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Phys. Ther. Korea 2023; 30(1): 50-58

Published online February 20, 2023

https://doi.org/10.12674/ptk.2023.30.1.50

© Korean Research Society of Physical Therapy

A Study on the Effectiveness of Face-to-face Physical Therapy and Non-face-to-face Physical Therapy in Individuals With Rounded Shoulder

Young-ji Cho , Min-je Kim , Cho-won Park , Ye-bin Cho , In-A Heo , Su-jin Kim , PT, PhD

Department of Physical Therapy, College of Medical Science, Jeonju University, Jeonju, Korea

Correspondence to: Su-jin Kim
E-mail: sujink@jj.ac.kr
https://orcid.org/0000-0002-5222-4538

Received: January 16, 2023; Revised: January 31, 2023; Accepted: January 31, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

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Background: This study was carried out to determine whether non-face-to-face physical therapy would have similar exercise effects to face-to-face physical therapy. Hence, we developed an approach for patients, unable to visit hospitals due to circumstances such as the COVID-19 pandemic, to conduct physical therapy comfortably at home. Objects: This study aimed to compare the effects of a face-to-face and a non-face-to-face physical therapy treatment on improving a rounded shoulder posture.
Methods: The participants with rounded shoulders were randomly divided into a face-toface group (n = 15) and a non-face-to-face group (n = 15), and each group performed exercises for four weeks. The exercise program consisted of the bare hands exercise, Thera-Band exercise, and foam roller exercise. The participants in the face-to-face group came to a designated place to perform their exercises, and those in the non-face-to-face group performed the exercises at their own home using Google Meet (Google). Acromial height, total scapular distance (TSD), shoulder pain and dysfunction index (SPADI), and pectoralis minor thickness were measured. Data analysis was performed using the R Statistical Software (R Core Team), and a normality test was performed using the Shapiro-Wilk test.
Results: There were no significant differences between the face-to-face and the non-face-toface groups (p > 0.05). When comparing the differences before and after the exercises, both the face-to-face and the non-face-to-face groups showed significant differences in acromial height, SPADI, and pectoralis minor thickness (p < 0.05), and both groups showed no significant difference in TSD before and after the exercises (p > 0.05).
Conclusion: The results of this study support the results of previous studies reporting that shoulder stabilization exercise and pectoralis minor stretching training improves round shoulders. In addition, this study revealed that both the face-to-face and the non-face-to-face physical therapy treatments had therapeutic effects.

Keywords: Acromion, Muscle stretching exercises, Pectoralis muscle, Posture, Telerehabilitation

INTRODUCTION

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A rounded shoulder refers to a state in which the acromion protrudes forward from the line of gravity when viewed in the sagittal plane. The characteristics of a rounded shoulder are protraction, downward rotation, and anterior tilt of the scapulae due to shortening of the pectoralis minor muscle [1,2]. The rounded shoulder is a serious concern in modern society and is observed in a high proportion of patients who experience musculoskeletal shoulder and neck pain [3]. In addition, individuals with rounded shoulders are vulnerable to structural damage due to repetitive micro-injury and stress applied to the bones, muscles, tendons, ligaments, and bursae due to excessive movement of the shoulder joint, which causes pain [4]. Previous studies have reported that strengthening of the lower trapezius and serratus anterior muscles and stretching of the shortened muscles (e.g., pectoralis minor muscle) are the key to improving rounded shoulders [1,5]. Therefore, posture correction and treatment using exercise programs that stretch and strengthen the muscles controlling the scapula are required to correct rounded shoulders [6].

Simple exercise programs, such as barehanded exercises, Thera-Band, and foam rollers, have achieved positive treatment effects for the rounded shoulder [7-9]. Myofascial release techniques using Gua sha therapy or weight training with a ‘lat pull-down’ machine have also been used to treat rounded shoulders. However, the latter two methods require expert supervision and guidance to ensure proper muscle stretching and strength training by patients. Conversely, training with a bare-handed, Thera-Band, or foam roller requires expert supervision only initially, but patients can quickly learn the exercises over a relatively short training period [8]. This simple training program indirectly stretched the pectoralis minor muscle and strengthens the lower trapezius and serratus anterior muscles. In addition, these exercises can conveniently observe the effect of training alone without the need for information on the exact location of the muscle [9].

As the number of patients who are reluctant to visit hospitals increases with the spread of COVID-19, the interest in non-face-to-face treatment is increasing in the field of physical therapy [10,11]. Non-face-to-face treatment refers to a telerehabilitation system in which the patient and the therapist do not meet in person but communicate through video applications such as Google Meet (Google, Mountain View, CA, USA), ZOOM (Zoom Video Communications, San José, CA, USA), and Webex (Webex, San José, CA, USA) [12]. Research comparing face-to-face and non-face-to-face treatments for neurological diseases, including stroke and Parkinson’s disease, and musculoskeletal disorders, such as shoulder impingement syndrome or shoulder joint replacement in physical therapy, is actively underway. These previous studies have reported that non-face-to-face treatment is as effective as face-to-face treatment [13-16]. However, compared with studies on non-face-to-face treatment of neurological patients, there are few studies on individuals with musculoskeletal disorders.

