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A Diagonal Movement Pattern of Arm Elevation and Depression in Overhead Throwing Athletes: An Exploratory Kinematic Analysis for Clinical Application

Appl. Sci. 2023, 13(19), 10691; https://doi.org/10.3390/app131910691

by Nuno Morais^1,2,*

, Joana Ferreira³, Jéssica Gordo⁴, João Paulo Vilas-Boas⁵

and Augusto G. Pascoal⁶

Reviewer 1:

SAMPATH DAKSHINA MURTHY ACHANTA

Reviewer 2: Anonymous

Reviewer 3: Anonymous

Appl. Sci. 2023, 13(19), 10691; https://doi.org/10.3390/app131910691

Submission received: 19 July 2023 / Revised: 15 September 2023 / Accepted: 23 September 2023 / Published: 26 September 2023

(This article belongs to the Special Issue Joint Kinematics Analysis and Injuries Recovery)

Round 1

Reviewer 1 Report

· In the literature survey section, the problems of the existing methods are not clearly explained and the results of the work related to them are not properly explained.

· Give more explanation in existing method about result and discussion part.

· Some recent reference documents should be included in related journals

· Novelty is missing .need to explain

· Add more explanation in conclusion part.

· Need more explanation in result analysis

· Revise the manuscript accordingly

Cite the below papers

Sampath Dakshina Murthy, Achanta, Thangavel Karthikeyan, and R. Vinoth Kanna. "Gait-based person fall prediction using deep learning approach." Soft Computing (2021): 1-9. https://doi.org/10.1007/s00500-021-06125-1

Murthy, A., B. Jagan, K. Raghava Rao, and P. Satyanarayana Murty. "A virtual reality research of Gait analysis in the medicine fields." In AIP Conference Proceedings, vol. 2426, no. 1. AIP Publishing, 2022.

The Language errors is seen in many places in the manuscript and typo errors are also seen in the manuscript.

Author Response

We would like to acknowledge the reviewer for her/his valuable insights and suggestions which have undoubtedly improved the quality of the article.

Comments and Suggestions for Authors

In the literature survey section, the problems of the existing methods are not clearly explained and the results of the work related to them are not properly explained.

We have opted to approach this problem more on the Discussion section rather than the Introduction section for readability purposes and interest of the readers. Problems of the existing methods are explained in lines 423–431 and lines 432–444.

Give more explanation in existing method about result and discussion part.

We have discussed extensively the methods used and contrasted them with the literature. Please, follow our text improvements highlighted in yellow color.

Some recent reference documents should be included in related journals

We have extensively re-searched the literature and the relevant papers on this subject have been incorporated and cited.

Novelty is missing .need to explain

The novelty is the study of scapular kinematic use of a clinically friendly functional arm movement pattern that has been understudied but widely used. We explain it during the Introduction and following the reviewer’s suggestion we have discussed ti in detail in paragraphs 2, 3 and 4 of the Discussion.

Add more explanation in conclusion part.

We have rephrased the Conclusion as suggested. It is now in the revised version of the manuscript as: “This study revealed statistically significant distinctions in 3D scapular orientation when comparing diagonal humeral elevation (PNF–D2) to humeral elevation in the traditional planes of motion (shoulder abduction, shoulder flexion, and shoulder scaption). However, no statistically significant differences were observed between athletes with clinically diagnosed scapular dyskinesis and non-athletes without this impairment. These findings are preliminary and underscore the need for further research in this area to clarify whether including a functional arm movement pattern when evaluating scapular position and movement in overhead athletes may be clinically relevant.”

Need more explanation in result analysis

We have improved the figures supporting the Results section and the English fluency, particularly when discussing the results, hoping that higher standards are now met the revised version of the article. Please, follow our text improvements highlighted in yellow color.

Revise the manuscript accordingly

We believe we did.

Cite the below papers

These are very interesting articles. Thank you for showing them. We are preparing papers on machine learning methods and virtual reality in shoulder rehabilitation in neurological patients and these are inspiring and citable works for those papers.

Comments on the Quality of English Language

The Language errors is seen in many places in the manuscript and typo errors are also seen in the manuscript.

We have extensively revised the manuscript to amend English grammatical errors and typos, as well as improve the fluency. These are highlight in yellow in the revised version of the manuscript.

Author Response File: Author Response.docx

Reviewer 2 Report

Please describe the abbreviations and symbols when they appear for the first time. Please reconsider SD as abbreviation for Scapular dyskinesis as »SD« is usually used for standard deviation. Abstract: explain »PNF-D2-flx/ext«. Please explain what is »p2«.

