Feasibility and Validity of the Coma Recovery Scale-Revised for Accelerated Standardized Testing: A Practical Assessment Tool for Detecting Consciousness in the Intensive Care Unit.

We developed and validated an abbreviated version of the Coma Recovery Scale-Revised (CRS-R), the CRS-R For Accelerated Standardized Testing (CRSR-FAST), to detect conscious awareness in patients with severe traumatic brain injury in the intensive care unit. In 45 consecutively enrolled patients, CRSR-FAST administration time was approximately one-third of the full-length CRS-R (mean [SD] 6.5 [3.3] vs 20.1 [7.2] minutes, p < 0.0001). Concurrent validity (simple kappa 0.68), test-retest (Mak's ρ = 0.76), and interrater (Mak's ρ = 0.91) reliability were substantial. Sensitivity, specificity, and accuracy for detecting consciousness were 81%, 89%, and 84%, respectively. The CRSR-FAST facilitates serial assessment of consciousness, which is essential for diagnostic and prognostic accuracy. ANN NEUROL 2023;94:919-924.

Characterization of Running Intensity in Canadian Football Based on Tactical Position.

This study aimed to use a data-driven approach to identify individualized speed thresholds to characterize running demands and athlete workload during games and practices in skill and linemen football players. Data were recorded from wearable sensors over 28 sessions from 30 male Canadian varsity football athletes, resulting in a total of 287 performances analyzed, including 137 games and 150 practices, using a global positioning system. Speed zones were identified for each performance by fitting a 5-dimensional Gaussian mixture model (GMM) corresponding to 5 running intensity zones from minimal (zone 1) to maximal (zone 5). Skill players had significantly higher (p < 0.001) speed thresholds, percentage of time spent, and distance covered in maximal intensity zones compared to linemen. The distance covered in game settings was significantly higher (p < 0.001) compared to practices. This study highlighted the use of individualized speed thresholds to determine running intensity and athlete workloads for American and Canadian football athletes, as well as compare running performances between practice and game scenarios. This approach can be used to monitor physical workload in athletes with respect to their tactical positions during practices and games, and to ensure that athletes are adequately trained to meet in-game physical demands.

Continuous suprascapular nerve blockade to potentiate intensive rehabilitation for refractory adhesive shoulder capsulitis: a cohort study.

PURPOSE: Evaluating the short- and long-term efficacy of a continuous ten day suprascapular nerve block combined with daily multidisciplinary rehabilitation on shoulder range of motion (ROM), pain, and function in patients with refractory adhesive capsulitis (AC). METHODS: In this retrospective cohort study, patients admitted to a specialized pain clinic for refractory AC for more than 6 months underwent continuous suprascapular nerve blockade for ten days and received 2 hours of physiotherapy and occupational therapy daily. Standardized assessments were performed at baseline, at days three, six, ten, 30, 90, and 180, and included active and passive ROM measurements, the visual analog scale (VAS) for pain and the disabilities of the arm, shoulder and hand (DASH) questionnaire to assess pain, disability, and quality of life. Improvements over time were assessed using ANOVAs. RESULTS: Thirty-two patients were followed (age: 52 ± 8 years, 25 females, mean symptoms duration of two years). There was a significant improvement in ROM for all amplitudes at day ten (short-term; range: 20-35°, p < 0.001) and at day 180 (long-term; range: 18-47°, p < 0.001). The pain and disability scores significantly reduced by day 180 (mean VAS reduction: 2.6 units, p < 0.001; mean DASH reduction: 9.5 points, p < 0.001). CONCLUSION: Continuous SSNB combined with intensive multidisciplinary rehabilitation represents an efficient therapeutic option for patients with chronic AC who did not respond to conventional treatments.

Sham-controlled randomized multicentre trial of transcranial direct current stimulation for prolonged disorders of consciousness.