Therefore, this study aimed to investigate differences in treatment effects between face-to-face and non-face-to-face methods on rounded shoulders, which account for a large proportion of shoulder diseases. We hypothesized that these two methods would result in similar treatment outcomes, measured by the height of the acromion, pain scale, scapular distance, and change in the thickness of the pectoralis minor muscle in individuals with rounded shoulders.

MATERIALS AND METHODS

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1. Participants

This study included 30 males and females aged 18 years or older with rounded shoulders. Study subjects were selected regardless of sex and were randomly assigned to either a face-to-face group (n = 15) or to a non-face-to-face group (n = 15). The inclusion criteria were as follows: 1) no surgery due to diseases or fractures in the shoulder area and 2) the distance from the table to the back of the acromion in the supine position was greater than 2.5 cm [17]. This study was approved by the Institutional Review Boards of Jeonju University (IRB no. jjIRB-210817-HR-2021-0825). Before participating in the experiments, all subjects confirmed understanding of the contents of the study and signed a consent form.

2. Measurements

1) Acromion height

The participants were placed in a comfortable supine position on the table and their arms were placed beside the trunk. An evaluator measured the height from the table to the acromion using a digital caliper (Figure 1) [7]. This method showed high reliability (0.95–0.97) for rounded shoulder posture analysis in a previous study [18].

Figure 1. Shoulder acromion height measurement.
2) Total scapular distance

The participants were placed in a relaxed sitting position and the evaluator marked the location of the inferior angle of the scapula and the spinous process of the third thoracic vertebra (T3) using tape. The distance between two points was measured and defined the total scapular distance (TSD) (Figure 2) [5].

Figure 2. Total scapular distance measurement.
3) Shoulder pain and dysfunction index

The shoulder pain and dysfunction index (SPADI) is a tool developed by Roach et al. [19] and has been widely used to evaluate shoulder dysfunction in activities of daily living and body function [20]. The SPADI was measured before and after exercising. The scores were summed, with higher scores indicating greater disability or disability. The reliability of the SPADI was excellent (r = 0.96) [21].

4) Thickness of the pectoralis minor

A universal ultrasound imaging system, H60 (Samsung Medison Inc., Seoul, Korea), and an ultrasound conductor were used to measure the thickness of the pectoralis minor muscle. The participants were placed in the supine position with both arms next to the trunk. The transducer was placed over the coracoid process in the transverse plane with a small caudal and lateral tilt (Figure 3) [22]. For consistency, one evaluator used an ultrasound system for all participants. Evaluators who received ultrasound training for 2 months (1 hour practice, 2 times a week, 8 weeks) measured the thickness of the pectoralis minor muscle of all participants.

Figure 3. Pectoralis minor thickness measurement.

3. Exercise Programs and Treatment Groups

1) Exercise programs

The exercise program in this study included three subexercises: bare hand, Thera-Band, and a foam roller [23]. Participants performed each subexercise in three sets, with 15 repetitions per set and 30 seconds of rest between sets. This subexercise was changed every two weeks from bare-handed to foam roller exercises to encourage the participants’ motivation. All participants exercised twice a week for 4 weeks.

a. Bare-handed exercise: First, the participants stretched their levator scapulae muscle. They held their head in a standing posture and pulled their ear to the shoulder (Figure 4A). Next, patients stretched their pectoralis major muscle and performed scapular depression and retraction. To stretch the pectoralis major muscle, patients extended both arms upward with their elbows and the backs of their hands touching the wall (Figure 4B) [24,25]. Detailed information on scapular depression and retraction is shown in Figure 4C and 4D.

Figure 4. Bare-hand exercises. (A) Levator scapulae stretching, (B) pectoralis major stretching, (C) scapular depression, and (D) Y to W. The picture on the left is the starting position, and on the right is the ending position.

b. Thera-Band exercise: The Thera-Band exercise was modified based on a previous study [8]. The first movement was the scapular adduction. The participants pulled both hands outward when holding the Thera-Band (Figure 5A) [26]. The second and third movements were shoulder pressing and shoulder abduction, respectively. Upon reaching the center of the band with their feet, participants raised their hands above their head (shoulder press) (Figure 5B) or to side-to-shoulder height (shoulder abduction) (Figure 5C).

Figure 5. Exercise with Thera-band. (A) Scapular retraction, (B) shoulder press, and (C) shoulder abduction. The picture on the left is the starting position, and on the right is the ending position.

c. Foam roller exercise: The first protective agent was a “pull elbow” with 90° elbow flexion. Then, while lying on the foam roller, participants were asked to lower their arms to touch the floor (Figure 6A). The second movement was internal and external rotation of the shoulders, and the last movement was shoulder protraction [9,27]. The start and end postures are shown in Figure 6.

Figure 6. Exercise with a foam roller. (A) Pulling elbow, (B) shoulder external rotation, (C) shoulder lifting, and (D) shoulder internal rotation. The picture on the left is the starting position, and on the right is the ending position.
2) Treatment groups

a. Face-to-face group (face group): Participants gathered at a set time and performed the same exercises in the same place. Voice and tactile feedback regarding the exercise was provided directly to the participants during the exercise.

b. Non-face-to-face group (Non-face group): Participants entered a video conference program at the pre-assigned time. Fifteen participants were divided into five teams, with three participants and one therapist in each team. They used a video camcorder and a microphone for communication. Voice feedback about the exercise was provided to the subjects in real-time during exercise performance.

