IAS Visiting Fellow Dr Fransiska M Bossuyt delivers a seminar on their research –
This seminar explores critical aspects of shoulder problems and pain, affecting two out of three individuals at some point in their lives and posing increased risks for wheelchair users. Shoulder pain can significantly impair an individual’s independence and ability to perform important activities such as eating, self-care, work, and sports. The cumbersome treatment and long rehabilitation process further highlight the need to improve injury prevention. The speaker discusses a research trajectory from basic science through to applied clinical application. The talk specifically delves into how repetitive activities, such as fatiguing wheelchair propulsion, impact shoulder biomechanics and tendon structures. The presented findings will shed light on injury mechanisms and recommendations for optimizing shoulder health in wheelchair athletes. Finally, future perspectives and insights into state-of-the-art technologies for understanding shoulder functioning and injury mechanisms will be discussed.
For more information about the IAS, please visit – https://www.lboro.ac.uk/research/ias
Thanks very much Kieran um I’d just like to welcome everybody who has joined us online uh on behalf of L University and thank the Institute of Bank studies for allowing us to fly Cisco over from Switzerland so um the Peter house center disp swort has had long standing
Relationship of working with people from the Swiss paric Research Center for which cisa was based and now she’s elsewhere in in Switzerland but we’ve collect a real of close working network with her and the reason why she’s over is sharing her knowledge not only in this presentation which is looking at
The shoulder Health in wheelchair athletes but also to collaborate with us on future work around athlete health and some of the work that we currently doing with GB wheelchair rugby and Tom o’ri has facilitated a really nice sort of dat collection opportunity for us to collaborate with with cisa would like to
Thank everyone for coming in the room here as well to join this particular session and I know cisa’s got a little bit of an introductory slide of who she is and where she’s she’s come from so I’ll pass the floor now back to to cisa and say thank you very much for joining
Us today thank you very much thank you everyone for coming and also from my side uh I’m really grateful for the invitation and the support from The Institute of advice science as well as Vicky for inviting me for coming here and mo ran for the organization with the
Assessments it’s been a truly great pleasure and I’m really excited that I can talk a bit more about shoulder Health in wheelchair athletes and what I’ve been up to um so sorry need to back okay okay so just a bit of an overview um about my talk so
I’ll start a bit with my background then I’ll talk more about um shoulder Health in um wheelchair users uh and specific followed by um how fatiguing wheelchair propulsion impacts also injury mechanisms which we’re trying to better understand to improve injury prevention uh and monitor Rehabilitation which will then lead into future perspectives and
What’s missing where we want to go and also what I will what I’m doing in my current role at the e in Zur so I’m originally from Belgium um from a very small village where it’s very flat I studied Science and Mathematics and then I went on to study Bachelor and
Master in physical education and movement Sciences at Gant University because I’ve always been truly passionate about sports and how that is instrumental in um good health and happiness um um I did an Erasmus Exchange in Finland got more introduced to the topic of biomechanics which I really like because of the
Interconnection between physics and the human body um so I decided I wanted to know a bit more about that and I went on to Liverpool um at John Morris University where I did the Masters in sports and clinical biomechanics looking at um fatigue injury mechanisms in
Landing strategy so in the lower limb um after that I went back to Belgium um volunteered at University got a research assistant position which then brought me to my PhD at the Swiss paraplegic Research Center which I’ll go talk a bit more about in a minute um and this was
Uh in collaboration with the University of lucern in central Switzerland during my PhD I also collaborated with the University of Pittsburgh I went there twice for a research visit which which is where I learned the um quantitative ultrasound protocols which I’ll talk a bit I’ll talk more about as well and
Which is what we have been doing with the wira rugby athletes uh during my stay here um so after that I had the feeling that I wanted to better understand we’re looking at these shoulder tendons but what is actually happening how are these why do we see these changes so I wanted
To get more to fundamental biomechanics and learn more about muscle tendon interactions um and this is what I did with uh in Calgary um at um Calvary University um where I did more animal research really directly measuring muscle forces tendon strains during a Locomotion Evo I then uh came back to
Switzerland um and wanted to apply this more fundamental research back to The Human Side uh came back to the paric research continuing um my work there and now since September I am at the um eth and Zer in the laboratory for movement biomechanics where I’m leading uh the shoulder project uh within the
Laboratory um and during this time um U what I didn’t really mention is that as I started my my masters in Liverpool I also started rowing and I I feel it a bit as as my biomechanics journey evolved I always continue rowing and I’ve been also a par coach in rowing and
Involved in the inclusion of par rowing at the pen rata which organizes the World Cup and this year the last qualifying Riata uh so at the same time I’m still applying bit of my sports background uh and the shoulder work but that’s enough about about me um