BACKGROUND AND PURPOSE: Transcranial direct current stimulation (tDCS) has been shown to improve signs of consciousness in a subset of patients with disorders of consciousness (DoC). However, no multicentre study confirmed its efficacy when applied during rehabilitation. In this randomized controlled double-blind study, the effects of tDCS whilst patients were in rehabilitation were tested at the group level and according to their diagnosis and aetiology to better target DoC patients who might repond to tDCS. METHODS: Patients received 2 mA tDCS or sham applied over the left prefrontal cortex for 4 weeks. Behavioural assessments were performed weekly and up to 3 months' follow-up. Analyses were conducted at the group and subgroup levels based on the diagnosis (minimally conscious state [MCS] and unresponsive wakefulness syndrome) and the aetiology (traumatic or non-traumatic). Interim analyses were planned to continue or stop the trial. RESULTS: The trial was stopped for futility when 62 patients from 10 centres were enrolled (44 ± 14 years, 37 ± 24.5 weeks post-injury, 18 women, 32 MCS, 39 non-traumatic). Whilst, at the group level, no treatment effect was found, the subgroup analyses at 3 months' follow-up revealed a significant improvement for patients in MCS and with traumatic aetiology. CONCLUSIONS: Transcranial direct current stimulation during rehabilitation does not seem to enhance patients' recovery. However, diagnosis and aetiology appear to be important factors leading to a response to the treatment. These findings bring novel insights into possible cortical plasticity changes in DoC patients given these differential results according to the subgroups of patients.

The awareness of injury prevention programmes is insufficient among French- and German-speaking sports medicine communities in Europe.

PURPOSE: Evaluate the current state of sports injury prevention perception, knowledge and practice among sports medicine professionals located in Western Europe and involved in injury prevention. METHODS: Members of two different sports medicine organizations (GOTS and ReFORM) were invited to complete a web-based questionnaire (in German and in French, respectively) addressing perception, knowledge and implementation of sports injury prevention through 22 questions. RESULTS: 766 participants from a dozen of countries completed the survey. Among them, 43% were surgeons, 23% sport physicians and 18% physiotherapists working mainly in France (38%), Germany (23%) and Belgium (10%). The sample rated the importance of injury prevention as "high" or "very high" in a majority of cases (91%), but only 54% reported to be aware of specific injury prevention programmes. The French-speaking world was characterized by lower levels of reported knowledge, unfamiliarity with existing prevention programmes and less weekly time spent on prevention as compared to their German-speaking counterparts. Injury prevention barriers reported by the respondents included mainly insufficient expertise, absence of staff support from sports organizations and lack of time. CONCLUSION: There is a lack of awareness regarding injury prevention concepts among sports medicine professionals of the European French- and German-speaking world. This gap varied according to the professional occupation and working country. Relevant future paths for improvement include specific efforts to build awareness around sports injury prevention. LEVEL OF EVIDENCE: Level IV.

Current practice for safe return-to-play after lateral ankle sprain: A survey among French-speaking physicians.

BACKGROUND: Recommendations are available for assessment criteria for safe return-to-play (RTP) after a lateral ankle sprain. However, their current use among physicians is unknown. METHODS: French-speaking physicians in Belgium, France and Switzerland were asked to complete an online survey and report their clinical assessment of selected RTP criteria. RESULTS: The respondent sample (n=109) included physicians with and without Sports Medicine education, varied level of experience and proportion of athletes in their practice population. Pain was the most selected criterion for safe RTP (90% of physicians), followed by ability to engage in functional tasks (82%), functional instability (73%), range of motion (61%), proprioception (47%), mechanical instability (39%), strength (38%) and swelling (31%). A low proportion of physicians use quantitative measures to assess these criteria (between 4% and 53%). CONCLUSIONS: A large proportion of physicians consider the recommended criteria for RTP decisions. However, physicians do not frequently use quantitative measures.

Temporal Profile of Recovery of Communication in Patients With Disorders of Consciousness After Severe Brain Injury.

OBJECTIVE: Characterize the temporal profile of recovery of communication after severe brain injury. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation hospital. PARTICIPANTS: Patients with severe acquired brain injury and no evidence of communication on the Coma Recovery Scale-Revised (CRS-R) (N=175). MAIN OUTCOME MEASURES: Time from injury to recovery of intentional communication (IC, inconsistent yes/no responses) and functional communication (FC, consistent and accurate yes/no responses) on the CRS-R Communication subscale. RESULTS: Patients (N=175) were included in the primary observation period of the first 8 weeks of inpatient rehabilitation (median [interquartile range, IQR]: 48 [27-61] years old, 105 men, 28 [21-38] days postinjury, 100 traumatic etiology). Fifty-four patients (31%) did not recover IC or FC. Thirty patients (17%) recovered IC only (median [IQR] days from injury to IC= 40 [34-54]), 72 patients (41%) recovered IC followed by FC (days from injury to FC=50 [42-61]), and 19 patients (11%) recovered FC without first recovering IC (43 [32-63]). The patients who recovered neither IC nor FC within 8 weeks of admission were admitted to rehabilitation later than those who recovered IC and/or FC (P<.01). Sixteen patients who did not recover communication within 8 weeks of admission to rehabilitation subsequently recovered FC prior to discharge. CONCLUSIONS: In patients with severe brain injury receiving inpatient rehabilitation, discernible yes-no responses emerged approximately 6 weeks postinjury and became reliable 1 week later. Approximately 1 in 3 patients did not demonstrate IC or FC within 8 weeks of admission to rehabilitation, although 33% of these individuals recovered communication prior to discharge. In total, 61% of patients recovered FC prior to discharge from rehabilitation.

