Test Re-test
ICC2,3 (IC95%) ICC2,3 (IC95%) ICC2,3 (IC95%) ICC2,1 (IC95%) ICC2,1(IC95%)
Sedentary male (n=20) 0.96 0.96 0.96 0.96 0.96
(0.89;0.98) (0.90;0.99) (0.89;0.98) (0.92;0.98) (0.92;0.98)
Sedentary female (n=20) 0.92 0.96 0.92 0.96 0.97
(0.80;0.97) (0.89;0.98) (0.81;0.97) (0.92;0.98) (0.93;0.99)
Active¥ Male (n=20) 0.89 0.84 0.90 0.93 0.95
(0.71;0.96) (0.58;0.94) (0.75;0.96) (0.95;0.99) (0.89;0.98)
Active¥ Female (n=20) 0.85 0.82 0.87 0.90 0.95
(0.62;0.94) (0.55;0.93) (0.67;0.95) (0.90;0.99) (0.90;0.98)
Male SIS£ (n=13) 0.91 0.93 0.92 0.96 0.97
(0.70;0.97) (0.75;0.98) (0.72;0.97) (0.88;0.99) (0.92;0.99)
Female SIS£ (n=15) 0.93 0.94 0.94 0.86 0.92
(0.78;0.98) (0.81;0.98) (0.81;0.98) (0.70;0.98) (0.82;0.97)
¥
Active = young healthy male or female recreationally active for upper extremity sport-specific.
£
SIS = subacromial impingement syndrome.

Anthropometric characteristics of samples could have test consider a unique value of 36-inches (91,44 cm)
influenced these results, mainly because height and weight distance between hands, independent of subject’s height [8],
are used in the formulas for calculating normalized score could limit the comparisons of performance among sub-
and power score, respectively. jects. For example, a taller person could perform the test
A possible justification regarding wider confidence faster than one smaller due the larger wingspan, which
interval of intersession reliability values of ICC of recre- could result in a greater score of number of touches,
ational athletic samples and SIS samples for all scores and consequently, in a greater value of normalized score
could be the variability of weight and height among and power score. Thus, when normalized score and power
subjects at the same group. Despite the excellent reliability score are analyzed, anthropometric variables are considered
for number of touches, it is important to consider that in the score estimates.
power and normalized score are dependent of the subject’s On the other hand, there is another possibility to dimin-
anthropometric variable. As adults composed the sam- ish the influence from the anthropometric characteristics
ples those variations is more likely to be from their body of the subject’s height on the number of touches score
weight changes. by setting the distance between hands as a percentage of
Moreover, considering the difference in the subject’s the total size of the subject’s wingspan or as a distance
wingspan, i.e. the distance between fingertip to fingertip between scapular acromions. However, further studies are
of middle fingers with the arms spread, the fact of this necessary to analyze if those changes in the CKC test are

Table 5 Standard error of measurement and minimal detectable change of each CKCUES Test score
Groups Number of touches Power Normalized score
SEM95 MDC95 SEM95 MDC95 SEM95 MDC95
Sedentary male (n=20) 1.45 2.05 12.58 17.79 0.02 0.03
Sedentary female (n=20) 2.43 3.43 12.94 18.30 0.04 0.05
¥
Active Male (n=20) 2.0 2.82 20.03 28.32 0.03 0.04
Active¥ Female (n=20) 2.76 3.91 12.94 18.30 0.04 0.06
Male SIS£ (n=13) 1.95 2.76 7.50 10.61 0.03 0.04
Female SIS£ (n=15) 1.89 2.67 6.02 8.52 0.03 0.04
¥
Active = young healthy male or female recreationally active for upper extremity sport-specific.
£
SIS = subacromial impingement syndrome.
SEM95 = standard error of measurement.
MDC95 = minimal detectable change.
Tucci et al. BMC Musculoskeletal Disorders 2014, 15:1 Page 8 of 9
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feasible, create reliable scores and safety biomechanics for Conclusion