The Swiss paric research uh I’m not sure if you have been there already or you may may know it but it’s um in central Switzerland and it’s really a unique set of resources that um overall aims to improve the lives of persons with a spinal cordiner and this goes from the
Um the date of injury uh Acute Care Rehabilitation to reintegration into life and and The Institute and the foundation really value the importance of sports as a way of a reintegration into life so you also have the sports medicine who’s supporting a lot of paralympic athletes um but uh going from
Any level so um from Recreation to competitive level and then they also have the research center so the research center is based in this um f-shaped building here which stands for for which means uh research in German and within the research center um I was part of the shoulder health and
Mobility Group which aims to improve Mobility and shoulder functioning in persons with spinal cord injury so this is fundamental because as uh injuries occur it has a direct impact on Independence Mobility uh quality of life and unfortunately uh or but unfortunately the shoulder is uh prone
To injury and um it’s um one of the most common complaints are related to the shoulder joints now the shoulder is for is very fascinating joint is the only joint in our body that allows for such a great range of motion and this is because of the limited stability anatomical stability which requires
Stabilization from the muscles surrounding the shoulder now I want to give you a little task and also those who are um listening online if you have a terab band or an elastic I’ll give it around here but please um try to do as many many repetitions as you can so you
Are in your elbows 90 deges of flexion and you will do an external rotation so it’s it’s pretty hard I don’t want you to go maximum uh but try to do as many repetitions as you can and then afterwards we can um get back to that so proba that on
Um so yeah we really need these muscles to um stabilize our joints so the prevalence is high in the general po population um it’s um ranging up to 2/3 of the population so the two3 of the persons will have show the pain at some point during their lives in
Persons with the spinal cord injury here um the prevalence is up to 73% um so it’s it is higher um we also see a high prevalence of um theer C abnormalities in persons who are performing activities that are specific Ally demanding for the shoulder so that includes wheelchair
Users so almost all wheelchair users will have some or of abnormalities also for example professional basketball athletes now we don’t really have exact numbers about wheelchair athletes so it would be interesting to see um more closely how performing these wheel sports uh impacts the the shoulder
Tendons and how that may be um different in person who are performing less sports or maybe less trained uh less trained uh at the shoulder so we know that tendons degenerate over time and as you age you will have more degeneration in your tendon as you can
See on this figure here um we go from less than 20 years old up to 8 years old we see that uh 60% of the population has some ton abnormalities if we look at vure users we can see that persons who are in a wheelchair were about 40 years old their
Tent abnormalities will have accelerated um as compared to someone who is not in the wheelchair um so they would be at have 10 abnormality similar to someone who is above 70 years old now that what we want to understand is how that relates uh to pain that may not
Necessarily mean that it leads to pain but we want to better understand what exactly is causing the so-called acceleration of degeneration so I spoke about these muscles that are supposed to stabilize the shoulder and they’re called the rotator cuff muscle so they form a cuff around the shoulder the shoulder is
Really mobile so we can do a big range of movements and if there’s any instability in this muscle in these muscles that can lead to an overloading at at certain points and lead to injury mechanisms um so we can look at the shoulder a bit
As a seal who’s floating on the water so the shoulder blade is floating on the TX and then it’s trying to balance a ball on its nose so the seal um would be so this would be the seal the shoulder blade would be balancing the ball of the
Humoral so the humal head on its nose so the scapula has to move dynamically so that the humal head stays balanced on this on this point and that is that is done through these muscles that form this cuff and try to stabilize this joint while you’re doing all these
Movements which you can imagine it is um uh demanding and and very complex so the most Comm diagnosis um is related to um the supraspinatus and the biceps tendon which are these tendons that lay within the subacromial space so they are between the humoral head and the acromium which is part of the
Shoulder blade and as um we’re moving our shoulder for example overhead we reduce the space and this could potentially lead to compression of the tendons um and um in combination with repetitive activities so for example if we are propelling a wheelchair we’re doing these repetitive activities but we also
Have this reduction in the super chromal space and animal work has shown that it’s especially this combination of overuse and compression that leads to the greatest injuries um but we don’t know um if that is how that specifically Works um in for example in human uh mechanisms so if we have a healthy
Tendon we see these nicely aligned collagen fibers um and on an ultrasound image here we can see a bicep standon so the bicep standon is visible in between these nicely distinct white lines and we can see these nice black and white lines um which represents the collagen fibers
