Shoulder Rehabilitation Research Articles

Development of a Cadaveric Shoulder Motion Simulator with Open-Loop Iterative Learning for Dynamic, Multiplanar Motion: A Preliminary Study.

Ex vivo shoulder motion simulators are commonly used to study shoulder biomechanics but are often limited to performing simple planar motions at quasi-static speeds using control architectures that do not allow muscles to be deactivated. The purpose of this study was to develop an open-loop tendon excursion controller with iterative learning and independent muscle control to simulate complex multiplanar motion at functional speeds and allow for muscle deactivation. The simulator performed abduction/adduction, faceted circumduction, and abduction/adduction (subscapularis deactivation) using a cadaveric shoulder with an implanted reverse total shoulder prosthesis. Kinematic tracking accuracy and repeatability were assessed using maximum absolute error (MAE), root mean square error (RMSE), and average standard deviation (ASD). During abduction/adduction and faceted circumduction, the RMSE did not exceed 0.3, 0.7, and 0.8 degrees for elevation, plane of elevation, and axial rotation, respectively. During abduction/adduction, the ASD did not exceed 0.2 degrees. Abduction/adduction (subscapularis deactivation) resulted in a loss of internal rotation, which could not be restored at low elevation angles. This study presents a novel control architecture, which can accurately simulate complex glenohumeral motion. This simulator will be used as a testing platform to examine the effect of shoulder pathology, treatment, and rehabilitation on joint biomechanics during functional shoulder movements.

A Novel Active Device for Shoulder Rotation Based on Force Control.

This article describes a one-degree-of-freedom haptic device that can be applied to perform three different exercises for shoulder rehabilitation. The device is based on a force control architecture and an adaptive speed PI controller. It is a portable equipment that is easy to use for any patient, and was optimized for rehabilitating external rotation movements of the shoulder in patients in whom this was limited by muscle-skeletal injuries. The sample consisted of 12 shoulder rehabilitation sessions with different shoulder pathologies that limited their range of shoulder mobility. The mean and standard deviations of the external rotation of shoulder were 42.91 ± 4.53° for the pre-intervention measurements and 53.88 ± 4.26° for the post-intervention measurement. In addition, patients reported high levels of acceptance of the device. Scores on the SUS questionnaire ranged from 65 to 97.5, with an average score of 82.70 ± 9.21, indicating a high degree of acceptance. The preliminary results suggest that the use of this device and the incorporation of such equipment into rehabilitation services could be of great help for patients in their rehabilitation process and for physiotherapists in applying their therapies.

Poster 103: Proximal Shoulder Muscle Recruitment with Blood Flow Restriction Exercise Under Various Occlusion Conditions: Is More Pressure Really Better?

