Game-Based Rehab for Scapular Dyskinesia

Scapular Dyskinesis

Overhead Athletes, Mobile Game, Adherence to Therapy, Digital Health Solutions, Tele-Rehabilitation, Scapular Stabilization

Scapular dyskinesia (SD) is a disorder defined by aberrant scapular placement and movement, which can have a substantial impact on athletes' performance, particularly those who participate in throwing sports like Frisbee. This study aims to investigate the prevalence of SD among Frisbee players in Malaysia, assess its effects on various aspects of athletic performance, and evaluate the effectiveness of gamified scapular rehabilitation exercises delivered via a mobile application. This study's approach is divided into three unique phases, where phase one consists of a prevalence and impact assessment using a cross-sectional study design, which will be carried out among several Frisbee clubs in Malaysia. This phase will use several outcome measures to evaluate SD and its impact along with respiratory muscle strength assessments to analyze the potential respiratory outcomes. Phase Two focuses on the creation of a mobile application that would gamify scapular rehabilitation exercises while embracing agile development approaches. The development process will include comprehensive testing procedures to ensure functionality and usability, such as functional testing to verify the application's features, usability testing to assess user experience, data validation to ensure accurate information processing, and regression testing to confirm stability after updates, and user acceptance testing to evaluate performance in real-world scenarios. Phase Three consists of intervention and evaluation by a randomized controlled trial (RCT) to determine the efficacy of the gamified rehabilitation intervention. The intervention, which consists of gamified scapular rehabilitation exercises given via a mobile application, will last eight weeks. Subjects will be followed up after 6 months of the intervention to determine their level of adherence to the rehabilitation.The expected outcomes of this study aim to significantly contribute to the field of sports medicine and rehabilitation by introducing and validating gamified rehabilitation techniques specifically designed for athletes with scapular dyskinesia. The study results are expected to promote the well-being of athletes by improving their sports performance and reducing the risk of injuries. In conclusion, this study not only advances our understanding of SD in athletes but also paves the way for innovative rehabilitation solutions that can be adopted across various sports and settings.