4. Statistical Analysis

Data analysis was performed using the R statistical program software (R statistical software; R Core Team, Vienna, Austria). Normality was tested using the Shapiro-Wilk test. Mixed-effect linear regression was used to examine differences before and after exercising and differences between groups. The dependent variables were the height of the acromion, the TSD, the SPADI, and the thickness of the pectoralis minor muscle. The test (before vs. after treatment) and group (face vs. non-face) were designated as fixed factors, while each individual was set as a random factor. The comparison of the model was performed using the log-likelihood ratio test using the ANOVA function provided in R and was the best model defined as the model with the lowest Akaike inclusion criteria. The Tukey test was performed as a post hoc test, and the statistical significance level was set at α = 0.05.

RESULTS

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1. General Characteristics of the Participants

The general characteristics of the participants are presented in Table 1. There were no statistically significant differences in age, height, or weight between the face and non-face groups (Table 1). However, there were more females than males in both groups.

Table 1 . Demographic characteristics of participants (N = 30).

VariableFace group
(n = 15)		Non-face group
(n = 15)		p-value
Age (y)21.0 ± 1.3721.27 ± 1.440.08
Height (cm)163.02 ± 5.69164.38 ± 7.160.10
Weight (kg)55.73 ± 9.2855.8 ± 11.880.11
Sex (male/female)2/133/120.92

Values are presented as mean ± standard deviation or number only..

2. Comparison of Differences Before and After Exercise

There were significant decreases in the height of the acromion, the SPADI score, and the thickness of the pectoralis minor muscle after exercise in both the face and non-face groups (p < 0.05). However, the TSD was not statistically different between groups (p > 0.05) (Table 2).

Table 2 . Result of the difference before and after exercise for 4 weeks.

GroupFacep-valueNon-facep-valueGroup comparison in Δchange
Shoulder acromion height (cm)Before5.63 ± 0.93< 0.0015.36 ± 1.43< 0.0010.3
After4.46 ± 1.093.82 ± 1.17
ΔChange–1.17–1.54
Total scapular distance (cm)Before19.83 ± 2.51> 0.99919.83 ± 1.280.800.42
After19.97 ± 1.7319.50 ± 1.69
ΔChange0.14–0.33
SPADIa (%)Before19.74 ± 13.35*< 0.00112.67 ± 10.01*< 0.0010.4
After7.90 ± 7.423.65 ± 3.77
ΔChange–11.84–9.02
Pectoralis minor thickness (cm)Before0.67 ± 0.19< 0.0010.66 ± 0.310.0050.70
After0.59 ± 0.160.60 ± 0.26
ΔChange–0.08–0.06

Values are presented as mean ± standard deviation or number only. SPADI, shoulder pain and dysfunction index. aSPADI is a patient-completed questionnaire with 13 items assessing pain level and extent of difficulty with ADLs requiring the use of the upper extremities. *Significant difference in SPADI score before training between groups (p = 0.05)..

3. Comparison of Differences Between Face-to-face and Non-face-to-face Groups

The changes before and after training in acromion height, scapular distance, SPADI, and pectoralis minor muscle thickness were not significantly different between the groups (p > 0.05) (Table 2).

DISCUSSION

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This study observed changes in acromion height, shoulder pain, and minor muscle thickness of the pectoralis after exercise, but not in the TSD. In both the face-to-face and non-face-to-face groups, the height of the acromion, the shoulder pain index and the thickness of the pectoralis minor muscle decreased after exercise. These results were consistent with previous studies that reported a statistically significant decrease in acromion height after an exercise program for individuals with rounded shoulders [17,23]. It can be concluded that exercises with either bare-hands, a Thera-Band, or a foam roller influence changes in the rounded shoulder.

The reduced SPADI index could have been due to improved shoulder alignment resulting from the shoulder blade stabilization exercises performed in this study. However, the reduction in this study was less than that reported in a previous study [28]. This may be because the previous study was aimed at patients with chronic shoulder pain, while the present study included young adults with rounded shoulders. The decrease in the thickness of the pectoralis minor muscle was also believed to have occurred because stretching exercises achieved a temporary but more rapid effect than stabilization exercises. This finding is consistent with that of a study by Ahmed et al. [29] reporting successive elongation of the pectoralis minor muscle after stretching.

Unlike the other variables, the TSD did not show any change before and after exercise in either group. In previous studies, a significant change in the total scapula distance was shown to be an immediate effect of exercise. This difference may be due to strengthening exercises that focused on the rhomboid muscle [30]. Since we focused on strengthening exercises for the rotator cuff muscle and stretching exercises for the shortened muscle rather than the strengthening rhomboid muscle, we may have overlooked the TSD change. Therefore, in the future, it will be necessary to study whether there are any changes in the shoulder blade distance after the exercise method used in this study and the rhomboid muscle strengthening exercise.