So with aging but also with overloading so potentially repetitive overuse combination with compression we can have um degeneration so tendonopathy um which would lead to disorganized fibers a capillary in growth maybe some fluid in there so on an ultrasound image this would look a bit more like this um and
So the talents adapt to are changing demand so we may have some um acute injuries but it can recover over time so it’s not that these changes would be permanent however if we constantly keep overstressing the tissue we can become we can get to a stage where it’s uh the
Changes are irreversible and this could lead to tendon tears tendon rupture which would then require um potentially even a surgical intervention so we don’t really understand how we go from these nicely healthy tendons to uh the tending degeneration so what are the exact steps leading to these um peric problems that
Are then irreversible and the problem or the difficulty in understanding the mechanisms is that a lot of um persons who have degeneration in their tenants are ASM asymptomatic so won’t have any symptoms and this can be for quite a long time um so the duration of being asymptomatic is is
Inconsistent and it does necessarily mean that if you have abnormalities that you will become symptomatic so we don’t really understand who are these persons who have this degeneration that will get symptomatic so we want to identify who these persons are so we can prevent injury to happen now one interesting uh parameter
That has been found is this so-called critical shoulder angle as a risk factor for or a predictive Factor almost for being someone who would develop Rotator C pathology or osteoarthritis so if you look at the critical shoulder angle which you can see here um as these yellow lines it’s the angle between the
Inclination of um the glenoid so that’s part of the scapula of the shoulder blades and the top of the acromium if this angle is above 35° over 80% of the subject so that would be here um were found to have Rotator cff pathologies while if the angle was below
30° um over 90% of those subjects had osteitis and this is uh hypothesized to be associated with um the mechanism that if you have a larger critical shoulder angle you need more stabilization from the Rotator C muscle so they will be more stress on those tendons EV link to
Pendon degeneration while if this angle is much smaller it changes the vectors with which the muscles are pulling on um on the humoris so you’ll have more compression in the joint which would be expected to lead to ostearthritis but we don’t understand how this critical shoulder angle or how this affects
Stress on the muscles and pendence during motion so we these are assumptions that that are made but we don’t really understand the mechanisms Behind These risk factors um and how the moving scapula plays a role in the loads Distribution on the muscles and attendance um so if we want to improve
Iny prevention we want to get to these risk factors these predictive factors so that we can really Target uh our our injury prevention strategies and previous research has shown that um risk factor for shoulder pathology and pain and wheelchair users include both um and and this is straightforward the demands
On the shoulder but also the capacity to meet those demands so this has to be in balance and so for example factors associated with capacity would be Sixx females have um most twice the odds of having shoulder pain as compared to males um as well as the injury characteristics so depending on what
Kind of impairment you have that will impact your shoulder loading um also this space for dependant if this there is more space for your um s so for your supat your protator cff pendant um this would be a potentially beneficial range of motion also your muscle strength how is it stabilizing your shoulder
Pense injury would also be um injury mechanism and then um age obviously as well then the demands on the shoulder relate to the shoulder loads um also body weight um the heavier you are the more you will have to push yourself forward transfer every time so even those little changes can have a
Significant impact on your shoulder loading um the propulsion by mechanics so there guidelines in terms of How It’s been recommended to propel a wheelchair because that is then associated with less shoulder loads as well as the wheelchair and setup as we’re doing bike fting um for cyclist um that obviously
Place also a significant role uh in minimizing the demand so that you can then optimize or have more room for um using the loads wisely so that for example if you optimize all these factors you can invest more in playing the sports and then get um also more
Your iric Capacity inov instead of them sort of losing um losing energy on um on a bad setup of a wheelchair would be unfortunate um I’m not sure if we’re taking questions in between there’s oh theend ah okay yeah so to the end yeah I’m sorry um so the recommendations in
Terms of propelling a wheelchair um as have been shown is that um it’s really recommended to propel wheelchair with these long and these smooth Strokes so not have these short forwards and backwards movement but really do the circle motion because that reduces the stress on the shoulder um so these two
Uh these two styles on the right hand side uh would um require least less uh muscle um muscle forces um in terms of um Rehabilitation and uh strengthening the shoulder joint there’s the stumps program from the group in the US at Los Angeles Rehabilitation Center which has been
Shown to uh reduce um shoulder pain uh and be effective uh in um wheelchair users so it includes three stretching exercises recommended to do two sets holding position at 20 seconds um and then which would then be followed by a um um an exercise program so you do a