Objectives: Blood Flow Restriction (BFR) training provides partial occlusion at the proximal upper and lower extremities and has been shown to improve muscular strength and hypertrophy following an injury or surgery. By eliciting hypoxic intramuscular conditions, we can stimulate adaptive processes in skeletal muscle in a similar manner to high intensity resistance training but at substantially lower and safer exercise workloads (20-30%1RM). While much of the literature has focused on tissues distal to the site of occlusion, recent findings (Lambert et al 2021, Bowman et al 2020) have observed proximal benefits (increased muscle mass, work capacity, and performance) to upper extremity BFR in the shoulder region during rotator cuff training in both general population adults and pitching athletes. These findings were partially attributed to increased muscle activation (via electromyography, EMG) observed while extremities were under occlusion. However, only one standardized occlusion pressure (50%LOP) was utilized during these investigations as typical in current literature. The purpose of the present study was to compare muscle activation (EMG amplitude, EMGa) of the shoulder region during BFR training at variable occlusion pressures in order to optimize application and muscle-specific targeting of BFR for rehabilitation and preventative shoulder training. Methods: Institutional review board approval was first obtained. Fifteen healthy subjects (7 males and 8 females; age 29.4 ± 4.26 y.o.) from a sports medicine physical therapy clinic were recruited and consented to participate in this study. Individuals were excluded if they had any pre-existing shoulder pathology in the dominant limb, active participation in a structured upper body weight regimen, or any history of vascular compromise that may render use of BFR inappropriate. Each participant underwent 4 different experimental sessions, which included performing 3 common exercises for the shoulder to failure on the dominant limb; dumbbell scaption, cable external rotation (ER) @ 0°, and cable internal rotation (IR) @ 0°. Exercises were completed with BFR using an automated tourniquet system (Delfi Medical Innovations®) at a different pre-assigned occlusion pressure (0, 25, 50, 75% LOP) each session. Load was determined using 20% of a one-repetition maximum (1RM) for each exercise utilizing a maximal voluntary isometric contraction (MVIC) test. EMGa data utilizing surface electrodes (Delsys, Natick, MA, US) were recorded from target shoulder muscles proximal to the occlusive cuff during testing - anterior deltoid, middle deltoid, posterior deltoid, infraspinatus, teres minor, and upper trapezius muscles. Repetitions to failure (RTF) and assessments of discomfort (VAS, 0-10) with each exercise at the various occlusive pressures were also collected for analysis. Raw EMGa measures were averaged across the first 30 contractions for IR and scaption as well as the first 20 contractions for ER following normalization to 5 calibration contractions at 0% LOP. A mixed model ANOVA repeated on occlusion pressure was performed followed by a Bonferroni post hoc test for pairwise comparisons. Type I error set at ∝=0.05. Results: EMG findings are presented in Figure 1 demonstrating a significant effect of occlusion level on shoulder muscle activation for all exercises (p<0.05). Of note, continued significant increases in EMGa were not observed above 50%LOP with the exception of the teres minor during IR (Figure 1A) or the posterior deltoid during scaption (Figure 1C). As shown in Figure 2, significant decreases in repetitions to failure relative to 0%LOP were observed at 75%LOP for all exercises as well as at 50%LOP for scaption (p<0.05). Also shown in Table 1, a linear increase in discomfort was observed for all exercises with increasing LOP (p<0.01). Conclusions: There appears to be several distinct differences in muscle activation about the shoulder complex based on the exercise as well as occlusive pressure; including a common trend of heightened EMG activity being concurrent with an increase in LOP. These findings may indicate that added occlusion leads to greater muscle utilization, enhancing exercise selection and prescription dependent on the targeted muscle group. However, based on these data, there may be an element of diminishing returns past 50% LOP for the exercises and musculature studied, ultimately limiting efficacy past this occlusion stimulus when considering discomfort or total achievable exercise volume. While limited to the population study, these findings paired with those found in general and athletic populations may be used to establish BFR guidelines which may be suitable for shoulder rehabilitation or injury prevention.

Characterization of composite material specimens manufactured in 3D printing for the construction of a shoulder Rehabilitation Prototype

The present work seeks to characterize polymer specimens with aluminum and stainless steel reinforcements, using additive manufacturing for their elaboration and thus increase their tensile strength and implement them for industrial, medical and automotive use. The methodology to follow consists of a documentary investigation of related articles and standards such as ASTM D638, where the tensile properties of plastics are specified, continuing with the manufacture of the test tubes in a 3D printer, this according to the corresponding standard., to later carry out stress tests on the universal machine. The contribution of the work developed lies in the increase in the tensile strength of the composite material experienced, resulting for a first test tube an increase of 52.4% in the maximum tensile strength with an aluminum reinforcement, and an increase of 59.1%, this with a steel reinforcement, in the second specimen submitted to tests with aluminum reinforcement an increase of 20.04% was obtained and with the steel reinforcement it was 84.54%.

Effect of an Artificial Intelligence–Based Self-Management App on Musculoskeletal Health in Patients With Neck and/or Low Back Pain Referred to Specialist Care

Self-management is a key element in the care of persistent neck and low back pain. Individually tailored self-management support delivered via a smartphone app in a specialist care setting has not been tested. To determine the effect of individually tailored self-management support delivered via an artificial intelligence-based app (SELFBACK) adjunct to usual care vs usual care alone or nontailored web-based self-management support (e-Help) on musculoskeletal health. This randomized clinical trial recruited adults 18 years or older with neck and/or low back pain who had been referred to and accepted on a waiting list for specialist care at a multidisciplinary hospital outpatient clinic for back, neck, and shoulder rehabilitation. Participants were enrolled from July 9, 2020, to April 29, 2021. Of 377 patients assessed for eligibility, 76 did not complete the baseline questionnaire, and 7 did not meet the eligibility criteria (ie, did not own a smartphone, were unable to take part in exercise, or had language barriers); the remaining 294 patients were included in the study and randomized to 3 parallel groups, with follow-up of 6 months. Participants were randomly assigned to receive app-based individually tailored self-management support in addition to usual care (app group), web-based nontailored self-management support in addition to usual care (e-Help group), or usual care alone (usual care group). The primary outcome was change in musculoskeletal health measured by the Musculoskeletal Health Questionnaire (MSK-HQ) at 3 months. Secondary outcomes included change in musculoskeletal health measured by the MSK-HQ at 6 weeks and 6 months and pain-related disability, pain intensity, pain-related cognition, and health-related quality of life at 6 weeks, 3 months, and 6 months. Among 294 participants (mean [SD] age, 50.6 [14.9] years; 173 women [58.8%]), 99 were randomized to the app group, 98 to the e-Help group, and 97 to the usual care group. At 3 months, 243 participants (82.7%) had complete data on the primary outcome. In the intention-to-treat analysis at 3 months, the adjusted mean difference in MSK-HQ score between the app and usual care groups was 0.62 points (95% CI, -1.66 to 2.90 points; P = .60). The adjusted mean difference between the app and e-Help groups was 1.08 points (95% CI, -1.24 to 3.41 points; P = .36). In this randomized clinical trial, individually tailored self-management support delivered via an artificial intelligence-based app adjunct to usual care was not significantly more effective in improving musculoskeletal health than usual care alone or web-based nontailored self-management support in patients with neck and/or low back pain referred to specialist care. Further research is needed to investigate the utility of implementing digitally supported self-management interventions in the specialist care setting and to identify instruments that capture changes in self-management behavior. ClinicalTrials.gov Identifier: NCT04463043.