The most crucial finding in this study was that there was no significant difference between the face-to-face and non-face-to-face groups in any of the measured variables. This finding is consistent with those of previous studies that compared face-to-face and non-face-to-face groups in other populations. For example, Azma et al. [31] reported no significant differences between the groups when face-to-face and non-face-to-face treatments were randomly applied to patients with knee osteoarthritis. Tousignant et al. [16] also reported that 48 patients who underwent artificial knee joint surgery, randomly divided into face-to-face and non-face-to-face treatments, did not show any differences between groups. For shoulder joint diseases, Pastora-Bernal et al. [15] randomly assigned patients with shoulder impingement syndrome who underwent face-to-face and non-face-to-face surgical operations. Both treatment groups reported significant improvements in shoulder pain and function, but there was no significant difference between the two groups [15]. However, Eriksson et al. [32] reported that the non-face-to-face treatment group achieved significantly better results compared to the face-to-face group in patients with shoulder joint replacement surgery. Taken together, it can be concluded that non-face-to-fact treatment is as effective as conventional face-to-face rehabilitation treatment [16]. Furthermore, non-face-to-face treatment can reduce the time and costs associated with face-to-face rehabilitation treatment, and is suitable for older individuals living in areas where it is difficult to visit a hospital. Therefore, it is a recommended program [31]. However, as there is currently no concrete evidence supporting the superiority of face-to-face over non-face-to-face treatment, any interpretation of this study should be made with caution [13]. However, in this study, the exercises performed could be easily performed without any expert supervision. The program provided immediate voice feedback on posture during non-face-to-face exercises, as for the face-to-face exercises. Thus, it was possible to reduce any differences attributable to advantages from the face-to-face treatment because the exercise video was developed to consider the degree of understanding of the exercise posture by the patient.

This study has several limitations. First, because the experiment was conducted with young adults in their twenties with rounded shoulders, it would be difficult to generalize that non-face-to-face physical therapy may have the same effect on other populations and conditions. Second, the experimental settings for the two groups were different. The face-to-face exercise was 1:1 with the therapist, but in non-face-to-face exercise the ratio was 3:1 with the therapist. Third, owing to the short duration of the experimental intervention, no follow-up was conducted to determine the duration of the effect. In future studies, monitoring the long-term effects of non-face-to-face treatment and applying a suitable experimental protocol to other disease populations will be necessary. Thus, future studies should determine whether the therapeutic effect of the treatment program is maintained. In addition, to activate non-face-to-face physical therapy programs, medical support and preparation, including expert intervention and treatment plans, will be needed to observe effects in as much detail as face-to-face physical therapy.

CONCLUSIONS

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In this study, participants with rounded shoulders were divided into face-to-face and non-face-to-face groups, and differences in therapy outcomes were compared. The face-to-face and non-face-to-face groups showed significantly decreased measured values before and after exercising. However, there were no significant differences between the two groups. Therefore, the non-face-to-face treatment applied in this study may be considered a helpful new method able to replace face-to-face treatment for busy individuals in modern society who prefer non-face-to-face exchanges due to concerns about contracting infectious diseases such as COVID-19 or who are too busy to visit hospitals.

FUNDING

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This study was supported by the Translational Research Program for Rehabilitation Robots (#NRCTR-EX19010), National Rehabilitation Center, Ministry of Health and Welfare, Korea.

AUTHOR CONTRIBUTION

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Conceptualization: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Data curation: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Formal analysis: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Funding acquisition: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Investigation: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Methodology: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Project administration: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Resources: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Software: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Supervision: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Validation: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Visualization: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Writing - original draft: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Writing - review & editing: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK.

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Article

Original Article

Phys. Ther. Korea 2023; 30(1): 50-58

Published online February 20, 2023 https://doi.org/10.12674/ptk.2023.30.1.50

Copyright © Korean Research Society of Physical Therapy.

A Study on the Effectiveness of Face-to-face Physical Therapy and Non-face-to-face Physical Therapy in Individuals With Rounded Shoulder

Young-ji Cho , Min-je Kim , Cho-won Park , Ye-bin Cho , In-A Heo , Su-jin Kim , PT, PhD

Department of Physical Therapy, College of Medical Science, Jeonju University, Jeonju, Korea

Correspondence to:Su-jin Kim
E-mail: sujink@jj.ac.kr
https://orcid.org/0000-0002-5222-4538

Received: January 16, 2023; Revised: January 31, 2023; Accepted: January 31, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: This study was carried out to determine whether non-face-to-face physical therapy would have similar exercise effects to face-to-face physical therapy. Hence, we developed an approach for patients, unable to visit hospitals due to circumstances such as the COVID-19 pandemic, to conduct physical therapy comfortably at home. Objects: This study aimed to compare the effects of a face-to-face and a non-face-to-face physical therapy treatment on improving a rounded shoulder posture.
Methods: The participants with rounded shoulders were randomly divided into a face-toface group (n = 15) and a non-face-to-face group (n = 15), and each group performed exercises for four weeks. The exercise program consisted of the bare hands exercise, Thera-Band exercise, and foam roller exercise. The participants in the face-to-face group came to a designated place to perform their exercises, and those in the non-face-to-face group performed the exercises at their own home using Google Meet (Google). Acromial height, total scapular distance (TSD), shoulder pain and dysfunction index (SPADI), and pectoralis minor thickness were measured. Data analysis was performed using the R Statistical Software (R Core Team), and a normality test was performed using the Shapiro-Wilk test.
Results: There were no significant differences between the face-to-face and the non-face-toface groups (p > 0.05). When comparing the differences before and after the exercises, both the face-to-face and the non-face-to-face groups showed significant differences in acromial height, SPADI, and pectoralis minor thickness (p < 0.05), and both groups showed no significant difference in TSD before and after the exercises (p > 0.05).
Conclusion: The results of this study support the results of previous studies reporting that shoulder stabilization exercise and pectoralis minor stretching training improves round shoulders. In addition, this study revealed that both the face-to-face and the non-face-to-face physical therapy treatments had therapeutic effects.