Can the Nociception Coma Scale-Revised Be Used in Patients With a Tracheostomy?

OBJECTIVE: To investigate the influence of the presence of a tracheostomy tube to assess pain with the Nociception Coma Scale-Revised (NCS-R) in patients with disorders of consciousness (DOC). DESIGN: A cohort study in which patients were evaluated at a single time point. SETTING: Patients were evaluated in a tertiary care hospital. PARTICIPANTS: Patients (N=125) (unresponsive wakefulness syndrome [UWS]: 46 patients, minimally conscious state [MCS]: 74 patients, emerging from MCS [eMCS]: 5 patients, mean age: 46±16y, time since injury: 817±1280d) in a convenience sample were evaluated with the NCS-R after noxious stimulation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We compared the NCS-R scores of patients with and without tracheostomy with a Mann-Whitney U test. A secondary outcome was to evaluate the influence of the presence of a tracheostomy on the previously described cutoff score of 2. RESULTS: The presence of a tracheostomy was associated with lower verbal subscores (P=.002) as well as total scores (P=.039). The cutoff score of 2 remained valid for the group of patients with tracheostomy with a high sensitivity (71.43%) and specificity (89.29%), as well as when we excluded the verbal subscore of the NCS-R (sensitivity=83.2% and specificity=92.4%). CONCLUSION: Our study confirms the validity of the NCS-R in DOC patients with a tracheostomy. However, the presence of a nonspeaking tracheostomy should be clearly mentioned when applying the NCS-R, because it significantly lowers the verbal subscore.

A systematic analysis of distressing near-death experience accounts.

Near-death experiences (NDEs) are usually associated with positive affect, however, a small proportion are considered distressing. We aimed to look into the proportion of distressing NDEs in a sample of NDE narratives, categorise distressing narratives according to Greyson and Bush's classification (inverse, void or hellish), and compare distressing and "classical" NDEs. Participants wrote down their experience, completed the Memory Characteristics Questionnaire (assessing the phenomenology of memories) and the Greyson scale (characterising content of NDEs). The proportion of suicidal attempts, content and intensity of distressing and classical NDEs were compared using frequentist and Bayesian statistics. Distressing NDEs represent 14% of our sample (n = 123). We identified 8 inverse, 8 hellish and 1 void accounts. The proportion of suicide survivors is higher in distressing NDEs as compared to classical ones. Finally, memories of distressing NDEs appear as phenomenologically detailed as classical ones. Distressing NDEs deserve careful consideration to ensure their integration into experiencers' identity.

Single tDCS session of motor cortex in patients with disorders of consciousness: a pilot study.

Primary Objective: Patients with disorders of consciousness (DOC) face a lack of treatments and risk of misdiagnosis, potentially due to motor impairment. Transcranial direct current stimulation (tDCS) showed promising results over the prefrontal cortex in DOC and over the primary motor cortex (M1) in stroke. Tis pilot study aimed at evaluating the behavioral effects of M1 tDCS in patients with DOC.Research Design: In this randomized double-blind sham-controlled crossover trial, we included 10 patients (49 ± 22 years, 7 ± 13 months since injury, 4 unresponsive wakefulness syndrome, 6 minimally conscious state, 5 traumatic etiologies).Methods and Procedures: One session of tDCS (2 mA for 20 min) and one session of sham tDCS were applied over M1 in a randomized order with a washout period of minimum 24 h and behavioral effects were assessed using the CRS-R. At the group level, no treatment effect was identified on the total score (p = .55) and on the motor subscale (p = .75). Two patients responded to tDCS by showing a new sign of consciousness (visual pursuit and object localization).Conclusions: One session of M1 tDCS failed to improve behavioral responsiveness in patients with DOC. Other application strategies should be tested.

