Motor Control Training for the Shoulder with Smart Garments

Tracking Upper Limb Motion via Wearable Solutions: Systematic Review of Research From 2011 to 2023

BACKGROUND

The development of wearable solutions for tracking upper limb motion has gained research interest over the past decade. This paper provides a systematic review of related research on the type, feasibility, signal processing techniques, and feedback of wearable systems for tracking upper limb motion, mostly in rehabilitation applications, to understand and monitor human movement.

OBJECTIVE

The aim of this article is to investigate how wearables are used to capture upper limb functions, especially related to clinical and rehabilitation applications.

METHODS

A systematic literature search identified 27 relevant studies published in English from 2011 to 2023, across 4 databases: ACM Digital Library, IEEE Xplore, PubMed, and ScienceDirect. We included papers focusing on motion or posture tracking for the upper limbs, wearable devices, feedback given to end users, and systems having clinical or rehabilitation purposes. We excluded papers focusing on exoskeletons, robotics, prosthetics, orthoses, or activity recognition systems; reviews; and books.

RESULTS

The results from this research focus on wearable devices that are designed to monitor upper limb movement. More specifically, studies were divided into 2 distinct categories: clinical motion tracking (15/27, 56%) and rehabilitation (12/27, 44%), involving healthy individuals and patients, with a total of 439 participants. Among the 27 studies, the majority (19/27) used inertial measurement units to track upper limb movement or smart textiles embedded with sensors. These devices were attached to the body with straps (mostly Velcro), providing flexibility and stability. The developed wearable devices positively influenced user motivation through the provided feedback, with visual feedback being the most common owing to the high level of independence provided. Moreover, a variety of signal processing techniques, such as Kalman and Butterworth filters, were applied to ensure data accuracy. However, limitations persist and include sensor positioning, calibration, and battery life, as well as a lack of clinical data on the effectiveness of these systems. The sampling rate of the data collection ranged from 50 Hz to 2000 Hz, which notably affected data quality and battery life. In addition, several findings were inconclusive, and thus, further future research is needed to understand and improve upper limb posture to develop progressive wearable systems.

CONCLUSIONS

This paper offers a comprehensive overview of wearable monitoring systems, with a focus on upper limb motion tracking and rehabilitation. It emphasizes the various types of available solutions; their efficacy, wearability, and feasibility; and proposed processing techniques. Finally, it presents robust findings regarding feedback accuracy derived from experiments and outlines potential future research directions.

Use of commercially available wearable devices for physical rehabilitation in healthcare: a systematic review

OBJECTIVES

To evaluate whether commercially available 'off-the-shelf' wearable technology can improve patient rehabilitation outcomes, and to categorise all wearables currently being used to augment rehabilitation, including the disciplines and conditions under investigation.

DESIGN

Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 statement checklist, and using the Grading of Recommendations, Assessment, Development and Evaluation approach.

DATA SOURCES

Embase, MEDLINE, Web of Science and the Cochrane Library were searched up to and including July 2023.

ELIGIBILITY CRITERIA

We included trials and observational studies evaluating the use of consumer-grade wearables, in real patient cohorts, to aid physical therapy or rehabilitation. Only studies investigating rehabilitation of acute events with defined recovery affecting adult patients were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used a standardised protocol to search, screen and extract data from the included studies. Risk of bias was assessed using the Cochrane Methods Risk of Bias in Randomised Trials V.2 and Risk of Bias in Non-Randomised Studies of Interventions tools for randomised controlled trials (RCTs) and observational studies, respectively.

RESULTS

Eighteen studies encompassing 1754 patients met eligibility criteria, including six RCTs, six quasi-experimental studies and six observational studies. Eight studies used wearables in Orthopaedics, seven in Stroke Medicine, two in Oncology and one in General Surgery. All six RCTs demonstrated that wearable-driven feedback increases physical activity. Step count was the most common measure of physical activity. Two RCTs in orthopaedics demonstrated non-inferiority of wearable self-directed rehabilitation compared with traditional physiotherapy, highlighting the potential of wearables as alternatives to traditional physiotherapy. All 12 non-randomised studies demonstrated the feasibility and acceptability of wearable-driven self-directed rehabilitation.

CONCLUSION

This review demonstrates that consumer-grade wearables can be used as adjuncts to traditional physiotherapy, and potentially as alternatives for self-directed rehabilitation of non-chronic conditions. Better designed studies, and larger RCTs, with a focus on economic evaluations are needed before a case can be made for their widespread adoption in healthcare settings.

PROSPERO REGISTRATION ID

CRD42023459567.