Keywords: Acromion, Muscle stretching exercises, Pectoralis muscle, Posture, Telerehabilitation

INTRODUCTION

A rounded shoulder refers to a state in which the acromion protrudes forward from the line of gravity when viewed in the sagittal plane. The characteristics of a rounded shoulder are protraction, downward rotation, and anterior tilt of the scapulae due to shortening of the pectoralis minor muscle [1,2]. The rounded shoulder is a serious concern in modern society and is observed in a high proportion of patients who experience musculoskeletal shoulder and neck pain [3]. In addition, individuals with rounded shoulders are vulnerable to structural damage due to repetitive micro-injury and stress applied to the bones, muscles, tendons, ligaments, and bursae due to excessive movement of the shoulder joint, which causes pain [4]. Previous studies have reported that strengthening of the lower trapezius and serratus anterior muscles and stretching of the shortened muscles (e.g., pectoralis minor muscle) are the key to improving rounded shoulders [1,5]. Therefore, posture correction and treatment using exercise programs that stretch and strengthen the muscles controlling the scapula are required to correct rounded shoulders [6].

Simple exercise programs, such as barehanded exercises, Thera-Band, and foam rollers, have achieved positive treatment effects for the rounded shoulder [7-9]. Myofascial release techniques using Gua sha therapy or weight training with a ‘lat pull-down’ machine have also been used to treat rounded shoulders. However, the latter two methods require expert supervision and guidance to ensure proper muscle stretching and strength training by patients. Conversely, training with a bare-handed, Thera-Band, or foam roller requires expert supervision only initially, but patients can quickly learn the exercises over a relatively short training period [8]. This simple training program indirectly stretched the pectoralis minor muscle and strengthens the lower trapezius and serratus anterior muscles. In addition, these exercises can conveniently observe the effect of training alone without the need for information on the exact location of the muscle [9].

As the number of patients who are reluctant to visit hospitals increases with the spread of COVID-19, the interest in non-face-to-face treatment is increasing in the field of physical therapy [10,11]. Non-face-to-face treatment refers to a telerehabilitation system in which the patient and the therapist do not meet in person but communicate through video applications such as Google Meet (Google, Mountain View, CA, USA), ZOOM (Zoom Video Communications, San José, CA, USA), and Webex (Webex, San José, CA, USA) [12]. Research comparing face-to-face and non-face-to-face treatments for neurological diseases, including stroke and Parkinson’s disease, and musculoskeletal disorders, such as shoulder impingement syndrome or shoulder joint replacement in physical therapy, is actively underway. These previous studies have reported that non-face-to-face treatment is as effective as face-to-face treatment [13-16]. However, compared with studies on non-face-to-face treatment of neurological patients, there are few studies on individuals with musculoskeletal disorders.

Therefore, this study aimed to investigate differences in treatment effects between face-to-face and non-face-to-face methods on rounded shoulders, which account for a large proportion of shoulder diseases. We hypothesized that these two methods would result in similar treatment outcomes, measured by the height of the acromion, pain scale, scapular distance, and change in the thickness of the pectoralis minor muscle in individuals with rounded shoulders.

MATERIALS AND METHODS

1. Participants

This study included 30 males and females aged 18 years or older with rounded shoulders. Study subjects were selected regardless of sex and were randomly assigned to either a face-to-face group (n = 15) or to a non-face-to-face group (n = 15). The inclusion criteria were as follows: 1) no surgery due to diseases or fractures in the shoulder area and 2) the distance from the table to the back of the acromion in the supine position was greater than 2.5 cm [17]. This study was approved by the Institutional Review Boards of Jeonju University (IRB no. jjIRB-210817-HR-2021-0825). Before participating in the experiments, all subjects confirmed understanding of the contents of the study and signed a consent form.

2. Measurements

1) Acromion height

The participants were placed in a comfortable supine position on the table and their arms were placed beside the trunk. An evaluator measured the height from the table to the acromion using a digital caliper (Figure 1) [7]. This method showed high reliability (0.95–0.97) for rounded shoulder posture analysis in a previous study [18].

Figure 1. Shoulder acromion height measurement.
2) Total scapular distance

The participants were placed in a relaxed sitting position and the evaluator marked the location of the inferior angle of the scapula and the spinous process of the third thoracic vertebra (T3) using tape. The distance between two points was measured and defined the total scapular distance (TSD) (Figure 2) [5].