Warmup where you have two sets 10 repetitions of each activity without resistance and then doing these activities so including hypertrophic exercises um as well as these urance exercises which are really helping to stabilize the shoulder joint and having this this balance uh at the shoulder and um they are applying this
This protocol as an intervention so also comparing the effect of when you do a homebased intervention versus um more interaction with the physio um and and this has been shown to be a really effective program so this is for example also what we’re applying with um with wheelchair uh with rowing parall rolling
Athletes but then making the exercises more functional so you can do the activities within the um position on the urometer so that the athlete is immediately in that position which will um be more sports related and more effective saving time in general for the um for the for the protocol um and I
Think this is something that we know that is there’s four exercises that can be implemented can be given with the athletes uh and that is already a great step in terms of uh prevention um now despite all the advancement and signs that have been um that we have
Reached over the last years uh and the increased interest also in shoulder research in in um in research as we can see there is a significant increase in the amount of Publications over the last years um there is still um a lack of um or the treatment um surgical options are still unsatisfying
In a way that there’s still quite a high rerupture rate following surgical treatment and the prevalence values are still high so this raises the question um what should we do differently like we’re doing so much more research on the shoulder we’re trying to understand what’s happening but what are we still
Missing and one idea is is this um idea of early identification of those persons who will become symptomatic over time because we have this difficulty in actually diagnosing um persons who have pathology that is asymptomatic we don’t want to um we don’t want to be um H be
Worried about every person who has some kind of tendent abnormalities but we want to really understand who are the ones that are will become symptomatic um and this early identification is something where I’m really interested in um in my um field of research so we um
In my PhD one of ways to look at that is to look at fatigue and how it impacts the shoulder structure because with um fatigue so this complex phenomenon in which physical and cognitive functioning is limited to interactions between perceived fatigability and per performance fatigability so performance
Fatigability would be a reduction in um maximum strength a change in heart rate a change in muscular activation perceived fatigability would be a change in uh perception so during this States we our bodies are particularly prone to adaptations so it offers a great way to see how our body is changing with fatig
So we can see these acute changes to better understand how that may lead to Chronic adaptations um so we studied fatigue um in uh a broad sample of U persons with a spinal cord injury ranging from persons who are inactive to par athletes uh at competing
At um par Olympic level um and we looked we investigated fatigue with this figure8 fatigue protocol which includes three times 4 minutes of overground wheel check propulsion so including these right left turn starts and stops that would mimic more what we um do during daily life but also um wheelchair
Sports related training and activities and then um one thing that we found was that um if we look at the startup propulsion biome mechanics so because this is really demanding if we accelerate the wheelchair we get the highest forces uh and we did see changes in the propulsion time on the whe at
This first stroke of start of propulsion so while there may not be changes of fatigue overall like this first stroke seem to be very uh critical which is important because that’s what what we would be doing more generally and also persons who were propelling with these less advised propulsion styles were
Found to show more signs of fatigue so again reinforcing to propit these long and these smooth strokes and for that we used uh this Smart Wheel which is um a wheel where we can measure the forces on the pushrim so we can actually get um biomechanics of
Propulsion um now this study was done so previous this study was done in the US in Pittsburgh but then we also collected data with 50 wheelchair users at the Swiss paraplegic Institute so this room that you’re seeing here is the laboratory there that’s based within this F shaped building
So we had a combination of uh several assessments that were conducted before um before during and after this figure eight fatigue protocol which we did in the corridor overall it took about four hours so we did maximum tests maximum Sprint tests maximum push tests um we took ultrasound exams uh just to better
Understand what is happening um we also looked at their propulsion biome mechanics before and after the fatiguing task um on the treadmill because that’s how we can standardize the power output um so all persons were propelling at fixed power outputs and then we would see if their proportion bi mechanics
Would be affected by the fatigue so looking at muscular activation uh and so so the ultrasound examinations in specific uh that we use and these are also the ones we have been doing with the rugby athletes uh include um so here in in lra so these assessment include
The AC chromal distance so that is the space between uh the acromium so the shoulder blade and the humal head um and we did that in a neutral position as well as in a push-up so we had a um push-up where we asked to retract the
Shoulders as well as a pushup that we where we didn’t give any instruction so there their style of pushing up um we also looked at their biceps and their supraspinatus pandon and these protocols so these quantitative ultrasound protocols um allow minimum error in probe location before and after the