The concurrent validity and reliability of virtual reality to measure shoulder flexion and scaption range of motion

BackgroundShoulder pain commonly has a detrimental impact on patient's work and social activities. Although pain is the most common reason for seeking care, a reduction in shoulder range of motion (ROM) is another common impairment. ROM assessment is used as an evaluation tool and multiple methods are available to measure shoulder ROM. Virtual reality (VR) has been introduced into shoulder rehabilitation, mostly when exercise and ROM measurement is indicated. This study evaluated the concurrent validity and system reliability of active ROM measurements of VR for people with and without shoulder pain. MethodsForty volunteers participated in this study. Virtual goniometry was used to assess active shoulder ROM. Participants performed flexion and scaption to six predetermined angles. Measurements from the VR goniometer and smartphone inclinometers were recorded simultaneously. To assess reliability, two identical test sequences were performed. ResultsThe concurrent validity ICCs were 0.93 for shoulder flexion and 0.94 for shoulder scaption. The VR goniometer application on average systematically overestimated the ROM compared to the smartphone inclinometer. The mean difference between goniometer values was −11.3 degrees for flexion and −10.9 for scaption. The system reliability was excellent with an overall ICC of 0.99 for the flexion movements and 0.99 for the scaption movements. ConclusionAlthough the VR system demonstrated excellent reliability, and high ICC’s for concurrent validity, the large range between the lower and upper 95% CI limits suggests it lacks measurement precision. This suggests VR, as used in this study, should not be used interchangeably with other measurement tools. Contribution of the paper•Virtual reality is a relatively new technology that is being increasingly adopted in clinical practice including the assessment and treatment of people with shoulder pain.•Virtual reality can support the growing demand for improved efficacy and efficiency of healthcare delivery by enabling physiotherapy assessment and treatment of patients via tele-health services.•The VR system (hardwear and software) tested in this study demonstrated excellent reliability and excellent concurrent validity, however, the wide limits of agreement associated with the VR system suggest that the current VR system should not be used interchangeably with digital inclinometry.

The effects of the mirror therapy on shoulder function in patients with breast cancer following surgery: a randomized controlled trial.