Brain networks predict metabolism, diagnosis and prognosis at the bedside in disorders of consciousness.

Recent advances in functional neuroimaging have demonstrated novel potential for informing diagnosis and prognosis in the unresponsive wakeful syndrome and minimally conscious states. However, these technologies come with considerable expense and difficulty, limiting the possibility of wider clinical application in patients. Here, we show that high density electroencephalography, collected from 104 patients measured at rest, can provide valuable information about brain connectivity that correlates with behaviour and functional neuroimaging. Using graph theory, we visualize and quantify spectral connectivity estimated from electroencephalography as a dense brain network. Our findings demonstrate that key quantitative metrics of these networks correlate with the continuum of behavioural recovery in patients, ranging from those diagnosed as unresponsive, through those who have emerged from minimally conscious, to the fully conscious locked-in syndrome. In particular, a network metric indexing the presence of densely interconnected central hubs of connectivity discriminated behavioural consciousness with accuracy comparable to that achieved by expert assessment with positron emission tomography. We also show that this metric correlates strongly with brain metabolism. Further, with classification analysis, we predict the behavioural diagnosis, brain metabolism and 1-year clinical outcome of individual patients. Finally, we demonstrate that assessments of brain networks show robust connectivity in patients diagnosed as unresponsive by clinical consensus, but later rediagnosed as minimally conscious with the Coma Recovery Scale-Revised. Classification analysis of their brain network identified each of these misdiagnosed patients as minimally conscious, corroborating their behavioural diagnoses. If deployed at the bedside in the clinical context, such network measurements could complement systematic behavioural assessment and help reduce the high misdiagnosis rate reported in these patients. These metrics could also identify patients in whom further assessment is warranted using neuroimaging or conventional clinical evaluation. Finally, by providing objective characterization of states of consciousness, repeated assessments of network metrics could help track individual patients longitudinally, and also assess their neural responses to therapeutic and pharmacological interventions.

Prevalence of coma-recovery scale-revised signs of consciousness in patients in minimally conscious state.

Different behavioural signs of consciousness can distinguish patients with an unresponsive wakefulness syndrome from patients in minimally conscious state (MCS). The Coma Recovery Scale-Revised (CRS-R) is the most sensitive scale to differentiate the different altered states of consciousness and eleven items detect the MCS. The aim of this study is to document the prevalence of these items. We analysed behavioural assessments of 282 patients diagnosed in MCS based on the CRS-R. Results showed that some items are particularly frequent among patients in MCS, namely fixation, visual pursuit, and reproducible movement to command, which were observed in more than 50% of patients. These responses were also the most probably observed items when the patients only showed one sign of consciousness. On the other hand, some items were rarely or never observed alone, e.g., object localisation (reaching), object manipulation, intelligible verbalisation, and object recognition. The results also showed that limiting the CRS-R assessment to the five most frequently observed items (i.e., fixation, visual pursuit, reproducible movement to command, automatic motor response and localisation to noxious stimulation) detected 99% of the patients in MCS. If clinicians have only limited time to assess patients with disorders of consciousness, we suggest to evaluate at least these five items of the CRS-R.

Strength and activity of the protractor and retractor muscles of the asymptomatic dyskinetic scapula.

The role of scapular dyskinesis as a risk factor of shoulder injury has been largely discussed. However, most studies have focused on symptomatic patients and less is known on the asymptomatic dyskinetic scapula. Removing the confounding effects of the pathologies could contribute to better characterize the scapula dyskinesis. As muscle properties (strength, fatigue, nerve injury …) have been identified as causative factors of scapular dyskinesis, this study focuses specifically on characterizing the protractor and retractor muscles of the dyskinetic scapula. Thirteen asymptomatic dyskinetic volunteers were compared to eleven asymptomatic non-dyskinetic control volunteers. Muscle characteristics were evaluated in terms of maximal strength, fatigue resistance and electromyographic activity during a functional closed-chained task. The results did not identify kinematic or muscle activity significant differences between the dyskinetic and the control group even in fatigue conditions. However, the results demonstrated that protractors vs. retractors fatigue resistance ratios were imbalanced (<0.8) in the dyskinetic group and significantly lower than in the non-dyskinetic one. Our study suggests that that strength imbalances are not necessarily related to the presence of pain at the shoulder joint. These results demonstrated the importance to complete the clinical assessments of the scapula with strength evaluations even for asymptomatic sport practitioners.