2.1 Study Design The study design follows a structured approach comprising three key phases where phase one assesses the prevalence and impact of SD on Frisbee players. Meanwhile, phase two focuses on developing mobile game incorporating scapular stabilization exercises. Lastly, phase three will evaluate the effectiveness of the gamified rehabilitation and the adherence level. Figure. 2 summarizes the flow of the three phases of study. 2.1.1 Phase One: Prevalence and Impact Assessment In the first phase of the study, a cross-sectional design will be employed to determine the prevalence and impact of SD among competitive Frisbee players in Malaysia. This approach will allow researchers to measure the prevalence and explore associations between variables at a specific point in time. The study will be conducted across various Frisbee clubs in Malaysia to ensure a representative sample of the target population. The participants will consist of competitive Frisbee players who have been diagnosed with SD, with a calculated sample size of 235 participants, determined using GPOWER 3.1 software, to provide statistical power and reliable prevalence estimates. The primary outcome measures include the Lateral Scapular Slide Test (LSST) for assessing scapular positioning and movement, the Visual Analog Scale (VAS) for evaluating pain levels, the Seated Medicine Ball Throw Test (SMBT) for measuring upper body strength and throwing ability, the Functional Throwing Performance Index (FTPI) for assessing throwing accuracy and velocity, and spirometry alongside respiratory muscle strength assessments to analyze the impact of SD on breathing patterns and forced vital capacity. 2.1.2 Phase Two: Mobile Application Development The second phase of the study focuses on the development of a mobile application tailored for Frisbee players with scapular dyskinesia. This phase will follow an agile development process, characterized by iterative and incremental progress, allowing for continuous improvements and flexibility based on user feedback. The application will be developed using Flutter and Dart to ensure cross-platform compatibility, enabling it to run smoothly on both iOS and Android devices. The development process will incorporate multiple testing phases to ensure the app's effectiveness and user-friendliness. These phases include functional testing to verify compliance with specified requirements, usability testing to evaluate the user interface and experience, data validation testing to ensure data accuracy and integrity, regression testing to verify that updates do not negatively impact existing functionalities, and user acceptance testing to gather feedback from end-users to ensure the app meets their needs effectively. 2.1.3 Phase Three: Intervention and Evaluation In the third phase, a randomized controlled trial (RCT) will be conducted to evaluate the effectiveness of the gamified rehabilitation intervention delivered through the mobile application. The study will involve Frisbee players diagnosed with SD, divided into three groups: an experimental group receiving gamified scapular rehabilitation exercises through the mobile application, a control group engaging in standard rehabilitation exercises without the gamification component, and a healthy group serving as a baseline comparison. The experimental group will undergo an 8-week gamified rehabilitation program designed to enhance scapular muscle strength, positioning, and throwing performance, delivered via the mobile application with engaging elements to improve adherence and motivation. The primary outcome measures for this phase will include pre and post-intervention assessments of scapular muscle strength, positioning, and throwing performance, as well as adherence to the rehabilitation program evaluated using the Rehabilitation Adherence Questionnaire-Modified (RAQ-M) (34). 2.2 Sample size For phase one, assuming the population size is 600, the confidence level is 95%, the margin of error set at 5% and the population with SD's proportion assumed as 50%, therefore, the calculated sample size is approximately 235. Phase two will employ a pilot study for user acceptance testing. A sample size of 15 participants will be employed for the user acceptance testing of the mobile application. This sample size is considered adequate to achieve the objectives of a pilot study while allowing for detailed feedback and iterative improvements. For phase three, the sample size calculation was done using G Power software, considering an attrition rate of 20%. With a desired power of 0.95, an effect size of 0.20, and a significance level of 0.05, a total sample size of 45 participants is required. This analysis accounts for three groups and eight repeated measurements per participant, with a moderate correlation among repeated measures. With this attrition rate factored in, the total sample size required is calculated to be 45 + 9 = 54 subjects. To distribute these subjects evenly among the groups, each group will consist of 18 subjects. This allocation ensures that each group has an adequate number of participants to detect meaningful differences in the outcomes being investigated while accounting for potential dropouts or withdrawals during the study. 2.3 Inclusion and Exclusion Criteria For this study, the inclusion criteria specify that participants must be competitive Frisbee players aged between 18 and 40 years. These individuals should engage in regular training sessions lasting 1.5 to 2 hours per session, with a minimum of one session per week. Additionally, participants are required to have a full range of motion in the Glenohumeral joint, as highlighted by (27). Participants will be excluded if they are recreational Frisbee players, as they may not have the same level of athletic conditioning or skill as competitive players. Further exclusion criteria include any recent head or neck injuries within the past three months or any upper body surgery in the past year. Acute fractures in the shoulder girdle, spine, or thoracic cage, as well as any history of Chronic Obstructive Pulmonary Disease (COPD), uncontrolled asthma, pulmonary infectious diseases, or respiratory tract infectious diseases, also disqualify potential participants. Additionally, individuals with neuromuscular or neurological disorders such as Amyotrophic Lateral Sclerosis (ALS), Guillain-Barré Syndrome (GBS), or Multiple Sclerosis (MS) are excluded to ensure that the study results are not affected by these conditions, which could interfere with the study's focus on scapular dyskinesis among healthy, competitive athletes. 2.4 Baseline measurements This section outlines the outcome measures used to evaluate the baseline measurements for phases one and three of the study. The measures encompass a range of tests and evaluations to assess various physical attributes and functions related to scapular dyskinesis, pain perception, upper body power, throwing performance, pulmonary function, respiratory muscle strength, breathing patterns, and scapular muscle strength. 