Abstract: the authors conclude »These findings should be considered in future biomechanical research and rehabilitation of shoulder movement-related impairments”, however it is not clear why and how this would be implemented. Please give some brief justification.

Methods. It would be of help to the readers to see the illustration of the movements performed by the participants and the position of the markers.

The authors claim that the participants were able to practice before the measurement. Please give more information. How long could they practice? What instruction were they given?

Line 125. The authors state “The main author…”. This could be unclear. Please clarify (add the initials) or “The first author…” or similar.

Line 170. Measuring one week apart is mentioned. Were the measurements repeated and average value calculated? If so, how many times and what was the range of measurements? Could the authors estimate the error of the method?

Results: I am a bit sceptical that some decisive conclusion can be made with only 11 subjects in the smallest group, in particular if the claim is that there is no differences between the groups. Even if the statistical power is adequate, such small number of cases could hardly be relevant for any clinically important decision. I suggest that the authors define the criteria for clinical relevance regarding the difference between the groups besides the statistical significance and power.

Statistical analysis: Table 1 presents a probability pertaining to the difference between the groups. Please explain the meaning of the probability p. In order to claim that the two groups were or were not different, it is also important to know whether the groups were large enough (contained adequate number of participants). Statistical power analysis can be added. Please report on statistical power analysis and state the results and conclusions for any comparison and difference claimed with the information of statistical significance.

Table 1. Please state in the Table title the parameters compared. Add to the Table 1 the number of subjects in each group and report on statistical power and clinical relevance criterion. There is some information in the Discussion on the required number of participants that estimate sufficient statistical power, but this number is higher than that considered in the analysis.

Line 269. Please explain the meaning of »interaction effect HT angle x task« What does the »x« symbol mean here?

Line 269. Please explain the meaning of parameter F. It has a peculiar subscript. Please explain the meaning of the indexes in the subscript.

I suggest that the authors use the expression »average« in describing the results of the group.

In description of Figure 1, to me it seems that the green and the blue curves are more similar while the blue one differs a bit, particularly at larger humerothoracic angles.

Discussion, first paragraph. It is difficult for the reader to comprehend the outline of the results. The illustration of the motion as suggested above would be of help here. Please refer to the illustration here.

Line 333-336. The authors state: »Despite sharing a similar pattern during arm elevation (and depression) tasks, this study found important differences in 3D scapular orientation between the diagonal arm elevation...« Please cite where this can be seen.

Conclusions. State in the conclusions that the results are subject to insufficient statistical power. In the light of the results, please remove from the title and all over the manuscript any conclusions regarding practical advice or clinical applications. Line 31: please remove »and rehabilitation«.

Author Response

We would like to acknowledge the reviewer for her/his valuable insights and suggestions which have undoubtedly improved the quality of the article.

Comments and Suggestions for Authors

We acknowledge the abbreviations issues. We now use ScDk to abbreviate scapular dyskinesis. We have provided a brief explanation of PNF-D2-flx/ext in the Abstract. It is now in the revised manuscript as: »...and a diagonal movement pattern mimicking a throwing (proprioceptive neuromuscular facilita-tion diagonal 2 for flexion/extension or PNF–D2–flx/ext). ». Regarding p2 we are not seeing this. It may be some bad conversion to pdf of eta square partial symbol (effect size statistics)?

We have clarified the Conclusion in the Abstract. It is now as: “The inclusion of a functional arm movement pattern when evaluating scapular position and movement in overhead athletes does not appear to be mandatory. However, these findings are preliminary and highlight the need for more research in this area.”

Methods. It would be of help to the readers to see the illustration of the movements performed by the participants and the position of the markers.

Illustrations exemplifying the movements performed by the participants and of the electromagnetic sensors position in a subject are now provided as Figure 1(a–d) and Figure 2, respectively.

The authors claim that the participants were able to practice before the measurement. Please give more information. How long could they practice? What instruction were they given?

In the revised version of the article, we have provided further information about the practice attempts. It is now in the text: “Participants practiced each motion, under the supervision of the research team, as often as necessary to become comfortable with the trials. After two or three attempts, all participants completed effortlessly the arm elevation/depression tasks conducted in the 3 standard planes of motion. Commands to maintain the thumb upwards and the elbow straight throughout the movement was necessary for some participants during preparation. For PNF–D2, most participants were given further directives to focus on a diagonal rotational movement pattern, especially external rotation of the shoulder and elbow flexion when reaching the end of PNF–D2–flx (referred to as “if you were cocking the arm to throw a ball or spike”). After 4 to 7 trial attempts participants could complete the di-agonal arm motion pattern firmly. Following a 2-minute resting period, motion tracking initiated. The research team was attentive during the recordings to ensure that participants performed the movements as instructed and practiced. A re-recording was conducted if a movement task was poorly performed.”