Fatiguing task because we we stick a metal marker to the skin which gives a reference pattern on the ultrasound image and from there we can then calculate the region of interest from which we can then quantify the average tendon thickness but also the gray scale
Um and and the contrast do we see nicely distinct fibers um so what we found was that after the fatiguing task um person who are propelling with shorter Strokes so again confirming um that this is something that also with fatigue would changing our propulsion biome mechanics
Um to this more demanding task and we we saw an increase in neuromuscular activation in specific muscles so in the pectoralis the deltoid and the upper trapezius uh specific um so the upper trapezius part here so this also is green is the lower and middle trap but
Those muscles um were mostly affected by the fatigan task and that could lead to muscle imbalances over time if we don’t complement it with um exercise training that would then also strengthen um the muscle surrounding the shoulder so that we keep this nice stable base for the
Shoulder joints um we then also identify person susceptible to fatigue and this was associated with uh injury mechanisms so person who had a complete lesion who were older at the age of injury um but also persons who propelled with these shorter less advisable Strokes were more susceptible to fatigue persons who had
Less muscular activation um as well as what’s interesting was that person who had a greater anerobic capacity with no differences in activity levels were more prone to fatigue and this may be associated with the fact that athletes who train for anerobic capacity in general are more susceptible to fatigue
As compared to athletes who trained for aerobic capacity really demonstrating the importance of of um comp menting the training protocols um if we looked at the um acromial distance what was interesting here was that we found that um in general um persons who would push up would show a reduction in the
Superal space which could potentially be um a risk factor for shoulder problems now those persons who had a greater anerobic capacity were actually able to maintain the acromio space so really supporting towards the value of muscle strength training doing um uh performance also Sports to have this
Capacity as a way to um yeah strengthen the shoulder joints um when we looked at the tendons we found an overall reduction in the supinatus tendon um which is um a natural response of repetitive activity to tendonous tissue so alignment of the collagen fibers however interestingly persons who are
Heavier actually showed an increase in the thickness um so this could Point towards that a natural response is this reduction but if you have this overloading because of your body mass potentially um that could lead to um uh overuse at the timing level um so in conclusion here from from
From this specific research it really supported the propulsion technique but also aerobic capacity uh potentially using high intensity interval training um but also anerobic capacity values of uh for maintaining um I mean not only but as one mechanism thereof would be maintaining the acromial distance uh and also the importance of neuromuscular
Activation um now what’s interesting is that um uh as I did this work uh and I presented it we uh and and as VII said they have collaborated before um I’ve been collaborating with this paric research we um fi then uh suggested to also apply these methods to the
Wheelchair rugby athletes and that’s in 2020 I came here and we collected data and now it’s we’ll have a second time point where we are looking at the shoulder ton so applying these same uh protocols but then looking at um at that time we looked at the effect of a
Maximum test to exhaustion when the athletes are in their Sports specific wheare um and um uh propelling how they would be propelling during a game play Al although it is on a tread bill but given that it is the maximum test offered as unique insights also with the addition of the physiological information
Um so interestingly what we found from these studies were that we saw a reduction in uh the echogenicity gray scale which points towards um a a reactive tendon mechanism so this would be a sign of overloading which is what we were to expect if you’re doing a maximum test to exhaustion now the
Interesting part there as well is how um how fast do the aete recover do depend and recover how much time do you needs uh until you can for example do such tests again um we also identify differences in the supinat segments between athletes with different impairments which also points towards
This uh importance of differentiating between different impairments um and the need of really more research into this field because we are uh really limited what we know um to date we also had a one specific case where we uh looked at um a left right shoulder in one athlete who had who was
Asymptomatic uh on one side and symptomatic on the other side uh and I think this is this is a very interesting topic as well that has been researched um lot also by the grul and lro these asymmetries and um what we found was that interestingly while the um
Symptomatic side had a higher Peak power there was a greater drop in Peak power so a greater fatigue index in the symptomatic shoulder and we did see that in the asymptomatic shoulder we saw this reduction in the supinat which we didn’t see in the symptomatic side so there were some asymmetries
Um could be that for example due to this increased fatigue index at the symptomatic shoulder maybe the asymptomatic shoulder may have to overcompensate uh this could lead to problems over time but just trying to better understand the mechanisms and what’s happening um how we can inform
The uh the coaches and the physio with this information would be extremely valuable um and so last last week and this week um we’re collecting more data with the witer rugby athletes so this is a picture and it’s been really a lot of fun uh with everyone um working together