Shoulder dysfunction is one of the most bothersome questions for breast cancer survivors. Studies show that mirror therapy can improve shoulder function in patients with a limited shoulder range of motion and shoulder pain. Here, this article reports the results of a randomized controlled trial investigating the effects of the mirror therapy on shoulder function in patients with breast cancer following surgical treatments. Totally, 79 participants were divided to two groups receiving active range-of-motion upper limb exercise based on the mirror therapy or active range-of-motion upper limb exercise respectively for 8 weeks. Shoulder range of motion, Constant-Murley Score, Disabilities of Arm, Shoulder, and Hand Questionnaire, Tampa Scale of Kinesiophobia, Visual analog scale, and grip strength were measured at baseline (T0), 2 weeks (T1), 4 weeks (T2), and 8 weeks (T3). The effects of the intervention on shoulder function were analyzed in generalized estimation equation, from group, time, and the interactions between group and time based on the data from participants who completed at least one post-baseline observation RESULTS: At least one post-baseline observation was performed by 69 participants (n=34 mirror group, n=35 control group). 28(82.35%) participants in the mirror group adhered to the exercise compared to 30(85.71%) in the control group. Generalized estimation equation model showed group had main effects on forward flexion (Waldχ²=6.476, P=0.011), with the Cohen's d=0.54. The effects of the group on abduction, Constant-Murley Score, and Disabilities of Arm, Shoulder, and Hand Questionnaire were significant when fix the effects of the time. At 8 weeks, participants in the mirror group showed an improvement in abduction compared to the control group (P=0.005), the Cohen's d was 0.70. At 8 weeks, participants in the mirror group had a higher Constant-Murley Score than control group (P=0.009), with Cohen's effect size value of d=0.64. The mirror group showed a greater improvement on the Disability of Arm, Shoulder, and Hand Questionnaire than control group at 2 weeks, 4 weeks, and 8 weeks (P≤0.032), but with a weak effect size value of all (r≤0.32). Group had main effects on Tampa Scale of Kinesiophobia (Waldχ²=6.631, P=0.010), with the Cohen's effect size value of d=0.56. Mirror therapy improved shoulder flexion, abduction, shoulder function in daily life, and arm function and symptom of the affected shoulder in patients with breast cancer following surgical treatment, while decreasing fear of movement/(re)injury. Mirror configuration needs to be improved in further research to increase its feasibility. Breast cancer survivors can try mirror therapy as a practical and effective method in shoulder rehabilitation for a promotion on effects. ClinicalTrial.gov Identifier: ChiCTR2000033080.

Shoulder rehabilitation: a neuro-fuzzy inference approach to recovery prediction

Shoulder rehabilitation: a neuro-fuzzy inference approach to recovery prediction

Scapular kinematics and muscle activity during Yi Jin Bang exercises.

Introduction: Scapular dyskinesis is commonly associated with subacromial pain syndrome (SAPS). Addressing scapular dyskinesis is widely accepted as an important component of shoulder rehabilitation. Our previous randomized controlled trial showed that Yi Jin Bang (YJB) exercises could effectively manage SAPS, but scapular motions and muscle activity during YJB exercises remain unknown. This study examined scapular kinematics synchronously with scapular muscle activation during YJB exercises. Methods: Thirty healthy participants with no shoulder complaints were enrolled in this study. Three-dimensional (3D) scapular kinematics and electromyography (EMG) activation of the upper trapezius, middle trapezius, lower trapezius, serratus anterior, anterior deltoid, middle deltoid, and posterior deltoid were synchronously measured during nine YJB movements. Results: During all YJB movements, the scapula was upwardly rotated and anteriorly tilted, with more upward rotation and a similar or less anterior tilt than the mean resting scapular angle. Column rotation, arm crossover, shoulder support circle, and armpit support high lift generated more internal rotation than the mean resting scapular angle, with the angles of internal rotation significantly greater than the other five movements (p < 0.001). Regarding EMG activity, all YJB movements elicited low activity (1.42%-19.19% maximal voluntary isometric contraction [MVIC]) from the upper trapezius and posterior deltoid and low to moderate activity (0.52%-29.50% MVIC) from the middle trapezius, lower trapezius, serratus anterior, anterior deltoid, and middle deltoid. Conclusion: YJB exercises could be useful in the middle to later phases of shoulder rehabilitation. For patients with insufficient external rotation, some YJB movements should be prescribed with caution.

A Projected AR Serious Game for Shoulder Rehabilitation Using Hand-Finger Tracking and Performance Metrics: A Preliminary Study on Healthy Subjects

Research studies show that serious games can increase patient motivation regardless of age or illness and be an affordable and promising solution with respect to conventional physiotherapy. In this paper, we present the latest evolution of our system for shoulder rehabilitation based on hand-finger tracking and projected augmented reality. This version integrates metrics to assess patient performance, monitors the game progress, and allows the selection of the game visualization mode (standard on-screen or projected augmented reality). Additionally, the new software tracks the velocity, acceleration, and normalized jerk of the arm-hand movements of the user. Specifically, sixteen healthy volunteers (eight technical and eight rehabilitation experts) tested our current prototype. The results showed that the serious game is engaging, its design is ergonomically sound, and the overall system could be a useful tool in shoulder rehabilitation. However, clinical validation is needed to assess that the serious game has the same effects as the selected therapy. This is the preliminary step toward laying the foundation for future studies that investigate abnormalities in shoulder movements by using hand-finger tracking.

Effect of Scapular Retraction on Lower Trapezius, Infraspinatus, and Deltoid Muscle Electromyographic Activity During the Side-Lying Abduction Exercise.