2.4.1 Lateral Scapular Slide Test (LSST) The Lateral Scapular Slide Test (LSST) assesses scapular position and dyskinesis. The test involves measuring the bilateral distance between the inferior angle of the scapula and the nearest vertebral spinous process in three distinct positions: with the arms relaxed at the side (0° humeral elevation), with the shoulder abducted to 40-45° with hands on hips, and with the shoulder abducted to 90° with arms in full internal rotation. A difference of more than 1.5 cm between the sides indicates scapular dyskinesis (1). While the LSST provides more objective measures compared to mere observation, it is not entirely reliable in assessing scapular asymmetry. Test-retest reliability ranges from 0.84 to 0.88, and intertester reliability varies between 0.77 and 0.85, according to (2). 2.4.2 Visual Analog Scale (VAS) The Visual Analog Scale (VAS) is used to measure the intensity of pain or other subjective experiences. It consists of a 10-centimeter horizontal or vertical line with anchor points representing extreme sensations, such as "No Pain" and "Worst Pain Imaginable." Participants mark a point on the line that reflects their experience. The distance from the "No Pain" end to the mark is measured, providing a quantitative score of the participant's perceived pain level (1). 2.4.3 Seated Medicine Ball Throw Test (SMBT) The Seated Medicine Ball Throw Test (SMBT) evaluates unilateral upper-extremity power by measuring the distance an individual can throw a 6-pound medicine ball from a seated position. The test assesses shoulder kinematics, movement patterns, and trunk engagement, with performance differences between dominant and non-dominant sides typically ranging from 5% to 10% (3). The test is considered a cost-effective and reliable method for assessing upper-body power. 2.4.4 Functional Throwing Performance Index (FTPI) The Functional Throwing Performance Index (FTPI) measures the accuracy of overhand throws. It is calculated by dividing the number of accurate throws by the total number of throws. Athletes stand 15 feet from a target and throw a ball at it as many times as possible within 30 seconds. Accuracy is determined by whether any part of the ball contacts the target (4). 2.4.5 Pulmonary Function Tests (PFTs) Evaluation of respiratory capacity will be done using a spirometer to measure Forced Expiratory Volume in one second (FEV1) and Forced Vital Capacity (FVC). Participants will be instructed to perform maximum inhalation and exhalation maneuvers, and the best result from three trials will be recorded. Normal FVC values range from 5.5 to 4.75 liters in males and 3.75 to 3.25 liters in females, while FEV1 values range from 4.5 to 3.5 liters in males and 3.25 to 2.5 liters in females. An FEV1/FVC ratio above 0.7 indicates normal pulmonary function (5). 2.4.6 Respiratory Muscle Strength Respiratory muscle strength is measured using a handheld respiratory pressure meter to assess Maximum Inspiratory Pressure (MIP) and Maximum Expiratory Pressure (MEP). Participants perform maneuvers involving maximal inhalation and exhalation with the help of a nose clip and a mouthpiece. Three attempts are recorded, and the average is used for analysis. Reference values suggest MIP should be less than -90 cmH2O for men and -70 cmH2O for women, while MEP should be greater than 140 cmH2O for men and 90 cmH2O for women (6). 2.4.7 Self-Evaluation of Breathing Questionnaire (SEBQ) The Self-Evaluation of Breathing Questionnaire (SEBQ) assesses breathing patterns and symptom severity. Participants respond to 25 items on a 3-point scale, indicating the frequency of symptoms, with higher scores suggesting more pronounced breathing dysfunction. Scores above 25 indicate significant diaphragmatic breathing issues (6). 2.4.8 Measurement of Throwing Velocity Throwing velocity is calculated by measuring the time it takes for a Frisbee to travel a fixed distance (60.5 feet) and using a stopwatch. The speed is calculated using the formula S=D/TS = D / TS=D/T, where SSS is speed, DDD is distance, and TTT is time. This speed is then converted to miles per hour (mph) for analysis (7). 2.4.9 Assessment of Scapular Muscle Strength Scapular muscle strength is assessed in two positions: seated and supine. Participants provide maximal strength against a handheld dynamometer, with manual resistance applied by the examiner. The test position is set between maximal scapular protraction and retraction, with participants asked to exert maximal strength like punching against the dynamometer (8). 2.5 Application development The development process involves collaboration among software developers, game designers, physiotherapists, and users to create a gamification framework that incorporates scapular stabilization exercises tailored to the needs of users. The agile development methodology is employed to ensure adaptability and collaboration, allowing the integration of features such as points, levels, challenges, feedback systems, and social features. The implementation utilizes the Flutter framework and Dart programming language within the Visual Studio IDE to ensure cross-platform compatibility, providing a consistent user experience on iOS and Android devices. Rigorous testing procedures, including functional, usability, data validation, regression, and user acceptance testing, are conducted to ensure the application's effectiveness, ease of use, and data integrity. These steps culminate in the creation of a user-friendly mobile application designed to make scapular rehabilitation engaging and effective for frisbee players with scapular dyskinesis. 2.6 Intervention and Follow Up The study will be conducted during pregame sessions, focusing on frisbee players diagnosed with SD identified in phase one. These players will be randomly divided into three groups using block randomization: an experimental group, Control Group A (both containing players with SD), and a healthy Control Group B consisting of players without SD. Each group will consist of 18 participants, with informed consent obtained prior to the study. Baseline outcome measures, such as Visual Analog Scale (VAS) scores, Seated Medicine Ball Throw Test (SMBT), scapular muscle strength, Functional Throwing Performance Index (FTPI), throwing accuracy, SEBQ, and pulmonary function tests, will be assessed. The experimental group will use a mobile application featuring gamified scapular stabilization and postural correction exercises, while Control Group A will only perform postural correction exercises, and Control Group B will continue regular training without interventions. The study adopts a single-blinded design, where assessors are unaware of group allocations during assessments. Both the experimental group and Control Group A will receive an 8-week intervention, with post-intervention outcome measures reassessed for data analysis, including adherence using the Modified Rehabilitation Adherence Questionnaire (RAQ-M) which will be done after 6 months of intervention. The RAQ-M evaluates adherence behaviors, exercise consistency, barriers, motivation, and satisfaction with the rehabilitation program, providing insights to optimize interventions for musculoskeletal conditions. Additionally, participants will perform specific postural correction exercises such as Chin Tucks, Upper Back Stretch, and Cat-Camel Stretch to improve posture and alignment, while adherence will be tracked through the RAQ-M to assess motivation, challenges, and perceived benefits, ensuring comprehensive evaluation of the intervention's effectiveness.

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