Exploring the efficacy of a set of smart devices for postural awareness for workers in an industrial context – A protocol for a single-subject experimental design (Preprint)

BACKGROUND

In manufacturing industries, tasks requiring poor posture, high repetition, and long duration commonly induce fatigue and lead to an increased risk of work-related musculoskeletal disorders. Smart devices assessing biomechanics and providing feedback to the worker for correction may be a successful way to increase postural awareness, reducing fatigue, and work-related musculoskeletal disorders. However, evidence in industrial settings is lacking.

OBJECTIVE

This study protocol aims to explore the efficacy of a set of smart devices to detect malposture and increase postural awareness, reducing fatigue, and musculoskeletal disorders.

METHODS

A longitudinal single-subject experimental design following the ABAB sequence will be developed in a manufacturing industry real context with 5 workers. A repetitive task of screw tightening of 5 screws in a standing position into a piece placed horizontally was selected. Workers will be assessed in 4 moments per shift (10 minutes after the beginning of the shift, 10 minutes before and after the break, and 10 minutes before the end of the shift) in 5 nonconsecutive days. The primary outcomes are fatigue, assessed by electromyography, and musculoskeletal symptoms assessed by the Nordic Musculoskeletal Questionnaire. Secondary outcomes include perceived effort (Borg perceived exertion scale); range of motion of the main joints in the upper body, speed, acceleration, and deceleration assessed by motion analysis; risk stratification of range of motion; and cycle duration in minutes. Structured visual analysis techniques will be conducted to observe the effects of the intervention. Results for each variable of interest will be compared among the different time points of the work shift and longitudinally considering each assessment day as a time point.

RESULTS

Enrollment for the study will start in April 2023. Results are expected to be available still in the first semester of 2023. It is expected that the use of the smart system will reduce malposture, fatigue, and consequently, work-related musculoskeletal pain and disorders.

CONCLUSIONS

This proposed study will explore a strategy to increase postural awareness in industrial manufacturing workers who do repetitive tasks, using smart wearables that provide real-time feedback about biomechanics. Results would showcase a novel approach for improving self-awareness of risk for work-related musculoskeletal disorders for these workers providing an evidence base support for the use of such devices.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/43637.

E-Textiles for Sports: A Systematic Review

This work presents a systematic review to provide an overview of the possibilities for coupling, fabrication or embedding of electronics into textiles whilst assuring the capability of these products to meet the requirements of a sports modality. The development of smart wearables systems for sports based on textiles attracts more and more users – motivated by design, by technology, as well as by the expectation of increased performance. A bibliographic search was carried out using the following databases: Scopus, Web of Science, IEEE Xplore and Science Direct. This study includes 32 articles and discusses these in a new taxonomy with three dimensions: measured variable, types of feedback and applications. Of the 23 technologies surveyed, this review showed that these wearable systems are mainly used for vital signs monitoring and to provide feedback on the electrical activity of the heart, with sensors mostly placed in the chest. Usually, the technologies are externally attachable rather than embedded in the textile. We observed that the implementation of design as the process of development of e-textile products is still only scarcely present in these studies.

Smart Clothing Framework for Health Monitoring Applications

Wearable technologies are making a significant impact on people’s way of living thanks to the advancements in mobile communication, internet of things (IoT), big data and artificial intelligence. Conventional wearable technologies present many challenges for the continuous monitoring of human health conditions due to their lack of flexibility and bulkiness in size. Recent development in e-textiles and the smart integration of miniature electronic devices into textiles have led to the emergence of smart clothing systems for remote health monitoring. A novel comprehensive framework of smart clothing systems for health monitoring is proposed in this paper. This framework provides design specifications, suitable sensors and textile materials for smart clothing (e.g., leggings) development. In addition, the proposed framework identifies techniques for empowering the seamless integration of sensors into textiles and suggests a development strategy for health diagnosis and prognosis through data collection, data processing and decision making. The conceptual technical specification of smart clothing is also formulated and presented. The detailed development of this framework is presented in this paper with selected examples. The key challenges in popularizing smart clothing and opportunities of future development in diverse application areas such as healthcare, sports and athletics and fashion are discussed.

A multicenter randomized controlled trial comparing gamification with remote monitoring against standard rehabilitation for patients after arthroscopic shoulder surgery

BACKGROUND

Gamification has become increasingly popular in rehabilitation and is viewed as a tool to improve patient activation, motivation, and engagement. The aim of this study was to compare the efficacy of validated exergames played through a system using "depth sensor" and bespoke software against standard physiotherapy in patients treated with arthroscopic shoulder surgery. This included the following common conditions: subacromial impingement syndrome, calcific tendinopathy, and rotator cuff tear.