The lower trapezius (LT) muscle, which stabilizes the scapula posteriorly during arm elevation, has been interesting to both clinicians and researchers for its importance in throwing-related shoulder rehabilitation and injury prevention. The purpose of this study was to investigate the electromyographic activity of the LT and other relevant muscles during scapular and shoulder activities in the side-lying position. Twenty collegiate baseball players volunteered to participate in this study. Electromyographic (EMG) output of the lower trapezius, infraspinatus, posterior deltoid, middle deltoid, serratus anterior, and upper trapezius muscles were collected. All the subjects performed isometric resistance exercises in four arm positions: 0° horizontal abduction from the coronal plane (NEUT) with protraction (NEUT-PRO), 15° horizontal adduction from the coronal plane (HADD) with protraction (HADD-PRO), and NEUT with retraction (NEUT-RET), and HADD-RET in a side-lying isometric abduction exercise with two external loads: a 9.1 kg dumbbell and 40% of the manual muscle test (MMT). The subjects also performed two more isometric resistance exercises: supine protraction and side-lying external rotation (ER) of the glenohumeral (GH) joint in GH adduction at 90° of GH ER or with as much ER as possible. All raw EMG data were normalized to maximal voluntary isometric contraction (% MVIC) of the corresponding muscle. LT activity was significantly greater in HADD-RET with 9.1 kg than that of HADD-PRO (p < 0.001) (55 vs 21% MVIC) while middle deltoid muscle activity was significantly decreased in both NEUT and HADD-RET compared to that of NEUT and HADD-PRO (p < 0.001). In contrast, IS muscle activity was significantly increased in HADD-RET with 9.1 kg compared with that 40% MMT (p < 0.001) (41 vs 22% MVIC). LT activity was modulated by changes in scapulothoracic and glenohumeral joint positioning during a side-lying isometric abduction exercise. These findings may help clinicians to select exercises to improve scapular muscle balance ratios during rehabilitation of the shoulder complex. Level 3b, Controlled laboratory study.

Assessing the Accuracy of the Azure Kinect for Telerehabilitation After Breast Cancer Surgery.

Rehabilitation plays a key role in the recovery of upper extremity function after breast cancer surgery. Motion capture (mocap) systems for serious gaming have shown the potential to enable home-based rehabilitation, but clinical accuracy needs to be examined. Validation of markerless mocap systems for telerehabilitation after breast cancer surgical intervention. The accuracy of the markerless mocap device Azure Kinect in detecting compensatory movements and postural disturbances has been compared to a gold standard Optitrack system in five volunteers. Subsequently, a serious game for mocap-based shoulder exercises has been developed and integrated into a telerehabilitation platform. The Azure Kinect shows good reliability for scapular elevation (ICC >0.80; MAE <2.1 cm) and trunk tilt (ICC=0.88; MAE=5°), moderate reliability for rounded shoulders (ICC=0.51; MAE=2.6cm) and poor reliability for kyphosis angle (ICC=0.22; MAE=18°). The Azure Kinect provides reasonable performance for shoulder rehabilitation. The proposed telerehabilitation platform has been tested by rehabilitation specialists and received positive feedback.

Prototype of a Continuous Passive Motion device for shoulder rehabilitation

Continuous Passive Motion - CPM - is a therapeutic method that provides fast and safe patient rehabilitation. Considering the fact that the equipment performs the movement along with the patient, who also does it but passively, this treatment procedure can immediately be applied in the postoperative care period. Although this technique makes recovery faster, as strains will be spared from ligaments, muscles and tendons, not all clinics can offer CPM therapy due to its high cost. Bearing in mind the existence of such equipment that performs the aforementioned motion, the objective of this work was the development and manufacture of a prototype device for continuous passive shoulder movement, with costs reduced to an approximate value of USD$730.00 compared to the average price in the market which is around USD$1510.00. This difference in values would make it affordable for a greater majority of clinics and offices to purchase them and, thus, promote the accelerated timely recovery of the limb after operation, for a larger number of patients, allowing these patients to return to their daily tasks in shorter period of time. For the execution of the prototype, specific mechanical manufacturing methods, such us turning, milling and welding of materials, were applied in order to make the equipment safe and effective, provide comfort for the patient and, above all, make the device affordable for most physiotherapy clinics. The material used for the production was stainless steel, cables, pulleys, tilting automation kit and inductive sensors.

Physiotherapist beliefs and perspectives on virtual reality supported rehabilitation for the management of musculoskeletal shoulder pain: A focus group study.

