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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 2  |  Issue : 1  |  Page : 31-34

Correlation between interscapular pain during the breast development phase, cup size, and thoracic index in adolescent school girls from 13 to 16 years of age


Department of Obstetrics and Gynaecology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission07-Sep-2019
Date of Decision11-Sep-2019
Date of Acceptance14-Mar-2020
Date of Web Publication03-Jul-2020

Correspondence Address:
Dr. Ashwini Bulbuli
Department of Obstetrics and Gynaecology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_54_19

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  Abstract 


Background: Physical symptoms associated with poor posture due to heavy breast leading to neck, shoulder, interscapular, and back pain are prevalent. Occurrence and persistence of musculoskeletal pain among children and adolescents may result in the development of chronic pain symptoms in adulthood. Hence, this study was conducted to determine if any correlation existed between interscapular pain, cup size, and thoracic index in adolescent school girls during the breast development phase.
Materials and Methods: A cross-sectional descriptive study was conducted where 2000 school girls aged between 13 and 16 years were screened to identify if they had interscapular pain. Two hundred of them were screened positive, of which 54 were excluded, as they carried a backpack weighing more than that recommended for their gender and age and one for psychological distress. One hundred and forty-five participants were evaluated for the intensity of pain using Numeric Pain Rating Scale, cup size using inch tape, and thoracic kyphosis using flexible curve ruler based on which thoracic index was calculated.
Results: About 10% had interscapular pain, of which 0.68% had mild, 68.96% moderate, and 30.34% had severe pain. Twenty-seven participants had cup size A, 107 had B, and 11 had C size. Nearly 37.24% had normal, 55.86% had less than normal, and 6.89% had more than normal thoracic index values, respectively. There was a correlation between interscapular pain, cup size, and thoracic index.
Conclusion: We conclude that no statistically significant correlation exists between interscapular pain, cup size, and thoracic index.

Keywords: Adolescent, Breast development, Interscapular pain, Musculoskeletal pain, Prevalence


How to cite this article:
Bulbuli A, Shaikh S. Correlation between interscapular pain during the breast development phase, cup size, and thoracic index in adolescent school girls from 13 to 16 years of age. Indian J Phys Ther Res 2020;2:31-4

How to cite this URL:
Bulbuli A, Shaikh S. Correlation between interscapular pain during the breast development phase, cup size, and thoracic index in adolescent school girls from 13 to 16 years of age. Indian J Phys Ther Res [serial online] 2020 [cited 2020 Aug 11];2:31-4. Available from: http://www.ijptr.org/text.asp?2020/2/1/31/288866




  Introduction Top


Interscapular pain is defined as the pain felt between the shoulder blades. This pain can range from mild discomfort to severe and debilitating. High pain prevalence and musculoskeletal pain symptoms among children and adolescents result in the development of chronic pain symptoms in adulthood and thus, consequently, leading to high economic cost in treating them.[1] To determine the severity of any condition, it is important to determine its source. When a muscle is held in a stretched position for a longer duration, it results in the development of trigger points within them. There is a muscle imbalance leading to shortening of one muscle group and lengthening along with weakness of the opposite muscle group, further leading to adaptive postural changes.[2] Carrying heavy bagpacks by children and adolescents has been a common topic of discussion and concern among parents and students over a period of time. As there is repeated load placed on rapidly growing spinal structures, they are believed to undergo structural damage if additional heavy load is placed on them.[3] Furthermore, there are studies that suggest the breast size to be an important factor that affects posture, especially thoracic kyphosis and lumbar lordosis.[4]

There is a prominent impact of psychosocial factors such as anxiety and depression on the perception of musculoskeletal pain symptoms in children and adolescents. Psychosomatic symptoms were the most common associative psychosocial factors affecting the perception of pain.[1] Psychological and physiological symptoms associated with macromastia have been reported. Physical symptoms associated with poor posture due to heavy breast like neck pain, shoulder and back pain are common. Anatomical correlation of poor posture with back pain has been given in numerous studies.[4] Therefore, the present study was carried out to find out the correlation between interscapular pain, cup size, and thoracic index in adolescent school girls and also to determine if it occurs specifically during the breast development phase.


  Materials and Methods Top


Study design and study sample

This is a cross-sectional study conducted with a target population of adolescent school girls from 13 to 16 years of age. The data were collected from schools in and around Belagavi city, Karnataka, India, for a 3-month duration. The sampling method adopted was nonprobability convenience sampling. Participants were explained in groups about the interscapular region on the body chart displayed on the black board. After initial screening, participants screened positive for interscapular pain were subjected to inclusion criteria and accordingly included in the study.