METHODS

Following arthroscopic shoulder surgery, patients were randomized into 1 of 2 groups: In the standard rehabilitation group, patients were followed up for 12 weeks after surgery with standard postoperative physiotherapy and underwent electronic measurements of their active range of movement (ROM). In the exergame group, patients followed a postoperative regimen of exergames using the principles of gamification with physiotherapy support. Patients were given an exergame schedule prescribed by their therapist on Medical Interactive Recovery Assistant (MIRA) software (MIRA Rehab, London, UK) paired with a Microsoft Kinect sensor (Microsoft, Redmond, WA, USA). The primary outcome was active ROM objectively measured by MIRA and Kinect. Secondary outcome measures included the Oxford Shoulder Score, the Disabilities of the Arm, Shoulder and Hand score, and the EQ-VAS score at 12 weeks after surgery.

RESULTS

A total of 71 patients were recruited to the study. We excluded 7 patients based on intraoperative findings. Thirty-three patients were treated with exergames, and 31 patients underwent conventional physiotherapy. There was no significant difference between the 2 groups in baseline ROM. Postoperatively, there was no significant difference in any of the cardinal planes of movement (forward flexion, P = .64; abduction, P = .33; and external rotation, P = .75). The mean Oxford Shoulder Score improved from 29.25 to 38.2 in the control group (P = .001) and from 27.1 to 35.1 in the trial group (P = .01); there was no significant difference between the groups at 12 weeks (P = .246). The mean Disabilities of the Arm, Shoulder and Hand score improved from 38.13 to 16.98 in the control group (P = .001) and from 42.3 to 22.54 in the trial group (P = .007); there was no significant difference between the 2 groups (P = .328). There was no significant difference in the EQ-VAS score in either group at any time point (P = .5866).

CONCLUSION

This randomized controlled trial demonstrates that exergames can be used effectively in the rehabilitation of patients following arthroscopic shoulder surgery. Outcomes, judged by ROM and patient-reported outcome measures, are equivalent to conventional physiotherapy rehabilitation protocols. This health care innovation has the potential to relieve some of the heavy burden placed on physiotherapy departments for "routine" postoperative care in shoulder surgery.

Skin Strain Analysis of the Scapular Region and Wearables Design

Monitoring scapular movements is of relevance in the contexts of rehabilitation and clinical research. Among many technologies, wearable systems instrumented by strain sensors are emerging in these applications. An open challenge for the design of these systems is the optimal positioning of the sensing elements, since their response is related to the strain of the underlying substrates. This study aimed to provide a method to analyze the human skin strain of the scapular region. Experiments were conducted on five healthy volunteers to assess the skin strain during upper limb movements in the frontal, sagittal, and scapular planes at different degrees of elevation. A 6 × 5 grid of passive markers was placed posteriorly to cover the entire anatomic region of interest. Results showed that the maximum strain values, in percentage, were 28.26%, and 52.95%, 60.12% and 60.87%, 40.89%, and 48.20%, for elevation up to 90° and maximum elevation in the frontal, sagittal, and scapular planes, respectively. In all cases, the maximum extension is referred to the pair of markers placed horizontally near the axillary fold. Accordingly, this study suggests interesting insights for designing and positioning textile-based strain sensors in wearable systems for scapular movements monitoring.

Health-Enabling Technologies to Assist Patients With Musculoskeletal Shoulder Disorders When Exercising at Home: Scoping Review

BACKGROUND

Health-enabling technologies (HETs) are information and communication technologies that promote individual health and well-being. An important application of HETs is telerehabilitation for patients with musculoskeletal shoulder disorders. Currently, there is no overview of HETs that assist patients with musculoskeletal shoulder disorders when exercising at home.

OBJECTIVE

This scoping review provides a broad overview of HETs that assist patients with musculoskeletal shoulder disorders when exercising at home. It focuses on concepts and components of HETs, exercise program strategies, development phases, and reported outcomes.

METHODS

The search strategy used Medical Subject Headings and text words related to the terms upper extremity, exercises, and information and communication technologies. The MEDLINE, Embase, IEEE Xplore, CINAHL, PEDro, and Scopus databases were searched. Two reviewers independently screened titles and abstracts and then full texts against predefined inclusion and exclusion criteria. A systematic narrative synthesis was performed. Overall, 8988 records published between 1997 and 2019 were screened. Finally, 70 articles introducing 56 HETs were included.