Virtual Reality (VR) is an immersive computer-generated environment that provides a multi-sensory experience for the user. Modern technology allows the user to explore and interact with the virtual environment, offering opportunities for rehabilitation. The use of immersive VR in the management of musculoskeletal shoulder pain is relatively new and research is required to demonstrate its feasibility and effectiveness in this field. The aims of this study were, firstly, to explore physiotherapists' beliefs and perspectives of immersive VR as a platform for rehabilitation in patients with musculoskeletal shoulder pain, secondly, to identify potential barriers and facilitators to using VR in a musculoskeletal setting and thirdly, to gain insight from clinicians that would inform the development of a VR intervention for the rehabilitation of musculoskeletal shoulder pain. This study used qualitative descriptive design methodology. A series of three focus group interviews were carried out, via Microsoft Teams. Physiotherapists received an Oculus Quest™ headset to use at home prior to the focus group interviews. A six-phase process of reflexive thematic analysis was carried out to identify themes within the data. Atlas Ti Qualitative Data Analysis software was used to facilitate thematic analysis. Five themes were identified within the data. They reflected physiotherapists beliefs that VR provides novel opportunities for shoulder rehabilitation and may offer new avenues for managing movement-related fear and improving concordance with rehabilitation. However, barriers related to safety and practical considerations associated with using VR were also identified in the final themes. These findings provide valuable insight into clinician acceptability of immersive VR as a platform for rehabilitation and the need for further research to answer the questions posed by physiotherapists in the current study. This research will contribute to human-centered design of VR-supported interventions for managing musculoskeletal shoulder pain.

Comparison of Muscle Coordination During Front Crawl and Backstroke With and Without Swimmer's Shoulder Pain.

Shoulder pain, known as swimmer's shoulder, is the most common injury for swimmers. Studies that have analyzed muscle activity have focused on the shoulder joint. However, the whole-body muscle coordination of swimmers with swimmer's shoulder is not clear, although swimming requires movements of the upper limbs, trunk, and lower limbs to obtain propulsive force. This study investigated differences in muscle coordination between swimmers with and without swimmer's shoulder during the front crawl and backstroke using muscle synergy analysis. Swimmers with swimmer's shoulder have muscle synergies differing from those without it. Case-control study. Level 4. A total of 20 elite swimmers who regularly swam front crawl and backstroke were included (swimmer's shoulder, n = 8; control, n = 12). Muscle synergy data were analyzed using the nonnegative matrix factorization method and compared between groups. For both front crawl and backstroke, there were 2 synergies in the control group and 3 synergies in the swimmer's shoulder group. During recovery, the control group showed coordinated triceps brachii, serratus anterior, upper trapezius, lower trapezius, internal oblique, and external oblique muscles activities; however, in the swimmer's shoulder group, the contribution of the upper limbs decreased and only that of the trunk muscles increased. A comparison of muscle coordination during the front crawl and backstroke performed by swimmers with and without swimmer's shoulder revealed that coordination differed during the recovery phase. During both front crawl and backstroke, the swimmer's shoulder group could not maintain coordination with the upper limb when the trunk rolled, and split synergy was formed between the upper limbs and trunk. Because coordination of the upper limbs and trunk is important during the recovery phase of front crawl and backstroke, swimmer's shoulder rehabilitation should introduce exercises to improve their coordination between the upper limbs and the trunk.

Shoulder Rehabilitation Exercises With Kinematic Biofeedback After Arthroscopic Rotator Cuff Repair: Protocol for a New Integrated Rehabilitation Program.

The recovery of scapular and humeral physiological kinematic parameters, as well as the sensorimotor control of movement, plays a primary role in the rehabilitation process after arthroscopic rotator cuff repair. A highly customized rehabilitation approach is required to achieve this aim. Biofeedback can be a useful tool, but there is poor evidence of its application in the rehabilitation after arthroscopic rotator cuff tear repair. The aim of this paper is to outline an innovative exercise-based rehabilitation program exploiting visual biofeedback for the recovery of patients arthroscopically treated for rotator cuff repair. For establishment of the innovative program, a multidisciplinary team involving experts in shoulder surgery, rehabilitation medicine, physical therapy, and biomedical and clinical engineering was formed. Starting from a conventional rehabilitation program, the team selected a set of exercises to be integrated with a biofeedback tool, named the INAIL (National Institute for Insurance against Accidents at Work) Shoulder and Elbow Outpatient program (ISEO program). ISEO is a motion analysis system based on inertial wearable sensors positioned over the thorax, scapula, humerus, and forearm. ISEO can return a visual biofeedback of humerus and scapula angles over time or of the scapula-humeral coordination, with possible overlap of patient-specific or asymptomatic reference values. A set of 12 progressive exercises was defined, divided into four groups based on humerus and scapula movements. Each group comprises 2-4 of the 12 exercises with an increasing level of complexity. Exercises can require the use of a ball, stick, rubber band, and/or towel. For each exercise, we present the starting position of the patient, the modality of execution, and the target position, together with notes about the critical factors to observe. The type of visual biofeedback to adopt is specified, such as the coordination between angles or the variation of a single angle over time. To guide the therapist in customizing the patient's rehabilitation program, a list of operative guidelines is provided. We describe various applications of the ISEO exercise program in terms of frequency and intensity. An innovative rehabilitation program to restore scapular and humeral kinematics after rotator cuff repair based on kinematic biofeedback is presented. Biofeedback is expected to increase patient awareness and self-correction under therapist supervision. Randomized controlled trials are needed to investigate the potential effect of the exercise-based biofeedback in comparison with conventional rehabilitation programs. DERR1-10.2196/35757.