Figure 2. Total scapular distance measurement.
3) Shoulder pain and dysfunction index

The shoulder pain and dysfunction index (SPADI) is a tool developed by Roach et al. [19] and has been widely used to evaluate shoulder dysfunction in activities of daily living and body function [20]. The SPADI was measured before and after exercising. The scores were summed, with higher scores indicating greater disability or disability. The reliability of the SPADI was excellent (r = 0.96) [21].

4) Thickness of the pectoralis minor

A universal ultrasound imaging system, H60 (Samsung Medison Inc., Seoul, Korea), and an ultrasound conductor were used to measure the thickness of the pectoralis minor muscle. The participants were placed in the supine position with both arms next to the trunk. The transducer was placed over the coracoid process in the transverse plane with a small caudal and lateral tilt (Figure 3) [22]. For consistency, one evaluator used an ultrasound system for all participants. Evaluators who received ultrasound training for 2 months (1 hour practice, 2 times a week, 8 weeks) measured the thickness of the pectoralis minor muscle of all participants.

Figure 3. Pectoralis minor thickness measurement.

3. Exercise Programs and Treatment Groups

1) Exercise programs

The exercise program in this study included three subexercises: bare hand, Thera-Band, and a foam roller [23]. Participants performed each subexercise in three sets, with 15 repetitions per set and 30 seconds of rest between sets. This subexercise was changed every two weeks from bare-handed to foam roller exercises to encourage the participants’ motivation. All participants exercised twice a week for 4 weeks.

a. Bare-handed exercise: First, the participants stretched their levator scapulae muscle. They held their head in a standing posture and pulled their ear to the shoulder (Figure 4A). Next, patients stretched their pectoralis major muscle and performed scapular depression and retraction. To stretch the pectoralis major muscle, patients extended both arms upward with their elbows and the backs of their hands touching the wall (Figure 4B) [24,25]. Detailed information on scapular depression and retraction is shown in Figure 4C and 4D.

Figure 4. Bare-hand exercises. (A) Levator scapulae stretching, (B) pectoralis major stretching, (C) scapular depression, and (D) Y to W. The picture on the left is the starting position, and on the right is the ending position.

b. Thera-Band exercise: The Thera-Band exercise was modified based on a previous study [8]. The first movement was the scapular adduction. The participants pulled both hands outward when holding the Thera-Band (Figure 5A) [26]. The second and third movements were shoulder pressing and shoulder abduction, respectively. Upon reaching the center of the band with their feet, participants raised their hands above their head (shoulder press) (Figure 5B) or to side-to-shoulder height (shoulder abduction) (Figure 5C).

Figure 5. Exercise with Thera-band. (A) Scapular retraction, (B) shoulder press, and (C) shoulder abduction. The picture on the left is the starting position, and on the right is the ending position.

c. Foam roller exercise: The first protective agent was a “pull elbow” with 90° elbow flexion. Then, while lying on the foam roller, participants were asked to lower their arms to touch the floor (Figure 6A). The second movement was internal and external rotation of the shoulders, and the last movement was shoulder protraction [9,27]. The start and end postures are shown in Figure 6.

Figure 6. Exercise with a foam roller. (A) Pulling elbow, (B) shoulder external rotation, (C) shoulder lifting, and (D) shoulder internal rotation. The picture on the left is the starting position, and on the right is the ending position.
2) Treatment groups

a. Face-to-face group (face group): Participants gathered at a set time and performed the same exercises in the same place. Voice and tactile feedback regarding the exercise was provided directly to the participants during the exercise.

b. Non-face-to-face group (Non-face group): Participants entered a video conference program at the pre-assigned time. Fifteen participants were divided into five teams, with three participants and one therapist in each team. They used a video camcorder and a microphone for communication. Voice feedback about the exercise was provided to the subjects in real-time during exercise performance.

4. Statistical Analysis

Data analysis was performed using the R statistical program software (R statistical software; R Core Team, Vienna, Austria). Normality was tested using the Shapiro-Wilk test. Mixed-effect linear regression was used to examine differences before and after exercising and differences between groups. The dependent variables were the height of the acromion, the TSD, the SPADI, and the thickness of the pectoralis minor muscle. The test (before vs. after treatment) and group (face vs. non-face) were designated as fixed factors, while each individual was set as a random factor. The comparison of the model was performed using the log-likelihood ratio test using the ANOVA function provided in R and was the best model defined as the model with the lowest Akaike inclusion criteria. The Tukey test was performed as a post hoc test, and the statistical significance level was set at α = 0.05.

RESULTS

1. General Characteristics of the Participants

The general characteristics of the participants are presented in Table 1. There were no statistically significant differences in age, height, or weight between the face and non-face groups (Table 1). However, there were more females than males in both groups.

Table 1 . Demographic characteristics of participants (N = 30).

VariableFace group
(n = 15)		Non-face group
(n = 15)		p-value
Age (y)21.0 ± 1.3721.27 ± 1.440.08
Height (cm)163.02 ± 5.69164.38 ± 7.160.10
Weight (kg)55.73 ± 9.2855.8 ± 11.880.11
Sex (male/female)2/133/120.92

Values are presented as mean ± standard deviation or number only..

2. Comparison of Differences Before and After Exercise

There were significant decreases in the height of the acromion, the SPADI score, and the thickness of the pectoralis minor muscle after exercise in both the face and non-face groups (p < 0.05). However, the TSD was not statistically different between groups (p > 0.05) (Table 2).