RESULTS

Identified HETs range from simple videoconferencing systems to mobile apps with video instructions to complex sensor-based technologies. Various software, sensor hardware, and hardware for output are in use. The most common hardware for output are PC displays (in 34 HETs). Microsoft Kinect cameras in connection with related software are frequently used as sensor hardware (in 27 HETs). The identified HETs provide direct or indirect instruction, monitoring, correction, assessment, information, or a reminder to exercise. Common parameters for exercise instructions are a patient's range of motion (in 43 HETs), starting and final position (in 32 HETs), and exercise intensity (in 20 HETs). In total, 48 HETs provide visual instructions for the exercises; 29 HETs report on telerehabilitation aspects; 34 HETs only report on prototypes; and 15 HETs are evaluated for technical feasibility, acceptance, or usability, using different assessment instruments. Efficacy or effectiveness is demonstrated for only 8 HETs. In total, 18 articles report on patients' evaluations. An interdisciplinary contribution to the development of technologies is found in 17 HETs.

CONCLUSIONS

There are various HETs, ranging from simple videoconferencing systems to complex sensor-based technologies for telerehabilitation, that assist patients with musculoskeletal shoulder disorders when exercising at home. Most HETs are not ready for practical use. Comparability is complicated by varying prototype status, different measurement instruments, missing telerehabilitation aspects, and few efficacy studies. Consequently, choosing an HET for daily use is difficult for health care professionals and decision makers. Prototype testing, usability, and acceptance tests with the later target group under real-life conditions as well as efficacy or effectiveness studies with patient-relevant core outcomes for every promising HET are required. Furthermore, health care professionals and patients should be more involved in the product design cycle to consider relevant practical aspects.

A Pilot Longitudinal Study of 3-Dimensional Head and Neck Kinematics During Functional Tasks in Individuals With Chronic Idiopathic Neck Pain Either Wait-Listed for or Receiving Chiropractic Spinal Manipulative Therapy With Exercise

OBJECTIVE

The purpose of this study was to determine if there is a relationship between pain and movement kinematics during functional tasks, evaluated over time, in individuals with chronic idiopathic neck pain.

METHODS

Ten participants with chronic idiopathic neck pain performed 2 functional tasks (overhead reach to the right and putting on a seatbelt) while evaluated using 8 Oqus 300+ cameras. Kinematic variables included joint angles and range of motion (ROM) (°), head segment relative to neck segment (head-neck [HN]); and head/neck segment relative to upper thoracic segment (head/neck-trunk), velocity (m/s), and time (% of movement phase). Pain was quantified using a 100-mm visual analog scale. Linear mixed effects regression models were used to analyze associations between pain and kinematic variables adjusting for treatment group.

RESULTS

For overhead reach, higher pain was associated with less HN peak rotation at baseline (β = -0.33; 95% CI -0.52 to -0.14, P = .003) and less HN total rotation ROM at 6 months (β = -0.19; 95% CI -0.38 to -0.003, P = .048). For the seatbelt task, higher pain was associated with less HN peak rotation (β = -0.52; 95% CI -0.74 to -0.30 to -0.74, P < .001) and less HN total rotation ROM at baseline (β = -0.32; 95% CI -0.53 to -0.10, P = .006). No other movement variables demonstrated meaningful relationships with pain for the reach or seatbelt tasks.

CONCLUSION

Higher pain is associated with less HN peak and total rotation during functional reaching tasks requiring head rotation. Recognizing altered functional kinematics in individuals with chronic neck pain may assist patient management.

Wearable systems for shoulder kinematics assessment: a systematic review

BACKGROUND

Wearable sensors are acquiring more and more influence in diagnostic and rehabilitation field to assess motor abilities of people with neurological or musculoskeletal impairments. The aim of this systematic literature review is to analyze the wearable systems for monitoring shoulder kinematics and their applicability in clinical settings and rehabilitation.

METHODS

A comprehensive search of PubMed, Medline, Google Scholar and IEEE Xplore was performed and results were included up to July 2019. All studies concerning wearable sensors to assess shoulder kinematics were retrieved.

RESULTS

Seventy-three studies were included because they have fulfilled the inclusion criteria. The results showed that magneto and/or inertial sensors are the most used. Wearable sensors measuring upper limb and/or shoulder kinematics have been proposed to be applied in patients with different pathological conditions such as stroke, multiple sclerosis, osteoarthritis, rotator cuff tear. Sensors placement and method of attachment were broadly heterogeneous among the examined studies.

CONCLUSIONS

Wearable systems are a promising solution to provide quantitative and meaningful clinical information about progress in a rehabilitation pathway and to extrapolate meaningful parameters in the diagnosis of shoulder pathologies. There is a strong need for development of this novel technologies which undeniably serves in shoulder evaluation and therapy.