A Scoping Review on the Use of Non-Invasive Brain Stimulation Techniques for Persistent Post-Concussive Symptoms.

BACKGROUND: In the context of managing persistent post-concussive symptoms (PPCS), existing treatments like pharmacotherapy, cognitive behavioral therapy, and physical rehabilitation show only moderate effectiveness. The emergence of neuromodulation techniques in PPCS management has led to debates regarding optimal stimulation parameters and their overall efficacy. METHODS: this scoping review involved a comprehensive search of PubMed and ScienceDirect databases, focusing on controlled studies examining the therapeutic potential of non-invasive brain stimulation (NIBS) techniques in adults with PPCS. RESULTS: Among the 940 abstracts screened, only five studies, encompassing 103 patients (12 to 29 per study), met the inclusion criteria. These studies assessed the efficacy of transcranial direct current stimulation (tDCS), or repetitive transcranial magnetic stimulation (rTMS), applied to specific brain regions (i.e., the left dorsolateral pre-frontal cortex (DLPFC) or left motor cortex (M1)) for addressing cognitive and psychological symptoms, headaches, and general PPCSs. The results indicated improvements in cognitive functions with tDCS. In contrast, reductions in headache intensity and depression scores were observed with rTMS, while no significant findings were noted for general symptoms with rTMS. CONCLUSION: although these pilot studies suggest promise for rTMS and tDCS in PPCS management, further research with larger-scale investigations and standardized protocols is imperative to enhance treatment outcomes for PPCS patients.

Short-term changes in the physiology of the primary motor cortex following head impact exposure during a Canadian football game.

OBJECTIVE: This study investigated the association between head impact exposure (HIE) during varsity Canadian football games and short-term changes in cortical excitability of the primary motor cortex (M1) using transcranial magnetic stimulation (TMS). METHODS: Twenty-nine university-level male athletes wore instrumented mouth guards during a football game to measure HIE. TMS measurements were conducted 24 hours before and 1-2 hours after the game. Twenty control football athletes were submitted to a noncontact training session and underwent identical TMS assessments. Between-group changes in short-interval intracortical inhibition (SICI) ratios over time were conducted using two-way ANOVAs. The relationship between HIE (i.e., number, magnitude, and cumulative forces of impacts) and SICI (secondary outcome) was also investigated using Pearson correlations. RESULTS: Relative to controls, the group of athletes who had played a full-contact football game exhibited a significant intracortical disinhibition (p = 0.028) on the SICI 3-msec protocol (i.e., short interstimulus interval of 3 msec) within hours following the game. Moreover, exposure to ≥ 40g hits positively correlated with SICI disinhibition (p < 0.05). CONCLUSIONS: Athletes exposed to subconcussive hits associated with Canadian football exhibit abnormal M1 corticomotor inhibition function, particularly when the recorded impact magnitude was ≥ 40g. Given the deleterious effects of decreased inhibition on motor control and balance, systematically tracking head impact forces at each game and practice with contacts could prove useful for injury prevention in contact sports.

Gender Specificities in Sleep Disturbances following Mild Traumatic Brain Injury: A Preliminary Study.

Mild traumatic brain injury (mTBI), or concussion, can lead to persistent cognitive and functional symptoms that impede quality of life to a varying extent. This condition is referred to as post-concussive syndrome (PCS). Sleep disturbances are part of it but their distribution among different genders remains scarcely investigated. This pilot cross-sectional anonymous web-based survey interviewed volunteer 18-55 years old participants with a recent (i.e., less than 5 years) reported history of mTBI. Questionnaires related to persistent post-concussive symptoms (PPCS; Rivermead post-concussion symptoms questionnaire), sleep quality (Pittsburgh Sleep Quality Index) and daytime sleepiness (Epworth Sleepiness Scale) were administered as part of the survey. Ninety-one participants' responses were analysed (61 female; 30 male); 43% of them suffered from post-concussive syndrome, 60% reported poor sleep quality and 34% experienced excessive daytime sleepiness. The proportion of PPCS was significantly higher in female participants as compared to males (female: 57%; male: 13%; Fisher's exact test p < 0.001). Excessive daytime sleepiness was also significantly more present in females (female: 44%; male: 13%; p < 0.001) whereas poor sleep quality was present in similar proportions between females and males (female: 66%; male: 50%; p = 0.176). Even though based on a relatively small sample, these findings highlight important gender differences that should be accounted for in PPCS medical care and management.