patients with shoulder dysfunctions. Results showed that CKCUES Test is a reliable tool for
To date, no studies analyzing the SEM and MDC of evaluating upper extremity functional activity in sedentary
scores of CKCUES Test were found. However, it is im- and upper extremity sport specific males and females and
portant to have knowledge about what is the minimal also in subjects with subacromial impingement syndrome.
difference in the scores of an evaluation tool between Results also showed that a change of at least 3 touches for
revaluation sessions that could be considered as a real sedentary active and subacromial impingement syndrome
improvement with no error [13,14]. Thus, our results could males, and at least 3 touches for subacromial impingement
guide clinicians and athletic trainers with these values syndrome females and 4 touches for active and sedentary
for subjects with and without SIS and with different female is necessary to be considered as an improvement
levels of physical activity lifestyle. in the CKCUES Test scores.
Considering values of SEM and MDC for females groups,
changes between sessions could be considered as a true
Implications for physiotherapy practice
change when number of touches score exceeds 4 touches
Different from lower extremity, upper extremity perform-
for a sedentary, 4 touches for a active and 3 for a SIS
ance test are not profuse. Any additional tool to asses upper
person. In groups of males, changes between sessions
extremity performance is important for practitioners if it
could be considered as a true change when number of
has clinical or sportive meaningful information, if it could
touches score exceeds 2 touches for a sedentary, 3 for
be simply fitted to clinical and sportive settings with low
active and 3 for a SIS person. With those number of
cost and, if it has clinimetric proprieties tested, as Reliability,
touches changes, normalized score and power score also
Standard Error Measurement and Minimum Detectable
will be changed. Thus, those number of touches values
Change. In this way, CKCUES Test showed to be a valuable
could be considered as the minimal change between
performance test for both healthy and subacromial
CKCUES Test evaluations that could be considered as a
impingement syndrome subjects with different levels
real change of improvement.
of physical activity lifestyle. Thus, this study had con-
Some healthy subjects reported shoulder pain after
tributed to practice presenting how much reliable is
test, even with no pain reporting before the test. A pos-
CKCUES Test and how to interpret the change in the
sible justification could be the fact that CKCUES Test
Number of Touches Scores when applying it as a per-
is a high level performance test, which can cause a high
formance follow-up test.
demand over shoulders. Lastly, based on reliability re-
sults from samples with SIS, shoulder pain was not an
Competing interests
impediment to those subjects performs the test, inde- The authors declare that they have no competing interests.
pendently of rating level. In samples with SIS, a greater
level of pain post test compared to pre test was expected Authors’ contributions
before by the same justification. Thus, clinicians should HTT: participated in the design of the study, data collecting, data analysis
have care when the test is considered in the initial clin- and draft the manuscript. JM: participated in the design of the study, data
collecting, performed the statistical analysis, and draft the manuscript. GCS:
ical evaluation of a subject with shoulder injury. Care participated the design of the study and recruitment of the subjects. ASO:
also should be taken when the test is being performed. participated in the design of the study and draft the manuscript. All authors
If a subject shows an incorrect body positioning or read and approved the final manuscript.
some compensatory movements, or if the subject re-
port pain during the test, an interruption might be ne- Acknowledgment
cessary, since the axial load applied to the arm 90 Authors are thankful for Fundação de Amparo à Pesquisa do Estado de
São Paulo - FAPESP (process numbers: 2008/50675-6 and 2008/51456-6)
degrees elevate in anterior flexion is close to body for financial support.
weight when the subject is touching hands in the end
of the swing phase. Funding
Results showed that CKCUES Test is a reliable tool Fundação de Amparo à Pesquisa do Estado de São Paulo - FAPESP
to evaluate upper extremity function in sedentary and (process numbers: 2008/50675-6 and 2008/51456-6) for financial support.
young male or female recreationally active subjects and Author details
also in subjects with SIS. However, this study has some 1
Department of Human Movement Science, Federal University of São Paulo,
limitations, such as subjects without shoulder injury Santos, Brazil. 2Department of Biomechanics, Medicine and Rehabilitation of
Locomotor Apparatus, School of Medicine, University of São Paulo, Ribeirão
are from a young population, elite athletes were not Preto, Brazil. 3Physiotherapy Orthopedic Clinic, Ribeirão Preto, Brazil.
included, and only with SIS participants represented 4
Post-Graduation Program in Rehabilitation and Functional Performance,
shoulder dysfunction in our sample. This way, the re- University of São Paulo, Ribeirão Preto, Brazil.
sults of this study should be carefully analyzed when Received: 10 May 2013 Accepted: 10 December 2013
extended to other populations. Published: 3 January 2014
 Tucci et al. BMC Musculoskeletal Disorders 2014, 15:1 Page 9 of 9
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doi:10.1186/1471-2474-15-1
Cite this article as: Tucci et al.: Closed Kinetic Chain Upper Extremity
Stability test (CKCUES test): a reliability study in persons with and
without shoulder impingement syndrome. BMC Musculoskeletal Disorders
2014 15:1.
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