Table 2 . Result of the difference before and after exercise for 4 weeks.

GroupFacep-valueNon-facep-valueGroup comparison in Δchange
Shoulder acromion height (cm)Before5.63 ± 0.93< 0.0015.36 ± 1.43< 0.0010.3
After4.46 ± 1.093.82 ± 1.17
ΔChange–1.17–1.54
Total scapular distance (cm)Before19.83 ± 2.51> 0.99919.83 ± 1.280.800.42
After19.97 ± 1.7319.50 ± 1.69
ΔChange0.14–0.33
SPADIa (%)Before19.74 ± 13.35*< 0.00112.67 ± 10.01*< 0.0010.4
After7.90 ± 7.423.65 ± 3.77
ΔChange–11.84–9.02
Pectoralis minor thickness (cm)Before0.67 ± 0.19< 0.0010.66 ± 0.310.0050.70
After0.59 ± 0.160.60 ± 0.26
ΔChange–0.08–0.06

Values are presented as mean ± standard deviation or number only. SPADI, shoulder pain and dysfunction index. aSPADI is a patient-completed questionnaire with 13 items assessing pain level and extent of difficulty with ADLs requiring the use of the upper extremities. *Significant difference in SPADI score before training between groups (p = 0.05)..

3. Comparison of Differences Between Face-to-face and Non-face-to-face Groups

The changes before and after training in acromion height, scapular distance, SPADI, and pectoralis minor muscle thickness were not significantly different between the groups (p > 0.05) (Table 2).

DISCUSSION

This study observed changes in acromion height, shoulder pain, and minor muscle thickness of the pectoralis after exercise, but not in the TSD. In both the face-to-face and non-face-to-face groups, the height of the acromion, the shoulder pain index and the thickness of the pectoralis minor muscle decreased after exercise. These results were consistent with previous studies that reported a statistically significant decrease in acromion height after an exercise program for individuals with rounded shoulders [17,23]. It can be concluded that exercises with either bare-hands, a Thera-Band, or a foam roller influence changes in the rounded shoulder.

The reduced SPADI index could have been due to improved shoulder alignment resulting from the shoulder blade stabilization exercises performed in this study. However, the reduction in this study was less than that reported in a previous study [28]. This may be because the previous study was aimed at patients with chronic shoulder pain, while the present study included young adults with rounded shoulders. The decrease in the thickness of the pectoralis minor muscle was also believed to have occurred because stretching exercises achieved a temporary but more rapid effect than stabilization exercises. This finding is consistent with that of a study by Ahmed et al. [29] reporting successive elongation of the pectoralis minor muscle after stretching.

Unlike the other variables, the TSD did not show any change before and after exercise in either group. In previous studies, a significant change in the total scapula distance was shown to be an immediate effect of exercise. This difference may be due to strengthening exercises that focused on the rhomboid muscle [30]. Since we focused on strengthening exercises for the rotator cuff muscle and stretching exercises for the shortened muscle rather than the strengthening rhomboid muscle, we may have overlooked the TSD change. Therefore, in the future, it will be necessary to study whether there are any changes in the shoulder blade distance after the exercise method used in this study and the rhomboid muscle strengthening exercise.

The most crucial finding in this study was that there was no significant difference between the face-to-face and non-face-to-face groups in any of the measured variables. This finding is consistent with those of previous studies that compared face-to-face and non-face-to-face groups in other populations. For example, Azma et al. [31] reported no significant differences between the groups when face-to-face and non-face-to-face treatments were randomly applied to patients with knee osteoarthritis. Tousignant et al. [16] also reported that 48 patients who underwent artificial knee joint surgery, randomly divided into face-to-face and non-face-to-face treatments, did not show any differences between groups. For shoulder joint diseases, Pastora-Bernal et al. [15] randomly assigned patients with shoulder impingement syndrome who underwent face-to-face and non-face-to-face surgical operations. Both treatment groups reported significant improvements in shoulder pain and function, but there was no significant difference between the two groups [15]. However, Eriksson et al. [32] reported that the non-face-to-face treatment group achieved significantly better results compared to the face-to-face group in patients with shoulder joint replacement surgery. Taken together, it can be concluded that non-face-to-fact treatment is as effective as conventional face-to-face rehabilitation treatment [16]. Furthermore, non-face-to-face treatment can reduce the time and costs associated with face-to-face rehabilitation treatment, and is suitable for older individuals living in areas where it is difficult to visit a hospital. Therefore, it is a recommended program [31]. However, as there is currently no concrete evidence supporting the superiority of face-to-face over non-face-to-face treatment, any interpretation of this study should be made with caution [13]. However, in this study, the exercises performed could be easily performed without any expert supervision. The program provided immediate voice feedback on posture during non-face-to-face exercises, as for the face-to-face exercises. Thus, it was possible to reduce any differences attributable to advantages from the face-to-face treatment because the exercise video was developed to consider the degree of understanding of the exercise posture by the patient.