Line 125. The authors state “The main author…”. This could be unclear. Please clarify (add the initials) or “The first author…” or similar.

We have changed in this version of the article to “The first author…”

We were using standardized guidelines from Equator Network (i.e., GRRAS) for reporting measurement properties of the system so that readers may appraise the consistency of the system for assessing arm elevation task. Yes, measurements were repeated and averaged for the analysis. We have reported that “Participants completed five consecutive repetitions of the task called PNF–D2–flx/ext (Figure 1a). Then, they performed two consecutive repetitions of raising and lowering the arm, with the thumb pointing upward and the elbow extended, in the frontal plane (shoulder abduction/adduction; Figure 1b), sagittal plane (shoulder flexion/extension; Figure 1c), and in the scapular plane (45 degrees anterior to the frontal plane or shoulder scaption; Figure 1d)” and that “Repetitions of each task were averaged for ulterior analysis. For PNF–D2–flx/ext (Figure 1a), repetitions 1 and 5 were removed having been averaged repetitions 2–4. For shoulder abduction/adduction, flexion/extension, and scpation (Figure 1b, 1c, 1d) this represents repetition 1 and 2”. We are preparing an article regarding the reliability and agreement of shoulder kinematics during PNF-D2, however, data is still being processed. From visual inspection alone, the consistency of the scapular measurement look very similar to those of traditional humeral elevation tasks (shoulder abduction, flexion and scaption), but we don’t have the numbers (SEM, MDC95%, Bland and Altman limits of agreement, ICC, etc.) yet.

We share the reviewer concern, even if we report the importance of the magnitude of mean differences, i.e., the effect size, the sample is to small and that's why we have wide confidence intervals in the athletes with and without scapular dyskinesis groups (all figures). We have disccused the clinical relevance of our findings in the 3rd and 4th paragraph. Robust evidence-based cutt-off values have not been established yet. We discuss the magnitude of differences that have been found between overhead athletes with and without shouldr injury or pain and contrat them with our findings in paragraph 3 and 4 of the Discussion, but further discussions/assumptions are precluded because of our small sample size.

Thank you for insights. Since p-value and post-hoc power is always connected, high p-values will show low observed power, and low p-values will show high observed power. Regarding the reviewer's concern we have added the effect size statisitics (eta square) which will show the importance of the magnitude of the differences and is parallel with our reporting of the scapular kinematics results. Again, thank you for alerting us.

We have performed the changes suggested by the reviewier. The number of subjects in each group, the paramenters compared in the title of the table and the effect size of the comparisons are now presented in Table 1 in revised version of the article,

Line 269. Please explain the meaning of »interaction effect HT angle x task« What does the »x« symbol mean here?

This (´) is the common symbol used to report the interaction of two or more independent variables or factors effects in the dependent variable. Other journals may use, for example, HT angle-by-task to highlight interaction statistics, however, in the absence of clear guidelines in Applied Sciences, we have used the notation »x« to report the interaction effects of 2 or more variables as commonly seen in statisitcal manuals, e. g., Field, Andy. Discovering Statistics Using SPSS. 5th ed., SAGE Publications, 2017.

Line 269. Please explain the meaning of parameter F. It has a peculiar subscript. Please explain the meaning of the indexes in the subscript.

The F value is a value on the F distribution used in analysis of variance (ANOVA), as the t value is a value of the t distibtution used in Student's t test. We have reported the F-statistic (value) and the degrees of freedom associated with it (the subscripts). F value is the model mean squares divided by the residual mean squares for the residuals (a.k.a, errors or unexplained variance). The first subscript represents the degrees of freedom for the effects of the model and the next, separated by a comma, the degrees of freedom for the residuals of the model) the subjects. When you don't see whole numbers e.g., F_2.5,113.9, it means the same but a Greenhouse-Geisser correction was used to adjust the degrees of freedom because the sphericity assumption (Mauchly’s test) was violated by one or a combination of factors (interaction effects of the independent variables).

I suggest that the authors use the expression »average« in describing the results of the group.

We acknowledge that this should be better stressed throughout the Results and Discussion section. In this version of the manuscript we have highlighted average with yellow color, for the reviewers appraisal. Thank you for alerting us.

In description of Figure 1, to me it seems that the green and the blue curves are more similar while the blue one differs a bit, particularly at larger humerothoracic angles.