Survey of physicians' and physiotherapists' ankle muscle strength assessment practices for safe return to sports after lateral ankle sprain: A short report.

BACKGROUND AND PURPOSE: Ankle muscle strength is an important criterion to consider and assess for return to play (RTP) after lateral ankle sprain (LAS). This study therefore focuses on the reported ankle muscle strength consideration for RTP by physicians and physiotherapists, both clinicians involved in RTP decisions, and how they assess it in daily practice. The primary aim is to compare reported clinical practice on ankle muscle strength evaluation between physicians and physiotherapists. Our secondary aims are: to assess the prevalence of use of qualitative versus quantitative assessment and; to determine if there are any differences in how clinicians with or without a Sports Medicine or Physiotherapy Education approach this assessment. METHODS: A survey on RTP criteria after LAS was completed by 109 physicians in a previous study. A number of 103 physiotherapists completed the same survey. A comparison between clinicians' answers was realized and additional questions on ankle muscle strength were analysed. RESULTS: Physiotherapists consider ankle strength for RTP more than physicians (p < 0.001). A large majority of physicians (93%) and physiotherapists (92%) reported assessing ankle strength manually and less than 10% use a dynamometer. Physicians and physiotherapists with Sports Medicine or Physiotherapy Education selected more quantitative assessment than those without (p < 0.001). DISCUSSION: Despite being recognized as an important criterion, ankle muscle strength is not always part of the RTP criteria after LAS in daily practice. The dynamometers are scarcely used by physicians and physiotherapists, whereas it could accurately quantify ankle strength deficits. Sports Medicine or Physiotherapy Education increases the use of quantitative ankle strength assessments by clinicians.

Differences in strength and fatigue resistance of scapular protractors and retractors between symptomatic and asymptomatic dyskinesis.

CONTEXT: Scapular dyskinesis is a shoulder dysfunction that can be asymptomatic or associated with pain or weakness. Reduced strength and fatigue resistance of the scapular protractor and retractors muscles that stabilize the scapula might contribute to dyskinesis. OBJECTIVE: To determine the strength and fatigue resistance profiles of subjects with symptomatic and asymptomatic scapular dyskinesis, and to compare them to healthy controls using isokinetic assessment. DESIGN: Cross-sectional study. SETTING: University Hospital. PARTICIPANTS: Twenty healthy controls and 21 overhead athletes with symptomatic (n=10) and asymptomatic (n=11) scapular dyskinesis. MAIN OUTCOME MEASURES: Strength (peak torque, maximum work), fatigue resistance (total work) and protraction/retraction ratios measured during a closed-chain isokinetic protocol (40 repetitions in concentric mode at 24.4 cm/s). RESULTS: The scapular protractors' strength and fatigue resistance were significantly higher (p<0.01) in healthy controls (peak torque: 5.0±0.9 N/Kg; maximum work: 2.4±0.5 J/Kg; total work: 72.4±0.6 J/Kg) than in asymptomatic (peak torque: 3.4±0.7 N/Kg; maximum work: 1.7±0.4 J/Kg; total work: 50.0±13.7 J/Kg) and symptomatic (peak torque: 3.8±0.6 N/Kg; maximum work: 1.8±0.3 J/Kg; total work: 58.1±12.9 J/Kg) dyskinetic participants. The dyskinetic symptomatic group presented the highest retractors' strength and fatigue resistance (p<0.01) values (peak torque: 5.2±0.6 N/Kg; maximum work: 2.9±0.8 J/Kg; total work: 87.7±22.7 J/Kg) followed by the healthy controls (peak torque: 4.7±1.0 N/Kg; maximum work: 2.1±0.5 J/Kg; total work: 65.3±17.9 J/Kg) and the asymptomatic dyskinetic participants (peak torque: 3.9±1.0 N/Kg; maximum work: 1.9±0.6 J/Kg; total work: 58.6±18.5 J/Kg). The protraction / retraction ratios showed a gradual decrease (p<0.001) from healthy controls (1.1) to asymptomatic (0.9) and symptomatic (0.7) dyskinetic subjects. CONCLUSIONS: Scapular dyskinesis is characterized by weaker scapular protractors and reduced agonist/antagonist ratios, especially when symptomatic. Targeting the scapular protractors for a better balance of scapular musculature in rehabilitation and strengthening programs may improve shoulder symptoms and function, but more interventional studies are required.