And having such an interdis disciplinary team um so hopefully next time I can present you some of the results like that so what are now the future perspectives um what are we still missing where do we want to go um first of all we we know there are these acute
Tendent adaptations even after a maximum test exhaustion after PE protocol we see changes so how do these changes now play a role on the long term can we you know complete that full picture from healthy to uh chronic degeneration and what is the impact of the impairments of the sports um the
Position in the wheelchair um and also how is that different following training Competition in addition um what we really need to understand is how these how the muscle forces impact the tendon strain because the tendon is immediately impacted by the muscle this is why I went to calary to try to better understand it uh but it’s just um possible in humans to directly measure
The muscle forces so we rely on um assumptions on simulations to get to this kind of information but what we really want to understand is this those response relationship what is the appropriate amount of loading because specifically for the pendant overloading can lead to micro damage but complete
Removal of load leads to a catabolic state so what is exactly the perfect amount where we can improve the Integrity of the pendant without degenerating it so this early identification of tendon degeneration which could then be used to monitor Rehabilitation and injury prevention and I think the biggest
Limitation to date is the lack of sensitive Technologies and assessments that can actually identify someone who is asymptomatic and has degeneration um and this is what my work leads into where I’m where I’m going now um also also to understand um how this scapula is exactly moving because even a 1 to 2
Mm change in the shoulder blade position can lead to up to 67% reduction of the s acromium space so pointing towards current methodologies motion capture systems where we have markers on the skin are just too limited to identify such subtle changes and that’s why in recent years um there has been an
Increased interest in groups that are are working with dual plan fluroscopy systems so it’s basically an x-ray system where you can see the shoulder blade during motion um now the limited the the systems to date are limited in that they are saic um patient has to remain
Stationary um and we cannot really do very functional assessments and there haven’t been any any um uh estimations of the actual strains on the pendon as I said we cannot directly measure the forces in humans but we need to get to those load um load mechanisms
So at the eth and Zer at the laboratory for moving bi mechanics they have developed a unique tracking dual plane fluroscopy system which is such dual plane system so which has this um x-ray that tracks the subject wirelessly as a moov moving through um through the lab
And um they have um been focusing on the knee uh and done a very fascinating um experiments with persons who have show uh knee implants where they can then actually have the forces as well as the um motion of the bones so our goal is to
Apply this to the shoulder and um get to more functional assessments to actually see how the shoulder is is moving during these functional assessments now it’s clear that we have to be cautious here about the radiation dosage and that this is uh still invasive even we uh try and
We minimize the radiation as much as possible um on the long term we don’t want to have everyone coming into a fluoroscopy system so that’s where we also um developments lead towards non invasive um assessments that can help us so for that we’re collaborating with um the University of California in San
Diego who has developed this stretchable ultrasound technology which is basically like a patch that you can tape to the skin and can then get ultrasound information up to 4 cm underneath the skin as well as modulus so get strain information of the tissue and they have shown um they have done experiments
Where they they had athletes and they had the patch on their shoulders followed them uh before and after Ecentric training and what you can see here is that as they have the Ecentric exercise and then they’ve applied natural natural recovery or different recovery strategies that they can
Actually reduce um the late onset muscle soreness with these recovery strategies so this would allow if we apply it in a wheelchair atlete populations you could have the patch um in a training week see how the tendons are changing before after training before after potentially gameplay which would be revolutionary in
Terms of monitoring their tendon Health um then we have also the um in silico and inv vitro simulations which can then if we combine the Technologies give us this information on the forces and the the tissue strains so so for that we’re collaborating um also with the group at in Sydney at mcara
University who developed a um Advanced shoulder simulator and to actually measure the muscle forces when simulating these shoulder movements um okay now the final part would be the non-invasive Optical tracking so from the fluoroscope we want to go to non-invasive scapular tracking using a technology that has been developed to
Quantify spinal alignments um and we want to apply this to actually get the information of the scapula U moving using them machine learning um and and deep learning methods so combining all of these te Technologies the projects that I’m working on aimed to shape Innovation for shoulder kinematic assessments leading
To then a biomechanical understanding of soft tissue loading um and injury in Vivo hoping to then uh improve injury prevention and um Rehabilitation so thank you very much and um I’ll be happy to answer any questions