When exporting figures from SPSS, something went wrong that has changed the colors of the error bars (95% confidence intervals). Also the scale was not the same across all task conditions. We have corrected these to a superior appraisal of the curves. Figures 1 is now Figure 3, in the revised version of the manuscript. Thank you for alerting us.

To guide readers, we outlined the similar scapular motion pattern during arm elevation tasks and the respective illustrations. The 1^st paragraph is now: “We specifically examined a diagonal movement pattern of arm elevation/depression (PNF–D2–flx/ext), which is distinct from traditional arm elevation/depression tasks conducted in the three standard planes of motion—shoulder abduction, shoulder flexion, and shoulder scaption– and has its unique scapular kinematics. Although the four arm elevation tasks generally exhibited a scapular motion pattern of external rotation, upward rotation and posterior tilting (Figures 3‑5), during arm movement, the scapula exhibited less upward rotation (Fig. 2) and more posterior tilt (Fig. 3) in PNF–D2 compared to shoulder abduction, flexion, or scaption. Particularly noteworthy was the consistent transition from internal rotation to external rotation (and vice versa) of the scapula in PNF-D2 (Fig. 1a). This transition was more prominent than in shoulder flexion (Fig. 1c), shoulder scaption (Fig. 1d), and, to a lesser extent, shoulder abduction (Fig. 1b). However, it is worth noting that differences between groups were not statistically significant across all tasks.

We have repahrased this sentence and have referenced readers to the respective illustrations: »“We specifically examined a diagonal movement pattern of arm elevation/depression (PNF–D2–flx/ext), which is distinct from traditional arm elevation/depression tasks conducted in the three standard planes of motion—shoulder abduction, shoulder flexion, and shoulder scaption– and has its unique scapular kinematics. Although the four arm elevation tasks generally exhibited a scapular motion pattern of external rotation, upward rotation and posterior tilting (Figures 3‑5), during arm movement, the scapula exhibited less upward rotation (Fig. 2) and more posterior tilt (Fig. 3) in PNF–D2 compared to shoulder abduction, flexion, or scaption. Particularly noteworthy was the consistent transition from internal rotation to external rotation (and vice versa) of the scapula in PNF-D2 (Fig. 1a). This transition was more prominent than in shoulder flexion (Fig. 1c), shoulder scaption (Fig. 1d), and, to a lesser extent, shoulder abduction (Fig. 1b). However, it is worth noting that differences between groups were not statistically significant across all tasks.”

In the Conclusions (abstract and main text) we reinforce that data are preliminary, and we have removed any direct recommendation for clinical purposes.

Author Response File: Author Response.docx

Reviewer 3 Report

Good work overall. A few issues I noted, if addressed will benefit the presentation and enable readers understanding as outlined below:

1. Provide details about DASH and its use. Importantly its precision and inter-rater agreement.

2. Visualise the assessment procedure.

3. Improve conclusions by including future directions. The study is preliminary - how a large clinical one should look like.

4. Provide a critical paragraph of the above in the discussion.

The level of English is satisfactory.

Author Response

We would like to acknowledge the reviewer for her/his valuable insights and suggestions which have undoubtedly improved the quality of the article.

Comments and Suggestions for Authors

Good work overall. A few issues I noted, if addressed will benefit the presentation and enable readers understanding as outlined below:

Provide details about DASH and its use. Importantly its precision and inter-rater agreement.

We have added the available psychometric properties of the Portuguese version of DASH to the text. This is now (lines 123–124): “(QuickDASH – sports module, Portuguese version; internal consistency, alpha Chronbach = .95; test-retest reliability, intraclass correlation coefficient [ICC] =.886),”. For consistency in the reporting, we also added measurement properties of the Scapular Dyskinesis Test (lines 135–136): “This method has demonstrated satisfactory reliability for clinical use in overhead athletes (percentage of agreement, 75%–82%; weighted kappa coefficients, .48–.61)”

Visualise the assessment procedure.

Illustrations exemplifying the movements performed by the participants are now provided as Figure 1(a–d)

Improve conclusions by including future directions. The study is preliminary - how a large clinical one should look like.

We have added future directions for studies throughout the discussion (lines 456–464; lines 466–470; lines 514–519) and have highlighted that the study is preliminary in the Conclusion section and that robust findings need greater sample size (lines 526–529) for superior clinical interpretability.

Provide a critical paragraph of the above in the discussion.

For readability purposes we have incorporated the suggested debate throughout the Discussion section most prominent in lines 456–464, lines 466–470, and lines 514–519.

Author Response File: Author Response.docx

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A Diagonal Movement Pattern of Arm Elevation and Depression in Overhead Throwing Athletes: An Exploratory Kinematic Analysis for Clinical Application

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