A Software Engineering Framework for Reusable Design of Personalized Serious Games for Health: Development Study.

The use of serious games in health care is on the rise, as these games motivate treatment adherence, reduce treatment costs, and educate patients and families. However, current serious games fail to offer personalized interventions, ignoring the need to abandon the one-size-fits-all approach. Moreover, these games, with a primary objective other than pure entertainment, are costly and complex to develop and require the constant involvement of a multidisciplinary team. No standardized approach exists on how serious games can be personalized, as existing literature focuses on specific use cases and scenarios. The serious game development domain fails to consider any transfer of domain knowledge, which means this labor-intensive process must be repeated for each serious game. We proposed a software engineering framework that aims to streamline the multidisciplinary design process of personalized serious games in health care and facilitates the reuse of domain knowledge and personalization algorithms. By focusing on the transfer of knowledge to new serious games by reusing components and personalization algorithms, the comparison and evaluation of different personalization strategies can be simplified and expedited. In doing so, the first steps are taken in advancing the state of the art of knowledge regarding personalized serious games in health care. The proposed framework aimed to answer 3 questions that need to be asked when designing personalized serious games: Why is the game personalized? What parameters can be used for personalization? and How is the personalization achieved? The 3 involved stakeholders, namely, the domain expert, the (game) developer, and the software engineer, were each assigned a question and then assigned responsibilities regarding the design of the personalized serious game. The (game) developer was responsible for all the game-related components; the domain expert was in charge of the modeling of the domain knowledge using simple or complex concepts (eg, ontologies); and the software engineer managed the personalization algorithms or models integrated into the system. The framework acted as an intermediate step between game conceptualization and implementation; it was illustrated by developing and evaluating a proof of concept. The proof of concept, a serious game for shoulder rehabilitation, was evaluated using simulations of heart rate and game scores to assess how personalization was achieved and whether the framework responded as expected. The simulations indicated the value of both real-time and offline personalization. The proof of concept illustrated how the interaction between different components worked and how the framework was used to simplify the design process. The proposed framework for personalized serious games in health care identifies the responsibilities of the involved stakeholders in the design process, using 3 key questions for personalization. The framework focuses on the transferability of knowledge and reusability of personalization algorithms to simplify the design process of personalized serious games.

Paper 02: Is There a Benefit of Sling Immobilization After Open Latarjet Surgery for Anterior Shoulder Instability™ A Randomized Control Trial

Objectives: Recurrent traumatic anterior shoulder instability occurs most commonly in young to middle-aged male athletes. The Latarjet procedure was reported to enable early return to sport compared to capsulolabral repair. Recent research has highlighted the negative effect of immobilization on shoulder rehabilitation. However, only few studies evaluated different rehabilitation programs after open Latarjet and their potential impact on complication rates, stiffness and time to return to sport. The reported immobilization periods ranged from zero to three weeks, and different types of mobilization protocols were used. The aim of this study was to evaluate the benefit of sling immobilization after open Latarjet procedure for anterior shoulder instability. The hypothesis was that immediate self-rehabilitation without sling immobilization would result in improved functional scores at 6 months compared to patient wearing a sling for 3 weeks postoperatively. Methods: We randomized 72 patients with anterior shoulder instability scheduled for open Latarjet procedure into sling and no-sling groups. Two partially 1 cm apart threaded 4.0-mm cancellous screws were used to secure the graft. Both groups started the same immediate self-rehabilitation protocol. Patients were evaluated clinically using Rowe score, the Single Assessment Numeric Evaluation (SANE) instability score as well as visual analogue pain scale (VAS) preoperatively and at 1.5, 3, and 6 months. A computed tomography was performed at 6 months to evaluate graft healing. Results: Both groups had similar preoperative patient characteristics. Both groups had a significant improvement in Rowe score (from 38.8 ± 20.4 to 81.6 ± 17.8, p &lt; 0.001), SANE instability score (from 42.5 ± 20.5 to 84.7 ± 13.2, p &lt; 0.001) and VAS (from 27.7 ± 21.8 to 13.9 ± 16.1, p &lt; 0.001) at 6 months postoperative. There was no difference in functional outcomes between the two groups at 6 months. Mean Rowe score was respectively 80.7 ± 15.9 and 82.6 ± 19.6 in the sling and no-sling group (p = 0.64). Mean SANE instability score was 83.7 ± 13.0 and 85.7 ± 13.6 (p = 0.53) and mean VAS 15.6 ± 14.8 versus 12.2 ± 17.5 (p = 0.38), for sling and no-sling group respectively. Finally, computed tomography evaluation revealed no significant differences regarding bone graft healing between both groups (p = 0.35). Conclusions: Both treatment groups resulted in excellent early functional outcomes. Absence of sling immobilization did not increase complication rates after open Latarjet. Sling immobilization seems therefore optional after open Latarjet procedure.