Inclusion and exclusion criteria

Girls with positive interscapular pain who gave consent during screening were included in the study. Those with the history of cardiac ailments, spinal deformity or trauma to the spinal column, neck and shoulder injury, psychologically distressed[1] having a score of 30, or more on Kessler Psychological Distress Scale (K-10)[5] and those carrying bagpacks of ≥15% of their bodyweight were excluded from the study.[3]

Procedure

Ethical clearance was obtained from the Institutional Ethical Review Committee. Of 2000 screened adolescent school girls, 145 participants who met the inclusion criteria during screening were included in the study after obtaining written informed consent from individual participants and assent from the guardian. Demographic details such as height and weight were taken, based on which body mass index (BMI) was calculated.

Included participants were further evaluated for the intensity of pain using the Numeric Pain Rating Scale (NPRS).[6] The cup size was assessed using a measuring tape. The cup size was determined based on the difference between overbust and underbust measurements, and a difference of <6.5 cm was categorized as A cup size, 6.5–13 cm as B cup size, 13–19.5 cm as C cup size, and >19.5 cm as D cup size.[4] The thoracic kyphosis index was determined by a flexible curve ruler. The curvature of the spine was traced by placing the ruler along the spinous process from C7 to T12. Quantification in degrees was done by drawing a line joining the two points (line l), and a line was drawn at the right angle in the middle of line l to the apex of curve (line h). The amount of curve was calculated applying the formula: Θ =4 [ARC tan (2 h/L)].[7] Values ranging from 23.5 to 42 were considered normal for the study group.[8]

Statistical analysis

Statistical analysis was performed using Microsoft Office Excel, and SPSS version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) was used to analyze the data. Pearson's correlation coefficient was used to determine the correlation between NPRS score, thoracic index, and cup size.


  Results Top


In the present cross-sectional descriptive study, 2000 adolescent school-going girls between 13 and 16 years of age were screened for interscapular pain, of which 200 (10%) were screened positive for pain. One participant who had severe psychological distress on K-10 scale, and 54 participants who carried backpack weighing more than indicated for their age and gender were excluded from the study. [Table 1] gives demographic details of the included participants in regard to age and BMI. [Figure 1] is frequency distribution graph which represents BMI and participants categorized according to pain severity. Descriptive statistics of outcome measures were analyzed for 145 participants presented in [Table 2]. The percentage of participants classified depending on the severity of interscapular pain on NPRS were as follows: mild (0.68%), moderate (68.96%), and severe (30.34%). For cup size measurement, 27 participants were categorized into A category, 107 participants into B category, and 11 participants in C category. For thoracic index values, 55.86% of patients were categorized to have less than normal, 37.24% were normal, whereas only 6.89% had more than normal age and gender indicated thoracic index values. [Table 3] gives Karl Pearson's correlation coefficient (r) values determining the correlation between interscapular pain and thoracic index, interscapular pain and cup size, and thoracic index and cup size. It shows that positive correlation exists between all the three variables with r = 0.001, 0.039, and 0.074 [Figure 2], [Figure 3], [Figure 4], with P values of 0.99, 0.64, and 0.37, respectively. However, these values do not have statistical significance.
Table 1: Age and body mass index of study participants

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Figure 1: Frequency distribution table depending on the body mass index and pain scores

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Table 2: Descriptive statistics of study participants

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Table 3: Karl Pearson's correlation coefficient between Numeric Pain Rating Scale, thoracic index, and cup size in school girls with interscapular pain

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Figure 2: Graphical representation of correlation between thoracic index and Numeric Pain Rating Scale

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Figure 3: Graphical representation of correlation between cup size and Numeric Pain Rating Scale

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Figure 4: Graphical representation of correlation between thoracic index and cup size

