**2.2. At home**

The hiatus introduced by the spacing between rehabilitation sessions is a known limitation to a faster and more effective recovery, leading to the recommendation by therapists of specific exercises to be performed as homework. These work as an extension of the training performed at the clinic and can also be adequate after clinic sessions are completed, as a way to manage pain in the long term or as prevention. Carrying the biofeedback approach to home training is a great advantage for recovery success, reinforcing the goals achieved at the clinic and working as a contribution to get results faster. It is also a more convenient approach to allow busy patients to get treated, decreasing the needed visits to the clinic, as the therapist can access all training results remotely and also adjust the exercise plan if needed.

Home training exercises can be aided by tools as simple as paper guides (e.g.), or more sophisticated like mobile applications and purpose-built sensors. Regardless of the tools, the goal is to complement the rehabilitation process while being away from the clinic. However, many times people easily drop out of the home training programs or change the programs themselves (e.g. thinking that more repetitions are better), without the therapist having a way of assessing neither the compliance nor the quality of the performed exercises.

#### **2.3. The clinic-home divide**

Typically, home training is a simple extension of the clinic session, based on printed images and parameters that constitute fairly monotonous procedures, which allied with the complexity of the motor learning process makes patients give up most of the times. Patients easily feel that they are not performing the exercises correctly, do not have professional guidance to help and give feedback, and it is easier not to compromise with homework exercise. Fortunately, technology walks side by side with progress in medicine, and new solutions appear every day. One solution for the above problem is the development of sEMG sensors that collect muscular electrical activity and, in conjunction with mobile apps, for example, allow patients to monitor their muscle behaviour in real time. Nowadays, technology can be made very friendly and easy to use; however, until recently, the devices were too cumbersome, complex and not so adaptable to the independent use by the patients. Furthermore, it was difficult to access the home sessions remotely and be aware of what was done at home by the patient.

activity and muscles participation in different movements. This gives the first information, combined with other tests performed, to define an exercise plan and specific exercises to help decrease symptoms. After this initial step, we get to the main purpose of the tool, which is to guide exercise execution in real time. Specific targets can be defined to challenge the patient and to make him/her climb to the next step in the recovery process. Recorded data from assessment and training can be compiled into a final report so that progress in-between reha-

The use of sEMG biofeedback equipment is associated to a 50% faster recovery time in conditions such as shoulder impingement and scapular instability (average of seven sessions), and

The hiatus introduced by the spacing between rehabilitation sessions is a known limitation to a faster and more effective recovery, leading to the recommendation by therapists of specific exercises to be performed as homework. These work as an extension of the training performed at the clinic and can also be adequate after clinic sessions are completed, as a way to manage pain in the long term or as prevention. Carrying the biofeedback approach to home training is a great advantage for recovery success, reinforcing the goals achieved at the clinic and working as a contribution to get results faster. It is also a more convenient approach to allow busy patients to get treated, decreasing the needed visits to the clinic, as the therapist

Home training exercises can be aided by tools as simple as paper guides (e.g.), or more sophisticated like mobile applications and purpose-built sensors. Regardless of the tools, the goal is to complement the rehabilitation process while being away from the clinic. However, many times people easily drop out of the home training programs or change the programs themselves (e.g. thinking that more repetitions are better), without the therapist having a way of assessing neither the compliance nor the quality of the performed

Typically, home training is a simple extension of the clinic session, based on printed images and parameters that constitute fairly monotonous procedures, which allied with the complexity of the motor learning process makes patients give up most of the times. Patients easily feel that they are not performing the exercises correctly, do not have professional guidance to help and give feedback, and it is easier not to compromise with homework exercise. Fortunately, technology walks side by side with progress in medicine, and new solutions appear every day. One solution for the above problem is the development of sEMG sensors that collect muscular electrical activity and, in conjunction with mobile apps, for example, allow patients to monitor their muscle behaviour in real time. Nowadays,

in a reduction of the recurrence of 75% after 2 years follow-up (9% recurrence) [5].

can access all training results remotely and also adjust the exercise plan if needed.

bilitation sessions at the clinic is objectively tracked.

**2.2. At home**

62 Biofeedback

exercises.

**2.3. The clinic-home divide**

In the following sections, we describe how home training is no longer isolated and unsupported. Patients can exercise at home with the confidence that the way they are mobilizing their muscles is correct and not potentially harmful. Home exercises are described as effective in accelerating the rehabilitation process [9]. In our approach, the process starts from a faceto-face session, where all sEMG assessments are performed by the physiotherapist, a treatment plan is designed, initial exercises are performed and a home plan is defined in order to continue what was started at the clinic. Once at home, the patient logs in his/her mobile app, checks where to apply the EMG sensors guided by visual cues on the app, reviews the list of exercises through example videos and executes all defined exercises supported by real-time biofeedback. In the end, a direct message can be sent to the physiotherapist via the application, to express how easy/hard was the session, how is the patient feeling, and so on, so the therapist can make sure the patient performs the exercises correctly and in an adequate quantity and change the prescribed plan if needed. Regular visits to the clinic must be scheduled, according to patient-specific needs and progress.

This is an important paradigm shift to the way physiotherapy can be seen and approached. As presented next, a modern infrastructure has been designed especially to support home rehabilitation sessions in an integrative way, by means of (1) wearable and user-friendly miniaturized sEMG sensors; (2) intuitive mobile apps prepared to easily guide the patients on the execution of the pre-configured exercises prescribed by their physiotherapist (in a serious game approach); (3) objective reports shared with the physiotherapist with the possibility to send messages about the session by the patient, which promotes a fluid communication between patient and physiotherapist; (4) online dashboards to access the home training results and make changes to the prescription, so that the next time the patient logs in the

**Figure 1.** Electromyographic (EMG) biofeedback software with a concentric circle graphic relative to one muscle, to guide the patient to execute the exercise correctly and within the needed time. The goal is to contract the muscle in order to put the red dots inside the circle, making them green. The opposite, to help the muscle to relax, is also possible.

home training app, changes will appear, adjusting the app to patients' exercise needs. With these solutions, the link between clinic and home training is straight and the knowledge regarding the activities performed by patients at home is direct, facilitating the configuration of follow-up physical therapy sessions and reducing the number of visits to the clinic whenever possible.