An upper body garment with integrated sensors for people with neurological disorders - early development and evaluation

Background

In neurology and rehabilitation the primary interest for using wearables is to supplement traditional patient assessment and monitoring in hospital settings with continuous data collection at home and in community settings. The aim of this project was to develop a novel wearable garment with integrated sensors designed for continuous monitoring of physiological and movement related variables to evaluate progression, tailor treatments and improve diagnosis in epilepsy, Parkinson’s disease and stroke. In this paper the early development and evaluation of a prototype designed to monitor movements and heart rate is described. An iterative development process and evaluation of an upper body garment with integrated sensors included: identification of user needs, specification of technical and garment requirements, garment development and production as well as evaluation of garment design, functionality and usability. The project is a multidisciplinary collaboration with experts from medical, engineering, textile, and material science within the wearITmed consortium. The work was organized in regular meetings, task groups and hands-on workshops. User needs were identified using results from a mixed-methods systematic review, a focus group study and expert groups. Usability was evaluated in 19 individuals (13 controls, 6 patients with Parkinson’s disease) using semi-structured interviews and qualitative content analysis.

Results

The garment was well accepted by the users regarding design and comfort, although the users were cautious about the technology and suggested improvements. All electronic components passed a washability test. The most robust data was obtained from accelerometer and gyroscope sensors while the electrodes for heart rate registration were sensitive to motion artefacts. The algorithm development within the wearITmed consortium has shown promising results.

Conclusions

The prototype was accepted by the users. Technical improvements are needed, but preliminary data indicate that the garment has potential to be used as a tool for diagnosis and treatment selection and could provide added value for monitoring seizures in epilepsy, fluctuations in PD and activity levels in stroke. Future work aims to improve the prototype further, develop algorithms, and evaluate the functionality and usability in targeted patient groups. The potential of incorporating blood pressure and heart-rate variability monitoring will also be explored.

Towards The Internet-of-Smart-Clothing: A Review on IoT Wearables and Garments for Creating Intelligent Connected E-Textiles

Technology has become ubiquitous, it is all around us and is becoming part of us. Together with the rise of the Internet-of-Things (IoT) paradigm and enabling technologies (e.g., Augmented Reality (AR), Cyber-Physical Systems, Artificial Intelligence (AI), blockchain or edge computing), smart wearables and IoT-based garments can potentially have a lot of influence by harmonizing functionality and the delight created by fashion. Thus, smart clothes look for a balance among fashion, engineering, interaction, user experience, cybersecurity, design and science to reinvent technologies that can anticipate needs and desires. Nowadays, the rapid convergence of textile and electronics is enabling the seamless and massive integration of sensors into textiles and the development of conductive yarn. The potential of smart fabrics, which can communicate with smartphones to process biometric information such as heart rate, temperature, breathing, stress, movement, acceleration, or even hormone levels, promises a new era for retail. This article reviews the main requirements for developing smart IoT-enabled garments and shows smart clothing potential impact on business models in the medium-term. Specifically, a global IoT architecture is proposed, the main types and components of smart IoT wearables and garments are presented, their main requirements are analyzed and some of the most recent smart clothing applications are studied. In this way, this article reviews the past and present of smart garments in order to provide guidelines for the future developers of a network where garments will be connected like other IoT objects: the Internet-of-Smart-Clothing.

Stroke Patients' Acceptance of a Smart Garment for Supporting Upper Extremity Rehabilitation

The objective is to evaluate to which extent that Zishi a garment equipped with sensors that can support posture monitoring can be used in upper extremity rehabilitation training of stroke patients. Seventeen stroke survivors (mean age: 55 years old, SD =13.5) were recruited in three hospitals in Shanghai. Patients performed 4 tasks (analytical shoulder flexion, functional shoulder flexion placing a cooking pot, analytical flexion in the scapular plane, and functional flexion in the scapular plane placing a bottle of water) with guided feedback on a tablet that was provided through inertial sensors embedded in the Zishi system at the scapula and the thoracic spine region. After performing the training tasks, patients completed four questionnaires for assessing their motivation, their acceptance of the system, its credibility, and usability. The study participants were highly motivated to train with Zishi and the system was rated high usability, while the subjects had moderate confidence with technology supported training in comparison with the training with therapists. The patients respond positively to using Zishi to support rehabilitation training in a clinical setting. Further developments need to address more on engaging and adaptive feedback. This paper paves the way for larger scale effectiveness studies.