How to Play the SHOULDER SHRUG Game (Isolated Scapular Elevation) ​ Game co-designed with a stroke survivor and developed from a clinically recommended exercise by Saebo to activate shoulder blade movement post-stroke. The game includes auditory and visual anticipatory cues to guide the participant on when to activate the switch positioned above the paretic shoulder. Aim To promote isolated scapular elevation by targeting the upper trapezius through a controlled shoulder shrug. This exercise trains the affected shoulder to activate independently, helping to rebuild strength and motor control after stroke. The game uses original music and visual cues to regulate the timing of the movement and encourage anticipatory control. The switch is placed above the paretic shoulder and should provide a clear end point, the switch should be secured with a heavy clamp or arm, so it does not lose position when it is pressed by the shoulder. ​ Objectives To develop isolated shoulder elevation in the paretic arm. To provide anticipatory auditory cueing using a 4-note musical pattern to support rhythm and pacing. To reinforce correct motor pathways and discouraging compensatory trunk involvement. This movement can be used both with stroke survivors with mild -moderate and severe hemiparesis. Overview The Shoulder Shrug Exercise involves lifting the affected shoulder upwards in a smooth, controlled motion to activate a switch positioned just above the shoulder at the end of the shrug range. This movement encourages active recruitment of the upper trapezius. The movement can highlight differences between muscle activation and compensatory patterns. ​ How to Perform the Shoulder Shrug Exercise Starting Position Sit upright in a chair with a backrest. Ensure your back is touching the back of the chair. Feet flat on the floor, hip-width apart. Hands resting naturally at your sides or on your lap. Look straight ahead with a neutral head position. Movement 6. Slowly raise your paretic shoulder upwards toward your ear without moving your torso. 7. When the shoulder reaches its peak, click the switch positioned above your shoulder. 8. Slowly lower the shoulder back down to the starting position with control. 9. Repeat for the number of repetitions dictated by the game. ​ Gaming and Musical Integration • The game features a 4-note ascending anticipatory cueing system: Note 1–2: Prepare and begin the shrug. Note 3: Reach and activate the switch at the peak of the movement. Note 4: Return the shoulder to rest. This structure guides the timing and supports smooth, paced repetitions. ​ Tips & Common Mistakes to Avoid • Do not lean forward or backward — the movement should come from the shoulder only. • Avoid lifting the arms or elbows. • Move slowly and with control, especially during the lowering phase. • If the switch isn’t reached at first, don't rush — focus on quality of movement over activation. ​ Compensation Awareness If the stroke survivor shows trunk movement, momentum, or a jerking motion the game can be slowed down or modified to support the stroke survivor being able to attempt an isolated scapular elevation. As noted by Schwarz et al. (2021), trunk displacement is a common strategy that often substitutes for upper limb function post-stroke and must be addressed during rehabilitation. This is an important reminder that switch activation does not always equate to movement quality - so it is important to focus on the quality of movement. ​ Clinical Application The Shoulder Shrug Exercise can be used to: • Encourage upper trapezius reactivation following shoulder subluxation or weakness • Train scapular control and postural awareness • Address selective motor control impairments (Mohammed et al., 2023) • Provide feedback and cueing for clients with severe hemiparesis • Support movement retraining in Neurologic Music Therapy (NMT) potentially using Patterned Sensory Enhancement (PSE) Music: RColclasure Gaming Platform: Stepmania Exercise Level Design: RColclasure