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  Discussion Top


The interscapular pain in school-going girls between 13 and 16 years of age was found to be 10% out of 2000 screened participants. The possible causative factors hypothesized were adaptive postural changes during the breast development phase, backpack weight, and psychological factors. A cross-sectional study conducted to determine the effect of backpack weight on postural angles in preadolescent children states that carrying a backpack weighing 15% of body weight changed all the postural angles in preadolescent children.[3] Furthermore, studies suggest wide variability in the way pain is reported. There is strong evidence that pain prevalence increases with age in the adolescent period, usually slightly earlier in girls, possibly corresponding with the time of puberty and there is some evidence that it is more common in girls than boys.[9] A systematic review of posture and psychosocial factors as contributors to the upper quadrant musculoskeletal pain in children and adolescents states that psychosocial factors, especially depression, mental distress, and psychosomatic complaints, have an influence on the development of the upper quadrant musculoskeletal pain in children and adolescents.[1] However, in the present study, the interscapular pain intensity seems to be unrelated to the psychological status of the participants. There was no correlation between interscapular pain and cup size, and these findings support the study conducted on young, nulliparous women stating that thoracic pain appeared unrelated to breast size.[10] However, our findings are contradicting to findings of a study, in which breast size seemed to be an important factor that affected posture, especially thoracic kyphosis and lumbar lordosis angles.[4] Recent longitudinal studies indicate that adolescent spinal pain, including the back, neck, shoulder, and low back is significantly associated with spinal pain in adult life.[9] In a study conducted to determine if back pain reporting in young girls was puberty-related states that reporting of low back pain increases in puberty until maturity regardless of age. Whereas it is stated that pain in the mid-back and neck do not seem to be linked with pubertal stage.[11]

The results are limited and cannot be generalized to the whole adolescent population, as only school girls were screened. Precise measurements and multiple readings for breast size and intensity of pain perceived through different phases of the menstrual cycle would help to rule out the impact of cyclic changes on breast size and pain perception. Considering the impact of other factors on postural angles along with the use of objective measurement tools for quantifying interscapular pain would produce better outcomes. Similar studies can be conducted with a wider age group range with detailed examination regarding the impact of backpack, considering components such as duration of carrying backpack, type of bag, muscle strength, joint range of motions, and compensatory or adaptive changes needs to be carried out. Nutritional status and physical activity level of individual participants should also be taken into consideration to come up with the conclusion for the causative factor of pain.


  Conclusion Top


We conclude that there is no statistically significant correlation that exists between interscapular pain, cup size, and thoracic index.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.



 
  References Top

1.
Prins Y, Crous L, Louw QA. A systematic review of posture and psychosocial factors as contributors to upper quadrant musculoskeletal pain in children and adolescents. Physiother Theory Pract 2008;24:221-42.  Back to cited text no. 1
    
2.
Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Philadelphia: Lippincott Williams&Wilkins; 1983.  Back to cited text no. 2
    
3.
Ramprasad M, Alias J, Raghuveer AK. Effect of backpack weight on postural angles in preadolescent children. Indian Pediatr 2010;47:575-80.  Back to cited text no. 3
    
4.
Findikcioglu K, Findikcioglu F, Ozmen S, Guclu T. The impact of breast size on the vertebral column: A radiologic study. Aesthetic Plast Surg 2007;31:23-7.  Back to cited text no. 4
    
5.
Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002;32:959-76.  Back to cited text no. 5
    
6.
Boonstra AM, Stewart RE, Köke AJ, Oosterwijk RF, Swaan JL, Schreurs KM, et al. Cut-off points for mild, moderate, and severe pain on the numeric rating scale for pain in patients with chronic musculoskeletal pain: Variability and influence of sex and catastrophizing. Front Psychol 2016;7:1466.  Back to cited text no. 6
    
7.
de Oliveira TS, Candotti CT, La Torre M, Pelinson PP, Furlanetto TS, Kutchak FM, et al. Validity and reproducibility of the measurements obtained using the flexicurve instrument to evaluate the angles of thoracic and lumbar curvatures of the spine in the sagittal plane. Rehabil Res Pract 2012;2012:186156.  Back to cited text no. 7
    
8.
Willner S, Johnson B. Thoracic kyphosis and lumbar lordosis during the growth period in children. Acta Paediatr Scand 1983;72:873-8.  Back to cited text no. 8
    
9.
Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: A systematic overview of the research literature. Spine (Phila Pa 1976) 2007;32:2630-7.  Back to cited text no. 9
    
10.
Wood K, Cameron M, Fitzgerald K. Breast size, bra fit and thoracic pain in young women: A correlational study. Chiropr Osteopat 2008;16:1.  Back to cited text no. 10
    
11.
Wedderkopp N, Andersen LB, Froberg K, Leboeuf-Yde C. Back pain reporting in young girls appears to be puberty-related. BMC Musculoskelet Disord 2005;6:52.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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