This study has several limitations. First, because the experiment was conducted with young adults in their twenties with rounded shoulders, it would be difficult to generalize that non-face-to-face physical therapy may have the same effect on other populations and conditions. Second, the experimental settings for the two groups were different. The face-to-face exercise was 1:1 with the therapist, but in non-face-to-face exercise the ratio was 3:1 with the therapist. Third, owing to the short duration of the experimental intervention, no follow-up was conducted to determine the duration of the effect. In future studies, monitoring the long-term effects of non-face-to-face treatment and applying a suitable experimental protocol to other disease populations will be necessary. Thus, future studies should determine whether the therapeutic effect of the treatment program is maintained. In addition, to activate non-face-to-face physical therapy programs, medical support and preparation, including expert intervention and treatment plans, will be needed to observe effects in as much detail as face-to-face physical therapy.

CONCLUSIONS

In this study, participants with rounded shoulders were divided into face-to-face and non-face-to-face groups, and differences in therapy outcomes were compared. The face-to-face and non-face-to-face groups showed significantly decreased measured values before and after exercising. However, there were no significant differences between the two groups. Therefore, the non-face-to-face treatment applied in this study may be considered a helpful new method able to replace face-to-face treatment for busy individuals in modern society who prefer non-face-to-face exchanges due to concerns about contracting infectious diseases such as COVID-19 or who are too busy to visit hospitals.

ACKNOWLEDGEMENTS

None.

FUNDING

This study was supported by the Translational Research Program for Rehabilitation Robots (#NRCTR-EX19010), National Rehabilitation Center, Ministry of Health and Welfare, Korea.

CONFLICTS OF INTEREST

No potential conflicts of interest relevant to this article are reported.

AUTHOR CONTRIBUTION

Conceptualization: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Data curation: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Formal analysis: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Funding acquisition: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Investigation: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Methodology: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Project administration: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Resources: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Software: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Supervision: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Validation: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Visualization: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Writing - original draft: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK. Writing - review & editing: Young-ji Cho, MK, CP, Ye-bin Cho, IAH, SK.

Fig 1.

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Figure 1.Shoulder acromion height measurement.
Physical Therapy Korea 2023; 30: 50-58https://doi.org/10.12674/ptk.2023.30.1.50

Fig 2.

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Figure 2.Total scapular distance measurement.
Physical Therapy Korea 2023; 30: 50-58https://doi.org/10.12674/ptk.2023.30.1.50

Fig 3.

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Figure 3.Pectoralis minor thickness measurement.
Physical Therapy Korea 2023; 30: 50-58https://doi.org/10.12674/ptk.2023.30.1.50

Fig 4.

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Figure 4.Bare-hand exercises. (A) Levator scapulae stretching, (B) pectoralis major stretching, (C) scapular depression, and (D) Y to W. The picture on the left is the starting position, and on the right is the ending position.
Physical Therapy Korea 2023; 30: 50-58https://doi.org/10.12674/ptk.2023.30.1.50

Fig 5.

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Figure 5.Exercise with Thera-band. (A) Scapular retraction, (B) shoulder press, and (C) shoulder abduction. The picture on the left is the starting position, and on the right is the ending position.
Physical Therapy Korea 2023; 30: 50-58https://doi.org/10.12674/ptk.2023.30.1.50

Fig 6.

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Figure 6.Exercise with a foam roller. (A) Pulling elbow, (B) shoulder external rotation, (C) shoulder lifting, and (D) shoulder internal rotation. The picture on the left is the starting position, and on the right is the ending position.
Physical Therapy Korea 2023; 30: 50-58https://doi.org/10.12674/ptk.2023.30.1.50

Table 1 . Demographic characteristics of participants (N = 30).

VariableFace group
(n = 15)		Non-face group
(n = 15)		p-value
Age (y)21.0 ± 1.3721.27 ± 1.440.08
Height (cm)163.02 ± 5.69164.38 ± 7.160.10
Weight (kg)55.73 ± 9.2855.8 ± 11.880.11
Sex (male/female)2/133/120.92

Values are presented as mean ± standard deviation or number only..

Table 2 . Result of the difference before and after exercise for 4 weeks.

GroupFacep-valueNon-facep-valueGroup comparison in Δchange
Shoulder acromion height (cm)Before5.63 ± 0.93< 0.0015.36 ± 1.43< 0.0010.3
After4.46 ± 1.093.82 ± 1.17
ΔChange–1.17–1.54
Total scapular distance (cm)Before19.83 ± 2.51> 0.99919.83 ± 1.280.800.42
After19.97 ± 1.7319.50 ± 1.69
ΔChange0.14–0.33
SPADIa (%)Before19.74 ± 13.35*< 0.00112.67 ± 10.01*< 0.0010.4
After7.90 ± 7.423.65 ± 3.77
ΔChange–11.84–9.02
Pectoralis minor thickness (cm)Before0.67 ± 0.19< 0.0010.66 ± 0.310.0050.70
After0.59 ± 0.160.60 ± 0.26
ΔChange–0.08–0.06

Values are presented as mean ± standard deviation or number only. SPADI, shoulder pain and dysfunction index. aSPADI is a patient-completed questionnaire with 13 items assessing pain level and extent of difficulty with ADLs requiring the use of the upper extremities. *Significant difference in SPADI score before training between groups (p = 0.05)..

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