Towards Wearable Augmented Reality in Healthcare: A Comparative Survey and Analysis of Head-Mounted Displays.

Head-mounted displays (HMDs) have the potential to greatly impact the surgical field by maintaining sterile conditions in healthcare environments. Google Glass (GG) and Microsoft HoloLens (MH) are examples of optical HMDs. In this comparative survey related to wearable augmented reality (AR) technology in the medical field, we examine the current developments in wearable AR technology, as well as the medical aspects, with a specific emphasis on smart glasses and HoloLens. The authors searched recent articles (between 2017 and 2022) in the PubMed, Web of Science, Scopus, and ScienceDirect databases and a total of 37 relevant studies were considered for this analysis. The selected studies were divided into two main groups; 15 of the studies (around 41%) focused on smart glasses (e.g., Google Glass) and 22 (59%) focused on Microsoft HoloLens. Google Glass was used in various surgical specialities and preoperative settings, namely dermatology visits and nursing skill training. Moreover, Microsoft HoloLens was used in telepresence applications and holographic navigation of shoulder and gait impairment rehabilitation, among others. However, some limitations were associated with their use, such as low battery life, limited memory size, and possible ocular pain. Promising results were obtained by different studies regarding the feasibility, usability, and acceptability of using both Google Glass and Microsoft HoloLens in patient-centric settings as well as medical education and training. Further work and development of rigorous research designs are required to evaluate the efficacy and cost-effectiveness of wearable AR devices in the future.

Limb Dominance Effects on Seated Single-Arm Shot-Put Limb Symmetry Indices Following Shoulder Rehabilitation

Typically, most clinical return to activity guidelines recommend that an injured shoulder achieve a 90% to 100% functional performance test limb symmetry index (LSI); however, as previous research demonstrated a 103% to 111% dominant limb bias in seated single-arm shot-put test (SSASPT) performance, the typical criteria might not be appropriate for interpreting SSASPT LSI. Thus, the current objective was to evaluate SSASP LSI differences between dominant and nondominant involved shoulders and to determine how many patients met the suggested 90% to 100% LSI criteria, as well as the 103% for dominant (89% for nondominant) normative SSASPT threshold reported in the literature, at the time of discharge. Cross-sectional. Patients with shoulder injury or surgery (n = 78) completed the SSASPT at the time of discharge from rehabilitation and were grouped according to whether the involved shoulder was the dominant (n = 42) or nondominant (n = 32) limb. LSI (involved/uninvolved × 100) was computed from the average of 3 SSASPT trial distances completed with each limb. The LSI for the nondominant involved group (88.9% [12.4%]) was significantly less (confidence intervalDiff, -12.1% to -22.1%) than the dominant involved group (106.0% [9.3%]). While 95.2% of patients in the dominant involved group exhibited LSI > 90%, only 43.8% of patients in the nondominant involved group attained LSI > 90%. Across the entire cohort, the odds of a nondominant involved LSI being below the respective SSASPT normative range were 2.04 (95% confidence interval, 0.80-5.21) times higher than the odds of a dominant involved LSI being below the normative range. Patients with dominant limb involvement exhibited higher LSI than patients with nondominant limb involvement at discharge from rehabilitation. Particularly when the nondominant shoulder is involved, these results suggest that patients with shoulder injury and surgery may require longer rehabilitation to attain higher levels of upper-extremity function.